Ellenbogen

UCL-Einwegset für den Fadendurchzug

Das Ellenbogen-UCL-Einwegset für den Fadendurchzug beinhaltet zwei FiberLoop-Fäden der Stärke 2 für die Fadenarmierung der Transplantatenden in einer Whip-Stitch-Technik, gebogene Drähte für den Fadendurchzug durch den Ulnartunnel, einen Fräser zur Entfernung scharfer Kanten an den Knochenlagern und -kanälen, ein Micro SutureLasso und eine Drahtschlaufe für den Einzug der fadenarmierten Transplantatenden in die vorbereiteten Knochenlager und Bohrkanäle im Epikondylus humeri sowie ein ca. 15,24 cm langes Lineal zur Bestimmung der Transplantatlänge. Das Set unterstützt sämtliche Fixierungsstechniken einschließlich der Jobe-Technik, der Docking-Technik, der DANE-TJ-Technik sowie jeder Technik, bei der eine Fixierung mit Tenodesis-Schrauben oder Buttons zum Einsatz kommt.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Ulnar Collateral Ligament Reconstruction Using the Docking Technique

Hi, my name is Doctor Anthony Romeo. I'm from Rush University Medical Center in Chicago, and today we're going to demonstrate a ulnar collateral ligament reconstruction in a 16 year old baseball pitcher. We'll be using a hamstring autograft for our graft choice. Our plan is to perform a tunnel for the ulna fixation. And then to dock the two ends of the graft on the humeral side. We will be using the Arthrex ulnar collateral ligament reconstruction tray that was specifically designed for this operation. It has a number of very valuable features that includes the fact that there is a V guide for the ulnar drill holes that allows us to create a tunnel with the first time through, not by hand, but with a guide system that will allow the easy passage of a graft at the sublime tubercle. And in addition, there is a humeral guide system, which allows us to create a socket of socket of approximately 15mm, which is the appropriate size for docking the graph, and then also to have that an articulated arm for the humeral guide. That will allow us to drill two holes that are two millimeters in diameter so that we can pass sutures through at the medial epicondyle ridge and then dock our graft into the humeral socket. So here's our graft. It's a hamstring graft that we trimmed down to fit appropriately for the size. And we'll slide this through. We'll try a 4.0 just to show that it easily goes through the 4.0. And it slides through the 3.5 without a problem. So I think this graph size is good for what we're planning on doing when we're making our ulnar collateral ligament incision. We we want to be careful not to put our incision directly over the prominence of the medial epicondyle. So here's our medial epicondyle. And our ulna of course will be just below this area here. And our ulnar collateral ligament will go from the medial epicondyle down to the ulna. And what we're particularly careful about is the ulnar nerve. So we can feel the groove, the cubital tunnel. And we know the nerve will wrap around in this direction. So we want to be careful, particularly on our ulnar side, to protect against an injury to the ulnar nerve. And the incision could be made either through the cubital tunnel, particularly if we're going to move the ulnar nerve or can be made more anterior to the medial epicondyle to stay off of the area of the ulnar nerve. And the medial epicondyle. We need to get exposure on the ridge of the medial aspect of the humerus, distal humerus, so that we can put our two drill holes that we'll use to dock our graft. And we need to get down to the ulna. Our major neurovascular concerns distally will be the antebrachial cutaneous nerves of the forearm. So we have to be a little careful about that. So here's one of our antebrachial cutaneous nerves. And we'd like to preserve that. So they don't experience numbness on their forearm or develop an aroma which can be painful. So we have to free this up just a little bit. Let's have a couple of sends, please. The plane to identify our ulnar collateral ligament is going to be in this fascial plane with the muscle behind it and the muscle in front of it. And that will be our muscle splitting approach to do our reconstruction. And so here's the tip of our sublime tubercle. So now we're going to make an incision in the capsule of our joint and expose the joint of the elbow on the medial aspect. Which one of these is a 3.5 diameter drill guide, and it will sit on both edges of the sublime tubercle. So we will slide this in. And we'll drill our two guides. There is a peg that will go inside once we're done with this drill. Charlie, can you put that in there for me? So this will hold our position accurately, and then we'll go ahead and drill our second drill hole. And then we're going to take a 4.0 curette and slide in. And we're going to connect our two. Make sure our two tunnels are connected. And the guide is set up so they are connected. This just helps to smooth off the edges and to take out any irregularities. So it'll be easier to pass our wire passing guide. And we'll go ahead and chamfer our hole so that it's it's the graft is well tolerated and slides through nicely with no edges to the bone. So there's a suture passing wire in the UCL reconstruction kit, which will help us to pass our graft through the ulnar tunnel. And then we'll do our best to identify that on the opposite side. And it should pretty easily. And that just makes it easier for us to pass our graft through this level. So the next thing is we'll take our graft. And once we have the sutures from our graft in place, then we can take our wire loop. Let's have a hemostat. Let's free that up a little bit on the back side here. Okay. So now we're going to lead the graft through. Do you have some mineral oil. Okay. And then we have a little mineral oil. Okay. And this should pass our graft through. Like that. So by using that wire loop and planning this all out ahead of time, we avoid any problems with our graph passing. And we have a nice solid graph with a tunnel that's a centimeter or more separated and very solid way of doing this without compromising any of our bone on the ulnar side. So now we'll go to the humeral side. And for this tunnel we need we have a 4.5 drill guide. And again we don't want to put too far medially or all the way in next to our articular surface. But we pick a point right in the middle in the center of the medial epicondyle. And we'll drill our tunnel. We have a drill that has a stop on it. So this should create a socket of about 15mm. And we'll take our chamfer again. So that'll be our socket that we're going to dock our graft into in just a moment. Now we're going to take the adjustable humeral guide that we use to place our tunnels that we'll pass our sutures through. And typically speaking, after we center this in our socket that we created, we'll then identify the proper position. Now surgeons sometimes will put both of the tunnels on the anterior aspect of the medial epicondyle. But you can put one anterior and one posterior as long as you watch out for the ulnar nerve, of course, or both of them on the anterior position. We're going to take our drill bit, which is a 2.0, and create our two tunnels one anterior, one posterior. Now this guide is set up so that once you've drilled the tip of this drill, will hit the tip of the inserted guide through the socket so that your tunnels are connected. We'll take our 2.0 drill guide and we'll go through the. The medial epicondyle ridge. And again this has a stop on it. So then we're all the way down. We should be in good position there. Okay. All right. Now we're going to go ahead and drill our second tunnel. So we'll go ahead and reposition this and pull back on this edge here. Let's extend that up just a little bit. Safer zone. Good. We're in good shape there. Okay. Great. All right. And then once we're done with that, we can then take our sked. We'll go back to we'll keep this in this position. We'll take our Cricut and just open this up enough so that we can see our tunnel, our socket that we created. We'll take our sked and we pass that through all the way in, and we aim towards the actual tunnel that we just created. So we pass it in, make sure it's seated and then aim towards the tunnel. Then we take a micro lasso. We put it down through the tunnel that we just created with the 2.0 drill. And what we'd like to do is we've got to be careful to aim towards our actual sked that we placed, and if it all lines up, the wire will hit the sked and bounce out and then be easy to pass. And because we're not quite done yet, we're going to go ahead and just put a suture in this position here. So if we can have a number two FiberWire. So you can if your graft is ready to go and you've already closed your ulnar collateral ligament, you can just use your wire loop to pass this through. But we'll go ahead and put a suture in place here to secure this down. And then we have to go ahead and also secure down our tunnel posteriorly. So we have a hemostat please. And again we'll go through the same sequence of events. We'll look for our tunnel. We'll make sure that with our micro lasso it goes through. And then we aim our skid directly towards the tunnel that we created. We just made a slight adjustment in our micro lasso. And sure enough, here comes our wire loop. We'll take an additional suture, so we'll pass this on through, take our skid out. And they're the most complicated part of this procedure For most of us is getting our tunnels established and making sure that we can pass our graft through. And that was simplified by the drill guides and our exposure. We'll take a hemostat, please. Okay. Next stitch please. The first limb of the graph, which is coming out posterior through our anterior tunnel. So we'll take this here and we'll use our suture as our suture passer. We'll just make a loop in our suture and pass this on through. And then we'll figure out the distance that we need to cut off our other side of our limb, of our graft, so that we can dock the graft and make sure that both limbs of the suture are nice and secure. So we'll pull on this and line this up and go through as we see here. And we'll pull this nice and secure. So it's all the way that's buried in. So we know that that's the greatest distance it can go in. So now what we have to figure out is where do we want to cut this graph. So we'll take a hemostat. And this is the opening to our tunnel right here. And then if we need the if we know that the tunnel is 15mm, we have to guess. We have to judge a little bit less than 15mm to make sure that there's room for both of the graphs to bottom out. So we typically choose about one centimeter. That should give us some play. So that we have about five millimeters of space available that we can rotate or shift our graft to make sure that it fits securely. We'll take a FiberLoop for the final limb, and we'll start at about the level where we think the graft will enter into the socket that we've created, and usually with the with the last. Right after the last one, we'll come back on the graft again to lock that last stitch in place. And once we're convinced that our graft is in a good position, which looks good, we'll take a knife. A fresh plate with a fresh blade, and we'll cut our graft. We'll take our remaining suture that we're using as a suture passer. Make our loop. Pull our second end of our tendon graft through. We'll get the suture through first. And now here's where we actually dock our graft. So we'll take an adson elevator. We'll back out our opposite graft. So we take a little tension off our other graft. We'll make sure that this graft will enter in appropriately as we see there. Almost. That looks tight. Yeah. Okay. So now. I'll tighten it down even more. We'll see the side. Yeah. We definitely we want to incorporate it into his native Mcrl2. So this is our our final reconstruction. The graph goes from the sublime tubercle. It's been placed through a tunnel and then brought together and reinforced and incorporated in with the patient's native ulnar collateral ligament. And it went through a tunnel in the medial epicondyle. And then it was fixed over the top of the epicondyle ridge with our sutures. So we have a nice secure graft. As we take this through a range of motion. You can see it's isometric. You don't see any change or stretch in the ligament. And it's a very secure graft. It's a tight graft that lines up well. And we'll be an excellent reconstruction. Allow them to get back to throwing a baseball. So now we'll go ahead and perform our closure. And our closure, as you can see is relatively straightforward. We'll take some number one bike roll. So this is our intramuscular layer that we've closed. We maintained our nerve Our cutaneous nerve to the forearm. Looks nice. Okay. Okay. So our next layer of wound closure is the. Is the subcutaneous layer. And we're using A20 monocryl. And then we'll finally put A30 monocryl with steri strips for our final wound closure.

Steven J. Lee, MD (New York, NY), performs a cadaveric demonstration of a lateral ulnar collateral ligament reconstruction of the elbow using a 4.75 mm fork-tip SwiveLock® anchor with FiberWire® or FiberTape® suture.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Lateral Ulnar Collateral Ligament Reconstruction

Hello, my name is Stephen Lee. I'm from New York. Orthopedics, the chief of hand and upper extremity surgery at Lenox Hill Hospital in New York City. Today we're going to be working on lateral ulnar collateral ligament reconstructions of the elbow using the Arthrex 4.75 4K SwiveLock with a tendon graft and an internal brace. Often, surgeons are frustrated in trying to perform this surgery because they often use techniques that are used on the medial side for ulnar collateral ligament reconstructions on the lateral side. I've tried doing that for many years and been frustrated by the won ability to do that, and to make a graph that's isometric and or to technically the putting that graft in on the lateral side is much more difficult because the landmarks are not the same and often variable. And as well as the lateral epicondyle is often has a very flat surface, as opposed to a prominent surface that you can drill bone tunnels through. So with the advent of the SwiveLock, it has allowed us to to place graphs in exact positions that we want on the humerus and the ulna, especially on the humerus. If that position is just off even a few millimeters, you'll find that your graft is significantly non-isometric, which will significantly frustrate you in the operating room. We're going to make this incision going from just proximal to the lateral epicondyle and extending down to the supinator crest. This is also known as pretty much a Kocher approach. So normally I'd just go ahead and palpate where the lateral epicondyle is. I'll feel where the radial head is. We can go move the radial head back and forth. And you can kind of feel where the lateral ligament is going to come down onto the supinator crest. And we can make an incision right straight through the fascia right on top of that. The nerve vascular bundles are pretty far away. The posterior interosseous nerve is far, far away. There's not really anything cutaneous nerves that we're too worried about here. So I'm coming straight down onto the lateral collateral ligament. The radial head is is up over here. This is the ulna that I'm down onto. And I'm just going ahead and dissecting onto the supinator crest, because we're going to try to find the isometric point with a with a guidewire. Because of this point, it might be a good idea just for this particular case to get a little rounder and flatten this out, and it'll help us to locate or stabilize our guidewire. So let's get a little rancher, take this little piece off. I've spent a lot of time trying to do this reconstruction via tunnels, like a Tommy John type procedure. And if you try to drill a tunnel on the lateral side, you see you have very little bone to work with, and it's very easy for you to break out and and cause yourself to have a fracture. Secondly, if you do any kind of tunnel system, then the entry point for your tunnel has to be somewhere about over here. You're going to see in a minute that that does not correspond to where we would normally pick our isometric point, and has led to many of my graphs that I put in via that method as being non-isometric. So in this cadaveric specimen, we have our patient who would normally be lying supine on the operating room table, and we have the arm on the floor. There are some radiological parameters we're going to need to go and look for. So there's a line that's made on the humerus that this particular line up over here. We want this to line up to be about 25 to 33% from the posterior humeral line. So you can make this line go anterior or posterior based on moving the elbow in this plane. So maybe we'll do that with a little live for live fluoro. So I'm going to hold down the fluoro. And you can see you don't see this posterior humeral line at all at this point. So I'm going to keep moving it. And if I move it to about here I Here, I can I think I can convince myself that's about 25% from the or quarter way from the posterior humeral line. Then once you have that position set, you need to find or be able to get as best as you can, concentric circles of the capitellum on the trochlea. And that position you're going to best do by moving the arm in this plane. So I'm holding the arm or the wrist in a position to hold my posterior humeral line where I want it to be. And after that I'm going to go ahead and move the arm into this plane so I can get my best concentric circles. The circles are pretty concentric. So if we hold that spot, we're going to go ahead and get it. Get a drill. A guide pin and start trying to see if we can find the very center of those concentric circles. And that would be two posterior. I think that's a pretty good spot right there. We're going to hold that and then go ahead and drill it that you might think this is the isometric point, but just basically off radiographic parameters is actually more anterior, which I think if you do a limited dissection, you'll, you'll actually think it looks to anterior. If you take a freer and look, you'll see how much space you have up until the joint. And that does look like it's the midpoint. The other way you can check clinically is you can feel where the radial head is, and at 90 degrees, I can get a pretty good idea where the radial head outline is with my fingers. This isometric point should be in the middle of my fingers, both at 90 degrees and then also in full extension. If I go ahead and open that together, I should be right in the middle. I don't know if you can see on the video, but you can see that I'm right in the middle of where I feel the radial head is. Swivelock we're going to use is a 4.75 4K tip SwiveLock, which you see here. The size of the drill that you're going to use may vary depending on one the size of the graph that you use, and theoretically Maybe how young or your patient is and or how hard the bone is that you're putting it into. I usually start with a 5.0 for a 4.75. Swivelock but if the it's too tight, you can always over drill with a 5.5mm drill on top of that. So we're going to go ahead and drill. So next we're going to go ahead and drill on the ulnar side. Finding the point on the ulnar is much easier. And this is the supinator crest. So if I feel this part here is the articular margin of the radial head. Right up over here is about the radial neck. You place that I want to go ahead and place. My drill is somewhere in between. So that's going to be right about this spot here. Okay. So here's here's my five millimeter drill. Drill that to about 15. Okay. So we went ahead and FiberLoop the tendon graft. So I'm going to have an assistant hold the end of my FiberLoop and put a little bit of tension on it. I'm going to take my fork tip and just grab maybe about the end a centimeter or two from the end with the fork tip, and just go ahead and dunk it right into the hole. Now I'm going to put the graft on the side that's facing the lateral epicondyle. And so my SwiveLock is on the opposite side. And we're going to have somebody my assistant also just hold very very gentle tension on that. So I have my graft dunked in. And as you hold the handle of the SwiveLock just go ahead and screw that SwiveLock in. Good. So I'm going to go ahead and test that one. You'll notice that our graph is maybe you can let go is pretty strong. It's able to lift this entire arm up without any issues. And not only that, but we also have dunked in the end of our FiberLoop, which we'll use as an internal brace, which is optional. You don't have to use it. I personally do use it. Okay. So now so we're going to dunk the humoral side. First thing I'm going to do is take a free FiberWire and hook it up onto my pitchfork. So this is the free FiberWire. This is going to act as my the other end of my internal brace. And so a question that comes up often is, is there a particular position I need to go ahead and put this graft in? The answer is no because this is more or less an isometric graft. I can put it pretty much in any position. So I normally keep it in whatever position the arm is laying in. And with just a very little bit of tension on this tendon graft over here, if I, if I pull too hard on it, I won't be able to push the graft down. So I'm going to put a little bit of tension on here and I'm going to go ahead and dunk this. Dunk dunk dunk. Good. So that's now set. I'm going to hold the handle and drive that SwiveLock into the hole. So that's the graft in itself which should be tied in very very securely. You can see I'm really pulling hard on this graph and it's pretty good. Now in addition to that, I think it's smart to go ahead and put in what we call an internal brace, which is my loop that we use for the FiberLoop for the ulnar side is secured and this loop is also secured as well. And all I need to do is tie these two together and it will give me even more fixation. And you could do this either together as one. Okay. I often do just a single tailed graft. If you are still of the method that you want to put a double tail graft in, you certainly can take this other end and dunk it in another spot over here. This graft feels really tight there. I'm going to put this in full extension. And you can see that this graph again is still very tight. Your closure is going to be your standard closure for fascia and subcutaneous and skin. And this operation should take about 20 to 30 minutes. In general, I will put them in a plaster splint for the first week. After that, they returned to the office, for which we'll take our sutures out and place the patient into a hinged type brace. I typically will allow range of motion, some range of motion from about 45 to 90 degrees. Again, because this is a isometric graft, there's no real science behind how much and what angles you're allowed to have. But I think that giving them some range of motion allows them some freedom. And at the same time, the brace itself protects my graft, even though I do believe this is a very strong graft for the addition of a biological graft and the internal brace with the FiberWire.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Ulnar Collateral Ligament Reconstruction Using the Docking Technique

Lateral Ulnar Collateral Ligament Reconstruction

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