The DANE TJ (David Altcheck, Neal ElAttrache, Tommy John) Technique is an elbow UCL reconstruction technique that combines proximal graft docking with a single distal interference screw fixation. The DANE TJ Technique can be performed using the Arthrex Elbow UCL Reconstruction Instrument Set. FiberWire and FiberLoop may be used to stitch the graft ends and for final humerus fixation and an Interference Screw for ulna fixation.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Kyle Anderson, MD, (Detroit, MI) discusses tips and tricks for elbow arthroscopy. Topics covered include operating room set-up, patient positioning options, portal placements and the relevant instruments and equipment available from Arthrex® to complete each procedure. Dr. Anderson also shows imaging options to best diagnose pathology and common arthroscopic elbow procedures.

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Advances in Elbow Arthroscopy Techniques

Elbow always seems to get thrown in at the end, even though I love it. In terms of positioning, I think we've already seen a couple of things that can be really useful. I like the idea that Bill presented with the TRIMANO for prone positioning. I find myself doing mostly supine positioning. Because most of the elbow arthroscopy I do is with something else, like a ligament or something like that. And I've used the TRIMANO for the supine position and can bring it down onto the hand table pretty quickly. We have a little extender at Beaumont that raises the clerk up, so that the TRIMANO gives you a little bit more excursion with that, but it's kind of nice and simple. I think we've all seen that if we're going to scope the elbow, obviously the proximity of our neurovascular structures is a greater issue than other joints that we deal with. So distension can be quite important regardless of position. And Lynch back in 86 showed us that we can have tremendous improvement in that safety if we get the elbow distended for a neutral position. So I don't want to ever lose sight of that. I was trained and still like the proximal lateral portal for my initial portal. I know a lot of us in the room like a medial portal as our starting portal, but this one gives me a lot of flexibility. I think the safety factor is is quite good, so I like the proximal lateral portal just anterior to the supracondylar ridge just above the epicondyle. Nice little soft spot there. And and again, quite safe. Everything that I do in the elbow. One of the exciting things for me is everything that I do arthroscopically can be done in either the arthroscopy tray that Arthrex now has, or the UCL tray that gives us a variety of options and for UCL reconstruction. But for the elbow arthroscopy, I've got everything in one set and that makes it really nice. Probably our most common indication for elbow arthroscopy is loose body removal. I think that's the bulk of what we do in an isolated arthroscopy arthroscopic procedure. And and so I guess it's fitting to put this first here, you see one in the anterior compartment right in there. I will use occasionally a spinal needle to localize it. I'll still go back and sometimes use outflow from the from my grasper cannula to bring the loose bodies toward me. I think it's a simple little thing to do that can make things quite nice. So we either have to do some dilation, which in the elbow can be dangerous. So there is a way of, of doing this more safely now with the dilation instrumentation that you see here. And again, I think that's quite nice. But I prefer to just break these up sometimes with a scissor. You can see we're going through with the one here. And then just take them out and fragments. And again, the Arthrex set has nice graspers that will let us take those out quite easily. Probably for me, the second most common excuse for elbow arthroscopy would be posteromedial impingement. This is almost exclusively with ligament reconstruction. I'm really hesitant to do any kind of decompression. In a thrower who is not also having a ligament reconstruction, I think it's a set up for a problem. We've seen that the stresses across the UCL go up, especially if we're removing normal bone. So I, I think it's a it's a UCL problem until proven otherwise. But fragmentation is notoriously negative on imaging. And even in when I was with David Walczak, we found that 38% was even missed on the MRI. So sometimes we'll get lucky and see it on this hyper flexion external rotation view where you see this little fragment here. And it's almost like a little mini nonunion. I'm going to skip through some of some of this very quickly. So we'll I really want you to use caution when you're doing any kind of resection of bone in the on the posterior medial olecranon, especially if you're not reconstructing the ligament. But I'll do the work through trans triceps portal while we're viewing from posterolaterally just lateral to the triceps tendon. And what we'll frequently see is this little fragment that again, it's almost like a little mini nonunion. It can be very easily missed because it becomes covered in fibrous tissue. If you see here, we'll kind of get in and look posterolaterally this one there in the obviously a supine position. And we'll this arthroscopic view will pick up in a second. You see where the spinal needle I don't know how well that this is kind of an old video, but you see that little fragment can move around and look fairly normal on your imaging. But yet I do think that causes a lot of grinding and a lot of pain. So I think it's really important, at least for me to look back here on every ligament that we do, we'll take a take a peek in the back, and then we'll come through and and debris that again trying not to remove a whole lot of normal bone. I think we've got pretty good evidence now that that's dangerous for our ligament. But those can be those can be very elusive. And also one of the things that we want to make sure we're doing is, is checking for a good valgus test. As soon as we do our initial assessment of the elbow. And very few of them are as obvious as this one here, where it really opens up quite a bit with, with with pronation and valgus stress. But in my hands, any opening basically is showing any significant opening. Here is a is a positive test. The problem is that you can have a symptomatic UCL and they don't open up a great deal, but you're reproducing their pain. So it's different than than our comparisons in the knee. Tennis elbow. I have to admit, is one thing that I go back and forth between whether I want to do this arthroscopically or open. I think it's compelling since the majority of the pathology is on the deep surface. Plus, we get to assess for other pathology. It is nice to do an arthroscope, but it's also quite gratifying and very simple to do it open and put a little split and then we can get a nice repair done open. Like excision is another one that's not extremely rare. For me and Neil and others have done some good work to show that golfers are a group that we see this in. I find it easiest to work through a posterolateral portal or I'm sorry, look through a posterolateral portal and work through a mid lateral portal. To to breed this. And actually the Torpedo shaver is great for this one. Just the entry is really nice with that. And so we can get that out of there and get rid of that painful clunk. And then lastly OCD lesions are something that less commonly need. At least for me. I'm not doing a great deal of this, but it's nice to do a microfracture of these. Again, working for me, mostly posterolateral because they're distal and addressing these. If I'm doing plugs, I'm usually opening for that. So but something that I certainly think in the right hands can be done. Arthroscopically. And then lastly capsule release or contracture release. I still like to work off of the humerus. I know there's a lot of people that can be very aggressive in removing capsule, but to me, if we if we're coming off of the humerus, I think our safety factor goes way up rather than what you see on the right, coming across straight across the capsule anteriorly. I don't think that the brachialis provides the protection that some people rely on. So we go ahead and do those capsule releases off the humerus. And again, I think the safety factor is much better for me. That's it. Nice and quick.

Augustus Mazzocca, MD, (Farmington, CT) discusses the diagnosis and treatment options for ulnar collateral ligament and lateral ulnar collateral ligament injuries. Available instrumentation and biologic graft augmentation allow precise transosseous tunnel formation for optimal patient outcomes.

UCL/LUCL Reconstruction with and without Biologic Augmentation

So briefly, the UCL off the anterior aspect of the medial epicondyle anterior is important when you drill that tunnel. They have a special guide for that. And then to the sublime tubercle basic physical exam, the milking maneuver by O'Brien. Really what you want to do is you want to stabilize that humerus and external rotation and really feel with your fingers the UCL as it goes through flexion and extension. And then obviously the moving valgus stress test by O'Driscoll, where you get a more of a dynamic feel for what's going on, trying to keep your fingers in the area of the UCL. You for imaging, although this is not the synequanon of of how to diagnose it. Obviously that's on physical exam in history. But you can see with the arthrogram the T sign nonsurgical rest anti-inflammatories. This is the UCL set. And any time you're going to be doing something where you need to drill converging tunnels to pass a graft, this is the set that you're going to want to have. This is just the approach to UCL. That doctor goes obviously over the epicondyle, making sure you have skin above and below, so you have plenty of room these videos that aren't running now, but we're running in the pre-op pre area show that this is a muscle splitting approach. There's not much controversy, but there's kind of two camps on whether you move the ulnar nerve or whether you keep the ulnar nerve based on where you're going to drill your tunnel, and then you split longitudinally on the video to the right the UCL to examine it. There's an ulnar offset guide, which there's been some articles on not doing kind of bone tunnels, but using kind of a tension slide technique to fix your UCL on the ulnar side. Jackson and Kyle Anderson just published an article in Jscs showing that the bone tunnels seemed superior to tension slide technique for strength and stiffness, but for some people this may be a good technique. This ulnar V guide I think is fabulous, and I was not trained either by Jimmy Andrews or at Kerlan-jobe, so I always had a certain amount of anxiety doing these UCL reconstructions. Somehow I was inferior. Doctor Bradley, of course, made me feel that way. And but by designing this set, you are set free now. So this is a very straightforward if you know the anatomy, then you absolutely can do a fabulous job. And it really is very a very successful system. They have both a 55 degree base if you want to have a 6.5mm bone bridge or 70 degree with an with an eight millimeter bone bridge. Whatever you want. They accommodate a 3.5 and four. There's a special operator that goes in so you don't mess up or drill outside of it. It really is fabulous. They have these SutureLasso wire skids where you can easily pin pass your wires. There's not a lot of fussing around trying to make sure that those tunnels connect, trying to make sure that they're wide enough to bring your graft through, or having your grass kind of cheese grater or get hung up. All of that's been eliminated. The humeral socket drill guide, like we said, coming off the anterior aspect of the medial epicondyle, 4.5 or 5, depending on how large your patient is or how big a tunnel you want, will form a 15 millimeter socket. And this is just us. I put my thumb and index finger around and drill up. Very straightforward, very easy to use. Then you put your guide in there, and then you go anterior and posterior for your docking technique. And that's kind of what I do clinically. This is this is just showing you the adjustable humeral guide. You can really adjust this wherever you want to be, wherever you feel safe, or wherever you think those. Tunnels. Are. Very, very straightforward. This is just showing the same thing where you're trying to put your sutures through those small tunnels up approximately to tie over a bone bridge. Sucking that docking technique in. You can see us bringing that into the sutures over that bone bridge, keeping it nice and tight, and then obviously sewing those two limbs together to increase the stiffness. Post-op splint and supination at 30 degrees for a week. Then we have an unloading brace. 0 to 45, 2 to 4. This is all off the Kerlan-jobe camp. That's the camp that I aspire to. Full range of motion after week six. Sometimes that can be a little delayed, but not to worry. There's a variability with that light grip. Immediately try to avoid all valgus stress for four months, and then between the next six months to a year, you start them on a slow throwing program for I've actually used this more often is from the lateral side. So terrible triad or chronically unstable or posterolaterally unstable elbows. Same type of system really. You're trying to do the same thing we do on the medial side or the ulnar side laterally. And that all comes to trying to drill those ulnar tunnels at the cristae in an anatomical sense, and then being able to pass that graft through those tunnels easily and effectively, and then up into the lateral epicondyle, this is the system we use. Just same kind of thing. Humeral prep on the lateral side is the same as what it is on the medial side as far as the docking procedure. And this becomes a very straightforward maneuver where you can really reconstruct laterally as as easily as you can do medially, then going way out of the of the box once again. Sternoclavicular joint. Another area of anxiety for me. This is a submariner. We have a naval base there in Groton, Connecticut who fell down the hatch. And you can see how this AC joint is popping up. And believe you me, I tried every non-operative thing to do to this guy, not to take him to the operating room. But when we got in there, what we were able to do is just kind of go right over that sternoclavicular joint. That's our incision. We did have a thoracic surgeon in there with us. So. Then you can see right here is the sternoclavicular joint. So this is the manubrium or the sternum. This is the clavicle. Just staying on bone. And then that is the unstable joint with this meniscal homolog right on the inside of it. Can we use that Eleanor Jewell guide to make the confluent tunnels on the sternum? Very straightforward because that's all you're doing. And then what we did was we drilled on the clavicle side about a centimeter from the edge of the joint and just pulled the sutures through and did kind of that same X type pattern that Jed Coon has talked about. A lot of other surgeons have demonstrated biomechanically. I was going to augment this to increase the stiffness with some interference screws. However, I was advised that in this area you don't want any kind of non-biological area, you don't want anything migrating into the chest. So we just left it and sewed it together. This elbow set really takes the pain and concern out of both ulnar collateral and lateral ulnar collateral ligament reconstructions, and it does give you good control when you're trying to drill confluent tunnels in other areas of the body. So thank you very much for having me.

DANE TJ Technique

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Advances in Elbow Arthroscopy Techniques

UCL/LUCL Reconstruction with and without Biologic Augmentation

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