Name: Ulnar Collateral Ligament Reconstruction Using the Docking Technique
Uploaded: 2022-09-20T00:00:00Z
Channel: Arthrex

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VID1-003559-en-US | A | Ulnar Collateral Ligament Reconstruction Using the Docking Technique

Anthony A. Romeo

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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.

Ulnar Collateral Ligament Reconstruction Using the Docking Technique

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