n tips & techniques
Section Editor: Steven F. Harwin, MD
S P OT L I G H T O N
upper
extremity
Novel Technique for Ulnar Collateral Ligament
Reconstruction of the Elbow
Daniel C. Acevedo, MD; Brian Lee, MD; Raffy Mirzayan, MD
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 modifications to the surgical technique have been introduced, including 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 allows proper tensioning of the graft and provides immediate
secure fixation that relies on metal implants as opposed to
sutures over bone bridges alone.
I
njuries to the medial side
of the elbow are becoming
increasingly recognized and
treated surgically. Injuries to
the ulnar collateral ligament
(UCL) in particular have received much attention in the literature. These injuries are usually seen in overhead athletes,
especially baseball pitchers.1
Overuse and excessive valgus
loads seen in overhead athletes
can cause attenuation and rupture of the UCL. Ulnar collateral ligament insufficiency can
cause a significant decrease in
athletic performance, mandating surgical intervention.
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
NOVEMBER 2012 |Volume35•Number11
Since Jobe et al2 first introduced his UCL reconstruction
technique in 1974, many advances have been made to improve the strength and ease of
ligament reconstruction.2-6 The
original reconstruction technique by Jobe et al2 involved
using a palmaris longus autograft that was weaved through
bone tunnels in the ulna and
medial epicondyle in a figureof-eight fashion using sutures
for graft tensioning and fixation2 and was a technically demanding procedure.
Modifications to the technique include the docking
technique,3 the interference
screw technique,4 the DANE
TJ or hybrid technique combining 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 modified techniques use methods of
fixation that rely on relatively
weak fixation, such as suture
knots or bony bridges; these
techniques also cause difficulties 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 sutures can cut through bone.
This article introduces a
novel technique used by the
senior author (R.M.) for UCL
reconstruction using an anterior cruciate ligament (ACL)
TightRope RT (Arthrex),
which is traditionally used
for ACL and posterior cruciate ligament reconstruction in
the knee, for humeral-sided
fixation of the graft in combination with a BicepsButton
(Arthrex) for primary fixation
in the ulna, supplemented with
an interference screw. The authors believe that this method
of fixation allows secure tensioning of the graft, provides
secure fixation that relies on a
metal implant rather than sutures over a bony bridge, and
is less technically demanding
than the original technique.
MATERIALS AND METHODS
The indication for surgery
is failed nonoperative manage-
947
n tips & techniques
Figure 2: After a medial
incision based over the
medial epicondyle, the
medial antebrachial cutaneous nerve is isolated
(A). The fascia of the
flexor carpi ulnaris (ulnar 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 tubercle seen through the
ulnar window. The drill
is aimed 30° distally and
30° caudally (C).
1B
1A
2A
1D
1C
1E
Figure 1: The palmaris longus tendon is isolated (A) and harvested (B)
through 3 small stab incisions. The graft is looped through the anterior cruciate 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.
ment of a correctly diagnosed
UCL injury. The senior author
begins treatment with 2 to 3
cycles of nonoperative management. Each cycle consists
of 6 weeks of no throwing but
continuation of all other coreand extremity-strengthening
exercises, including strengthening 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 injury, he or she may return to
play. If the patient’s symptoms
persist, surgical intervention
is warranted.
SURGICAL TECHNIQUE
The patient is placed in the
supine position with the operative extremity on an arm
board. The palmaris longus
tendon is harvested through 3
percutaneous incisions directly over the tendon on the volar
surface of the forearm without
using a tendon stripper (Figure
1A, B). If the palmaris longus is absent or insufficient in
948
caliber, then an allograft tendon 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 between 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 TightRope 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 sutures 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 tension on the back table and kept
moist.
The approach to the elbow
is a muscle-splitting technique
2B
2C
described by Thompson et al.8
The skin is incised over the
medial epicondyle, and the
medial antebrachial cutaneous
nerve is identified and dissected 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, beginning at the medial epicondyle
down to the sublime tubercle
of the ulna. The muscle is retracted to expose the native
UCL (Figure 2B). Care must
be taken not to injure the ulnar
nerve with aberrant retractor
placement inferiorly. The ulnar nerve is not routinely exposed 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 ligament off of the ulna, exposing 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 exposure past this point.9 A 3.2mm 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 interosseous nerve as described by Lee
ORTHOPEDICS | Healio.com/Orthopedics
n tips & techniques
Figure 3: An L-shaped fascial incision is made proximally (humeral
window) (A). A 3.2-mm spadetipped 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
3A
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
et al.10 Use of fluoroscopic
guidance is encouraged for
the first few cases until the
surgeon becomes comfortable
with the ulnar guide pin placement. The length of the tunnel
should be assessed using the
calibration marks on the guide
pin. The tunnel should be approximately 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 medial epicondyle12 and can be
seen deep to the flexor tendon
attachment. To expose the anterior surface of the medial
epicondyle, a separate fascial
incision is made proximal to
the medial epicondyle (humeral window) (Figure 3A). The
muscle fibers are gently elevated 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 proximally. The distal and proximal
portion of the medial epicondyle is now visible through
the 2 fascial windows. The
flexor–pronator tendonous origin is left undisturbed. A 2.4mm 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 posteriorly and injure the ulnar
nerve. A 4.5-mm cannulated
reamer is used over the guide
NOVEMBER 2012 |Volume35•Number11
4B
wire to ream the proximal tunnel for the graft. The reamer
should penetrate the anterior
cortex of the medial epicondyle entirely. The tunnel length
will be approximately 12 to
15 mm. The tunnel should be
aimed in a slightly lateral direction 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 toward 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 sutures from the free ends of the
graft are then placed through
a BicepsButton. The suture
ends must be passed in opposite directions into the button 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 using an arthroscopic knot pusher. 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 fascial incisions are then closed
with an 0 polyglactin 910 suture. The subcutaneous tissue
is closed with 2-0 polyglactin
910 suture in an inverted sub-
949
n tips & techniques
6A
5A
6B
Figure 6: Postoperative 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).
5B
5C
5D
dermal fashion, and the skin
is closed with a 3-0 monofilament absorbable suture
in a subcuticular fashion.
Postoperative radiographs are
obtained (Figure 6).
Postoperatively, the patient is placed in a long-arm,
posteriorly based splint for 1
week. The rehabilitation protocol involves initial splinting
of the elbow in 90° of flexion
with neutral forearm rotation.
Ten days postoperatively, the
splint is discontinued, and active range of motion exercises
of the shoulder, elbow, and
wrist are started. Range of
motion is gradually increased
so that full range of motion
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5D
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 BicepsButton into the ulnar
tunnel (C). After the BicepsButton is anchored
on the far ulnar cortex, the
suture limbs are cinched
to pull the graft into the
tunnel (D). Abbreviation:
Nv, nerve.
is obtained at 6 weeks postoperatively. Four to 6 weeks
postoperatively, strengthening exercises are initiated.
Throwing progression is initiated approximately 4 months
postoperatively, starting with
a ball toss, and return to play
occurs approximately 10
months postoperatively.7
DISCUSSION
The 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 providing valgus stability. This
structure is frequently overused and undergoes micro-
6C
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, various modifications in technique
and graft fixation have been
described.3-6
The goal of any reconstruction is to achieve immediate,
secure fixation to allow early
rehabilitation. With older techniques, fixation was tenuous
and rehabilitation was limited
to avoid early failure. With
modern techniques, including
the one described here, immediate fixation is achieved to allow for early rehabilitation.
The results of UCL reconstructions 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 followup. Eighty-three percent of pa-
tients returned to their previous
level of competition or higher
after a figure-of-eight reconstruction without transposition
of the ulnar nerve.14
Bowers et al15 had similar results using the modified
docking technique in 21 patients. This method relied on
using bone tunnels in the ulna
and 2 small converging tunnels 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 reconstructions using prior techniques have been excellent
but are fraught with technical intraoperative complications. The original technique
ORTHOPEDICS | Healio.com/Orthopedics
n tips & techniques
described by Jobe2 uses more
than 1 bony tunnel in the ulna
and the humerus. These tunnels can cause fractures of
the medial epicondyle if inaccurately placed. The converging ulnar tunnels also pose
difficulties during graft passage. Fixation primarily relies
on suturing the graft to itself,
which can cause poor tensioning of the graft.
The docking technique
minimizes the tunnel formation, 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 attempt to minimize tunnel formation and improve stability
and tensioning of the graft using 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 technique alone is that the graft
cannot be retensioned after insertion of the screw. New techniques have included suspension button fixation for ulnar
fixation.9
The current authors believe their method offers many
advantages over previously
described methods. This reconstruction technique allows
for technical ease and immediate secure fixation. By using 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 humerus. The ACL Tightrope RT
offers the same fixation and
ability to tension on the ulnar
side at the desired elbow flexion angle. This also allows tensioning of the graft for a second time to ensure proper tension. 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 offers 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 tunnels. In addition, this assists in
maintaining graft isometry.
To the the authors’ knowledge, this particular method of
fixation has not been described
in the literature. Further clinical and biomechanical studies
are needed to evaluate the effectiveness of this technique,
and long-term outcome studies are needed to validate the
clinical use of this technique.
NOVEMBER 2012 |Volume35•Number11
CONCLUSION
Ulnar collateral ligament
reconstructions have had excellent results in restoring valgus stability of the elbow and
returning athletes to sports.
Modern advances in orthopedic implants have allowed for
several new UCL reconstruction techniques. The authors’
method, which uses an ACL
TightRope RT to dock the humeral portion of the ligament
and a BicepsButton with a
polyetheretherketone interference screw for ulnar-sided fixation, offers secure fixation
and is less technically demanding than prior procedures.
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Raffy Mirzayan