ulnar collateral ligament reconstruction

The ulnar collateral ligament (UCL) can become stretched, frayed, or torn through the repetitive stress of the throwing motion. The risk of injury to the UCL is believed to be extremely high, as the amount of stress through the structure approaches its ultimate tensile strength during a hard throw.Fleisig, G.S., “The biomechanics of baseball pitching”, in Biomechanical Engineering. 1994, University of Alabama: Birmingham. p. 163.

This injury is associated with baseball, although it sometimes appears in other sports. Compared to athletes who play other sports, baseball players are at elevated risk of overuse injuries and injuries caused by early sports specialization among children and teenagers.{{cite journal |vauthors = Feeley BT, Agel J, LaPrade RF |title = When Is It Too Early for Single Sport Specialization? |journal = The American Journal of Sports Medicine |volume = 44 |issue = 1 |pages = 234–241 |date = January 2016 |pmid = 25825379 |doi = 10.1177/0363546515576899 |s2cid = 15742871}}

The results of a 2002 study suggest that the total number of pitches thrown is the greatest determinant.{{cite journal |vauthors = Lyman S, Fleisig GS, Andrews JR, Osinski ED |title = Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers |journal = The American Journal of Sports Medicine |volume = 30 |issue = 4 |pages = 463–468 |year = 2002 |pmid = 12130397 |doi = 10.1177/03635465020300040201 |s2cid = 17750974}} The study examined the throwing volume, pitch type and throwing mechanics of 426 pitchers aged nine to fourteen for one year. Compared to pitchers who threw 200 or fewer pitches in a season, those who threw 201–400, 401–600, 601–800, and 800+ pitches faced an increased risk of 63%, 181%, 234%, and 161% respectively. The types of pitches thrown showed a smaller effect; throwing a slider was associated with an 86% increased chance of elbow injury while throwing a curveball was associated with an increase in pain. There was only a weak correlation between throwing mechanics perceived as bad and injury-prone.

Research into throwing injuries in young athletes has led to age-based recommendations for pitch limits.{{cite journal |vauthors = Lyman S, Fleisig GS, Waterbor JW, Funkhouser EM, Pulley L, Andrews JR, Osinski ED, Roseman JM |display-authors = 6 |title = Longitudinal study of elbow and shoulder pain in youth baseball pitchers |journal = Medicine and Science in Sports and Exercise |volume = 33 |issue = 11 |pages = 1803–1810 |date = November 2001 | pmid = 11689728 |doi = 10.1097/00005768-200111000-00002 | s2cid = 37361297 |doi-access = free}}

Increasingly often, pitchers require a second procedure after returning to pitching. During the periods from 2001 to 2012 and 2013 to 2015, 18 major-league pitchers underwent the procedure for a second time. As of April 2015, the average amount of time between procedures is 4.97 years.{{cite magazine| vauthors = Verducci T |title=The post-Tommy John surgery calculus that is changing the game |magazine=Sports Illustrated |issue=April 21, 2015 |url=https://www.si.com/mlb/2015/04/21/tommy-john-surgery-jordan-zimmermann-matt-harvey |access-date=21 April 2015}}

There is a risk of damage to the ulnar nerve.{{cite journal | vauthors = Purcell DB, Matava MJ, Wright RW | title = Ulnar collateral ligament reconstruction: a systematic review | journal = Clinical Orthopaedics and Related Research | volume = 455 | pages = 72–77 | date = February 2007 | pmid = 17279038 | doi = 10.1097/BLO.0b013e31802eb447 | s2cid = 30674621 }}

Some baseball pitchers believe that they can throw harder after ulnar collateral ligament reconstruction than they could beforehand. As a result, orthopedic surgeons have reported that parents of young pitchers have asked them to perform the procedure on their uninjured sons in the hope that it will increase performance.{{cite news| vauthors = Longman J |author-link=Jere Longman|date=July 20, 2007 |title=Fit Young Pitchers See Elbow Repair as Cure-All |work=The New York Times |url=https://www.nytimes.com/2007/07/20/sports/baseball/20surgery.html?pagewanted=all&_r=0 |access-date=October 23, 2013}} However, many people, including Frank Jobe, believe that any post-surgical increases in performance are most likely the result of the increased stability of the elbow joint and pitchers' increased attention to their fitness and conditioning.{{cite web |vauthors = Keri J |author-link=Jonah Keri |date=September 13, 2007 |title=Interview With Dr. Frank Jobe |url=http://static.espn.go.com/mlb/columns/bp/1431308.html |access-date=October 13, 2008 |work=ESPN.com}} Jobe believed that rather than allowing pitchers to gain speed, the surgery and rehab protocols merely allow pitchers to return to their pre-injury levels of performance.{{cn|date=November 2023}}

A surgical incision of {{convert|3|–|4|inch|cm|abbr=off}} is made near the elbow.{{cite web |url=http://e2i.rice.edu/ucl-reconstruction/ |title=Tommy John surgery/UCL reconstruction (graphic surgical video) |publisher=Orthopedic Physician Associates, Seattle, WA |author=Khalfayan EE/MD/Surgeon |date=2016|access-date=7 January 2017}} Holes to accommodate a replacement graft tendon are drilled in the ulna and humerus bones of the elbow. A harvested tendon, such as the palmaris tendon{{cite news |vauthors =Carroll W |title=Dr. Frank Jobe, Tommy John and the Surgery That Changed Baseball Forever |url=http://bleacherreport.com/articles/1672080-dr-frank-jobe-tommy-john-and-the-surgery-that-changed-baseball-forever?hpt=hp_t3 |work=Bleacher Report |publisher=Turner Broadcasting System, Inc. |access-date=July 17, 2013}} from the forearm of the same or opposite elbow, the patellar tendon, hamstring, toe extensor or a donor's tendon (allograft), is then woven in a figure-eight pattern through the holes and anchored. The ulnar nerve is usually moved to prevent pain, as scar tissue can apply pressure to the nerve. The procedure is performed on an outpatient basis allowing discharge the same day, with the arm in a splint to protect the repair for the first week. After one week, a brace is employed to protect the reconstruction for about six weeks following surgery.

Repair is largely viable in cases of acute UCL avulsion type-injury at the proximal or distal end, with the main benefit of the procedure is reduced rehabilitation time compared to that of UCL reconstruction.{{cite journal |vauthors = Lawton CD, Lamplot JD, Wright-Chisem JI, James EW, Camp CL, Dines JS |title = State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes |journal = Current Reviews in Musculoskeletal Medicine |volume = 13 |issue = 3 | pages = 338–348 |date = June 2020 |pmid = 32323247 |pmc = 7251011 |doi = 10.1007/s12178-020-09621-3 |url =}} Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008.

The rehabilitation process following surgery is typically divided into four separate phases.

1. Rehabilitation phase 1 (postoperative weeks zero to three) consists of prevention of stiffness, promotion of healing, and simultaneous protection of the reconstructed graft with a hinged elbow brace{{cite journal |vauthors = Jang SH |title = Management of Ulnar Collateral Ligament Injuries in Overhead Athletes |journal = Clinics in Shoulder and Elbow |volume = 22 |issue = 4 |pages = 235–240 | date = December 2019 |pmid = 33330225 |doi = 10.5397/cise.2019.22.4.235 |pmc = 7714305 |doi-access = free }}
2. The goals of phase 2 (weeks four to eight) are to gain strength and gain full range of movement
3. During phase 3 (weeks nine to 13), the rehabilitation is focused on flexibility and neuromuscular control with a progression toward sports-related activities
4. The progression to a throwing program is made during phase 4 (weeks 14 to 26) for overhead athletes

Full competition throwing is usually permitted at seven to nine months, and pitchers are ready to return to the game at approximately 10 to 18 months.

Over two decades preceding 2016, the number of UCLR surgeries increased threefold, a rate that was expected to continue to rise.{{cite journal |vauthors = Mahure SA, Mollon B, Shamah SD, Kwon YW, Rokito AS |title = Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review |journal = Journal of Shoulder and Elbow Surgery |volume = 25 |issue = 6 |pages = 1005–1012 |date = June 2016 |pmid = 27197888 |doi = 10.1016/j.jse.2016.02.036}} A 2015 study showed that the rate of UCLR surgery for those aged 15 to 19 was the highest among all age ranges and was increasing by 9% each year.{{cite journal |vauthors = Erickson BJ, Nwachukwu BU, Rosas S, Schairer WW, McCormick FM, Bach BR, Bush-Joseph CA, Romeo AA |display-authors = 6 |title = Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States: A Retrospective Review of a Large Private-Payer Database From 2007 to 2011 |journal = The American Journal of Sports Medicine |volume = 43 |issue = 7 |pages = 1770–1774 |date = July 2015 |pmid = 26129959 |doi = 10.1177/0363546515580304 |s2cid = 33623945}}

USA Baseball, Major League Baseball, and Little League Baseball initiated the Pitch Smart program designed to lower the risk of elbow injuries in adolescent pitchers.{{cite web |url=http://m.mlb.com/pitchsmart/ |archive-url=https://web.archive.org/web/20141109101543/http://m.mlb.com/pitchsmart |url-status=dead |archive-date=November 9, 2014 |title=Pitch Smart |publisher=Major League Baseball |date=2016 |access-date=26 October 2016}} The main risk factors for elbow injury from overhand throwing are the number of pitches per game, innings pitched per season, months pitched per year and poor pitching biomechanics that may increase torque and force on the elbow.{{cite journal |vauthors = Fleisig GS, Andrews JR |title = Prevention of elbow injuries in youth baseball pitchers |journal = Sports Health |volume = 4 |issue = 5 |pages = 419–424 |date = September 2012 | pmid = 23016115 |pmc = 3435945 |doi = 10.1177/1941738112454828}}

{{main|List of baseball players who underwent Tommy John surgery}}

File:Tommy John 2008 bronx.jpg

At the time of John's operation, Jobe estimated the chance for success of the operation at one in 100.{{cite web|date=22 July 2013|title=Frank Jobe's Hall of Fame Life |url=http://mlb.mlb.com/news/article.jsp?ymd=20130722&content_id=54371126&v |access-date=March 7, 2014 |publisher=Major League Baseball}} By 2009, the odds of complete recovery had risen to 85–92%.{{cite web |vauthors = Rosenhek E

|date=July 1, 2009 |title=The gory details of Tommy John surgery |url=http://thegoodpoint.com/tommy-john-surgery-procedure |access-date=April 6, 2014 |publisher=The Good Point}}

Following his 1974 surgery, John missed the entire 1975 season rehabilitating his arm before returning for the 1976 season. Before his surgery, John had won 124 games. He won 164 games after surgery, retiring in 1989 at age 46.

For baseball players, full rehabilitation takes about 12{{ndash}}15 months for pitchers and about six months for position players. Players typically begin throwing about 16 weeks after surgery.{{cite news |vauthors = Dodd M |date=July 29, 2003 |title=A year of rehab for Tommy John patients|work=USA Today |url=https://www.usatoday.com/sports/baseball/2003-07-29-tommy-john-rehab-schedule_x.htm}} While 80% of players return to pitching at the same level as before the surgery, for those Major League Baseball pitchers who receive the surgery twice, 35% never pitch again in the major leagues.

Jobe has stated that if he had invented the technique ten years earlier, it might have been nicknamed Sandy Koufax surgery, after Dodgers hall of famer Sandy Koufax, who retired with "essentially the same thing as Tommy John."{{Cite web |last=Pouliot |first=Matthew |date=2012-07-15 |title=Dr. Frank Jobe: 'It could have been Sandy Koufax surgery' |url=https://mlb.nbcsports.com/2012/07/14/dr-frank-jobe-it-could-have-been-sandy-koufax-surgery/ |access-date=2022-05-03 |website=MLB {{!}} NBC Sports |language=en-US}}

{{reflist}}

{{Bone, cartilage, and joint procedures}}

{{DEFAULTSORT:Ulnar collateral ligament reconstruction}}

Category:Orthopedic surgical procedures

Category:Sports medicine

Category:1974 introductions

Category:American inventions