Ulnar collateral ligament reconstruction

Ulnar collateral ligament reconstruction, colloquially known as Tommy John surgery, is a

Uses

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The

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 did 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 postsurgical 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.

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

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]

References