UTK Special 5/4/23

A Better Miracle

Over the past few years, we’ve seen elbow surgery change. Instead of every UCL injury needing a full reconstruction after even a relatively minor tear, in the style of the original operation done in 1974 on Tommy John by Dr. Frank Jobe, there are now options. It gets a bit confusing since any elbow surgery is often reported as “Tommy John surgery” since that’s one of the most understood baseball medical terms.

What can be done now are variants on ligament repair, augmented by SutureTape in a manner known as InternalBrace. The technique was largely developed by Gordon McKay, a Scottish surgeon who focused on ACL repair. That was then developed into an elbow procedure by Dr. Jeff Dugas at Andrews Sports Medicine in Birmingham.

(Dr. Dugas also makes some darn fine spirits at his distillery, also in Birmingham.)

Many others have been doing variants of InternalBrace surgery, as I detailed in this landmark article from 2017. Things have been advancing quickly since then, with new variants and more practice, though there’s still something of a reluctance to use “new” techniques on elite athletes. More have been done at lower levels, often when final year players have no other chance to come back. The success rate on these has been very high despite some exceptionally quick returns.

The one thing that really hasn’t made it to the top is the quick return times. While repair can often be faster than Tommy John rehab, which can take as much as 18 months, it is still in the 12 month range for major league pitchers. This is largely due to the reluctance to push a rehab, so there’s still advantage to be had when a college pitcher can be back in a few months.

While there’s no question that InternalBrace repair is different and gives surgeons options for their patients, the technique is new enough that there’s little evidence that it’s better. Key in here on “evidence”, which is the result of years-long scientific studies. You can’t do a ten year study on a technique that’s only been used for about eight.

However, anecdotal evidence is strong. Use of InternalBrace with ACL repair (and even reconstruction) is very common. ACL reconstruction in all its variants is as near-standard a sports surgery as there is, ranging across sports and even genders. All that practice has led to slight improvements and a success rate approaching 90 percent. Failure, in this case, is damage to the reconstructed ligament resulting in a revision. Many times failure will be defined in studies as a player not going back to sport, which can often be the result of a high school or collegiate athlete deciding that the rehab time and effort isn’t worth it, resulting in a net higher rate.

However, talking with several orthopedic surgeons who use InternalBrace techniques, the revision rate on the various surgeries may be exceptionally low. I started digging in to this because of the known MLB InternalBrace elbows, I couldn’t find a single failure. Moreover, the more common thumb UCL repair using InternalBrace, an operation which has become near-standard, has the same apparent zero failure/revision rate.

Speaking with Dr. Dugas, he said the rate isn’t zero. “It’s rare,” he told me via email. There are definitely cases where the revision of a standard Tommy John is done with InternalBrace, but that’s not what I’m looking for. Speaking with three surgeons who have done UCL thumb repairs on MLB players, not one of them could recall a case where there’d been a revision or even a problem. “I don’t know how long it holds up, but it’s theoretically forever. Definitely longer than they’ll be playing,” one said.

The same is true for ACLs. Dr. Chad Lavender, who has created a further revision of the technique with his Fertilized ACL procedure, told me that he’s seen failure rates go from about 10 percent in standard ACL reconstructions down to “something like one percent” in Fertilized ACLs.

There’s more variations coming, with one key surgeon testing using the bracing fiber in a different way than most. I hope to have more on this soon, but I do believe the technique has been used on major league players. Whether we will see reduced rehab times in the near future is the bigger question and one that could do more to change the game than anything, aside from maybe reducing the numbers altogether, especially at the youth level.

However, absent a reduction in occurrence, if the rate of revision is reduced significantly, we will see a reduction in the sheer numbers of second and third surgeries. With younger and younger pitchers needing surgery, we’re seeing more and more Tommy John reconstructions simply wear down over the course of high school, college, and pro careers. An operation done at age-15 often doesn’t last through both growth and abuse put on the elbow. A fuller use of bracing in these procedures could lead to significantly longer periods of function and fewer incidences of failure.

Of course, this will lead to a question: “Should my son just go ahead and have an InternalBrace before he gets injured?” The answer is no. No one should ever have surgery, except as a last resort. While nearly a third of MLB pitchers have had Tommy John surgery, that means two-thirds have not. The odds aren’t even a coin flip, so the math, let alone the medical ethics, don’t agree.

More interestingly, only one pitcher - John Smoltz - has had Tommy John surgery and gone on to the Baseball Hall of Fame.* It’s a quirk to be sure, partly explained by the rarity of the operation ahead of the mid-1990s, but it’s more than that. I believe only two players have won the Cy Young Award after having Tommy John surgery - Justin Verlander, in 2022, and Jacob deGrom. Verlander and Smoltz won Cy Youngs before their Tommy Johns, but having only a pair of Cy winners is a stunning result. If the only way to be in Cy contention is to have an intact elbow, maybe that will convince the parents not to ask.

However, given the apparent results, if the necessity is for surgery, the InternalBrace method is clearly showing advantages. Add in the possibility of reducing the rehab time and I have to wonder if Dr. Jobe’s miracle is in for a renewal. Less time lost. Less chance of failure. It’s hard to see a downside, when it’s needed.

*If we look down the line, the next Tommy John guy who has a real shot at the Hall of Fame is Billy Wagner. Wagner went over 50 percent this year, a key threshold. Among active WAR pitchers, four of the top ten have had Tommy John surgery. Those are Justin Verlander, Adam Wainwright, Jacob deGrom, and Chris Sale. All of those have a good Hall case, I believe, and show we might be just getting into the era where Tommy John gets proportional representation.