Tommy John surgeries evolve as demand increases

ST. PETERSBURG — Shane McClanahan. Jacob deGrom. Shohei Ohtani. The list of elite pitchers who have had or might be facing their second Tommy John surgery — or a revision, as it is called by surgeons — sadly reads like a preseason favorites list for the American League Cy Young Award.

As baseball tries to deal with the concerning number of elbow injuries among its best pitchers, the remedies needed to keep these talented arms on the field are trying to keep up as well.

“We’re cautiously optimistic, that for these hard-throwing, high-level pitchers, we can help protect the (ulnar collateral ligament), particularly in second surgeries,” Mets team surgeon Dr. David Altchek said. “It’s a little soon to tell, but so far we’re seeing good results.”

Tommy John surgery was revolutionary in 1974 when Dr. Frank Jobe performed the ulnar collateral ligament reconstruction on the former Yankees pitcher it is named after. Over the years, doctors have perfected the docking of the grafted tendon that holds the upper arm to the forearm to the point where around 80% of professional pitchers who have the procedure return to compete professionally. Among those who needed a second surgery, however, the results were less than half that.

And the need for the revisions has just grown.

As the average fastball velocity has risen over the last few years — in 2022 it was 93.9 mph — the number of pitchers needing revisions has grown, too, but doctors are seeing more success stories like former Rays pitcher Nathan Eovaldi, Jameson Taillon and Hyun-Jin Ryu.

Stronger sutures that remain in the elbow, called an internal brace by some, are what surgeons like Altchek see as the key to Tommy John “revisions,” and is the suggested surgery for elite, high-velocity pitchers.

“I’m not a huge fan in really hard, professional throwers of just a primary (ligament) repair,” said Altchek, who is based at the Hospital for Special Surgery in New York, which is top-ranked in the nation for orthopedics.

“The tissue failed and I think you’ve got to do more to make sure it doesn’t fail again. These sutures are heavy, they don’t heal, and they protect the ligament. That is what I am using with professional, hard-throwing pitchers.”

“I am not a fan of that for (a first) repair for high school pitchers or some kind of lower pitchers,” Altchek added, “but for elite pitchers, meaning college and pro pitchers, now I do this hybrid docking procedure with adding these heavy sutures and, it’s too soon to tell, but it seems to be working.”

These sutures, or braces, are newer to baseball surgeries but have been used on athletes from other sports to help repair ankle and shoulder ligaments.

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Dr. Keith Meister has been doing the hybrid surgery with the brace, pioneered by Dr. Jeffrey Dugas, for ulnar collateral ligament surgeries for nearly five years. That is what Meister used on Jeffrey Springs, even though it was his first surgery, earlier this year.

“The understanding that I have is the ligament is repaired, but then it has support in there. It’s like a synthetic tape, just extra support,” Springs said. “They basically take the ligament and they weave a synthetic fiber kind of with it. So if you think of a rope, you have extra rope in there to help. So the ligaments are not taking all the stress directly.”

Drew Rasmussen, the second Rays starter whose season was ended by elbow surgery this year, had two Tommy John surgeries even before he threw a pitch professionally. This time, Meister decided he did not need the full reconstruction of the ligament, but he just implanted the brace over the ligament to reinforce it.

“It’s supposed to support the ligament and make it stronger,” Rasmussen said. “It’s a different experience (than traditional Tommy John). I had less swelling and more flexibility right away. It’s supposed to be a shorter recovery time.”

Surgeons like Altchek, one of a handful of doctors performing these surgeries on elite pitchers, feel the brace and the hybrid Tommy John surgery are just a way to try and keep up with their growing number of patients.

McClanahan and the Rays are one example of how important the evolution of Tommy John surgery is to the game. The Rays have had eight pitchers since 2020, including three starters this year, suffer a season-ending elbow injury.

“More pitchers are throwing harder, and many with less-perfect mechanics,” Altchek said. “We think that group of pitchers may benefit. It’s too soon to tell, but hopefully, we will see that with these heavier sutures, they will not reinjure these ligaments.”

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