Name: Lateral Ulnar Collateral Ligament Reconstruction
Uploaded: 2014-05-23T00:00:00Z
Channel: Arthrex

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.

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VID1-00044-en-US | B | Lateral Ulnar Collateral Ligament Reconstruction

Steven J. Lee

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

Operationstechnikvideos

Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

Vídeos de técnicas cirúrgicas

Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

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.

Lateral Ulnar Collateral Ligament Reconstruction

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