Elbow MCL and UCL (Medial and Ulnar Collateral Ligament) Injuries - Modified “Tommy John” Surgery

   
Research has demonstrated that modified Tommy John surgery improves outcomes for athletes, compared to traditional surgery.

Injury Overview:

Ulnar collateral ligament (UCL) injury refers to a sprain, partial tear or complete tear of the ligament that traverses the inside (or medial side) of the elbow. The UCL is the primary stabilizer of the elbow and plays an important role in throwing and hitting sports, such as baseball, football and tennis.

An injury to the UCL has two main causes. First, repetitive stress, as seen in an overhand pitcher, can cause micro-tears in the ligament that, over time, weaken the ligament. This may be due to poor throwing mechanics, fatigue or lack of conditioning.

Second, and less common, injury can be brought about by an acute traumatic event, such as an elbow dislocation, which can lead to chronic pain and rupture of the UCL. UCL injury due to acute trauma can be identified by a painful “popping” sensation or range-of-motion loss in the elbow.

The medial collateral ligament (MCL) links and stabilizes bones of the upper and lower arm where they meet at the elbow. MCL injury is also seen mostly in athletes involved in overhead throwing sports. These sports require a high-velocity throwing motion that exerts exceptional force on the elbow. Repeated over time, this motion can cause inflammation and micro-trauma, which can eventually lead to an MCL tear. After treating an MCL tear, an individual will regain full range of motion and can go about daily life, but it is unlikely that a professional or semi-professional athlete will perform at his usual level because he cannot exert a significant force.

Treatment Options: Modified “Tommy John” Surgery:

“Tommy John” surgery is the traditional treatment for MCL and UCL injuries of the elbow, in which a tendon taken from a person’s forearm or hamstring is grafted into the elbow to act as a replacement for the injured ligament. Surgeons weave the harvested tendon in a figure eight pattern through bone tunnels drilled in the bones and suture the tendon into place.

David W. Altchek, M.D., co-chief of the Sports Medicine and Shoulder Service at Hospital for Special Surgery in New York City, has modified this procedure in a number of ways, using less invasive techniques that have been studied in clinical research.

“Research has demonstrated that modified Tommy John surgery improves outcomes for athletes, compared to traditional surgery,” says Dr. Altchek.

Dr. Altchek’s approach, called the docking procedure, begins with an arthroscopic (minimally invasive) evaluation to examine and fix residual problems. Then, to gain access to the bone, he uses a muscle-splitting technique that gently pries apart muscle fibers. Major muscles do not need to be detached, and the nerve can be left intact in most cases.

This modified procedure reduces the number of holes drilled into the bones – from three to one – thus decreasing the risk of post-operative bone fracture. “In classic Tommy John surgery, the graft enters the humerus bone in one hole, exits through a second hole and goes into a third before being tied to itself,” Dr. Altchek explains. In the docking procedure, “the graft enters the humerus bone but never exits. Instead, sutures secure the tendon and exit the bone through much smaller exit punctures.”

The docking procedure has been gaining popularity among other surgeons; it is likely that, with time, it will become the “gold standard” for treating athletes with MCL and UCL injuries.

Expectation for Recovery:

Surgical treatment using the docking procedure has demonstrated increased success rates compared to traditional Tommy John surgery. In a study of 100 athletes who underwent the docking procedure, after an average follow-up of three years, 90 percent had an excellent result (returned to the same or higher level of competition) and 7 percent had a good result (able to compete at a lower level for more than 12 months). With the traditional Tommy John procedure, studies have shown that only 68 percent of elite level throwers return to their prior level of throwing. In addition, 20 percent have nerve complications, while this is much rarer (3 percent) with the modified procedure.

The operative time of each procedure also differs. Dr. Altchek’s docking procedure requires less time in the operating room than the traditional surgery, though recovery from MCL and UCL surgeries is lengthy after both methods of Tommy John surgery. Patients must wait 9-12 months before the ligament is fully healed to the bone, after which athletes can begin to return to competitive play. Patients can participate in a rehabilitation program during this healing.

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Tracy Hickenbottom
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Elyse Bernstein
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