Heezy1323

I'm an orthopedic surgeon, but not a hand/wrist specialist. The difficult part here for me is- I can't really find any specifics on what surgery Kirilloff had performed. I can only find 'ligament repair' in his wrist. Unfortunately, there are numerous ligaments in the wrist and they may each have different implications. Secondarily, with regards to the cartilage- there are at least 10 bones that I would consider being part of 'the wrist', so there could be cartilage wear between any of those bones (or multiple). If a proposed procedure to remedy this is cutting the ulna and shortening it (what we would call an ulnar shortening osteotomy), the arthritic changes (cartilage wear) probably involve wither the distal radioulnar joint (DRUJ) or the lunate (one of the pebble shaped bones of the wrist). The distal radioulnar joint is the area where the two forearm bones meet just above the wrist. The radius rotates around the ulna as one turns their hand from palm up to palm down position. If there is arthritis between these bones, as is being reported, I'm not aware of any good fixes. Because I don't do much hand/wrist stuff, there may some cutting edge things I'm not aware of. But this, to me, is a pretty significant bummer. I wish I could say different, but I'm not super-optimistic for a resolution of this problem. It's possible more information would change my opinion.

I propose a thought exercise. I believe most would agree (regardless of position on robo umps) that calling balls and strikes in a game of 10-year-olds is easier than at the MLB level. What is the reason, exactly? Presumably, it is because the pitches are coming in much more slowly, and are breaking a much smaller distance. For the sake of argument, let's take this to an extreme. Let's pretend that the ability of pitchers to continue to improve their velocity knows no limit. Let's pretend that, say, 20 years from now it is routine to have pitchers throwing 110-115mph. Perhaps with even more break. What is the upper limit of human ability to make ball/strike calls with reasonable accuracy? Clearly if a baseball is coming in at 200mph, and breaking 30" or something, a human brain has no shot at telling if the ball goes through a defined box- particularly on borderline pitches. And logically, there is also a gradient along the way, such that with increasing velocity and break, the ability of even the best umpires to delineate balls from strikes goes down. Where, precisely, is the threshold at which this becomes 'unacceptable'? We already use computers in thousands of scenarios every day where the ability of the human senses is unable to reasonably discern one situation from another. I view this as no different. I don't believe it's because the umpires are necessarily 'bad' at their job. I just don't think it's reasonable to expect even those most skilled to be able to do this correctly 100% of the time. We've all seen games, series or even careers turn on ball/strike calls that were bad. We either have, or soon will have, the ability to be better. It's time. I can't imagine a scenario where a human is calling balls and strikes even 10 years from now. Merry Christmas TD. All the best to each of you.

Agreed on the good ice/bad ice analogy. Not sure I follow the second paragraph. The purpose of the internal brace is to avoid stretching of the graft (by resisting tension/reducing stress) during it's initial period of relative weakness after implantation, and perhaps some degree of protection of the graft going forward by acting as a sort of 'rebar.' This allows the graft to heal in at a more desirable (i.e. tighter) tension, rather than becoming loosened, as it might without the internal brace in place.

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...)

This is another HUGE variable in evaluation of these patients. The appearance of the UCL on MRI is often not particularly helpful. Let's go through the scenarios: 1) The UCL looks completely normal (rare at the MLB level): rest and rehab, perhaps a PRP injection 2) The UCL is completely torn, obvious to everyone that the athlete needs surgery (maybe 20% of the time): proceed with surgery in most cases, though on occasion PRP or other means of treatment can be tried. 3) The UCL is somewhere in between. Small to moderate damage, but nothing terrible (this is the case the majority of the time): A huge range of possibilities. Some pitchers can throw for years on a partially torn ligament. Others can have an MRI that looks essentially normal and can't throw without pain despite extensive non-surgery treatments. This is what makes these decisions REALLY hard in a lot of cases. The exact same MRI findings can indicate opposite things in two different patients. Trying to figure out which patients will be successful with non-surgical treatment is tough. And remember, the return to play rate after TJ surgery is quite good (somewhere around 90%), but that still means 1 in 10 will not get back. This is why, in many cases, the athlete has to 'prove' they aren't going to be successful without surgery by trying the rest and rehab route initially before proceeding with surgery. Sometimes the calendar, an athlete's contract status or year in school, or other factors will push us to surgery faster.

This is mostly, but not completely accurate. Hill had a UCL repair in the sense that he did not have a new graft put in place, but simply had a direct repair of his existing ligament tissue. However, he had previously undergone UCL reconstruction in the early 2010s and as such had a repair of a previously reconstructed UCL, which is really a distinct situation from the vast majority of these operations in which the athlete's native ligament is reattached to the bone. Agree with Lucas that we will probably see more of these 'primary repair' operations going forward. Hopefully they will be able to reduce the time needed for recovery for a subset of UCL-injured players.

Agree with Nine of twelve, this pitch looks to have hit him just at or above the wrist, almost certainly on the ulnar side. At the level of the wrist, the ulna is the smaller bone on the small finger side of the forearm. It's obviously hard to say exactly where this pitch hit him- whether it is a fracture of the ulna right at the wrist and into the wrist joint (what we would call intra-articular) or more on the shaft of the ulna (away from the joint a bit, within the bone itself or extra-articular). Neither is ideal, obviously, but you would prefer that the fracture be away from the joint so that there is less risk of damage to the cartilage of the wrist joint. Cartilage has less blood supply and therefore less healing potential when compared to bone. We do occasionally hear about injuries to part of the wrist cartilage in baseball players. This is called the Triangular Fibro-Cartilage Complex (TFCC for short). I believe Carl Crawford and Matt Holliday had this issue some years ago. I am hopeful this is a fracture above the wrist joint, and involves only the bone of the ulna. This would typically be fixed with a plate and several screws to hold the bone in the appropriate position while the body heals the fracture. Healing of these type of fractures often takes around 6-8 weeks. On occasion, ulna fractures can have trouble healing and may heal slowly, or in rare cases not heal at all. In those cases, sometimes additional surgery or other treatments may be needed to get the bone to heal. There are also tendons that glide close to the ulna in this area, and the sheath they glide in could potentially be damaged as well in this case. This can occasionally cause issues for baseball players as well (i.e. Mark Tiexeira). Overall, definitely a bummer for Rooker, who was having a nice start to his career. Without knowing details, it's difficult to comment on the time frame for recovery or the likelihood of this affecting him in the future. Let's hope it's a straightforward fracture and surgery goes smoothly. I know the Twins have an excellent group of physicians to take great care of him. Let me know if folks have questions or would like me to clarify anything. GO TWINS!!!

"Of course there are undoubtably additional factors that put pitchers at risk for arm injuries. Twins Daily’s very own medical expert, Lucas Seehafer, did a great job of illustrating the roll proper mechanics can play in pitcher injury prevention and the increase of specialization at a young age has also been cited as a potential cause of injury. College and minor league pitchers have a much higher rate of Tommy John surgery than their MLB counterparts, which fits our narrative as they’re likely to be throwing a higher mix of fastballs and have less developed mechanics." As a clarification of perspective, there are a greater number of TJ surgeries performed on college and minor league players when compared to MLB; however, there are MANY more players at the college and minor league level than MLB. As such the raw number is higher in college and MiLB, but the rate is much higher in MLB. There is definitely information to take away from this fact (such as early specialization, throwing harder at younger age, year-round play, etc.) but I don't think you can make the correlation to more fastballs meaning higher rate of TJ in these non-MLB players. The Twins and other MLB teams are starting to do some work on managing workload on an individual basis and understanding what stresses each athlete is placing on their elbow (rather than using a universal 'recipe' for every player). This is being done using Motus sleeves and other cutting edge technology (mo-cap, etc.). We are still probably in, like, mile 3 of a 26 mile marathon to understanding all of this, but we are now in a better position from a technology standpoint to make meaningful advancements. I hope we can find a way for me to do fewer TJ surgeries- especially on young players. As much as I love to operate, I'd be totally on board with a dramatic decrease in UCL reconstruction being necessary in the first place.

Tom Verducci posted an article today on SI.com about Noah Syndergaard and the relationship between velocity and elbow injury. I thought it was pretty good. Also, feel free to check out my blog posts about TJ surgery decision-making and techniques, if you're interested.

For those who have a subscription to the Athletic, there is a very interesting article I saw that was a deep dive into the 2019 postseason baseball, indicating that there is some evidence that the balls used in 2019 were a mix of 2019 and 2018 postseason balls. Fascinating for a baseball nerd like me. Thought some others might like it as well. Stay safe, all. heezy

I haven't done 100, but I've done a fair number on appropriate candidates. I see many more teenagers than I do professional athletes in my practice, so it is definitely a good tool to have in the toolbox for this age group. Most don't have the cumulative damage to their ligament that someone who is older might. Good luck to your son! Sounds like he is progressing very well. Being diligent about the rehab is also critical, and it sounds like he has done his part. Nice job!

The studies looking at injury early in the season for pitchers are often skewed IMO because they don't always account accurately for those injuries that have been simmering through the offseason. So if someone (like Sale, Severino etc.) ends up having TJ in March or April, the injury can get recorded as occurring in 'March' or 'April', when in reality it has (in most cases) occurred earlier, was being monitored in hopes that it would improve without surgery, but ultimately doesn't. So it's hard to know how to use that info when calculating injury rates. I do think the injury rate is probably higher earlier in the season, but probably not as dramatically different as some studies seem to show. For position players, I think it is likely more accurate. A very minor point about PRP- the platelets release chemical signalers called cytokines that are somewhat different from hormones. Hormones can make people think things like 'steroids' (which are naturally produced- or sometimes injected- hormones), when what PRP provides is an alphabet soup of things like TGF-beta, IGF, PDGF, VEGF and others that regulate cell activities like inflammation and healing. I just think it is important to make a distinction that injecting PRP is different from a steroid injection (whether anabolic or corticosteroid- which is a whole other discussion).

http://twinsdaily.com/blog/1036/entry-11884-rich-hill-elbow-surgery-discussion/ It got a little longer than I anticipated, but hopefully you'll find it helpful. Thanks for the question!

Rich Hill Elbow Surgery Discussion Heezy 1323 Happy Supposed-To-Be Opening Day everyone. Since the baseball season is (unfortunately) on hold due to the coronavirus pandemic, about the only recent baseball-related news to report has been that both Chris Sale and Noah Syndergaard (in addition to Luis Severino earlier this spring) are in need of Tommy John surgery. I covered some information about Sale’s injury and some discussion regarding techniques used in UCL reconstruction in previous blog posts. In the comment section of the latter post, TD user wabene asked an astute question about Rich Hill’s surgery and how it is similar or different from typical UCL reconstruction. Hill’s surgery is indeed different from a typical Tommy John surgery, and I thought a post about it might be interesting to some readers. As usual, my disclaimer: I am not an MLB team physician. I have not seen or examined Hill or reviewed his imaging studies. I am not speaking on behalf of the Twins or MLB. I am only planning to cover general information about this type of surgery and my take on what it might mean. Twins Daily contributor Lucas Seehafer posted an excellent article about Hill’s surgery back in January that was a good look into the surgery basics and some background about UCL primary repair. There was some additional discussion in the comments as well. Since Lucas did such a nice job covering the surgery, I won’t go into excessive detail in this post, but I’ll give my version of the basics, and then cover how Hill’s surgery is similar and different. Basics of UCL Primary Repair As covered in my post about Sale, the UCL is a strong ligament at the inside of the elbow that resists the stretching forces that occur when trying to throw a baseball. Obviously, hurling a baseball 90+ mph can take a toll on this ligament and it can, in some cases, result in a tear. These tears can occur at the top (humeral) end, bottom (ulnar) end or in the middle (called midsubstance). The figure above is from a study we did when I was in fellowship indicating the location of the ligament injury in 302 patients who had undergone surgery with Dr. Andrews. The most common areas of injury are at either end of the ligament, with the humeral end being slightly more common (at least in this series) than the ulnar end. These patients all underwent UCL reconstruction, which is the standard operation to treat these injuries when non-surgery treatments have failed to result in adequate improvement. More recently (I would say within the past 5-7 years), there has been emerging interest in performing a different operation for a subset of these patients called UCL Primary Repair. This operation differs from UCL Reconstruction in that when the repair is chosen, the injured ligament is reattached back to the bone at the site of the injury using special anchors. There is typically also a strong stitch called an ‘internal brace’ that is passed across the joint along the path of the repaired UCL as well. I often refer to this internal brace as a ‘seat belt’ stitch. The idea behind the internal brace is that early in the healing process, before it has re-developed strong attachments to the bone, the ligament is susceptible to reinjury which could cause failure to heal (or compromised strength of healing). The internal brace (theoretically) helps protect the healing ligament and allows for development of a stronger attachment back to the bone. Once healing has occurred, the internal brace is thought to act like ‘rebar’, adding some strength to the ligament (though the exact magnitude of this contribution is unclear). This figure illustrates the repair technique with the blue ‘internal brace’ also in place. This is different from UCL reconstruction, where tissue from elsewhere in the body (typically either a forearm tendon called palmaris or a hamstring tendon called gracilis) is passed through bone tunnels and used to create a ‘new’ ligament. One of the reasons for the interest in primary repair of the UCL has to do with the length of time needed for recovery from UCL reconstruction. As many of us know from having watched numerous pitchers undergo (and subsequently return from) Tommy John surgery, there is usually around 12-18 months needed for full return to pitching at the major league level. There are a number of reasons for this long time frame, but a major contributor is that this is the amount of time needed for the graft to fully heal. Recall, we are taking a tendon (which normally attaches muscle to bone) and putting it in the place of a ligament (which normally attaches one bone to another bone). Though tendons and ligaments are similar, there are differences in their microscopic structure. Over time, as the graft starts to heal and have new stresses placed on it (namely throwing), it begins to change its microscopic structure and actually becomes a ligament. In fact, there have been animal studies done that have shown that a biopsy of a sheep ACL graft (which was originally a tendon) over time evolves into what is nearly indistinguishable from a ligament. We call this process ‘ligamentization’, and it is probably the most important part of what allows the new ligament to withstand the stresses of throwing. This process, however, takes time. And because of this, the recovery from UCL reconstruction is lengthy. With primary repair of the UCL, this process of conversion of the tendon to ligament is not necessary since we are repairing the patient’s own ligament back to its normal position. Some healing is still required; namely the healing of the detached ligament back to the bone where it tore away. But this process does not typically require the same amount of time as the ligamentization process. So why, then, wouldn’t everyone who needed surgery for this injury just have a primary repair? In practice, there are a few issues that require consideration when choosing what surgery is most suitable for a particular athlete. The first brings us back to the first graph from this post regarding location of injury to the UCL. It turns out that asking an injured ligament to heal back to bone is a much different thing than asking a torn ligament to heal back to itself. Specifically, trying to heal a tear in the midsubstance of the UCL (which requires the two torn edges of the ligament to heal back together) results in a much less strong situation than a ligament healing to bone. That makes those injuries that involve the midsubstance of the UCL (about 12% in our study) not suitable for primary repair. It can only be realistically considered in those athletes who have an injury at one end of the ligament or the other. In addition, there is significant consideration given to the overall condition of the ligament. One can imagine that repairing a nearly pristine ligament that has a single area of injury (one end pulled away from the bone) is a different situation than trying to successfully repair a ligament that has a poorer overall condition. Imagine looking at a piece of rope that is suspending a swing from a tree branch- if the rope is basically brand new, but for some reason breaks at its attachment to the swing, it seems logical that reattaching the rope to the swing securely is likely to result in a well-functioning swing with less cause for concern about repeat failure. Conversely, if you examine the rope in the same situation and notice that it is thin and frayed in a number of places, but just happened to fail at its attachment to the swing, you would be much less likely to try and repair the existing rope. More likely, you would go to the store and buy a new rope to reattach the swing (analogous to reconstruction). Similarly, when we are considering surgical options, we examine the overall health of the ligament on the MRI scan, and also during the surgery to determine whether repair is suitable or whether a reconstruction is needed. If there is a significant amount of damage to the UCL on MRI, primary repair may not be presented to the athlete as an option. Also, consideration is given to the particulars of an athlete’s situation. For example, let’s say I see a high school junior pitcher who has injured his elbow during the spring season. Let’s also say that he wants to return to pitching for his senior year but has no interest in playing baseball competitively beyond high school. In this case, the athlete is trying to return relatively quickly (the next spring) and is not planning to place long term throwing stress on the UCL beyond the next season. If this athlete fails to improve without surgery (such that all agree a surgery is needed), and his MRI is favorable- he is a good candidate for UCL primary repair. This would hopefully allow him to return in a shorter time frame (6-9 months) for his senior season, which would not be possible if a reconstruction was performed. Indeed, this is the exact type of patient that first underwent this type of surgery by Dr. Jeff Dugas at American Sports Medicine Institute in Birmingham, AL. Dr. Dugas is a protégé of Dr. James Andrews and has been instrumental in pioneering the research behind UCL primary repair. As you can probably imagine, the longer players (and pitchers in particular) play baseball, the more likely it is that there is an accumulation of damage to the UCL over time. This is the factor that most commonly eliminates the option of primary repair of the UCL in many of these players. So how does any of this relate to Twins pitcher Rich Hill? Let’s discuss. Hill underwent UCL reconstruction of his left elbow in 2011. He was able to successfully return from his surgery but has certainly faced his share of injury concerns since then (as described nicely in Lucas Seehafer’s article). This past season he began to have elbow pain once again and was placed on the 60-day IL as a result. He then underwent surgery on the elbow in October 2019 by Dr. Dugas (noted above). The procedure performed was a repair procedure, but in this case instead of repairing Hill’s own UCL, the repair was performed to reattach the previously placed UCL graft. I don’t have any first-hand knowledge of Hill’s surgery, but my best guess is that the technique was very similar to what was described above for a typical primary repair with internal brace. To my knowledge, this has not been attempted before in a major league pitcher. There is data showing a relatively good return to play rate with primary repair that is very similar to UCL reconstruction. However, most UCL repair patients are much younger than Hill and the vast majority that have been studied to this point are not major league pitchers. There are a couple of ways you can interpret this data when it comes to Hill. One perspective is that he had a repair of a ‘ligament’ (his UCL graft) that was only 8 years old (since his TJ was done in 2011), and as such it likely doesn’t have as much cumulative damage as his UCL might otherwise have if he had not had any prior surgery. An opposing perspective would be that this is his second UCL operation, and even though his most recent surgery was not a reconstruction, the data that would be most applicable to him would be data regarding athletes who have undergone revision UCL reconstruction (meaning they have had a repeat TJ procedure after the UCL failed a second time). This data is less optimistic. Most studies would put the rate of return to play after normal UCL reconstruction around 85% (depending on exactly how you define successful return to play). In most studies, the rate of return to play after revision UCL reconstruction is much lower, around 60-70%. There are two MLB pitchers that I am aware of that have undergone primary repair of the UCL (Seth Maness and Jesse Hahn). Maness has yet to return to MLB and Hahn didn’t fare very well in 6 appearances in 2019. Finally, my last input on this topic as it pertains to Hill is to imagine the specific position he is/was in. He is likely nearing the end of his career (he turned 40 in March 2020). He had a significant elbow injury that was not getting better without surgery. Presumably his choices were four: 1) Continue trying to rehab without surgery and see how it goes, understanding that the possibility exists that rehab may not be successful. (Perhaps a PRP injection could be tried) 2) Retire. 3) Undergo revision UCL reconstruction with its associated 12-18 month recovery timeline, likely putting him out for all of 2020 with a possible return in 2021 at age 41. 4) Undergo this relatively new primary repair procedure with the possibility of allowing him to return to play for part of the 2020 season, but with a much less known track record. In fact, a basically completely unknown track record for his specific situation. If that doesn’t seem like a list filled with great options, it’s because it isn’t. If I’m being honest, I think Hill probably made the best choice (presuming that he still has a desire to play), even with the unknowns regarding his recovery. He obviously couldn’t have seen this virus pandemic coming, but that would seem to make the choice even better since he is not missing any games (because none are being played). For Hill’s and the Twins sake, I hope his recovery goes smoothly and he is able to return and pitch at the high level he is used to. He sure seems like a warrior and is certainly the kind of person that is easy to root for. But based on what we know about his situation, there is an element of uncertainty. If I were Hill’s surgeon, I likely would have told him that he had around a 50-60% chance to return and pitch meaningful innings after this type of surgery. Let’s hope the coin falls his way, and also that we can figure out how to best handle this virus and get everyone back to their normal way of life as soon and safely as possible. Thanks for reading. Be safe everyone. Feel free to leave any questions in the comment section.

It was! Quite different, in fact. Let me see what I can put together.

http://www.quickmeme.com/img/87/87f8bff37864a91ee3d279c3167dcb6037f74096eb3961d1cbbc9c855f72580f.jpg

UCL Reconstruction Surgery Heezy1323 I recently posted a blog about Chris Sale and the news that he was set to undergo UCL reconstruction. That post covered some questions surrounding the diagnosis and decision-making that occurs when players/teams are faced with this dilemma. That post got a little lengthy, and I chose not to delve into the surgery itself, as I felt that may be better presented as a separate entry. My intention with this post is to discuss some of the different techniques that are used to perform UCL reconstruction. This does get fairly technical, and I apologize in advance if it is more than people would like to know. First, we should revisit the anatomy. The ulnar collateral ligament (UCL) is a small but strong ligament on the medial (or inner) part of the elbow. It is around the size of a small paper clip. Ligaments (by definition) connect one bone to an adjacent bone. The UCL spans from the medial epicondyle of the humerus (the bump you can likely feel on the inside of your elbow) to the sublime tubercle of the ulna (one of the two forearm bones). (As an aside, sublime tubercle is one of my favorite terms in all of anatomy). As with nearly any reconstructive surgery in orthopedics, our aim is to recreate the native/normal anatomy as closely as possible. In order to do this, most techniques utilize small tunnels that are drilled into the bone at the ligament attachment sites. The tissue that is used to reconstruct the ligament is then woven through these tunnels and tightened to create a secure new ‘ligament’ that heals and strengthens over time. The primary differences between different techniques are the ‘approach’ (or how tissues are moved aside to see the damaged areas), the specifics of how the tunnels are made and used, the type of tissue (or graft) that is used to make the new ligament, and the way that the graft is secured in place. There are a number of variations that exist, but I’ll cover a few of the most commonly used methods. First, some history may be in order. The first UCL reconstruction was, famously, performed on Tommy John. Tommy John was an outstanding pitcher for the LA Dodgers in the early 1970’s, and had compiled a 13-3 record in 1974 when he had a sudden injury to his elbow and was unable to throw. Imaging was performed, and the diagnosis of a UCL tear was made by pioneering orthopedic surgeon, Dr. Frank Jobe (of the famous Kerlan Jobe clinic in LA). Dr. Jobe had an idea to perform a reconstruction of the UCL, and practiced on several cadavers until he felt he had worked out a promising technique. He told Tommy that he thought he had a 1 in 100 chance of a successful return to MLB pitching. John decided to go ahead. The surgery was ultimately successful, and John returned to pitching in 1976. Though Tommy made it back, he did have a temporary palsy of his ulnar nerve after surgery, which is the ‘funny bone’ nerve that is near the UCL. This caused him significant weakness in his hand at first, but fortunately the strength returned over time and Tommy was able to return to pitching. Interestingly, he won more MLB games after surgery than he did before surgery, and pitched until 1989. There is a story that Jose Canseco hit a homer off John late in his career. Apparently Canseco’s father was Tommy’s dentist, and Tommy said something to the effect of “When your dentist’s kid starts hitting home runs off you, it’s time to retire.” The technique used for this first surgery was termed the Jobe Technique (for obvious reasons). It involved removing the attachment of the muscles to the inner part of the elbow and pulling the muscles toward the wrist to get a good look at the UCL itself. Tunnels were drilled in the bone at the normal attachment sites of the ligament, and a small tendon from the forearm (called the palmaris) was used to weave through the tunnels making a ‘figure-8’ in order to make a new ligament. (The palmaris is a non-necessary tendon that is located in the forearm of about 2/3 of the population. For those patients who don’t have a palmaris, we usually use a hamstring tendon called the gracilis for this procedure.) The old ligament was left in place and sewed into the graft. The nerve was also moved from its normal location (behind the bump) to in front of the bump to take some of the tension off. This is called a ‘transposition’ of the ulnar nerve. This technique was used for a while, but it did have some drawbacks, such as a high percentage of patients having ulnar nerve problems after surgery and some weakness resulting from detaching and reattaching the muscles of the forearm. Because of this, other surgeons sought new ways to perform this surgery. One commonly used technique was termed the ASMI-modification of the Jobe Technique. ASMI stand for American Sports Medicine Institute (in Birmingham, AL) and this modification was initially described by Dr. James Andrews and colleagues. This involved similar bone tunnels, but the main difference was in the way that the muscles were treated. Rather than detaching the muscle and reattaching at the end of the surgery, in the ASMI technique the muscle was lifted up (and not detached) and the work was done underneath the muscle. The ulnar nerve is transposed when this technique is used (like the Jobe technique). The passing and fixation of the graft is essentially identical to the Jobe Technique as well. Another commonly used technique is called the ‘docking method’. There are a couple of main differences between the docking method and ASMI method. First, the docking method utilizes a ‘muscle-splitting’ approach rather than a ‘muscle-lifting’ approach like the AMSI technique (see figure). This means that the muscle is divided between its fibers and a ‘window’ is created in the muscle in order to see the torn UCL and make the tunnels. There is also a difference in the way the tunnels are made. In the ASMI technique, the tunnels are the same size all the way through, and the graft tissue is passed all the way through the tunnels. In the docking technique, the tunnel on the ulna side is the same. But on the humeral side, the tunnels are sort-of half tunnels with smaller tunnels continuing on through the back side of the bone. This is because the graft is fixed in a different way- there are strong stitches that are attached to the ends of the graft that pull each end into the large tunnels. The stitches then pass through the small portion of the tunnels and are tied behind the bone, which secures the graft in place. This technique does not require transposition of the ulnar nerve, which is an advantage because less handling of the nerve generally means less risk of trouble with the nerve after surgery. There are a handful of other techniques that are slight variations on these themes, primarily using different devices such as anchors, interference screws or metal buttons to achieve graft fixation. There have been a number of cadaver biomechanical studies done that have compared methods, and they have been found to be largely equivalent. There seems to be a smaller incidence of ulnar nerve symptoms after surgery when the nerve is not handled/transposed (which makes some sense). The return to play rates are very similar regardless of which technique is used, with perhaps a slight favor to docking technique depending on the study. I trained with Dr. Andrews, and performed nearly 100 UCL reconstruction cases during my fellowship using the ASMI technique. In my own practice, I tend to use the docking technique most commonly. I do this because I would prefer not to transpose the nerve if I don’t have to in order to decrease the likelihood of nerve problems after surgery. We also saw some problems with fracture of the bone near the humeral tunnels when using the ASMI technique, and using the docking technique allows us to make smaller tunnels. This makes fracture in this area less likely. That said, Dr. Andrews has had (and continues to have) tremendous success using this technique. As we have learned more about this type of surgery, it has become clear that it is important that the bone tunnels be made very accurately, as improperly placed tunnels seem to be a risk factor for inability to return to full participation. There has also been some investigation as to whether addition of PRP or other biologics to the reconstruction area at the time of surgery makes a difference in healing speed or strength. At this time, I am not aware that any research has shown a difference. If anyone has managed to make it this far without falling asleep, I hope you found this discussion interesting. Feel free to leave a comment below if you have additional questions. Thanks for reading. Safe wishes to you and your families.