By David Klein
The five scariest words a baseball pitcher can hear are, “You need Tommy John Surgery.” Ulnar collateral ligament (UCL) reconstruction is performed when someone tears the stabilizing ligament in his elbow. This injury is common among athletes who compete in overhead throwing sports and affects professional baseball players in particular. Thanks to major breakthroughs in sports medicine, what used to be a career-ending injury, can now be fixed with a routine surgery.
The UCL is located on the elbow and connects the upper arm to the forearm. It is a thick band made up of tissue whose primary function is to stabilize and strengthen the elbow. It is made up of an anterior, posterior and transverse band. The anterior band is the primary source for the elbow’s stability (Borak, 2009).
This injury is often seen in baseball pitchers because the UCL plays a major role in flexing the elbow. With the elbow fully extended, the ligament makes up roughly thirty percent of the elbow’s stability. However, when the elbow is at a 90 degree angle, the UCL contributes to more than half of the arm’s stabilization. The force at which a pitcher delivers the ball is considerably higher than the strength of the UCL ligament. Repeatedly moving the elbow in high stress situations leads to inflammation and the eventual tearing of the ligament (Borak, 2009).
The UCL reconstruction is commonly referred to Tommy John Surgery. It was named after baseball pitcher Tommy John who was the first patient to successfully undergo the surgery in 1974. Prior to Tommy John, an injury to the UCL was thought to be career-ending for pitchers. However, Dr. Frank Jobe revolutionized sports medicine by pioneering the first procedure of ulnar collateral ligament reconstruction in 1974 (Sperry, 2012). Dr. David Altchek, orthopedic surgeon and co-chief of sports medicine and shoulder service at Hospital for Special Services stated that “before Dr. Jobe developed this surgical technique, an UCL tear was often a career-ending injury. Today, athletes that undergo UCL reconstruction often play as well as they did before the surgery, and, in some cases even better” (Altcheck 2004). With a successful surgery and a proper rehabilitation regiment, many baseball pitchers have been able to return to the game and perform at a top level.
In his article “Is Surgery Changing Baseball”, Robert Lamb (2009) compares Tommy John Surgery to repairing a broken shoelace. Lamb (2009) states,”The Tommy John procedure follows a basic design. Imagine you have two boots and the lace on one breaks beyond your ability to repair it. The lace on your other boot, however, is in great condition and has plenty of length. Why not simply cut some excess lace from one boot and use it to mend the other?”To reconstruct the torn ligament, surgeons take a tendon from either the patient’s hamstring or forearm and graft it onto the elbow. This new ligament is the equivalent of the extra shoelace. Since the shoelace needs holes to be laced through, the surgeon must drill holes into the ulna and humerus bones to create space for the new ligament. The tendon is then weaved through to create tension and stability at the elbow, similar to how a shoelace is weaved through holes created to keep the shoe tight (Lamb, 2009).
The procedure Dr. Frank Jobe created saved Tommy John’s career and allowed him to pitch for fifteen more seasons in the majors. This method is considered to be the traditional procedure. Dr. Jobe drilled a total of four holes in the two bones that meet to form the elbow. Specifically, two holes were drilled into the medial epidcondyle of the humerus and two were drilled in the ulna. He then weaved the replacement ligament in a figure eight pattern through the holes (Borak, 2009).
While this traditional method is successful, Jobe’s procedure was not perfect. Complications with the one of the nerves that run through the forearm muscle as well as concerns with short bony bridges were not uncommon during early procedures. These concerns have led to advancements in the reconstruction of ulnar collateral ligaments (Nissen, 2008).
A major modification to Jobe’s original method is the docking technique. This procedure was developed by Dr. David Altchek and differs in several ways. First, access to the bone is obtained by performing a technique that gently pries apart the muscle fibers. This is different from Jobe’s technique in which he detached the muscles from the bone. This traditional technique also does not require any interaction with the nerve, thus preventing the possibility of nerve damage in the forearm. Another difference is the number of holes drilled into the bone. With fewer holes being drilled into the bone, the risk of bone fracture is decreased. Altchek’s method also employs a different weaving pattern when compared to Jobe’s. Instead of the figure eight pattern, Altcheck’s docking technique performs a pattern similar to a “D.” Borak writes, “The graft enters the humerus bone, but never exits. Instead, sutures secure the tendon and exit the bone through much smaller exit punctures” ( Borak, 2009). Therefore, the docking technique provides greater tension on the graft relative to Jobe’s method because the two ends of the tendon are tied together (Borak, 2009).
A 2010 study performed by Andrea Bowers (2010), an orthopedic surgeon at Burlington County Orthopedics Specialty, followed 21 athletes who underwent UCL reconstruction via the docking method. The results showed that 19 out of the 21 athletes were able to return to their same or higher level of play prior to the injury. Over 90 percent of the athletes who went under received UCL reconstruction by way of the docking method received excellent results with a low complication rate (Bowers, 2010).
Another study performed by Kristofer Jones (2012), an orthopedic surgeon at Hospital for Special Surgery, also looked at the effectiveness of the docking method. He examined the clinical results of eight patients who underwent UCL reconstruction via the docking technique. In his follow-up, Jones looked at 46 athletes from ages 12-18 who underwent UCL reconstruction via the docking method. These patients were examined and evaluated for two years after the surgery. In the end, he found that 41 out of the 46 athletes were able to return to their sport and perform at the same level prior to the injury (Jones, 2012).
A third study compared the modified Jobe technique to Altchek’s new docking method. The study was performed by Michael Ciccotti (2009), an orthopedic surgeon and director of sports medicine at the Rothman Institute. He evaluated the ability of both techniques to restore elbow movements such as bending and rotating. This study was performed on ten cadaver elbows. What he found was that both techniques were equally successful in restoring the range of movement for the elbows (Ciccotti, 2009). If an athlete tears his UCL, he has the option either to go through rehab or undergo UCL reconstructive surgery. Athletes who opt for non-surgical procedures for a torn UCL typically find negative results. If an athlete wants to return to his respective sport at the same level prior to the injury, he must undergo surgery to reconstruct to the torn ligament because the torn ligament is usually unable to heal to a point where it is able to undergo the stress of throwing at high velocities. The Jobe and docking technique are the most popular techniques used by orthopedic surgeons for UCL reconstruction (Onkst, 2011).
In all three studies, the docking method proved to be every bit as successful in returning athletes to their physical capabilities as the Jobe method. In addition to the high success rate, the new technique also decreases the probability that complications may arise in the arm post-surgery, making it the more advantageous technique when condsidering UCL reconstruction.
With travel baseball teams and year-round leagues, pitchers are exposing their elbows to a considerably higher amount of stress, causing an increase in the number of athletes who have injured their ulnar collateral ligament. Thanks to Dr. Jobe’s creativity and skill, many pitchers’ careers have been saved. The major advancements in sports medicine have made the reconstruction process of the ulnar collateral ligament more efficient and decreased the number of complications in patients post-surgery. Because of these improvements, a tear in the ulnar collateral ligament is no longer congruent with career ending injuries.
Altchek, D. (2004, March 31). Interview by Nancy Novick . Elbow throwing injuries: The medial collateral ligament (mcl) and tommy john surgery., Retrieved from http://www.hss.edu/conditions_elbow-throwing-injuries-mcl-tommy-john.asp
Borak, T. (2009). Ulnar collateral ligament reconstruction: A look inside tommy john surgery. The Surgical Technologist, 41(4), 163-173.
Bowers, A., Dines, J., Dines, D., & Altchek, D. (2010). Elbow medial ulnar collateral ligament reconstruction: Clinical relevance and the docking technique. American
Academy of Orthopaedic Surgeons: Special Techniques, 19(2), 110-117. Ciccotti, M., Siegler, S., Kuri, J., Thinnes, J., & Murphy, D. (2009). Comparison of the biomechanical profile of the intact ligament with the modified jobe and the docking reconstructed elbow. (2009). The American Journal of Sports Medicine, 37(5), 974-eoa.
Jones, K., Dodson, C., Osbahr, D., Parisien, R., Weiland, A., Altchek, D., & Answorth, A. (2012). The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes. Journal of Shoulder and Elbow Surgery, 21(3), 389-395.
Lamb, R. (2009, February 11). Is surgery changing baseball. Retrieved from http://science.howstuffworks.com/life/human-biology/surgery-change-baseball1.htm Nissen, C. (2008). Effectiveness of interference screw fixation in ulnar collateral ligament reconstruction.Orthopedics, 31(7).
Onkst, T. (2011, April 14). Rehabilitation of a ucl in the elbow vs. surgery read more: http://www.livestrong.com/article/421164-rehabilitation-of-a-ucl-in-the-elbow-vs- surgery/
Sperry, T. (2012, April 24). Tommy john accepts role in baseball and medical history. Retrieved from http://www.cnn.com/2012/04/24/health/tommy-john-surgery