Ulnar Collateral Ligament Reconstruction of the Elbow: The Docking Technique

Abstract

Reconstruction of the ulnar collateral ligament (UCL) is one of the most commonly performed surgical procedures in overhead throwing athletes. Since its initial description, the procedure has undergone a number of technical modifications and advancements. This has resulted in multiple described techniques for UCL reconstruction. One of the most commonly performed UCL reconstruction methods is the docking technique. It has the advantages of minimizing injury to the flexor-pronator mass, avoiding the ulnar nerve, allowing robust graft tensioning, and reducing the amount of bone removed from the medial epicondyle compared with previously described techniques. This article provides a detailed description and video demonstration of how to perform this technique. When precise surgical steps are followed and postoperative rehabilitation appropriately progresses, this procedure has a well-documented history of reliably returning athletes to competitive throwing.

Fig 1

Our preferred graft is the ipsilateral palmaris longus. (A) With the patient supine and the left arm on an arm table, the graft is harvested through a single incision in the distal forearm. (B) As shown on this left elbow, the incision (dotted line) is approximately 8 cm long, travels just anterior to the center of the medial epicondyle (ME) toward the sublime tubercle, and does not cross the path of the ulnar nerve (UN). (C) The medial antebrachial cutaneous nerve (MABCN) is preserved, and the fascia is incised at the anterior aspect of the flexor carpi ulnaris (FCU).

Fig 2

(A) When viewing the medial aspect of this left elbow, once the capsule and native ulnar collateral ligament have been split longitudinally, the ulnohumeral (UH) joint is easily visualized. The 2 ulnar tunnels are anterior and posterior to the sublime tubercle and coalesce at their bases. (B) Proximally, the humeral socket is created at the origin of the ulnar collateral ligament at the anterior-inferior aspect of the medial epicondyle (ME). (C) Two 1.5-mm sockets are created proximally that connect to the base of the 4.5-mm socket. Sutures are later retrieved through these sockets to dock the graft in the 4.5-mm socket.

Fig 3

(A) Viewing this left elbow from the medial side, one can see that the graft has been passed through the ulna and the sutured end is docked in the 4.5-mm socket. The free end is then tensioned across the entry site of the socket, and the length is marked at this location. A Krackow suture is placed at this location, and the excess graft is trimmed. This suture is passed into the 4.5-mm socket and retrieved through the empty 1.5-mm socket. (B) After both ends are docked, the graft is tensioned and the sutures are securely tied over the bone bridge between the two 1.5-mm sockets. (UCL, ulnar collateral ligament.)