Elbow Ulnar Collateral Ligament Reconstruction Using the Novel Docking Plus Technique in 324 Athletes
- 314 Downloads
This retrospective case series examined 324 athletes who received elbow ulnar collateral ligament (UCL) reconstruction by a single surgeon in a private practice over a 9-year period. The novel Docking Plus technique for elbow UCL reconstruction in 324 athletes provided good or excellent Conway score results in 88% of patients. The preponderance of previous studies examining UCL reconstruction outcomes were performed by surgeons at one of only three institutions (Andrews Institute, Hospital for Special Surgery, Kerlan Jobe Orthopedic Clinic).
Patients undergoing UCL reconstruction from November 2005 to December 2014 were identified and contacted with a mailed survey and phone call. These patients were given a subjective 19 question survey assessing their outcomes from surgery.
The participants who responded to our survey were 90% male and 77% baseball players, 73% of which were pitchers. Of the baseball players who responded, 51.9% were in high school at the time of their surgery, 37% college, 6.5% minor leagues, and 2.2% in Major League Baseball. After surgery, 36% of survey responders returned to a higher level of competition than previously. For example, a high school athlete who had UCL reconstruction and went on to pitch in college. Further, 45% returned to the same level, and 7% returned to a lower level. Subjective “satisfaction,” was reported in 92% of responders and 97.2% reported that, “having surgery was a good idea.” Symptom onset in the responding athletes was 58.9% sudden, and 41.1% gradual. Overall, 90.9% of respondents returned to play in less than 1.5 years while 6.3% never were able to return. Re-tear occurred in 2.5% of patients, while 8.8% had subjective nerve dysfunction for at least 3 months following surgery.
The Docking Plus technique can produce excellent subjective and objective results in athletes. Further study is warranted to see the effects of this procedure in other settings and determine which method of reconstruction or repair is superior.
KeywordsUCL Elbow Baseball Tommy John Surgery Ligament reconstruction
Active range of motion
Disabilities of the Arm Shoulder & Hand
Kerlan Jobe Orthopedic Clinic
Mayo Elbow Performance Index
Major League Baseball
Passive range of motion
Return to play
Ulnar collateral ligament
The majority of UCL reconstruction outcomes studies are from just three major institutions
Eighty-eight percent of survey respondents who completed their rehab protocols following UCL reconstruction with the Docking Plus technique had a Conway-Jobe score of good or excellent
More studies examining objective outcomes following UCL reconstruction are needed
Injury to the elbow ulnar collateral ligament (UCL) and its surgical reconstruction in throwing athletes is well described [2, 4, 5, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 29, 32, 33, 34, 35, 36, 41, 43, 47, 60, 64, 74]. The incidence of UCL reconstruction surgery is increasing, among high school athletes and professional athletes [6, 17, 35, 46, 77, 79].
The UCL is the primary valgus stabilizer of the elbow. It experiences the most torque in the late cocking and early acceleration phases of the pitching motion kinetic chain [38, 40, 41, 58, 59, 75]. Pitching velocity and volume have both been associated with an increased risk of UCL injury [3, 14, 28, 31, 39, 52, 61, 62, 67, 78].
Patients often, though not always, complain of acute or chronic medial elbow pain when throwing, which affects velocity and accuracy. Physical exam generally reveals pain with elbow valgus stress testing and palpation of the UCL . MRI with intra-articular contrast and dynamic ultrasound have the highest sensitivity in diagnosis of UCL injuries [20, 37, 71, 76]. Reconstructive surgery is typically recommended for full-thickness tears as well as partial thickness tears refractory to non-operative management. Internal bracing for partial tears has recently emerged as a possible alternative to full reconstruction .
Since the year 2000, published case series of surgical outcomes for UCL reconstruction have demonstrated rates of return-to-play (RTP) of 74–100% [4, 10, 13, 19, 21, 22, 24, 29, 49, 50, 63, 66, 69, 72]. Studies of Major League Baseball (MLB) pitchers have shown RTP rates of 67–87% [34, 44, 50, 53, 56].
A variety of surgical techniques have been described, including the Docking Plus technique . Though UCL reconstruction patient outcomes have been measured in multiple level 3 and 4 studies, these studies have typically had low numbers (< 100) of patients. Also, the preponderance of the included surgeries were performed by surgeons at one of only three institutions (Andrews Institute, Hospital for Special Surgery, Kerlan Jobe Orthopedic Clinic). The purpose of this paper is to provide data from previously unreported outcomes of 324 athletes at a single surgeon center who underwent UCL reconstruction using the “Docking Plus,” technique.
We identified all UCL reconstructions performed by the senior author (TEK) from November 2005 to December 2014. We did so by searching the senior surgeon’s practice patient database by surgeon and Current Procedural Terminology (CPT) code (24346). CPT code 24346 is defined as, “Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft)”. This yielded 655 results of 647 unique patients. These reconstructions were all done with the docking plus technique and utilized the contralateral palmaris longus tendon for the graft when present. If the patient did not have palmaris longus tendons, a gracilis tendon autograft was used.
A literature search was conducted to compare our study’s outcomes to previously reported data. We searched PubMed and Google Scholar for UCL reconstruction outcome studies and found 25 such studies published between 1986 and 2014 [4, 8, 10, 13, 19, 21, 22, 25, 29, 34, 44, 48, 49, 50, 51, 53, 55, 56, 63, 65, 66, 69, 70, 72]. Of these studies, 19 [4, 8, 10, 13, 19, 21, 22, 25, 29, 49, 51, 54, 55, 63, 65, 66, 69, 70, 72] detailed outcomes by surgeon authors, while 6 studies [34, 44, 48, 50, 53, 56] reported outcomes with data from MLB databases.
For each study, we charted the outcomes and patient and injury characteristics measured. All of the 19 case series measured the competition level of return-to-play with 12 of these studies explicitly using Conway-Jobe or modified Conway-Jobe criteria in their classifications. Several other outcome metrics were used in these case series, including the Andrews-Timmerman elbow score (3 of 19 studies) [22, 51, 55], the KJOC (Kerlan Jobe Orthopedic Clinic) Score (1 of 19) , DASH (Disabilities of the Arm, Shoulder, & Hand) score (1 of 19) , and MEPI (Mayo Elbow Performance Index) score (1 of 19) .
A 2-page, 19-question survey was designed with questions about demographics (e.g., age, gender), sports participation (e.g., sport, position, handedness), the nature of the injury (e.g., speed of onset, timing, prior surgery), subjective outcomes (e.g., patient satisfaction), and objective outcomes (e.g., timing and level of return-to-play, Conway-Jobe score, career longevity, reasons for retirement, complications).
We used contact information (mailing address, telephone number) provided by patients at the time of prior clinical encounters to contact the patients. We mailed letters containing a URL link to the survey and a unique, anonymized patient identification number. In addition to standard mail, we contacted patients by telephone to provide them with the survey URL, their identification numbers, and to briefly describe the purpose of the outcomes study. We obtained an advisory opinion which states that our survey posed minimal risk and met criteria for being IRB exempt.
Postoperative rehabilitation utilized standard timelines of immobilization, strengthening, throwing programs, and return-to-play [9, 42, 68]. In weeks 1–2, evaluation of ulnar nerve function is critical. This is monitored closely by the physical therapist and the surgeon is made aware of any possible deficit. The elbow is passively ranged from 30 to 90°, which can be increased if tolerated. Extension is dependent and posterior pinching. Active range of motion (AROM) at the wrist is encouraged and exercises involving grip and hand strength are performed. Cryotherapy and electrical stimulation are also utilized around the elbow. The patients brace is left locked at 60°. Sutures are removed at 10–14 days. At 3 weeks, the brace is set at 30–90° following approval by the surgeon. Isometric wrist and forearm exercises are begun. Elbow flexion and extension isometrics are started. AROM advanced to 20–105° if tolerating. At week 4, the brace is set at 15–105° and they are passively ranged from 10 to 120. Hand intrinsic muscle therapy is progressed and cardiovascular conditioning on a stationary bike is started. In weeks 5–6, the brace is fully opened and taken off by the end of week 6. Passive range of motion (PROM) is increased to 0–130°. Wrist and elbow resistance exercises with 1 lb of weight are begun. A shoulder strengthening program is started.
Of the 647 patients who received a survey, 3 were excluded because they did not undergo UCL reconstruction and 2 because they underwent revision UCL reconstruction. We received 335 responses to the survey, although 9 were found to be duplicate responses, 1 patient failed to respond with either his survey ID number or name, and 1 patient responded with a nonsense ID number. Therefore, we analyzed 324 responses for a 50.1% response rate. These patients had all undergone UCL reconstruction using the “Docking Plus” technique.
Survey responders were 90% (290 of 324) male, while 10% (34 of 324) were female.
Baseball was the primary sport for 77% (248) of responders. Other primary sports included softball (13), football (14), wrestling (9), volleyball (6), gymnastics (5), golf (5), cheerleading (4), tennis (4), lacrosse (4), rugby (1), and track and field (1).
Prior to surgery, the level of performance for all athletes was middle school (2.5%), high school (51.9%), college (37.0%), minor league (6.5%), and major league (2.2%). After surgery, the highest level of performance reached was middle school (1.9%), high school (27.2%), college (54.9%), minor league (14.2%), or major league (1.9%).
While patients described pre-op symptom duration and non-operative management for as little as 0–3 months and as long as greater than 2 years, 43.3% (138) had symptoms for 0–3 months and 68.1% (194) underwent physical therapy for 0–3 months.
Symptom onset was sudden in 58.9% (188), but insidious/gradual in 41.1% (131). Of baseball pitchers, the symptom onset was sudden in 50.5% (93), but insidious in 49.5% (91). Then, 7.2% (23) had undergone prior surgery on the same elbow.
RTP timing varied from less than 9 months to over 2 years. Further, 90.9% (259) returned in less than 1.5 years, while 2.5% (7) returned in 1.5–2 years, 0.4% (1) returned in over 2 years, and 6.3% (18) did not return to play. Among pitchers, self-reported return-to-play was similar, with less than 9 months (7%, 11), 9–12 months (48%, 75), 1–1.5 years (33%, 52), 1.5–2 years (3%, 5), > 2 years (1%, 1), and never (8%, 13).
Complications included UCL re-tear in 2.5% (8) and additional same-side elbow surgery for any reason in 5.6% (18). Then, 8.8% (28) described some element of nerve dysfunction for at least 3 months postoperatively, although the survey did not distinguish between transient or permanent incision site numbness and ulnar nerve dyesthesia.
In baseball pitchers, there was self-reported subjective improvement in pitch velocity, control, ERA, and innings pitched as compared with pre-injury. Of the 155 who have by now discontinued playing their sport, only 14.8% (23) state that retirement was caused by elbow disability.
There are many UCL reconstruction outcome studies in published literature. However, most are produced by the same few pioneering institutions, such as the Andrews Institute [4, 13, 29, 63, 66, 69], Hospital for Special Surgery [10, 22, 24, 50, 69], and Kerlan Jobe Orthopedic Clinic [19, 21, 49, 72]. This raises questions as to whether or not the results can be extrapolated to other centers. This study was also performed at only one center by one surgeon, raising similar questions. However, any addition to the pool of data regarding UCL reconstruction outcomes can help the community direct future goals and studies. This study also likely represents the largest case series of women (34 athletes) who have undergone UCL reconstruction. It is the only case series published on patients who have had UCL reconstruction with the “Docking Plus” technique.
The Docking Plus technique, a variation on previously described Modified Docking techniques, has been previously described  and tested biomechanically , though outcome studies have not yet validated its use.
Conway scores by study
Osbahr et al. 
Jones et al. 
Savoie et al. 
Dines et al. 
Dugas et al. 
Kodde et al. 
Cain et al. 
Bowers et al. 
Dines et al. 
Dodson et al. 
Paletta and Wright 
Koh et al. 
Petty et al. 
Rohrbough et al. 
Thompson et al. 
Azar et al. 
Andrews and Timmerman 
Conway et al. 
Jobe et al. 
Subjective patient satisfaction scores in this study indicate that almost 96% patients think that it was a good decision for them to have surgery. Nearly as many, 92.9%, were satisfied with their surgery. This compares very favorably to patient satisfaction information from a study by Conte et al. in 2015 that found that only 72% of professional baseball players would have the surgery again and 17% would not have the surgery .
Our data regarding symptom onset (59% acute, 41% gradual) varies from those results previously published in the literature that are closer to a 1:1 incidence of these two presentations . Though, in baseball pitchers, our symptom onset (51% acute, 49% gradual) was consistent with the reported incidences. Even when the presentation is described as “acute” or “traumatic” in throwing athletes, it is likely that there have been some underlying chronic degenerative changes to the UCL.
Time to return-to-play varies based on position and sport. There has been debate about delaying further professional pitchers timing of return-to-play based on some trends in improved pitching in the second year compared with in the first year after return-to-play [69, 72].
The rehabilitation protocol for pitchers dictates a return-to-play at 11–14 months if there are no setbacks. Eighty-one percent of these studies pitchers returned to pitch at 9–18 months postoperative. This is consistent with surgeon outcome studies that have shown a 11–13 month average return-to-pitch timing [10, 14, 15, 73].
Outcome studies that have utilized information from MLB databases have shown a mean return-to-play timing of 16–20 months [1, 69, 72, 78]. However, analysis of MLB data by a journalist have demonstrated that median return-to-play times in this population since 2002 have been consistently 13 months . It seems that a few extended and complicated postoperative courses in MLB pitchers have skewed up the means reported in academic studies. Return-to-play is faster for baseball position players and non-baseball players.
The data in this study was self-reported and so is vulnerable to recall bias. Electronic medical records were accessed for the date of surgery and CPT code, but not for details of the patients’ histories and physical exams.
Return to sport can be affected by a variety of social and medical factors unrelated to the technical success of the surgical procedure including continued interest in sport, skill level, and commitment to a lengthy rehabilitation process. As much as the senior surgeon’s patient selection includes operating on patients who have the interest and ability to continue competing, these variables may change over time.
While a patient response rate of 50.1% of consecutive patients compares favorably with existing literature on UCL surgery outcomes, it is low enough to introduce significant selection bias into the results, especially those regarding patient satisfaction.
The Docking Plus technique, performed in a private practice setting outside of the previously mentioned UCL reconstruction pioneering hospitals, produces excellent subjective (e.g., patient satisfaction) and objective (e.g., Conway score) results. Further study is warranted to see if these results can be extrapolated to other surgeons and patient populations.
No financial support was received for the conduct of this study or preparation of this manuscript.
Availability of Data and Materials
Please contact author for data requests.
DBF designed the study and did data analysis, literature review, and writing. LMG executed the data retrieval and analysis, literature review, and writing. KTE performed the surgeries being studied, helped to obtain the data, and assisted in writing and editing. All authors read and approved the final manuscript.
Ethics Approval and Consent to Participate
Our study was determined to be IRB exempt as it was an anonymous survey. ShulmanIRB # 201607774.
Consent for Publication
No individual person’s data is present.
The authors, Benjamin Donohue, Marc Lubitz, and Timothy Kremchek, declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- 2.Ahmad CS. Treatment of medial collateral ligament injuries of the elbow with use of the “Tommy John” operation: indications and results. JBJS Rev. 2014;2(6):1–9.Google Scholar
- 6.Assouline J. Tommy John Surgery and Throwing 95+ MPH. http://www.fangraphs.com /. http://www.fangraphs.com/community/tommy-john-surgery-and-throwing-95-mph/.
- 7.Atanda A, Buckley PS, Hammoud S, Cohen SB, Nazarian LN, Ciccotti MG. Early anatomic changes of the ulnar collateral ligament identified by stress ultrasound of the elbow in young professional baseball pitchers. Am J Sports Med. 2015;43(12):2943–9. https://doi.org/10.1177/0363546515605042.CrossRefPubMedGoogle Scholar
- 17.Conte SA, Fleisig GS, Dines JS, et al. Prevalence of ulnar collateral ligament surgery in professional baseball players. Am J Sports Med. 2014. https://doi.org/10.1177/0363546515580792.
- 26.Domb BG, Davis JT, Alberta FG, et al. Clinical follow-up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe orthopaedic clinic overhead athlete shoulder and elbow score (KJOC score). Am J Sports Med. 2010;38(8):1558–63. https://doi.org/10.1177/0363546509359060.CrossRefPubMedGoogle Scholar
- 35.Erickson BJ, Nwachukwu BU, Rosas S, et al. Trends in medial ulnar collateral ligament reconstruction in the United States: a retrospective review of a large private-payer database from 2007 to 2011. Am J Sports Med. 2015;43(7):1770–4. https://doi.org/10.1177/0363546515580304.CrossRefPubMedGoogle Scholar
- 43.Gassko D. Have pitchers become more fragile? 2007. http://www.hardballtimes.com/have-pitchers-become-more-fragile/.Google Scholar
- 47.Humphrey B. Why the MLB pitching “Win” stat is obsolete in one graph. http://www.vivaelbirdos.com/2014/1/13/5296618/why-the-stat-of-pitching-wins-is-obsolete-in-one-graph. Accessed 25 May 2016.
- 52.Kaplan KM, ElAttrache NS, Jobe FW, Morrey BF, Kaufman KR, Hurd WJ. Comparison of shoulder range of motion, strength, and playing time in uninjured high school baseball pitchers who reside in warm- and cold-weather climates. Am J Sports Med. 2011;39(2):320–8. https://doi.org/10.1177/0363546510382230.CrossRefPubMedGoogle Scholar
- 54.Kodde IF, Rahusen FTG, Eygendaal D. Long-term results after ulnar collateral ligament reconstruction of the elbow in European athletes with interference screw technique and triceps fascia autograft. J Shoulder Elb Surg. 2012;21(12):1656–63. https://doi.org/10.1016/j.jse.2012.07.010.CrossRefGoogle Scholar
- 56.Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, Ahmad CS. Performance, return to competition, and reinjury after Tommy John surgery in Major League Baseball pitchers: a review of 147 cases. Am J Sports Med. 2014;42(6):1323–32. https://doi.org/10.1177/0363546514528864.CrossRefPubMedGoogle Scholar
- 63.Osbahr DC, Cain EL, Raines BT, Fortenbaugh D, Dugas JR, Andrews JR. Long-term outcomes after ulnar collateral ligament reconstruction in competitive baseball players: minimum 10-year follow-up. Am J Sports Med. 2014;42(6):1333–42. https://doi.org/10.1177/0363546514528870.CrossRefPubMedGoogle Scholar
- 64.Osbahr D, Swaminathan S, Allen A. Combined Flexor-Pronator Mass and Ulnar Collateral Ligament Injuries in the Elbows of Older Baseball Players. AJSM. 2010.Google Scholar
- 68.Roegele J. An analysis of available Tommy John surgery data. The hardball times. 2014. http://www.hardballtimes.com/an-analysis-of-available-tommy-john-surgery-data/.Google Scholar
- 76.Wood N, Konin JG, Nofsinger C. Diagnosis of an ulnar collateral ligament tear using musculoskeletal ultrasound in a collegiate baseball pitcher: a case report. N Am J Sports Phys Ther. 2010;5(4):227–33. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3096144&tool=pmcentrez&rendertype=abstract PubMedPubMedCentralGoogle Scholar
- 77.Youth UCL Surgery (“Tommy John surgery”). 2016. http://www.asmi.org/research.php?page=research§ion=UCL.Google Scholar
- 78.Zaremski JL, Horodyski M, Donlan RM, Brisbane ST, Farmer KW. Does geographic location matter on the prevalence of ulnar collateral ligament reconstruction in collegiate baseball pitchers? Orthop J Sport Med. 2015;3(11):2325967115616582. https://doi.org/10.1177/2325967115616582.CrossRefGoogle Scholar
- 79.Zimmerman J. Velocity’ s relationship with pitcher arm injuries. Hardballtimes; 2016. p. 1–18. http://www.hardballtimes.com/velocitys-relationship-with-pitcher-arm-injuries/ Google Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.