Ulnar collateral ligament reconstruction

Last updated

Ulnar collateral ligament reconstruction
Other namesUCL reconstruction, Tommy John surgery
ICD-9-CM 81.85

Ulnar collateral ligament reconstruction, colloquially known 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.

Contents

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, whose record of 288 career victories ranks seventh among left-handed pitchers. 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. [1]

Uses

The ulnar collateral ligament (UCL) can become stretched, frayed, or torn through the repetitive stress of the throwing motion. The risk of injury to the UCL is believed to be extremely high, as the amount of stress through the structure approaches its ultimate tensile strength during a hard throw. [2]

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. [3]

The results of a 2002 study suggest that the total number of pitches thrown is the greatest determinant. [4] 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. [4]

Research into throwing injuries in young athletes has led to age-based recommendations for pitch limits. [5]

Increasingly often, pitchers require a second procedure after returning to pitching. During the periods from 2001 to 2012 and 2013 to 2015, 18 major-league pitchers underwent the procedure for a second time. As of April 2015, the average amount of time between procedures is 4.97 years. [6]

Risks

There is a risk of damage to the ulnar nerve. [7]

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. [8] 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. [9] 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.[ citation needed ]

Technique

Reconstruction

A surgical incision of 3–4 inches (7.6–10.2 centimetres) is made near the elbow. [10] Holes to accommodate a replacement graft tendon are drilled in the ulna and humerus bones of the elbow. [10] A harvested tendon, such as the palmaris tendon [11] 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. [10] The ulnar nerve is usually moved to prevent pain, as scar tissue can apply pressure to the nerve. [11] 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. [10] After one week, a brace is employed to protect the reconstruction for about six weeks following surgery. [10]

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. [12] Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008. [12]

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 [13]
  2. The goals of phase 2 (weeks four to eight) are to gain strength and gain full range of movement [13]
  3. During phase 3 (weeks nine to 13), the rehabilitation is focused on flexibility and neuromuscular control with a progression toward sports-related activities [13]
  4. The progression to a throwing program is made during phase 4 (weeks 14 to 26) for overhead athletes [13]

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. [13]

Incidence

Over two decades preceding 2016, the number of UCLR surgeries increased threefold, a rate that was expected to continue to rise. [14] 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. [15]

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. [16] 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. [17]

History

Tommy John, for whom the surgery is named, in 2008 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. [18] By 2009, the odds of complete recovery had risen to 85–92%. [19]

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 12–15 months for pitchers and about six months for position players. Players typically begin throwing about 16 weeks after surgery. [20] 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. [6]

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." [21]

Related Research Articles

<span class="mw-page-title-main">Rotator cuff</span> Group of muscles

The rotator cuff is a group of muscles and their tendons that act to stabilize the human shoulder and allow for its extensive range of motion. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are:

<span class="mw-page-title-main">Pitcher</span> Player who pitches the ball in baseball

In baseball, the pitcher is the player who throws ("pitches") the baseball from the pitcher's mound toward the catcher to begin each play, with the goal of retiring a batter, who attempts to either make contact with the pitched ball or draw a walk. In the numbering system used to record defensive plays, the pitcher is assigned the number 1. The pitcher is often considered the most important player on the defensive side of the game, and as such is situated at the right end of the defensive spectrum. There are many different types of pitchers, such as the starting pitcher, relief pitcher, middle reliever, lefty specialist, setup man, and the closer.

<span class="mw-page-title-main">Ulnar collateral ligament of elbow joint</span> Ligament on the elbow

The ulnar collateral ligament (UCL) or internal lateral ligament is a thick triangular ligament at the medial aspect of the elbow uniting the distal aspect of the humerus to the proximal aspect of the ulna.

<span class="mw-page-title-main">Anterior cruciate ligament reconstruction</span> Surgical process

Anterior cruciate ligament reconstruction is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after an injury. The torn ligament can either be removed from the knee, or preserved before reconstruction through an arthroscopic procedure. ACL repair is also a surgical option. This involves repairing the ACL by re-attaching it, instead of performing a reconstruction. Theoretical advantages of repair include faster recovery and a lack of donor site morbidity, but randomised controlled trials and long-term data regarding re-rupture rates using contemporary surgical techniques are lacking.

<span class="mw-page-title-main">Frank Jobe</span> American orthopedic surgeon and co-founder of the Kerlan-Jobe Orthopaedic Clinic

Frank Wilson Jobe was an American orthopedic surgeon and co-founder of the Kerlan-Jobe Orthopaedic Clinic. Jobe pioneered both elbow ligament replacement and major reconstructive shoulder surgery for baseball players.

<span class="mw-page-title-main">Anterior cruciate ligament injury</span> Ligament injury near the knee

An anterior cruciate ligament injury occurs when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. The most common injury is a complete tear. Symptoms include pain, an audible cracking sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours. In approximately 50% of cases, other structures of the knee such as surrounding ligaments, cartilage, or meniscus are damaged.

<span class="mw-page-title-main">Golfer's elbow</span> Tendon inflammation disease of the elbow

Golfer's elbow, or medial epicondylitis, is tendinosis of the medial common flexor tendon on the inside of the elbow. It is similar to tennis elbow, which affects the outside of the elbow at the lateral epicondyle. The tendinopathy results from overload or repetitive use of the arm, causing an injury similar to ulnar collateral ligament injury of the elbow in "pitcher's elbow".

<span class="mw-page-title-main">Unhappy triad</span> Medical condition of the knee

The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.

<span class="mw-page-title-main">Little League elbow</span> Medical condition

Little League elbow, technically termed medial epicondyle apophysitis, is a condition that is caused by repetitive overhand throwing motions in children. "Little Leaguer's elbow" was coined by Brogdon and Crow in an eponymous 1960 article in the American Journal of Radiology.

<span class="mw-page-title-main">Medial patellofemoral ligament</span> Ligament of the knee

The medial patellofemoral ligament (MPFL) is one of several ligaments on the medial aspect of the knee. It originates in the superomedial aspect of the patella and inserts in the space between the adductor tubercle and the medial femoral epicondyle. The ligament itself extends from the femur to the superomedial patella, and its shape is similar to a trapezoid. It keeps the patella in place, but its main function is to prevent lateral displacement of the patella.

<span class="mw-page-title-main">Overhand throw</span> Single-handed throw of an object from above the shoulder

The overhandthrow is a single-handed throw of a projectile where the object is thrown above the shoulder.

<span class="mw-page-title-main">Ulnar collateral ligament injury of the elbow</span> Medical condition

Ulnar collateral ligament injuries can occur during certain activities such as overhead baseball pitching. Acute or chronic disruption of the ulnar collateral ligament result in medial elbow pain, valgus instability, and impaired throwing performance. There are both non-surgical and surgical treatment options.

<span class="mw-page-title-main">Lucas Giolito</span> American baseball pitcher (born 1994)

Lucas Frost Giolito is an American professional baseball pitcher for the Boston Red Sox of Major League Baseball (MLB). He has previously played in MLB for the Washington Nationals, Chicago White Sox, Los Angeles Angels, and Cleveland Guardians.

<span class="mw-page-title-main">Christian Garcia (baseball)</span> American baseball player (born 1985)

Christian J. Garcia is an American former professional baseball pitcher. Garcia pitched for the Washington Nationals of Major League Baseball in 2012.

Christopher S. Ahmad is the head team physician for the New York Yankees and a member of the Major League Baseball Team Physicians Association. He is a professor of clinical orthopaedic surgery at the Columbia University College of Physicians and Surgeons and an attending orthopaedic surgeon at the New York-Presbyterian/Columbia University Medical Center. In 2013, New York Yankee Alex Rodriguez filed a medical malpractice lawsuit against Ahmad, which he subsequently dropped.

Gabriel Isaac Cramer is an Israeli-Canadian-American professional baseball right-handed pitcher who is currently a free agent. He throws a 99 mph fastball. He plays for the Israel National Baseball Team.

Kenneth Jaden Hill is an American professional baseball pitcher for the Colorado Rockies of Major League Baseball (MLB). He played college baseball for the LSU Tigers.

Dr. Jeremy Bruce is an Orthopaedic Surgeon at Erlanger Hospital in Chattanooga, Tennessee. He is also a Program Director and Director of Sports Medicine for the Orthopedic Residency program at The University of Tennessee College of Medicine in Chattanooga. He is a ringside physician that has covered UFC fights, Bellator fights, Ringside World Boxing championship, USA Boxing events and is a member of the USA Boxing Medical Commission. Dr. Bruce was a member of the USA Bobsled and Skeleton Team and competed alongside future Olympic gold medalist Jim Shea in the North American Skeleton Championship in Calgary, AL (1994).

Cole Robert Waites is an American professional baseball pitcher in the San Francisco Giants organization. He played college baseball at the University of West Alabama, and was drafted by the Giants in the 18th round of the 2019 MLB draft. He made his Major League Baseball (MLB) debut in 2022.

References

  1. ↑ Grantland staff (July 23, 2013). "30 for 30 Shorts: Tommy and Frank". Grantland. Retrieved August 17, 2013.
  2. ↑ Fleisig, G.S., “The biomechanics of baseball pitching”, in Biomechanical Engineering. 1994, University of Alabama: Birmingham. p. 163.
  3. ↑ Feeley BT, Agel J, LaPrade RF (January 2016). "When Is It Too Early for Single Sport Specialization?". The American Journal of Sports Medicine. 44 (1): 234–241. doi:10.1177/0363546515576899. PMID   25825379. S2CID   15742871.
  4. 1 2 Lyman S, Fleisig GS, Andrews JR, Osinski ED (2002). "Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers". The American Journal of Sports Medicine. 30 (4): 463–468. doi:10.1177/03635465020300040201. PMID   12130397. S2CID   17750974.
  5. ↑ Lyman S, Fleisig GS, Waterbor JW, Funkhouser EM, Pulley L, Andrews JR, et al. (November 2001). "Longitudinal study of elbow and shoulder pain in youth baseball pitchers". Medicine and Science in Sports and Exercise. 33 (11): 1803–1810. doi: 10.1097/00005768-200111000-00002 . PMID   11689728. S2CID   37361297.
  6. 1 2 Verducci T. "The post-Tommy John surgery calculus that is changing the game". Sports Illustrated. No. April 21, 2015. Retrieved April 21, 2015.
  7. ↑ Purcell DB, Matava MJ, Wright RW (February 2007). "Ulnar collateral ligament reconstruction: a systematic review". Clinical Orthopaedics and Related Research. 455: 72–77. doi:10.1097/BLO.0b013e31802eb447. PMID   17279038. S2CID   30674621.
  8. ↑ Longman J (July 20, 2007). "Fit Young Pitchers See Elbow Repair as Cure-All". The New York Times . Retrieved October 23, 2013.
  9. ↑ Keri J (September 13, 2007). "Interview With Dr. Frank Jobe". ESPN.com. Retrieved October 13, 2008.
  10. 1 2 3 4 5 Khalfayan EE/MD/Surgeon (2016). "Tommy John surgery/UCL reconstruction (graphic surgical video)". Orthopedic Physician Associates, Seattle, WA. Retrieved January 7, 2017.
  11. 1 2 Carroll W. "Dr. Frank Jobe, Tommy John and the Surgery That Changed Baseball Forever". Bleacher Report. Turner Broadcasting System, Inc. Retrieved July 17, 2013.
  12. 1 2 Lawton CD, Lamplot JD, Wright-Chisem JI, James EW, Camp CL, Dines JS (June 2020). "State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes". Current Reviews in Musculoskeletal Medicine. 13 (3): 338–348. doi:10.1007/s12178-020-09621-3. PMC   7251011 . PMID   32323247.
  13. 1 2 3 4 5 Jang SH (December 2019). "Management of Ulnar Collateral Ligament Injuries in Overhead Athletes". Clinics in Shoulder and Elbow. 22 (4): 235–240. doi: 10.5397/cise.2019.22.4.235 . PMC   7714305 . PMID   33330225.
  14. ↑ Mahure SA, Mollon B, Shamah SD, Kwon YW, Rokito AS (June 2016). "Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review". Journal of Shoulder and Elbow Surgery. 25 (6): 1005–1012. doi:10.1016/j.jse.2016.02.036. PMID   27197888.
  15. ↑ Erickson BJ, Nwachukwu BU, Rosas S, Schairer WW, McCormick FM, Bach BR, et al. (July 2015). "Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States: A Retrospective Review of a Large Private-Payer Database From 2007 to 2011". The American Journal of Sports Medicine. 43 (7): 1770–1774. doi:10.1177/0363546515580304. PMID   26129959. S2CID   33623945.
  16. ↑ "Pitch Smart". Major League Baseball. 2016. Retrieved October 26, 2016.
  17. ↑ Fleisig GS, Andrews JR (September 2012). "Prevention of elbow injuries in youth baseball pitchers". Sports Health. 4 (5): 419–424. doi:10.1177/1941738112454828. PMC   3435945 . PMID   23016115.
  18. ↑ "Frank Jobe's Hall of Fame Life". Major League Baseball. July 22, 2013. Retrieved March 7, 2014.
  19. ↑ Rosenhek E (July 1, 2009). "The gory details of Tommy John surgery". The Good Point. Retrieved April 6, 2014.
  20. ↑ Dodd M (July 29, 2003). "A year of rehab for Tommy John patients". USA Today.
  21. ↑ Pouliot, Matthew (July 15, 2012). "Dr. Frank Jobe: 'It could have been Sandy Koufax surgery'". MLB | NBC Sports. Retrieved May 3, 2022.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.