Efficacy of interference screw and double-docking methods
using palmaris longus and GraftJacket for medial collateral
ligament reconstruction of the elbow
Keizo Furukawa, MD, PhD,a Jamie Pichora, MSc,b Scott Steinmann, MD,c Kenneth J. Faber, MD, FRCSC,b
James A. Johnson, PhD,b and Graham J. W. King, MD, MSc, FRCSC,b Nagasaki, Japan, London, Ontario,
Canada, and Rochester, MN
Single-strand elbow medial collateral ligament reconstruc-
tion strength was evaluated by use of double-docking
and interference screw methods with either a palmaris
longus tendon or GraftJacket as the reconstruction mate-
rial. Thirteen upper extremities were mounted in 90° of
valgus orientation and subjected to cyclic valgus loading
that increased progressively until failure occurred. The
double-docking reconstructions outperformed the interfer-
ence screw reconstructions (P ⬍ .05), whereas the pal-
maris longus and GraftJacket performed comparably
(P ⬎ .05). The favorable initial strength of the GraftJacket
make it a potentially viable alternative to the use of au-
togenous palmaris longus tendons; however, further stud-
ies are required to evaluate graft strength during healing.
The clinical use of the double-docking technique of single-
strand medial collateral ligament reconstruction should be
considered because of its simplicity and initial strength.
(J Shoulder Elbow Surg 2007;16:449-453.)
T he anterior bundle of the medial collateral ligament
(MCL) is the most important valgus stabilizer of the
elbow.13-15 Repetitive valgus stresses on the elbow
may cause MCL insufficiency in high-performance
overhead-throwing athletes, resulting in pain and loss
of performance.8 Chronic MCL insufficiency may also
occur after traumatic dislocations and fracture-
dislocations of the elbow.10,18
From the aDivision of Orthopaedic Pathomechanism, Department
of Developmental and Reconstructive Medicine, Nagasaki Uni-
versity Graduate School of Biomedical Sciences, Nagasaki;
bBioengineering Research Laboratory, Hand and Upper Limb
Centre, Lawson Health Research Institute, St Joseph’s Health
Care London, London; and cMayo Clinic, Rochester.
Funding was provided by the Canadian Institutes of Health Re-
search and Wright Medical Technology.
Reprint requests: Graham J. W. King, MD, MSc, FRCSC, Hand and
Upper Limb Centre, 268 Grosvenor St, London, Ontario, N6A
4L6, Canada (E-mail: gking@uwo.ca).
Copyright © 2007 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2007/$32.00
doi:10.1016/j.jse.2006.09.020
Since Jobe and colleagues8 described their recon-
structive technique for the MCL-deficient elbow, many
methods have been reported by use of autologous free
tendon grafts, such as the palmaris longus, toe exten-
sors, hamstring, or plantaris tendons. The original figure-
of-8 Jobe technique required a transposition of the ulnar
nerve, detachment of the flexor-pronator muscles, and
creation of 2 ulnar drill holes. Because of problems with
ulnar neuropathy, the technique was modified to allow
the ulnar nerve to remain in situ.19 The surgical ap-
proach was also modified to allow the flexor-pronator
muscles to remain attached to the medial epicondyle.16
A recent biomechanical study by Armstrong et al3
demonstrated that a simplified method using a single-
strand reconstruction of the anterior band of the MCL
was able to restore valgus stability. Subsequently, sev-
eral authors have proposed single-strand methods for
MCL reconstruction.2,4 A single-strand technique mini-
mizes the risk of injury to the ulnar nerve from a second
more posterior drill hole and reduces trauma to the
flexor-pronator muscles by allowing a more limited ex-
posure. Docking of the MCL reconstruction in the medial
epicondyle has gained popularity because of the ability
to tension the graft and to obtain secure fixation.17,22
However, the effectiveness of docking the graft in the
ulna has not been reported. Furthermore, the effective-
ness of fixation with interference screws is controversial,
with one study reporting excellent initial strength
whereas another had less encouraging findings.2,4
In addition to problems with the ulnar nerve, a
number of complications have been reported from
harvesting autogenous tendon grafts, including inju-
ries to the median nerve in particular.20 Up to 15% of
patients lack a palmaris longus tendon, requiring autol-
ogous grafts to be harvested from other extremities, such
as the contralateral arm or the lower limb. The availabil-
ity of a safe and effective commercially available sub-
stitute for autologous donor tendons is attractive be-
cause of the potential decrease in operative time and
patient morbidity. GraftJacket (Wright Medical Technol-
ogy, Arlington, TN), a modified dermal tissue, has
shown promise in a number of applications1,7,11,12,21;
449
450 Furukawa et al
Figure 1 Two reconstruction techniques. A, The double-docking technique used a single-strand reconstruction and
tying of the sutures over a bone bridge on the ulna and medial epicondyle. B, After the graft was secured into the
ulnar drill hole, the interference screw method used a docking technique on the humeral side to tension the graft
before insertion of the screw.
however, its effectiveness as a material for MCL recon-
struction of the elbow has not been reported.
The purpose of this study, therefore, was to com-
pare the initial biomechanical strength of 2 single-
strand reconstruction methods of the MCL of the elbow:
double-docking and interference screw techniques. Two
graft types were evaluated: palmaris longus tendon
graft and GraftJacket.
MATERIALS AND METHODS
Specimen preparation and testing apparatus
configuration
Seven pairs of fresh-frozen human cadaveric upper ex-
tremities (mean age, 66.4 years; range, 61-71 years) were
used. All specimens were thawed overnight at room tem-
perature and kept moist with normal saline solution during
testing. Each specimen was sectioned 12 cm proximal and
distal to the elbow. The biceps, triceps, brachialis, and
flexor-pronator muscles and the anterior and posterior cap-
sule, as well as the posterior bundle of the MCL, were
excised, with the anterior bundle of the MCL and lateral soft
tissues being left intact. Optical markers with metal pins
were attached to the humerus and ulna near the attachment
sites of the anterior bundle of the MCL by use of epoxy resin
(Hardsetting Adhesive; Measurements Group, Raleigh,
NC). These locations were chosen to ensure that the mark-
ers did not affect the mechanical performance of the tissue.
The proximal humerus and distal forearm were rigidly fixed
in 7.5-cm-diameter cylinders with polymethyl methacrylate
cement. The forearm was fixed in maximal pronation with a
3.5-mm cortical screw inserted between the radius and
ulna. Each specimen was mounted in a custom testing jig,
which has been reported on previously,4 with the elbow at
90° of flexion and parallel to the floor, facing upward to the
J Shoulder Elbow Surg
July/August 2007
medial side. This configuration permitted valgus loading
via a force applied to the ulna, as described later. The
forearm and cylinder with cement were weighed at the
point of load application after the MCL was excised from
each specimen. A digital camera (DFW-SX900; Sony, To-
kyo, Japan) was placed perpendicular to the bony markers
to measure displacement between the ulna and humerus.
The resolution of the optical measurement system was such
that a 20-␮m change in position could be detected.
Reconstruction techniques
The paired specimens were randomly divided into two
groups; one underwent MCL reconstruction with GraftJacket
and the other with palmaris longus. In both groups, two
different reconstruction techniques were used (Figure 1).
The first reconstruction was performed by use of 5 ⫻
15–mm metal interference screws (Arthrex, Naples, FL),
and the second was done via a double-docking technique.
The origin and insertion of the isometric fibers of the
anterior bundle were identified visually by placing the
elbow through flexion and extension. A 6.0-mm tunnel was
created at the ulnar insertion on the sublime tubercle for
reconstruction by use of the GraftJacket, whereas a 5.5-mm
tunnel was used for the palmaris longus. The drill did not
perforate the lateral cortex. A 50 ⫻ 25–mm GraftJacket
graft was trimmed and rehydrated according to the manu-
facturer’s instructions. The GraftJacket was folded into thirds
and the palmaris longus was folded in two to create a
single-strand graft. A No. 2 FiberWire suture (Arthrex) was
placed at one end of the graft and locked 3 times by use of
a running locked suture technique.
A cannulated screwdriver and interference screw were
used for fixation of the graft in the ulna. The graft sutures were
tied over the ulnar interference screw to augment fixation
according to the manufacturer’s recommended technique.
J Shoulder Elbow Surg
Volume 16, Number 4
Figure 2 Mean (⫾ SD) maximum load for both MCL reconstruction
methods. There was no significant difference between the GraftJacket
and palmaris longus graft materials (P ⬎ .05), but the GraftJacket with
the double-docking technique performed significantly better than the
GraftJacket with the interference screw technique (P ⬍ .05).
A tunnel of the same size was created at the origin of the
isometric fibers of the anterior bundle on the medial epicon-
dyle without disturbing the posterior cortex. Two 1-mm drill
holes located 10 mm apart were placed through this hole and
perforated the posterior aspect of the medial epicondyle. After
reduction of the joint, the graft was trimmed to the proper
length to avoid bottoming out in the humeral tunnel while
tensioning the graft. The proximal interference screw fixation
method differed from the manufacturer’s recommended tech-
nique so that similar graft tensioning could be established for
all graft types. The proximal end of the graft was sutured with
No. 2 FiberWire by use of a running locked suture technique.
The sutures were passed through the holes in the medial
epicondyle rather than through the cannulated screw and
screwdriver, and the grafts were pretensioned at 20 N for 5
minutes by use of a spring scale. The proximal sutures were
tied over the posterior aspect of the medial epicondyle bone
bridge. Proximal graft fixation was obtained via an interfer-
ence screw that eccentrically displaced the graft toward the
trochlea within the medial epicondyle tunnel.
The bone tunnels used for the interference screw method
(6.0 mm for GraftJacket and 5.5 mm for palmaris longus)
were also used for the double-docking technique. GraftJacket
and palmaris longus grafts were prepared in the same way
as the reconstruction via the interference screw technique.
The graft sutures were passed through 1.0-mm drill holes
placed through the ulnar bone tunnel and tied over the dorsal
surface of the ulna. After reduction of the joint, the graft was
trimmed to length, sutured, pretensioned, and tied over the
bone bridge on the posterior aspect of the medial epicondyle
in the same way as the interference screw technique.
Biomechanical testing and statistical analyses
After each reconstruction, cyclic loading in the lateral
direction (ie, valgus) was applied 12 cm distal to the
anatomic axis of the radiohumeral joint for 500 cycles at a
frequency of 0.5 Hz. This force was generated via a
position-feedback pneumatic cylinder (model PFC-096-XLP;
Furukawa et al 451
Figure 3 Mean (⫾ SD) maximum number of cycles for both MCL
reconstruction methods.There was no significant difference between the
GraftJacket and palmaris longus graft materials (P ⬎ .05), but the
GraftJacket the double-docking technique performed significantly better
than the GraftJacket with the interference screw technique (P ⬍ .05).
Bimba Manufacturing, Monee, IL) by means of a propor-
tional pressure controller (model PPC5C-AAA-AGCB-BBB-
JD; MAC Valves, Wixon, MI) under computer control. Cap-
ture images of the 2 optical markers were taken every 2.5
cycles by the digital camera, and the distances between the
2 markers were determined by custom software coded by
use of LabVIEW 6i and IMAQ (National Instruments, Aus-
tin, TX). The initial cyclic load was 40 N (assembly weight
plus applied load). The applied load was increased by 10
N every 500 cycles. Failure of the reconstruction was
defined as either complete graft failure or a 10-mm increase
in distance between the 2 optical markers.
The data were analyzed by use of a 2-way repeated-
measures analysis of variance via SPSS software (version
11.0; SPSS, Chicago, IL).
RESULTS
One upper extremity was deemed unsuitable dur-
ing testing because of the presence of moderate
arthritis and was discarded. The mean maximum load
to failure was 65 ⫾ 12 N for the double-docking
technique and 45 ⫾ 5.5 N for the interference screw
technique with GraftJacket and 59 ⫾ 11 N for the
double-docking technique and 56 ⫾ 14 N for the
interference screw technique with palmaris longus (Fig-
ure 2). There was no significant difference between the
GraftJacket and palmaris longus graft materials (P ⬎
.05), but the GraftJacket with the double-docking tech-
nique performed significantly better than the GraftJacket
with the interference screw technique (P ⬍ .05).
The mean maximum number of cycles sustained be-
fore failure was 1292 ⫾ 562 for the double-docking
technique and 356 ⫾ 292 for the interference screw
technique with GraftJacket and 1105 ⫾ 479 for the
double-docking technique and 924 ⫾ 690 for the interfer-
ence screw technique with palmaris longus (Figure 3). For
452 Furukawa et al
Figure 4 Comparison of survivorship curves for both MCL reconstruc-
tion methods. The interference screw technique with GraftJacket (GJ )
showed early failure, but the other constructs had similar survival
curves. PL, Palmaris longus.
the maximum number of cycles, there was no signifi-
cant difference between the GraftJacket and palmaris
longus graft materials (P ⬎ .05), but the GraftJacket
with the double-docking technique performed signifi-
cantly better than the GraftJacket with the interference
screw technique (P ⬍ .05).
The GraftJacket reconstructions with the interfer-
ence screw technique had all failed by 60 N,
whereas the other reconstructions showed similar sur-
vival results (Figure 4). For the double-docking tech-
nique with GraftJacket or palmaris longus, all failures
occurred as a result of the sutures slipping in the tissue
and stretching of the materials. For the interference
screw technique with GraftJacket, the graft slipped
out from the ulnar tunnel with or without the screws in
5 specimens. In 1 specimen, the GraftJacket with a
screw broke through the edge of the ulna into the
joint. For the interference screw technique with pal-
maris longus tendon, 2 grafts were torn at their con-
tact point with the screw in the humeral drill hole. The
palmaris longus graft slipped out of the ulnar drill
hole in 1 specimen, whereas a fracture occurred at
the edge of the ulna and into the joint in another. The
other 3 failures occurred by sutures slipping and
stretching of the palmaris longus graft.
DISCUSSION
Single-strand reconstruction of the MCL has previ-
ously been shown to restore the kinematics and sta-
bility of the elbow.3 The advantage of this technique
is that it avoids the use of 2 drill holes in the sublime
tubercle of the ulna, thereby reducing the risk of
fracture during passage of the graft. Centering the
ulnar drill hole in the sublime tubercle provides a
better approximation of the insertion site of the ante-
rior band of the MCL and also avoids a more poste-
J Shoulder Elbow Surg
July/August 2007
rior drill hole, which lies in close proximity to the ulnar
nerve as it passes through the flexor carpi ulnaris.
Our in vitro findings suggest that single-strand MCL
reconstructions using the double-docking technique
are superior to those using the metal interference
screw. This finding is similar to a previous in vitro
study in which the metal interference screw was not as
effective as other fixation methods.4 This outcome
does not agree with a previous laboratory study using
bioabsorbable screws in younger specimens.2 The
age of the specimens and the biomechanical behav-
ior of the metal compared with bioabsorbable screws
may, in part, be responsible for these differences. The
magnitudes of failure loads for the double-docking
technique are similar to previous reports from our
laboratory using a single-docking method.4 The col-
lagen fibers in ligaments and tendons are aligned
primarily along the line of tensile load, whereas der-
mis has a more random collagen orientation. This
may explain the lower initial failure loads observed
with GraftJacket relative to those observed with the
palmaris longus tendon. The palmaris grafts were cut
by the interference screws in 2 cases, possibly as a
result of the longitudinal orientation of the collagen
fibers. The GraftJacket seemed to be more deform-
able than the palmaris longus, as it was formed into a
tubular structure by folding the dermis upon itself. This
may result in a tendency of the GraftJacket to slip out
from around the interference screw.
The clinical technique of interference screw use
was modified in this study in the humeral tunnel to
ensure similar tensioning of the grafts between the
interference screws and docking techniques for a
more accurate comparison. To tension the grafts, the
suture was not tied around the humeral interference
screw but, rather, was tied over the medial epicon-
dyle, similar to that used in the docking method.
Although this is a weakness of our in vitro biomechani-
cal study relative to the clinical situation, we believe that
the fact that failures with the interference screw tech-
nique tended to be on the ulnar side supports our
contention that this modification, if anything, favored the
interference screw method by providing additional
strength on the humeral side by tying the sutures over the
medial epicondyle, as in the docking technique.
One proposed advantage of interference screw
fixation of soft-tissue grafts is the establishment of
aperture fixation, whereby the total length of graft that
is subjected to potential elongation is reduced to the
length between the two tunnels’ apertures.5,6 Our
study does not support this advantage, but further in
vivo work is necessary to determine whether interfer-
ence screw aperture fixation improves graft healing
within the tunnels and alters the viscoelastic proper-
ties of the graft.
The potential advantages of the double-docking
technique are 3-fold: other than a suture, no addi-
J Shoulder Elbow Surg
Volume 16, Number 4
tional costly implants are required; the risk of inflam-
matory response is less than with bioabsorbable
screws; and the likelihood of tunnel fracture is less
than with interference screws. The disadvantage of
the double-docking technique is the need for a second
small incision over the subcutaneous border of the
ulna if a medial skin incision is used for the recon-
struction. However, this is not required if a more
posterior skin incision is used, as is typically em-
ployed at our center.9
The favorable initial performance of the Graft-
Jacket suggests that it may be a viable alternative to
the harvesting of autogenous palmaris longus tendon
grafts. This has important implications in clinical prac-
tice, as harvesting the palmaris longus adds to the
operating time and morbidity of the surgery. Nerve
injuries and wrist stiffness have been reported after
harvesting of the palmaris longus.20 In addition, not
all patients have a palmaris longus available, thus
creating the need for harvesting tendons from other
sites, such as the knee or foot, which adds to patient
morbidity and requires general anesthesia.
The remodeling and healing of GraftJacket, a der-
mal allograft tissue, when compared with autograft
and allograft tendons, require further study to ensure
that sufficient structural strength and laxity are main-
tained for these high-demand patients. Although there
are some favorable animal studies documenting
GraftJacket remodeling, it is unknown whether this
new material maintains its initial structural strength
over time.1,7 The use of GraftJacket instead of autog-
enous or allograft tendon grafts should be avoided in
overhead-throwing athletes until further information is
available regarding its remodeling behavior in vivo.
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