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Modified Jobe Approach With Docking Technique for Ulnar Collateral Ligament Reconstruction
Technical Note
Modified Jobe Approach With Docking Technique for Ulnar Collateral Ligament Reconstruction Daniel J. Kaplan, B.A., Sergio A. Glait, M.D., William E. Ryan Jr., B.S., and Laith M. Jazrawi, M.D.
Abstract: The ulnar collateral ligament (UCL) of the elbow acts as the primary restraint to valgus force experienced in the late cocking and early acceleration phases of overhead throwing. If the UCL or dynamic flexor-pronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation. Before the first UCL reconstruction, performed by Frank Jobe in 1974, this injury was considered career ending in overhead athletes. Since the index procedure, further techniques have been developed to minimize dissection of the flexor-pronator mass and improve the biomechanical strength of graft fixation with the goal of increased return to athletic competition. We describe our techniquedincluding pearls and pitfalls, as well as advantages and disadvantagesdwhich combines the docking technique, through a flexor muscle-elevating approach with transposition of the ulnar nerve using a fascial sling. Harvest and preparation of a palmaris longus tendon autograft is also described.
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he ulnar collateral ligament (UCL) of the elbow acts as the primary restraint to valgus force experienced in the late cocking and early acceleration phases of overhead throwing.1 Chronic microtrauma during repetitive throwing can lead to attenuation of the UCL and eventual failure, resulting in pain, instability, and diminished function. If the UCL or dynamic flexorpronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation.2,3 Before the first UCL reconstruction, performed by Frank Jobe in 1974, this injury was considered career ending in overhead athletes. Since the index procedure, further techniques have been developed to minimize dissection of the flexor-pronator mass4,5 and improve the biomechanical strength of graft fixation6-8 with the goal of increased return to athletic competition.
From the Sports Medicine Division, Orthopaedic Department, New York University Langone Medical Center, New York, New York, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received March 21, 2016; accepted August 2, 2016. Address correspondence to Daniel J. Kaplan, B.A., NYU Hospital for Joint Diseases, 333 East 38th Street, 4th Floor, New York, NY 10016, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16240/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.002
Arthroscopy Techniques, Vol
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We describe our technique, which combines the docking technique, as described by Rohrbough et al.,9 through a flexor muscle-elevating approach, as detailed by Azar et al.,10 with transposition of the ulnar nerve using a fascial sling. We favor a docking technique because of the decreased risk of fracture of the medial epicondyle and increased load to failure strength it provides. In addition, a muscle-elevating approach anterior to the path of the ulnar nerve provides for minimal trauma to the soft tissue while being able to visualize and protect the ulnar nerve during the entire procedure.
Preoperative Setup We examine the patient preoperatively for the presence of a palmaris longus (PL) tendon, if using an autograft for the ligament reconstruction. If no tendon is present, a gracilis tendon graft can be used. The patient is placed supine on an operative table with the involved extremity on a hand table. A tourniquet is placed proximally on the arm before prepping the extremity. Draping of the extremity is done as per surgeon preference, but the entire arm should be available for access except for the most proximal aspect where the tourniquet is present. The UCL reconstruction tray (Arthrex, Naples, FL) is a helpful instrument tray available that has most of the tools needed to perform this procedure. In addition, a tendon stripper (Arthrex) is also needed to harvest the PL tendon at the
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fascia of the FCU muscle (Fig 2). Once the overlying fascia of the FCU muscle is incised, one can bluntly separate the muscle fibers overlying the ulnar nerve with the blunt end of a Senn retractor (Sklar, West Chester, PA). It is important to adequately release the distal fascia of the FCU to allow posterior retraction of the nerve to expose the underlying ulna.
Fig 1. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, it is seen how after preliminary exposure, release of the ulnar nerve is performed with care to protect it using a small vessel loop. The ulnar nerve is identified near the cubital tunnel proximal to the medial epicondyle, and is dissected proximally through the arcade of Struthers, releasing a part of the medial intermuscular septum. Dissection is carried distally as well, incising the cubital tunnel along the fascia of the flexor carpi ulnaris muscle.
wrist or hamstring at the knee if necessary. Before incision several folded sterile towels are placed under the elbow to allow easy posteromedial access to the elbow and dissection of the ulnar nerve and the sublime tubercle. We perform the procedure without a nerve block to examine ulnar nerve function postoperatively.
Surgical Approach Initial Exposure This technique can be seen in Video 1. The incision is based over the medial epicondyle extending proximally 3 to 4 cm along the medial condylar ridge of the humerus (distal third of the intermuscular septum). Distally, the incision is extended another 3 to 4 cm along the flexor carpi ulnaris (FCU) muscle belly overlying the sublime tubercle. Dissection is carried down to the muscular fascia overlying the medial side of the elbow (Fig 1). Care should be exercised to identify and protect the medial antebrachial cutaneous nerve, which often has a posterior branch crossing proximal to, or at the level of the medial epicondyle.11 Ulnar Nerve Decompression After initial exposure is done as described above, release of the ulnar nerve is performed with care to protect it using a wide penrose drain looped around the nerve. The ulnar nerve is identified near the cubital tunnel proximal to the medial epicondyle, and is dissected proximally through the arcade of Struthers, releasing a part of the medial intermuscular septum. Dissection is carried distally as well, incising the cubital tunnel and following the nerve to incise the overlying
Exposure of the Ulnar Insertion of the UCL Blunt dissection is performed down to bone, over the course of the ulnar nerve in the FCU muscle belly. With the nerve retracted posteriorly, this dissection directs the surgeon down onto the sublime tubercle. Sharp elevation of the anterior flexor muscle mass is then performed, proceeding proximally and anteriorly with care not to cut into the native UCL fibers. A Cobb elevator (Medline, Mundelein, IL) can be a useful tool to perform this task. A blunt Hohmann retractor (Arthrex) is safely placed over the anterior edge of the ulna, distal to the site of the native UCL fibers inserting onto the medial epicondyle. Care is taken not to detach the flexor-pronator mass at the medial epicondyle, but to elevate enough tissue to provide easy access for bone tunnel placement. Ulna Bone Tunnel The native UCL is incised in line with its fibers to identify the joint (Fig 3). The first bone tunnel is placed at the level of the sublime tubercle using a 3.5-mm drill bit (Arthrex) and the ulna 55 V-guide (Arthrex) (Fig 4). A V-shaped bone tunnel is made and care should be taken to ensure that this bone tunnel is at least 0.5 cm distal to the joint, with one tunnel anterior and another posterior to the sublime tubercle allowing for a 1- to 1.5-cm bone bridge. Intra-articular penetration of the bone tunnel is a risk at this stage of the
Fig 2. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, sharp elevation of the anterior flexor muscle mass is performed, proceeding proximally and anteriorly with care not to cut into the native ulnar collateral ligament (UCL) fibers. A blunt Hohmann retractor is safely placed over the anterior edge of the ulna, proximal to the site of the native UCL fibers inserting onto the medial epicondyle.
MODIFIED JOBE APPROACH FOR UCL RECONSTRUCTION
Fig 3. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, dissection to the joint can be seen. Care is taken not to detach the flexor-pronator mass at the medial epicondyle, but to elevate enough tissue to provide easy access for bone tunnel placement. The native ulnar collateral ligament is incised in line with its fibers and the joint is identified.
procedure. The ulnar nerve is retracted posteriorly while the tunnel is drilled, which is another structure at risk for injury. Angled curettes (Arthrex) are used to remove any bony debris allowing smooth passage of the tendon graft and a rasp (Smith & Nephew, London, UK) can be used to chamfer the edges of the tunnels to
Fig 4. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the first bone tunnel is placed at the level of the sublime tubercle using a 3.5-mm drill bit and instrumented guide. A V-shaped bone tunnel is made. The ulnar nerve is retracted posteriorly while the tunnel is drilled. The tunnel is positioned at least 0.5 cm away from the joint, with one tunnel anterior and another posterior to the sublime tubercle allowing for a 1- to 1.5-cm bone bridge.
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Fig 5. The patient is placed supine on an operative table with the involved extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the medial epicondyle tunnels (the docking tunnel) are drilled based on the isometry location. The anatomic insertion of the native ulnar collateral ligament (UCL) on the medial epicondyle is the location of the first drill tunnel. Using a 4.5-mm drill bit and soft tissue protector with a 15-mm stop, the entry tunnel into the medial epicondyle is drilled in a similar orientation to the inserting UCL fibers.
remove sharp bony edges that can affect the tendon graft. The orientation of the tunnel should be perpendicular to a line extending from the medial epicondyle insertion to the sublime tubercle. Lastly, a passing stitch is placed through the tunnel as per surgeon preference for later graft passage. This passing stitch can also be tensioned and placed against the UCL insertion on the medial epicondyle to check the isometric point with elbow range of motion. Medial Epicondyle Bone Tunnel Next, the medial epicondyle tunnels (the docking tunnel) are drilled based on the location of isometry previously described. The anatomic insertion of the native UCL on the medial epicondyle is the location of the first drill tunnel. Using a 4.5-mm drill bit (Arthrex) with a calculated 15-mm depth stop and the corresponding 4.5 15 mm humeral socket drill guide (Arthrex) the entry tunnel into the medial epicondyle is drilled in a similar orientation to the inserting UCL fibers (Fig 5). To orient the tunnel appropriately up the humeral shaft, the medial intermuscular septum can be used as a guide for the angle of the tunnel. A small curette is used to check for cortical breaching before proceeding with the docking technique. Next, 2 connecting tunnels are drilled using a 2-mm bit (Arthrex). These tunnels should be anterior and posterior to the main docking tunnel with at least a 1-cm bone bridge between them (Fig 6). Drilling can be performed either freehand, with a straight curette in the main tunnel for proprioceptive guidance, or using an adjustable humeral guide (Arthrex) that inserts into the 4.5-mm tunnel previously created simplifying the creation of the interconnecting 2-mm tunnels. It is important to mark the entry site of the 2-mm drill
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Fig 6. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, 2 connecting tunnels are drilled using a 2-mm bit. These tunnels should be posterior (A) and anterior (B) to the main docking tunnel with at least a 1-cm bone bridge between them.
(Arthrex) bit because the soft tissue can obscure the hole, making it difficult to insert a passing stitch. A passing stich is placed through each 2-mm tunnel and exit together through the 4.5-mm docking tunnel. This can be performed using the microlasso and skid present in the UCL suture passing kit (Arthrex) or can also be done as per surgeon preference.
Graft Preparation The authors’ choice for an autograft is to harvest the PL if available, with the ipsilateral gracilis tendon harvest. A 0.5-mm incision is made at the wrist crease and a small hemostat is used to lift the tendon out of the wound. A second incision is made 5 cm proximally, exposing the tendon. The PL is confirmed by pulling the tendon at the proximal incision, and visualizing movement along the distal portion of the tendon. The tendon is then cut distally and pulled out of the proximal incision. A third, small incision is made at the level of the mid-forearm to find the musculotendinous junction. The tendon is then pulled out of the proximal incision and amputated. The tendon is sized to fit a 3.5-mm tunnel. Another method to harvest the PL is to identify the tendon at the wrist crease and bluntly release any adhesions surrounding the tendon, and then transect it at the wrist crease and use a tendon stripper (Arthrex) to harvest. Care should be taken to aim the tendon stripper toward the medial epicondyle as you push it up the forearm.
on the tendon 12 to 13 mm from the tunnel. The tendon is whipstitched along this 12- to 13-mm portion of the graft with 2-0 FiberWire (Arthrex) and the remaining tendon is cut. The tendon is then passed into the docking tunnel using the posterior tunnel sutures. This step, when the tendon is cut slightly shorter, allows for the graft to enter the docking tunnel without prematurely bottoming out causing laxity in the construct. Finally, the docking sutures are tied over a bony bridge with the elbow in 30 of flexion with a varus load to ensure graft tightness. The knot is a potential area of postoperative irritation and should be sufficiently covered with surrounding soft tissue during the closure. In addition, the body of the graft can be sewn into the underlying UCL that was split in line with its fibers allowing better tendon to ligament healing and reinforcement.
Graft Passage The graft is first passed through the ulnar tunnel using a passing stitch, resulting in 2 limbs: an anterior and posterior limb. The posterior limb of the ulnar tunnel is then passed into the docking tunnel using the anterior passing stitch (Fig 7). The graft is pulled all the way into the docking tunnel until it bottoms out and the ligament is taught. While holding tension on the anterior graft of the docking tunnel, the other free limb of the graft (anterior limb of the ulnar tunnel) is held taught to the entry site of the docking tunnel. The tendon is marked at this spot. A second mark is placed
Fig 7. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the graft is first passed through the ulnar tunnel using a passing stitch, resulting in 2 limbs: an anterior and posterior limb. The posterior limb of the ulnar tunnel is then passed into the docking tunnel using the anterior passing stitch. The graft is pulled all the way into the docking tunnel until it bottoms out and the ligament is taught.
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MODIFIED JOBE APPROACH FOR UCL RECONSTRUCTION
postoperatively. Shoulder and elbow strengthening is progressed at the 6-week mark with the Throwers 10 program, which is graduated throughout the rehabilitation process. Athletes can expect a return to sport around 9 to 12 months after reconstruction.
Discussion
Fig 8. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the ulnar nerve is transposed anteriorly under a fascial sling of the flexor-pronator mass at the medial epicondyle. A large rectangular window is created and the nerve is placed anterior and under the fascial sling, which is loosely closed with absorbable suture.
Ulnar Nerve Transposition Before closure, the ulnar nerve is transposed anteriorly under a loose fascial sling of the flexor-pronator mass at the medial epicondyle. A rectangular fascial flap that is distally based is created and the nerve is transposed anteriorly under this fascial sling, which is loosely closed over the nerve preventing it from falling back posteriorly (Fig 8). This fascial sling is closed using an absorbable suture and it should not compress the nerve with elbow range of motion. Any other technique for anterior transposition of the ulnar nerve is appropriate as per surgeon preference. Pearls, pitfalls, and complications can be seen in Table 1.
Postoperative Care The arm is placed in a posterior well-padded splint, which is removed at the first postoperative visit (7-10 days). A hinged elbow brace is then applied allowing motion from 30 to 100 . Brace settings should be gradually increased to allow full motion by 5 weeks
UCL reconstruction has been shown to produce excellent outcomes with up to an 80% to 90% return to play, although rates vary among techniques.12 The most common complication is ulnar nerve neuropraxia, which can be seen in approximately 10% of cases. Different techniques have been described for the approach to the flexor-pronator mass, location of humeral tunnels, choice of graft fixation, and performance of an ulnar nerve transposition. Our preferred technique is a combination of a flexor muscle-elevating approach described by Azar et al.,10 with fixation through bone tunnels using a docking technique outlined by Rohrbough et al.9 In their original series, Azar et al.10 performed UCL reconstructions in 91 patients (37 professional) with an 81% rate of return to play and 1% rate of ulnar neuropraxia. Their approach involved dissection of the flexor-pronator mass at the distal insertion of the anterior bundle of the UCL with retraction anteriorly, but left the musculature on the medial epicondyle intact. In 2002, Rohrbough et al. described the docking technique, developed because of the concern over high rates of ulnar nerve neuropraxia and medial epicondyle fracture associated with the Jobe technique. In a recent systematic review comparing UCL reconstruction techniques, the docking technique resulted in a significantly higher rate of return to play (90.4% vs 66.7%) and a lower complication rate (6.0% vs 29.2%) when compared with the Jobe and modified Jobe techniques.12 In a biomechanical comparison of fixation methods, the docking technique had a significantly higher load to failure compared with Jobe and interference screw techniques13 (Table 2).
Table 1. Pearls, Pitfalls, and Complications Pearls
Pitfalls
Complications
Place folded sterile towels under the elbow allowing posteromedial access Release the distal fascia of the flexor carpi ulnaris allowing adequate posterior retraction of the ulnar nerve Position ulna tunnels at least 0.5 cm away from the joint Use a passing stich through the ulnar bone tunnel to check the isometric point Check for cortical breaching with a curette after drilling tunnels
Using a nerve block, which would prevent postoperative ulnar nerve examination Damage to the medial antebrachial cutaneous nerve during the initial approach Do not detach the flexor-pronator mass, just elevate Elbow joint penetration in drilling the ulna bone tunnel Difficulty in placing the passing stitch at the humeral bone tunnel because of not marking the site of the 2-mm drill bit entry
Ulnar nerve neuropraxia
Cut the tendon 12-13 mm from entry into the humeral tunnel to prevent prematurely bottoming out. This will affect graft tension if not done properly.
Elbow stiffness Ulnar tunnel fracture Hematoma Infection
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Table 2. Advantages and Disadvantages of the Docking Technique and Modified Jobe Approach Modified Jobe Approach with a Docking Technique
Advantages
Disadvantages
Approach
Muscle splitting less traumatic than muscle detachment
Fixation
Reduced complications, particularly related to the ulnar nerve Less tunnels drilled in the medial epicondyle Decreased risk of fixation failure and graft stretching Higher load to failure Higher rate of return to play
Our technique has advantages and disadvantages. Using a docking technique on the humeral side allows for strong fixation with a higher load to failure compared with other techniques as previously described.13 This hopefully allows for better graft viability in the long run. In addition, docking the graft into the humerus decreases the risk of fracture or penetration of the bone tunnels along the medial column of the humerus because the tunnels do not have to be large to pass the full graft as described in the original Jobe technique.9 We believe docking the graft versus sewing it to itself in a figure-8 fashion decreases the risk of fixation failure and stretching of the graft over time. In addition, dissecting between the FCU muscle distally in line with the ulnar nerve allows for visualization of the nerve during the entirety of the case and in our opinion leads to lower risk of nerve injury as opposed to other approaches to reach the sublime tubercle. Lastly, our approach does not use bone anchors, which helps decrease the cost of the overall procedure. There are also some disadvantages to our technique. Passing the graft through bone tunnels can be difficult and in our experience is sometimes the hardest part of the procedure. The risk of joint penetration is a real possibility at the site of the sublime tubercle, and this risk is probably decreased with other fixation methods such as using an interference screw to dock the tendon in a single ulnar tunnel. Lastly, because the ulnar nerve is constantly being retracted and handled during the case, care needs to be taken not to cause a neuropraxia by being aware of tension on the nerve at all times. Improvements in UCL reconstruction techniques have made successful return to preinjury level of competition more likely, resulting in greater indications for surgery. With the evolution of UCL reconstruction techniques, including minimal dissection of the flexorpronator mass, decreased handling of the ulnar nerve, and improved fixation strength, athletes undergoing UCL reconstruction can reliably expect a successful return to athletic competition with a low rate of complication within 9.8 to 26.4 months.14
Retraction and manipulation of the ulnar nerve throughout the case Passing the graft through the tunnels can be challenging Risk of the ulnar tunnel fracture
References 1. Gregory B, Nyland J. Medial elbow injury in young throwing athletes. Muscles Ligaments Tendons J 2013;3:91-100. 2. Dugas J. Valgus extension overload: Diagnosis and treatment. Clin Sports Med 2010;29:645-654. 3. Ahmad CS, ElAttrache NS. Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med 2004;23:665-676. 4. Smith G, Altchek D, Pagnani M, Keeley J. A musclesplitting approach to the ulnar collateral ligament of the elbow. Am J Sports Med 1996;24:575-580. 5. Andrews J, Timmerman L. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995;23: 407-413. 6. Ahmad CS, Lee T, ElAttrache NS. Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation. Am J Sports Med 2003;31:332-337. 7. Dodson CC, Thomas A, Dines JS, Nho S, Williams R, Altecheck D. Medial ulnar collateral ligament reconstruction of the elbow in throwing athletes. Am J Sports Med 2006;34:1926-1932. 8. Conway J. The DANE TJ procedure for elbow medial ulnar collateral ligament insufficiency. Tech Shoulder Elb Surg 2006;7:36-43. 9. Rohrbough J, Altchek D, Hyman J. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med 2002;30:541-548. 10. Azar F, Andrews J, Wilk K. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23. 11. Lowe J, Maggi S, Mackinnon S. The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans. Plast Reconstr Surg 2004;114:692-696. 12. Watson JN, McQueen P, Hutchinson MR. A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med 2014;42:2510-2516. 13. Armstrong A, Dunning C, Ferreiera L, Faber K, Johnson J, King G. A biomechanical comparison of four reconstruction techniques for the medial collateral ligament deficient elbow. J Shoulder Elb Surg 2005;14:207-215. 14. Vitale M, Ahmad C. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: A systematic review. Am J Sports Med 2008;36:1193-1205.
Modified Jobe Approach With Docking Technique for Ulnar Collateral Ligament Reconstruction Daniel J. Kaplan, B.A., Sergio A. Glait, M.D., William E. Ryan Jr., B.S., and Laith M. Jazrawi, M.D.
Abstract: The ulnar collateral ligament (UCL) of the elbow acts as the primary restraint to valgus force experienced in the late cocking and early acceleration phases of overhead throwing. If the UCL or dynamic flexor-pronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation. Before the first UCL reconstruction, performed by Frank Jobe in 1974, this injury was considered career ending in overhead athletes. Since the index procedure, further techniques have been developed to minimize dissection of the flexor-pronator mass and improve the biomechanical strength of graft fixation with the goal of increased return to athletic competition. We describe our techniquedincluding pearls and pitfalls, as well as advantages and disadvantagesdwhich combines the docking technique, through a flexor muscle-elevating approach with transposition of the ulnar nerve using a fascial sling. Harvest and preparation of a palmaris longus tendon autograft is also described.
T
he ulnar collateral ligament (UCL) of the elbow acts as the primary restraint to valgus force experienced in the late cocking and early acceleration phases of overhead throwing.1 Chronic microtrauma during repetitive throwing can lead to attenuation of the UCL and eventual failure, resulting in pain, instability, and diminished function. If the UCL or dynamic flexorpronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation.2,3 Before the first UCL reconstruction, performed by Frank Jobe in 1974, this injury was considered career ending in overhead athletes. Since the index procedure, further techniques have been developed to minimize dissection of the flexor-pronator mass4,5 and improve the biomechanical strength of graft fixation6-8 with the goal of increased return to athletic competition.
From the Sports Medicine Division, Orthopaedic Department, New York University Langone Medical Center, New York, New York, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received March 21, 2016; accepted August 2, 2016. Address correspondence to Daniel J. Kaplan, B.A., NYU Hospital for Joint Diseases, 333 East 38th Street, 4th Floor, New York, NY 10016, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16240/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.002
Arthroscopy Techniques, Vol
-,
We describe our technique, which combines the docking technique, as described by Rohrbough et al.,9 through a flexor muscle-elevating approach, as detailed by Azar et al.,10 with transposition of the ulnar nerve using a fascial sling. We favor a docking technique because of the decreased risk of fracture of the medial epicondyle and increased load to failure strength it provides. In addition, a muscle-elevating approach anterior to the path of the ulnar nerve provides for minimal trauma to the soft tissue while being able to visualize and protect the ulnar nerve during the entire procedure.
Preoperative Setup We examine the patient preoperatively for the presence of a palmaris longus (PL) tendon, if using an autograft for the ligament reconstruction. If no tendon is present, a gracilis tendon graft can be used. The patient is placed supine on an operative table with the involved extremity on a hand table. A tourniquet is placed proximally on the arm before prepping the extremity. Draping of the extremity is done as per surgeon preference, but the entire arm should be available for access except for the most proximal aspect where the tourniquet is present. The UCL reconstruction tray (Arthrex, Naples, FL) is a helpful instrument tray available that has most of the tools needed to perform this procedure. In addition, a tendon stripper (Arthrex) is also needed to harvest the PL tendon at the
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fascia of the FCU muscle (Fig 2). Once the overlying fascia of the FCU muscle is incised, one can bluntly separate the muscle fibers overlying the ulnar nerve with the blunt end of a Senn retractor (Sklar, West Chester, PA). It is important to adequately release the distal fascia of the FCU to allow posterior retraction of the nerve to expose the underlying ulna.
Fig 1. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, it is seen how after preliminary exposure, release of the ulnar nerve is performed with care to protect it using a small vessel loop. The ulnar nerve is identified near the cubital tunnel proximal to the medial epicondyle, and is dissected proximally through the arcade of Struthers, releasing a part of the medial intermuscular septum. Dissection is carried distally as well, incising the cubital tunnel along the fascia of the flexor carpi ulnaris muscle.
wrist or hamstring at the knee if necessary. Before incision several folded sterile towels are placed under the elbow to allow easy posteromedial access to the elbow and dissection of the ulnar nerve and the sublime tubercle. We perform the procedure without a nerve block to examine ulnar nerve function postoperatively.
Surgical Approach Initial Exposure This technique can be seen in Video 1. The incision is based over the medial epicondyle extending proximally 3 to 4 cm along the medial condylar ridge of the humerus (distal third of the intermuscular septum). Distally, the incision is extended another 3 to 4 cm along the flexor carpi ulnaris (FCU) muscle belly overlying the sublime tubercle. Dissection is carried down to the muscular fascia overlying the medial side of the elbow (Fig 1). Care should be exercised to identify and protect the medial antebrachial cutaneous nerve, which often has a posterior branch crossing proximal to, or at the level of the medial epicondyle.11 Ulnar Nerve Decompression After initial exposure is done as described above, release of the ulnar nerve is performed with care to protect it using a wide penrose drain looped around the nerve. The ulnar nerve is identified near the cubital tunnel proximal to the medial epicondyle, and is dissected proximally through the arcade of Struthers, releasing a part of the medial intermuscular septum. Dissection is carried distally as well, incising the cubital tunnel and following the nerve to incise the overlying
Exposure of the Ulnar Insertion of the UCL Blunt dissection is performed down to bone, over the course of the ulnar nerve in the FCU muscle belly. With the nerve retracted posteriorly, this dissection directs the surgeon down onto the sublime tubercle. Sharp elevation of the anterior flexor muscle mass is then performed, proceeding proximally and anteriorly with care not to cut into the native UCL fibers. A Cobb elevator (Medline, Mundelein, IL) can be a useful tool to perform this task. A blunt Hohmann retractor (Arthrex) is safely placed over the anterior edge of the ulna, distal to the site of the native UCL fibers inserting onto the medial epicondyle. Care is taken not to detach the flexor-pronator mass at the medial epicondyle, but to elevate enough tissue to provide easy access for bone tunnel placement. Ulna Bone Tunnel The native UCL is incised in line with its fibers to identify the joint (Fig 3). The first bone tunnel is placed at the level of the sublime tubercle using a 3.5-mm drill bit (Arthrex) and the ulna 55 V-guide (Arthrex) (Fig 4). A V-shaped bone tunnel is made and care should be taken to ensure that this bone tunnel is at least 0.5 cm distal to the joint, with one tunnel anterior and another posterior to the sublime tubercle allowing for a 1- to 1.5-cm bone bridge. Intra-articular penetration of the bone tunnel is a risk at this stage of the
Fig 2. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, sharp elevation of the anterior flexor muscle mass is performed, proceeding proximally and anteriorly with care not to cut into the native ulnar collateral ligament (UCL) fibers. A blunt Hohmann retractor is safely placed over the anterior edge of the ulna, proximal to the site of the native UCL fibers inserting onto the medial epicondyle.
MODIFIED JOBE APPROACH FOR UCL RECONSTRUCTION
Fig 3. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, dissection to the joint can be seen. Care is taken not to detach the flexor-pronator mass at the medial epicondyle, but to elevate enough tissue to provide easy access for bone tunnel placement. The native ulnar collateral ligament is incised in line with its fibers and the joint is identified.
procedure. The ulnar nerve is retracted posteriorly while the tunnel is drilled, which is another structure at risk for injury. Angled curettes (Arthrex) are used to remove any bony debris allowing smooth passage of the tendon graft and a rasp (Smith & Nephew, London, UK) can be used to chamfer the edges of the tunnels to
Fig 4. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the first bone tunnel is placed at the level of the sublime tubercle using a 3.5-mm drill bit and instrumented guide. A V-shaped bone tunnel is made. The ulnar nerve is retracted posteriorly while the tunnel is drilled. The tunnel is positioned at least 0.5 cm away from the joint, with one tunnel anterior and another posterior to the sublime tubercle allowing for a 1- to 1.5-cm bone bridge.
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Fig 5. The patient is placed supine on an operative table with the involved extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the medial epicondyle tunnels (the docking tunnel) are drilled based on the isometry location. The anatomic insertion of the native ulnar collateral ligament (UCL) on the medial epicondyle is the location of the first drill tunnel. Using a 4.5-mm drill bit and soft tissue protector with a 15-mm stop, the entry tunnel into the medial epicondyle is drilled in a similar orientation to the inserting UCL fibers.
remove sharp bony edges that can affect the tendon graft. The orientation of the tunnel should be perpendicular to a line extending from the medial epicondyle insertion to the sublime tubercle. Lastly, a passing stitch is placed through the tunnel as per surgeon preference for later graft passage. This passing stitch can also be tensioned and placed against the UCL insertion on the medial epicondyle to check the isometric point with elbow range of motion. Medial Epicondyle Bone Tunnel Next, the medial epicondyle tunnels (the docking tunnel) are drilled based on the location of isometry previously described. The anatomic insertion of the native UCL on the medial epicondyle is the location of the first drill tunnel. Using a 4.5-mm drill bit (Arthrex) with a calculated 15-mm depth stop and the corresponding 4.5 15 mm humeral socket drill guide (Arthrex) the entry tunnel into the medial epicondyle is drilled in a similar orientation to the inserting UCL fibers (Fig 5). To orient the tunnel appropriately up the humeral shaft, the medial intermuscular septum can be used as a guide for the angle of the tunnel. A small curette is used to check for cortical breaching before proceeding with the docking technique. Next, 2 connecting tunnels are drilled using a 2-mm bit (Arthrex). These tunnels should be anterior and posterior to the main docking tunnel with at least a 1-cm bone bridge between them (Fig 6). Drilling can be performed either freehand, with a straight curette in the main tunnel for proprioceptive guidance, or using an adjustable humeral guide (Arthrex) that inserts into the 4.5-mm tunnel previously created simplifying the creation of the interconnecting 2-mm tunnels. It is important to mark the entry site of the 2-mm drill
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Fig 6. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, 2 connecting tunnels are drilled using a 2-mm bit. These tunnels should be posterior (A) and anterior (B) to the main docking tunnel with at least a 1-cm bone bridge between them.
(Arthrex) bit because the soft tissue can obscure the hole, making it difficult to insert a passing stitch. A passing stich is placed through each 2-mm tunnel and exit together through the 4.5-mm docking tunnel. This can be performed using the microlasso and skid present in the UCL suture passing kit (Arthrex) or can also be done as per surgeon preference.
Graft Preparation The authors’ choice for an autograft is to harvest the PL if available, with the ipsilateral gracilis tendon harvest. A 0.5-mm incision is made at the wrist crease and a small hemostat is used to lift the tendon out of the wound. A second incision is made 5 cm proximally, exposing the tendon. The PL is confirmed by pulling the tendon at the proximal incision, and visualizing movement along the distal portion of the tendon. The tendon is then cut distally and pulled out of the proximal incision. A third, small incision is made at the level of the mid-forearm to find the musculotendinous junction. The tendon is then pulled out of the proximal incision and amputated. The tendon is sized to fit a 3.5-mm tunnel. Another method to harvest the PL is to identify the tendon at the wrist crease and bluntly release any adhesions surrounding the tendon, and then transect it at the wrist crease and use a tendon stripper (Arthrex) to harvest. Care should be taken to aim the tendon stripper toward the medial epicondyle as you push it up the forearm.
on the tendon 12 to 13 mm from the tunnel. The tendon is whipstitched along this 12- to 13-mm portion of the graft with 2-0 FiberWire (Arthrex) and the remaining tendon is cut. The tendon is then passed into the docking tunnel using the posterior tunnel sutures. This step, when the tendon is cut slightly shorter, allows for the graft to enter the docking tunnel without prematurely bottoming out causing laxity in the construct. Finally, the docking sutures are tied over a bony bridge with the elbow in 30 of flexion with a varus load to ensure graft tightness. The knot is a potential area of postoperative irritation and should be sufficiently covered with surrounding soft tissue during the closure. In addition, the body of the graft can be sewn into the underlying UCL that was split in line with its fibers allowing better tendon to ligament healing and reinforcement.
Graft Passage The graft is first passed through the ulnar tunnel using a passing stitch, resulting in 2 limbs: an anterior and posterior limb. The posterior limb of the ulnar tunnel is then passed into the docking tunnel using the anterior passing stitch (Fig 7). The graft is pulled all the way into the docking tunnel until it bottoms out and the ligament is taught. While holding tension on the anterior graft of the docking tunnel, the other free limb of the graft (anterior limb of the ulnar tunnel) is held taught to the entry site of the docking tunnel. The tendon is marked at this spot. A second mark is placed
Fig 7. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the graft is first passed through the ulnar tunnel using a passing stitch, resulting in 2 limbs: an anterior and posterior limb. The posterior limb of the ulnar tunnel is then passed into the docking tunnel using the anterior passing stitch. The graft is pulled all the way into the docking tunnel until it bottoms out and the ligament is taught.
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MODIFIED JOBE APPROACH FOR UCL RECONSTRUCTION
postoperatively. Shoulder and elbow strengthening is progressed at the 6-week mark with the Throwers 10 program, which is graduated throughout the rehabilitation process. Athletes can expect a return to sport around 9 to 12 months after reconstruction.
Discussion
Fig 8. The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the ulnar nerve is transposed anteriorly under a fascial sling of the flexor-pronator mass at the medial epicondyle. A large rectangular window is created and the nerve is placed anterior and under the fascial sling, which is loosely closed with absorbable suture.
Ulnar Nerve Transposition Before closure, the ulnar nerve is transposed anteriorly under a loose fascial sling of the flexor-pronator mass at the medial epicondyle. A rectangular fascial flap that is distally based is created and the nerve is transposed anteriorly under this fascial sling, which is loosely closed over the nerve preventing it from falling back posteriorly (Fig 8). This fascial sling is closed using an absorbable suture and it should not compress the nerve with elbow range of motion. Any other technique for anterior transposition of the ulnar nerve is appropriate as per surgeon preference. Pearls, pitfalls, and complications can be seen in Table 1.
Postoperative Care The arm is placed in a posterior well-padded splint, which is removed at the first postoperative visit (7-10 days). A hinged elbow brace is then applied allowing motion from 30 to 100 . Brace settings should be gradually increased to allow full motion by 5 weeks
UCL reconstruction has been shown to produce excellent outcomes with up to an 80% to 90% return to play, although rates vary among techniques.12 The most common complication is ulnar nerve neuropraxia, which can be seen in approximately 10% of cases. Different techniques have been described for the approach to the flexor-pronator mass, location of humeral tunnels, choice of graft fixation, and performance of an ulnar nerve transposition. Our preferred technique is a combination of a flexor muscle-elevating approach described by Azar et al.,10 with fixation through bone tunnels using a docking technique outlined by Rohrbough et al.9 In their original series, Azar et al.10 performed UCL reconstructions in 91 patients (37 professional) with an 81% rate of return to play and 1% rate of ulnar neuropraxia. Their approach involved dissection of the flexor-pronator mass at the distal insertion of the anterior bundle of the UCL with retraction anteriorly, but left the musculature on the medial epicondyle intact. In 2002, Rohrbough et al. described the docking technique, developed because of the concern over high rates of ulnar nerve neuropraxia and medial epicondyle fracture associated with the Jobe technique. In a recent systematic review comparing UCL reconstruction techniques, the docking technique resulted in a significantly higher rate of return to play (90.4% vs 66.7%) and a lower complication rate (6.0% vs 29.2%) when compared with the Jobe and modified Jobe techniques.12 In a biomechanical comparison of fixation methods, the docking technique had a significantly higher load to failure compared with Jobe and interference screw techniques13 (Table 2).
Table 1. Pearls, Pitfalls, and Complications Pearls
Pitfalls
Complications
Place folded sterile towels under the elbow allowing posteromedial access Release the distal fascia of the flexor carpi ulnaris allowing adequate posterior retraction of the ulnar nerve Position ulna tunnels at least 0.5 cm away from the joint Use a passing stich through the ulnar bone tunnel to check the isometric point Check for cortical breaching with a curette after drilling tunnels
Using a nerve block, which would prevent postoperative ulnar nerve examination Damage to the medial antebrachial cutaneous nerve during the initial approach Do not detach the flexor-pronator mass, just elevate Elbow joint penetration in drilling the ulna bone tunnel Difficulty in placing the passing stitch at the humeral bone tunnel because of not marking the site of the 2-mm drill bit entry
Ulnar nerve neuropraxia
Cut the tendon 12-13 mm from entry into the humeral tunnel to prevent prematurely bottoming out. This will affect graft tension if not done properly.
Elbow stiffness Ulnar tunnel fracture Hematoma Infection
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Table 2. Advantages and Disadvantages of the Docking Technique and Modified Jobe Approach Modified Jobe Approach with a Docking Technique
Advantages
Disadvantages
Approach
Muscle splitting less traumatic than muscle detachment
Fixation
Reduced complications, particularly related to the ulnar nerve Less tunnels drilled in the medial epicondyle Decreased risk of fixation failure and graft stretching Higher load to failure Higher rate of return to play
Our technique has advantages and disadvantages. Using a docking technique on the humeral side allows for strong fixation with a higher load to failure compared with other techniques as previously described.13 This hopefully allows for better graft viability in the long run. In addition, docking the graft into the humerus decreases the risk of fracture or penetration of the bone tunnels along the medial column of the humerus because the tunnels do not have to be large to pass the full graft as described in the original Jobe technique.9 We believe docking the graft versus sewing it to itself in a figure-8 fashion decreases the risk of fixation failure and stretching of the graft over time. In addition, dissecting between the FCU muscle distally in line with the ulnar nerve allows for visualization of the nerve during the entirety of the case and in our opinion leads to lower risk of nerve injury as opposed to other approaches to reach the sublime tubercle. Lastly, our approach does not use bone anchors, which helps decrease the cost of the overall procedure. There are also some disadvantages to our technique. Passing the graft through bone tunnels can be difficult and in our experience is sometimes the hardest part of the procedure. The risk of joint penetration is a real possibility at the site of the sublime tubercle, and this risk is probably decreased with other fixation methods such as using an interference screw to dock the tendon in a single ulnar tunnel. Lastly, because the ulnar nerve is constantly being retracted and handled during the case, care needs to be taken not to cause a neuropraxia by being aware of tension on the nerve at all times. Improvements in UCL reconstruction techniques have made successful return to preinjury level of competition more likely, resulting in greater indications for surgery. With the evolution of UCL reconstruction techniques, including minimal dissection of the flexorpronator mass, decreased handling of the ulnar nerve, and improved fixation strength, athletes undergoing UCL reconstruction can reliably expect a successful return to athletic competition with a low rate of complication within 9.8 to 26.4 months.14
Retraction and manipulation of the ulnar nerve throughout the case Passing the graft through the tunnels can be challenging Risk of the ulnar tunnel fracture
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