Elbow pain is a pitcher's worst nightmare. Why? It could mean that you are out for an entire season or more recovering from Tommy John surgery.
Tommy John surgery is the procedure performed to repair a damaged ulnar collateral ligament, which is a triangle-shaped ligament in the elbow that helps stabilize the joint. Unfortunately, this injury is far too common. Pitchers, coaches and baseball organizations need to do a better job of preventing the injury from occurring in the first place.
Recently, Dr. Jeffrey Dugas, an orthopaedic surgeon and sports medicine specialist at the renown Andrews Sports Medicine and Orthopaedic Center, along with other surgeons throughout the country, have been experimenting with a new procedure called "primary repair," which appears to be a highly effective alternative to Tommy John surgery.
STACK chatted with Dugas to learn more about this innovative procedure and what it means for baseball players in the future.
Why does Tommy John surgery take so long to recover from?
According to Dugas, Tommy John surgery is a fairly invasive surgery in which the UCL is replaced with a tendon from your hamstring or forearm. The ligament replacement is attached via holes drilled in your bones.
The replacement ligament then needs to bond to your bones and incorporate into the surrounding soft tissues. Once the healing process is complete, you need to gradually stress the new ligament with rehab exercises and a light throwing program to prepare it for the extreme stress of pitching a ball at full speed.
"It's a process that takes longer than people expect," says Dugas. "At the higher levels of baseball, the major league levels, the average return time is almost 18 months. It takes longer the better you get."
What's the story behind the primary repair technique?
According to Dugas, not every UCL injury is created equal.
"When we are doing these operations, some people's ligaments are blown in half, some people have some partial tears and we've had the same answer for that for a long time," he explains.
That answer has been Tommy John surgery, which is a highly effective method for fixing an injured UCL. "We all know the success rate of Tommy John surgery, and it's been great operation. That hasn't changed; it's still a great operation," Dugas says.
However, doctors began to investigate alternative methods for repairing less-severe UCL injuries in hopes of reducing the recovery time from the surgery. The first primary repair surgery was performed in 2013.
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How is primary repair surgery different from traditional Tommy John surgery?
Primary repair surgeries repair the UCL instead of replacing it. According to Dugas, who has performed over 100 of them, a piece of super strong tape is attached directly to the UCL. The tape is coated in collagen, which helps the ligament heal.
It's a less invasive and less painful procedure than Tommy John surgery—although Dugas says that Tommy John surgery isn't terribly painful.
However, he emphasizes that primary repair surgery isn't appropriate for every UCL injury.
"It's not for somebody whose ligament is trashed, the ligament tissue is bad or they have a deficiency in the ligament and need more tissue," he explains. In most cases, it's appropriate for less-severe injuries and young athletes without too much wear-and-tear on their ligament.
Often, it's not even possible to tell if someone is a candidate for primary repair until the doctor actually opens up their arm and sees their ligament.
"When we consult these people for surgery, we may think that they are good candidates for this [primary repair], but ultimately the decision is made based on the actual tissue and what we see or feel," says Dugas.
What's the recovery process like?
Since the procedure repairs the ligament rather than replacing it with a tendon that has to function like a ligament, recovery time is significantly faster than Tommy John surgeries.
Dugas explains: "We put them in a brace for six weeks and they start range of motion just a couple of days after surgery. They begin doing plyometrics, which is a more advanced type of exercise, after the end of the week six and through week 10. Then they begin a throwing program, whereas [formerly] they wouldn't begin throwing until week 18."
Sounds promising for those who are candidates for the surgery.
What's the outlook for primary repair?
So far, so good.
"We're just writing up the first 50 or so people who have a minimum of a one year followup and it's been like 97 or 98 percent have returned to the same or higher level of play in several different sports," Dugas says.
The first three Major League Baseball players who had this procedure, including Cardinals reliever Seth Maness, are expected to return this season. Dugas expects that other pitchers, general managers and physicians will be keeping a close eye on them to see if the primary repair technique can effectively restore a major league elbow to full functioning.
However, he cautions that a major part of effectiveness is to be strict in limiting the use of the method to patients who are legitimate candidates and not construing it as a total replacement for traditional Tommy John surgery.
"Universally, with the people who have had it, the results have been pretty good, and I attribute that not just to the operation but to the fact that the high quality elbow surgeons who have started to use it have known not to expand the indications for people with bad ligament tissue," he adds.
But if it can help even a few athletes get back to their sport faster, we should consider primary repair a success.
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