The UCL Instrument Set makes precise sockets and tunnels along with easy suture/graft passage and includes all the instrumentation needed to perform elbow UCL reconstructions. It will accommodate all techniques including the Modified Jobe technique, Docking technique, DANE TJ technique, as well as any technique using Tenodesis Screws or button fixation with sockets. 

 
This set allows the precise placement of bone tunnels and sockets in the ulna and humeral epicondyle using guided instruments, drills and/or reamers. A recommended disposables kit provides novel instruments to easily pass sutures through the prepared bone tunnels and sockets, making graft passage a quick and easy part of the case.

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Arthroplasty Shoulder

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

Christopher L. Camp, MD (Rochester, MN), demonstrates a cadaveric medial ulnar collateral ligament (MUCL) reconstruction docking technique using the UCL reconstruction set and disposable UCL kit.

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Docking Technique for Elbow MUCL Reconstruction

Here we have our specimen. Distal is to the left. Proximal is to the right. We're looking at the medial aspect of the elbow. So I'm going to draw out a few landmarks. Here is our medial epicondyle. Obviously the ulnar nerve is behind that. For our incision we're going to start about two centimeters proximal and travel about 4 to 6cm distal. For this distal aspect of the incision we'll try to center that over the sublime tubercle. In most patients you can palpate the sublime tubercle through the flexor pronator mass. So I tend to do that to help orient my incision. We are not planning on doing an ulnar nerve transposition in this case. If I were considering doing an ulnar nerve transposition, I would cheat my incision a little bit posterior. So that way at the end of the case, the ulnar nerve would be in the front. The incision would be in the back. So if I were ever in a setting where I had to go back in on the elbow to revise something, I would be making my incision over an area where the ulnar nerve is safe and far away. But since we're going to leave the ulnar nerve alone. I'm going to make my incision right over the medial epicondyle. Heading down to the sublime tubercle. So as we come down on the medial side, we're going to be looking for the medial antebrachial cutaneous nerve of the forearm. Here I can see it superficial to the fascia and deep to all the soft tissue. So we'll try to preserve that throughout the entirety of the case. Once I'm down to the fascia, I'll then take a raytech or a sponge and sweep it to clean it off so that I can identify the underlying muscle. I will also make an effort to palpate and know the the location of the ulnar nerve, which is back posterior to the medial epicondyle. Usually easier to palpate if you go proximal to the medial epicondyle. So I know where it is. We're not going to expose it. But I do want to know where it is so that we can keep it protected during the case. We're going to start by making our tunnel on the ulna. Before doing that, it's critical that we understand where the joint line is. There's a few different ways you can do this. One of the more common ways is to make a split in the middle of the ligament, in line with the fibers. That can be helpful. However, I often like to exploit the injury. So in this case, we're going to assume that this is a complete proximal rupture. So I'll simulate that now by releasing the ligament proximally off the medial epicondyle. So in this case this is going to represent my proximal disruption rather than cutting the ligament in line with the fibers. I'm actually going to exploit this interval to help me find the joint line. So I'll split the capsule just anterior and posterior to this. And I'll elevate the ligament off. In its entirety. And now I've not violated the mid portion or the mid substance of that ligament. I've left it attached on the sublime tubercle and flipped it over. And you can easily see and identify the joint line there. So before we drill our tunnel on the ulnar side, I'm going to place a locking whipstitch using a 200 FiberWire suture. In this, which will allow us to repair it underneath the reconstruction. So now we have a running lock stitch in our native ligament that will repair down at the end, and will repair this underneath the reconstructed ligament, so that the reconstruction lies in an extra articular fashion. Now we'll turn our attention to the ulna clear to see where the joint line is. I'll now come make a small area just anterior to the sublime tubercle to breed the soft tissue. Get down to bone and then posterior. We'll do the same. Obviously, here we want to be mindful of the ulnar nerve which is posterior to this. And again this we make about a centimeter distal to the joint line in the distal aspect of the sublime tubercle. And when we do our drilling we're going to be very careful to make sure that the drill doesn't penetrate intra-articular. And now we've created a landing spot on either side of the Sublime Tubercle. So we're going to introduce our v shaped drill guide to drill two sockets that converge at their base. So I'll put that in place. Again, I'm straddling the sublime tubercle. We'll drill the posterior hole first. Perfect. Now we can place the obturator to hold us in position. And then we'll drill the other socket. Again, these drill bits have a hard stop on them, so you get the same depth every time. Remove the obturator. We'll remove the guide. Next we're going to take our small angled curette. And we'll use that to remove any bone debris that may remain. And I like to insert it in one side and visualize it in the other to know that my tunnel is complete. I'll do that on both sides. We'll then take our chamfer tool to chamfer both of these to remove any sharp bony edges. Prevent it from cutting our graft. Next we'll use our needle with the loop nitinol wire that comes in the disposable UCL kit. We'll use that to shuttle a suture through the tunnel that we've created. And now we'll pass a looped suture through here, and we'll tag that and lay it aside. And later this will be used to shuttle our graft through the ulnar side. So now we're done on the ulna. We'll turn our attention to the humeral side. So first I'm going to clean up the insertion point on the medial epicondyle. A common mistake is to put this out too far. Medial on the tip. The the normal origin of the medial ulnar collateral ligament is actually quite lateral on the medial epicondyle near the the trochlea. So with one hand I'm going to hold the medial epicondyle so I know exactly where it is in space. I understand my anatomy which is critical. And then I'll place the guide. This is the 4.5mm guide in the center of the origin. This has a depth stop on it that will allow it to drill to a depth of 15mm. Millimeters. So now I'll use the chamfer tool to clean up the edges so that I don't accidentally cut the graft. Next we'll use our humeral intersecting guide. This is designed so this piece can be placed into the socket that we just created. We'll then rotate this up to the anterior aspect of the of the humerus. I want to put both of my holes on the anterior aspect. I don't want any knots tied posteriorly to irritate the ulnar nerve or any other structures there. So I'm going to use the drill to see where I would come through the flexor pronator mass. I mark my spot there, and then I'm going to make just a small split in the fascia. So that way I can do it cleanly with a knife in line with the fibers, rather than in a traumatic fashion with the drill. Now I'll make two penetrating holes. There's the first, so I'll move anterior to get these at least one centimeter apart. So we have an adequate bony bridge between the two. We'll then remove our guide, insert the sled into the socket, and we'll take our micro SutureLasso find the holes we just created and then shuttle the wire through. So we'll shuttle this through. I'll keep the looped in on the distal side, and we'll tag this and set it aside. We'll then repeat that process for our other hole. So now we've passed all of our shuttle sutures. We're ready to bring our graft up to the field and pass it on the ulnar side. So this is our palmaris longus autograft that we harvested at the beginning of the case. This is my preferred graft for these types of cases. So you can see we already put a locking whipstitch in the graft when we harvested it. So we'll pass this sutured limb through our ulnar side first. So we'll use the suture that we placed previously in the ulnar tunnel to shuttle this graft down. So often there's a lot of resistance that you can meet there if needed. You can always trim trim the graft down to size or contour it to make it a little bit less cylindrical and bulky at the tip. So now you can see we have one sutured limb and one free limb. I'm going to take the sutured limb, as well as one of the stitches that I put in the native UCL at the beginning of the case, and I'm going to shuttle those into the socket on the humeral side. And as you see, that pulls our native ligament nice and tight and then docs the graft into the humeral socket. I'm going to pull on the other side to take all of the tension out of the graft and get it as tight as I possibly can. I'll then fold it over. We're going to take the elbow and cycle it through an arc of flexion and extension to remove any creep that might be in the graft. And I'll then use a marking pen to mark my entrance into my humeral socket. I'll tag the stitches to Churches to help hold the graft in place. And then we'll run a locked whip stitch in the free limb of the graft. I've made this mark at where I anticipate this will enter the tunnel. So I'm going to start about ten millimeters proximal to that mark to start my whip stitch. And then we'll travel distal after our whip stitch. We'll then cut off the excess graft. If you have a very small graft you can actually keep this and fold it over and make A33 tailed graft. I generally don't do that if I have a graft that's of adequate size. So now I have a graft. I like my length. I'm going to combine this suture with the other stitch that I placed in the native muscle. And we'll then shuttle those three into the socket. I'm going to independently tension each one. So now we'll hold tension. So I've tagged the sutures that are in the graft. And next I'm going to tension this. And I'm going to tie the two sutures that were used to repair the native ligament. This gives me that robust repair underneath the reconstructed ligament. So then after final tensioning, we'll tie the sutures that are in the two limbs of the graft to secure it into place. And this is over the one centimeter bone bridge that we created earlier. We're doing this while the elbow is held in about 30 degrees of flexion of varus load is applied to reduce the medial elbow and full supination. So at the end this is our construct. We have the two limbs of the graft here. The repaired native UCL is underneath. Then remember we did make a split in the capsule on both sides of the of the native UCL at the beginning. So we're going to close that. So this all becomes one solid structure. So I would use an absorbable suture to do this at the end of the case. So now we can see the new graft is united with the repaired UCL underneath and everything is extracapsular. We'll then remove our retractors, close our fascia. Both are fascia split here and the small split we made up proximally for our proximal drillholes, using buried sutures so that they're not prominent. We'll allow the medial antebrachial cutaneous nerve to rest back in its normal place, and then close in layers post-operatively. We'll apply a sterile dressing, and this patient will go in a splint with the elbow in approximately 70 degrees of flexion and neutral rotation. Generally we'll keep them in that for a period of two weeks. We'll then remove that at two weeks post-op, place them in a hinged elbow brace and work on progressive elbow range of motion, with the goal of restoring full range of motion. Around six weeks post-op. At that time, we begin some gentle strengthening and depending on the nature of the tear and the repair, usually will initiate a gradual return to throw program somewhere around 3 to 4 months post-operative if they meet appropriate criteria.

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.

French (Français) - fr

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Epaule & Coude

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Elbow UCL Reconstruction Set (AR-7700S)

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.

Dr. Scott Steinmann from the Mayo Clinic (Rochester, MN) describes helpful tips for operative set up, patient positioning as well as methods to establish safe portals for common elbow arthroscopy procedures. Several new products are highlighted to assist surgeons in elbow positioning, tissue retraction, capsulotomy, and novel instrumentation for osteophyte removal. Dr. Steinmann also presents an interesting approach to traumatic elbow dislocation injuries that may provide better patient compliance and outcomes.

Elbow Arthroscopy and Arthroscopic Tennis Elbow

Thank you, Brian. Thank you. Reinhold. I would like to echo what Gus was saying about the UCL. Said. I think it's really made a big, big difference. And I use it on the lateral and medial side of the elbow. And the last thing we're working on is making a smaller Chinese finger trap to help pull it through. I think a lot of us have had trouble. You put the whip stitches in, you try and pull the graft through and it gets caught. And with the Chinese finger trap, you can pull it through a lot, a lot easier. So I don't think that'll that'll really help. And as you heard, there's a lot of new new products coming out. Arm holders. And what I'll talk about is I'll kind of go through the arthroscopic part a little, little bit quick. I think we kind of have an idea about elbow arthroscopy, and I'll just focus on some, some new things that we can do with, with some of the new products. Well, it's obviously becoming more common for elbow arthroscopy with the continued advancement in techniques, I think we're becoming much better at dealing with arthritis in the elbow and dealing with all areas of arthritis in the elbow. There's still a real risk of neurovascular injury with elbow arthroscopy. I think that's the key thing that we've been trying to do is to try to try and make this technique safer, and therefore more available to more surgeons that don't do arthroscopy, the elbow that commonly. Typically you see an x ray like this, but if you actually get a CT scan, it gives you a real roadmap of a 3D CT to kind of see what you need to go osteophytes in the railhead, fossa loose bodies by the coronoid, and then posteriorly you can see osteophytes coming off of the sides of the electron. And I'll show a video in a little bit. But the, the new PoweRasp that was developed primarily for the shoulder, actually, I think is a great new product for the elbow because it makes taking out that osteophyte there safe, whereas I typically use a round bur which can easily wrap up the ulnar nerve that lives right, right over here, and we'll be able to see that later. Not wrapping up the ulnar nerve, but I tend to use general anesthesia in the in the lateral decubitus position. Here's a typical setting. You can see the armhole that we'll talk about tilting the table a little bit toward the surgeon itself, trying to get that dependent arm out of the way of your knee and hip so you can actually get into the patient a little bit more ergonomically. And the ability to move this arm holder both in and away and up and down. So if you have a female patient you can adjust it. And a male patient and potentially a fairly inexpensive product for most hospitals. You can see here we're tilting the patient toward the surgeon as something I've sort of noticed over the years that as you do a long case, the patient will tend to pull backward from you, and then suddenly you'll have the arm holder in the antecubital fossa, which is obviously inhibiting your ability to get anteriorly in the elbow. And you want to make sure also that you can actually flex the elbow up. Particularly important when you're working in the back and in the back of the elbow. I always like to say the elbow should be the highest thing in the room. So when you're prepped and draped, if you have a shaver in here, you're not banging against the side of the body, but you have 360 access to the elbow, and the elbow is not down here, in which case your shaver, your camera bangs into the side of the body. Looks like that just before you're about to start. There are no wrong portals in the elbow. You kind of have to have a imagine a three dimensional view in your mind of where the nerves are. It's all about avoiding the nerves. As long as you're not going through a nerve or an artery, it's a safe portal. And so it really doesn't matter to me whether you start medial, lateral or posterior. I'll start in the back of the elbow. If there's more work to do in the back of the elbow, usually it's more to do in the front, but if there's more to do in the back based on the CT scan, that's that's where I'll start. There's no limit on the number of portals, but I think it's best to try and just make the portals you need, just as in the shoulder, to avoid blowing up the blowing up the joint, and to mark out all your potential portals. First we're looking at the lateral side there. I tend to do an anterolateral portal first, because that's the portal that's going to be closest to a major nerve, the radial nerve. If I get that portal done out of the way before the elbow swollen at all. All the elbow portals are easier to start from that. I think insufflating the elbow is a very important aspect. I don't do that in the shoulder and you can see why here. If you don't insufflate the elbow and you come with your trocar, you will slide across. Most of the time, the capsule inflating the joint just allows you to pop in. It doesn't move the nerve further away. It's still right on the capsule, but allows you just easier to get in and get started. Typically easier to do that right over the radar BioPatella joint itself. And so that's where we typically do the anterolateral portal first. If I feel I'm in the joint just to speed things up, I'll just push straight across and then take a scalpel and cut down on that side. You can see here we're just. I can tell that. I can tell that I'm in the joint. So I just immediately cut down and then we're off and going and get things started. Thinking about the elbow arthroscopy set that makes it makes us all a little bit, a little bit easier. Do a switching stick to get to the to the other side. I find this articulating retractor that's also in the set that we developed. Helpful, particularly to get the ulnar nerve sort of out of the way. If you're in the back of the elbow, you can bring that in close to the nerve and lift up rather than just lever down. And I think that's very helpful when you're working, particularly if you've got osteophytes on the medial side steps. We kind of went through anterolateral portal first, at least in my practice. Do your bony work first. Here you see a burr, which is obviously we'll talk about the PoweRasp in a little bit. Take out your loose bodies, then do a capsular resection. And I've learned that it's not important to take out all the capsule, but I usually leave a large postage stamp, so to speak, over where the radial nerve is coming down over the radial head. I think that's important. There's really no no need to take out all the capsule just off of the humerus and off of the insertion down onto the ulna. Protecting your radial nerve as you do that. Now, switching this is actually looking in the posterior medial gutter. So this is posteriorly. Right behind the PoweRasp is the ulnar nerve right behind the capsule. Now imagine having a burr right there. Yeah it'd be scary. But with the with the PoweRasp you can see this osteophyte just melts away. And it's important to get these osteophytes out if you really want to do a good job. Taking just a tip of the electron as it comes into olecranon fossa is not enough. You go down both sides of the olecranon to really clean it, clean out the elbow, and you can see here we've. We have the ulnar nerve on the other side. And then if this was a stiff elbow then I would release the capsule here exposing the ulnar nerve. But don't do that until you've finished taking the osteophytes off. So I'm not worried about the ulnar nerve. We're just a short while ago I would be. So I think that's a that's a big help toward making elbow arthroscopy a safer for for all of us. You can watch it again if you want. And again, as I mentioned, just above the radial head, there's a fat pad. You can see that at arthroscopy. And the radial nerve is right there. This is not always part of a standard part of the elbow arthroscopy formula. But you can you can see radial head down here. The radial nerve. Truly when you do a complete capsule ectomy as I did here kind of it almost doesn't want to go back, see. But it just wants to hang out there. That's when you see that fat pad. That's when you need to slow down and preserve that part of the capsule that's right there. On the nerve. As I was showing the PoweRasp, I was working down here and you can tell the ulnar nerve is right on the other side there. So you need to preserve that OCD just briefly. These lesions are often hard to get. People complain to me. It's hard to get there. It's really not that hard to get if you if you do an ergonomic 9090 approach going underneath the anconeus, giving you a view such as that so you can look at your lesion and very easy to microfracture and debris that if you just go under the anconeus the head up into. That region and just. Briefly on on tennis elbow. Some people say it should be called Rover's Elbow because it was described actually the sculling way before people were playing lawn tennis or whatever tennis was called back then. I think this is an important article by Marty Bowyer and Jill Hastings. If you think of the attachments on the lateral side of the elbow between two sides of a mountain, the sort of the safe side where the CRB and EDC complexes, that's what we're supposedly reading. And the lower half you can see here is the danger zone. This is where the lateral ligament would be. And you want to avoid taking that down. But just concentrating on the upper half of the capitellum when you're doing a release. I think we've kind of seen this. I'll just show the very, very beginning. But if you want to see from the medial side is this, and you want to be coming in reading the tissue off the lateral capitellum there, and that will give you a good, a good. Exposure. And just to finish up just something we've been we've been doing actually just for the past past few weeks. But if you have a traumatic patient that has a very traumatic dislocation of their elbow. Just to switch from arthroscopy for a moment, typically we've been using external fixers to hold these patients in place, and we've argued whether we should be using a hinged or static ex-fix as I've moved on just to static. Much easier, easier to put on, but I think using some of some of the techniques that we've learned, maybe this InternalBrace. But this is this was an elbow from a traumatic car accident. I didn't do any dissection. The patient did it themselves. Very unstable, exploded both the medial and lateral aspects of the elbow. But by putting a in this case we used a 3.5 SwiveLock with two FiberTape. And what we're going to do is pull that up and then put a 4.75 SwiveLock in here. This is an elbow that in the old days, which was not long ago, I would have put an external fixator on statically for just about 3 to 4 weeks. But here we're using this very strong fixation. Pulling that up. Repairing. Even putting an extra, extra number two FiberWire through. And we'll use those two number two fibers to secure the soft tissues. Using this as an internal ex-fix or brace to hold the elbow together, anticipating that it's not going to last, you know, six, eight weeks. But I don't really want it to. I just want to last until the soft tissues here heal. And we're going to stitch the muscle back together. That was all exploded. And then look at the medial side of the elbow, but very stable right out of the box. And this patient actually went back. You can see an open wound over here for some plastic surgery procedures. And multiple times at least two times back to the Or undergoing anesthesia. And you worry obviously about them pulling the elbow out during that time frame. I just saw her back in the clinic and she was doing fine. So I think I think potentially we were just in the lab a little while ago working on that. So I think this might be, in certain instances, a way to avoid using an ex-fix for the very traumatized elbow situation. Thank you very much.

UCL Suture Passing Disposables Kit (Includes: #2 TigerLoop, #2 FiberLoop, Curved Micro SutureLasso w/Wire Loop, 4.5 mm Wire Skid, Chamfer Tool, two Suture Passing Wires, SuturePasser, blunt curved needle with Nitinol Loop and 6 inch ruler)

Kit de instrumental desechable para pasar suturas LLI

Kit de descartáveis para passagem de sutura UCL

BicepsButton, 2.6 x 12 mm, titanium

BicepsButton, 2.6 x 12.0 mm, Titan, steril, IM

Tenodesis Screw, PEEK, Vented, 5.5 x 15 mm

PEEK Tenodesis Schraube, 5.5 x 15.0 mm, steril, IM

Tornillo Tenodesis de PEEK, Ø 5.5 mm x 15 mm

Parafuso de PEEK com orifícios para tenodese, 5,5 x 15mm

Parafuso PEEK orifício tenodese 5,5x15mm

Tenodesis Screw, PEEK, 5.5 mm x 10 mm

PEEK Tenodesis Schraube, 5.5 x 10.0 mm, steril, IM

Tornillo Tenodesis de PEEK, Ø 5.5 mm x 10 mm

Parafuso de interferência em PEEK, 5,5 x 10mm

Tenodesis Screw, PEEK, 5.5 mm x 12 mm

PEEK Tenodesis Schraube, 5.5 x 12.0 mm, steril, IM

Tornillo Tenodesis de PEEK, Ø 5.5 mm x 12 mm

Parafuso de interferência em PEEK, 5,5 x 12mm

Destornillador Tenodesis para articulación AC

CHAVE DE PARAFUSO TENODESIS PARA ARTICULACAO ACROMIOCLAVICULAR

Elbow UCL Reconstruction Instrument Set

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Docking Technique for Elbow MUCL Reconstruction

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Advances in Elbow Arthroscopy Techniques

UCL/LUCL Reconstruction with and without Biologic Augmentation

Elbow Arthroscopy and Arthroscopic Tennis Elbow

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Elbow UCL Reconstruction Set (AR-7700S)

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