Tommy John Surgery

tommy john

Tommy John surgery (TJS), known in medical practice as ulnar collateral ligament (UCL) reconstruction, is a surgical graft procedure in which a ligament in the elbow is replaced with a tendon from elsewhere in the body (ligaments and tendons are connective tissue; the former connects bones to each other and latter connects muscles to bone). The procedure is common among collegiate and professional athletes in several sports, particularly baseball pitchers.

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 record of 288 career victories ranks seventh all time among left-handed pitchers.

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. At the time of Tommy John’s operation, Jobe put his chances of playing again 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.

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. 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.

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.

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 child’s 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.

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