UCL Reconstruction (Tommy John Surgery)

UCL Reconstruction (Tommy John Surgery) AnatomyYears ago if a thrower tore their UCL it was the end of their career. However, Dr. Frank Jobe invented an operation that rebuilt the torn ligament by replacing it with a tendon from the forearm. It worked, and has become a well-known surgery among pitchers. The technique has been refined, but the principle has remained the same—a tendon is woven back and forth between the bones (ulna and humerus) of the elbow to fabricate a new ligament. This is not an arthroscopy surgery, but rather an open surgery. Over the years the incision has become smaller.

Years ago if a thrower tore their UCL it was the end of their career.

Graft Placement

The graft is placed in tunnels drilled in the bones of the elbow.

The ligament sits under the flexor tendon on the inner side of the elbow. This tendon must be split or moved out of the way to get to the ligament. The ulnar nerve, a major nerve around the elbow, is nearby and must be protected. Holes are drilled in each bone where the ligament normally attaches, and the tendon is inserted into the holes. There are a few choices for the source of the tendon. Usually I will use a tendon from the forearm (palmaris) which has essentially no function so it is not missed after removal. However, not everyone is born with this tendon. In those individuals I will use either a tendon from their knee (gracilis, one of the tendons I use for ACL reconstruction in the knee) or a tendon from an organ donor (“allograft”). These tendons all provide a strong ligament replacement, and the choice is determined by the athlete’s preference after we discuss the pros and cons.

UCL Tunnels

UCL Tunnels

UCL Graft

UCL Graft

Tradition Graph Placement

Tradition Graph Placement

Once secured in place the tendon must be given a chance to heal to the bone. Once this has occurred, the tendon must then mature to become strong enough to tolerate throwing. It takes about 6 weeks for the ligament to heal to the bone, and about 3 – 4 months for it to mature enough to tolerate even easy throwing.

UCL Brace

Brace worn after UCL surgery.

So, after the surgery I restrict the patient’s movement, allowing gradually increasing motion until 6 weeks post-op. At that time, hopefully the elbow motion is full. Light tossing can begin 3 – 4 months after the surgery. The athlete gradually progresses his/her throwing, hopefully reaching the mound by 5 – 6 months post-op.

While all athletes think that they will have fastest recovery ever, the truth is that it takes at least 6 months to resume playing catcher or pitching. There are often setbacks during the journey back to pitching. Many times it takes a full year to return to the pre-injury level of competition. This is because it takes time to build arm strength after so much time off, plus the ligament must continue to mature. Remember, the forces on the UCL while throwing are among the highest ever measured and the ligament and arm must be given ample opportunity to strengthen.

UCL Incision

UCL Incision

In our study of professional baseball players, Dr. Jereb and I found that players who had undergone UCL reconstruction before they were drafted and had recovered enough to get drafted had an 80% chance of playing at least 4 years of professional baseball without serious elbow problems. Another study showed that a high school pitcher has about a 70 – 75% chance of returning to that level of baseball after UCL reconstruction, and major league players had a >80% chance of returning to major league ball after this surgery. Though the recovery time remains long, this is quite an improvement compared to the days before Dr. Jobe invented this surgery. What used to be a career-ending injury is now usually a repairable injury.

UCL MRI

UCL MRI

There seems to be a correlation between throwing curveballs and sliders at a young age (under 14 yrs) and the later need for UCL reconstruction. For years leading baseball doctors have recommended against throwing breaking pitches during the peak growth years, and now there are some studies that strongly support this (Andrews J, AJSM 2004; Chandler J, Professional Baseball Athletic Trainers Society Proceedings 2004). In essence, if your pitchers are throwing curveballs and/or sliders at 12 and 13 yrs of age, they have a higher chance of needing major elbow reconstructive surgery when they are in high school.

For more information, contact Dr. David Lintner in Houston at 713.986.5560. Also, on Dr. Lintner’s website you can find detailed information regarding the postoperative rehabilitation after UCL reconstruction.

Dr. David Lintner - Houston Orthopedic Surgeon