Elbow Ligament Reconstruction: The 'Tommy John Surgery'

The ulnar collateral ligament (UCL) is one of the main stabilizing ligaments in the elbow and is involved especially with overhead activities such as throwing and pitching. When this ligament is injured, it can end a thrower’s career unless surgery is performed. Some common sports activities that may cause UCL injury are:

• Baseball and pitching sports
• Javelin throwing
• Tennis
• Fencing
• Contact sports such as football and wrestling

UCL injuries occur most often from repetitive overhead activities. The repetitive activity can cause microscopic tears, inflammation to the ligament and, eventually, complete tearing.

Signs and symptoms of UCL injury can include the following:

• A popping sound may be heard when engaging in overhead throwing activities
• Inability to continue throwing sports (decrease in velocity and/or control)
• Elbow pain on the inner or medial side that appears suddenly or gradually
• Achy pain to the inner side of the elbow with overhead throwing activity
• Numbness and tingling sensation to the ring finger and little finger
• Pain that radiates to the inner forearm, hand or wrist

The first surgery to repair a UCL injury was performed in 1974 on Tommy John, a famous pitcher at that time. As a result, you may hear the term “Tommy John surgery” when discussing UCL reconstruction surgery. Your physician will confirm the diagnosis of UCL insufficiency by collecting medical history, performing a physical examination and reviewing diagnostic tests such as X-rays/MRI scans.

Conservative treatment options that are recommended include the following:

• Activity Restrictions: Limit use and rest the arm from activities that worsen symptoms.
• Orthotics: Splints or braces may be ordered to decrease stress on the injured tissues.
• Ice: Ice packs applied to the injury will help diminish swelling and pain. Ice should be applied over a towel to the affected area for 20 minutes four times a day for a couple days. Never place ice directly over the skin.
• Medications: Anti-inflammatory medications may be ordered to treat the pain and swelling.
• Physical Therapy: This may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased.
• Pulsed Ultrasound: This is a non-invasive treatment used by therapists to break up scar tissue and increase blood flow to the injured ligament to promote healing.
• Professional biomechanical instruction: Consulting with a sports professional to assess and instruct in proper technique to help prevent recurrence.

If conservative treatment options fail to resolve the condition or surgery is recommended directly, it may be recommended to undergo UCL Reconstruction surgery, also called Tommy John surgery, which involves replacing the torn ligament with a tendon from elsewhere in the body or from a cadaver. The most frequently used tissue graft is the Palmaris longus tendon in the forearm.

UCL Reconstruction Surgery

• The surgery is performed in an operating room under general anesthesia.
• A 9 cm incision is made the inside of the elbow at the medial epicondyle area.
• Care is taken to move muscles, tendons and nerves out of the way.
• The donor tendon is harvested from either the forearm or below the knee.
• Bone sockets are drilled into the ulna and humerus bones.
• The donor tendon is inserted through the drilled holes in a special pattern.
• The tendon is then attached into the bone sockets with sutures.
• The incision is closed with sutures and covered with sterile dressings. A splint is applied with the elbow flexed.

After the surgery, you will be advised for a regular follow-up and also for structured rehabilitation program for better and quicker recovery.