'Tommy John' surgery
by Jennifer Dawkins, drkoop.com

A torn medial collateral ligament has put John Smoltz on the sidelines for the season, casting a shadow on the Atlanta Braves' hopes of returning to the World Series. Missing an entire season may seem devastating, but the same injury 25 years ago would have ended a pitcher's career.

Not today, thanks to Dr. Frank Jobe, who was told to "make up something" by Los Angeles Dodgers pitcher Tommy John, who was diagnosed with a career-threatening torn ulnar collateral ligament in 1974. Instead of just making up something, Jobe made history.

Jobe extracted a tendon from John's right arm and used it to replace the torn ligament on his left, pitching arm, threading the healthy tendon through holes drilled into the bone above and below the elbow. At the time, no one was certain of the outcome, but John went on to win 170 additional games; the procedure thereafter became known as 'Tommy John surgery.' Without Jobe's help, John would never have pitched another baseball.

Since then, Jobe has performed more than 200 of these operations and has passed the technique on to other surgeons, such as Dr. James Andrews, who will perform Smoltz's operation.

Dr. John Bergfeld, executive director of Cleveland Clinic Sports Health, said, "Slight modifications have been made, but the principle of the surgery is the same: to repair a ligament that is frayed and torn with an accessory tendon from the arm."

The accessory tendon does not have a useful function otherwise and is usually taken from the hand, wrist or forearm. According to Bergfeld, 12 percent to 13 percent of patients do not have such a tendon in either arm, in which case one is taken from the leg or toe.

The ulnar collateral ligament is a band or sheet of fibrous tissue that connects two or more bones and supports the arm muscles used while pitching. It is located on the inside of the elbow. If the ligament is torn or damaged, it is impossible to gain velocity while throwing any object, especially a fastball.

The exact cause of the ligament ruptures is unknown. It could be wear-and-tear or it could be a single jolt that rips the tissue away from the bone. The wide variety of breaking pitches used today, such as the sharp-curve ball, cutter and split-finger fastball, can cause strain on the elbow, perhaps inducing these ruptures.

"It's the mechanics of the way you throw. It is an unnatural motion that wears on the ligaments that causes small tears and fraying," Bergfeld said. "Repeated small tears add up to one big tear."

When players notice discomfort and changes in their pitching ability, it is not immediately apparent that something is seriously wrong. Ruptures are detected through a magnetic resonance imaging test, or MRI, sometimes after days or weeks of mild pain.

Injured players today will spend less time in the operating room and start rehabilitation right away. John spent four hours on the table, whereas the current operation only takes an hour and a half. John was in a cast or splint that restricted his arm movement for 16 weeks. Now, physical therapy starts as soon as possible.

Bergfeld said patients start with slight movement in their hands and wrists usually within a week of surgery. The amount of time before players can begin to throw again differs, depending on what the individual surgeon finds. Rehabilitation exercises have been perfected and most feel ready to step back into the game in just seven months. For caution's sake, most players, such as Wood, refrain from play for almost a year. Non-pitchers recovering from the surgery, such as Seattle Mariners outfielder Jay Buhner, may return even sooner.

Once rehabilitation is complete, the good news is that many players come back with a few more miles per hour on their fastball. Transplanted tendons have three times the amount of collagen, the substance that makes up cartilage, than the original tendon. John, for example, never won more than 16 games in a season before his surgery, but came back to win 20 games his first season and 22 games in a later season.

Not all surgeries, however, are success stories. There is only a 70 percent to 80 percent success rate, according to Dr. Art Rettig, associate clinic professor at Indiana University and physician at Methodist Sports Center. Rettig has performed approximately 25 ligament replacements. "You only hear about the ones who come back," he said, "but I've had some college players who didn't. It's not 100 percent."

Although this is a revolutionary surgery, it isn't magic. Woods has worked hard to get back to his team and is still not projected to pitch in a game until May. Chances are Smoltz will find the next year just as challenging.

Jobe may have paved the road back to baseball for these injured players, but they must still endure the trip.

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