Baseball players and fans call it Tommy John surgery, after the pitcher who was the first to have the surgery 29 years ago. By any designation, it is one of the major advancements in sports medicine in the last quarter century. Technically it is a ulnar ulnar collateral Ligament Reconstruction">collateral ligament replacements procedure. Pitching overhand is a particularly stressful motion; the strain it puts on a player’s joint is commonly injurious. Pitchers such as Kerry Wood, Matt Morris, John Smolt z, Mariano Rivera, Tom Gordon, and Eric Gagne all have a four inch scar on their pitching arms as evidence of this career saving surgery. These players typically perform as well, if not better, after the operation and have stronger arms, with radar gun readings to match.
‘It felt so good when I came back, I said I recommend it to everybody… regardless what your ligament looks like,’ Chicago White Sox reliever Billy Koch says jokingly. He blew out his elbow in his third professional appearance, in 1997. A torn elbow ligament once was a pitcher’s sentence to the broadcast booth or the monthly autograph show at the local Holiday Inn. No longer. Tommy John surgery — technically an ulnar collateral ligament replacement procedure — has saved the careers of hundreds of Major League players.
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It may one day make the Hall of Fame case for its inventor, surgeon Frank Jobe (who was Hollywood enough to trademark the name ‘Tommy John procedure’).
Thirty years after Jobe invented this surgery, baseball players are still using it. The elbow is a hinge joint, moving in only one dimension (flex or extend), making it relatively simple from an architectural and functional standpoint. The humerus bone in the upper arm connects to the two bones of the forearm by means of various connective tissues. For a pitcher, one of the most important of these connections is the un lar collateral ligament (UCL).
The UCL offers much of the stability that is necessary for the elbow to withstand the extreme stresses created by throwing a baseball at high velocity.
Its function is to stabilize against lateral forces and to keep the arm connected across the joint space. Sometimes the UCL will weaken and stretch (technically a sprain), making it incompetent. Other times a catastrophic stress will cause the structure to ‘pop’ or blow out. The injury isn’t tremendously painful, and it can be incredibly difficult to diagnose without sophisticated imaging (such as an MRI), but incompetent or blown out, a damaged UCL will prevent a player from throwing at full velocity or with effective control.
Prior to 1974 it is unknown how many pitchers career’s may have been saved from this surgery. But today we do know that out of 700 pitchers in the major leagues 75 of them are Tommy John surgery patients. Many believe that Sandy Kofax’s “dead arm” may have been surgically repaired by this procedure. Crudely described, what Jobe did was build John a new ligament.
Since no artificial tissue can fully approximate the function of the body’s own connective tissues, and since the body doesn’t have a whole lot of spare ligaments lying around, Jobe began by harvesting a healthy tendon. In most cases the tendon is harvested from the forearm of the patient, one attached to the palmaris longus muscle. This tendon is not crucial for anatomical function, and in fact, 15% of people do not have the tendon. To see your palmaris longus tendon, look at the palm-side of your forearm. Touch your thumb and little finger and then make as much of a fist as possible.
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85% of you should be able to see this tendon running down your arm. San Francisco Giants team orthopedist Ken Akizuki reports that when the palmaris longus tendon is unavailable, the surgeon will often use the plantaris tendon in the ankle or a small part of the hamstring tendon in the leg. Usually this tendon will be harvested from the leg that is not used as the plant foot in the pitcher’s delivery. The removal of either of these tendons has a negligible effect on function. Then, the surgeon opens up the elbow. In the original procedure, Frank Jobe used a large incision to get exposure to the joint.
For an idea of the size of this incision, hold your right arm out from your body with your palm pointed upwards. With your other hand, feel along the inside of the elbow until you can find what feels like a hard round nub. That’s the proximal end of your ulna bone. The incision would have taken place along the inside of the arm, beginning several inches above the elbow and ending several inches below. As Dr. Akizuki explains, ‘In order to get exposure to the joint you used to have to detach the entire flexor attachment [the muscles that flex the elbow — you can feel those muscles by feeling along the incision site].
You used to just fillet that open.’ Once inside the elbow the un lar nerve is recognized, lifted out, and moved to provide greater access to the joint. This is the ‘funny bone’ nerve and it runs inside the ulnar groove. With the muscle separated and the ulnar nerve safely out of the way, the surgeon would then locate the damaged ligament. First scraping out the damaged tissue, then the next step is to drill tunnels in the elbow. Two different drill passes are made through the humerus in a V-shape aimed at the ulna, and one more tunnel runs through the ulna at approximately a perpendicular angle to the humerus. The result is a pattern that allows for the surgeon to loop the harvested tendon through the various holes in a series of figure-eight patterns.
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Over a period of time, the transplanted tendon ‘,’ which pretty much means it learns to become a ligament. There is a good healthy blood supply from the muscle above the surgery site (the one the surgeon had to cut through), and there is also a hope that the drilling will give the harvested tendon access to the vascular supply of the humerus and ulna. It is not completely clear how it is that a tendon becomes a ligament, although Dr. Akizuki thinks that range of motion exercises help the tendon learn that it is being used as a ligament now and that it needs to adopt. Surgeons don’t go back in to biopsy the repaired elbow to see how the tissue has changed, but follow-up MRIs show that the new tissue is acting as a ligament should. That’s basically it.
A surgery that baseball players and fans have grown to appreciate, and one of the more scientific breakthroughs in modern sports medicine. And after doing this report I’m fascinated by the modern science and how a tendon in your wrist can be used as a ligament. Works Cited 1. web x. htm 2. web 3.
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