Repair and reconstruction, the words are often used interchangeably but are referring to two different surgeries performed on damaged ligaments. Deciding between a repair or reconstruction depends on the location of the tear, severity of the injured ligament goals of the patient. Before committing to a surgery, it is probably best to know what is happening during the surgery and what to expect when it comes time to rehab. The first step is to understand the difference in the two types of surgeries.
In general, reconstructive surgery is needed when there is a complete tear of a ligament, especially if that tear occurs in an area that may have less blood flow. For example, the proximal portion of the UCL has better blood flow than the mid portion of the UCL in the elbow. UCL tears of similar size may be treated differently depending on the location of injury to the ligament. This is also common amongst ACL tears where proximal tears have a better chance of healing due to blood flow than mid portion tears. Direct repair of a ligament is a newer form of surgery that is gaining traction. A repair provides valuable benefits for candidates that meet the criteria. It is very patient specific and the patient must be carefully selected to achieve the full benefits. The candidates can range in age and performance level but severity of the injury and location of the tear on the ligament will factor in the decision.
Reconstructive surgery involves taking graft from another muscle of your own body or from a cadaver and inserting it to replace failed ligament. These types of surgery typically have longer healing times and more extensive rehab but have shown to have great overall outcomes in regards returning to sport at the prior level of function. Rehab for reconstructive surgery is a longer more conservative process for a few reasons, namely the new graft and soon to be ligament is typically a tendon from another area of the body. That means removing a tendon from another area of your body and using it to replace the injured ligament. Upon, inserting the new tendon in the place where the ligament once was the surgeon will have to drill tunnels into the bone and attach anchors to secure the graft. Over the course of the healing, the biological properties of a tendon (the new graft) must now change to the biological properties of a ligament. As you could assume this healing process will take longer than allowing the original ligament to heal (if that’s a possibility). Complete reconstruction of a ligament has allowed plenty of athletes to return to their prior level of performance prior to the injury, although with longer recovery and rehab times it remains the gold standard to treat complete ligament tears.
While reconstruction continues to be the gold standard of treating the tear of a ligament, recent advances in medicine has made direct repairs a great option for lower level tears with an array of benefits, including significantly shorter rehab and healing times. A direct repair of a ligament typically involves internal bracing which requires placing a collagen-coated fiber tape, along with anchors to the attachment of the ligament to the bone. The collagen-coated fiber tape allows the ligament to heal itself. Basically, the thought behind a direct repair is, why try and convert other collagen substitutes into a ligament, if the original ligament can be preserved. This alternative surgery has the potential to cut rehab time in half. Further research is necessary to evaluate the long-term benefits and disadvantages of a repair but as of now there are very few pitfalls. As with every surgery, proper patient selection is key. A direct repair has advantages including avoiding graft complications, maintaining anatomy, and accelerated rehab and return to sport.
The table below outlines some key differences in timeline between a Direct Repair and a Reconstruction with the Ulnar Collateral Ligament of the Elbow.
Keep in mind each patient and program will be different and specific to the individual. These are not the only options when having a ligament injury. As medicine progresses, there will continue to be new and improved options.
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