Ulnar collateral ligament reconstruction: The docking technique

OVERVIEW

Chapter synopsis

The docking technique has resulted in excellent outcomes for athletes at all levels of play and has proven to be a less invasive and reliable method of reconstruction of the ulnar collateral ligament (UCL).

Important points

The palmaris longus and gracilis tendons are ideal grafts for UCL reconstruction.
Elbow arthroscopy can be performed before UCL reconstruction to address common pathologies seen in the throwing athlete.
The ulnar nerve does not need to be addressed unless the patient demonstrates preoperative symptoms of ulnar nerve compression in the cubital tunnel.

Clinical/surgical pearls

Use a muscle splitting approach to the UCL
Protect the ulnar nerve with a dull, broad retractor when drilling the inferior most ulna tunnel
The optimal length of the graft is determined by placing the second limb of the graft adjacent to the humeral tunnel to avoid under-tensioning.
Place the arm in 45-60 degrees of elbow flexion with maximum supination and a varus force to reduce the elbow joint during final graft tightening.

Clinical/surgical pitfalls

Aggressive retraction of the medial antebrachial cutaneous nerve and the ulnar nerve can lead to postoperative neuropathies.
A bone bridge less than 2 cm can lead to fracture of graft tunnels.
Avoid a sharp turn into the humeral tunnel to avoid graft impingement.

Introduction

The anterior bundle of the ulnar collateral ligament (UCL) of the elbow is the primary restraint to valgus load. Originally described in javelin throwers, UCL injury is almost exclusively seen in overhead throwing athletes, especially baseball pitchers. Throwing athletes are prone to injury of this structure due to the repetitive valgus loads to the elbow created by the overhead pitching motion. Injury to the UCL has also been reported in wrestlers, tennis players, professional football players, gymnasts, combat athletes, and arm wrestlers. These non-overhead throwing athletes can often be successfully treated with nonoperative management. ^, However, while nonthrowing athletes with a UCL injury can have excellent results with nonoperative intervention, the overhead throwing athlete may find a UCL injury to be a career-ending event if surgical intervention is not employed.

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