Authors Preferred Method

The preoperative examination in the throwing athlete who has a UCL injury often reveals an intra-articular injury that needs to be evaluated and addressed at the time of ligament reconstruction. In addition, some athletes who have suspected ligament laxity might have equivocal opening on valgus stress examination. For these reasons, we often evaluate the elbow using arthroscopic surgery in conjunction with the ligament reconstruction procedure.

The arthroscopic evaluation permits visualization of the anterior and posterior compartments. The surgeon evaluates the anterior compartment for loose bodies and spur formation and examines the capitellum surface for reciprocal chondral lesions, which occur in acute or chronic UCL deficiency, and for osteochondritis disse-cans lesions (Fig. 7.8). Application of a valgus stress produces from 2 to 3 mm of opening between the medial ul-nohumeral joint in patients who have UCL insufficiency and serves as a useful diagnostic confirmation when ligament instability is uncertain.18 Although only 20% to 30% of the anterior bundle is visible from the anterior portal,16 medial elbow stability can be assessed during arthroscopic surgery.

We use arthroscopic surgery to evaluate the posterior compartment for loose bodies as well. Overhead-throwing athletes often develop a medial olecranon spur in association with the valgus extension overload that occurs during throwing.15 The surgeon easily can debride the spur at this time. We also evaluate the chondral surfaces of the posterior compartment. We have seen a characteristic reciprocal chondral lesion of the medial crista of the posterior humeral trochlea occur in association with the olecranon spurring in throwers who have UCL insufficiency. For these reasons, we have found arthros-copy to be a valuable adjunct to the evaluation and treatment of UCL injuries.

For arthroscopy alone, we prefer prone positioning of the patient. However, to prepare for both the arthroscopic surgery and the reconstruction, the patient is positioned supine. The arm is placed in the over-the-chest position, and an assistant either holds the hand or secures it with an arm holder, such as the McConnell® device. A pneumatic tourniquet is used for hemostasis. Routine arthros-copy portals are used to evaluate the elbow. After completion of the arthroscopic surgery, the arm is abducted and externally rotated and is placed on an arm board for the reconstruction procedure.

The surgeon makes a 10-cm curvilinear incision that is centered over the medial epicondyle. The fascia and aponeurosis of the flexor-pronator muscle group are carefully exposed, and the medial antebrachial cutaneous nerve is isolated and protected (Fig. 7.10). The nerve crosses the field anywhere from 3 to 60 mm distal to the epicondyle.32 If the patient has had a previous ulnar nerve transposition, the surgeon should isolate and protect this nerve. This possibility emphasizes the need for taking a thorough preoperative history.

After exposing the flexor pronator, the surgeon has two options for exposing the ligament. The standard approach, as Jobe et al. described, involves transecting the conjoined tendon of the flexor-pronator muscle mass 1 cm distal to the medial epicondyle and reflecting it distally to gain exposure to the medial capsule (Fig. 7.11).12 Although this technique is reliable for ligament exposure, we prefer the less traumatic, potentially less time consuming muscle-splitting approach.32

The interval for the muscle split is the fascial raphe between the ulnar-innervated flexor carpi ulnaris muscle and the median-innervated common flexor muscle mass. This raphe usually is identified easily at the posterior one-third of the flexor-pronator muscle group (Fig. 7.10). The

Flexorpronator Aponeurosis

FIGURE 7.10. Exposure of the fascia and aponeurosis of the flexor-pronator muscle mass. Branches of the medial antebrachial cutaneous nerve cross the surgical field. The raphe separating the common flexor muscle origin and the flexor carpi ulnaris muscle marks the line for the fascial incision for the muscle-splitting approach.

FIGURE 7.10. Exposure of the fascia and aponeurosis of the flexor-pronator muscle mass. Branches of the medial antebrachial cutaneous nerve cross the surgical field. The raphe separating the common flexor muscle origin and the flexor carpi ulnaris muscle marks the line for the fascial incision for the muscle-splitting approach.

Medial epicondyle

Medial epicondyle

Flexor Aponeurotic Release
FIGURE 7.11. The conjoined tendon of the flexor-pronator muscle mass is cut approximately 1 cm distal to the medial epicondyle and retracted to expose the ulnar collateral ligament and capsule. UCL, ulnar collateral ligament. (From Jobe FW, et al.12)

surgeon incises the fascia longitudinally along the raphe from the medial epicondyle to 1 cm distal to the sublime tubercle of the ulna, which he or she identifies using deep fingertip palpation through the flexor mass. The ulnar nerve lies just posterior to this interval, and the surgeon should identify and protect it before completing the muscle split. To expose the medial joint capsule, the surgeon uses blunt dissection to split the muscle fibers longitudinally in line with the fibers (Fig. 7.12). This interval separates the flexor carpi ulnaris muscle (medial) from the palmaris longus muscle (lateral) in the superficial dissection and separates the flexor carpi ulnaris muscle from the flexor digitorum superficialis muscle in the deeper dissection.32 After exposing the capsule, the surgeon exposes the medial ulna distal to the sublime tubercle using subperiosteal dissection to avoid transecting the mo-

Sublime Tuercle Elbow
FIGURE 7.12. The muscle-splitting approach to the ulnar collateral ligament demonstrating the insertion of the anterior bundle on the sublime tubercle of the ulna. UCL, ulnar collateral ligament.

tor branches of the flexor carpi ulnaris muscle. When developing the approach, Smith and associates used anatomic dissection data that identified the points of motor branch innervation from both the median and ulnar nerves to avoid denervation of the surrounding muscle.32

Next, blunt retractors are used to retract the anterior and posterior muscle masses, giving access to the capsule and ligament. A valgus stress is applied with the elbow flexed to 30° to assess the ligament. If the ligament is insufficient, the joint opens at least 3 to 4 mm when the surgeon applies a valgus stress.

By incising the ligament longitudinally, the surgeon gains access to the medial portion of the joint and can assess it for intra-articular injury. He or she should preserve as much as possible of the ligament's origin and insertion. The ligament and capsule can be closed before graft ten-sioning in a pant-over-vest imbrication to add support to the reconstruction. The entire anterior bundle is exposed from its origin to the insertion on the ulna. The subpe-riosteal dissection is continued distally for approximately 1 cm on the ulna to allow for graft tunnel placement.

We prefer the muscle-splitting approach for its ease of exposure of the medial capsule, low risk of muscle den-ervation, and potentially lower postoperative morbidity. In addition, if the preoperative examination indicates ul-nar neuropathy, anterior subcutaneous ulnar nerve transposition can be achieved easily through this approach. However, if the surgeon prefers a submuscular transposition of the nerve, the flexor-pronator muscle mass turndown as described by Jobe et al. is the best approach for combining these procedures.12 The surgeon must take care to preserve the motor branches to the flexor carpi ulnaris muscle.

Graft fixation is achieved through bony tunnels in the ulna and in the medial epicondyle. For fixation in the ulna, we continue to use the technique that Jobe et al. originally described; it entails placing convergent drill holes at the anterior and posterior margins of the sublime tubercle of the ulna separated by a 1-cm bone bridge (Fig. 7.13).12 The hard cortical surface of the tubercle provides an excellent bone bridge for graft fixation. The surgeon connects the holes under the bridge using a small, curved curette, taking care to preserve the bone bridge.

For graft fixation in the medial epicondyle, Jobe and associates described fashioning divergent drill holes from a single entry hole on the anterior portion of the distal epicondyle (Fig. 7.13).12 Using this technique, the surgeon advances the graft into one tunnel, around the epi-condyle, and back through the second tunnel in a figure-of-eight fashion. The graft is tensioned and secured to itself.

We have developed an alternative technique of countersinking the proximal ends of the graft into one uni-cortical drill hole at the anterior portion of the distal epi-condyle (or the origin of the anterior bundle) and tensioning the graft over bone-bridge sutures on the prox-

FIGURE 7.13. Placement of drill holes for ulnar collateral ligament reconstruction. Convergent drill holes are placed in the ulna anterior and posterior to the sublime tubercle with an approximately 1-cm bone bridge. Divergent drill holes are placed in the medial epicondyle in preparation for a figure-of-eight tendon weave.

FIGURE 7.13. Placement of drill holes for ulnar collateral ligament reconstruction. Convergent drill holes are placed in the ulna anterior and posterior to the sublime tubercle with an approximately 1-cm bone bridge. Divergent drill holes are placed in the medial epicondyle in preparation for a figure-of-eight tendon weave.

imal epicondyle. We use a 3.2-mm drill or small burr to create a 1.5- to 2-cm-long cylindrical unicortical tunnel in the medial epicondyle, preserving the proximal anterior cortex of the epicondyle. After burring, we use a curette to extend the tunnel proximally to the undersur-face of the cortex. Two 2-mm divergent drill holes are placed through the proximal anterior cortex entering into the cylindrical graft-docking tunnel to allow the graft-grasping sutures to pass through the epicondyle. The resulting bone bridge is used to tension and secure the graft in the medial epicondyle.

After preparing the bone tunnel in the epicondyle, the surgeon harvests the graft. We prefer the ipsilateral palmaris longus tendon. Its presence must be confirmed during the preoperative examination. If the tendon is not present, one of the alternative free tendon grafts named earlier must be used.

Traditionally, the surgeon harvests the ipsilateral palmaris longus tendon using a two transverse-incision technique. First, the tendon is identified through a transverse 2-cm incision at the distal palmar crease of the wrist. Using gentle blunt dissection to mobilize the tendon, the surgeon takes care to avoid the underlying median nerve and its palmar cutaneous branch. The proximal tendon is identified through another transverse incision about 10 cm proximal to the distal palmar crease. The distal tendon is cut at its insertion at the palmar fascia and advanced out of the proximal incision. It is transected at the musculo-tendinous junction and provides a graft of approximately 15 cm. The ends of the graft are secured with a no. 1 braided nonabsorbable suture using a running whipstitch. Instead of using the traditional technique, we have begun harvesting the tendon with a small tendon stripper using only the initial incision at the distal palmar crease. The harvest is faster and easier, and our patients have had no associated morbidity from bleeding or median nerve trauma.

The surgeon secures one end of the graft with a no. 1 braided suture (or grasping suture) using a running whipstitch. The graft is passed through the ulnar bony tunnels using a flexible suture passer or a passing stitch. Using the unicortical tunnel technique, the surgeon achieves proximal graft fixation by passing the secured end of the graft into the medial epicondyle tunnel and passing the suture out one of the proximal suture holes. This end of the graft then is tensioned manually to fully countersink the tendon end into the tunnel. Next, the free end of the graft is tensioned overlying the medial epicondyle before placment of the grasping suture. With one end tensioned in the tunnel and the other end tensioned overlying the medial epicondyle, the free end of the graft is cut approximately 1 cm proximal to the tunnel edge (Fig. 7.14). This cut allows the free end of the tendon to be countersunk into the tunnel, providing adequate room for ten-sioning. The free end of the tendon then is secured with a no. 1 nonabsorbable suture in the same fashion as the other end. The grasping suture is passed out of the second suture hole in the proximal epicondyle using a flexible suture passer or passing stitch. With both ends countersunk into the tunnel, the graft is tensioned (Fig. 7.15). The sutures are tied over the epicondylar bone bridge (Fig. 7.16).

We prefer the unicortical tunnel technique to the divergent tunnel technique of Jobe et al.12 because of its ease of graft tensioning and secure bone-bridge fixation. The tunnel must be fashioned carefully in a cylindrical, as opposed to a conical, shape to allow the graft to be countersunk adequately into the tunnel during tensioning. The graft also must be cut precisely to allow adequate countersinking in the tunnel for bony ingrowth, but it must not be so long that the surgeon cannot tension it within the confines of the tunnel.

Regardless of the proximal fixation technique used, the optimal arm position for tensioning the graft is approximately 30° of flexion. We prefer application of a varus

FIGURE 7.14. A unicortical hole is drilled in the medial epicondyle at the origin of the anterior bundle. Each grasping suture is brought out of one of the divergent 2-mm drill holes, which a bone bridge separates, in the proximal portion of the epicondyle.
Anteroposterior Elbow Instability
FIGURE 7.15. The ends of the tendons are inserted into the unicortical drill hole, and the graft is countersunk in the tunnel and tensioned.

stress to close the medial joint before tensioning the graft. Some forearm supination seems to help medial joint closure. Before final graft tensioning and fixation, the incised medial capsule and incompetent anterior bundle are closed in a pant-over-vest fashion to imbricate the capsule and augment the reconstruction. The surgeon moves the elbow through a full range of motion to assess final graft isometry and applies a gentle valgus stress in 30° of flexion to assess fixation. The tourniquet is released and he-mostasis is obtained. When using the muscle-splitting technique, we have not found the need to drain the wound.

Closure for the muscle-splitting technique is relatively simple. If the flexor-pronator muscle mass is turned down, it should be reattached securely. The fascial split is closed using interrupted no. 2-0 absorbable sutures. The skin is closed routinely and the arm is placed in a bulky, light-compression dressing. The elbow is splinted in 90° of flexion and neutral forearm rotation. The wrist is often left free.

FIGURE 7.16. With the medial joint closed, the sutures are tied over the bone bridge.
Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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