Ulnar Collateral Ligament Reconstruction Techniques Research Articles

Tommy John Ligament Repair with Ulnar Collateral Ligament Internal Brace

Ulnar collateral ligament (UCL) injuries commonly occur in overhead athletes as a result of excess valgus stress on the elbow and can be functionally debilitating, requiring surgical intervention. Since the advent of the first initial UCL reconstruction technique pioneered by Dr. Frank Jobe performed on professional baseball player Tommy John, UCL, or Tommy John Ligament reconstruction has successfully returned athletes to sport following injury and shown enhanced clinical outcomes with minimal complication rates. Tommy John surgery continues to evolve with the development of various techniques over recent years. This technical note describes a UCL repair with an internal brace using knotless suture anchors and aims to contribute to the current literature a technique that is efficacious and reproducible and offers satisfactory stability, functionality, and return to play.

Ulnar collateral ligament reconstruction techniques in elbow instability: Jobe versus Docking technique. A systematic review

Ulnar collateral ligament reconstruction techniques in elbow instability: Jobe versus Docking technique. A systematic review

Ulnar Collateral Ligament Reconstruction with Hamstring Autograft

Background: Ulnar collateral ligament (UCL) reconstructions have become increasingly common, particularly in youth overhead throwing athletes. These injuries are most commonly due to overuse and repetitive trauma on the inner elbow. Throwers with a deficient UCL often report decreased pitching speeds in addition to elbow pain and instability. Indication: The indications for this procedure include symptomatic valgus elbow instability during overhead throwing motions and a verified rupture of the UCL on advanced imaging. Technique Description: The ipsilateral gracilis tendon is harvested and prepared as an autograft. A 5-cm incision is then made centered over the medial epicondyle. The ulnar nerve is identified and neurolysis is performed both proximally and distally. The fascia overlying the flexor carpi ulnaris is incised, and the two heads of the muscle are split. From this base, the sublime tubercle is identified, and the UCL is opened longitudinally in line with its fibers. A standard guide is used to drill holes in the posterior and anterior aspects of the sublime tubercle. These holes are then connected using a curved curette, and a suture is passed along the tunnels for later graft passage. A 15-mm blind-end tunnel is drilled two-thirds from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with K-wires to pass sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is then passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is then undertaken so that both ends are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the two limbs of the graft are sutured together to appropriately tension the graft. Results: In our experience, 94% of athletes return to previous levels of play and experience high patient-reported outcome scores. Discussion/Conclusion: Advancements in UCL reconstruction techniques and our understanding of elbow anatomy should prompt surgeons to continue considering this treatment for patients with significant throwing pain and a strong desire to return to high levels of throwing. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Similar Biomechanics Between the Double-Cortical Button and Docking Techniques for Ulnar Collateral Ligament Reconstruction: A Cadaveric Evaluation.

The docking technique is widely used to perform ulnar collateral ligament (UCL) reconstructions because of its high failure torque and reliable clinical outcomes. A double-cortical button technique was recently described, with advantages including the ability to tension the graft at the ulnar and humeral attachments and the creation of single bone tunnels. To compare the biomechanics between the docking and double-button UCL reconstruction techniques using cadaveric specimens. We hypothesized that there would be no difference in postoperative stiffness or maximum strength between the techniques. Controlled laboratory study. Eight matched pairs of cadaveric elbow joints underwent controlled humeral valgus torsion cycles in a test frame. Toe region stiffness, elastic region stiffness, and maximum torque were measured during a 4-step protocol: intact, injured, reconstructed (10 and 1000 cycles), and ramp to failure. Graft strains were calculated using 3-dimensional motion capture. After 10 cycles, intact ligaments from the docking and double-button groupsexhibited mean ± SD elastic torsional stiffness of 1.60 ± 0.49 and 1.64 ± 0.35 N·m/deg (P = .827), while docking (1.10 ± 0.39 N·m/deg) and double-button (1.05 ± 0.29 N·m/deg) reconstructions were lower (P = .754). There were no significant differences in maximum torque between the docking (3.45 ± 1.35 N·m) and double-button (3.25 ± 1.31 N·m) groups (P = .777). Similarly, differences in maximum graft strains were not significant between the docking (8.1% ± 7.2%) and double-button (5.5% ± 3.1%) groups (P = .645). The groups demonstrated similar decreases in these measures after cyclic loading. Ramp-to-failure testing showed no significant differences in ultimate torque between the docking (8.93 ± 3.9 N·m) and double-button (9.56 ± 3.5 N·m) groups (P = .739). The biomechanical behavior of the double-button technique was not significantly different from that of the docking technique. Both reconstruction techniques restored joint stability, but neither fully recapitulated preinjury joint stiffness. With its procedural advantages, results preliminarily support the use of the double-button reconstruction technique for UCL reconstruction as a reliable single-tunnel technique for primary or revision cases.

Biomechanical comparison of ulnar collateral ligament reconstruction with single-tunnel proximal suspensory fixation versus modified docking technique

Despite technical advancement, elbow ulnar collateral ligament (UCL) reconstruction is a challenging procedure due to the limitations regarding the challenging tunnel placement and potential injury to the ulnar nerve. Furthermore, current techniques for reconstruction and repair are inferior functionally and biomechanically when compared to native UCL tissue. A modified docking technique using a single-tunnel proximal suspensory fixation may reduce complications and potentially provide a technique for UCL reconstruction that is biomechanically superior. Decreasing the number of bone tunnels decreases the number of places that bone tear through could occur. The purpose was to evaluate and compare the biomechanical performances for 2 elbow UCL reconstruction techniques: (1) standard docking technique (SD) and (2) a proximal single tunnel (PST) technique using a suspensory fixation. We hypothesized that the PST technique would be biomechanically superior to the SD technique. Twelve matched pairs of cadaveric elbows were dissected and fixed at 70 degrees for biomechanical testing. Gracilis grafts were used for a docking reconstruction and the modified reconstruction with a PST suspensory fixation. A cyclic valgus torque protocol was used to precondition specimens for either reconstruction technique and the ulnohumeral gapping was then assessed. Following gapping measurements, postsurgical specimens underwent a valgus rotation applied at a rate of 5°/s until the anterior band of the UCL failed or fracture occurred. Ultimate load to failure, stiffness, and mode of failure were recorded. There were no statistical differences between the two groups. Mean rotational stiffness of the SD (2.3±0.6 Nm/deg) compared to the PST (1.9±0.7 Nm/deg) (P=.41) and mean ultimate failure torque of the SD (30.5±9.2 Nm) compared to the PST (30.9±8.6 Nm) (P=.86) were similar. There was also no statistically significant difference (P=.83) when comparing the native UCL ulnohumeral gapping (6.0±2.0 mm) to the mean ulnohumeral gapping of the SD reconstruction (6.0±1.8 mm). This study compares the biomechanical strength of elbow UCL reconstructions performed using the SP technique to that of a PST technique. Among all tested parameters, including ultimate failure torque, stiffness, and ulnohumeral gapping, there were no statistically significant differences between the 2 techniques.

Biomechanical comparison of two InternalBrace™ reinforced thumb ulnar collateral ligament reconstruction techniques.

Chronic ulnar collateral ligament ruptures of the thumb metacarpophalangeal joint are often not eligible for direct surgical repair and ligament reconstruction could be considered. Several reconstruction techniques are published, with different types of configurations and fixation methods of the tendon grafts. However, failure of the reconstruction with recurrent instability is still a problem, despite stable graft to bone fixation. Augmentation of the free tendon graft with non-resorbable suture material is gaining popularity, aiming to withstand elongation or rupture of the graft. The purpose of this study was to compare two different augmented ulnar collateral ligament reconstruction methods in a cadaver model. Ten matched pairs of cadaveric upper extremities were used. The thumbs were disarticulated at the trapezometacarpal joint and the ulnar collateral ligament was excised then reconstructed with InternalBrace™ reinforced tendon graft, which was fixed to the bones using either a Tenodesis screw or DX Swivelock® anchor. The thumbs were biomechanically tested with valgus stress, while the force and displacement were simultaneously measured and plotted. The mean (SD) load at clinical failure and maximum load were 19.4 (5.3) and 31.4 (9.5) N in the Tenodesis group, and 21.0 (10.0) and 31.4 (13.9) N in the DX SwiveLock® group, respectively. None of these differences were significant. These results are comparable with previous publications. The Tenodesis screw and the DX SwiveLock® thumb ulnar collateral ligament reconstruction with InternalBrace™ reinforced free tendon graft showed equal strength, both methods are feasible alternatives in the clinical setting.

Paper 12: Biomechanical Comparison of Anatomic Restoration of the Ulnar Footprint Versus Traditional Ulnar Tunnels in Ulnar Collateral Ligament Reconstruction

Objectives:Current techniques for ulnar collateral ligament (UCL) do not reproduce the anatomic ulnar footprint of the UCL. The purpose of this study was to describe a novel UCL reconstruction technique that utilizes proximal-to-distal ulnar bone tunnels to better recreate the anatomy of the UCL and compare the biomechanical profile at time zero between this technique, the native UCL, and the traditional docking technique. Our hypothesis was that the biomechanical profile of the anatomic technique is similar to the native UCL and traditional docking technique.Methods:Ten matched cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and bones were sectioned 14 cm proximal and distal to the elbow joint. Specimen testing included: (1) native UCL testing performed at 90° flexion with 0.5 Nm valgus moment preload, (2) cyclic loading from 0.5-to-5 Nm valgus moment for 1000 cycles at 1 Hz, and (3) load to failure at 0.2 mm/s. Elbows then underwent UCL reconstruction with one elbow of each pair receiving the classic docking technique using either anatomic (proximal-to-distal) or traditional (anterior-to-posterior) tunnel locations. Specimen testing was then repeated, as described above.Results:There was no difference between maximum load at failure or valgus angle between the anatomic or traditional tunnel location techniques (34.90 ± 10.65 Nm vs. 37.28 ± 14.26 Nm, P = 0.644) or the native UCL (45.83 ± 17.03 Nm, P = 0.099). Additionally, there was no difference in valgus angle after 1000 cycles across the anatomic (4.58 ± 1.47°), traditional (4.08 ± 1.28°), or native UCL (4.07 ± 1.99°). Anatomic group and the native UCL had similar valgus angles at failure (24.13 ± 5.86° vs. 20.13 ± 5.70°, P = 0.083), while the traditional group had a higher valgus angle at failure compared to the native UCL (24.88 ± 6.18° vs. 19.44 ± 5.86°, P = 0.015).Conclusions:UCL reconstruction with the docking technique utilizing proximal-to-distal ulnar tunnels to restore the anatomic ulnar footprint better recreates the anatomy of the UCL while providing valgus stability comparable to reconstruction with docking technique using traditional anterior-to-posterior ulnar tunnel locations. These results suggest that utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties compared to the traditional method at the time of initial fixation (i.e., not accounting for healing following reconstruction in vivo) while keeping the ulnar tunnels further from the ulnar nerve. Further studies are warranted to determine if an anatomically based UCL reconstruction results in differing outcomes compared to traditional reconstruction techniques.

Biomechanical Comparison of Anatomic Restoration of the Ulnar Footprint vs Traditional Ulnar Tunnels in Ulnar Collateral Ligament Reconstruction

Background: Current techniques for ulnar collateral ligament (UCL) reconstruction do not reproduce the anatomic ulnar footprint of the UCL. The purpose of this study was to describe a novel UCL reconstruction technique that utilizes proximal-to-distal ulnar bone tunnels to better re-create the anatomy of the UCL and to compare the biomechanical profile at time zero among this technique, the native UCL, and the traditional docking technique. Hypothesis: The biomechanical profile of the anatomic technique is similar to the native UCL and traditional docking technique. Study Design: Controlled laboratory study. Methods: Ten matched cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and bones were sectioned 14 cm proximal and distal to the elbow joint. Specimen testing included (1) native UCL testing performed at 90° of flexion with 0.5 N·m of valgus moment preload, (2) cyclic loading from 0.5 to 5 N·m of valgus moment for 1000 cycles at 1 Hz, and (3) load to failure at 0.2 mm/s. Elbows then underwent UCL reconstruction with 1 elbow of each pair receiving the classic docking technique using either anatomic (proximal to distal) or traditional (anterior to posterior) tunnel locations. Specimen testing was then repeated as described. Results: There were no differences in maximum load at failure between the anatomic and traditional tunnel location techniques (mean ± SD, 34.90 ± 10.65 vs 37.28 ± 14.26 N·m; P = .644) or when including the native UCL (45.83 ± 17.03 N·m; P = .099). Additionally, there were no differences in valgus angle after 1000 cycles across the anatomic technique (4.58°± 1.47°), traditional technique (4.08°± 1.28°), and native UCL (4.07°± 1.99°). The anatomic group and the native UCL had similar valgus angles at failure (24.13°± 5.86° vs 20.13°± 5.70°; P = .083), while the traditional group had a higher valgus angle at failure when compared with the native UCL (24.88°± 6.18° vs 19.44°± 5.86°; P = .015). Conclusion: In this cadaveric model, UCL reconstruction with the docking technique utilizing proximal-to-distal ulnar tunnels better restored the ulnar footprint while providing valgus stability comparable with reconstruction with the docking technique using traditional anterior-to-posterior ulnar tunnel locations. These results suggest that utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties to the traditional method at the time of initial fixation (ie, not accounting for healing after reconstruction in vivo) while keeping the ulnar tunnels farther from the ulnar nerve. Further studies are warranted to determine if an anatomically based UCL reconstruction results in differing outcomes than traditional reconstruction techniques. Clinical Relevance: Current UCL reconstruction techniques do not accurately re-create the ulnar UCL footprint. The UCL is a dynamic constraint to valgus loads at the elbow, and a more anatomic reconstruction may afford more natural joint kinematics. This more anatomic technique performs similarly to the traditional docking technique at time zero, and the results of this study may offer a starting point for future in vivo studies.

Utilization of Internal Bracing in Elbow Medial UCL Stabilization: From Biomechanics to Clinical Application and Patient Outcomes.

Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.

Ulnar Collateral Ligament Reconstruction With the Modified Jobe Technique in Baseball Pitchers.

Background:Tearing and insufficiency of the ulnar collateral ligament (UCL) of the elbow result in valgus instability, which can lead to pain while throwing and decline in performance in overhead athletes.Purpose:To assess the clinical results of a modified UCL reconstruction technique using 1 bone hole in the ulna and 1 bone tunnel in the humerus in baseball players.Study Design:Case series; Level of evidence, 4.Methods:The inclusion criteria were medial elbow pain preventing effective playing, clinically medial elbow laxity, and magnetic resonance imaging results consistent with UCL injury. Patients who were engaged in other sports and in other positions in baseball except pitchers were excluded from this study. Our modified Tommy John procedure was performed via a muscle-splitting approach and an original single-bone-tunnel technique, using a suture anchor. After a minimum of 24 months, patients were evaluated using the Conway scale and the Timmerman-Andrews score.Results:Of 31 patients, 20 baseball pitchers (20 male: 5 high school, 5 collegiate, 8 nonprofessional, and 2 professional pitchers) were reviewed. The mean patient age at the time of operation was 21.9 years, and the mean postoperative follow-up period was 35.1 months (range, 24-66 months). The mean Timmerman-Andrews subjective score improved significantly from pre- to postoperatively (from 68.3 to 98.3; P < .05); the objective score also improved significantly (from 81.1 to 96.4; P = .01). No complications were detected at the latest follow-up. Overall, 19 patients were able to return to their preinjury level of sports or higher.Conclusion:UCL reconstruction with 1 bone hole in the ulna and 1 bone tunnel in the humerus demonstrated satisfactory results in baseball pitchers. Our modified technique was safe and achieved satisfactory clinical results, with a 95% rate of return to sports.

Modified Jobe Versus Docking Technique for Elbow Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis of Clinical Outcomes

Background: The modified Jobe and docking techniques are the most common techniques used for elbow ulnar collateral ligament (UCL) reconstruction. Previous systematic reviews have suggested that the docking technique results in superior outcomes as compared with the Jobe (figure-of-8) technique. However, these included results from earlier studies in which the flexor-pronator mass (FPM) was detached and an obligatory submuscular ulnar nerve transposition was performed. Purpose/Hypothesis: The purpose was to compare the outcomes and return-to-play (RTP) time between the docking and figure-of-8 techniques for UCL reconstruction. We hypothesized that there would be no significant difference in the proportion of excellent outcomes between techniques when the FPM was preserved and no obligatory submuscular ulnar nerve transposition was performed. We also hypothesized that there would be no significant difference in RTP time between techniques. Study Design: Systematic review and meta-analysis. Methods: This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In the primary analysis, techniques were compared in random effects models by using the restricted maximum likelihood method, with weighted effect sizes calculated as the Freeman-Tukey double-arcsine transformed proportion of excellent outcomes for variance stabilization and with summary effects estimated from the inverse double-arcsine transformation per the harmonic mean of the sample sizes. Mean RTP times for techniques were compared in a separate model. Results: There were 21 eligible articles identified, with results for 1842 UCL reconstructions (n = 320, docking; n = 1466, figure-of-8). Without controlling for the effects of flexor-pronator detachment and submuscular ulnar nerve transposition, a significantly larger proportion of excellent outcomes was observed with docking reconstruction (86.58%; 95% CI, 80.42%-91.85%) than with figure-of-8 reconstruction (76.76%; 95% CI, 69.65%-83.25%; P = .031); however, there was no significant difference between techniques when controlling for FPM preservation or detachment with submuscular nerve transposition (P = .139). There was no significant difference between techniques in time to return to sports (P = .729), although no reconstructions with FPM detachment and submuscular ulnar nerve transposition were available for RTP time analysis. Conclusion: There was no significant difference in the proportion of excellent Conway Scale outcomes or RTP time between the docking and modified Jobe techniques for UCL reconstruction when the FPM was preserved and routine submuscular ulnar nerve transposition was not performed.

The Role of Biologic Agents in the Non-operative Management of Elbow Ulnar Collateral Ligament Injuries.

Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells. Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.

State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes.

There has been a marked increase in the number of ulnar collateral ligament reconstructions performed annually and an associated increase in the amount of recent literature published. It is paramount that surgeons remain up to date on the current literature, as modern indications and surgical techniques continue to improve clinical outcomes. Our understanding of ulnar collateral ligament (UCL) injuries, treatment indications, and surgical techniques for UCL reconstruction continues to evolve. Despite the rapidly increasing amount of published literature on the topic, a clear and concise surgical algorithm is lacking. Studies have suggested a trend towards improved clinical outcomes and decreased complications with various modifications in UCL reconstruction techniques. Current sport-specific outcome studies have reported conflicting results regarding the effect of UCL reconstruction on an athlete's performance upon returning to sport. With the rising incidence of UCL reconstruction and growing media attention, UCL injuries, reconstruction techniques, and return to sport following UCL surgery are timely topics of interest to clinicians and overhead throwing athletes. Several technique modifications have been reported, and these modifications may lead to improved outcomes and lower complication rates. Studies assessing sport-specific outcome measures will be necessary to provide a more critical and informative analysis of outcomes following UCL reconstruction.

Comparison of Ulnar Collateral Ligament Reconstruction Techniques in the Elbow of Sports Players

Ulnar collateral ligament injuries have been increasingly common in overhead throwing athletes. Ulnar collateral ligament reconstruction is the current gold standard for managing ulnar collateral ligament insufficiency, and numerous reconstruction techniques have been described. Although good clinical outcomes have been reported regarding return to sports, there are still several technical issues including exposure, graft selection and fixation, and ulnar nerve management. This review article summarizes a variety of surgical techniques of ulnar collateral ligament reconstructions and compares clinical outcomes and biomechanics.

Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: Biomechanical Comparison of a Novel Anatomic Technique to the Docking Technique.

Background:In recent years, understanding of the anatomy of the ulnar collateral ligament (UCL) has evolved, demonstrating that the insertional footprint of the UCL on the ulna is more elongated and distally tapered than previously described. Current UCL reconstruction configurations do not typically re-create this native anatomy, which may represent a potential area for improvement.Purpose/Hypothesis:The purposes of this study were (1) to describe a novel anatomic UCL reconstruction technique designed to better replicate the native UCL anatomy and (2) to biomechanically compare this with the docking technique. The hypothesis was that the ultimate load to failure for the anatomic technique would not be inferior to the docking technique.Study Design:Controlled laboratory study.Methods:A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were utilized. One elbow in each pair was randomized to receive UCL reconstruction via the docking technique or the novel anatomic UCL reconstruction technique with palmaris tendon autograft. Following reconstruction, biomechanical testing was performed by applying valgus rotational torque at a constant rate of 5 deg/s until ultimate mechanical failure of the construct occurred. Maximal torque (N·m), rotation stiffness (N·m/deg), and mode/location of failure were recorded for each specimen.Results:The mean ultimate load to failure for elbows in the docking technique group was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic technique group (P = .045). Mean rotational stiffness was 1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups, respectively (P = .338). The most common mode of failure was suture pullout from the graft, which occurred in all 8 (100%) docking technique specimens and 7 of 8 (88%) specimens that underwent the anatomic UCL reconstruction technique.Conclusion:Ultimately, the anatomic UCL reconstruction technique demonstrated superior strength and resistance to valgus torque when compared with the docking technique, and this was comparable with that of the native UCL from prior studies. Increased initial strength may allow for earlier initiation of throwing postoperatively and potentially shorten return-to-play times.Clinical Relevance:Current UCL reconstruction techniques do not accurately reproduce the UCL insertional anatomy on the ulna. The novel anatomic technique described may result in more natural joint kinematics. This study demonstrated load-to-failure rates that are significantly higher than with the docking technique and consistent with the native ligament, as reported from previous studies. These findings may serve as a foundation for future clinical study and optimization of this technique.

Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers

Background: Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring surgical reconstruction. Despite acceptable published return-to-play outcomes, multiple techniques and graft types have been described. Purpose: This study compares UCL reconstruction (UCLR) outcomes based on tunnel configuration and graft type. Study Design: Cohort study; Level of evidence, 3. Methods: After approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCLR between 2010 and 2014 were identified and included. The following patient characteristics were analyzed: age, pitching role (starter vs reliever), level of play (MLB vs Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique, graft type, and concomitant procedures. Primary outcome measures consisted of the ability to return to play at any level (RTP), ability to return to the same level of play (RSL), time to return, subsequent elbow injuries, and need for subsequent or revision elbow surgery. The effects of patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling. Results: The RTP rate was 79.9%, and the RSL rate was 71.2%. Grafts used to reconstruct the UCL included the palmaris longus autograft (n = 361, 63.7%), the gracilis autograft (n = 135, 23.8%), and other grafts (n = 70, 12.5%). Surgical techniques utilized were the docking technique (n = 171, 30.2%), the modified Jobe technique (n = 290, 51.2%), and other techniques (n = 105, 18.6%). There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the docking versus modified Jobe technique (80.1% vs 82.4%, respectively; P = .537) and for the 2 primary graft types (83.1% for palmaris longus vs 80.7% for gracilis; P = .596). The rate of subsequent elbow surgery was 10.5% for the docking technique versus 14.8% for the modified Jobe technique (P = .203), and the rate of revision UCLR was 2.9% versus 6.2% for the docking versus modified Jobe technique, respectively (P = .128). Significant trends toward an increasing use of the palmaris longus autograft (P = .023) and the docking technique (P = .006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP (P < .001) and RSL (P < .001), but they required a longer time to return (mean difference, 35 days; P = .039) and had a higher likelihood of subsequent elbow (odds ratio [OR], 3.58 [95% CI, 2.06-6.23]; P < .001) and forearm injuries (OR, 5.70 [95% CI, 1.99-16.30]; P = .004) but not subsequent elbow surgery. No specific variables correlated with the rates of subsequent elbow surgery or revision UCLR in the multivariate analysis. The use of concomitant ulnar nerve transposition did not affect outcomes. Conclusion: Surgical outcomes in professional baseball players are not significantly influenced by UCLR technique or graft type. There was a high rate (46.3%) of subsequent throwing elbow injuries. MLB pitchers were more likely to RTP and RSL, but they had a higher frequency of subsequent elbow and forearm injuries than MiLB pitchers. Both the docking technique and the palmaris longus autograft are increasing in popularity among surgeons treating professional baseball players.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With a Modified Docking Technique With and Without Suture Augmentation

Background: Throwing athletes with ulnar collateral ligament (UCL) injury and symptomatic valgus instability can expect to return to the same or higher level of play. Reconstruction with tendon graft is the dominant method of surgical treatment. Recent evidence suggests that spanning the joint with a suture anchored on both sides is biomechanically equivalent to reconstruction, with faster time to return to play. The authors developed a hybrid UCL reconstruction technique augmented with a suture brace to improve joint stability. Purpose/Hypothesis: The purpose of this study was to biomechanically evaluate a hybrid reconstruction technique and compare its performance to reconstruction without augmentation. The authors hypothesized that (1) both groups would lose stability after the simulated tear and regain stability with treatment, (2) the suture augmentation would improve stability, and (3) the addition of the suture anchors near the bone tunnels would not decrease the strength of the hybrid reconstruction. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric arms were dissected to expose the UCL. Each elbow was mounted on a test frame at 90° of flexion. A cyclic valgus rotational torque was applied to the humerus with the UCL in its intact state and repeated in its surgically torn state. Finally, each specimen received either a hybrid reconstruction with suture brace or a reconstruction and was again put through the cyclic protocol, followed by a valgus rotation load-to-fail protocol. Results: Gap formation in the torn state for the reconstruction and hybrid reconstruction groups (0.9 ± 0.1 mm and 0.8 ± 0.1 mm, respectively) was significantly higher (P = .009 and P = .0002) than in the intact state (0.6 ± 0.2 mm and 0.6 ± 0.3 mm, respectively). After the procedures, the hybrid group showed greater resistance to gapping (P = .017) as compared with the reconstruction group (0.4 ± 0.2 mm and 0.6 ± 0.1 mm). During load to failure, no hybrid reconstructions failed from bone fracture or screw pullout. No statistical differences were found for failure torque (P = .058) and stiffness (P = .101). Gap at 10 N·m was significantly lower (P = .014) for the hybrid reconstruction group than for the reconstruction group. Conclusion: The current study showed that hybrid reconstruction with suture bracing replicated the time-zero strength of traditional UCL reconstruction and may be more resistant to joint gapping during low cyclic load and load to failure. The combination of the bone tunnels and fixation screw holes did not appear to weaken the construct. Clinical Relevance: This study demonstrated that reconstruction with suture bracing has important time-zero stability and strength as compared with the gold standard of UCL reconstruction. This technique may be useful for throwing athletes who need UCL reconstruction.

Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers

Objectives:Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring subsequent surgical reconstruction. Despite acceptable published return to play outcomes, multiple techniques and graft types have been described. There is a paucity of clinical data in the current literature comparing UCL reconstruction surgical technique and graft type. Even less is known about the risks for subsequent injury, surgery, or revision UCL reconstruction. Accordingly, this study compares UCL reconstruction outcomes based on tunnel configuration and graft type.Methods:Following approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCL reconstruction between 2010 and 2014 were identified and included. The following patient demographics were analyzed: age, pitching role (starter vs. reliever), level of play (MLB vs. Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique (Docking vs. Modified Jobe), graft type (palmaris longus autograft vs. gracilis autograft), and concomitant procedures. Primary outcome measures consisted of: the ability to return to play at any level (RTP), to return to the same level of play (RSL), the time to return, subsequent elbow injuries, and the need for subsequent or revision elbow surgery. The impact of the patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling.Results:The overall RTP was 79.9% and RSL was 71.2%. There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the Docking vs. Modified Jobe techniques (80.1% vs. 82.4%; p=0.537) and for the two primary graft types (83.1% for palmaris vs. 80.7% for gracilis; p=0.596). The risk of subsequent elbow surgery was 10.5% for the Docking Technique vs. 14.8% for the Modified Jobe (p=0.203); and the risk for subsequent UCL revision reconstruction surgery was 2.9% vs. 6.2% for the Docking vs. Modified Jobe Techniques, respectively (p=0.128). Significant trends towards an increasing use of palmaris autograft (p=0.023) and the docking technique (p=0.006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP (p<0.001) and to RSL (p<0.001), but they required a longer time to return (mean difference 35 days; p=0.039), had a higher likelihood of subsequent elbow (OR 3.58; 95% CI 2.055 to 6.231; p<0.001) and forearm injuries (OR 5.695; 95% CI 1.99 to 16.302; p=0.004), but not subsequent elbow surgery. No specific variables were noted to be predictive of subsequent elbow or revision surgery in the multivariate analysis.Conclusion:Surgical outcomes in professional baseball players are not significantly influenced by ulnar collateral ligament reconstruction technique or graft type usage. Major League players are more likely to RTP and RSL, but they have a higher frequency of subsequent elbow and forearm injuries. Both the Docking Technique and palmaris autograft are increasing in popularity amongst surgeons treating professional baseball players.

Osseous Vascularity of the Medial Elbow After Ulnar Collateral Ligament Reconstruction: A Comparison of the Docking and Modified Jobe Techniques.

Background:Although vascularity plays a critical role in healing after ulnar collateral ligament (UCL) reconstruction, intraosseous blood flow to the medial epicondyle (ME) and sublime tubercle remains undefined.Purpose:To quantify vascular disruption caused by tunnel drilling with the modified Jobe and docking techniques for UCL reconstruction.Study Design:Controlled laboratory study.Methods:Eight matched pairs (16 specimens) of fresh-frozen cadaveric upper extremities were randomized to 1 of 2 study groups: docking technique or modified Jobe technique. One elbow in each pair underwent tunnel drilling by the assigned technique, while the contralateral elbow served as a control. Pregadolinium and postgadolinium magnetic resonance imaging were performed to quantify intraosseous vascularity within the ME, trochlea, and proximal ulna. Three-dimensional computed tomography (CT) and gross dissection were performed to assess terminal vessel integrity.Results:Ulnar tunnel drilling had minimal impact on vascularity of the proximal ulna, with maintenance of >95% blood flow for each technique. Perfusion in the ME was reduced 14% (to 86% of baseline) for the docking technique and 60% (to 40% of baseline) for the modified Jobe technique (mean difference, 46%; P = .029). Three-dimensional CT and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the ME for the modified Jobe technique.Conclusion:Although tunnel drilling in the sublime tubercle appears to have a minimal effect on intraosseous vascularity of the proximal ulna, both the docking and modified Jobe techniques reduce flow in the ME. This reduction was 4 times greater for the modified Jobe technique, and these findings have important implications for UCL reconstruction surgery.Clinical Relevance:As the rate of revision UCL reconstructions continues to rise, investigation into causes for failure of primary surgery is needed. One potential cause is poor tendon-to-bone healing due to inadequate vascularity. This study quantifies the amount of vascular insult that is incurred in the ME during UCL reconstruction. While vascular insult is only one of many factors that affects the surgical success rate, surgeons performing this procedure should be mindful of this potential for vascular disruption.

Elbow Ulnar Collateral Ligament Reconstruction Using a 4-Strand Docking Plus Technique

The “Docking Plus” technique for elbow ulnar collateral ligament (UCL) surgery is described in the following text and video. Depite the general success of UCL surgery, significant rates of retear and failure of return to competition persist. Hypothesized reasons for UCL surgery failure include insufficient graft strength (midsubstance tears), insufficient graft tensioning (functional UCL insufficiency, valgus extension overload), and insufficient healing of graft to bone (proximal avulsions). This technique is meant to incorporate the best aspects of the previously described techniques for UCL reconstruction to create a larger, stronger, better-tensioned graft with a larger healing surface area to bone, a lower retear rate, and a lower risk of complications. The Docking Plus technique has been used since 2012.