TOMMY JOHN SURGERY

The number of Tommy John injuries in pitchers of all competitive levels has been increasing over the last 10 years. The success rates following Tommy John Surgery have been encouraging, with greater than 80% of patients commonly able to return to play at a high level. Unfortunately, as the number of Tommy John Surgeries continues to rise, the number of second time Tommy John Surgeries increase. Second Tommy John Surgery is commonly referred to as revision Tommy John Surgery. In MLB, there were more revision Tommy John Surgery in the 3 years from 2012 and 2014 than in the prior 12 years combined.

• Number of increasing Tommy John Surgeries being performed, especially in younger patients
• Increased incentive to continue playing. Patients who, in the past, would have discontinued baseball with a failed Tommy John Surgery are now more incentivized to keep playing and undergo a revision.

• Accelerating the recovery process. A shorter time from the Tommy John Surgery to return to play is associated with an increase risk of revision Tommy John Surgery.
• Increased workload. Another risk factor is an increase in pitching workload after Tommy John Surgery compared to before the injury.
• Unfortunately, younger age at the time of Tommy John Surgery (22.9 for those requiring revision Tommy John Surgery vs. 27.3 for those not requiring revision Tommy John Surgery) is another risk factor.

Dr. Alkhatib and his team will perform a thorough evaluation of a player when injury to his Tommy John Surgery is suspected.

Symptoms Similar to patients who sustain a tear of their native UCL but often less severe

• Medial elbow as well as loss of accuracy and velocity.
• The pain is often nagging, and continues to worsen over time.
• Alternatively, some patients complain of a single, distinct injury when they felt a “pop” in their elbow following a specific pitch, although this can happen, especially if the patient sustained a fracture through their one of their bone tunnels.
• Alkhatib will obtain the operative report of the initial surgery if it was done by another surgeon. The graft choice, surgical technique (including surgical approach: muscle split vs. elevation), management of the ulnar nerve, and any concomitant elbow pathology is necessary information.

• X-rays are carefully inspected for fracture through the prior tunnels, and to determine the position of the prior tunnels, and possible calcium deposits.
• MRI and MR arthrography (MRA) are used to evaluate the UCL graft as well as cartilage injuries, flexor pronator injuries, and bone stress injuries.
• CT scan is used to evaluate bone spurs and exact location of the prior ulnar and humeral tunnels as well as the bone quality of these tunnels. The tunnels can be assessed for widening, fracture, and malposition.

• Dr. Alkhatib and his team will perform a physical exam of the patient with a presumed UCL re-tear similar to a patient who has not had prior surgery. There will be additional physical exam assessments.
  • The location of the scar will be critically evaluated.
  • The ulnar nerve location will be assessed.
  • The prior graft harvest site is evaluated.
  • Kinetic chain issues such as spine or core weakness, inflexibility, or muscle imbalance as well as improper throwing mechanics are assessed.

• The status of prior tunnels can have significant implications on the surgical technique used for the revision Tommy John Surgery.
• The ulnar tunnels should ideally be located 2 to 4 mm distal to the joint line and equidistant on both sides of the sublime tubercle. Sublime tubercle morphology can be altered by bone spurs. The medial ulnar ridge can serve as a guide to the proper location of the sublime tubercle.
• The inferior position of the humeral tunnel should start at least 5 mm anterior to the 6 o’clock position of the medial epicondyle.
• Malpositioned tunnels result in a non-isometric graft. For example, if the tunnels are placed too far posterior, which is a common error, this will result in a tight graft in flexion. As a result either elbow flexion will be limited or, if flexion is obtained, the graft subsequently becomes loose. A graft that is placed too superficial on the epicondyle will result in a small length of the epicondyle and will be less isometric.

• As with a tear of the native UCL, an injury to the reconstructed UCL can be managed initially in a non-operative manner.
• Non-operative treatment includes rest, rehabilitation, electrical stimulation, ultrasound, and other modalities used by therapists.
• Use of biologics such as platelet rich plasma (PRP) have shown positive results

• The causes of failure following primary Tommy John Surgery can be broken down into technical errors, patient factors, rehabilitation problems, or failure of the graft.
• Surgical technique errors include poor tunnel placement, improper tensioning of the graft, and poor graft fixation. If the medial epicondyle socket is not placed at the isometric point, it will cause the graft to load unevenly and can lead to increased stress seen by the graft and ultimate failure. Similarly, if the ulnar tunnel is not parallel to the joint surface, or is too proximal or too distal, it may lead to failure of the graft. If less than a 1cm bone bridge is left for the ulnar tunnel, or if the medial epicondyle socket is too far medial, these bone bridges can break and cause catastrophic failure. Depending on the surgical technique utilized, if the graft is not properly secured, it runs the risk of loosening over time.
• Patient factors can lead to failure of graft incorporation and ultimately failure of the primary Tommy John Surgery such as steroid use, smoking, and failure to comply with rehabilitation protocols. Likewise, if the patient does not participate in therapy, or if the therapy being given is not tailored to the specific patient, the pitcher may never optimize their throwing mechanics and can continue to improperly stress their UCL. Failure to achieve full shoulder and elbow range of motion (ROM) can put the pitcher at increased risk for a recurrent UCL tear.
• Finally, there is the chance that the UCL graft will degenerate and wear out over time. Studies have shown that pitchers who have their index Tommy John Surgery at earlier ages are more likely to require a revision Tommy John Surgery. This is likely because the number of pitches the reconstructed UCL sees in a younger patient is higher than in a pitcher at the end of their career.

As in primary Tommy John Surgery, there are several graft choices available in the revision setting. If the index procedure was performed with an ipsilateral palmaris longus autograft, I prefer hamstring autograft.

• If the patient had a previous ulnar nerve transposition, the nerve should be identified intraoperatively, isolated, protected, and re-transposed at the end of the procedure.
• Great care should be taken when isolating the nerve as this is often encased in scar tissue and can be easily injured.

• Revision Tommy John Surgery is much more complicated than first time Tommy John Surgery.
• If the patient had a fracture through their ulnar tunnel, or has significant widening on the ulnar or humeral tunnel, the standard docking technique may not be effective. Modifications to the technique may need to be made in order to properly secure the graft.