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n tips & techniquesSection Editor: Steven F. Harwin, MD

Novel Technique for Ulnar Collateral Ligament Reconstruction of the ElbowDaniel C. Acevedo, MD; Brian Lee, MD; Raffy Mirzayan, MD

Injuries to the medial side of the elbow are becoming

increasingly recognized and treated surgically. Injuries to the ulnar collateral ligament (UCL) in particular have re-ceived much attention in the lit-erature. These injuries are usu-ally seen in overhead athletes,

especially baseball pitchers.1 Overuse and excessive valgus loads seen in overhead athletes can cause attenuation and rup-ture of the UCL. Ulnar collat-eral ligament insufficiency can cause a significant decrease in athletic performance, mandat-ing surgical intervention.

Since Jobe et al2 first intro-duced his UCL reconstruction technique in 1974, many ad-vances have been made to im-prove the strength and ease of ligament reconstruction.2-6 The original reconstruction tech-nique by Jobe et al2 involved using a palmaris longus auto-graft that was weaved through bone tunnels in the ulna and medial epicondyle in a figure-of-eight fashion using sutures for graft tensioning and fixa-tion2 and was a technically de-manding procedure.

Modifications to the tech-nique include the docking technique,3 the interference screw technique,4 the DANE TJ or hybrid technique combin-ing an interference screw with the docking technique,5 and EndoButton (Smith & Nephew, Memphis, Tennessee) fixation, which is traditionally used in the knee.6 Many of the modi-fied techniques use methods of fixation that rely on relatively weak fixation, such as suture knots or bony bridges; these techniques also cause difficul-ties in properly tensioning the graft. With the advent and use

of commercially available super sutures (ie, OrthoCord [DePuy, Warsaw, Indiana] and FiberWire [Arthrex, Naples, Florida]), bone bridges do not allow for secure fixation because the su-tures can cut through bone.

This article introduces a novel technique used by the senior author (R.M.) for UCL reconstruction using an ante-rior cruciate ligament (ACL) TightRope RT (Arthrex), which is traditionally used for ACL and posterior cruci-ate ligament reconstruction in the knee, for humeral-sided fixation of the graft in com-bination with a BicepsButton (Arthrex) for primary fixation in the ulna, supplemented with an interference screw. The au-thors believe that this method of fixation allows secure ten-sioning of the graft, provides secure fixation that relies on a metal implant rather than su-tures over a bony bridge, and is less technically demanding than the original technique.

Materials and MethodsThe indication for surgery

is failed nonoperative manage-

Drs Acevedo, Lee, and Mirzayan are from the Department of Orthopaedic Surgery, USC Keck School of Medicine, Los Angeles, and Dr Mirzayan is also from the Department of Orthopaedic Surgery, Kaiser Permanente, Baldwin Park, California.

Drs Acevedo, Lee, and Mirzayan have no relevant financial relationships to disclose.

Correspondence should be addressed to: Raffy Mirzayan, MD, Department of Orthopedic Surgery, Kaiser Permanente, 1011 Baldwin Park Blvd, Baldwin Park, CA 91706 (lakersdoc@yahoo.com).

doi: 10.3928/01477447-20121023-05

Abstract: Ulnar collateral ligament (UCL) reconstruction of the elbow has been shown to restore function in overhead athletes with valgus instability. Since the initial description of using bone tunnels for reconstruction, many modifica-tions to the surgical technique have been introduced, includ-ing the modified Jobe technique, the docking technique, fixation with interference screws, and button fixation. The authors introduce a technique that uses a button on each of the humeral and ulnar sides for fixation. This method al-lows proper tensioning of the graft and provides immediate secure fixation that relies on metal implants as opposed to sutures over bone bridges alone.

extremityS P OT L I G H T O N

upper

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ment of a correctly diagnosed UCL injury. The senior author begins treatment with 2 to 3 cycles of nonoperative man-agement. Each cycle consists of 6 weeks of no throwing but continuation of all other core- and extremity-strengthening exercises, including strength-ening the flexor and pronator muscles. This is followed by a throwing program over a 6-week period. If the patient is pain free 3 months after in-jury, he or she may return to play. If the patient’s symptoms persist, surgical intervention is warranted.

surgical techniqueThe patient is placed in the

supine position with the op-erative extremity on an arm board. The palmaris longus tendon is harvested through 3 percutaneous incisions direct-ly over the tendon on the volar surface of the forearm without using a tendon stripper (Figure 1A, B). If the palmaris lon-gus is absent or insufficient in

caliber, then an allograft ten-don can be used. The authors’ preferred allograft is a 4- or 4.5-mm gracilis tendon. The graft length should be longer than 120 mm so that it will be at least 60 mm in length when doubled over. The preferred diameter of the graft is be-tween 4 and 4.5 mm.

An ACL TightRope RT is used for humeral fixation of the graft. The graft is folded over and placed through the suture loop of the ACL Tight-Rope RT (Figure 1C). Each of the 2 tail ends of the graft is sewn with #2 FiberWire suture in a Krakow fashion (Figure 1C) approximately 15 to 20 mm up the graft. The white su-tures from the ACL TightRope RT are then toggled, reducing the BicepsButton down to the graft, and the toggle sutures are tied together (Figures 1D, E). The graft is left under ten-sion on the back table and kept moist.

The approach to the elbow is a muscle-splitting technique

described by Thompson et al.8 The skin is incised over the medial epicondyle, and the medial antebrachial cutaneous nerve is identified and dissect-ed out (Figure 2A). The fascia of the flexor carpi ulnaris is incised in line with the muscle fibers (ulnar window). Blunt dissection is used to develop a plane in line with the fibers of the flexor carpi ulnaris, begin-ning at the medial epicondyle down to the sublime tubercle of the ulna. The muscle is re-tracted to expose the native UCL (Figure 2B). Care must be taken not to injure the ulnar nerve with aberrant retractor placement inferiorly. The ul-nar nerve is not routinely ex-posed or decompressed unless the patient has preoperative ulnar nerve symptoms.5

The UCL is incised in line with the muscle fibers and the fascial incision. Anterior and posterior leaflets are created by sharply dissecting the liga-ment off of the ulna, expos-ing the sublime tubercle. A safe zone has been described as 1 cm distal to the insertion of the UCL, and care must be taken not to extend the expo-sure past this point.9 A 3.2-mm spade-tipped guide pin is then placed at the sublime tubercle and angled distally to exit out of the posterior ulnar cortex (Figure 2C). Care must be taken to avoid the proximal radioulnar joint to not affect rotation of the forearm. The guide pin should be angled 30° distally and caudally to protect the posterior interosse-ous nerve as described by Lee

Figure 1: The palmaris longus tendon is isolated (A) and harvested (B) through 3 small stab incisions. The graft is looped through the anterior cruci-ate ligament TightRope RT (Arthrex, Naples, Florida) (C). The toggle sutures on the anterior cruciate ligament TightRope RT are pulled (D), reducing the BicepsButton (Arthrex) to the graft, and tied (E), securing the BicepsButton to the graft.

1A1B

1D

1E1C

2A

Figure 2: After a medial incision based over the medial epicondyle, the medial antebrachial cu-taneous nerve is isolated (A). The fascia of the flexor carpi ulnaris (ul-nar window) is incised, and a muscle-splitting approach is made to the native ligament (B). The spade-tipped guide pin is placed at the sublime tu-bercle seen through the ulnar window. The drill is aimed 30° distally and 30° caudally (C).

2B

2C

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et al.10 Use of fluoroscopic guidance is encouraged for the first few cases until the surgeon becomes comfortable with the ulnar guide pin place-ment. The length of the tunnel should be assessed using the calibration marks on the guide pin. The tunnel should be ap-proximately 30 mm in length. A 4.5-mm cannulated reamer is then used to ream the ulnar tunnel over the guide wire, taking care not to penetrate the far cortex.

Once the ulnar tunnel is prepared, attention is directed to the proximal origin of the UCL. The anterior band of the UCL originates at the anterior and inferior portion of the me-dial epicondyle12 and can be seen deep to the flexor tendon attachment. To expose the an-terior surface of the medial epicondyle, a separate fascial incision is made proximal to

the medial epicondyle (humer-al window) (Figure 3A). The muscle fibers are gently elevat-ed off the bone. Care is taken to remain anterior to the medial intermuscular septum to avoid injury to the ulnar nerve. The anterior aspect of the medial epicondyle is exposed proxi-mally. The distal and proximal portion of the medial epicon-dyle is now visible through the 2 fascial windows. The flexor–pronator tendonous ori-gin is left undisturbed. A 2.4-mm spade-tipped guide pin is drilled from the origin of the UCL at the distal aspect of the medial epicondyle to the proximal anterior aspect of the medial epicondyle (Figure 3B). The guide pin is directed toward the anterior humeral cortex so it does not exit pos-teriorly and injure the ulnar nerve. A 4.5-mm cannulated reamer is used over the guide

wire to ream the proximal tun-nel for the graft. The reamer should penetrate the anterior cortex of the medial epicon-dyle entirely. The tunnel length will be approximately 12 to 15 mm. The tunnel should be aimed in a slightly lateral di-rection to avoid overhang of the ACL TightRope RT on the medial cortex.

After the 2 tunnels have been prepared, the free ends of the graft are passed through the humeral tunnel from the proximal end, exiting to-ward the joint (Figure 4). The graft is pulled until the ACL TightRope RT lays flat and rests on the anterior surface of the medial epicondyle. The su-tures from the free ends of the graft are then placed through a BicepsButton. The suture ends must be passed in op-posite directions into the but-ton to allow the button to flip

on the far cortex (Figure 5A). The BicepsButton is placed in the ulnar tunnel through the far cortex with the insertion tool (Figures 5B-D). The #2 FiberWire sutures are pulled, and the graft is reduced into the ulnar tunnel. The sutures are pulled and the graft tensioned at the desired flexion angle of the elbow (60°-70° of flexion is preferred) and then tied us-ing an arthroscopic knot push-er. The knots are advanced to the base of the ulnar tunnel. A 3.5-mm polyetheretherketone SwiveLock tenodesis screw (Arthrex) is inserted into the ulnar tunnel for additional fixation. The native ligament is repaired over the graft with an absorbable suture. The fas-cial incisions are then closed with an 0 polyglactin 910 su-ture. The subcutaneous tissue is closed with 2-0 polyglactin 910 suture in an inverted sub-

3A

Figure 3: An L-shaped fascial inci-sion is made proximally (humeral window) (A). A 3.2-mm spade-tipped guide pin is drilled from the origin of the ulnar collateral ligament at the distal aspect of the medial epicondyle, exiting on the anterior aspect of the medial epicondyle (B). Abbreviation: Nv, nerve.

3B

Figure 4: The graft is passed through the medial epicondyle from a proximal-to-distal direction (A), ensuring that the button is flush against the bone (B). Abbreviation: Nv, nerve.

4A 4B

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dermal fashion, and the skin is closed with a 3-0 mono-filament absorbable suture in a subcuticular fashion. Postoperative radiographs are obtained (Figure 6).

Postoperatively, the pa-tient is placed in a long-arm, posteriorly based splint for 1 week. The rehabilitation pro-tocol involves initial splinting of the elbow in 90° of flexion with neutral forearm rotation. Ten days postoperatively, the splint is discontinued, and ac-tive range of motion exercises of the shoulder, elbow, and wrist are started. Range of motion is gradually increased so that full range of motion

is obtained at 6 weeks post-operatively. Four to 6 weeks postoperatively, strengthen-ing exercises are initiated. Throwing progression is initi-ated approximately 4 months postoperatively, starting with a ball toss, and return to play occurs approximately 10 months postoperatively.7

discussionThe UCL is the primary

stabilizer of valgus stress at the elbow.13 The anterior band is the most important part of the UCL complex in pro-viding valgus stability. This structure is frequently over-used and undergoes micro-

trauma in overhead athletes that results in chronic valgus instability. Ulnar collateral ligament reconstruction is aimed at reconstructing the anterior band of the UCL to restore valgus stability. Since the original technique used for UCL reconstruction, vari-ous modifications in technique and graft fixation have been described.3-6

The goal of any reconstruc-tion is to achieve immediate, secure fixation to allow early rehabilitation. With older tech-niques, fixation was tenuous and rehabilitation was limited to avoid early failure. With modern techniques, including the one described here, imme-diate fixation is achieved to al-low for early rehabilitation.

The results of UCL recon-structions have improved as the technique has evolved.3-6 Cain et al14 reported the largest series of UCL reconstructions, with more than 700 patients with a minimum 2-year follow-up. Eighty-three percent of pa-

tients returned to their previous level of competition or higher after a figure-of-eight recon-struction without transposition of the ulnar nerve.14

Bowers et al15 had simi-lar results using the modified docking technique in 21 pa-tients. This method relied on using bone tunnels in the ulna and 2 small converging tun-nels in the humerus where the graft was tensioned and tied over a bony bridge. Excellent results were achieved for more than 90% of patients with no complications. No long-term follow-up was noted.15

Similar results were noted by other authors using the modified Jobe technique8 and the docking technique.3 Newer techniques have been described,4-6,10 but long-term results are lacking.

The results of UCL recon-structions using prior tech-niques have been excellent but are fraught with techni-cal intraoperative complica-tions. The original technique

5D

Figure 6: Postopera-tive anteroposterior (A), oblique (B), and lateral (C) radiographs. Note that the tunnel has been aimed in a slightly lateral direction to avoid overhang of the BicepsButton (Arthrex, Naples, Florida) on the medial cortex (A) and that the tunnel has been directed away from the lesser sigmoid notch (B).

6B6A

6C

Figure 5: The sutures from the graft are passed through the BicepsButton (Arthrex, Naples, Florida) in opposite directions (A). The Button Inserter (Arthrex) is loaded (B) and used to place the Bi-cepsButton into the ulnar tunnel (C). After the Bi-cepsButton is anchored on the far ulnar cortex, the suture limbs are cinched to pull the graft into the tunnel (D). Abbreviation: Nv, nerve.

5C

5B

5A

5D

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described by Jobe2 uses more than 1 bony tunnel in the ulna and the humerus. These tun-nels can cause fractures of the medial epicondyle if inac-curately placed. The converg-ing ulnar tunnels also pose difficulties during graft pas-sage. Fixation primarily relies on suturing the graft to itself, which can cause poor tension-ing of the graft.

The docking technique minimizes the tunnel forma-tion, but the fixation relies on tying the graft over a small bony bridge.3 This method of fixation can be tenuous if the bone between the sutures is thin. Modern techniques of interference screw fixation at-tempt to minimize tunnel for-mation and improve stability and tensioning of the graft us-ing a screw.10 This is a strong method of fixation, and the authors used an interference screw in their technique for this reason. The problem with the interference screw tech-nique alone is that the graft cannot be retensioned after in-sertion of the screw. New tech-niques have included suspen-sion button fixation for ulnar fixation.9

The current authors be-lieve their method offers many advantages over previously described methods. This re-construction technique allows for technical ease and imme-diate secure fixation. By us-ing the ACL TightRope RT

for humeral-sided fixation, the authors minimize tunnel formation to a single tunnel as opposed to 2 tunnels, thus reducing the risk for fracture. This also makes the procedure technically easier to perform.

The BicepsButton is low profile and sits securely on the anterior surface of the hu-merus. The ACL Tightrope RT offers the same fixation and ability to tension on the ulnar side at the desired elbow flex-ion angle. This also allows ten-sioning of the graft for a sec-ond time to ensure proper ten-sion. The ulnar-sided fixation also relies on a cortical metal button rather than sutures over a bony bridge. The use of the interference screw on the ulnar side of the graft of-fers additional fixation of this portion of the graft. The use of 1 tunnel on the ulna allows the surgeon to place the graft at the exact insertion point of the anterior bundle of the UCL on the sublime tubercle and avoids the risk of fracturing the bone bridge between 2 tun-nels. In addition, this assists in maintaining graft isometry.

To the the authors’ knowl-edge, this particular method of fixation has not been described in the literature. Further clini-cal and biomechanical studies are needed to evaluate the ef-fectiveness of this technique, and long-term outcome stud-ies are needed to validate the clinical use of this technique.

conclusionUlnar collateral ligament

reconstructions have had ex-cellent results in restoring val-gus stability of the elbow and returning athletes to sports. Modern advances in orthope-dic implants have allowed for several new UCL reconstruc-tion techniques. The authors’ method, which uses an ACL TightRope RT to dock the hu-meral portion of the ligament and a BicepsButton with a polyetheretherketone interfer-ence screw for ulnar-sided fix-ation, offers secure fixation and is less technically demand-ing than prior procedures.

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Jobe FW. Understanding shoul-der and elbow injuries in base-ball. J Am Acad Orthop Surg. 2007; 15:139-147.

2. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986; 68:1158-1163.

3. Rohrbough JT, Altchek DW, Hyman J, Williams RJ III, Botts JD. Medial collateral ligament reconstruction of the elbow us-ing the docking technique. Am J Sports Med. 2002; 30:541-548.

4. Ahmad CS, Lee TQ, ElAttrache NS. Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation. Am J Sports Med. 2003; 31:332-337.

5. Conway JE. The DANE TJ pro-cedure for elbow medial ulnar collateral ligament insufficien-cy. Tech Shoulder Elbow Surg. 2006; 7:36-43.

6. Armstrong AD, Dunning CE, Ferreira LM, Faber KJ, Johnson JA, King GJ. A biomechanical

comparison of four reconstruc-tion techniques for the medial collateral ligament-deficient elbow. J Shoulder Elbow Surg. 2005; 14:207-215.

7. Hariri S, Safran MR. Ulnar col-lateral ligament injury in the overhead athlete. Clin Sports Med. 2010; 29:619-644.

8. Thompson WH, Jobe FW, Yocum LA, Pink MM. Ulnar collateral ligament reconstruction in throw-ing athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder El-bow Surg. 2001; 10:152-157.

9. Smith GR, Altchek DW, Pag-nani MJ, Keeley JR. A muscle- splitting approach to the ul-nar collateral ligament of the elbow: neuroanatomy and op-erative technique. Am J Sports Med. 1996; 24:575-580.

10. Lee GH, Limpisvasti O, Park MC, McGarry MH, Yocum LA, Lee TQ. Revision ulnar collat-eral ligament reconstruction us-ing a suspension button fixation technique. Am J Sports Med. 2010; 38:575-580.

11. O’Driscoll SW, Jaloszynski R, Morrey BF, An KN. Origin of the medial ulnar collateral liga-ment. J Hand Surg Am. 1992; 17:164-168.

12. Dugas JR, Ostrander RV, Cain EL, Kingsley D, Andrews JR. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg. 2007; 16:657-660.

13. Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res. 1987; 5:372-377.

14. Cain EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010; 38:2426-2434.

15. Bowers AL, Dines JS, Dines DM, Altchek DW. Elbow medi-al ulnar collateral ligament re-construction: clinical relevance and the docking technique. J Shoulder Elbow Surg. 2010; 19:110-117.