Journal Club - UCL Repair With Internal Brace Versus Tommy John Reconstruction

Journal Club is a recurring series where we look at recent research in orthopedic sports medicine and talk through what it may mean for our patients.

Title

Clinical Outcomes of Ulnar Collateral Ligament Repair With Internal Brace Versus Ulnar Collateral Ligament Reconstruction in Competitive Athletes

Authors

Jeffrey R. Dugas, MD; Ryan J. Froom, MS, ATC; Eric A. Mussell, MS, MBA; Sydney M. Carlson, BS; Anna E. Crawford, BS; Kevin E. Wilk, PT, DPT; Marcus A. Rothermich, MD; Matthew P. Ithurburn, PT, DPT, PhD; Benton A. Emblom, MD; E. Lyle Cain Jr., MD; and colleagues at the American Sports Medicine Institute

Journal

The American Journal of Sports Medicine. 2025;53(3):525-536.

Study design

Cohort study. Level of evidence, 3.

What this study looked at:

UCL reconstruction, known to most families as Tommy John surgery, has been the standard treatment for a torn ligament on the inside of the elbow since 1974. It replaces the ligament with a tendon graft. UCL repair with an internal brace is a newer option that preserves the athlete's own ligament and reinforces it with a strong suture tape, which acts as both a backstop against valgus stress and a scaffold while the ligament heals.

The question this study set out to answer is a practical one. For the athlete who is a candidate for either operation, do the two procedures actually perform the same?

The authors reviewed competitive athletes treated at a single center in Birmingham, Alabama between 2013 and 2021, all at least two years out from surgery. Of 461 athletes with complete data (average age 19, and mostly baseball players), 268 had a repair with internal brace and 155 had a reconstruction. Average follow-up was about five years.

What they found

• Patient-reported elbow function was similar between the two groups once follow-up time was accounted for, using the ASES-E, KJOC, and Andrews-Carson scores.

• Among athletes who attempted to return, 98 percent of the repair group and 99 percent of the reconstruction group made it back to their preinjury level of sport. The difference was not statistically significant.

• Return to practice averaged 6.7 months after repair compared with 10.2 months after reconstruction. Return to competition averaged 9.2 months compared with 13.4 months. Both differences favored repair.

• Reoperation rates were similar, at 9 percent after repair and 8 percent after reconstruction.

The authors concluded that for a well-selected athlete, repair with internal brace performs comparably to reconstruction at midterm follow-up, with a meaningfully faster return to sport.

Discussion - What this means for throwers and their families

The ulnar collateral ligament sits along the inside of the elbow and is the main restraint against the enormous valgus force created during the throwing motion. It is the structure that gives way when a pitcher feels a pop, or more often, when velocity and command quietly slip away over a season. When rest, rehabilitation, and time do not restore an athlete's ability to throw, surgery becomes part of the conversation.

For decades that conversation had one answer. This study is useful because it puts numbers behind a second one.

A few things stand out to me. The first is the timeline. Four fewer months to return to competition is not a small thing for a high school junior hoping to be seen, or for a college athlete with eligibility that does not wait. The second is that this speed did not appear to come at a cost. Function scores, return to sport, and reoperation rates all landed in the same range as reconstruction.

The most important line in the paper, though, is the one about selection. Repair only works when there is a ligament worth saving. It is generally suited to an avulsion off the bone at either end with good remaining tissue quality, and it is not the right choice when the ligament is attritional, calcified, or chronically degenerated. The authors make the point that tissue quality often cannot be fully judged on MRI alone, which is why they prepare athletes for either procedure and make the final call in the operating room. That is how I approach it as well, and it is a conversation I would rather have with a family well before surgery day than during it.

A word on how to read this study. It is a level 3 cohort study, not a randomized trial, and no randomized trial on this question exists yet. The two groups were also not identical. The repair group had more partial tears and skewed toward high school athletes, while the reconstruction group had more complete tears and more college athletes. That reflects sound surgical judgment, but it does mean some of the faster recovery may reflect a less severe injury rather than the procedure alone. The study was also funded in part by industry, which the authors disclose. None of this undoes the findings. It does mean the honest summary is that repair is a very good option for the right elbow, rather than a better operation for every elbow.

If your son or daughter has been told they have a UCL injury, the useful questions are these. Is this a tear that could be repaired? Where in the season are we? And what does the tissue actually look like? Those answers, more than the name of the procedure, tend to shape how the year goes.

About the author

Dr. Josh Eskew is a fellowship-trained orthopedic sports medicine surgeon at Prisma Health's Steadman Hawkins Clinic of the Carolinas in Greenville, South Carolina. He completed his sports medicine fellowship at the Hospital for Special Surgery in New York City, where he served as Administrative Chief Fellow and cared for athletes with the New York Mets and St. John's University. He is a team physician for the Hub City Spartanburgers and for Presbyterian College athletics, and his practice and research focus on the throwing shoulder and elbow.

Disclaimer: The material on this website reflects the opinions of Dr. Eskew and should not be taken as medical advice. Every patient's situation is different, and a complete assessment requires a history, physical examination, and review of imaging. If you would like Dr. Eskew's opinion on your specific case, please contact our office to schedule an appointment.