Tommy John Surgery: Indications, Technique and Outcomes

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1 Tommy John Surgery: Indications, Technique and Outcomes Neal S. ElAttrache, MD Kerlan-Jobe Orthopaedic Clinic Head Team Physician, Los Angeles Dodgers

2 Prevalence of UCLR in MLB Conte, Patterson, ElAttrache 24.6% MLB pitchers had undergone TJ surgery in career 15% minor league pitchers had undergone TJ surgery 86% MLB pitchers had the surgery while in pro ranks 91% minor league pitchers had the surgery in HS or college

3 Epidemiology The annual number of UCL reconstruction performed in professional baseball from 1974 to 2016 rose steadily overall (R 2 =0.674; p<0.001), for MLB pitchers (R 2 =0.821; p<0.001), and MiLB pitchers (R 2 =0.569; p<0.001). Camp, et al. 2017, unpublished data

4 Epidemiology Conte et al., AJSM 2015: 24.6% MLB pitchers with UCLR during career 15% minor league pitchers with UCLR 86% MLB pitchers had the surgery while in pro ranks 61% minor league pitchers had the surgery in HS or college l Patients are getting younger Erickson et al., AJSM 2015 Overall average incidence of UCL reconstruction by age of patients.

5 The KJOC Experience: UCLR primary and revision TJs 0% 18% 48% 34% 43% 57% 37% 63% Pro High School College Jr High Acute* *Single pitch tear Chronic Partial Complete 2% 8% 0% Humeral Origin 39% 51% Sublime Tubercle Proximal and Distal Mid-body Keller et al. 2017, unpublished data

6 Factors for Increasing Incidence in UCL Injuries l Overuse in professional ranks l Overuse in youth baseball Year round baseball Early specialization fatigue l Max throwing velocity l Velocity-average velocity of starting pitcher has increased l Pitch types:? Sinker or slider cause more stress on elbow

7 Treatment

8 Non-op Treatment: results l Rettig, athletes/20 pitchers/3 pros Rest and rehab 42% RTP No MRI data l Podesta, baseball players/16 pitchers/2 pros PRP + rest 88% RTP No control group l Noonan personal communication 45 pitchers Rest and rehab x 3 months 90% return NEED TO GIVE LIGAMENT A CHANCE TO HEAL BUT TIMING IS A PROBLEM

9 Timing of TJ Surgery Average/Month/Year ( ) 2 Poly. (Average/Month/Year ( )) 0-2 Month January February March April May June July August September October November December : peak in June 2014: peak in March/April Conte, ElAttrache, et al, AJSM, 2015

10 Reconstruction Technique Options l Modified Tommy John Procedure Frank W. Jobe, MD Flexor mass divided Without detachment Ulnar n. transposition for more severe ulnar neuropathy

11 Reconstruction Technique Options l Modified Tommy John Procedure James Andrews, MD Flexor mass elevated with partial detachment Subcutaneous ulnar n. transposition in all cases

12 Reconstruction Technique Options l Docking procedure David Altchek, MD Flexor mass divided without detachment 3 converging bone tunnels in medial epicondyle 2 converging bone tunnels in ulna Two strand free tendon graft Wide ulna tunnels Graft docked into medial epicondyle Sutures sewn over bone bridge Subcutaneous ulnar n. transposition in a few cases

Reconstruction Technique Options l Interference Screw Method Neal ElAttrache, MD Flexor mass divided without detachment Single bone tunnel in medial epicondyle Single bone tunnel in ulna

13 Reconstruction Technique Options l Interference Screw Method Neal ElAttrache, MD Flexor mass divided without detachment Single bone tunnel in medial epicondyle Single bone tunnel in ulna Two strand free tendon graft Graft secured with interference screws in ulna Graft secured with interference screws in medial epicondyle Subcutaneous ulnar n. transposition in a few cases

14 Reconstruction Technique Options l Hybrid interference and Docking procedure David Altchek, MD Neal ElAttrache, MD l 2-ply vs 3-ply 3-ply more stiff, higher load-to-failure (unpublished data)

15 Surgical Treatment: Graft Choice l Need ~ 15-17cm l Palmaris most common Biomechanical studies document failure load (357N) greater than Anterior bundle UCL (260N) Minimal compromise on pitching biomechanics (Azar AJSM 2000) l Other Choices Gracilis? Allograft hamstring

16 Reconstruction Technique

17 Graft Healing/ Ligamentization l Graft/tunnel 0-8 wks = sharpey fiber formation SF mature at 12 weeks l Necrosis/revascularization 0-12 weeks l Repopulation/remodeling 12 months l Maturation > 24 months l Graft strength - 50% normal at 1 year (extrapolate from ACL reconstruction data)

18 Post-op Management l Splint in supination at 60º for 10 days l Brace permitting motion 20-60º week 2 4 l Unlock brace week 4 6 l Full ROM after week 6 don t force flexion l May begin light grip immediately l Avoid all valgus stress for 4 months l Progressive throwing program at 5 months l? Build in rest?

19 Throwing programs l Most programs are similar l Begin throwing at 4-5 months post-op l Throw off mound at 7-8 months post-op l Throw in minor league games at months post-op May be too aggressive ** Too much emphasis on velocity ** May need to build in time for healing

20 Time to Return Following TJ l Reports vary in the literature l 20.5 months Romeo, 2014 l 16.8 months Makhni, 2014 l 18.5 months Gibson, 2007 l 11.6 months Cain, 2010 l 11.5 months Paletta and Wright, 2006 l 13.1 months Koh, 2006

21 Time to Return Following TJ Conte, unpublished data l 144 ML pitchers l Median return 14 mo l Avg return 16.8 mo l 18 mo avg return in pitchers return before June

22 Surgical Reconstruction: results l Studies use varying measures of success l Cain, Andrews, % overall, 73-75% in major and minor league players l Vitale, %, systematic review Muscle split, docking: better outcomes l Bradley, in press No difference between docking and fig 8

23 Surgical Reconstruction: results l Makhani, pitchers 80% returned to at least 1 game 67% returned to same level for > 10 yrs 57% returned to DL because of injuries to throwing arm Performance parameters declined but NOT statistically different from similar declines in age matched controls who did not have TJ surgery

24 Surgical Reconstruction: results l Erikson, pitchers 83% returned to major leagues 97% returned to major or minor leagues 3% never returned Performance measures declined in year prior to UCLR vs control group After surgery performance measures improved compared to pre-surgery and compared to controls Performance improved the second year back compared to the first

25 Velocity l Landsdown, OJSM dec velocity esp in older pitchers l Jiang no difference vs. controls l Makhani No difference vs controls Cases and controls declined with age

26 Summary? Epidemic? but concerning l Pre-existing abuse may be coming home to roost l Velocity kills l Rest/rehab + biologics effective for many partial thickness tears? Durability l Reconstruction highly effective although not as high or as quick as we may believe

30 RTP minor league game 12 mo post-op

31 Revision TJ Surgery l = 8 revisions l = 10 revisions l = 23 revision l Revisions Early Late

46 Outcomes: Revision UCLR Dines, Yocum, ElAttrache, et al l 15 Baseball Players l Revision reconstruction l 5/15 (33%) with Excellent outcomes 4 good; 2 fair; 4 poor l Worse outcomes and increased complications can be expected Andrews, AJSM l 25% Return Conte, unpublished data l 12% return to starting position

Rehabilitation versus Surgery

Rehabilitation of Ulnar Collateral Ligament Injuries and Reconstruction Stan Conte, PT, DPT, ATC Conte Injury Analytics Rehabilitation versus Surgery Nonoperative treatment of UCL injuries in throwing