The Docking Procedure for UCL Reconstruction

In this article, orthopedic surgeons from the Rothman Institute in Philadelphia and the Hospital for Special Surgery in New York City team up to instruct other surgeons about the value of the Docking procedure to reconstruct the ulnar collateral ligament (UCL).

The UCL is also known as the medial collateral ligament. The ulnar collateral ligament is on the medial (the side of the elbow that's next to the body) side of the elbow and the lateral collateral is on the outside. Together, these two ligaments (one on each side of the elbow) keep the elbow joint stable and help prevent dislocation during trauma or injury.

The ulnar collateral ligament is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle, and a thinner, transverse ligament.

The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the stress of repetitive throwing motions. If it does not heal correctly the elbow can be too loose or unstable. The ulnar collateral ligament can also be damaged by overuse and repetitive stress, such as the throwing motion.

Professional pitchers have been the athletes treated most often for this problem. Javelin throwers, football players, as well as athletes involved in racquet sports, ice hockey, wrestlers, and water polo players have also been reported to injure the UCL. A fall on an outstretched arm can also lead to UCL rupture (often with elbow dislocation).

Sometimes an injury to the UCL can be treated conservatively (without surgery). The nonoperative approach can work well for patients who have a partially torn but not completely ruptured ligament. The conservative approach may also be recommended for patients who are not athletes and therefore not involved in activities that require overhead throwing.

On the other hand, when there is a complete tear, overhead throwing athletes really are not good candidates for conservative care. Studies have conclusively shown that reconstruction is definitely needed for these athletes if they want to return to full sports play. Of the different surgical procedures that can be done to reconstruct the damaged UCL, as we mentioned, the Docking procedure is the focus of this report.

The surgeons describe and illustrate the operation with color photos taken during the surgery. Type of anesthesia (usually regional) and positioning of the elbow and hand are shown. The technique is done arthroscopically with full details of tunnel positions, type of sutures, care to prevent nerve damage, and ways to split the muscles to gain access to the ligament. The way in which special tools are used (such as the suture passers, burrs of different sizes) is also part of the surgeons' report.

If a repair procedure is performed, the surgeon reattaches the torn ligament to its original position. But if the ligament is completely ruptured, reconstruction is done with a graft. The graft tissue comes from the patient (usually either the palmaris longus or gracilis tendon is used).

Graft harvest, graft tension, ulnar nerve transpositioning (moving the nerve to a different location), and suturing of the fascia over the muscles are discussed. The 'docking' portion of the surgery refers to suturing the graft to the humerus (upper arm bone). A final section on postoperative management with expected results is provided. Athletes can expect to be in a splint for a week after surgery and then transferred to a hinged splint for six more weeks.

Physical therapy is started early and continues until the athlete has advanced through a program aimed at returning to full sports participation. Returning to sports that require overhead throwing is done in stages. Speed of throw and distance are gradually increased over time. When the patient can throw 180 feet without pain, then that person is allowed to resume competitive sports. Usually this takes nine months to a year.

These surgeons say they have had good to excellent results using the Docking reconstructive technique for 100 overhead throwing athletes. Ninety per cent of the group (90 athletes of the 100) were able to return to full sports play. Of the remaining 10 athletes, seven of them were able to play at a lower level.

They concluded that the Docking technique they use is a good choice. It is minimally invasive, reliable, and reduces the risk of nerve injury. Athletes interested in returning to competitive sports play can expect full return with proper rehabilitation. This can take up to a full year. Complications (e.g., numbness, pain) are few and far between and usually temporary. Only a very few athletes must give up their overhead throwing activities.

References: Christopher C. Dodson, MD, and David W. Altchek, MD. Ulnar Collateral Ligament Reconstruction Revisited: The Procedure I Use and Why. In Sports Health. September/October 2012. Vol. 4. No. 5. Pp. 433-437.