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Tommy John surgery is a medical procedure during which the ulnar collateral ligament (UCL) in the elbow is removed and replaced with a transplanted tendon. In most cases, the surgery becomes necessary when the UCL becomes damaged or torn as the result of repetitive strain. While anyone can find themselves in need of Tommy John surgery, the procedure is mostly associated with athletes, especially baseball players and pitchers in particular.

Historical Context

Tommy John surgery was pioneered by Dr. Frank Jobe, an orthopedic surgeon who founded a practice in the Los Angeles area in the 1960s. Early on, he and partner Dr. Robert Kerlan formed a working relationship with the Los Angeles Dodgers—the local Major League Baseball franchise—and began providing services for players such as legendary pitcher Sandy Koufax. In this capacity, Jobe quickly learned that proper functionality of the elbow and its anatomical components was of critical importance to athletes such as Koufax who relied heavily on their ability to throw balls or other objects. He also noticed that injuries to the UCL were particularly problematic for such athletes, often ending their careers.

Eager to find an effective means of addressing UCL issues, Jobe noted the success surgeons were having in restoring the functionality of injured fingers through the transplantation of certain ligaments and wondered whether a similar approach might work for the elbow. After carefully developing an experimental surgical procedure for replacing the UCL with a transplanted tendon, Jobe needed a suitable candidate willing to be a test subject. That candidate was Tommy John, a Dodgers pitcher who had likely been throwing with a damaged UCL his entire career. Hoping to avoid an early retirement, John agreed to undergo Jobe's experimental surgery in July 1974. Although his subsequent recovery prevented him from returning to the field for an entire season, the surgery was a success and John was ultimately able to continue playing until 1989. In recognition of being the first person to undergo the operation, John became the honorary namesake of Jobe's revolutionary procedure.

The Procedure

Formally known as UCL reconstruction, Tommy John surgery is a relatively noninvasive surgical procedure used to treat patients who have damaged or torn a UCL because of repetitive extreme stress. By removing the damaged UCL and replacing it with a transplanted tendon, surgeons can restore functionality and afford patients relief from pain.

To perform a Tommy John procedure, the surgeon first extracts a substitute tendon from another part of the patient's body or from a cadaver. These tendons can be taken from a number of places, including the forearm, knee, hamstring, hip, or foot. The most commonly used replacement tissue, however, is the Palmaris, a redundant tendon found in the wrist. Once the replacement tendon is secured, the surgeon removes the damaged UCL and drills holes in the humerus (upper arm bone) and the ulna (a lower arm bone). Next, the surgeon passes the tendon through the holes in a figure-eight pattern and attaches the ends of the tendon to the remaining portions of the original UCL. Finally, the incision is closed and the surgery is completed.

More often than not, Tommy John surgery does not carry a significant risk of complications. Only 5 to 20 percent of patients who undergo the procedure experience any sort of significant problems afterward. The most common issue associated with Tommy John surgery is ulnar nerve damage, but infection can also occasionally occur.

Recovery

While Tommy John surgery itself usually takes only about an hour to complete, the patient's recovery period is a much longer process that often requires about a year of rehabilitation and physical therapy. Following surgery, the patient's elbow is typically immobilized for anywhere from one week to ten days. During that time, the patient can engage in gentle range-of-motion activities as well as light arm and shoulder strengthening exercises. After about four to five weeks, athletes who have undergone Tommy John surgery can resume throwing balls, although they are usually advised to avoid windups. At six weeks, most patients can begin to work on strengthening the affected elbow itself. Most pitchers begin throwing normally again after seven months. From there, the recovery timetable depends largely on the individual and the specifics of his or her condition. For pitchers who are no longer experiencing pain and have regained full range of motion, it may be possible to return to full competition in as little as nine months. For others, complete rehabilitation may take longer.

Success and Controversy

Since Jobe first operated on Tommy John himself, the surgery has become a widely accepted medical procedure that has helped countless athletes to overcome debilitating UCL injuries and extend their careers. For baseball in particular, Tommy John surgery has been especially significant. By allowing elite pitchers to remain on the mound as long as possible, Tommy John surgery has increased competitiveness and improved the quality of play at virtually every level of the game. Indeed, many of baseball's greatest modern pitchers, including Joba Chamberlain, Stephen Strasburg, and Brian Wilson, have benefitted from the procedure.

The effectiveness of Tommy John surgery, though undoubtedly great for baseball, has also led to controversy at the sport's lower levels. Seeing how the procedure has improved the performance of the players who have had it, some parents of underperforming Little Leaguers have sought to give their children a competitive boost by putting them through the surgery even though they do not have UCL injuries. Numerous physicians, including Jobe, have refuted the usefulness of this sort of strategic Tommy John surgery, however, arguing that while the procedure may appear to improve performance, it is really only returning players to the skill level they were at before they were injured.

Bibliography

Ansorge, Rick. "Tommy John Surgery." WebMd. WebMd, LLC. 11 Feb. 2014. Web. 19 Mar. 2015. http://www.webmd.com/fitness-exercise/tommy-john-surgery-ucl-reconstruction?page=1

Carroll, Will. "Dr. Frank Jobe, Tommy John, and the Surgery That Changed Baseball Forever." Bleacher Report. Turner Broadcasting System, Inc. 17 July 2013. Web. 19 Mar. 2015. http://bleacherreport.com/articles/1672080-dr-frank-jobe-tommy-john-and-the-surgery-that-changed-baseball-forever?utm_source=cnn.com&utm_medium=referral&utm_campaign=editorial&hpt=hp_t3

Carroll, Will. "Tommy John Surgery: The Realities and Myths of Sports' Most Famous Operation." Bleacher Report. Turner Broadcasting System, Inc. 17 July 2013. Web. 19 Mar. 2015. http://bleacherreport.com/articles/1675444-tommy-john-surgery-the-realities-and-myths-of-sports-most-famous-operation

Dodd, Mike. "Tommy John Surgery: Pitcher's Best Friend." USA Today. Gannett Company, Inc. 28 July 2003. Web. 19 Mar. 2015. http://usatoday30.usatoday.com/sports/baseball/2003-07-28-cover-tommy-john_x.htm

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