The new alternative to Tommy John surgery

The certainties of life: Death, taxes, the annual flooding of Minot, North Dakota, and the elbow pain from your favorite pitcher being merely a euphemism for a torn ulnar collateral ligament. We have heard of hundreds of pitchers over the years that have underwent the knife for ulnar collateral ligament reconstruction, which we also know colloquially as Tommy John surgery.

Entering through the elbow, holes are drilled in the bones where the ligament once was located. A tendon - often from the wrist, leg, or even a cadaver - is threaded and tied through the holes. With time, the body assimilates the tendon into a makeshift ligament, allowing the pitcher to function as he did before the injury. The recovery time is roughly one year, though some pitchers (Mike Pelfrey) come back a few months early and others (too many to name) sometimes take longer, either due to setbacks or as a precautionary measure.

Due to the yearlong recovery, many players attempt to stave off surgery for as long as they can. Though it’s frustrating as very few players are actually successful with avoiding surgery, players and doctors often go that route in the hopes that taking just a couple months off is all that was necessary for the ligament to heal, rather than the full year. Albert Pujols and Masahiro Tanaka are two current players that avoided surgery and managed to continue playing despite suffering damaged UCLs.

However, Pujols and Tanaka are just two players among hundreds that unsuccessfully rehabbed their torn UCLs. Enter former St. Louis Cardinal Seth Maness. A sinkerballing reliever, the 28-year old Maness relied on grounders and impeccable control to retire hitters. His 2017 season though saw his strikeout rate shrink to minuscule levels and his control regressed from elite to merely above-average. Though there wasn’t that familiar “pop” in the elbow, it was eventually discovered that Maness had suffered significant damage to his UCL.

Tommy John surgery is the go-to for repairing the UCL, but Dr. George Paletta told Maness that he was a candidate for the UCL repair with internal brace construction surgery, or “primary repair.” Paletta, an orthopedic surgeon in St. Louis, had done the surgery on many high school and college pitchers, along with fellow Cardinal Mitch Harris this past year as well, but it had never been done on an established major leaguer.

Instead of introducing a tendon into the elbow, primary repair is, well, a repair of the ligament near the bone. That’s the critical piece in order to be a candidate for the surgery; if the UCL is damaged near the bone, primary repair is an option. If the tear occurred in the middle of the UCL, you’re stuck with Tommy John.

The surgery entails repairing the ligament and then anchoring it to the bone. A brace system is then introduced inside the elbow by using Arthrex tape, an ultra-high strength 2-millimeter wide tape. According to Paletta, there have been no failures among his 50+ cases of primary repair. Likewise, Dr. Jeffrey Dugas, who works with Dr. James Andrews (perhaps the most famous doctor for performing Tommy John surgeries) has done around 150 primary repairs of his own and claims that none have required a second repair or subsequent Tommy John surgery.

Since primary repair doesn’t require the body to adapt to the improvised ligament from Tommy John surgery, the recovery period is five to six months less. Maness underwent his primary repair in mid-August and has been throwing this offseason in the hopes of securing a major league contract after being non-tendered by the Cardinals. Understandably, teams have been cautious over guaranteeing even a million dollars to a pitcher that relied on smoke and mirrors for his success and hasn’t proven that he’s fully recuperated from his operation. A minor league deal is likely in his future, but Maness has the chance to become the first major leaguer to pitch in a game after undergoing primary repair of his UCL.

Although the surgery cannot be performed on every pitcher with damage to his UCL, Maness has the chance to demonstrate that it could be a worthwhile alternative to the full UCL reconstruction surgery. Any amount of success this season or even over the next couple years could lead to us dubbing Maness as this generation’s Tommy John.