MCL Reconstruction
-Palmaris Harvest: 1cm transverse incision made at distal end of Palmaris to
expose the tendon. A freer is placed under the tendon and the tendon is dissected
all the way distally until it starts to fan out and you see wrinkles in the palmar skin.
A whipstitch is then placed in the distal end of the tendon for about 2-3 cm and then
the tendon is cut with a 15-blade at its distal end. Adhesions are freed up on all
sides of the tendon and a tendon stripper is then used to free up the tendon (aiming
at the medial epicondyle). A wet sponge is placed over the graft and placed on the
back table for later use.
-Plantaris Harvest: 2cm incision over the medial aspect of the Achilles tendon (~1
fingerbreath above the calcaneus). Dissect down until the tendon is seen on the
anterior aspect of the Achilles tendon (~3-5mm wide). Place a whip stitch in the
tendon and then run a tendon stripper up to the knee.
-Skin incision made from 4cm proximal to the medial epicondyle and distal along
sublime tubercle (make sure skin incision is anterior to the ulnar nerve). Dissect
down and identify the medial antebrachial cutaneous nerve (usually anterior to the
medial epicondyle) and protect. Make full thickness skin flaps on both sides.
-Identify the ulnar nerve proximally and take the triceps posteriorly with the ulnar
nerve (find the intermuscular septum and take the whole mass posteriorly). If
needed excise the intermuscular septum and expose the posterior aspect of the
humerus.
-Find the flexor-pronator mass on the medial epicondyle and incise the fascia at the
anterior 2/3 and posterior 1/3. Bluntly split the muscles 1-2cm and incise the
deeper fascia layer of the FP mass and continue to bluntly split the muscle. Expose
the UCL and capsule and then incise the capsule/ligament in line with its fibers (for
later repair) and expose the area surrounding the sublime tubercle.
-Modified Jobe: Use a 3.5mm drill to make 2 holes 1-1.5cm apart near the joint line
at the sublime tubercle and connect the drill holes with curette.
-KY Modification: Use a 4mm round burr to make a hole at the isometric point and
create a cavity (take care not to drift posteriorly). Use a Beath pin to drill across and
out the lateral cortex of the ulna, create a 2cm accepting incision over the lateral
ulna and then tie the sutures of the graft over a button.
-Use a 4mm drill (or 4mm round burr) to make a hole at the insertion site of the
anterior band of the MCL (which is on the anterior-inferior surface of the medial
epicondyle at the joint line directed upward). Now you can use a 3.5mm drill to
make one anterior hole and one posterior hole (if using modified Jobe figure 8
techniqe) or a 2mm drill or 2mm straight burr (if using the docking technique).
-Place the Palmaris graft through the ulnar tunnel and then cross the proximal ends
(figure 8) into the anterior and posterior holes (but both enter the insertion site).
Tension the grafts and then sew them together with fiberwire. If using the docking
technique estimate the entry site in the tunnel and then place a Krackow stich going
distal to the entry site and amputate the rest of the graft. If using a plantaris, use a
quad-looped graft.