The patient was taken to the operating room and placed in the prone position. A standard diagnostic elbow arthroscopy was performed as seen in Fig. 22.4a–c. The radiocapitellar joint and capsule were found to be normal. The medial aspect showed evidence of instability but no signs of capsular damage. The medial gutter was found to be normal. A thickened plica was noted within the lateral gutter and was excised. The arthroscopic portion was completed.

The arm was then rotated to expose the medial aspect of the elbow and the open portion of the case was completed as seen in Fig. 22.5a–d. A direct approach to the medial ulnar collateral ligament was used. A split in the flexor-pronator fascia was made posterior to the medial conjoined tendon while keeping a blunt retractor in position to protect the ulnar nerve. Upon inspection of the MUCL, the ligament itself appeared in good condition. The humeral insertion was intact; however, a small ossicle and disruption of the ulnar attachment were noted. The ligament was carefully dissected to visualize the attachment site on the sublime tubercle. The small ossicle was excised, and the bony footprint was roughened to improve healing of the ligament. A double-loaded suture anchor was placed at the footprint. Two limbs of the anchor were placed through the more posterior aspect of the ligament, while the remaining two limbs were placed through the anterior aspect. The two strands were then tied, securing the MUCL to its footprint. A #1 Vicryl was then used to plicate the midportion of the tendon. The elbow was tested and found to be stable. The incision was then irrigated and closed in standard fashion.