Modified Jobe Approach With Docking Technique for Ulnar Collateral Ligament Reconstruction

Abstract

The ulnar collateral ligament (UCL) of the elbow acts as the primary restraint to valgus force experienced in the late cocking and early acceleration phases of overhead throwing. If the UCL or dynamic flexor-pronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation. Before the first UCL reconstruction, performed by Frank Jobe in 1974, this injury was considered career ending in overhead athletes. Since the index procedure, further techniques have been developed to minimize dissection of the flexor-pronator mass and improve the biomechanical strength of graft fixation with the goal of increased return to athletic competition. We describe our techniquedincluding pearls and pitfalls, as well as advantages and disadvantagesdwhich combines the docking technique, through a flexor muscle-elevating approach with transposition of the ulnar nerve using a fascial sling. Harvest and preparation of a palmaris longus tendon autograft is also described.

Ulnar Collateral Ligament Reconstruction Technique Utilizing Suture Tape Augmentation

“…The modified Jobe technique (our preferred technique) has been previously described, 13 as has the use of the Arthrex drill guides. We will go through the steps briefly only to add a few slight modifications that have not been previously described.…”

“…Harvest of both the palmaris longus and the gracilis tendons have also been previously described. The ipsilateral palmaris longus autograft is harvested in standard fashion as described by Kaplan et al 13 Gracilis tendon autograft may also be used if the palmaris longus is not present. This is harvested as described by Dugas et al 14 Once the graft is harvested, 2 FiberLoop sutures are incorporated into the graft, 1 on either side in whipstitch fashion (Fig 6).…”

“…The graft is then passed in a figure-of-8 fashion as previously described (Figs 10 and 11-16). 13 It is important to keep countertension on the graft as you pull the graft through each bone tunnel ( Table 1). The FiberLoop sutures and the FiberTape sutures (Arthrex) are passed back through the ulnar tunnel and are tied over the bone bridge completing an implant-less internal brace (Fig 17).…”

Revision Ulnar Collateral Ligament Reconstruction in Professional Baseball: Current Trends, Surgical Techniques, and Outcomes

“…29 The most commonly used grafts are either the palmaris longus tendon or one of the hamstring tendons (gracilis vs semitendinosus). 2,18,19,29 However, no consensus is available regarding optimal surgical technique, graft selection, tunnel configuration, or other surgical variables for revision UCL reconstruction. These data are critical because an improved understanding of the epidemiologic patterns, surgical practices, and outcomes data for revision UCL reconstruction in professional baseball pitchers will help guide clinical practice and optimize results.…”

Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction

“…6 Knowing these parameters, the entry point for distal fixation during reconstruction is adjacent to the proximal radioulnar joint (PRUJ) and intra-articular penetration can be a concern with far cortical fixation. 11 Violation of the PRUJ can compromise the normal biomechanics and function of the elbow. 14 However, to our knowledge, there are no publications regarding a standard angle at which the cortical button can be reliably deployed in a safe manner, specifically without violation of the PRUJ.…”