Tommy John surgery–fact and fiction

(This is the second installment of Dr. Ciccotti's series on UCL reconstruction. Part one can be seen here.)

In baseball, perhaps one of the most devastating elbow injuries involves the ulnar collateral ligament (UCL)—the same injury that has sidelined numerous professional players such as Stephen Strasburg of the Washington Nationals. When UCL injuries such as partial or complete tearing occur baseball players, particularly pitchers, are often unable to throw competitively. For mild injuries, nonoperative treatment may be successful. For high grade partial or complete tears, often surgery is required—otherwise known as "Tommy John" surgery.

This revolutionary procedure was first performed by Dr. Frank Jobe in 1974 on then Dodgers pitcher Tommy John. This reconstruction of the UCL allowed John to return to professional baseball for arguably the best years of his career. Since then, this famous procedure has been performed tens of thousands of times on all types of athletes. Those procedures have lead to all types of "fact and fiction."

Let's review some of the facts about this surgery…

I) Not all injured throwers need Tommy John surgery. The main indications include:

1) high grade partial or complete tear in a baseball player, particularly a pitcher.

2) failure of a thrower to improve after a well coordinated nonoperative rehabilitation program. (see Part I of this series)

3) Non-throwers who have persistent symptoms that prevent work or recreational activities.

II) This surgery is termed a reconstruction. Studies have shown that most often the UCL is so severely damaged that the torn ends can not be sutured together or repaired. Only in very young athletes with no prior history of injury is repair considered. Therefore, most often, tissue from another part of the body, called a graft, is utilized to reconstruct or replace the damaged UCL.

III) The most common graft is the palmaris longus tendon taken from the forearm. This is tendon can be utilized without any adverse affects on gripping or throwing. Other possible graft sources include tendons from the leg (hamstring, medial Achilles, toe extensor, etc.)

IV) Though several variations of Dr. Jobe's technique exist, the basic principles of this surgery are the same. The graft is woven through tunnels precisely placed in the bones of the elbow in the location of the normal UCL. The graft is then secured and gradually heals in to become the new UCL

V) If an athlete has any additional injury with the UCL tear, then this is corrected as well at the time of the Tommy John surgery. This may include shifting the adjacent Ulnar Nerve ("funny bone nerve") if the athlete has persistent numbness or tingling in his/her ring or little fingers.

What about some of the "fiction" surrounding this surgery?

I) There is an urban myth that "Tommy John" surgery will increase a thrower's velocity and improve control. No studies have ever clearly shown that to occur. Most likely, these injured throwers have had a progressive, subtle decrease in velocity and control as the UCL has become slowly injured. And so after full recovery from the surgery, these athletes may feel like they are throwing faster and more accurately. Also, the rehabilitation after this surgery includes full reconditioning of not only the elbow, but also the shoulder, back, core/abdominal muscles, hips and legs—all of which are vitally important to throwing successfully with maximum velocity and control. All too often, the injured thrower was not fully conditioned prior to the UCL injury.

II) Some people believe that Tommy John surgery is a reliable means of getting a ballplayer to the next level of play—a future in the big leagues. Obviously, no study has ever shown that. Concern always exists for the young athlete who requires surgery; that's why we try to treat this non-operatively. If it is necessary, future success of that athlete is just as dependant on that athlete's inherent ability, dedication, and determination.

And so there you have the fact and fiction surrounding "Tommy John" surgery. Stay tuned for the next part of this blog series which will discuss life after "Tommy John" surgery—return to play.

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