Comparison of Ulnar Collateral Ligament Reconstruction Techniques in the Elbow of Sports Players.

Ulnar collateral ligament injuries have been increasingly common in overhead throwing athletes. Ulnar collateral ligament reconstruction is the current gold standard for managing ulnar collateral ligament insufficiency, and numerous reconstruction techniques have been described. Although good clinical outcomes have been reported regarding return to sports, there are still several technical issues including exposure, graft selection and fixation, and ulnar nerve management. This review article summarizes a variety of surgical techniques of ulnar collateral ligament reconstructions and compares clinical outcomes and biomechanics.

INTRODUCTION

The ulnar collateral ligament (UCL) of the elbow is the primary restraint to valgus stress and is an important structure to overhead throwing athletes. Since the first description of UCL rupture in javelin throwers [1], interest in UCL injuries has increased due to both the epidemic of injury among patients involved in throwing sports and media interest in professional overhead throwing athletes.

Since Dr. Jobe first performed UCL reconstruction (UCLR) in 1974, and published his experience in 1986 [2], UCLR has been a popular treatment for insufficient UCL. There have been many modification and advancements in surgical techniques, and optimal UCLR continues to be a topic of debate. Despite use of various techniques of UCLR for UCL injuries, studies reviewing surgical techniques from the traditional to currently existing or new methods are lacking. The purpose of this review was to address surgical techniques of UCLR by summarizing and comparing clinical outcomes and biomechanics.

SURGICAL TECHNIQUES

Original Jobe Technique

The first successful UCLR was performed by Frank Jobe (Kerlan-Jobe Orthopedic Clinic, Inglewood, CA, USA) on Los Angeles Dodgers pitcher Tommy John in 1974. After surgery, John resumed pitching at his pre-injury level. Jobe et al. [2] published their initial results in a population of baseball pitchers and javelin throwers in 1986. The original technique utilized the palmaris longus tendon or plantaris tendon as an autograft and required detachment of the flexor-pronator musculature at its origin and submuscular transposition of the ulnar nerve. At the humeral origin of the UCL, two tunnels were created in a “V” configuration through the posterior cortex to configure the graft in a figure-8 fashion. Two drill holes in the ulna and three in the medial epicondyle were made with a 3.2-mm drill bit (Fig. 1).

Fig. 1.

Illustration of the original Jobe technique. A free tendon graft is pulled through the ulnar and humeral tunnel and forms a figure-8. It is then put under tension and sutured to itself.

This series reported a 63% success rate (10 of 16 patients), as defined by return to preinjury or better level of participation in athletic activity. However, it was also associated with a 32% complication rate, primarily related to postoperative ulnar neuropathy. A later study by Conway et al. [3] of 56 UCLR cases with a mean 6.3 years of follow-up showed 68% excellent outcomes in which the patient was able to compete at the same or higher level as before the injury for >12 months.

Modified Jobe Technique

Due to the high rate of ulnar nerve complications, Jobe modified his technique using a muscle splitting approach without detaching the flexor-pronator, no ulnar nerve transposition, and larger humeral tunnel through the anterior cortex. He reported better outcomes, with 5% of patients experiencing transient ulnar nerve symptoms and 93% showing an excellent result [4].

Andrews et al. [5] and Andrews and Timmerman [6] also used the Jobe technique, except with subcutaneous ulnar nerve transposition and combined arthroscopy. Exposure of the UCL was achieved with elevation of the flexor-pronator mass, and a humeral tunnel was made with a 3.5-mm drill bit to create a Y-shaped tunnel configuration. Another study from the same institution showed excellent results in 81% of 78 baseball players who underwent UCRL [7]. In the largest series on UCLR to date, Cain et al. [8] reported on 1,281 patients treated with this technique. Among the 733 individuals with reconstruction, 83% had excellent results and 16% developed transient ulnar nerve paresthesia, with most of these cases resolving within 6 weeks. Arthroscopic debridement of olecranon osteophytes was the most common additional surgery in 7.2% of patients. This modified technique was called the Andrews technique or the American Sports Medicine Institute (ASMI) modification.

Docking Technique

David Altchek developed the docking technique and reported results of the first 36 patients treated with this technique in 2002 [9]. Key elements of the docking technique included a muscle-splitting approach without routine transposition of the ulnar nerve, routine arthroscopic assessment, treatment of associated lesions, and docking the two ends of the tendon graft into a single humeral tunnel (Fig. 2). Rohrbough et al. [9] first described the docking technique and provided significant improvement of technical issues such as graft fixation and tensioning of the previous technique. They raised several concerns about the previous Jobe technique, which included the large drill holes within the limited area of the epicondyle, the difficulty in holding tension on the graft during fixation, and the strength of tendon fixation.

Fig. 2.

Illustration of the docking technique. Two ulnar tunnels and a single humeral tunnel are created, followed by two small exit holes. Sutures of both limbs from the ulnar tunnel are tied over the humeral bony bridge.

The ulnar tunnel is created in the same manner as in the Jobe technique. The humeral tunnel is created with a single inferior tunnel and two small superior exit tunnels, creating a Y-shaped tunnel. A 4.5-mm drill or burr is used to create a socket in the center of the footprint to a depth of 15 mm. and two 1.5-mm sockets that converge to the single 4.5-mm socket are drilled. The two 1.5-mm sockets should be just anterior to the medial intermuscular septum and at least 5 to 10 mm apart (Fig. 3) [10,11]. Dodson et al. [11] reported that 90% of patients were able to return to their preinjury level of activity after UCLR with the docking technique.

Fig. 3.

(A) The skin incision is 8 cm centered over the medical epicondyle. (B) Longitudinal splitting of the flexor pronator muscle exposes an ulnar collateral ligament (asterisk). (C) When the docking suture is tied, the tension on the graft may be supported with a yolk stitch (asterisk). ST, sublime tubercle; ME, medial epicondyle; MABCN, medial antebrachial cutaneous nerve.

MODIFIED DOCKING TECHNIQUE

Paletta and Wright [12] reported a case series using further modification of the docking technique using a four-strand palmaris longus graft, and 23 of 25 participants (92%) were able to return to their preinjury levels of competition. Koh et al. [13] modified the docking technique using a three-strand construct with a double anterior bundle and a single posterior bundle. Bower et al. [14] described another three-strand docking technique with excess graft sutured to the anterior band, while tension was maintained on the excess graft. McGraw et al. [15] and Donohue et al. [16,17] reported a novel docking plus technique that used four strands of the palmaris longus tendon.

David Altchek and Neal ElAttrache for Tommy John (DANE TJ) Technique

In 2006, Conway [18] described a new procedure, the DANE TJ technique. This technique utilizes a combination of fixation techniques of docking fixation on the humeral side and interference screw fixation on the ulnar side (Table 1, Fig. 4). He preferred a gracilis tendon as autograft and used an interference screw (4.75-, 5.5-, 6.0-mm diameter) for ulnar side fixation. This technique originated from a biomechanical study using interference screws [18]. Ahmad et al. [19] demonstrated that the load to failure strength was 90% of that of the native ligament when the tendon graft was locked to the interference screw with sutures. The DANE TJ technique may be valuable when the sublime tubercle is compromised or a revision surgery is required. However, graft trauma from screw-graft-tunnel mismatch and proximal ulnar fracture is concerning. In addition, another biomechanical study showed that interference screw fixation did not provide sufficient fixation [20]. Dine et al. [21] reported excellent results in 86% of 22 athletes treated with this technique.

Table 1.

Three UCL reconstruction techniques and their differences

Technique	Inventor	Year published	FPM approach	Graft configuration	Ulnar preparation fixation	Humeral preparation fixation	Ulnar nerve treatment
Jobe [2]	Frank Jobe	1986	Transection	Figure-8	Tunnel	Tunnel	Submuscular transposition
					None	Suture to tendon
Docking [9]	David Altchek	2002	Split	Triangle	Tunnel	Socket	Only if symptomatic
					None	Suture over bridge
DANE TJ [18]	David Altchek,	2006	Split	Linear	Socket	Socket	Only if symptomatic
	Neal ElAttrache				Interference screw	Docking over bridge

UCL, ulnar collateral ligament; FPM, flexor pronator muscle; DANE TJ, David Altchek and Neal ElAttrache for Tommy John.

Fig. 4.

Illustration of the David Altchek and Neal ElAttrache for Tommy John (DANE TJ) technique. This technique utilizes a combination of fixation techniques. On the ulnar side, an interference screw is fixed with a single drill hole; on the humeral side, docking fixation is used.

Repair with or without an Internal Brace Augmentation

Despite good clinical outcomes after UCLR, patients require a long recovery time prior to return to sports (RTS), which is a challenge for high-demand athletes. In addition, UCL injuries vary in degree, from partial tears to chronic complete tear. These observations imply that repair is an option for some athletes. Although initial data on UCL repair demonstrated poor outcomes, recent studies showed promising results in symptomatic UCL injury to the proximal or distal end of the ligament. Savoie et al. [22] reported 93% good to excellent results, and 97% of patients RTS after repair using suture anchors with arthroscopic assistance.

Alternative Technique

Hechtman et al. [23] described a hybrid technique that uses an ulnar osseous tunnel and suture anchor fixation on the humerus and reported that their method closely reproduced the normal anatomy without any marked difference in reconstruction strength compared with traditional bone tunnels. Savoie et al. [24] and Hurt et al. [25] reported the short-term outcomes of 116 patients who underwent UCLR with hamstring allograft. Myeroff et al. [26] and Acevedo et al. [27] described UCLR using cortical buttons on humeral and ulnar fixation that create a single tunnel. This technique may offer an alternative solution to bony insufficiency in revision surgery.

BIOMECHANICAL STUDIES

There have been biomechanical studies comparing the native UCL with reconstructive UCL and UCLR techniques for clinical applications. As in native elbow, the valgus stability of UCLR elbow can vary with flexion angle [28]. Mullen et al. [29] found that UCLR with Jobe technique had stability similar to the native UCL at flexion angles of 30°–90°. However, Ciccotti et al. [30] showed that UCLR with modified Jobe and docking technique provided valgus stability at flexion angles >90°. Paletta et al. [31] compared stability of UCLR with that of the Jobe technique with a four-strand docking technique and concluded that the docking technique can provide greater initial stability. Ahmad et al. [19] evaluated the stability of interference screw fixation and found the average ultimate moment of UCLR with interference screw was 95% of that of native UCL. However, Armstrong et al. [20] performed a biomechanical comparison of native ligament strength, the docking and Jobe techniques, interference screw fixation, and reconstruction with an Endobutton and concluded that UCLR with either the docking technique or Endobutton may be the best option biomechanically. The authors also expressed concerns over graft rupture with interference screw fixation. McAdams et al. [32] compared cyclical valgus stability of the docking technique and interference screw fixation. Valgus stability was greater with interference screw fixation at early cycles, but no difference was found at 1,000 cycles. The tension slide technique involves a single ulnar bone tunnel with a tendon graft attached to a cortical button and use of interference screw. In a cadaveric study, biomechanical results showed superiority of strength and stiffness of ulnar fixation with the bone tunnel technique [33].

Recently, several biomechanical studies have evaluated valgus stability of an internal brace combined with UCRL or repair [34-38]. Most studies demonstrated augmentation with an internal brace providing stability similar to that of the docking technique or more resistance to the valgus load. These results support use of repair or reconstruction with an internal brace technique for UCL insufficient patients. One systemic review about biomechanical testing with UCLR showed that the most common mode of failure following UCLR in a laboratory setting was suture failure. While failure of the graft represented 27% and bone tunnel fracture was 14% of the failure, suture failure was much higher at 51% [24].

SPORTS PERFORMANCE OUTCOMES

Jobe and various modifications and biomechanical studies have demonstrated that UCLR can appropriately restore elbow stability and provide superior outcomes in UCL insufficient athletes. However, while athletes who underwent UCLR can RTS, players who return to pre-injury level are not numerous. Erickson et al. [39] evaluated the performance of 179 major league baseball (MLB) pitchers on RTS and found that they pitched fewer innings in a season and had fewer wins and losses per season compared to before surgery. Furthermore, Jiang and Leland [40] and Lansdown and Feeley [41] reported small, but statistically significant, decreases in velocity of fastball and changeup pitches thrown by pitchers who return to MLB after UCLR from pre-injury to post-injury years [42]. In addition, there is increase in number of UCLR revisions among primary UCLR athletes, and performance and longevity after revision surgery decrease [46] (Table 2).

Table 2.

Summary of clinical outcomes of UCLR

Study	UCLR technique	No. of cases	Mean follow-up	Rate of RTS (%)	Complication
Jobe et al. (1986) [2]	Jobe	16	51 mo	63	3 (Reop)
Azar et al. (2000) [7]	ASMI	78	35 mo	79	8 (4 Donor site, 2 reop, 1 infection, 1 UN)
Thompson et al. (2001) [4]	Modified Jobe	33	2 yr	100	5% UN
Rohrbough et al. (2002) [9]	Docking	36	3.3 yr	92	2 (1 Hematoma, 1 UN)
Dodson et al. (2006) [11]	Docking	100	36 mo	96	3 (2 UN, 1 stiffness)
Dine et al. (2007) [21]	DANE TJ	22	35.9 mo	86	4 (2 UN, 2 stiffness)
Cain et al. (2010) [8]	ASMI	743	38.4 mo	83	1 48 (121 UN, 55 reop for osteophyte)
Hechtman et al. (2011) [23]	Hybrid	34	6.9 yr	85	1 (UN)
Dugas et al. (2012) [43]	ASMI	120	>2 yr	87.5	42 (25 UN, 8 reop)
Savoie et al. (2013) [24]	Jobe, docking	116	39 mo	95	7 (3 UN, 2 wound, 1 med epicondylar fracture, 1 tendon tear)
Erickson et al. (2016) [44]	Docking, double docking	188	60 mo	94.1	10 (reop)
Myeroff et al. (2018) [26]	Cortical button	23	42.7 mo	82.6	1 Failure
Donohue et al. (2019) [16]	Docking plus	324	>24 mo	90.9	28 UN, 8 retear, 18 reop
Dugas at al. (2019) [45]	Repair with internal brace	111	>12 mo	92	5 (3 UN, 1 heterotopic bone, 1 retear)

UCLR, ulnar collateral ligament reconstruction; RTS, return to sports; Reop, reoperation; ASMI, American Sports Medicine Institute; UN, ulnar neuropathy; DANE TJ, David Altchek and Neal ElAttrache for Tommy John.

CONCLUSION

Since the first UCLR surgery in 1974, several modifications and new techniques for UCL injuries for athletes have been proposed. The Jobe technique and modified Jobe technique, docking technique and modified docking technique, and DANE TJ technique have been most often used for UCLR surgery. Clinical studies have reported successful outcomes and a high rate of RTS in overhead throwing athletes. Several modifications including flexor pronator muscle splitting approach and minimal handling of the ulnar nerve might improve outcomes. Newer fixation techniques such as augmentation with an internal brace may allow a faster RTS. Finally, with the perception of lower performance after surgery, efforts are needed to focus on education and injury prevention.