Unless you are entirely new to baseball, you have heard of the infamous Tommy John surgery at some point. However, you may not understand exactly what that entails. Let us discuss it below. Yet, before we do that, here are some definitions to know quickly. Medially means toward the midline of the body or moving toward the body. Laterally means toward the outside of the body or moving away from the body. A ligament is a dense band of fibrous bodily tissue connecting a bone to another.
This now-common surgery is named after the former baseball pitcher Tommy John, who was the first professional athlete to have this surgery performed on him in 1974. However, the technical name is ulnar collateral ligament (UCL) reconstruction. It is so named for the ligament that connects one’s upper arm bone (humerus) to the ulnar bone of the forearm. If you are uncertain where this ligament is, hold your arms to your side with your palms facing forward and thumbs outward. The inside part of the elbow nearest your torso is where this ligament lives. It is somewhat extended in length but relatively thin and designed to protect against a medially directed force from one’s side. Like the medial collateral ligament (MCL) on the opposite side of the elbow, these two ligaments exist to prevent elbow dislocation or laxity from a medial or lateral force to the arm or elbow directly.
As human beings developed, we ascended from not much more than upright primates to intelligent hunters and gatherers. Before this, only a simple ligament was necessary to protect the elbow from dislocation, as excessive force applied repetitively to the UCL was uncommon in daily existence. As we advanced to throwing stones, javelins, and so forth, more torque and force were applied through the elbow, but as this was only performed in hunting for the most part, and life spans were shorter, an evolutionary need for developing a thicker and stronger ligament was not present. However, as humans have developed throwing sports in the modern age, excessive pressures upon the UCL have become commonplace with such athletes. Thus, a ligament designed by nature to provide simple protection from the medial displacement of the elbow is now becoming sprained, stretched, frayed, and even torn from new repetitive forces placed upon it daily by the demands of the sport.
When a surgeon reconstructs this ligament, they do so using either part of a ligament from the patient or an undamaged cadaverous ligament. We call the ligament graft either endogenous (from the same body) or exogenous (from a different body). The surgeon will discuss the options and which are best for the patient before the surgery occurs. However, it is more common to use a ligament from one’s own body, such as the palmaris longus tendon of the forearm.
The procedure begins with the patient under general anesthetic. The surgeon makes a 3-to-4-inch incision and pulls the tissue from the area to expose the damaged ligament below the skin. He then removes the damaged ligament and drills holes into the bone where the UCL once anchored into each bone. Of course, if a ligament is harvested from the same patient, he will perform this procedure first. If possible, the surgeon will affix any undamaged ligament portion to the new ligament graft. This helps to reinforce it and provide extra strength. The surgeon will anchor this new ligament graft into each hole and reinforce the anchor with a screw or other method. This is the surgeon’s preference. He then closes the wound and sutures the incision. The entire surgery usually takes 60 to 90 minutes, and the patient is generally released from the surgery center on the same day.
Complications of this surgery are most commonly: infection, permanent nerve damage, extensive and/or recurrent swelling (edema), retearing of the graft ligament and loosening of the anchor. Of these, infection is the most concerning, and the surgeon will monitor the patient for at least two weeks to ensure proper healing before the patient is permitted to begin rehabilitation. The rehabilitation process for this injury is detailed and lengthy for the patient, especially the professional or aspiring amateur athlete attempting to return to sport. For these athletes, the recovery time is usually closer to the 18 months of the commonly seen 12-to-18-month healing time frame. Likewise, random delays in healing are not uncommon.
