Leon E. Popovitz, MD
Top-Rated Orthopedic Surgeon
Specializing in Arthroscopic Surgery of the Shoulder & Knee.
For appointments 212.759.4553

Tommy John Surgery (UCL Reconstruction)

“Tommy John surgery” was named after the Los Angeles Dodgers’ pitcher, Tommy John, who was the first to undergo the procedure in 1974. More formally known as Medial Ulnar Collateral Ligament (UCL) Reconstruction, the procedure repairs the ulnar collateral ligament and improves elbow instability. Elbow instability is most often caused by a trauma (such as a fall onto an outstretched arm), repetitive stress from participation in an overhead sport (such as baseball or javelin throwing), dislocation, overuse or an elbow deformity.The ulnar collateral ligament is located along the inner side of the elbow and unites the humerus (the upper part of the arm) to the ulna (one of two bones that make up the forearm). When the ligament is torn, a patient may undergo Tommy John surgery to repair the injury.

During the procedure, the orthopedic surgeon will replace the torn ligament with a tissue graft taken from one of the patient’s other tendons. Most commonly, tendons are taken from the wrist, forearm, toe, hamstring, hip, knee or Achilles tendon. In some cases, tissue from a cadaver (a person who has passed away) will be used. This is called an allograft. After the graft has been selected and removed from its current location, sutures are attached to both ends. Next, the surgeon makes an incision along the elbow joint and forearm so he or she can view and access the areas of the elbow and arm necessary to perform the procedure. Then, the surgeon drills holes in the ulna and humerus. The grafts are woven through the holes into their new location and attached to the graft in such a way that allows them to hold the elbow joint in position. Sometimes, to increase the strength and stability of the new ligament, parts of the original, torn ligament are reattached to the tendon graft. After this has been done, the incision is closed with sutures and the elbow is placed in a large bandage and splint.

WHO NEEDS TOMMY JOHN SURGERY?

While Tommy John surgery can help improve elbow instability caused by trauma, dislocation and deformity, athletes who play overhead sports that require throwing (such as college and professional level baseball pitchers) tend to be the most likely to undergo the surgery. Throwing motions that twist and bend the elbow put repetitive strain on the Medial Ulnar Collateral Ligament which, over time, can cause it to fray, tear or become unstable.

Patients with elbow instability who have tried conservative treatments such as rest, ice nonsteroidal anti-inflammatory drugs and physical therapy, without favorable outcomes, may be good candidates for surgery. Athletes who want to resume strenuous throwing may also benefit from the surgery.

A successful operation will improve or eliminate symptoms such as elbow pain during and after throwing activities.

PREPARING FOR SURGERY

Your orthopedic specialist will review your previous treatments and your current condition to determine if UCL Reconstruction would be a beneficial procedure for you. Once the decision to have the surgery has been made, your physician may suggest that you go through a complete physical examination to ensure you are in good enough health to have the operation. During this appointment your doctor may also ask you questions about your medical history, take X-rays, and create a list of all your medications and allergies.

During this visit, it is likely your surgeon will also walk you through what will happen during the procedure. Take the time to ask any questions you may have. Knowing what to expect the day of your operation will help to keep you at ease.

Depending on what type of anesthesia you will be receiving, you may be told not to eat or drink anything after midnight the night before your surgery. Your doctor may also request that you stop taking certain medications before to your procedure, however pre-operative instructions will vary from patient to patient.

On the day of your surgery, you may be asked to arrive a few hours before your operation. Before you are admitted, you will be asked to fill out paperwork. Next, you will be admitted, evaluated by an anesthesiologist and sedated with a general anesthetic. You will sleep throughout the duration of your operation and you will not feel any pain.

POST-OPERATIVE CARE

After the operation has been completed and the anesthesia has worn off, you will wake up in a hospital bed. The majority of people are discharged home after UCL reconstruction surgery.

Your arm will be immobilized with a splint and covered in a bulky dressing. Immobilization gives the surgical wounds time to heal and allows the tendon graft to become less fragile. You may be given medication to help ease the pain at the incision site. Heat and ice can also be used to manage discomfort. In the first few days following your surgery, try to keep your elbow elevated above your heart while sleeping or sitting to avoid swelling and pain. Stack a few pillows on top of each other to create an elevated platform.

If your doctor used sutures to close your surgical incision that do not dissolve on their own, you will need to have the sutures removed 10-14 days after your procedure if performed. Once your physician has told you that you no longer need to wear your immobilization splint, you will likely begin physical therapy to regain your strength and mobility.

POST-OPERATIVE LIMITATIONS

The first few weeks following surgery, the new ligament graft is very fragile. It is important to follow any instructions your care provider has given you regarding immobilization and post-operative limitations. Also, following surgery, certain tasks may be difficult or painful to execute. Such tasks and limitations may include:

  • Work– After surgery you will need to wear a splint. This may make it difficult to use the computer, write or perform other work-related tasks.
  • Eating with the operated arm– Because eating involves bending the elbow to bring food to the mouth, eating with the operated arm may not be possible.
  • Exercise– Do not use the arm that underwent surgery to do any type of exercises or strenuous movements until your doctor gives you clearance to do so. You should also avoid running and jumping. The force of these activities can disrupt the healing process.
  • Driving – Depending on the splint your using and the postoperative medications prescribed, driving may not be permitted.

PHYSICAL THERAPY FOLLOWING SURGERY:

Physical therapy, sometimes referred to as “PT”, typically starts five to seven days after Tommy John Surgery. The tendon graft is very fragile following surgery and transforming it into a functioning ligament requires a slow and steady rebuilding process. Most patients will meet with their physical therapist one or two times per week, up to a year after their surgery. However, specific rehabilitation recommendations will vary from patient to patient.

Goals of physical therapy after Tommy John surgery include:

  • Protecting the elbow and the tendon graft
  • Decreasing elbow pain and inflammation
  • Preventing muscle loss and improving arm, shoulder and core strength
  • Increasing the elbow’s range of motion
  • Returning the patient to their previous level of physical ability
  • Eliminating elbow pain while throwing or doing sport specific drills

When you first start physical therapy, you will likely start off doing gentle exercise modalities such as:

  • Passive Range Of Motion (PROM) – The goal of PROM is to slowly increase a patient’s range of motion while decreasing pain, swelling, and stiffness. During these gentle exercises a physical therapist or a piece of assistive equipment manually moves the patient’s elbow, wrist, hand, and shoulder joints through a series of motions while the patient relaxes.
  • Active Range Of Motion (AROM) exercises– Like PROM, the goal of AROM exercises is to gently increase range of motion and decrease stiffness in the elbow, wrist, hand, and shoulder. AROM consists of strengthening exercises that are done actively with or without assistance from a therapist.
  • Walking on a treadmill
  • Cycling on a stationary bike

Over time you will build up to more active rehabilitation exercises such as:

  • Functional Exercises– These exercises help retrain the body to carry out everyday activities and movements.
  • Throwing Program- The goal of a throwing program is to help patients who plan to return to overhead sports develop proper throwing mechanics and restore their sense of joint positioning.
  • Flexibility, plyometric, conditioning, coordination, aerobic and strengthening exercises– These exercises will help athletes and active patients return to their physical condition prior to surgery and will help prevent future injury.

Your physical therapist may give you exercises to do at home between sessions. Keeping up with prescribed exercises is an important aspect of the healing process and may help to speed the rate of your recovery. Many patients who follow their physical therapy regime carefully are able to return to athletic activities within six months to a year after surgery. However, competitive throwing athletes may require up to a year of rehabilitation before returning to their sport.

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