What Is Tommy John Surgery?

Ulnar Collateral Ligament Reconstruction (UCLR)

surgical instruments image
Surgical Instruments. Photo © Paul Tearle/Getty Images

What Is Tommy John Surgery?

Ulnar Collateral Ligament Reconstruction, or UCLR, is more commonly known as Tommy John surgery. It is a procedure that is done to repair a damaged ligament in the elbow called the ulnar collateral ligament (some use the term medial collateral ligament). This injury typically makes the elbow feel unstable and requires physical therapy. If the injury does not respond to physical therapy, surgery is typically the next treatment considered.

Ulnar collateral ligament issues are common in serious “throwing” athletes, such as professional baseball pitchers. Throwing activities place unusual levels of stress on the elbow, making injury to the area more likely than with other sports. For many athletes, Tommy John surgery can restore full function and for some, a complete recovery is possible.

For some patients, the surgery isn’t performed to allow them to continue to perform as an athlete, but to alleviate the symptoms of the injury—mostly elbow pain and numbness in the hand of the affected arm.

Ulnar Collateral Ligament

The ulnar collateral ligament is a thick band of tissue similar to a very strong rubber band. It works with the lateral collateral ligament to stabilize and strengthen the elbow. The ligament can be injured by tearing, stretching and dislocation. Overuse injuries, where the ligament becomes damaged by repetitive movement, are among the most common types of ulnar collateral ligament issues.

Why Is It Called Tommy John Surgery?

Tommy John was a professional pitcher for the Los Angeles Dodgers. In 1974 he damaged his ulnar collateral ligament, which was considered to be a career-ending injury for a professional pitcher. John, however, elected to have a procedure that was experimental at the time, replacing the injured ligament with a tendon from his other arm.

With low expectations that he would ever be able to pitch again, Tommy John consented to have Dr. Frank Jobe perform the procedure. He then took the remainder of the 1974 and then the 1975 baseball season off to rehabilitate his arm. The end result was revolutionary—John pitched professionally until 1989—and the procedure is now commonly known as Tommy John surgery.

The Tommy John Procedure

The Tommy John surgery is performed under general anesthesia by an orthopedic surgeon. Once the patient is intubated and anesthesia has taken full effect, the procedure begins with an incision on the inside surface of the elbow, through which the damaged ligament is removed. The procedure is a minimally invasive one, therefore, the incision is small, as the procedure is done using a laparoscope.

If a repair is needed, this small incision is used to insert instruments into the joint area and repair the torn ligament. If a reconstruction is needed, an additional incision is made, often on the forearm of the opposite arm, to recover a tendon from an uninjured area of the body.

While the forearm is a very common choice, other potential sites include the upper and lower leg. Less commonly, a donor tendon may be utilized in lieu of the patient’s own tendon.

Once the tendon graft is obtained, it is sewn into place as a replacement for the removed ulnar collateral ligament. For some patients who are experiencing symptoms of numbness and tingling in the hand, the ulnar nerve may be moved slightly to help full sensation return.

Risks of Surgery

In addition to the standard risks of surgery and the risks of anesthesia, Tommy John surgery presents unique challenges for the patient. For some, neuropathy, or a lack of nerve impulses, can leave the affected hand numb, tingling and/or weak. This condition may improve over time or may be a permanent complication of the original injury. For some patients, a lack of flexibility is notable after surgery, while others may always have a feeling of instability around the elbow. While it is normal after surgery to have difficulty straightening the arm completely, this movement may never return to the range of motion that was present prior to the injury.

Recovery After Tommy John Surgery

Recovering after surgery for this type of injury is relatively straightforward. Tommy John surgery typically requires an overnight stay in the hospital, followed by extensive rehabilitation therapy. For the first few weeks, the elbow may be in an immobilizer, keeping the elbow supported and held in place. The new graft is very fragile during the initial weeks following surgery, so it is essential to follow the surgeon’s instructions to protect the surgery site.

You may be provided pain medication during the early days of recovery, after which heat and ice are used to minimize pain. Once the immobilizer is no longer needed, physical therapy begins to regain strength and range of motion. For some, range of motion returns in 6-8 weeks, however, for a competitive athlete, more extensive rehabilitation may last over a year to return to full performance.

Many recreational athletes feel that they are stronger than they were prior to surgery, as they were “babying” the arm in response to pain. The vast majority make a complete recovery and are able to return to their normal activities.

Sources

Ulnar Collateral Ligament Reconstruction. C.A. Bush Joseph, MD. Accessed April, 2012. http://www.rushortho.com/forms/Ulnar_Collateral_Ligament_Reconstruction_Protocol.pdf

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