| Tommy John surgery | |
|---|---|
| Intervention | |
| ICD-9-CM | 81.85 |
Tommy John surgery, known in medical practice as ulnar collateral ligament (UCL) reconstruction, is a surgical procedure in which a ligament in the medial elbow is replaced with a tendon from elsewhere in the body (often from the forearm, hamstring, knee, or foot of the patient). The procedure is common among collegiate and professional athletes in several sports, most notably baseball.
The procedure was first performed in 1974 by Dr. Frank Jobe, who today serves as a Special Advisor to the Los Angeles Dodgers, and is named after former major league pitcher Tommy John whose 288 career victories ranks seventh all time among left-handed pitchers.
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After the tendon from the forearm of the same or opposite elbow or below the knee (or from a cadaver) is harvested, it is then woven in a figure-eight pattern through tunnels that have been drilled in the ulna and humerus bone that are part of the elbow joint.
In 2009, chances of a complete recovery after surgery are estimated at 85 to 92 percent.[1] At the time of Tommy John's operation, Jobe put his chances at 1 in 100. After his surgery in 1974, John spent 18 months rehabilitating his arm, returned for the 1976 season, and went on to pitch in the major leagues until 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.[2]
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.[3]
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.[4] 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 curve ball was associated with an increase in shoulder 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[5] 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.[6]
In younger athletes, for whom the growth plate (the medial epicondylar epiphysis) 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 Ulnar Collateral Ligament.
There is a risk of damage to the ulnar nerve.[7]
In some cases baseball pitchers throw harder after the procedure than they did beforehand. As a result, orthopedic surgeons have reported that increasing numbers of parents are coming to them and asking them to perform the procedure on their un-injured sons in the hope that this will increase their performance. However, many people — including Dr. Frank Jobe, the doctor who invented the procedure — believe most post-surgical increases in performance are generally due to two factors. The first is pitchers' increased attention to conditioning. The second is that in many cases it can take several years for the UCL to deteriorate. Over these years the pitcher's velocity will gradually decrease. As a result, it is likely that the procedure simply allows the pitcher to throw at the velocity he could before his UCL started to degrade.[8]
All players listed are quarterbacks unless noted otherwise.