Ulnar collateral ligament reconstruction, colloquially known as Tommy John surgery (TJS), is a
surgical graft procedure where the
ulnar collateral ligament in the
medial elbow is replaced with either a
tendon from elsewhere in the patient's body, or with one from a deceased donor. The procedure is common among collegiate and professional athletes in several sports, particularly in
baseball
Baseball is a bat-and-ball sport played between two teams of nine players each, taking turns batting and fielding. The game occurs over the course of several plays, with each play generally beginning when a player on the fielding t ...
.
The procedure was devised in 1974 by
orthopedic surgeon Frank Jobe, a
Los Angeles Dodgers
The Los Angeles Dodgers are an American professional baseball team based in Los Angeles. The Dodgers compete in Major League Baseball (MLB) as a member club of the National League (NL) National League West, West division. Established in 1883 i ...
team physician who served as a special advisor to the team until his death in 2014. It is named after the first baseball player to undergo the surgery, major league
pitcher
In baseball, the pitcher is the player who throws ("pitches") the baseball from the pitcher's mound toward the catcher to begin each play, with the goal of retiring a batter, who attempts to either make contact with the pitched ball or dr ...
Tommy John, whose record of 288 career victories ranks seventh among left-handed pitchers. The initial operation, John's successful post-surgery career, and the relationship between the two men was the subject of a 2013 ESPN ''
30 for 30'' documentary.
Uses
The
ulnar collateral ligament (UCL) can become stretched, frayed or torn through the repetitive stress of the throwing motion. The risk of injury to the UCL is believed to be extremely high, as the amount of stress through the structure approaches its ultimate
tensile strength
Ultimate tensile strength (UTS), often shortened to tensile strength (TS), ultimate strength, or F_\text within equations, is the maximum stress that a material can withstand while being stretched or pulled before breaking. In brittle materials ...
during a hard throw.
This injury is associated with baseball, although it sometimes appears in other sports. Compared to athletes who play other sports, baseball players are at elevated risk of
overuse injuries and injuries caused by early sports specialization among children and teenagers.
While some sources say that an individual's style of throwing or the type of pitches that they throw are the most important determinant of their likelihood to sustain an injury, the results of a 2002 study suggest that the total number of pitches thrown is the greatest determinant. A 2002 study examined the throwing volume, pitch type and throwing mechanics of 426 pitchers aged 9 to 14 for one year. Compared to pitchers who threw 200 or fewer pitches in a season, those who threw 201–400, 401–600, 601–800 and 800+ pitches faced an increased risk of 63%, 181%, 234% and 161% respectively. The types of pitches thrown showed a smaller effect; throwing a
slider was associated with an 86% increased chance of elbow injury while throwing a
curveball was associated with an increase in pain. There was only a weak correlation between throwing mechanics perceived as bad and injury-prone.
However, because there are many effective styles of pitching, incorrect throwing mechanics can be difficult to define and determine. One of the most common denominators among virtually all pitchers is "reaching back" with the throwing arm prior to release and follow-through. This repeated motion is believed to be a major contributing factor in UCL injuries, as it stretches the ligament in an unnatural manner and direction. Simply raising the pitching arm and bringing it forward with a complete follow-through produces the same levels of spin rate, velocity, movement and location while helping to protect the UCL from unnecessary injury.
Research into throwing injuries in young athletes has led to age-based recommendations for pitch limits. A 2016 study explained 22% of the variation in those needing ulnar collateral ligament reconstruction, identifying handedness, standard deviation of release point, days lost to arm and shoulder injuries, previous ulnar collateral ligament reconstruction, number of hard pitches, ERA- and age as the known risk factors.
In younger athletes whose
epiphyseal plate (growth plate) is still open, the force on the inside of the elbow during throwing is more likely to cause the elbow to fail at this point than at the ulnar collateral ligament. This injury is often termed "
Little League elbow" and can be serious but does not require reconstructing the UCL.
Increasingly often, pitchers require a second procedure after returning to pitching. During the periods from 2001 to 2012 and 2013 to 2015, 18 major-league pitchers underwent the procedure for a second time. As of April 2015, the average amount of time between procedures is 4.97 years.
Risks
There is a risk of damage to the
ulnar nerve.
Misconceptions
Some baseball pitchers believe that they can throw harder after ulnar collateral ligament reconstruction than they did beforehand. As a result, orthopedic surgeons have reported that parents of young pitchers have asked them to perform the procedure on their uninjured sons in the hope that it will increase performance. However, many people, including Frank Jobe, believe that any postsurgical increases in performance are most likely the result of the increased stability of the elbow joint and pitchers' increased attention to their fitness and conditioning. Jobe believed that, rather than allowing pitchers to gain speed, the surgery and rehab protocols merely allow pitchers to return to their pre-injury levels of performance.
Technique
Reconstruction
A surgical incision of is made near the elbow.
Holes to accommodate a replacement
graft tendon are drilled in the
ulna and
humerus bones of the elbow.
A harvested tendon, such as the
palmaris tendon from the forearm of the same or opposite elbow, the
patellar tendon
The patellar tendon is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar ligament as it forms a bone to bone connection when ...
, hamstring, toe
extensor or a donor tendon (
allograft), is then woven in a figure-eight pattern through the holes and anchored.
The
ulnar nerve is usually moved to prevent pain, as
scar tissue can apply pressure to the nerve.
The procedure is performed on an
outpatient
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care ...
basis allowing discharge the same day, with the arm in a
splint to protect the repair for the first week.
After one week, a
brace
Brace(s) or bracing may refer to:
Medical
* Orthopaedic brace, a device used to restrict or assist body movement
** Back brace, a device limiting motion of the spine
*** Milwaukee brace, a kind of back brace used in the treatment of spinal c ...
is employed to protect the reconstruction for about six weeks following surgery.
Repair
Repair has been shown to be largely viable in cases of acute UCL avulsion type-injury at the proximal or distal end, with the main benefit of the procedure being reduced rehabilitation time compared to that of UCL reconstruction.
Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008.
Recovery
The rehabilitation process following surgery is typically divided into four separate phases.
# Rehabilitation phase 1 (postoperative weeks zero to three) consists of prevention of stiffness, promotion of healing and simultaneous protection of the reconstructed graft with a hinged elbow brace.
# The goals of phase 2 (weeks four to eight) are to gain strength and gain full range of movement.
# During phase 3 (weeks nine to 13), the rehabilitation is focused on flexibility and neuromuscular control with a progression toward sports-related activities.
# The progression to a throwing program is made during phase 4 (weeks 14 to 26) for overhead athletes.
Full competition throwing is usually permitted at seven to nine months, and pitchers are ready to return to the game at approximately 10 to 18 months.
Incidence
Over the past two decades, the number of UCLR surgeries has increased threefold, a rate that is expected to rise in upcoming years.
A study has shown that the rate of UCLR surgery for those aged 15 to 19 is the highest among all age ranges and is increasing by 9% each year.
USA Baseball
USA Baseball is the national governing body for organized baseball in the United States, and is a member of the United States Olympic Committee and the World Baseball Softball Confederation. The organization selects and trains the World Basebal ...
,
Major League Baseball
Major League Baseball (MLB) is a professional baseball organization and the oldest major professional sports league in the world. MLB is composed of 30 total teams, divided equally between the National League (NL) and the American League (A ...
and
Little League Baseball have initiated the Pitch Smart program designed to lower the risk of elbow injuries in adolescent pitchers. The main risk factors for elbow injury from overhand throwing include number of pitches per game, innings pitched per season, months pitched per year and poor pitching
biomechanics that may increase
torque
In physics and mechanics, torque is the rotational equivalent of linear force. It is also referred to as the moment of force (also abbreviated to moment). It represents the capability of a force to produce change in the rotational motion of th ...
and
force on the elbow.
History
At the time of John's operation, Jobe estimated the chance for success of the operation at 1 in 100.
By 2009, the odds of complete recovery had risen to 85–92%.
Following his 1974 surgery, John missed the entire 1975 season rehabilitating his arm before returning for the 1976 season. Before his surgery, John had won 124 games. He won 164 games after surgery, retiring in 1989 at age 46.
For baseball players, full
rehabilitation
Rehabilitation or Rehab may refer to:
Health
* Rehabilitation (neuropsychology), therapy to regain or improve neurocognitive function that has been lost or diminished
* Rehabilitation (wildlife), treatment of injured wildlife so they can be retur ...
takes about 12–15 months for pitchers and about six months for position players. Players typically begin throwing about 16 weeks after surgery. While 80% of players return to pitching at the same level as before the surgery, for those
Major League Baseball
Major League Baseball (MLB) is a professional baseball organization and the oldest major professional sports league in the world. MLB is composed of 30 total teams, divided equally between the National League (NL) and the American League (A ...
pitchers who receive the surgery twice, 35% never pitch again in the major leagues.
Jobe has stated that if he had invented the technique 10 years earlier, it might have been nicknamed Sandy Koufax surgery, after Dodgers hall of famer
Sandy Koufax, who retired with "essentially the same thing as Tommy John."
References
{{DEFAULTSORT:Ulnar collateral ligament reconstruction
Orthopedic surgical procedures
Sports medicine
1974 introductions
American inventions