Tommy John surgery (TJS), known in medical practice as ulnar collateral ligament (UCL) reconstruction, is a surgical graft procedure in which the ulnar collateral ligament in the medial elbow is replaced with a tendon from elsewhere in the body. The procedure is common among collegiate and professional athletes in several sports, most notably baseball.
The procedure was first performed in 1974 by orthopedic surgeon Dr. Frank Jobe, then a Los Angeles Dodgers 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 Tommy John, whose 288 career victories ranks seventh all time among left-handed pitchers. The initial operation, John’s successful post-surgery career, and the relationship between the two men is the subject of a 2013 ESPN 30 for 30 documentary.
Procedure
Tommy John, for whom the surgery is named, in 2008.The patient’s arm is opened up around the elbow. Holes to accommodate a new 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, or a cadeveric tendon, 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.
Prognosis
At the time of Tommy John’s operation, Jobe put his chances at 1 in 100. In 2009, prospects of a complete recovery had risen to 85–92 percent. 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 takes about one year for pitchers and about six months for position players. Players typically begin throwing about 16 weeks after surgery. While eighty percent of players return to pitching at the same level as before the surgery, for those Major League pitchers who receive the surgery twice, thirty five percent do not return to pitch in the majors at all.
Risk factors
The UCL can become stretched, frayed, or torn through the repetitive stress of the throwing motion. The risk of injury to the throwing athlete’s ulnar collateral ligament of elbow joint is thought to be extremely high as the amount of stress through this structure approaches its ultimate tensile strength during a hard throw. While many authorities suggest that an individual’s style of throwing or the type of pitches 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. Thus, although there is a large body of other evidence that suggests mistakes in throwing mechanics increase the likelihood of injury it seems that the greater risk lies in the volume of throwing in total. Research into the area of throwing injuries in young athletes has led to age-based recommendations for pitch limits for young athletes.
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 – the periods from 2001-2012 and 2013-2015 both saw eighteen Major League pitchers going under the knife a second time. As of April 2015, the average amount of time between procedures is 4.97 years.
Complications
There is a risk of damage to the ulnar nerve.
Misconceptions
Some baseball pitchers believe they can throw harder after Tommy John Surgery than they did beforehand. As a result, orthopedic surgeons have reported that parents of young pitchers have come to them and asked them to perform the procedure on their un-injured sons in the hope that this will increase their sons’ performance. However, many people—including Dr. Frank Jobe—believe any post-surgical increases in performance are most likely due to 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 velocity, the surgery and rehab protocols merely allow pitchers to return to their pre-injury levels of performance.
List of baseball players who underwent Tommy John surgery
- Player Position Date of surgery
- Brady Aiken Pitcher March 2015
- Brett Anderson Pitcher July 14, 2011
- Rick Ankiel Pitcher / Outfielder July 2003
- Bronson Arroyo Pitcher July 2014
- Rocco Baldelli Outfielder June 2005
- Brandon Beachy Pitcher June 2012
- Erick Fedde Pitcher June 3, 2015
- Michael Matuella Pitcher April 2015
Candidates for Tommy John Surgery
UCL injuries are usually first treated with conservative (non-surgical) therapies.
These therapies include:
- rest
- ice
- nonsteroidal anti-inflammatory drugs (NSAIDs)
Patients then typically undergo physical therapy. This strengthens surrounding muscles to compensate for the injured UCL.
But some athletes may be candidates to have surgery right away. Tommy John surgery is most commonly recommended for athletes who:
Don’t respond to non-surgical treatments
Want to resume strenuous overhead or throwing activities
What Happens During Tommy John Surgery
During Tommy John surgery, a tendon is taken from someplace in the patient’s body, such as his or her:
- wrist
- forearm
- toe
- hamstring (thigh)
- hip
- knee
- foot (Achilles tendon)
Sometimes, surgeons use a tendon donated from the body of someone who has died.
Surgeons drill tunnels in the ulna and humerus. The tendon (called a “graft”) is passed through the tunnels. It is then woven into a figure-eight pattern to reconstruct the ligament.
To give the graft added strength, any remnants of the original ligament are attached to the tendon.
Complications can occur in anywhere from 5% to 20% of patients, depending on the technique that is used. The most common complication is damage to the ulnar nerve.
Other complications can include infection or hematoma. Rarely, a complication will require additional surgery.
Tommy John Surgery Rehabilitation
Rehabilitation from Tommy John surgery usually takes about a year. In some cases, up to 2 years are needed for athletes to return to their previous level of ability. Other types of UCL surgery may not need this much rehabilitation.
Rehabilitation should be closely monitored by the patient’s doctor and physical therapist. Some rehabilitation programs follow a three-phase process:
Phase I.
After surgery, patients take these steps:
- Wear a splint for 7 to 10 days to immobilize the elbow.
- Do gentle range-of-motion exercises for the wrist, hand, and shoulder.
- Wear a range-of-motion brace to gradually regain full motion of the elbow joint.
- Do exercises to strengthen the arm and shoulder.
- Perform total-body conditioning exercises.
Phase II. Starting about 6 weeks after surgery:
- Most patients can begin to perform elbow-strengthening exercises. For at least the next 4 months, most patients are advised to avoid activities that overstress the graft.
Phase III. In the final phase of rehabilitation, patients take these steps:
- About 4 or 5 months after surgery, athletes may toss a ball without a wind-up motion.
- After 6 months, athletes may start to use an easy wind-up when throwing.
- After 7 months, baseball pitchers may return to the mound.
- After 9 months, pitchers may throw in competition if they are pain-free and have regained their normal strength and range of motion.
When surgeon Frank Jobe, MD, performed the first UCL reconstruction on Tommy John in 1974, a torn UCL tear was considered to be a game-ending injury for most players.
But now, up to 85% of patients who undergo this surgery are able to resume their sport at, or even above, their previous level of competition.
Tommy John Surgery are more common among youth athletes, has been concluded in a study by American Orthopaedic Society for Sports Medicine. Check out at: http://womenfitness.net/news-flash/tommy-john-surgery-athletes/
Tommy John surgery has since become commonplace among big league players — especially pitchers. Whether you’re throwing a baseball or a javelin, you put a great deal of stress on the elbow. Keep it up and the repetitious strain can lead to inflammation, microscopic tissue trauma and ultimately a tear in the ulnar collateral ligament (UCL), also known as the medial collateral ligament (MCL).
In the past, such an injury would spell the end of a career. While the hurt player would still be able to perform day-to-day movements, he would never again be able to throw with significant force or speed.
The Tommy John procedure follows a basic design. Imagine you have two boots and the lace on one breaks beyond your ability to repair it. The lace on your other boot, however, is in great condition and has plenty of length. Why not simply cut some excess lace from one boot and use it to mend the other? Surgeons do much the same thing to a UCL tear. They take a tendon from the patient’s forearm or hamstring and graft it into the elbow to replace the torn ligament. Of course, there are no holes for the “laces,” so the surgeon first drills a series of holes into the arm’s ulna and humerus bones. After these holes are completed, the tendon is weaved into a figure eight pattern through the holes.
Sound simple? Well, the surgery is far from a quick fix. Recipients face a year of strenuous rehabilitation before they can return to action. Moreover, the operation presents its share of risks. The surgeon has to detach major muscles and move the ulnar nerve out of the way, all of which can result in infection, fracture, nerve irritation and numbness. When Tommy John himself received the procedure, the odds of recovery were 1 in 100. Today, around 83 percent of the operations go as planned.
