Revision Ulnar Collateral Ligament Reconstruction

Jeremy R. Bruce, MD; Neal S. ElAttrache, MD; James R. Andrews, MD


J Am Acad Orthop Surg. 2018;26(11):377-385. 

In This Article

Surgical Management

Preoperative Planning

Planning for revision UCL reconstruction starts with analyzing the initial surgical technique, including the location of the humeral and ulnar tunnels; the presence, type, and location of retained implants; the type of graft used; ulnar nerve handling and/or transposition; and other concomitant procedures. Elbow radiographs are obtained to assess for any arthritic changes, loose bodies, tunnel widening, tunnel position, avulsion fractures, and posteromedial olecranon osteophytes (Figure 1, Figure 2 and Figure 3). MRI and/or US can help the clinician to assess the integrity of the initial graft, flexor/pronator tears, impinging plicas, articular cartilage, and other soft-tissue abnormalities for which additional procedures may be needed.

Approach and Graft Selection

The previous surgical incision often can be used for the revision procedure. Extra care is required when looking for the medial antebrachial cutaneous and ulnar nerves because scarring from the initial surgery can distort anatomy and make it difficult to identify the nerves.

For primary UCL reconstruction, a palmaris autograft frequently is the graft of choice. In patients in whom this graft was used for the index procedure, the senior author (J.R.A.) prefers to use a contralateral gracilis autograft for the revision surgery. Options include a contralateral palmaris autograft or an allograft tendon. The gracilis graft has a larger diameter tendon than a palmaris tendon, which theoretically should provide increased initial strength. The disadvantage of a larger-diameter graft is that larger drill holes are required, which could increase the risk of medial epicondyle fracture. The use of gracilis grafts has been shown to increase the risk of medial epicondyle fractures in the setting of the figure-of-8 technique, most likely as a result of the large drill holes and strong pull of the larger tendon.[20]


Several surgical techniques for primary UCL reconstruction have been described, including the Jobe figure-of-8 technique and modifications, the docking technique, the David Altchek and Neal ElAttrache for Tommy John (DANE TJ) technique, and hybrid procedures.[21] The initial surgical technique, residual anatomy, and the cause of failure often dictate the revision surgical technique. Tunnel widening is less common in revision UCL reconstruction than in revision anterior cruciate ligament (ACL) reconstruction, most likely because the tunnels are extra-articular and are not bathed in articular fluid; therefore, unlike with occasional ACL revision reconstructions, bone grafting and staged procedures are unnecessary. However, like most revision procedures, revision UCL reconstruction is a technically demanding procedure as a result of scarring, formation of adhesions, and distorted anatomy. When UCL reconstruction failure appears to be caused by midsubstance graft laxity or a tear, the same surgical technique used for the primary procedure may be used, assuming good tunnel position and bone stock are present. For example, figure-of-8 tunnels created via a modified Jobe/ASMI technique for the primary procedure can be used again for the revision procedure if the tunnels are in good position with no evidence of widening[22] (Figure 5). However, the surgeon must thoroughly inspect the original tunnels for cortical thinning, bone loss, and/or complete fracture, which could make a classic bone tunnel technique a poor option.

Figure 5.

Illustration showing the American Sports Medicine Institute technique with figure-of-8 tunnels and tensioning with stitches on the graft. (Reproduced from Bruce JR, Andrews JR: Ulnar collateral ligament injuries in the throwing athlete. J Am Acad Orthop Surg 2014;22[5]:315–325.)

The docking technique is commonly used in primary UCL reconstruction. Some believe there is less risk for medial epicondyle fractures using the docking technique,[4] which requires one humeral tunnel with the limbs tied over a bony bridge. Another theoretical advantage over the figure-of-8 technique is the preservation of more proximal cortical bone stock, which may allow for more options during revision surgery.

Techniques to Address Ulnar Bone Loss, Insufficiency, or Fracture

During revision surgery, ulnar-sided bone loss, fracture, or sublime tubercle insufficiency makes use of previous bone tunnels, as in the classic figure-of-8 technique, a poor choice. Lee et al[23] demonstrated a cortical button technique on the ulnar side for revision UCL reconstruction in the setting of ulnar cortical bone loss or fracture (Figure 6). In this technique, the single ulnar-sided drill hole is started on the sublime tubercle at the UCL insertion and aimed 30° posterolateral to avoid the posterior interosseous nerve. The cortical button is locked on the ulna and then tensioned on the humeral side with a docking technique.[23] Another ulnar-sided revision option for ulnar bone insufficiency is to use a single drill tunnel at the insertion and secure the graft with an interference screw, as seen in the DANE TJ technique[4,24,25] (Figure 7).

Figure 6.

Illustration of the elbow joint showing the cortical button technique, which can be used for ulnar bone loss and tunnel fracture.

Figure 7.

Illustration showing the David Altchek and Neal ElAttrache for Tommy John (DANE TJ) technique with interference screw fixation in the ulna and the docking technique in the humerus. (Reproduced from Ahmad CS, ElAttrache NS: Elbow valgus instability in the throwing athlete. J Am Acad Orthop Surg 2006;14[12]:693–700.)

Techniques to Address Humeral Bone Loss, Insufficiency, or Fracture

Management of humeral bone insufficiency can be a challenge in the setting of revision UCL reconstruction. As mentioned previously, medial epicondyle fractures have been a rare complication of UCL reconstruction.[20] The figure-of-8 technique, which requires three drill holes at the humeral side, could increase the risk of fracture, especially when larger grafts and tunnels are used.[20]

Most fractures can be fixed with a single 3.5- or 4.5-mm compression screw (Figure 3). UCL stability should be reassessed in the operating room after fixation. When a fracture occurs >1 year after the primary procedure, the UCL may have healed and may not be affected by the fracture. When the graft has not had enough time to integrate, medial epicondyle fractures must be fixed immediately to prevent graft retraction. When the graft has been compromised, suture anchor fixation is an option to avoid redrilling tunnels in this already compromised area.

Hechtman et al[26] described a primary technique using suture anchors on the humeral and ulnar sides, alleviating the need for tunnels. This technique could be useful for revision procedures when bone tunnels may not be an option. Vertical bone troughs are made at the origin and insertion of the anterior bundle of the humerus and ulna, and two suture anchors are placed on each side. The center of the graft is tied down at the humeral side. Two loops of suture from the anchors are made on the ulnar side. The graft is passed through the loops on the ulnar side and then the graft is tied back on itself under tension.[26]

Hechtman et al[27] described another hybrid technique that uses traditional ulnar tunnels and suture anchors placed on the humerus, which may be a good option when only the humeral bone is deficient (Figure 8). Dugas et al[28] analyzed internal bracing with spanning tape anchored on the humerus and ulna to augment UCL repairs; this method may also have a role in UCL reconstruction revision to provide added stability.

Figure 8.

Illustration of the elbow joint demonstrating the use of a hybrid technique using a bone trough and suture anchors on the humerus for ulnar collateral ligament reconstruction.