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9/1/21 - Kenta Maeda had Tommy John Surgery
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Posted by roger,
Today's Strib had a good report of what occurred. The Texas doctor has done about 50 of these to pitchers, both major league and amateur. It is TJ surgery, but with a new wrinkle in which he inserts a brace...whatever that means. It could/should shorten the recovery period from the normal 12-16 months to as little as 9-12.
If Kenta can be on the mound pitching in the minors in 10 months, that would be July 1. A month of rehab would put him back at Target Field on August 1, in time for the Twins run to the playoffs. So assuming he can meet the shorter rehab period enabled by this surgery, it would be like trading for a top pitcher come next year's trading deadline. And if his rehab doesn't progress like hoped for, they will see him in spring training, 2023.
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Posted by Heezy1323,
Ok- I'll give it a shot. Hopefully there's something valuable I can share.
I did not see the STrib article (my bad, would've liked to read it), but I have been aware of the internal brace concept being utilized with UCL reconstructions for a short time.
Feel free to review my prior blog post about UCL injuries.
Nomenclature is important here. Recall that UCL repair means that the athlete's own ulnar collateral ligament (UCL) is repaired back to bone. This repair is often protected with an especially strong suture called an 'internal brace'.
The internal brace has been around for a number of years. It has been (and is currently) used in a number of other places in the body to protect various ligament or tendon repairs. It began (if I recall correctly) being used to help protect the repair of ligaments at the outside part of the ankle when patients required surgery for chronic ankle instability. With it's success there, it has gradually been expanded to other parts of the body. By way of example, I have used it in basically every one of my ACL reconstructions for the past 2.5 years to protect the healing graft during recovery (somewhere around 150 ACL's). I have also used it to help protect PCL, MCL, patellar tendon and posterolateral corner surgeries in the knee, among others.
When the UCL is repaired, the idea is that the tissue of the UCL is healthy/strong enough that it can successfully withstand the forces of pitching once it has become firmly healed back to the bone. The injury in these cases is to the area where the ligament meets the bone, not within the ligament itself. The purpose of the internal brace in this case is to 'protect' the repair. Specifically, when a patient moves the elbow after surgery (even if they aren't doing something demanding such as throwing), there is microscopic movement at the interface between the healing ligament and the bone. In theory, if there is excessive stress at this junction, the healing will be less robust and therefore the ligament less able to withstand substantial forces of throwing later on in the rehab process. By using an internal brace, the idea (as I understand it), is that the relatively small forces of day to day movements of the elbow are now shared between the healing ligament and the internal brace suture. Therefore, this stress is less likely to cause a negative effect on the healing progress of the ligament back to the bone. Hopefully (the idea goes) this results in more strong and robust amount of healing of the ligament when compared to a repair done without an internal brace.
(Feel free to review my previous blog post about UCL repair vs. reconstruction here.)
That leads us to this particular case with Kenta of a UCL reconstruction performed with an internal brace. This is similar, but not identical to the situation discussed above. Recall that the term 'reconstruction' is used when tissue (almost always a TENDON) from somewhere else (either the patient themselves or in some cases a donor/cadaver) is used to make a NEW ligament. There are numerous reasons why this option might be chosen rather than a repair, but most commonly it is because there is an accumulation of damage to the native ligament that makes it unlikely to be strong enough itself to stand up to the necessary stresses once healed. Indeed, most UCL repairs are performed on young athletes who don't have the same cumulative amount of damage as MLB pitchers.
As a result of this, there is an additional variable in these cases of reconstruction. Namely, in addition to successful healing, the TENDON also requires time to 'turn into' a LIGAMENT. This is primarily why the recovery from UCL repair surgery is typically so much shorter than UCL reconstruction --> in a UCL repair the ligament is already a ligament. So it doesn't require time to undergo this transition from tendon tissue to ligament tissue (called ligamentization).
(I know this is getting tedious- and I apologize. Hang with me here...)
So the use of the internal brace with UCL reconstruction has a slightly different goal than with primary repair (again, as I understand it). Obviously, when you use a tendon to replace a ligament, you have to remove that tendon from the body completely for a short time in order to reimplant it. As a result, the tendon is completely removed from its normal blood supply. Once implanted, the body has to reestablish blood supply to this tendon in its new location in order to keep it alive. This takes some time to accomplish. There have been animal studies done that have shown that the strength of the newly implanted tendon in situations such as this actually goes down for the first few weeks after surgery, then starts to increase again. As a result, there is a period of time after surgery when this graft is vulnerable to 'stretching out' which could compromise the ultimate strength of the graft. The internal brace seeks to avoid this problem by protecting or 'bracing' the graft during this period of time so that it doesn't stretch out and is able to heal in more strongly and at the appropriate tension.
How much difference in 'looseness' (what we would call laxity) is too much? Well, during my fellowship with Dr. Andrews we did a study that showed that when placed under stress, the injured elbow opened up on average only 0.3mm (that's a third of a millimeter!) more than their opposite, uninjured elbow. So it appears that it doesn't take much difference in laxity to cause a problem in a thrower's elbow.
There is a mountain of data supporting the use of an internal brace with UCL repair. There is very little data available that I am able to find regarding the use of an internal brace with UCL reconstruction. I found one biomechanical paper that showed that the use of an internal brace with UCL reconstruction allowed the biomechanics of the elbow to more closely replicate a normal elbow than when UCL reconstruction was done without internal brace (this was a cadaver study). I was not able to find any clinical data reporting on the success rate of UCL reconstructions done with internal brace compared to those done without. My guess is that this data is coming, just not published yet.
Logically, it makes a lot of sense to me that the use of an internal brace in conjunction with a UCL reconstruction would improve the success rate, but medicine doesn't always follow logic. I'll be interested to see the results in the future.
Also, I don't know exactly which reconstruction technique Dr. Meister uses, which could potentially have some influence on results as well.
One reservation I have about the idea that this internal brace shortens the return to play timeline is that despite the fact that this internal brace likely results in a 'tighter' ligament once healing is complete, the internal brace probably does not do anything to speed up the transition of the tendon tissue into ligament tissue that occurs over time. Perhaps we can be a bit more aggressive with the rehab when an internal brace is present, without as much concern for the new ligament 'stretching out'. But ultimately, the new ligament has to be (very) strong in order to withstand the extreme forces of pitching, especially at the MLB level. Time will tell if this new modification to UCL reconstruction technique will allow for a quicker return to play. I hope it does- 18 months is a darn long time.
If you've managed to read this far- thank you. This is pretty dense stuff (sorry...)
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