New Orleans, LA—March 10, 2018
Ulnar collateral ligament (UCL) reconstructions have not only been on the rise but so have their revisions. Different techniques have been developed to improve the success of this reconstruction, more commonly known as Tommy John surgery, yet no comparative clinical studies have examined the procedures head-to-head.
Today, researchers from Hospital for Special Surgery (HSS) presented study findings comparing the two leading techniques, Docking and the Modified Jobe, at this year’s annual meeting for the American Academy of Orthopaedic Surgeons (AAOS). This cadaver study has important clinical implications as both techniques are currently widely used by surgeons.
"While our results following Tommy John surgery are good, they’re not perfect," said Joshua S. Dines, MD, sports medicine surgeon at HSS and senior author. "Two ways that outcomes can be improved are through surgical techniques and post-operative rehabilitation - this study focuses on perfecting the surgical technique."
Some known reasons for why UCL reconstructions may fail include inadequate healing at the bone-tendon interface and bony fracture through drill tunnels.
The HSS study set out to determine how the two different reconstruction techniques affect intra-osseous blood flow to the medial epicondyle (ME) and sublime tubercle (ST), the critical sites for ligament graft healing. Additionally, the study looked to quantify vascular disruption caused by tunnel drilling in both techniques.
In the controlled laboratory experiment, eight matched pairs of upper extremities were assigned one of the two techniques, with the other paired elbow acting as a control.
After the surgeries, imaging (both MRI and CT) and statistical analysis revealed that drilling of the ulnar tunnels had a minimal impact on the intra-osseous vascularity of the ulna in both techniques.
However, blood flow to the ME was reduced by 14 percent with the Docking technique and 60 percent with the Modified Jobe, creating a mean difference of 46 percent. After the reduction, the Docking technique maintained 86 percent of blood flow while the Modified Jobe maintained only 40 percent.
"While the ideal amount of blood flow for optimal graft healing is unknown, we do know that more blood supply to the area is better," said Dr. Dines. "Our results showed that the Docking technique has the advantage over the Modified Jobe when it comes to vascularity. The more blood we can get to the affected area, the better the outcomes will be."
These findings can be applied in the operating room, not only for primary procedures, but for revisions as well.
The cause of failure after UCL reconstruction, in many cases, is multifactorial including returning to throwing too soon, poor throwing mechanics and inappropriate postoperative rehabilitation. Surgical factors may also contribute to the need for revision surgery if tendon to bone healing doesn’t occur to the extent that it should after the first procedure. Anything that can be done surgically to remove tendon to bone healing as a potential cause for surgical failure should be investigated further with the hopes that we continue to improve outcomes for Tommy John surgeries overall.
"We’re looking at each different part of the procedure to see how it can be improved. If, with each slight modification, we can increase the return to sport rate by 1 percent, then that’s a victory," said Dr. Dines who added that the research team is also looking at different ways to fix the graft to allow for better healing.
About HSS | Hospital for Special Surgery
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the eighth consecutive year) and No. 3 in rheumatology by U.S. News & World Report (2017-2018). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In 2017 HSS provided care to 135,000 patients from 80 countries and performed more than 32,000 surgical procedures. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Innovation Institute was formed in 2015 to realize the potential of new drugs, therapeutics and devices; the global standard total knee replacement was developed at HSS in 1969, and in 2017 HSS made 130 invention submissions (more than 2x the submissions in 2015). The HSS Education Institute provides continuing medical curriculum to more than 15,000 subscribing musculoskeletal healthcare professionals in 110 countries. Through HSS Global, the institution is collaborating with medical centers worldwide to advance the quality and value of care and to make world-class HSS care more accessible to more people.