Ulnar collateral ligament is a thick, triangular band. When this ligament gets ruptured, it interrupts with the elbow movement and control. It is most commonly injured in baseball pitchers but it can occur in windmill softball pitchers, javelin throwers, gymnasts and wrestlers. To repair this injury, a reconstruction surgery is performed which is also called Tommy John surgery. Tommy John Surgery was named after the first baseball player to undergo this type of surgery.
What Is Tommy John Surgery
Tommy John Surgery or the UCL reconstruction is a surgery commonly used to repair a torn ulnar collateral ligament inside the elbow by replacing it with a tendon from elsewhere in the body. The goal of the Tommy John Surgery is to stabilize the elbow, reduce or eliminate pain and restore stability and range of motion.
The UCL reconstruction surgery or the Tommy John Surgery is named after former Los Angeles Dodgers pitcher Tommy John. He was the first candidate who underwent the first surgery of this type.
Why Is Ulnar Collateral Ligament Important
Ulnar collateral ligaments are the most important source of stability for the elbow. They can be torn if there is an injury or dislocation of the elbow. The ulnar collateral ligament can also be damaged by overuse and repetitive stress, such as the throwing motion. It is most commonly injured in baseball pitchers but it can occur in windmill softball pitchers, javelin throwers, gymnasts and wrestlers. If they are not treated correctly the elbow can be too loose or unstable.
Who Needs Tommy John Surgery?
The UCL is located on the inside of the elbow. Often pitchers feel a pop when they injure this ligament. However, the ligament can also gradually stretch out and cause pain with repetitive hard throwing. Pitchers with a UCL injury frequently complain of pain with throwing and loss of velocity. Tommy John surgery is designed to restore medial stability of the elbow. The main goal of Tommy John surgery is to fully return to the previous activity levels, especially true for those athletes who want to remain active and competitive in sports.
Before The Tommy John Surgery
The decision of undergoing the Tommy John surgery should be made jointly by you and your doctor. Once the decision has been made, your surgeon may suggest a complete physical examination to ensure that you are in the best possible condition to undergo the Tommy John surgery. To prepare yourself for the procedure, you should wear comfortable clothing including a button down shirt if possible. You should not eat or drink anything after midnight for arrivals before noon. Otherwise, do not eat or drink anything seven hours prior to your arrival at the surgery center.
Procedure: How Is Tommy John Surgery Done?
When nonsurgical treatment fails for an ulnar collateral ligament tear the surgical treatment involves replacement of the ligament with a tendon graft.
The Tommy John Surgical Procedure is done in two ways. One common technique used to replace the damaged ulnar collateral ligament is called the docking technique. The surgeon drills two holes in the ulna and three in the medial epicondyle ( the small bump of bone on the inside of the elbow at the end of the humerus). The two holes in the ulna form a tunnel that the tendon graft will be looped through. The three holes in the medial epicondyle form a triangle. The bottom hole will be bigger than the top two holes, so that the surgeon can slide the end of the tendon graft into the bottom hole. The two top holes are used to pull the tendon graft into the tunnel using sutures that are attached to the graft and threaded through the two holes.
After the tendon is harvested, sutures are attached to both ends. The tendon is looped through the lower tunnel formed in the ulna, and stretched across the elbow joint. The two sutures attached to the ends of the graft are threaded into the larger bottom tunnel in the medial epicondyle and each is threaded out one of the upper, smaller holes.
Using these two sutures, the surgeon pulls the end of the graft farther into the upper tunnel until the amount of tension is correct to hold the joint in position. The surgeon carefully puts the elbow through its full arc of motion and readjusts the tension on the sutures until he is satisfied that the proper ligamentous tension is restored. The two sutures are tied together to hold the tendon graft in that position.
Another common technique to reconstruct the ulnar collateral ligament is the figure of eight technique. In this technique, the tendon graft is threaded through two pairs of holes – two drilled in the medial epicondye and two in the ulna. The graft is looped through the holes in a figure of eight fashion. The two ends of the tendon are sutured to the tendon itself.
If there is any concern that the ulnar nerve has been stretched and damaged due to the instability (as mentioned above) , it may be re-routed so that it runs in front of the elbow joint rather than through the cubital tunnel in the back of the elbow. The incision is sutured together and the elbow is placed in a large bandage and splint.
There are several newer techniques being developed that hopefully will make the procedure even less invasive while retaining the success that the docking technique has enjoyed.
Risk And Complications Of Tommy John Surgical Procedure
Tommy John surgery, like other surgeries, runs the risk of infection or complications due to anesthesia. There is also a low risk of damage to blood vessels or nerves in the elbow. If the ulnar nerve is being irritated as a result of the surgery, it can be moved to another part of the elbow.
Other complications of Tommy John Surgery may arise due to the new tendon. The new tendon that’s attached to the bones in the elbow joint may stretch and tear, requiring a second operation. In rare cases, complications also develop in the part of the body from which the replacement tendon was harvested. These can be treated effectively with medication.
During your recovery, it’s critical that you pay attention to signs of complications or setbacks, or signs that your elbow isn’t ready for the burden of your sport. Talk with your doctor and trainers about what to be on the alert for after surgery.
Though Tommy John Surgery has a success rate of between 80-85 percent, in some cases players may achieve a lower performance level after surgery. In fact, sometimes conservative or non-surgical approaches work best for treating elbow ligament injuries.
Recovery Period After Tommy John Surgery
Following Tommy John Surgery, patient may start with range of motion activities as soon as the doctor gives permission and if these activities do not cause pain. The athlete can start with throwing exercises generally in about two months and slowly work up to a full recovery. Complete recovery can take anywhere from 18 to 24 months. The recovery is gradual and generally follows the following phases:
After surgery, patients wear a splint for about 10 days to immobilize the elbow. Gentle range of motion exercises are started. After about 6 weeks of Tommy John Surgery, the patient can begin to perform elbow-strengthening exercises. For about 4 months, the patient has to take a lot of care to avoid activities that overstress the graft. After 4 to 5 months following Tommy John Surgery, Interval Throwing Program can be started. After 6 months mound work can be started. The patient/player can return to competition level of activity after about 8 to 12 months.
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