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?

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Incidence of MLB Tommy John Reconstructions

Baseballheatmaps.com

#UCLRs

Epidemic?

2000 2011 (12 yrs)

15.4 UCLRs per year

2012 2014 (3 yrs)

28.3 UCLRs per year

Minor league trend?

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Incidence of MLB Tommy John

Reconstructions

Prevalence of UCLR in MLBConte, 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

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Average/Month/Year (2000-2013)

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

2000 2013: peak in June2014: 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, 73-75% 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 UCLRDines, 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

as fast as you can . even 15 mph per hour

with one consideration

Progress

Dont scare the women and children

Injury Prevention & Treatment

Techniques

In memory of Lewis A. Yocum, MD

November 20 22, 2015