Modified Jobe Approach With Docking Technique for Ulnar Collateral Ligament Reconstruction  Daniel J. Kaplan, B.A., Sergio A. Glait, M.D., William E. Ryan, B.S., Laith M. Jazrawi, M.D.  Arthroscopy Techniques  Volume 5, Issue 6, Pages e1321-e1326 (December 2016) DOI: 10.1016/j.eats.2016.08.002 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, it is seen how after preliminary exposure, release of the ulnar nerve is performed with care to protect it using a small vessel loop. The ulnar nerve is identified near the cubital tunnel proximal to the medial epicondyle, and is dissected proximally through the arcade of Struthers, releasing a part of the medial intermuscular septum. Dissection is carried distally as well, incising the cubital tunnel along the fascia of the flexor carpi ulnaris muscle. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, sharp elevation of the anterior flexor muscle mass is performed, proceeding proximally and anteriorly with care not to cut into the native ulnar collateral ligament (UCL) fibers. A blunt Hohmann retractor is safely placed over the anterior edge of the ulna, proximal to the site of the native UCL fibers inserting onto the medial epicondyle. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, dissection to the joint can be seen. Care is taken not to detach the flexor-pronator mass at the medial epicondyle, but to elevate enough tissue to provide easy access for bone tunnel placement. The native ulnar collateral ligament is incised in line with its fibers and the joint is identified. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the first bone tunnel is placed at the level of the sublime tubercle using a 3.5-mm drill bit and instrumented guide. A V-shaped bone tunnel is made. The ulnar nerve is retracted posteriorly while the tunnel is drilled. The tunnel is positioned at least 0.5 cm away from the joint, with one tunnel anterior and another posterior to the sublime tubercle allowing for a 1- to 1.5-cm bone bridge. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 The patient is placed supine on an operative table with the involved extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the medial epicondyle tunnels (the docking tunnel) are drilled based on the isometry location. The anatomic insertion of the native ulnar collateral ligament (UCL) on the medial epicondyle is the location of the first drill tunnel. Using a 4.5-mm drill bit and soft tissue protector with a 15-mm stop, the entry tunnel into the medial epicondyle is drilled in a similar orientation to the inserting UCL fibers. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, 2 connecting tunnels are drilled using a 2-mm bit. These tunnels should be posterior (A) and anterior (B) to the main docking tunnel with at least a 1-cm bone bridge between them. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the graft is first passed through the ulnar tunnel using a passing stitch, resulting in 2 limbs: an anterior and posterior limb. The posterior limb of the ulnar tunnel is then passed into the docking tunnel using the anterior passing stitch. The graft is pulled all the way into the docking tunnel until it bottoms out and the ligament is taught. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 The patient is placed supine on an operative table with the right extremity on a hand table. Viewing inferiorly toward the medial side of the elbow, the ulnar nerve is transposed anteriorly under a fascial sling of the flexor-pronator mass at the medial epicondyle. A large rectangular window is created and the nerve is placed anterior and under the fascial sling, which is loosely closed with absorbable suture. Arthroscopy Techniques 2016 5, e1321-e1326DOI: (10.1016/j.eats.2016.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions