UTK Special: The Shohei Special

Inventing Something To Rebuild A Unicorn

One of the complications of talking about any elbow surgery in baseball is that there’s now options. For the last forty-nine years, Dr. Jobe’s miracle - Tommy John surgery, the nickname for UCL reconstruction - has been largely unchanged because it works. Yes, there’s variants and yes, there’s better tools, but the fundamentals of the surgery are the same, for good reason. It works.

Over the last couple years - less than a decade - baseball has had an influx of new techniques. InternalBrace repair, which needs a nickname. Tommy John revision, which is just a re-do, basically. (I could confuse you with minute details of how some surgeons do the revision slightly differently, but I won’t.) Even things like biologics - PRP, stem cells, and the like - have gotten involved and even become standard, despite mixed results in studies.

In a vastly oversimplified way, the way to differentiate between the two procedures is the difference between repair - sewing a damaged ligament back together - and reconstruction - taking out the damaged ligament and replacing it with a graft, usually a hamstring tendon. Anything else is an add on to those two basic procedures, whether it’s a brace, a tensioner, or biologic injections. A surgery could be a reconstruction (Tommy John) with a brace over it and it’s still a Tommy John, though we don’t yet know if rehab time can be reduced on that. I know, it’s confusing.

Enter Shohei Ohtani. The “Unicorn” has his second UCL injury and as unique as Ohtani is in baseball history and lore, doesn’t he deserve his own surgery? At least two surgeons, among the double-digit surgeons that have been consulted by Ohtani and his agent, Nez Balelo, are considering doing a new type of surgery, or at least a variant on the types we’ve seen. Both are repair variants, given the location and severity (not yet publicly known) of the sprain.

While details are difficult to come by, I have confidence that both of these were part of the presentation/consultation given by the respective surgeons. However, given the high profile nature of this, it’s unlikely that a top surgeon is going to do something untested. I believe these are techniques that have been done in lower-level athletes and perhaps even a minor-league athlete. Both involve InternalBrace, but differ in how they are applied.

In the first proposed technique, the UCL itself would not be repaired. Instead, the InternalBrace would overlay the ligament and be tensioned to take more stress. The ligament would then be flooded with biologics, likely stem cells. Ligaments do not heal well on their own because of poor blood supply. The biologics would augment the natural healing, at least in theory. In theory, this could heal very quickly, basically the time for the anchors to set, about six to eight weeks. There has to be a balance between the biologic structure and the support from anything else, so this one seems dubious to medical sources I spoke with.

In the second technique … well, this one I understand less. While wrapping a ligament in a substance like the super-strong fibers of SutureTape (the fabric that makes up an InternalBrace) makes sense on some level, there’s also the complications of a moving, dynamic, and highly stressed anatomy. As far as I know, some kind of surrounding mesh doesn’t exist, and would be difficult to anchor. Wrapping a piece of fabric around a ligament would be nearly impossible to tension and could “choke” the ligament in certain positions.

The second technique somehow prepares the ligament and the bracing together. Call it a cyborg, if you will, and I will admit even having it explained by a source didn’t make complete sense to me. Why not just use the fabric, as is often done in animals? My dog had surgery to replace his CCL (the canine equivalent of an ACL) over a decade ago and he was walking normally in weeks. His knee lasted longer than he did, rest his fuzzy soul. It’s simply not done in humans, with the exception of some tightrope surgeries in the “high ankle”, where the device is inserted and the ligament is not repaired. Admittedly, this is unusual and only done in a small number of non-athletic cases. There is also the ACL Tightrope for humans, which is newer but growing in usage and has a graft construct like what I believe is being discussed for the elbow. The video below shows more:

Again, these are just possibilities. As yet, we only know that Balelo believes there will be a “procedure” of some kind. A doctor and a type of surgery has not yet been chosen, to my knowledge. I do believe that the timing is key. Balelo told the media that the key to Ohtani is not losing playing time, with the goal being hitting on Opening Day. Given the timing we have seen with Bryce Harper (standard Tommy John) and Trevor Story (InternalBrace repair), neither gets Ohtani from the end of this season to Opening Day 2024. Close, and perhaps possible with a more aggressive rehab than we’ve seen in the major leagues, but that we have seen in lower-level athletes that were time-constrained and more willing to take on risks. It’s easier to let a high school senior rush things for that last season than for Ohtani, who will be a highly valued asset on a new contract as he’s returning from whatever surgery is decided.

Please, please note that I admit that I do not fully understand these techniques and in my description, may have made some technical errors. I’m not a doctor, let alone a highly skilled surgeon that can do these kind of techniques. I’ve done my best to explain these in non-technical terms and hope I’ve done that.