Ulnar collateral ligament reconstruction: The modified jobe technique

OVERVIEW

Chapter synopsis

The Jobe technique was the first technique reported for ulnar collateral ligament (UCL) reconstruction, and several subsequent modifications have been described. The procedure involves passage of a graft, most commonly the palmaris longus tendon, through the ulnar and humeral tunnels in a figure-of-eight fashion. More than 80% of athletes return to their previous level of sport.

Important points

Accurate diagnosis is paramount.
Medial elbow pain during late cocking or early acceleration phase of throwing is a hallmark of UCL insufficiency.
Surgery is indicated after failure of nonoperative treatment.
Prolonged rehabilitation period must be discussed with the patient.

Clinical and surgical pearls

A muscle splitting approach or elevation of the flexor-pronator mass without detachment from the medial epicondyle can be used to expose the UCL.
Identify and protect the ulnar nerve while drilling the tunnels.
Tension graft with elbow flexed to 30 degrees, forearm supinated, and varus stress applied to elbow.
Identify valgus extension overload with olecranon osteophytes preoperatively because recognition and treatment can prevent persistent pain postoperatively.

Clinical and surgical pitfalls

Ulnar or medial antebrachial cutaneous nerve neurapraxia is the most common complication. Identify and protect these nerves during surgery.
Fractures through bone tunnels can occur. Place tunnels 10 mm apart to minimize risk.

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus forces at the elbow. Injury to this structure can occur in individuals whose elbows are subjected to large valgus loads, as in throwing or as a result of elbow dislocation. Injury to the UCL is most commonly seen in overhead or throwing athletes whose elbows are subjected to repetitive valgus loads during the late cocking and early acceleration phases of throwing. Once injured, throwing athletes with UCL insufficiency often experience disabling elbow pain and are unable to compete at a high level. Jobe and colleagues provided the first description of surgical reconstruction of the UCL in 1986. Since that time, this procedure has become the gold standard for surgical treatment of UCL deficiency. Several modifications have been made to the original technique to decrease the amount of soft tissue dissection required and lessen the technical demands of the operation. Reports have shown patients who have undergone this operation to return to their previous level of competition or a higher level more than 80% of the time. This chapter describes the modified Jobe technique for UCL reconstruction, as well as discussing preoperative considerations and offering a brief review of reported results.

Preoperative considerations

History

UCL insufficiency can manifest as either an acute or a chronic injury. The hallmark symptom is medial elbow pain during the late cocking and early acceleration phases of the throwing motion, which is present in 85% of patients. Acute injuries can be accompanied by a “pop,” acute pain, and inability to continue throwing. Chronic injuries typically involve an insidious onset of medial elbow pain associated with loss of velocity or accuracy. It is important to solicit a history of pain or paresthesias in the ulnar two digits that may indicate associated ulnar neuritis. Valgus extension overload (VEO), a clinical entity often related to UCL insufficiency, can cause posteromedial elbow pain in the deceleration phase (or follow-through phase) of the throwing motion, limited extension, and mechanical symptoms. Occasionally, symptoms of VEO may overshadow those of UCL insufficiency at initial presentation.

Signs and symptoms

Medial elbow pain during late cocking and/or early acceleration
Loss of accuracy or velocity of throws
Feeling of a “pop” in acute injuries
Ulnar nerve symptoms—paresthesias, radiating pain, weakness
VEO symptoms—posteromedial pain, loss of extension, mechanical symptoms

Physical examination

Tenderness over the UCL or its insertions at the base of the medial humeral epicondyle and the sublime tubercle of the proximal medial ulna may be present, especially if the ligament is acutely injured. Several special tests for UCL injury have been described. Applying a valgus stress with the elbow flexed to 25 degrees may elicit medial pain or excessive gapping. The moving valgus stress test begins with the application of a valgus force to the maximally flexed elbow. While the valgus torque is maintained, the elbow is rapidly extended to 30 degrees. Reproduction of the patient’s medial elbow pain is a positive test result. With the milking maneuver, the examiner places valgus stress on the flexed elbow by grasping and pulling on the thumb of the affected hand. Reproduction of the patient’s medial elbow pain is a positive test result, as with the moving valgus stress test. A positive Tinel sign at the cubital tunnel may be present in patients with associated ulnar neuritis. A thorough neurovascular examination, with special focus on the sensorimotor function of the ulnar nerve, should be completed. Palpation of the ulnar nerve at the cubital tunnel through the elbow’s full range of motion should be performed to identify concomitant ulnar nerve subluxation. Patients with associated VEO will have pain and tenderness over the posteromedial olecranon tip. They also may have pain with valgus stress and rapid hyperextension simulating the follow-through phase of the throwing motion.

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