Primary Repair Surgery – Returning Pitchers to the Field Faster

When pitchers injure their ulnar collateral ligament (UCL), there are very few things to be happy about. If you’re cheering for your favourite player, or your favourite team, you don’t get to see the best players compete. If you ARE the pitcher injuring your UCL, it means you don’t get to play your sport for at least a year, and you have a painstaking rehabilitation process ahead of you. Go ahead and read “The Arm” by Jeff Passan – and tell me you’d want to wish the process described by Todd Coffey and Daniel Hudson on anyone.

Tommy John Surgery is an exceptional feat of modern medicine. First being performed by the legendary Dr. Frank Jobe in the mid 70’s, this surgery allows pitchers who suffer an injury that was once career ending, to continue pitching at the highest level. Check out Jon Roegele’s Tommy John Surgery list (https://twitter.com/mlbplayeranalys) – there were no teams in the MLB in 2016 who did not employ a pitcher who once had Tommy John Surgery. Despite it no longer being a death sentence for pitching careers, it does keep pitchers out of the game for a long period of time. The average time to return from a Tommy John Surgery (or UCL reconstruction) remains between 11 and 30 months (Erickson et al., 2014).

This week, the internet was buzzing about Seth Maness, and the surgery he received from Dr. George Paletta (h/t, Jon Roegele). Instead of reconstruction Manness’ UCL, Dr. Paletta performed a repair of the ligament. What had everyone excited, was the return time from this injury was 6 ½ months – much shorter than that of the Tommy John Surgery rehabilitation and return to competition timeline. In Derek Goold’s article in the St. Louis Post-Dispatch, the “primary repair” procedure is described, and the surgeons describe the procedure as being appropriate for “the right pitchers”.

What is this procedure? How does it differ from Tommy John Surgery, and how new is it in the medical community? What are the implications for pitchers moving forward? Why don’t you relax on the questions and I’ll try and get you some answers, pal?

The concept of UCL repair goes back all the way to the 70’s, as described by Barnes & Tullos (1978). In their review of symptomatic baseball players, they highlight successful returns from collateral ligament repair, and discuss several players that continued throwing after ligament repair for 2 and 3 years. Jobe and Nuber (1986) were the first to formally describe the reconstruction technique that is now formally known as Tommy John Surgery. In a study by Conway et al., (1992), the benefits of UCL repair are discussed – faster return from injury, and shorter rehabilitation times. Why didn’t this procedure catch on as the silver bullet of UCL ligament injury treatment?

The most extensive examination of UCL repair vs. reconstruction was conducted by Conway et al., (1992). They examined a group of 71 athletes who suffered valgus instability of the elbow – the clinical term for a failure of the ligaments to provide stability to protect the nerves of the elbow during throwing. Of these 71 athletes, 14 of them received UCL repair, and 56 received UCL reconstruction.

These athletes included many major-league baseball pitchers, but also, minor league, college, and high school baseball players. The authors defined an excellent result of the surgery if the pitchers could return to the same, or higher level, for more than 12 months. For major league pitchers, 65% of the reconstructed elbows had excellent surgical results, but only 29% of the repair group had excellent results. When expanding to the rest of group, 50% of the pitchers who had their UCL repaired had excellent results, compared to 68% of the reconstructed ligaments.

The reconstruction of UCLs in baseball pitchers has only gotten better throughout the years, with the success of operative and non-operative treatments being highlighted in Jeff Passan’s “The Arm”, and by Dr. James Andrews and Dr. Glen Fleisig’s research groups at the American Sports Medicine Institute (Ford et al., 2016, for example).

Why did so few of the patients in Conway’s study receive UCL repair, as compared to UCL reconstruction? Part of this has to do with the nature of the UCL tear. Essentially, to make use of the existing ligament after a UCL injury, the ligament has to be damaged in a very specific way. Conway states,

“if a patient has an acute injury with no associated ulnar nerve symptoms, has an operation soon after the injury, and the UCL appears to be normal except for an avulsion fracture, they are suitable for UCL repair”.

An avulsion fracture occurs when a ligament pulls so hard, that it rips directly off the bone. Hopefully you weren’t eating while reading this. This is obviously a catastrophic injury, but the silver lining with this injury, is that the UCL is completely intact. Have you ever heard someone say that it’s better to break a bone than to tear a ligament?

That’s because in many situations, when a ligament is completely ruptured, the recovery time is much longer compared to that of a fracture. In Conway’s experimental group, only 1 had a clean avulsion fracture. This is a much less common cause of elbow instability than a traditional rupture of the ligament. This is one of the main reasons primary repair of the UCL hasn’t been as prominent of a solution for elbow injuries in major league pitchers.

Dr. Jeffrey Dugas has been at the forefront of the Primary Repair procedure, but was also the author on one of the most recent papers examining the primary repair procedure, and how it influences the stability of the elbow. In an article published in the American Journal of Sports Medicine, Dugas and his team compared the results of the different surgical options on 18 cadaver arms.

After completing primary UCL repair on 9 elbows, and UCL reconstruction using the palmaris tendon transplant on 9 other elbows, the researchers then go to do every scientist’s favourite thing – destroy stuff. The elbows were ramped up to failure, and the peak torque, and rotational stiffness at failure were calculated. Furthermore, the method of failure was noted for each arm.

The results of this study found there were no significant differences in the peak rotational torque at failure, ligament stiffness, or the gap between bony structures in the elbow, regardless of surgical technique. This is an important finding, because it shows that repair vs. reconstruction doesn’t lead to mechanical disadvantages in the elbows. Theoretically, this means a repaired elbow is just as strong as the reconstructed elbow.

Dugas and colleagues discuss similar benefits of UCL repair as Conway and colleagues reported over 12 years earlier. Return to play can occur much faster when the ligament is repaired compared to reconstructed. However, the same caveat is issued – the ligament has to be in good shape to be useful for repair. Going back to Passan’s “The Arm”, Jeff describes the surgical procedure completed by Dr. Neal ElAttrache on Todd Coffey.

The veteran pitcher’s elbow has an extensive amount of damage to the ligament, muscle, and joint capsule. Despite the best training protocols, recovery regimes, and workload monitoring, baseball pitching is still a very unnatural act. With years and years of pitching, structures deteriorate, and the ligament may no longer be worth preserving. Dugas’ conclusions in this paper, are “repair replicates failure strength of traditional reconstruction, but requires less soft tissue dissection and is bone preserving”.

To summarize this review, UCL repair has significant benefits over UCL reconstruction – primarily, an expedited return to play. However, it is not appropriate for all UCL injuries, and is better suited for younger pitchers than older pitchers. The most convincing biomechanical evidence is provided by Seth Manness’s surgeon, Dr. Jeffrey Dugas, but even he admits that there are limitations of his study – primarily, the use of cadavers with an average age of 63 years. Primary repair of the UCL is not a new procedure, but understanding the strengths, weaknesses, and appropriateness of the this operation can help get young MLB pitchers back on the field faster than ever before.

References:

Barnes, D. A., & Tullos, H. S. (1977). An analysis of 100 symptomatic baseball players. The American journal of sports medicine, 6(2), 62-67.

Conway, J. E., Jobe, F. W., Glousman, R. E., & Pink, M. (1992). Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am, 74(1), 67-83.

Erickson, B. J., Gupta, A. K., Harris, J. D., Bush-Joseph, C., Bach, B. R., Abrams, G. D., … & Romeo, A. A. (2014). Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers. The American journal of sports medicine, 42(3), 536-543.

Ford, G. M., Genuario, J., Kinkartz, J., Githens, T., & Noonan, T. (2016). Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries Comparison of Operative Versus Nonoperative Treatment Based on Magnetic Resonance Imaging Findings. The American journal of sports medicine, 44(3), 723-728.

Goold, D. (2017, January 12). Maness a trailblazer? New surgery for elbow repair cut recovery time. St Louis Post-Dispatch. St. Louis.

Jobe, F. W., & Nuber, G. (1986). Throwing injuries of the elbow. Clinics in sports medicine, 5(4), 621-636.

Passan, J. (2016). The arm: inside the billion-dollar mystery of the most valuable commodity in sports. New York, NY: Harper, an imprint of HarperCollins.

Dugas, J. R., Walters, B. L., Beason, D. P., Fleisig, G. S., & Chronister, J. E. (2016). Biomechanical Comparison of Ulnar Collateral Ligament Repair With Internal Bracing Versus Modified Jobe Reconstruction. The American journal of sports medicine, 44(3), 735-741.