UCL reconstruction with double-docking and standard-docking techniques

Issue: November 2015

ByAnthony A. Romeo, MD

ByBrandon J. Erickson, MD

ByPeter N. Chalmers, MD

ByMark S. Cohen, MD

Ulnar collateral ligament injuries of the elbow are occurring with increased frequency among overhead athletes. These injuries are thought to be due to an acute-on-chronic mechanism of microtrauma of overuse. Although most commonly seen in pitchers, ulnar collateral ligament injuries can also occur in javelin throwers, gymnasts, quarterbacks and other overhead athletes who exert a valgus stress across the elbow. The injury occurs more frequently in men, and is diagnosed by history and physical exam using primarily the milking maneuver and the moving valgus stress test. Radiographs are typically normal, but advanced imaging, including ultrasound and MRI (Figure 1), play a role in confirming the diagnosis.

Several recent studies have examined the anatomy and biomechanics of the ulnar collateral ligament (UCL) to determine the best surgical treatment option. The anterior bundle of the UCL is the primary restraint to valgus force, and the goal of UCL reconstruction is to anatomically restore this portion of the ligament. The anterior bundle originates on the anteriorly facing surface of the anteroinferior aspect of the medial epicondyle of the humerus with a footprint that is 9.6-mm wide. The origin is positioned on the central aspect of the epicondyle. Previously, it was believed that the UCL inserted on a small area of the sublime tubercle of the proximal ulna, but recent evidence demonstrates the UCL inserts in a broad fashion over a span of 25 mm on both the sublime tubercle and UCL ridge.

Frank Jobe, MD, first published his initial UCL reconstruction technique in 1986 which involved elevating the flexor pronator mass, a figure of eight graft configuration, and tunnels on both the ulna and humerus. During the years, there have been several modifications to this technique including the modified Jobe, docking, DANE-TJ and ASMI modification. These modifications include changes in relation to treatment of the ulna and humerus, graft choice and management of the flexor pronator mass. However, despite these advances, no consensus has been reached in the literature about the optimal technique for UCLR. The modified Jobe, docking, DANE-TJ, ASMI modification and others have all shown good results in biomechanical testing as well as clinical application. Furthermore, several options exist for the graft utilized in the reconstruction, including palmaris longus autograft, plantaris, allograft Achilles, and autograft or allograft hamstring. To date, no study has demonstrated superiority of one graft over another. Complications of the procedure include ulnar nerve entrapment, superficial infection, medial epicondyle avulsion fracture, hematoma formation and heterotopic ossification.

Coronal T2 MRIs demonstrate a tear of the UCL.

Surgical technique

Some authors elect to perform routine elbow arthroscopy prior to UCL reconstruction to remove posteromedial osteophytes, address chondral defects, remove loose bodies and to assess the overall status of the elbow joint. We do not routinely perform an elbow arthroscopy unless concomitant pathology that is clinically relevant exists and is amenable to arthroscopic treatment. Prior to exposing the elbow, the graft is harvested, or in the case of an allograft, prepared. As an ipsilateral palmaris longus tendon autograft is the most common graft choice for the UCL reconstruction, this graft harvest will be described.

The surgeon must verify preoperatively on physical examination that the patient does in fact have a palmaris longus tendon. The palmaris longus tendon is palpated just proximal to the wrist flexion crease and an apex radial chevron incision or small transverse incision is made to expose the tendon. The tendon is whip-stitched with a suture of the surgeon’s choice, and cut as distal as possible. Care is taken not to delaminate the tendon. The tendon is freed of any adhesions. A tendon stripper is used to harvest the tendon, aiming towards the medial epicondyle where the muscle originates. The graft should be placed in a moist sponge in a secure location on the back table.

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We use a muscle-splitting approach as this has been shown to decrease postoperative ulnar neuropraxia. Prior to incision, the medial epicondyle, path of the UCL and ulnar nerve are marked out. The incision should be curvilinear, coursing posterior to the medial epicondyle. The medial antebrachial cutaneous nerve branches are identified, freed and protected to avoid postoperative medial forearm numbness and neuroma formation. The humeral and ulnar heads of the flexor carpi ulnaris (FCU) are then identified, and the ulnar nerve is identified running between these two heads. It can also be decompressed by releasing the overlying fascia proximal to the epicondyle adjacent to the medial intermuscular septum. We do not formally transpose the ulnar nerve in patients without preoperative symptoms of ulnar nerve compression, but do identify the nerve routinely to ensure it is protected throughout. The sublime tubercle is then identified using palpation and a split in line with the fibers of the FCU is made directly overlying the tubercle. The UCL and sublime tubercle are identified through this muscular split. The UCL and elbow capsule are then split longitudinally, and a valgus stress is applied to the elbow to confirm medial gapping of the articular surface. Anthony A. Romeo, MD, prefers to perform a standard-docking technique. Mark S. Cohen, MD, performs a hybrid-docking/endobutton technique. Both techniques are described.

Standard docking

In the standard-docking technique, two blind-ended cortical tunnels are drilled on either side of the sublime tubercle and connected. We prefer to perform this technique using a system and guide (UCL Reconstruction Set; Arthrex Inc.) specially formulated for this technique. The sublime tubercle is exposed such that the 3.5-mm V-shaped ulnar drill guide can be placed so it sits on both edges of the sublime tubercle, parallel to the articular surface. The anterior of the two holes is drilled using a drill with a stop, after which a peg is placed into the hole to stabilize the guide during drilling of the posterior tunnel. The 55° V-guide is set up such that the two holes converge and create a tunnel with a bony bridge of at least 1 cm. Once both holes are drilled, a 4-mm curette and a chamfer are used to smooth any remaining bony spicules that may impinge upon or abrade the graft. A suture-passing wire is then passed through the ulnar tunnel from posterior to anterior. The sutures from the graft are then fed though the suture passing wire, and the graft is passed through the ulnar tunnel. Placing a small amount of sterile mineral oil on the graft can help to facilitate graft passage.

Intraoperative photographs demonstrate the use of an endobutton for fixation of the UCL graft at the humeral origin.

The humeral tunnels are then drilled. The medial epicondyle is exposed and a 4.5-mm drill guide is placed on the medial epicondyle, ensuring it is not too medial, or too close to the articular surface, but rather in the middle of the face of the medial epicondyle. The drill is placed through the guide to drill a socket that is 15-mm deep. The chamfer is then used to smooth out the edges of the socket. A specialized, variable angle humeral drill guide can be used to drill the two posterior suture holes to allow “docking” of the graft. This guide creates two 2-mm posterior holes with an intervening bone bridge of 5 mm to 10 mm. Marking these tunnels with electrocautery can help to identify them after drilling. Care should be taken with both tunnels and with electrocautery as the ulnar nerve is very close to this location. Once both tunnels are created, a skid is placed in the socket aiming towards the more anterior of the two humeral tunnels, and a small suture-passing device can be used to pass the suture. This process can be repeated with the more posterior of the tunnels.

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The graft can then be docked into the humerus. The limb of the graft coming out of the anterior ulnar tunnel is passed into the anterior humeral tunnel using the sutures previously placed in this limb of the graft. The graft is recessed as much as possible into this humeral socket. The posterior limb is then measured such that it will recess 10 mm into the humeral socket. Because the humeral socket was drilled to a depth of 15 mm, an intra-tunnel graft length of 10 mm allows leeway for proper tensioning. This side of the graft is then prepared with a looped, reinforced, large-bore suture and the graft is cut using a knife with a fresh blade at the level previously measured. The graft is then passed through the posterior tunnel and docked into the humeral socket. The sutures are tied under maximum manual tension over the bony bridge with the arm in supination, and a varus force is applied to the elbow.

The elbow is then taken through a range of motion to ensure the graft remains isometric throughout the arc of motion. The native UCL is sutured to the graft for reinforcement. In addition, the limbs of the graft can be sewn to one another to further tension and reinforce the graft.

Intraoperative photograph of the final reconstructed UCL. Note the ulnar nerve (penrose drain) and the branches of the medial antebrachial cutaneous nerve posteriorly that have been protected.

Double docking

In the double-docking technique, a single, isometric drill hole is created to the size of the graft in both the ulna and the humerus. This simplifies the procedure by obviating the need for a bone bridge. It lessens the dissection of the native ligament from its ulnar insertion and decreases posterior retraction and exposure, which can put the ulnar nerve at risk. The ulnar hole is drilled at the center of the sublime tubercle. A 4.5-mm drill is run through the first cortex to where it bounces into the far cortex. A 0.0625-inch Kirschner wire is then used to drill two divergent holes through the tunnel exiting the posterolateral cortex of the ulna opposite the entry point. It is helpful to release the fascia along the posterior ulna so a retractor can be placed and the exits points identified. Care is taken to leave at least a 1 cm separation between the two exit points. Suture passers are then used to pass the sutures on the end of the prepared graft through the tunnel and dock the graft. The sutures are tied over the cortex opposite the tunnel.

The humeral tunnel is then prepared with a 4.5-mm drill as well. For this purpose, a 4.5-mm cannulated drill placed over a Kirschner wire is helpful. This allows the path of the tunnel to be determined first with a wire. The wire begins at the center of the humeral footprint exiting out the posteromedial column of the humerus. Care must be taken to retract the ulnar nerve out of harm’s way proximally. Once the position of the wire is optimal, the tunnel is drilled with the 4.5-mm cannulated drill. The graft is then measured and cut at the appropriate length to be docked into the humerus.

We have found it easiest to simply pass all sutures through the humerus and tie them posteriorly over an endobutton (Figure 2). Alternatively, one can use a shorter humeral tunnel with divergent holes for the sutures as described above. The elbow should be taken through a full arc of motion to ensure that the graft remains isometric throughout the entire arc. The native UCL can then be sutured to the graft for reinforcement.

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Postoperative care, return to sport

Postoperatively, the elbow is immobilized in a splint for the first week. Following this, rehabilitation begins initially concentrating on the recovery of elbow motion. Overhead athletes begin sport-specific training during weeks nine to 13 of rehabilitation, with emphasis placed on proper body core mechanics and initiating plyometric (jump training) exercises at week 12. Weeks 14 through 26 involve a throwing progression program which progresses as follows: short toss (45 ft.), followed by lofted long toss (120 ft.), long toss on a line, throwing from the knees, throwing from the mound (if the patient is a pitcher), game simulation, and finally, competitive play. Players often begin early competitive throwing between 7 months to 9 months, but often are not able to return to play at the same level of pre-injury competency until more than a year after surgery.

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For more information:
Brandon J. Erickson, MD; Peter N. Chalmers, MD; Mark S. Cohen, MD; and Anthony A. Romeo, MD, can be reached at Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60654; Erickson’s email: berickso.24@gmail.com; Chalmers’s email: p.n.chalmers@gmail.com; Cohen’s email: mcohen3@rush.edu; Romeo’s email: anthony.romeo@rushortho.com.

Disclosures: Erickson, Chalmers and Cohen report no relevant financial disclosures. Romeo reports he receives royalties from Arthrex Inc., is on the speakers bureau for Arthrex Inc., is a paid consultant for Arthrex Inc., receives research support from Arthrex Inc., DJO Surgical, Smith & Nephew and Ossur, and has received other financial support from Arthrex Inc.