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Operative Strategies for Ulnar Collateral Ligament Insufficiency

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The Unstable Elbow

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Abstract

The first described medial ulnar collateral ligament (UCL) reconstruction, popularly referred to as Tommy John surgery, was performed in 1974 by Dr. Frank Jobe. Since the first description, a number of technique and rehabilitation modifications have been described, with notable improvement in outcomes for throwing athletes. As the rate of UCL reconstruction surgery continues to increase across the country, particularly in adolescent baseball players, there has been an increased focus on efforts to reduce UCL injury in this population, including pitch count limits and scheduled time off from throwing for young athletes. When surgery is required, modern techniques utilizing a flexor–pronator splitting approach have provided consistent results, with return to sport rates of 90 % frequently reported, while avoiding ulnar nerve symptoms that plagued early reconstructions. Despite the increased incidence of UCL reconstruction, the rate of revision UCL reconstruction surgery has decreased, likely secondary to improved surgical techniques and rehabilitation protocols. In addition to providing a review of UCL reconstruction outcomes, we provide a description of the docking technique, the authors preferred method of UCL reconstruction.

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  1. Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA, 52242, USA

    Kyle R. Duchman MD, Robert W. Westermann MD & Brian R. Wolf MD, MS

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  1. Department of Orthopedics, University of Utah School of Medicine, Salt Lake City, Utah, USA

    Robert Z. Tashjian

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Ulnar Collateral Ligament Reconstruction using the Docking Technique. The medial epicondyle and sublime tubercle are identified through a flexor–pronator mass splitting approach. The ulnar nerve is identified during the approach and, in this case, mobilized anteriorly for later ulnar nerve transposition due to ulnar nerve subluxation. After preparing converging tunnels on the sublime tubercle, the graft is passed through the ulna. The free ends of the graft are prepared with a braided synthetic Krackow suture. The humeral tunnel is then prepared and two drill holes connected to the tunnel for suture and graft passage. With sutures passed through the humeral drill holes, the two ends of the graft are pulled into the humeral tunnel. It is important to make sure that the graft is of appropriate length so that the free limbs do not both bottom out in the humeral tunnel. While maintaining the elbow in varus, the two suture limbs are tied over a bone tunnel on the humeral side. The completed ulnar collateral ligament reconstruction is then visualized through the flexor–pronator mass split (MP4 31156 kb)

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Duchman, K.R., Westermann, R.W., Wolf, B.R. (2017). Operative Strategies for Ulnar Collateral Ligament Insufficiency. In: Tashjian, R. (eds) The Unstable Elbow. Springer, Cham. https://doi.org/10.1007/978-3-319-46019-2_12

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