Baseball’s next miracle surgery
Baseball’s next miracle surgery (FanSided by Will Carroll)
“It’s a game changer.”
That phrase is often just hype, but when you hear it come from not one, but four of the top orthopedic surgeons in the country, it’s time to take note.
True changes in sports medicine come about once in a generation. Tommy John surgery, the arthroscope, the use of orthobiologic agents like PRP — these innovations are now part of the sports medicine landscape, and regularly help athletes come back from injuries that were career-altering or even career-ending not that long ago.
The latest new method isn’t on the drawing board; it’s in athletes already. And we’re about to see a lot more of it.
The innovation is really a product, not a surgery. It’s called SutureTape and it’s made by Arthrex, the large medical device manufacturer, after consultation with some of the top orthopedic surgeons. It’s use in surgery is called “InternalBrace.” The tape is affixed during surgery to brace a ligament or reconstruction as it heals, allowing early load and sometimes even return to play prior to complete biologic healing.
Many of the surgeons who consulted Arthrex on the development of SutureTape were on the stage at the recent Lewis Yocum Baseball Medicine Conference, run by the Kerlan-Jobe Clinic and super-surgeon Neil ElAttrache’s staff. A discussion among ElAttrache, Dr. John Conway of the Ben Hogan Clinic in Fort Worth, Dr. Orr Limpisvasti and Dr. Steven Shin of Kerlan-Jobe showed just how much potential this has.
Dr. Orr Limpisvasti is at the forefront of this research, working closely with Arthrex to develop the techniques and the best practices for this surgery. “We’re actively researching what the best ways and places to use this. Obviously, we’re always guided by the patient and getting the best result for him or her. What this technique is allowing us to do is safely putting the athlete back in the game faster while decreasing their risk of reinjury during the healing process.”
In essence, Limpisvasti’s technique is to use the SutureTape to enhance the injured ligament or tendon, weaving it into the structure. It acts as a check on the ligament, strengthening and limiting the motion. This allows a much quicker return to function, because the SutureTape doesn’t need to heal. It provides immediate strength and stability, allowing the ligament itself to heal.
What that means for the athlete is more of their most valuable resource: time. In some cases, Limpisvasti has seen the time it takes for an athlete to return to play cut in half. For a severe knee injury like an ACL tear, that could mean reducing recovery time from nine months to four. For a thumb injury, it could go from three months to four weeks. In one example, a bull rider was able to return from an elbow reconstruction in four months, not the year it typically takes.
“It’s not appropriate for everyone,” said Limpisvasti. “It needs good tissue to repair, so a lot of chronic to acute — like what we see with pitchers who wear out their elbow until it finally pops — might not be candidates. We’re learning where it can best be used.”
However, the technique is already being used on athletes. Dr. Jeff Dugas of Andrews Sports Medicine in Birmingham recently reported that he’s done 50 operations on damaged elbow ligaments. The results are almost too good, with no documented failures. By comparison, Tommy John surgery has about a 17 percent failure rate over a large population.
The procedures Dugas carried out were on the ulnar collateral (UCL) ligament in the elbow. But, unlike in Tommy John surgery, the new technique and the new material allow Dugas to repair the ligament rather than replace it.
Dugas told me he’s using the same technique first developed by Scottish surgeon Gordon Mackay, who focuses on rugby. (Several of the other doctors I spoke to mentioned Mackay as well.) Dugas has, in the past, described the surgery as “taping up the ligament,” but that doesn’t seem to fully capture it.
Dugas has worked on baseball pitchers, but not at the pro level. However, Dr. George Paletta recently used Dugas’ technique on St. Louis Cardinals pitcher Seth Maness. Maness had a partial-thickness tear of his UCL and had the surgery as an alternative to Tommy John.
Normally, the rehabilitation time after Tommy John surgery is between 12 and 14 months, though there’s been some movement on that timeline in the last few years. The return time from this new repair is expected to be around six months.
That’s a huge gain, especially considering the salaries pro players are on. Maness, a 27-year-old reliever, is hardly Matt Harvey or Stephen Strasburg in terms of value, but he was worth $1.4 million dollars last season. Cutting his rehab time in half could theoretically be worth around half a million.
Another technique that’s becoming increasingly popular involves the use of orthobiologic agents. Several pitchers, including Garrett Richards of the Angels and Masahiro Tanaka of the Yankees, treated small ulnar collateral ligament tears by using PRP (plasma rich platelet) or stem cell injections (stem cells are usually taken from aspirated bone marrow extracted from the patient’s own hip).
These injections have been used more frequently despite a lack of scientific certainty about how they actually work. It’s clear at this point the injections do no harm, but they haven’t been successful as consistently as InternalBrace.
There’s a possibility, however, the two techniques could be combined. Limpisvasti said the use of orthobiologics along with the InternalBrace would preserve both the biology and the biomechanics.
The next step is more research and development — the toughest part now is determining exactly how much tension to put in. This is easier in some areas than others. Dr. Steven Shin told me, for example, that the thumb gives a good guide for tension when it’s placed at a certain angle.
After Dr. Frank Jobe did the first Tommy John surgery, it was almost three years before he did another. We’re not likely to see that kind of gap between Maness and the next athlete. In fact, other professional and high-level collegiate athletes have already had the procedure.
Dr. Shin spoke about an athlete that was able to return inside of six weeks from an InternalBrace procedure on a torn thumb ligament. Dr. Shin couldn’t name the athlete due to privacy regulations, but I believe it was Andrelton Simmons of the Los Angeles Angels. He returned from the surgery in a little over five weeks, where others took 10 to 12.
Dr. John Conway told a story about repairing the elbow ligament of a bull rider. The rider’s rope arm was damaged and repaired, and the athlete was able to return in four months, rather than a year, with no issues with the elbow. This is despite the obvious violent movement and tension on the elbow from the mechanics of rodeo riding.
Limpisvasti used the technique on a college football player with a sprained ACL, an injury that used to end careers and is these days typically a season-ender at least. Limpisvasti used this technique in a partially torn ACL in a collegiate football player with an unstable knee following repair and internal brace. “He pressed back to full return (largely against my advice) in around eight weeks because he felt so good,” Limpisvasti explained.
All the doctors I spoke with told me they’re doing this procedure regularly. There are many more athletes I suspect have benefitted from internal brace. Chris Paul recently had his thumb repaired by Dr. Shin and is expected to return in six to eight weeks. If he comes back sooner, you’ll know why. Holly Holm is returning from a severe thumb ligament tear and will be fighting soon for a UFC title.
All that this surgical technique lacks is a catchy name, but that will be tough. This technique works in so many different places that we won’t have one pioneer like a Tommy John. What we’ll have is athletes coming back in-season rather than the next season. We’ll have athletes returning from injuries and getting back on the field quicker, with fewer setbacks. We’ll have less time on the disabled list and more time in the game.
We should just call it a miracle.