Ulnar collateral ligament reconstruction

Ulnar collateral ligament reconstruction, sometimes referred to as Tommy John surgery 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. The surgery is performed to restore optimal function for repetitive elbow movements or specifically throwing ability, often extending the careers of professional athletes. In many athletes, the surgery is done more than once during their careers.

The procedure was devised in 1974 by orthopedic surgeon Frank Jobe, 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, who played in Major League Baseball (MLB) for 26 seasons. 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.<ref name=30for30>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Uses

The ulnar collateral ligament (UCL) can become stretched, frayed, or torn through the repetitive stress of the throwing motion.<ref name="calculus">Template:Cite magazine</ref> The risk of injury to the UCL is believed to be extremely high,<ref name=calculus/> as the amount of stress through the structure approaches its ultimate tensile strength during a hard throw.<ref>Fleisig, G.S., "The biomechanics of baseball pitching", in Biomechanical Engineering. 1994, University of Alabama: Birmingham. p. 163.</ref>

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.<ref>Template:Cite journal</ref>

The results of a 2002 study suggest that the total number of pitches thrown is the greatest determinant.<ref name=":2">Template:Cite journal</ref> The study examined the throwing volume, pitch type and throwing mechanics of 426 pitchers aged nine to fourteen 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.<ref name=":2" />

Research into throwing injuries in young athletes has led to age-based recommendations for pitch limits.<ref>Template:Cite journal</ref>

Pitchers may require a second procedure after recovering from a first surgery. From 1999 to 2015, 39 major league pitchers had a "revision" – a second Tommy John surgery, with an average of about 5 years between the first and second surgeries.<ref name=calculus/> The need for a second UCL reconstruction in major league pitchers is an important factor in the duration of their contracts.<ref name=calculus/>

Risks

There is a risk of damage to the ulnar nerve.<ref name="pmid17279038">Template:Cite journal</ref>

Misconceptions

Some baseball pitchers believe that they can throw harder after ulnar collateral ligament reconstruction than they could 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.<ref>Template:Cite news</ref> However, many people, including Frank Jobe, believe that any post-surgical 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.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> 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.Template:Cn

Technique

Reconstruction

A surgical incision of Template:Convert is made near the elbow.<ref name="surg">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Holes to accommodate a replacement graft tendon are drilled in the ulna and humerus bones of the elbow.<ref name="surg" /> A harvested tendon, such as the palmaris tendon<ref name="jobe">Template:Cite news</ref> from the forearm of the same or opposite elbow, the patellar tendon, hamstring, toe extensor or a donor's tendon (allograft), is then woven in a figure-eight pattern through the holes and anchored.<ref name="surg" /> The ulnar nerve is usually moved to prevent pain, as scar tissue can apply pressure to the nerve.<ref name="jobe" /> The procedure is performed on an outpatient basis allowing discharge the same day, with the arm in a splint to protect the repair for the first week.<ref name="surg" /> After one week, a brace is employed to protect the reconstruction for about six weeks following surgery.<ref name="surg" />

Repair

Repair is largely viable in cases of acute UCL avulsion type-injury at the proximal or distal end, with the main benefit of the procedure is reduced rehabilitation time compared to that of UCL reconstruction.<ref name=":0">Template:Cite journal</ref> Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008.<ref name=":0" />

Recovery

The rehabilitation process following surgery is typically divided into four separate phases.

1. 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<ref name=":1">Template:Cite journal</ref>
2. The goals of phase 2 (weeks four to eight) are to gain strength and gain full range of movement<ref name=":1" />
3. During phase 3 (weeks nine to 13), the rehabilitation is focused on flexibility and neuromuscular control with a progression toward sports-related activities<ref name=":1" />
4. The progression to a throwing program is made during phase 4 (weeks 14 to 26) for overhead athletes<ref name=":1" />

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.<ref name=":1" />

Incidence

Over two decades preceding 2016, the number of UCLR surgeries increased threefold, a rate that was expected to continue to rise.<ref name="mahure">Template:Cite journal</ref> A 2015 study showed that the rate of UCLR surgery for those aged 15 to 19 was the highest among all age ranges and was increasing by 9% each year.<ref name="ajsm">Template:Cite journal</ref>

USA Baseball, Major League Baseball, and Little League Baseball initiated the Pitch Smart program designed to lower the risk of elbow injuries in adolescent pitchers.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The main risk factors for elbow injury from overhand throwing are the number of pitches per game, innings pitched per season, months pitched per year and poor pitching biomechanics that may increase torque and force on the elbow.<ref>Template:Cite journal</ref>

History

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File:Tommy John 2008 bronx.jpg

Tommy John, for whom the surgery is named, in 2008

At the time of John's operation, Jobe estimated the chance for success of the operation at one in 100.<ref name="dougmiller">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> By 2009, the odds of complete recovery had risen to 85–92%.<ref name="Rosenhek">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

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 12Template:Ndash15 months for pitchers and about six months for position players. Players typically begin throwing about 16 weeks after surgery.<ref>Template:Cite news</ref> While 80% of players return to pitching at the same level as before the surgery, for those Major League Baseball pitchers who receive the surgery twice, 35% never pitch again in the major leagues.<ref name="calculus" />

Jobe has stated that if he had invented the technique ten 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."<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>