Tommy John Epidemic

Neal S. ElAttrache, MD
Kerlan-Jobe Orthopaedic Clinic
Head Team Physician, Los
Angeles Dodgers
Stan Conte, PT, DPT, ATC
Vice President, Medical Services
Head Athletic Trainer
Los Angeles Dodgers

Is this an epidemic?
Incidence of MLB Tommy John Reconstructions

#UCLRs
40
35
30
25
20
15
10

5
0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

Baseballheatmaps.com

Epidemic?

2000 2011 (12 yrs)

15.4 UCLRs per year

2012 2014 (3 yrs)

Incidence of MLB
Tommy John
Reconstructions

28.3 UCLRs per year

Minor league trend?

40
35
30
25
20
15
10
5
0

2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014

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

Factors for Increasing

Incidence in UCL Injuries
Overuse in professional ranks
Overuse in youth baseball

Year round baseball

Early specialization

fatigue

Max throwing velocity

Velocity-average velocity of starting
pitcher has increased
Pitch types: ? Sinker or slider cause
more stress on elbow

Treatment

Non-op Treatment: results

Rettig, 2001
31 athletes/20 pitchers/3 pros
Rest and rehab
42% RTP
No MRI data
Podesta, 2014
27 baseball players/16 pitchers/2 pros
PRP + rest
88% RTP
No control group
Noonan personal communication
30 players/19 pitchers w partial thickness tears
Rest and rehab x 3 months
90% return
NEED TO GIVE LIGAMENT A CHANCE TO HEAL
BUT TIMING IS A PROBLEM

Timing of TJ Surgery
10

6
2014
4

Average/Month/Year (2000-2013)
Poly. (Average/Month/Year (20002013))

-2

2000 2013: peak in June

2014: peak in March/April

Reconstruction Technique
Options

Modified Tommy John Procedure

Frank W. Jobe, MD

Flexor mass divided

Without detachment
Ulnar n. transposition
for more severe ulnar
neuropathy

Reconstruction Technique
Options

Modified Tommy
John Procedure
James Andrews, MD

Flexor mass elevated

with partial detachment
Subcutaneous ulnar n.
transposition in all
cases

Reconstruction Technique
Options

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

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

Reconstruction Technique
Options

Hybrid interference and Docking

procedure
David Altchek, MD

Neal ElAttrache, MD

Surgical Treatment:
Graft Choice

Need ~ 15-17cm
Palmaris most common
Biomechanical studies document

failure load (357N) greater than

Anterior bundle UCL (260N)
Minimal compromise on pitching
biomechanics (Azar AJSM 2000)

Other Choices
Gracilis
? Allograft hamstring

Put the graft in the right spot

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

Post-op Management

Splint in neutral at 60 for 10 days

Brace permitting motion 20 - 60 week 2 4
Unlock brace week 4 6
Full ROM after week 6 dont force flexion
May begin light grip immediately
Avoid all valgus stress for 4 months
Progressive throwing program at 5 months
? Build in rest?

Throwing programs
Most programs are similar
Begin throwing at 4-5 months post-op
Throw off mound at 7-8 months post-op
Throw in minor league games at 11-12
months post-op

May be too aggressive

** Too much emphasis on velocity
** May need to build in time for healing

Time to Return Following TJ

Reports vary in the literature
20.5 months Romeo, 2014
16.8 months Makhani, 2014
18.5 months Gibson, 2007
11.6 months Cain, 2010
11.5 months Paletta and Wright, 2006
13.1 months Koh, 2006

Time to Return Following TJ

Conte, unpublished data
144 ML pitchers
Median return 14 mo
Avg return 16.8 mo
18 mo avg return in pitchers return
before June

Surgical Reconstruction:
results
Studies use varying measures of
success
Cain, Andrews, 2010 83% overall, 7375% in major and minor league players
Vitale, 2008 83%, systematic review

Muscle split, docking: better outcomes

Bradley, in press
No difference between docking and fig 8

Surgical Reconstruction:
results

Makhani, 2014 147 pitchers

80% returned to at least 1 game
67% returned to same level for > 10 games
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

Surgical Reconstruction:
results

Erikson, 2014 179 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

Velocity
Landsdown, OJSM dec velocity esp in
older pitchers
Jiang no difference vs. controls
Makhani

No difference vs controls
Cases and controls declined with age

RTP minor league game 12

mo post-op

Revision TJ Surgery
2006-08 = 8 revisions
2009-11 = 10 revisions
2012-14 = 23 revision

Revisions
Early
Late

Outcomes: Revision UCLR

Dines, Yocum, ElAttrache, et al. 2007

15 Baseball Players
Revision reconstruction
5/15 (33%) with Excellent outcomes
4 good; 2 fair; 4 poor

Worse outcomes and increased complications can be

expected

Andrews, AJSM
25% Return
Conte, unpublished data
12% return to starting position

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

Progress
as fast as you can .
even 15 mph per hour
with one consideration
Dont scare the women
and children

Injury Prevention & Treatment

Techniques

In memory of Lewis A. Yocum, MD

November 20 22, 2015