In 1974 Dr. Jobe estimated Tommy John's chance of regaining form was 1 in 100-NY Times

3/7/14, "A Revolutionary Surgery, Now as Typical as a Sinker," NY Times, Mike Tierney, "How Tommy John Surgery Has Evolved Since Frank Jobe"

Tommy John in 1989, had surgery in 1974

"Pitchers who had Tommy John surgery might have felt like raising a toast to Dr. Frank Jobe on Thursday night. But that very motion might not have been possible, at least without triggering elbow pain, if not for Jobe’s pioneering technique. 

Jobe, who died Thursday at 88, began an almost quixotic bid in 1974 to prolong the career of a major league pitcher. The successful treatment, more technically known as ulnar collateral ligament reconstruction, now extends to pitchers at multiple levels of the game, as well as tennis players and javelin throwers, from athletes as young as 14 to those nearing retirement. 

In the past four decades, advancements in the operation — which involves grafting a tendon from the forearm into the elbow to act as a ligament — and the rehabilitation process have cut the standard recovery period nearly in half.

Given the virtually year-round demands on pitchers that can increase stress on their arms, the need for Tommy John surgery has never been more pronounced.

“With the number of people playing overhead sports who have an injury to the U.C.L., this is an international phenomenon, allowing athletes from all over the world to keep up their level of play,” said Dr. Bradford Parsons, the chief of shoulder surgery at the Icahn School of Medicine at Mount Sinai in New York.

Dr. David Altchek, the medical director for the Mets and a co-chief in the Sports Medicine & Shoulder Service at the Hospital for Special Surgery in New York, said baseball patients were amazed to learn that the condition was not caused by an improper pitching style. 

“Really, really good technique increases it the most,” he said, adding that as players got bigger and stronger, the need for surgery would only increase.

The efficiency of the operation has prompted some parents of teenage athletes to ask whether the procedure is appropriate without a diagnosis of a torn ligament, based partly on an assumption that the operation improves arm strength. 

Dr. Spero Karas, the director of the Emory Orthopaedic Sports Medicine Fellowship Program in Atlanta, said he discouraged surgery for anything short of fixing a tear of the ligament. 

At the same time, he said he was not surprised that more athletes, especially pitchers, were having the operation.

“Kids are superspecialized now,” Karas said. “As the pressure to excel increases, where livelihoods depend on a player’s success, driving guys into the ground becomes unfortunately all too common.”

In 1974, Jobe estimated that John’s chance of regaining his form was 1 in 100. Current studies suggest a rate of success, generally defined as an athlete’s reaching the same plane for at least one season, of more than 80 percent.

“We think it’s a very successful surgery, especially given where it has come in a short period of time,” said Dr. Frederick Azar, chief of staff at Campbell Clinic Orthopaedics in Memphis. “It’s a lot better operation from where it started out.”

It has evolved to where surgeons can select from several approaches. 

One option, developed by Altchek, is known as the docking technique, in which fewer holes are drilled in the humerus bone and the graft is looped in differently. The docking approach also uses a less invasive tactic known as muscle-splitting, in which the surgeon enters the affected area between muscles rather than removing and later reattaching a muscle.

Altchek said the approach achieved “the same thing with a little less trauma for the athlete.” 

Dr. James Andrews of Birmingham, Ala., is perhaps the most renowned active surgeon associated with Tommy John surgery and has been credited with helping to advance the treatment. But surgeons’ approaches are often based largely on their comfort levels.

“I liken it to a golfer with his ball 3 feet off the green,” Karas said, adding that putting or chipping from that distance could be equally effective.

The operation does raise questions, including whether the elbow winds up stronger than before.

The inserted tendon that replaces the damaged ligament is stronger, doctors agree, but most say it is unclear if the elbow’s biomechanics become upgraded.

Athletes often convince themselves that is the case, although the feeling may be explained more by high-degree exercises and treatment of the elbow that the athlete was not previously receiving.

Further shortening the time frame for recovery remains “probably the next hurdle to leap over,” Azar said. He added, “We are happy with it now, but we’d like to trim it down.”

Attempts to accelerate rehab have mostly misfired.

“A lot of us have tried to push this envelope, and we’ve failed,” Altchek said. At some point, the thinking goes, the body must heal at its own pace.

“But when you compare how far we’ve come in 40 years, that’s pretty good,” Karas said, alluding to the 18 months of rehabilitation John needed. With some pitchers, depending on when the surgery was conducted, “we’ve given them a year back,” Karas said.

Doctors who were acquainted with Jobe said they would remember him as much for his unwavering care for each patient and his humility as for his contribution to sports medicine."...image, "Tommy John pitching for the Yankees in 1989, 15 years after Dr. Frank Jobe repaired his elbow. John, who had won 124 games before the pioneering surgery, went on to win 164 more. Credit Stephen Dunn/Allsport"

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