New York—March 21, 2013
A study at Hospital for Special Surgery (HSS) found that a surgical procedure known as the "docking technique" to repair a torn elbow ligament in teenage athletes yielded favorable results. The outcomes were better than those in previously published reports on reconstruction of the ulnar collateral ligament (UCL), also known as Tommy John surgery, in this age group and may be attributed to technique-specific factors, according to the study authors.
The paper, titled, "The Docking Technique for Elbow Ulnar Collateral Ligament Insufficiency: Two-Year Follow Up in Adolescent Athletes," will be presented at the annual meeting of the American Academy of Orthopaedic Surgeons on March 21 in Chicago.
“Over the last decade, the incidence of ulnar collateral ligament tears has dramatically increased in the adolescent population due to widespread participation in overhead sports such as baseball," said David W. Altchek, M.D., senior author of the study and co-chief of the Sports Medicine Service at HSS. Dr. Altchek is also medical director for the New York Mets baseball team and medical consultant for the National Basketball Association.
Dr. Altchek noted that previous reports suggest that clinical outcomes following UCL reconstruction in teenage athletes are inferior to results in higher-level adult athletes. He and his colleagues set out to determine if UCL surgery using the docking technique would result in improved outcomes in adolescent athletes.
The ulnar collateral ligament links and stabilizes bones of the upper and lower arm where they meet at the elbow. UCL injury is most common in professional and amateur athletes involved in overhead throwing sports such as baseball, softball, football, lacrosse and tennis. A UCL tear can occur suddenly or it can develop over time due to repetitive stress on the elbow.
When the ligament is torn, an individual still retains full range of motion and can go about daily activities. But a professional or aspiring pro athlete cannot perform at his usual level, and this is when surgery is considered. "he reason for surgery in the majority of cases is to get a serious athlete back to playing baseball or an overhead sport," explained Joshua Dines, M.D., an orthopedic surgeon in the Sports Medicine Service at HSS and one of the study authors. An intact ulnar collateral ligament isn’t needed for 98 percent of what people do in the game of life."
Patient selection and patient counseling are very important, according to Dr. Dines. "We carefully evaluate each patient to determine his or her goals and to see which treatment option would be best, and patient expectations are critical," he said. “We generally start with a conservative strategy of rest, anti-inflammatory medication and physical therapy. If those treatments fail and a young athlete wants to get back to his or her previous level of competition, surgery is considered." Patients must also be prepared for nine to 12 months of recovery and rehabilitation after the procedure. Dr. Dines is also a team physician for the U.S. Davis Cup Tennis Team and assistant team physician for the New York Mets.
The original UCL reconstruction surgery, first performed in 1974 by Dr. Frank Jobe on Tommy John, who played for the Los Angeles Dodgers, involves taking a tendon from the patient's forearm or hamstring and then grafting it into the elbow to act as a replacement for the injured UCL. Surgeons weave the harvested tendon in a figure eight pattern through bone tunnels drilled in the ulna (lower arm bone) and humerus (upper arm bone) and suture the tendon into place. To do so, muscles are detached and the ulnar nerve needs to be moved.
Considered less traumatic than traditional UCL reconstruction or Tommy John surgery, the docking technique entails gently splitting the muscles rather than detaching them, requires that fewer holes be drilled in the humerus, and allows the ulnar nerve to remain in place. The muscle splitting technique allows surgeons to gain access to the bone by gently prying apart muscle fibers, similar to the way you can poke a finger through a knitted sweater. By minimizing the number of holes drilled into the bone, there is decreased risk of a postoperative fracture.
In the Hospital for Special Surgery study, 46 adolescent athletes (mean age 17 years, range 12-18 years) underwent UCL reconstruction using the docking technique. The majority of patients were baseball players, along with three gymnasts and three javelin throwers. Patients were evaluated at a minimum of two years postoperatively based on their ability to return to athletic activity.
At the most recent follow up, 89 percent (41 out of 46) of patients had excellent results (were able to return to the same or a higher level of competition). The study also had one good, two fair and two poor results. The fair result was noted in a revision case, and the two poor results occurred in patients who had concomitant capitellar osteochondritis dissecans (OCD) lesions. There were four postoperative complications in four patients (two gymnasts and two javelin throwers) who developed ulnar neuritis following reconstruction.
The study concludes that the docking technique results in favorable clinical outcomes in adolescent athletes with a UCL tear at two-year follow-up. Overall, results were better than those in previously published reports and may be attributed to technique. The paper also notes that athletes with coexisting elbow conditions or injuries should be counseled that they may experience inferior clinical outcomes from UCL surgery. Additionally, gymnasts and javelin throwers may be at increased risk for postoperative complications due to their sport's increased stress on the elbow.
Other Hospital for Special Surgery contributing authors were Kristofer Jones, M.D.; Brian Rebolledo, M.D.; Kenneth D. Weeks, M.D.; and David M. Dines, M.D.
Paper: The Docking Technique for Elbow Ulnar Collateral Ligament Insufficiency: Two-Year Follow Up in Adolescent Athletes (Paper 506)
Thursday, March 21, 5:18 p.m.— 5:24 p.m. CDT, McCormick Place, Room N427
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 ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). 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. The global standard total knee replacement was developed at HSS in 1969. 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 and performed more than 32,000 surgical procedures. People from all 50 U.S. states and 80 countries travelled to receive care at HSS. 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 Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The culture of innovation is accelerating at HSS as 130 new idea submissions were made to the Global Innovation Institute in 2017 (almost 3x the submissions in 2015). The HSS Education Institute is the world’s leading provider of education on the topic on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.