In the largest study of its kind, surgeons at Hospital for Special Surgery have determined that by modifying a classic ligament surgery, they can return more athletes, such as baseball players, to their prior level of competition. The modified surgery repairs a torn medial collateral ligament (MCL), which links and stabilizes bones of the lower and upper arm where they meet at the elbow.
Less traumatic than the classic Tommy John surgery, the modified surgery called the docking procedure, with time, is likely to become the gold standard for treating these injuries.
"This paper, in the largest series of patients ever published, shows that this particular operation in throwing athletes demonstrates better results than the classic operation," said David W. Altchek, M.D., senior author of the study and co-chief of the Sports Medicine and Shoulder Service at Hospital for Special Surgery (HSS) in New York. The study was presented at a special session of the American Shoulder and Elbow Surgeons, held during the American Academy of Orthopedic Surgeons annual meeting.
MCL injury is most common in professional and amateur athletes involved in so-called overhead throwing sports, such as baseball, softball, football, lacrosse and tennis. These sports involve a throwing motion at high velocity that exerts an exceptional force at the elbow. Repeated over time, this motion can cause inflammation and microtrauma, which can eventually lead to an MCL tear. When this ligament is torn, an individual has a full range of motion and can go about daily life, but a professional or semi-professional athlete cannot perform at their usual level because they cannot exert a significant force.
Specifically, the MCL attaches the ulna, one of two long bones that run from the elbow down to the wrist, with the humerus, the bone of the upper arm. For 30 years, athletes have undergone the Tommy John surgery or Jobe surgery (named after its inventor), in which a tendon is taken from a person's forearm or hamstring and then 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 ulna and humerus bones and suture the tendon into place. Dr. Altchek's technique modifies the Jobe procedure in several ways. First, he begins with an arthroscopic evaluation of the elbow to examine and fix residual problems. An unstable ligament leads to a shifting elbow, which can cause further problems such as cartilage damage.
Second, Dr. Altchek gains access to the bone in a different way. In the Jobe surgery, surgeons detach major muscles and move the so-called ulnar nerve out of the way to gain access to the bone. Dr. Altchek uses a muscle splitting technique through which surgeons can gain access to the bone by gently prying apart muscle fibers, similar to the way you can poke a finger through a knitted sweater. He doesn't have to detach major muscles and, in most cases, the nerve can be left intact, reducing the problems of postoperative nerve damage. Damage to the ulnar nerve results in numbness and tingling in the ring and small fingers.
Dr. Altchek's procedure also differs from the traditional Jobe surgery by minimizing the number of holes drilled into the bones, thus decreasing the risk of postoperative bone fracture. In Dr. Altchek's surgery only one hole instead of three is drilled into the humerus. Instead of a figure eight design, one can think of the pattern as an elongated D, says Christopher Dodson, M.D., a resident in the Department of Orthopaedic Surgery at HSS and an author of the study.
"In the classic operation, the graft enters the humerus bone in one hole, exits in another and goes into another and then the graft gets tied to itself," Dr. Altchek explained. 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.
Dr. Altchek first developed the docking surgery in 1994, but it wasn't until now, that it was tested in such a large patient population.
In a study of 100 athletes (mean age 22) who had the docking surgery, with 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). Only 3 percent had postoperative nerve complications. With the traditional Jobe surgery, studies have shown that only 68 percent of elite level throwers return to either their prior or a higher level of throwing and 20 percent have nerve complications.
Surgeons and athletes have applauded Dr. Altchek's modifications. Many surgeons have already been employing his technique in the clinic to improve outcomes, and with time, it is likely that the docking procedure will become the gold standard for treating these athletes.
This study recently appeared in the December issue of the American Journal of Sports Medicine (Am J Sports Med 2006;34(12):1926-1932). The Institute for Sports Medicine Research supported the work.
An attending orthopaedic surgeon at Special Surgery, Dr. Altchek serves as medical director for the New York Mets professional baseball team and medical director for the Nets professional basketball team.
Written from a news release by Hospital for Special Surgery.
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