Alternative to Tommy John

February 14, 2017

In the world of baseball, “Tommy John surgery” has become a household name. With the number of ulnar collateral ligament (UCL) reconstruction procedures on the rise, doctors have been working to design a alternative surgery that shortens rehab time and minimizes the chances of sustaining a second UCL tear.

“UCL repair with internal brace construction,” also known as “primary repair,” has been moving up in the ranks as the new and improved technique for repairing UCL tears. While Tommy John requires a graft of a ligament from one arm to the other, primary repair focuses on repairing the original ligament and anchoring it to the bone. Instead of waiting for the grafted ligament to assimilate to its new position with Tommy John, doctors can construct a bracing system out of Arthrex tape with primary repair to reinforce the area, helping it to heal quicker.

Thanks to this change, players who undergo primary repair have a much better outlook on returning to the field. While Tommy John surgery requires rehab for about 12 months, the average recovery time needed for primary repair is only 6.5 months.

“We’re repairing the existing ligament and reinforcing it with a scaffold that provides increased strength for healing from time zero. From the get-go,” George Paletta, MD, Head Orthopedic Physician for the St. Louis Cardinals, told the St. Louis Post-Dispatch.

The differences between Tommy John and primary repair do not end with recovery time. According to the American Sports Medicine Institute, “10 percent to 20 percent of pitchers never make it back to their previous level after Tommy John surgery,” and some players have had to undergo a second UCL reconstruction after the first one failed.

Alternatively, Dr. Paletta and Jeffrey Dugas, MD, a Managing Partner at the Andrews Sports Medicine and Orthopedic Center in Birmingham, Ala., have completed a combined average of about 200 primary repair surgeries. Neither have seen any that needed repeating or required Tommy John down the road. In fact, 32 of about 50 patients for Paletta have pitched in the two seasons since their procedure. 

Of course, there are some stipulations as to which players can and cannot receive this operation. If a player’s ligament tissue is in bad condition or if the tear is in the middle of the ligament, he or she will need to undergo complete reconstruction. However, if the player’s ligaments are substantial enough and the tear is closer to the end, the chances for a successful primary repair operation increase.

Primary repair is just making its way to Major League Baseball, as doctors have been warily moving up the ladder from prep players to college players. For Seth Maness, former St. Louis Cardinals relief pitcher and current free agent, taking a chance on the procedure was a no-brainer.

“It was a game-time decision,” said Maness. “I’m going into [the surgery] sort of expecting Tommy John and hoping for the other one. You go from looking at missing a whole season to possibly being back at the start of the year—that’s a big relief.”

Like many other players, Maness had been nervous of admitting to any pain in the first place. Doctors are hopeful that knowledge of primary repair will push athletes to seek help earlier, lessening strain on the injury.

Maness underwent surgery on Aug. 18, 2016 and is expected to return to the mound this month. As of the time of this writing, Maness is one of three major league pitchers who have received primary repair.

While early results show a high success rate, there is still question as to the effect of primary repair on major leaguers. As with any advancement, the only way to tell if it will continue to lower rehab time and save careers is to keep an eye on the progress of players like Maness.

“There is a lot that we need to learn from Seth, a lot that we need to learn from all of the guys [who have had it],” said Dr. Dugas. “We need the data. There are still so many hurdles to go over, but we’re excited to watch what is going to happen because of what is possible. We’re going to follow him very closely.”