Repair of the Thumb Ulnar Collateral Ligament With Suture Tape Augmentation

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Abstract

One of the most commonly injured structures of the thumb metacarpophalangeal (MCP) joint is the ulnar collateral ligament (UCL). An acute injury of this ligament is often amenable to primary repair. Despite the favorable outcomes of primary repair, the thumb is often restricted during initial healing of the ligament with immobilization and delayed rehabilitation. We present a novel technique to augment the repair of the UCL with suture tape to provide immediate biomechanical support and strength during the critical time of ligament healing. We describe the surgical technique of suture tape augmentation for thumb UCL repair. At the ulnar aspect of the thumb MCP joint, a longitudinal midaxial incision is made. Subsequently, the adductor pollicis aponeurosis and extensor mechanism are identified, incised, and retracted. The UCL is exposed and usually torn off the volar-ulnar base of the proximal phalanx. A 2.5-mm PushLock anchor loaded with 1.3-mm SutureTape and 3-0 FiberWire suture, is placed into a hole at the volar-ulnar base of the proximal phalanx after preparation with a 1.8-mm drill bit. The 3-0 FiberWire is used for direct repair of the ligament. Both tails of the 1.3-mm SutureTape is then brought proximally over the ligament and loaded into a 3.5-mm SwiveLock anchor. A 3.2-mm drill bit is then used to make a hole at the ulnar aspect of the metacarpal head, just proximal to the attachment of the proximal UCL. With the thumb MCP joint held in at least 30 degrees of flexion, the tape-loaded 3.5-mm SwiveLock anchor is inserted into metacarpal head. Reinforcement of the repair is then carried out with fine absorbable suture to surrounding capsular tissue. We present a representative case of a professional basketball player treated with this novel procedure. After the surgical repair, the patient was placed in a plaster splint for 3 days to immobilize the thumb and wrist. At 3 days postsurgery, the splint was removed and therapy initiated. Practice drills were initiated at 1 week postsurgery with the use of a removable hand-based thumb spica custom splint. During the entire postoperative period, the left thumb MCP joint had excellent stability to radial stress at full extension and 30 degrees of flexion. In addition, at 3 weeks postsurgery, the patient was able to oppose the thumb tip to the palmar-digital crease of the small finger and MCP joint motion was 0 to 50 degrees. The patient began strengthening exercises at this time, along with the ability to participate in all position-specific drills. At 5 weeks postsurgery, the patient was cleared to return to full play, without use of a splint. At 37 days postsurgery, the patient returned to competitive play. During competitive play, the player completed the entire remaining season of 25 games as well as extended competition into the playoffs of 7 games without further incident or time missed. At the latest follow-up, the patient is 6 months postprocedure and continues to remain asymptomatic with full participation in playing sports. During the critical time of ligament healing, the UCL repair can be enhanced with synthetic material to obviate the need for prolonged postoperative immobilization. We offer a novel surgical technique that enhances primary repair of the thumb UCL through appended biomechanical support. Under these circumstances, with structural support augmentation, the recovery and rehabilitation process can be expedited for patients to allow an earlier return to activities.

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