Thumb Ulnar Collateral Ligament Tear Repair
Prior to beginning an examination under anesthesia with a valgus load to the MP joint should yield frank instability of the MP joint as shown here. See how the metacarpal is stabilized, and the proximal phalanx is loaded. The incision is placed on the ulnar border of the MP joint beginning at the level of the metacarpal head and extending towards the proximal phalanx space. The key is to avoid incision placement within the webspace. Prior to skin incision, the surgical site is infiltrated with a local anesthetic.
An incision is placed. Care is taken to not injure any of the crossing radial sensory nerve branches below the skin incision. Blunt dissection is then performed down to the extensor mechanism.
Branches of the radial sensory nerve will be evident within the surgical field. They should be adequately mobilized and then retracted either volarly or dorsally out of the surgical field.
If a Stener lesion is present, it will be evident at this point as demonstrated here with the ulnar collateral ligament sitting avulsed and on top of the adductor aponeurosis.
In order to expose the footprint of the ulnar collateral ligament, the adductor aponeurosis is released longitudinally, and the extensor mechanism elevated dorsally.
The plane between the extensor mechanism and the MP joint capsule is developed as shown here. Once that plane is developed, the extensor mechanism is elevated dorsally and a retractor placed behind it. This will protect both the extensor mechanism and any branches of the radial sensory nerve above it.
With the footprint of the ulnar collateral ligament exposed and debrided down to bleeding bone, the ligament is then mobilized and confirmed to be able to reach its footprint for subsequent repair.
Optionally, the MP joint can be pinned using a 0.045 K-wire as shown here to stabilize the joint and protect the repair prior to performing the actual repair. This K-wire can then be removed in the office approximately 3 to 4 weeks postoperatively.
The repair will be performed with a suture anchor placed in the footprint. Prior to placing the suture anchor, the footprint is freshened up using a Rongeur as shown here.
With the ligament mobilized, the joint pinned, and the footprint freshened up, the suture anchor is placed. The suture anchor used is one that can carry a 2-0 or 3-0 non-absorbable, braided suture as shown here.
Once anchored, the sutures are then loaded on a needle driver. Either a locking or a non-locking stitch is placed through the ligament. Here, a non-locking box stitch is placed through the ligament and then repaired in simple fashion. With the ligament held down against the footprint of the repair site by an assistant, the ligament is subsequently repaired.
With the primary repair completed, the repair is then augmented by taking the two suture ends and sewing them distally to the MP joint capsule as shown here. This will further reinforce repair as well as increase the distal translation of the ligament relative to the MP joint.
Here, closer inspection of the repair site confirms excellent coverage of the ligament to its footprint, as well as reinforcement to the MP joint capsule while not sewing in the extensor mechanism or branches of the radial sensory nerve.
If so desired, the repair can be augmented with sutures placed from the capsule into the ligament as shown here being placed along the dorsal border of the ulnar collateral ligament. This can also be performed on the volar side as well.
Once satisfied with the repair, the closure begins with repair of the adductor aponeurosis as shown here. It is mobilized and then repaired back to the extensor hood. An absorbable, monofilament suture is being used for the repair. Lastly, the wound is washed, and the skin closed next. Care is taken not to inadvertently capture any branches of the radial sensory nerve during closure. Postoperatively, a bulky soft dressing is applied that's left in place until the office visit. The patient is then converted to a removable splint. The pin is kept in for 4 weeks. After 4 weeks, the pin is pulled, and therapy is initiated. Thank you.