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On the Mound
Tommy John surgical procedure helps pitchers return to the game


March 2015

Brewers pitcher Johnny Hallweg had the Tommy John surgery.

"Sooner or later, the arm goes bad. It has to." That prescient observation, made by Yankees Hall of Fame pitcher Whitey Ford a half century ago, still holds true today. But modern medicine can delay that inevitable outcome.

Ulnar collateral ligament reconstruction, better known as Tommy John surgery, was first performed in 1974 on major league pitcher Tommy John by legendary sports surgeon Dr. Frank Jobe. In the procedure, the UCL is replaced with a tendon from somewhere else in the body.

Milwaukee Brewers team physician Dr. William Raasch estimates heís performed that surgery about 100 times on baseball pitchers at all levels and on other athletes whose sports put stress on the UCL, such as wrestlers and gymnasts.

"Itís basically the ACL (anterior cruciate ligament, a common knee injury) of the elbow," Raasch says. "Itís when the amount of stress is greater than the ligament can bear."

The most common transplant source for replacing the ligament is a small tendon in the forearm, but if a patient does not have that tendon (15 to 20 percent of people do not), a hamstring tendon can be employed. Surgeons create a tunnel in the bone where the torn ligament was attached. The old ligament is replaced with the reconstructed ligament, which can be as strong or stronger than the original.

"Itís not a difficult procedure," says Raasch who explains the outpatient operation usually lasts around 45 minutes. "But itís a technical procedure. You have to know exactly where youíre putting those tunnels because thereís very little margin for error."

The procedureís success rate is high, 80 to 90 percent for major league pitchers, but the success rate drops in the lower levels of pitching. "Some of these kids who tear their ligament, that may be secondary to very poor mechanics," Raasch says. "They go back and throw the same way afterwards, so itís (the ligament reconstruction) is going to fail."

But sometimes, even great pitching mechanics cannot overcome unfortunate genetics. "To be a major league pitcher, you have to push your body to the limit of what it can do, and then you have to have the genetics that will allow that body to recover each time and hold up," Raasch says. "We run into individuals that have the talent to pitch but their body doesnít have the durability and they break."

Ligaments can fail on one catastrophic single pitch, or in most cases, wear down to the breaking point over time. After the surgery, patients will spend a month in a brace to protect the reconstruction. The next step (6 to 8 weeks post-op) is to regain the range of motion. At the four-month mark, when the ligament has had time to grow into the bone, pitchers can start throwing short distances from flat surfaces, building up to longer distances before throwing off a mound after six months. The rehab process is slowed down at the slightest sign of discomfort.

Typical recovery time for a major league pitcher who performs at the gameís highest level is 18 months. College and high school pitchers, who face less daunting performance standards, may be ready to compete again sooner.

"If a high school pitcher can throw 85 miles an hour, doesnít need perfect control and just needs to throw hard, he can be successful," Raasch says. "It takes longer for the professionals since they need to be perfect with their control."

Raasch diagnosed the need for Tommy John surgery for Brewers pitcher Johnny Hellweg last April. Renowned sports surgeon Dr. James Andrews performed the operation, and Hellweg is targeting an early to mid-2015 season return to action.

Raasch, a professor of orthopedic surgery at the Medical College of Wisconsin who performs countless procedures on athletes and non-athletes, says every surgery is critical, but admits thereís a special aura in the room when a professional athlete is on the operating table.

"Thereís a little elevation in everyone, a higher expectation, but every single procedure, we treat it the same," he says. You could say this pitcher is a Cy Young Award winner, but this high school kid weíre fixing could be a future Cy Young Award winner."


This story ran in the March 2015 issue of: