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Ulnar collateral ligament reconstruction: The DANE technique


Overview

Chapter synopsis

  • Elbow ulnar collateral ligament (UCL) injuries are potentially career ending. The DANE technique is an effective way to reconstruct the ligament. It is performed through a muscle splitting approach and employs a combination of interference screw fixation on the ulna and the docking technique on the humerus. Clinical outcomes are excellent in about 90% of patients.

Important points

  • Ligament reconstruction can be considered in patients with medial-sided elbow pain who have examination findings and imaging studies consistent with UCL tear and in whom conservative management has failed.

  • It is important to identify associated pathology, such as ulnar nerve injuries and/or symptoms consistent with valgus extension overload.

  • Postoperatively, patients should not start a throwing program until the 4-month mark and return to competition should not occur before 9–12 months after surgery.

Clinical and surgical pearls

  • To reconstruct the ligament, a muscle splitting approach should be used.

  • With use of an interference screw for fixation on the ulna, only one socket is needed distally, potentially decreasing risk to the ulnar nerve.

  • The native ligament should be repaired after the graft is secured in the ulnar socket, before docking of the graft into the humerus.

  • The graft should be tensioned with the elbow flexed 30 degrees, the forearm supinated, and a varus stress applied.

Clinical and surgical pitfalls

  • Protect the graft when inserting the interference screw.

  • Make sure the ulnar socket is distal enough to avoid penetration into the joint.

  • Cycle the graft before determining the appropriate amount to dock into the humeral socket.

Video available

  • : Elbow ulnar collateral ligament reconstruction by the DANE technique

Elbow medial ulnar collateral ligament (UCL) reconstruction is the treatment of choice for overhead athletes with symptomatic ligament insufficiency who want to return to their previous level of sport. UCL injuries are the result of the extreme valgus forces generated during the late cocking and early acceleration phases of throwing. The primary restraint to these forces is the anterior bundle of the UCL; however, each throw approaches the ultimate tensile strength of the ligament. Shoulder internal rotation and the forearm flexors help stabilize the elbow, but repeated throwing can lead to microtrauma and eventual ligament failure.

Before Jobe’s description of a reconstruction technique for UCL insufficiency, the injury was career ending. Despite successful results in about 70% of patients, concerns with elevation of the flexor-pronator mass, ulnar nerve complications, and relatively large bone tunnels in the medial epicondyle of the humerus led to modifications to Jobe’s technique. A novel modification was the docking technique, which relied on smaller holes in the relatively small medial epicondyle and simplified graft tensioning. Based on the clinical success of the docking technique combined with biomechanical studies that showed improved construct strength with interference screws, the DANE technique was developed ( Table 51.1 ). , It relies on proximal docking of the graft, as described by David Altchek (DA) and distal interference screw fixation on the ulna based on work by Neal ElAttrache (NE).

TABLE 51.1
Results of Studies of the DANE Technique
Author No. of Patients Outcome
Conway 7 Excellent outcome in 6 of 7 (85%)
Dines et al. 22 Excellent results in 19 of 22 (86%); fair result in 2; poor result in 1
Nissen 6 Excellent results in 6 patients, lower tourniquet time for DANE procedure.

Additional benefits of the DANE technique include better restoration of native ligament anatomy (based on cadaver studies showing that the UCL tapers to a narrower insertion on the ulna) ; decreased risk of ulnar nerve injury by obviating the need for a posterior ulnar tunnel; decreased risk of ulnar bone bridge fracture; and improved tendon-to-bone healing in the ulnar socket because of compression with the interference screw and aperture fixation. There is also evidence that the DANE technique is associated with decreased tourniquet times and overall operative times. The technique is particularly useful with sublime tubercle insufficiency and for certain revision UCL procedures. The DANE technique is described in the following sections.

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