Ulnar Collateral Ligament Reconstruction: Current Philosophy in 2016
The ulnar collateral ligament (UCL) is the primary static restraint to valgus stress at the elbow. Since Jobe pioneered reconstruction in 1974, thousands of throwers have undergone UCL reconstruction, and good results have been achieved. The high-profile nature of the elite pitcher has brought this technique into the spotlight, and extensive research has been performed with new techniques emerging. The standard reconstruction, modified only slightly since Jobe’s original description, remains the gold standard for treatment of UCL insufficiency. Throwers are able to return to the same or even higher levels of competition in the majority of cases. In this article, we present our standard technique and results and discuss emerging techniques for treatment of UCL injuries.
Nonoperative Management
Nonoperative treatment is recommended for 3 months prior to performing reconstruction. Patients are given complete rest from throwing, but rehabilitation is initiated immediately. Rehabilitation exercises and nonsteroidal anti-inflammatory medications are prescribed, and activities that place valgus stress across the elbow are avoided. After resolution of symptoms, an interval throwing program is initiated, and the athlete is gradually returned to sport. Unfortunately, due to season-specific schedules and time-sensitive demands in high-level throwers, operative treatment is often chosen without an extended period of conservative treatment.
Platelet-rich plasma (PRP) therapy has recently been shown to improve healing rates and promote healing in partial UCL tears,23 and as orthobiologics are advanced, they will likely play a larger role in the treatment of UCL injuries.
Surgical Technique
At our institution, UCL reconstruction is performed with the modified Jobe technique as described by Azar and colleagues.17 Arthroscopy prior to reconstruction was routinely performed at our institution until we recognized that arthroscopy rarely changed the preoperative plan.16 Currently, the presence of anterior pathology such as loose bodies or osteochondral defect is our only indication for arthroscopy before reconstruction.
Ipsilateral palmaris autograft is our current graft of choice. This must be examined preoperatively because 16% of patients have unilateral absence and 9% have bilateral absence.24 In revision cases or in patients with insufficient or absent palmaris, contralateral palmaris followed by contralateral gracilis tendon is used. The contralateral gracilis is chosen because of ease of setup and position of the surgeon during the harvest. Gracilis tendon is also used in cases with bony involvement of the ligament based on the results from Dugas and colleagues.25 Toe extensors, plantaris, and patellar tendon grafts have also been used. One recent study showed that neither graft choice nor diameter affected resistance to valgus stress, and that all reconstruction types restored strength at 60° to 120° of flexion.26
Ulnar nerve transposition is performed in all cases regardless of the presence of preoperative nerve symptoms. A complete decompression is completed proximally to the Arcade of Struthers and distally to the deep portion of the flexor carpi ulnaris. A single fascial sling of medial intermuscular septum originating from the epicondylar attachment is used to stabilize the nerve without compression. At wound closure, the deep fascia on the posterior skin flap is also sewn into the cubital tunnel to prevent the nerve from subluxating back into the groove. A single suture is placed distally closing the muscle fascia to prevent propagation of the fascial incision, which can lead to herniation. Transposition is necessary because of the ulnar nerve exposure required in the modified Jobe technique to allow elevation of the deep flexor muscle mass for ligament exposure.
The reconstruction is completed as described by Jobe14 but with a few modifications as described by Azar and colleagues17 and slight adaptations implemented since that time. The flexor-pronator mass is retracted laterally instead of detachment or splitting as described by Thompson and colleagues.27 A subcutaneous rather than a submuscular ulnar nerve transposition is used.
The patient is positioned supine using an arm board. If gracilis tendon is chosen, the contralateral leg is prepped and draped simultaneously. A tourniquet is inflated after exsanguination. A medial approach is performed, and the medial antebrachial nerve is located and protected. The ulnar nerve is then located in the cubital tunnel and mobilized. The neurolysis extends to the deep portion of the flexor carpi ulnaris distally and proximally to the Arcade of Struthers, and the nerve is retracted with a vessel loop. The flexor muscle mass is not elevated from the medial epicondyle; rather, it is retracted anteriorly by small Hohmann retractors. The dissection is carried down to the UCL and found at its attachments to the medial epicondyle and sublime tubercle. If no tear is seen on the superficial surface of the ligament, a longitudinal incision is made through the ligament. Undersurface tears, partial tears, and avulsions can then be identified (Figure 4). 
The autologous graft of choice is then harvested. Our technique for palmaris harvest is performed with three 1-cm transverse incisions. The palmaris is palpated and marked with the first incision made near the distal wrist crease, and the second incision is made 3 to 4 cm proximal to the first. The tendon is found in both distal incisions and cut distally with the wrist flexed to maximize tendon length. The tendon is then pulled through the second incision and tensioned to identify the most proximal location the tendon can be palpated. A third incision is made directly over this point and carried down to cut the tendon. This usually provides a graft length of 15 to 20 cm; 13 cm is the minimum graft length to ensure good graft fixation. Muscle is removed from the tendon and each end is secured with a No. 1 nonabsorbable suture in a locking fashion.
If posterior osteophytes are present, they are removed through a posterior, vertical arthrotomy. Over-resection of the olecranon must be avoided, as this can further destabilize the elbow and place increased stress on the reconstruction. Posterior loose bodies can also be removed through this arthrotomy. The arthrotomy is then closed with absorbable suture.
Tunnel placement is critical to success. A 3.2-mm drill bit is used with palmaris grafts and a 4-mm drill bit is used with gracilis grafts. Two convergent tunnels are drilled in the medial epicondyle in a Y fashion and 2 convergent tunnels are drilled at the sublime tubercle in a U or V fashion. After drilling the first tunnel on each side, a hemostat is placed in the tunnel as an aiming point to ensure a complete tunnel is made. The junction is smoothed with a curette, leaving a 5-mm bone bridge between the articular surface and the tunnels. A bent Hewson suture passer is used to pass one end of the graft through the ulna. The 2 limbs of the tendon graft are then passed through the humeral tunnels, creating a figure-of-eight. A varus stress is applied with the elbow at roughly 30° and the 2 limbs are tied together with a No. 1 nonabsorbable suture. If enough graft remains, one or both limbs are passed back through the tunnels and secured again with No. 1 nonabsorbable suture. The 2 limbs are then tied side-to-side, incorporating the native ligament to further secure and tighten the reconstruction.
The ulnar nerve is then secured using a strip of medial intermuscular septum left intact to its insertion at the medial epicondyle. This is attached to the flexor-pronator muscle fascia with a 3-0 nonabsorbable suture. Enough length should be harvested from the septum to ensure there is no compression on the nerve. The deep posterior fascial tissue is then sewn to the periosteum of the medial epicondyle to further prevent subluxation of the nerve back into the groove. The skin is then closed in layered fashion over a superficial drain. The patient is placed in a well-padded posterior splint for 1 week, then the rehabilitation protocol is initiated as discussed below.
