This video features Dr. Anthony A. Romeo performing a left-sided Ulnar Collateral Ligament (UCL) Reconstruction-commonly referred to as Tommy John surgery-on a young female athlete. Because the patient is part of the minority of the population missing the palmaris longus tendon in both arms, the surgeon utilizes a gracilis hamstring autograft.

The procedure, clinical rationales, and recovery trajectory are detailed below:

Graft Selection & Harvesting

Dr. Romeo selects the gracilis hamstring tendon rather than the larger semitendinosus because its diameter (typically 3.5 mm to 4.0 mm) perfectly mimics a natural palmaris tendon. This allows for smaller bone tunnels, preserving the patient's native bone structure. The graft is harvested from the leg on the same side as the surgery for operational efficiency. Once extracted, the remaining muscle tissue is meticulously cleaned off using the blunt end of a blade, and the graft is trimmed into a tapered "bullet-nose" shape before high-strength FiberLoop sutures are stitched into the ends to help pull it through the bone.

Surgical Approach & Addressing Pathology

• Incision & Nerve Protection: A medial incision is made over the elbow. The surgeon takes extreme care to isolate and protect the ulnar nerve posteriorly, as well as the antebrachial cutaneous nerves distally, preventing postoperative numbness or painful neuromas.
• Muscle-Splitting Technique: Rather than detaching the flexor-pronator muscle mass from the bone, Dr. Romeo uses a modern muscle-splitting approach. This creates a clean, virtually bloodless window directly down to the joint capsules and the native UCL.
• Pathology Removal: The patient had developed significant bone ossicles (calcifications) directly within the tissue from chronic instability. The surgeon carefully dissects and peels these bony pieces out of the ligament. Because this leaves a massive physical defect in the native tissue, a full reconstruction is required instead of a standard repair.

Tunnel Drilling & Graft Fixation

• Ulnar Side: Using a specialized V-guide system, two convergent tunnels are drilled near the sublime tubercle on the ulna. This instrument ensures a perfect 1 cm bone bridge remains between the holes to prevent the ulna from fracturing. A wire loop system known as a "candy cane" is used to cleanly thread the graft through.
• Humeral Side: A 5.0 mm blind socket is drilled freehand into the center of the medial epicondyle to a precise depth of 15 mm. Small suture exit holes are then drilled using a mini-ACL guide, ensuring the ulnar nerve is safely shielded out of harm's way.
• Tensioning & Closure: The limbs of the hamstring graft are guided into the humeral socket using a shifting, sequential technique. To lock in the correct tension without over-constraining the joint, the elbow is held flexed between 30° and 70° with varus stress applied. The sutures are knotted at the front of the bone, away from the nerve, and buried. The native UCL is then stitched side-to-side over the reconstruction to keep the new graft extra-articular (outside the joint lining) so it won't catch or snap during movement. Finally, the split muscle layer is anatomically closed with absorbable stitches.

Postoperative Care & Rehabilitation

Citing large-scale data from Major League Baseball’s tracking systems, Dr. Romeo notes that this specific procedure yields an excellent 85% to 90% success rate for athletes returning to their previous level of play. The timeline for recovery includes:

• Weeks 1 to 4: The arm is placed in a hinged brace initially locked at 75° of flexion. Over the first month, it is gradually opened up to allow motion from 20° short of full extension up to 120° of flexion. Limiting full extension protects the healing graft from excessive tension.
• Weeks 4 to 8: The brace is entirely removed, and the patient works to regain a full, natural range of motion. An aggressive, non-valgus strengthening program is initiated for the biceps, triceps, forearm, and rotator cuff.
• Months 3 to 6: Sports-specific training begins at month three. By four to four and a half months, the athlete is cleared for a flat-surface throwing program (starting with light tosses). By six months, pitchers can begin throwing hard off a mound, and position players can throw hard from a flat surface.
• Months 7 to 12: Athletes transition back into competitive game scenarios between seven and nine months, typically reaching their full pre-injury performance capacity by the one-year mark.