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  • Writer's pictureThe San Juan Daily Star

Tommy John surgery at 50: More ubiquitous than ever but continuing to evolve

Houston Astros pitcher Justin Verlander in action against the Philadelphia Phillies in Philadelphia on Nov. 3, 2022. In 2022, Verlander became the first pitcher to win the Cy Young Award in his first season back from a UCL reconstruction. (Doug Mills/The New York Times)

By Cody Stavenhagen

In baseball, the words “Tommy John surgery” are uttered every day. And with a rash of injuries sidelining stars in the MLB, we are hearing the phrase more than ever.

The number of injuries to pitchers’ ulnar collateral ligaments keeps rising, an epidemic swallowing the sport and leading to changes in the surgical landscape. But it is no longer as simple as a pitcher tearing his ligament, going under the knife and returning a little more than a year later.

Now, there are pitchers undergoing second, or even third, operations, known as revisions, with slightly different techniques and recovery times at play. And many players are gravitating toward a newer option: the internal brace procedure.

One thing is clear: Tommy John surgery is going to continue to be an important part of baseball.

What is Tommy John surgery?

The ulnar collateral ligament is on the inside of the elbow, attaching the upper bone of the arm, the humerus, to a forearm bone, the ulna. When pitchers injure the UCL, they may sometimes choose a conservative treatment plan, often consisting of rest and plasma-rich platelet injections. In many cases, this is simply delaying the inevitable.

“We often try it because there’s really nothing to lose with it,” said Eric Bowman, an orthopedic surgeon and the head team physician for Vanderbilt University and the Class AAA Nashville Sounds. “There’s very little downside to it. It has growth factors, and we hope that it provides a healing stimulus. But at least the data we currently have doesn’t really point to it being a huge boost for conservative treatment.”

Especially in the cases of substantive tears to the ligament, a full reconstruction is often required. The procedure we now know as Tommy John surgery originated in 1974, when Frank Jobe, an orthopedic surgeon, performed the procedure on pitcher Tommy John. The surgery involves replacing the existing UCL with a graft usually harvested from a hamstring tendon, the Palmaris tendon in the forearm or a tendon from a cadaver. Surgeons attach the new tendon by drilling holes in the humerus and the ulna. The graft is then threaded through the two holes and secured by sutures, buttons or screws.

Why has ‘T.J.’ become so common?

At the major league level, there were 275 pitchers who had Tommy John surgery last season, up from 190 in 2016.

But surgeons in the industry indicate that the largest increases in UCL injuries are at the youth level. Tommy John surgery was once nearly unheard of for high school players. Now, it is becoming common. As far back as 2015, one study indicated that 56.8% of the procedures were performed on the 15-19 age group.

“I think it’s playing year-round,” said Brian Schulz, team physician for the Los Angeles Angels. “I think it’s early sport specialization, not taking time off and playing other sports. I think there’s a lot of kids that understand that velocity is a very important factor if they want to be a pitcher, and they’re doing weighted-ball programs and velocity-enhancement programs at a young age. You’re putting a lot of stress on the inner elbow doing that.”

How does Tommy John surgery affect performance?

Previously viewed as a last-chance operation, Tommy John in the 21st century no longer has such a negative stigma. But the idea that all pitchers return as harder-throwing superhumans comes with misconceptions.

“Probably 10 years ago, people were coming in and almost wanting it electively for their kids because they thought it would make them throw harder, which is crazy,” said Josh Dines, an orthopedic surgeon at the Hospital for Special Surgery who has worked with the New York Mets and the Los Angeles Dodgers. “It’s like assault and battery on your kid.”

Although the rate of athletes returning to play is high, the rate of players returning to the same level of play was “less frequent and took longer, with 67% to 87% of MLB pitchers returning in about 15 months,” according to a 2020 study. Plenty of pitchers have returned from Tommy John to have successful careers, but the road back can come with bumps. In 2022, Justin Verlander became the first pitcher to win the Cy Young Award in his first season back from a UCL reconstruction. John Smoltz is the only pitcher to have had Tommy John surgery and be elected to the Hall of Fame.

Conversely, the 2020 study showed pitchers who had UCL reconstructions had ERAs and WHIPs “equal or better” than controls, but it also found that fastball use and velocity tended to decrease slightly after surgery. Overall, there is little clinical data to suggest Tommy John directly correlates with enhanced long-term performance.

How does a UCL revision differ from a reconstruction?

Not long ago, there was a common belief that a Tommy John procedure would all but guarantee a healthy UCL for at least 10 years. That belief, Schulz said, was never based on clinical data.

If a pitcher has Tommy John surgery at 17 and continues pitching at a high level, it could be natural for a pitcher to need another procedure by 27. There is also anecdotal concern that increases in velocity and force applied to the UCL could be shortening the life span of the Tommy John procedure.

If a player requires a revision, the clinical term for a second (or third) Tommy John surgery, the procedure often differs from the first.

“The procedure itself is a little bit more complex,” Bowman said, “because you’re having to work around scar tissue. When you’re going in and it’s sort of a pristine environment, you can put things exactly where you want it, and the tissue overall might look fairly normal. When you go in on a revision situation, there’s scar tissue, there is already tunnels and hardware in place. Sometimes, you have to navigate that.”

While initial Tommy John procedures across all levels come with a return-to-sport rate of close to 90%, the data is murkier when it comes to UCL revisions. Return-to-play rates hover at about 75%, Bowman said, but return to previous performance level is closer to 55%.

Is the internal brace a revolution?

In recent years, a new surgical technique has become increasingly popular. It’s called the internal brace, where an athlete’s existing UCL is reinforced with a tapelike suture that is anchored into the humerus and ulna. The internal brace can serve as a Tommy John alternative for athletes who have not completely torn their UCL. MLB players such as Lucas Giolito and infielder Trevor Story are among those who have recently had the internal brace procedure, but it is more common for amateur players, Bowman said.

Athletes can typically return to throwing in about six months after an internal brace procedure. Many major league pitchers, however, may not be good candidates for the surgery.

“The problem when you get toward the majors level is the tissue isn’t as good, so you have to replace the tissue,” Bowman said. “Just putting the internal brace in there or the suture, it can help relieve some of the stress, but the bad tissue just isn’t going to heal very reliably, so that’s when you have to put the graft in.”

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