A look at multiple techniques in UCL reconstruction

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, 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.

Click here to read the full Surgical Technique in the November issue of Orthopedics Today.