“Tommy John” Surgeries: Pearls, Pitfalls, and Protocols (AAOS Now)
A roundtable on treating ulnar collateral ligament overuse injuries
The incidence of ulnar collateral ligament (UCL) overuse injuries has increased substantially in recent years—and not only among major league baseball players. According to the results of one study, about 60 percent of professional pitchers had a precipitating minor injury to the UCL when they were in youth baseball.
Recently, AAOS Now editorial board member Frank B. Kelly, MD,discussed this injury with the following leaders in the field:
- James R. Andrews, MD, a founding member of Andrews Sports Medicine and Orthopaedic Center in Birmingham, Ala., a member of the Medical and Safety Advisory Committee of USA Baseball and the Board of Little League Baseball, Inc., and medical director of the Tampa Bay Rays
- James P. Bradley, MD, clinical professor of orthopaedic surgery at the University of Pittsburgh School of Medicine, team physician for the Pittsburgh Steelers, and consultant for the Miami Marlins
- Thomas John Noonan, MD, of the Steadman Hawkins Clinic in Denver, Colo., and head team physician for the Colorado Rockies major league baseball team
- Neal S. ElAttrache, MD, of the Kerlan-Jobe Orthopaedic Clinic, Los Angeles, and team physician for the Los Angeles Dodgers
- Kevin E. Wilk, PT, DPT, associate clinical director for Champion Sports Medicine (a physiotherapy facility) in Birmingham, Ala., and the rehabilitation consultant for the Tampa Bay Rays
This report focuses on surgical management and rehabilitation. For more on the pathology, mechanism of injury, precipitating factors, diagnosis, and nonsurgical management of these injuries, see “Treating Ulnar Collateral Ligament Overuse Injuries” in the February 2015 issue of AAOS Now.
Dr. Kelly: I suppose the indications for surgery will be a failure to respond to conservative treatment or patient preference, as long as the patient is willing to participate in a long rehabilitation protocol.
Could each of you share your pearls or tips on anchoring and tensioning the graft? What do you do with the ulnar nerve? Do you divide the muscle?
Dr. Bradley: My advice is to find a procedure that you’re good at, do it a lot, and know all the nuances of whichever procedure you choose. I perform one of two procedures. I was taught by Frank Jobe, MD, so I perform a modified Jobe technique that splits the flexor groups. I do not address the ulnar nerve unless absolutely necessary. I typically would not utilize a docking technique unless I have to use a gracilis tendon because a good palmaris longus tendon isn’t available.
Dr. Noonan: I would echo that. Several different approaches can be used with good results. My preference is to use autograft tissue, preferably a quadrupled palmaris tendon graft or a doubled gracilis tendon graft. I also warn patients that if we choose to use the palmaris graft and it is too small (less than 3.2 mm in diameter after doubled), we may need to additionally harvest the gracilis tendon.
I also use a muscle-splitting approach and prefer to not address the ulnar nerve unless the athlete had chronic preoperative symptoms. I use a docking technique that requires less drilling in the bone (Fig. 1) and, I think, results in fewer complications.
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| Fig. 1 Drilling the humeral tunnel during the docking procedure. Courtesy of Thomas John Noonan, MD |
Dr. Kelly: Are better results available from using a muscle-splitting procedure than from stripping the muscle from the ligament? What’s the impact of not mobilizing the ulnar nerve?
Dr. ElAttrache: In the first generation of Tommy John operations, surgeons removed the flexor mass from the epicondyle. Today, using Dr. Andrews’ technique, the surgeon lifts the flexor mass and moves the ulnar nerve to reach the ligament. I use a muscle-splitting approach and don’t move the nerve unless the patient has persistent paresthesias or an unstable ulnar nerve. In that case, I will transpose the nerve.
If the patient has reasonable native tissue remaining, I like to save that tissue so I close up the native ligament tissue underneath, separating my graft from the joint. The graft doesn’t sit in the joint, but on top of the native tissue.
If radiographs and MRI scan show ossification or deficits in the native ligament tissue, the repair tissue should have as much collagen as possible. If I’m concerned about the size of the palmaris, I’ll use the gracilis to get a lot of collagen. I try to get at least three strands of palmaris across the joint (Fig. 2), but four is better to increase the amount of collagen in place of injured tissue.
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| Fig. 2 Passing the graft through the ulnar tunnel. Courtesy of Thomas John Noonan, MD |
Unfortunately, over the past couple years, the number of revisions I’ve seen has increased. In revision situations, the quality of the bone is a concern. I try to minimize drilling new tunnels in the bone, especially in the epicondyle. I try to make just one tunnel in a revision situation. I use a titanium button on top of the epicondyle so I don’t have to drill three new tunnels into a bone that has already been drilled.
Dr. Andrews: I start with a standard medial incision overlying the medial epicondyle. After identifying the branches of the medial antebrachial nerve, I split between the two heads of the flexor carpi ulnaris. By dissecting the muscle from proximal to distal, I identify the sublime tubercle. I go under flexor carpi ulnaris, moving the medial nerve, so I can work right through the groove. I reflect the flexor sublimis muscle attachment from the sublime tubercle area and then detach the ligament itself so I can get a good exposure.
That gives me a good pathway to drill both distal and proximal tunnels. I like to use tunnels in the old-fashioned way because I think part of the blood supply to the graft comes through those tunnels. The size of the tunnel is an issue. If there is ossification within the ligament, a larger graft is needed, which requires a bigger tunnel. In doing so, exercise caution in recovery because if the player returns to the mound too early, the medial epicondyle can pull off due to the pull of the flexor mass. We use the gracilis about 40 percent of the time.
Although we all use the gracilis, some discussions recently have focused on the increased amount of collagen. The speculation is that the ligament may be so thick and strong that it doesn’t get completely revascularized and it takes longer to mature. Additionally, the graft may be so big that it doesn’t heal as fast as it did when we didn’t use as much collagen tissue. With the bending moment proximally, it can disrupt as it goes into the medial epicondyle.
A limited muscle split approach requires an experienced surgeon so that the ulnar nerve is not traumatized when the tunnels are drilled. The error that can be made with this approach is putting the tunnels too far medial and anteromedial to avoid the ulnar nerve.
Splitting the ligament is done to identify the joint line and the more substantial deep layer of the ulnar collateral ligament. It’s often difficult to see the tearing from the peripheral superficial part of the ligament, which may very well be intact.
Therefore, splitting the ligament shows the undersurface tearing that is so common. I split it and then “fish mouth” the normal ligament around the graft and sew the graft on top, distally down to the sublime tubercle drill hole. This helps save all of the native ligaments (Fig. 3).
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| Fig. 3 Completed reconstruction showing placement of the graft across the joint. Courtesy of Thomas John Noonan, MD |
I’m concerned about why the number of redos is increasing. Is it that players are pushing harder to return to play? Most major league teams, for example, are taking longer to bring high-level players and prospects back to pitching. They’re not letting them begin any throwing program for 6 months or more just to be on the safe side. Players frequently don’t pitch competitively for up to 18 months.
Dr. Kelly: That leads into the issues of postoperative management and expected outcomes. Dr. Wilk, what’s the appropriate postoperative management for a typical Tommy John surgery?
Dr. Wilk: Postoperative rehabilitation is based on the surgical technique and physician preference. Because Dr. Andrews uses the modified Jobe procedure, we have the patient wear a posterior splint for the elbow for 5 to 7 days after surgery. The wrist and hand are free to move, but the brace or splint holds the elbow at 90 degrees. During week two, range of motion exercises begin.
Recently, we’ve been taking a more aggressive approach to gaining motion. We usually expect full elbow range of motion by 5 or 6 weeks postoperatively, but it’s fine if that happens earlier.With palmaris longus grafts, we leave the wrist alone for the first 5 to 7 days, but begin working the soft tissue and stretching the plantar aponeurosis during the second or third week. With gracilis tendon grafts, it is important, from a rehabilitation standpoint, not to do calf or hamstring stretching for 2 to 3 weeks to allow the muscle to heal.
As far as the rehab for return to throwing, shoulder exercises start right away. Isometrics for the posterior spine start in the first week and progress to isotonics. The throwers 10-exercise program usually starts at 3 to 4 weeks, with the emphasis on restoring shoulder range of motion. At 12 weeks, we start a plyometric program and two-hand throwing. At 14 weeks postop, plyometric throwing with one hand (baseball style) starts. Doing plyometrics before starting an interval throwing program is important.
Typically, if everything progresses well, we initiate a long-toss program at 4 months postop. It starts at 45 feet and the distances gradually increase to 120 feet over the next 6 to 8 weeks. At 6 months, flat ground throwing at 60 feet distance is allowed, progressing to off-the-mound throwing over the next 2 weeks.
Even after mound throwing starts, it is actually a long progression to get up to 100 percent and game ready. It usually takes about 9 months before confidence in the arm returns. It’s probably 12 months before the player feels that the elbow is sufficient to pitch in a game situation or simulated game. Often, the second year is better than the first, but we try to get players back at 9 to 12 months postoperatively just so they’re productive and back with the team.
Dr. Kelly: Let’s discuss expected outcomes and the factors that can affect a return to play or a retear.
Dr. Bradley: A literature review shows outcomes across the board are in the mid 80 percent range. But most of these studies do not use outcome measures specific to throwing athletes. The only really good outcome measure that I know of is the Kerlan-Jobe Scale developed by Dr. ElAttrache.
I generally have about an 83 percent return to sports level, using either the docking procedure or the modified Jobe procedure. My retear rate is relatively small—in the 5 percent range—but I have a younger patient population without many chronic elbow problems. Since I learned that major league players are out 14 to 17 months before return to sport, I’ve pushed back my full return timeframe for pitchers to 14 months.
Dr. Noonan: My results are similar, with few retears. In dealing with younger players, I try to emphasize the limitations of this operation to them and their parents. Previous research has shown the average career length following reconstruction is about 4 years. Often, other factors than the elbow contribute, but young players who want to make it professionally are asking a lot of that operation. Having a UCL reconstruction at age 15 or 16 and thinking that you can have a significant professional career is a long shot.
Dr. ElAttrache: I agree. These days, more people who throw the ball really hard are having surgery. The number of pitchers who can throw the ball in the range of 90 mph or higher has increased. I ask patients about their throwing velocity when they were healthy. If they say about 90 mph, I’m careful about how quickly I let them get back to competitive baseball. I’ve seen several players who throw in that mid 90 mph range and above, and I’m waiting to see what will happen.
I tell them to put the radar gun away and not look at velocity. I want them to work on pitching mechanics, to think smooth. Velocity will come. I want them to be well conditioned. I don’t want them muscling the ball. That can lead to retears and failures.
Dr. Andrews: In our large series, about 83 percent of players returned to baseball; among younger players, the return-to-play was a bit higher, about 85 percent. Among major league baseball players, about 80 percent return to play, but only 75 percent actually get back to the major leagues.
For several years, my retear rate was 1 in 100 but last year, there were three retears on one team. That raised some questions, but when you perform a lot of the same type of surgeries, your complication rate will increase based simply on the numbers.
AAOS Now
March 2015 Issue
http://www.aaos.org/news/aaosnow/mar15/clinical1.asp