Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: Biomechanical Comparison of a Novel Anatomic Technique to the Docking Technique

Abstract

Background:In recent years, understanding of the anatomy of the ulnar collateral ligament (UCL) has evolved, demonstrating that the insertional footprint of the UCL on the ulna is more elongated and distally tapered than previously described. Current UCL reconstruction configurations do not typically re-create this native anatomy, which may represent a potential area for improvement.Purpose/Hypothesis:The purposes of this study were (1) to describe a novel anatomic UCL reconstruction technique designed to better replicate the native UCL anatomy and (2) to biomechanically compare this with the docking technique. The hypothesis was that the ultimate load to failure for the anatomic technique would not be inferior to the docking technique.Study Design:Controlled laboratory study.Methods:A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were utilized. One elbow in each pair was randomized to receive UCL reconstruction via the docking technique or the novel anatomic UCL reconstruction technique with palmaris tendon autograft. Following reconstruction, biomechanical testing was performed by applying valgus rotational torque at a constant rate of 5 deg/s until ultimate mechanical failure of the construct occurred. Maximal torque (N·m), rotation stiffness (N·m/deg), and mode/location of failure were recorded for each specimen.Results:The mean ultimate load to failure for elbows in the docking technique group was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic technique group (P = .045). Mean rotational stiffness was 1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups, respectively (P = .338). The most common mode of failure was suture pullout from the graft, which occurred in all 8 (100%) docking technique specimens and 7 of 8 (88%) specimens that underwent the anatomic UCL reconstruction technique.Conclusion:Ultimately, the anatomic UCL reconstruction technique demonstrated superior strength and resistance to valgus torque when compared with the docking technique, and this was comparable with that of the native UCL from prior studies. Increased initial strength may allow for earlier initiation of throwing postoperatively and potentially shorten return-to-play times.Clinical Relevance:Current UCL reconstruction techniques do not accurately reproduce the UCL insertional anatomy on the ulna. The novel anatomic technique described may result in more natural joint kinematics. This study demonstrated load-to-failure rates that are significantly higher than with the docking technique and consistent with the native ligament, as reported from previous studies. These findings may serve as a foundation for future clinical study and optimization of this technique.

Revision Medial Ulnar Collateral Ligament Reconstruction in Baseball Pitchers: Review of Epidemiology, Surgical Techniques, and Outcomes

“…There are a multitude of techniques described for primary UCL reconstruction including the original figure of 8 technique by Jobe in 1986 [1], the docking technique [6,30], the modified Jobe [18], the DANE TJ technique [7], interference screw only [31], and a newly described anatomic reconstruction [32]. A survey of MLB orthopedic surgeons revealed a preference for the docking technique with palmaris autograft [33].…”

The Effect of Ulnar Collateral Ligament Repair With Internal Brace Augmentation on Articular Contact Mechanics: A Cadaveric Study

“…6,15,19,20,24,29 First described by Frank Jobe in 1986, the procedure has undergone significant evolution in terms of refinement of technique, surgical approaches, variations in tunnel drilling, graft choice, and fixation methods. 1,7,8,18,21 Return to play at the same or higher level has also been reported at rates between 83% and 95%. 6,10,11,23,28 In contrast, repair, rather than reconstruction, of the UCL had historically poorer return-to-sport outcomes, ranging between 29% and 63%.…”

Comparison of a Novel Anatomic Technique and the Docking Technique for Medial Ulnar Collateral Ligament Reconstruction

“…The purpose of this study was to compare the gap size under valgus stress of the ''anatomic'' UCLR technique 3 versus the standard docking technique. We hypothesized that the anatomic technique, which restores the native UCL insertion using more distal fixation, would provide greater resistance to valgus stress (smaller increase in ulnohumeral gap) as compared with the standard docking technique.…”

“…Rather than a simple attachment on the sublime tubercle, the ligament insertion tapers as it extends distally along a consistent osseous ridge, with a mean length of 27.4 to 29.2 mm, 9,19 a mean width of 4.0 to 7.6 mm, 1,17 and an average insertional area of 187.6 mm. 3,4,9 As a result, surgeons have considered moving their reconstruction position more distally. Although the distal UCL fibers do not significantly contribute to gap resistance, 6 Camp et al 3 showed that a reconstruction with a larger distal ulnar attachment fails at higher loads than a reconstruction with the more traditional proximal ulnar attachment.…”