What Tommy John surgery looks like today: Revision surgeries, internal brace

In baseball, the words “Tommy John surgery” are uttered every day. And with a rash of injuries sidelining stars around the league, we are hearing the phrase more than ever. The number of injuries to pitchers’ ulnar collateral ligaments keeps rising, an epidemic swallowing the sport and leading to changes in the surgical landscape. But it’s no longer as simple as a pitcher tearing his ligament, going under the knife, and returning a little over a year later. Now there are many pitchers undergoing second, or even third, surgeries, known as revisions, with slightly different techniques and recovery times at play. And many players are gravitating towards a newer option, the internal brace procedure, which is adding a dimension to a seemingly familiar landscape. One thing is clear: Tommy John surgery, in its various forms, is going to continue to be an important part of baseball for the foreseeable future.

What is Tommy John surgery, exactly?

The ulnar collateral ligament is located on the inside of the elbow, attaching the upper bone of the arm, the humerus, to a forearm bone, the ulna. When a pitcher suffers an injury to their UCL, they may sometimes choose a conservative treatment plan, often consisting of rest and plasma-rich platelet injections. In many cases, this is simply delaying the inevitable.

“We often try it because there’s really nothing to lose with it,” said Eric Bowman, an orthopedic surgeon and the head team physician for the Vanderbilt Commodores and Triple-A Nashville Sounds. “There’s very little downside to it. It has growth factors and we hope that it provides a healing stimulus. But at least the data we currently have doesn’t really point to it being a huge boost for conservative treatment.”

Especially in the cases of substantive tears to the ligament, a full reconstruction is often required. The procedure we now know as Tommy John surgery originated in 1974, when orthopedic surgeon Frank Jobe performed the procedure on MLB pitcher Tommy John. The surgery involves replacing the existing UCL with a graft usually harvested from either a hamstring tendon, the Palmaris tendon in the forearm or a tendon from a cadaver. Surgeons attach the new tendon by drilling holes in the humerus and the ulna. The graft is then threaded through the two holes and secured by sutures, buttons or screws.

“When players like Sandy Koufax had torn up elbows, they didn’t have a procedure like this,” Bowman said. “When Tommy John was the first one that had it, that was a newer procedure, and all of a sudden we were able to get these players back to playing.”

Why has ‘TJ’ become so common?

At the major-league level, there were 275 pitchers who had Tommy John surgery last season, up from 190 in 2016.

But surgeons in the industry indicate the largest increases in UCL injuries are actually seen at the youth level. Tommy John surgery was once nearly unheard of for high school players. Now it is becoming common. As far…