The Docking Technique for Medial Ulnar Collateral Ligament Reconstruction

Medial ulnar collateral ligament injury is common in the elbow following repetitive use in overhead athletes and acute trauma such as a fall on to an outstretched hand. This leads to valgus elbow instability confirmed with provocative testing. In patients with functional limitation and radiographic evidence of a midsubstance or diffuse ulnar collateral ligament tear, reconstruction with tendon graft remains the best option. The docking technique, which consists of hubbing the graft in a humeral socket and securing it over a bone bridge, has become the cornerstone of medial ulnar collateral ligament reconstruction, and is a vital tool in the upper-extremity surgeon's repertoire. Docking has improved on the prior figure-of-eight construct with the ability to tension the graft at the time of final fixation. Over the last 20 years, new wisdom has been accumulated around the technique. Here, we present evidence-based guidance and our own institutional knowledge for navigating this technically challenging surgery, detailing the relevant anatomy and approach, protection of the ulnar and medial antebrachial cutaneous nerves, ulnar and humeral tunnel creation, graft passage, and final graft tensioning. We also present technical pearls, such as graft selection criteria, avoiding tunnel coalescence, internally bracing the construct with suture tape and incorporation into the joint capsule, and addressing common anatomical variants. Management of potential complications and postoperative rehabilitation are also discussed. This overview aims to provide comprehensive guidance for trainees, serve as a reference for junior surgeons, and uncover new facets of this exciting operation for veteran readers.