The Double Button™ technique is a method of UCL reconstruction developed by Dr. Raffy Mirzayan that fixes the tendon graft in place using a metal button on each end, rather than tying sutures over a bridge of bone or stitching the graft back to itself. It requires only one bone tunnel in the humerus and one bone tunnel in the ulna, instead of the two bone tunnels on each side that traditional techniques require. In the published literature it is described as double suspensory or bisuspensory fixation. Dr. Mirzayan published the surgical technique in 2012 and the clinical outcomes in 2020.
Why I developed it
I was not satisfied with the fixation I was getting from the standard techniques.
In the Jobe technique, the graft is woven through bone tunnels in a figure-of-eight and then sutured to itself. The construct is only as strong as those stitches. In the docking technique, sutures attached to the graft are tied over a small bridge of bone on the medial epicondyle. That bridge can be thin, and modern high-strength sutures can cut through bone. In laboratory testing of reconstructed ligaments, the most common mode of failure is at the suture-graft interface.
The second problem is the bone tunnels. Both techniques require two bone tunnels on the humeral side and two on the ulnar side. Drilling small bone tunnels close together risks having them converge into one another, collapse, or fracture the bone between them. Bone tunnel-related problems account for a meaningful share of reconstruction failures.
I wanted fixation that did not depend on knots or bone bridges, and a construct that used a single bone tunnel per side.
How the Double Button™ technique works
The palmaris longus tendon is harvested from the forearm through three small stab incisions. If the palmaris is absent, I use a gracilis graft. The graft is folded over itself two or three times to create a thicker construct and loaded onto an adjustable-loop button.
The elbow is approached through a muscle-splitting technique that leaves the flexor-pronator origin intact. The ulnar nerve is not routinely moved or released; I only transpose it in patients who already have nerve symptoms before surgery.
A single bone tunnel is drilled in the medial epicondyle, and a single bone tunnel in the ulna at the sublime tubercle. The graft is passed through the humeral bone tunnel until the button flips and seats flat against the anterior surface of the medial epicondyle. That position matters. It reproduces the natural origin of the UCL, so the graft runs in an anatomic line toward the ulna rather than making a sharp turn.
How strong is the fixation?
Strong enough that I can demonstrate it during the operation. Once the graft is through the humeral bone tunnel and the button is seated, I can grab the graft and pull on it hard enough to shake the patient's entire body on the table. The construct does not move.
That is the whole point of the design. Fixation that secure means the graft is holding load from the moment surgery ends, rather than depending on knots or a bone bridge to hold. It is also why my patients come out of the postoperative splint at the first visit and are not placed in a brace afterward.
The ulnar side
The ulnar button is passed through the bone tunnel and flipped on the far cortex of the ulna, where it sits buried under muscle. Patients cannot feel it, and it is undetectable to touch.
Once the button is flipped, I can pull the graft down into the bone tunnel using a tension-slide technique and tension it with the elbow at 90 degrees of flexion. That is a meaningful practical advantage: the graft can be tensioned, assessed, and re-tensioned before anything is locked down, which is difficult with techniques that require the graft to be sutured to itself. An interference screw is then placed in the ulnar bone tunnel for additional compression, and the native ligament is repaired over the top of the graft.
Where the internal brace fits in
The suture tape internal brace is built into the Double Button™ construct rather than added as a separate step. The tape passes through the same humeral button and down the same ulnar bone tunnel with the graft, secured by the same screw. Every patient gets it.
What the biomechanical testing shows
This is not only my impression in the operating room. A cadaveric study comparing bisuspensory fixation against the docking technique found that both restored valgus laxity to the intact state, with no significant difference between them in stiffness, ultimate torque, angle at ultimate torque, or energy absorbed. Separate testing has shown that button-based fixation outperforms interference screw and Jobe-type reconstructions in load to failure and in the number of loading cycles survived before failure.
Published results
Dr. Mirzayan published outcomes on 36 baseball players who underwent Double Button™ reconstruction, with a minimum of two years of follow-up and an average of more than four and a half years.
The headline finding is the timeline: mean return to play was 9 months, with a range of 6 to 16 months. That is meaningfully earlier than the 12 to 18 months commonly cited for UCL reconstruction.
The rest of the results:
- 83 percent returned to playing baseball, with 67 percent at the same level or higher
- Kerlan-Jobe scores improved from 33.2 to 89.7, and SANE scores from 20.7 to 93.6
- 69 percent had an excellent Conway score and another 14 percent a good score
- 94 percent were satisfied or extremely satisfied and would have the surgery again
- One patient required revision reconstruction and returned to play; one required removal of the humeral button
- No medial epicondyle or ulnar fractures occurred
The complication I am most pleased about is one that did not happen. No patient developed new ulnar nerve symptoms after surgery. Published rates of postoperative ulnar neurapraxia after UCL reconstruction range from about 2 percent to nearly 21 percent, and in the largest series ever reported it was 16 percent. Ours was zero. I attribute that to the muscle-splitting approach and to leaving the ulnar nerve alone unless the patient has a reason to need it addressed.
Of the six athletes who did not return to baseball, only one stopped because of his elbow. The other five graduated high school or lost interest and were not seeking to play at a higher level.
What I want you to know about these numbers
These were high school, college, and minor league players, not Major League pitchers. It was a single-surgeon series without a randomized comparison group, which is a real limitation and one I stated in the paper.
I would rather tell you that plainly than present the results as more than they are. What they do show is that a reconstruction fixed with buttons on both ends produces excellent function, a low complication rate, and a return to pitching at around nine months.
The bottom line
The Double Button™ technique uses a single bone tunnel on each side of the elbow and fixes the graft with a button at each end, avoiding the knots, bone bridges, and paired bone tunnels that traditional reconstructions rely on. The fixation is secure enough to allow early motion without bracing, the internal brace is built into the construct, and in the published series athletes returned to pitching at a mean of nine months with no new ulnar nerve complications.
References — publish at the bottom of the page, smaller type
- Mirzayan R, Benvegnu N, Sidell M, Acevedo DC, DeWitt DO, Lowe N, Singh A. Functional outcomes of ulnar collateral ligament reconstruction with a novel double suspensory fixation. J Shoulder Elbow Surg. 2020;29(8):1530-1537.
- Mirzayan R, Schoell K, Acevedo DC, Singh A. Ulnar collateral ligament reconstruction of the elbow with double suspensory fixation. Arthrosc Tech. 2021;10(2):e303-e309.
- Acevedo DC, Lee B, Mirzayan R. Novel technique for ulnar collateral ligament reconstruction of the elbow. Orthopedics. 2012;35(11):947-951.
- Jackson TJ, Adamson GJ, Peterson A, Patton J, McGarry MH, Lee TQ. Ulnar collateral ligament reconstruction using bisuspensory fixation: a biomechanical comparison with the docking technique. Am J Sports Med. 2013;41(5):1158-1164.
- Armstrong AD, Dunning CE, Ferreira LM, Faber KJ, Johnson JA, King GJW. A biomechanical comparison of four reconstruction techniques for the medial collateral ligament-deficient elbow. J Shoulder Elbow Surg. 2005;14(2):207-215.
- Cain EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426-2434.
