Tommy John, the former MLB pitcher whose name became synonymous with ulnar collateral ligament reconstruction, died Aug. 15 at age 83. But the procedure that bears his name traces its medical legacy to orthopedic surgeon Frank Jobe, MD, and generations of orthopedic surgeons who have refined his groundbreaking operation over the last five decades.
Mr. John tore the UCL in his left elbow while pitching for the MLB’s Los Angeles Dodgers in July 1974. At the time, significant arm surgery for a pitcher was rare and potentially career-ending, and his injury was so severe that continuing to pitch would require a procedure that had never been attempted on a baseball player.
Dr. Jobe performed the operation Sept. 25, 1974, replacing Mr. John’s damaged ligament with a tendon taken from his right wrist. He drilled holes into the humerus and ulna and passed the graft through them in a figure-eight configuration. Dr. Jobe initially placed Mr. John’s chances of pitching again at about 1%. John returned to the majors in April 1976.
The operation became known as Tommy John surgery, but the procedure itself has been shaped by several generations of orthopedic surgeons.
Dr. Frank Jobe establishes the foundation
Dr. Jobe, along with orthopedic surgeons Herbert Stark, MD, and Stephen Lombardo, MD, published their early experience with UCL reconstruction in a landmark 1986 study. They reported on 16 throwing athletes who underwent reconstruction using a free tendon graft; 10 returned to their previous level of competition. The study also identified ulnar nerve complications that would help drive later modifications to the operation.
Surgeons refine Dr. Jobe’s original technique
The fundamental idea of replacing a deficient UCL with a tendon graft endured, but surgeons began changing how they accessed the ligament and managed the surrounding muscles, bone and ulnar nerve.
A major modification came with a muscle-splitting approach that avoided lifting the flexor-pronator muscle from the bone and made ulnar nerve transposition selective rather than routine. A 2024 review of the procedure’s evolution identified flexor-pronator management, ulnar nerve management, graft selection and fixation as key areas in which the operation evolved after Dr. Jobe’s original technique.
Advancing the docking technique
Another milestone came in 2002, when orthopedic surgeons David Altchek, MD, Joel Rohrbough, MD, and colleagues published the docking technique.
The approach used a muscle-splitting exposure without routine ulnar nerve transposition and docked the graft ends into a single humeral tunnel. It was designed to simplify graft tensioning and fixation while reducing disruption of surrounding structures. In the initial series, 33 of 36 athletes returned to or exceeded their previous level of competition.
Dr. Neal ElAttrache carries Dr. Jobe’s mentoring forward
Neal ElAttrache, MD, provides one of the clearest direct connections between Dr. Jobe’s original work and modern sports medicine.
Dr. ElAttrache came to Los Angeles in 1990 for a sports medicine fellowship to train with Dr. Jobe, Robert Kerlan, MD, and other physicians at Los Angeles-based Kerlan-Jobe Orthopaedic Clinic. He ultimately remained with the practice and built his career there.
Dr. ElAttrache also became part of the procedure’s technical evolution. The DANE TJ technique, referring to Dr. Altchek, Dr. ElAttrache and Mr. John, combines docking fixation on the humeral side with interference-screw fixation on the ulna. Clinical results published in 2007 found excellent outcomes in 19 of 22 athletes treated with the technique.
On the procedure’s 50th anniversary in 2024, Dr. ElAttrache told Becker’s that although the operation has changed in technical details, its underlying concept and philosophy have remained largely intact. What has changed substantially, he said, are the demands placed on pitchers’ elbows as throwing velocity and force have increased.
That shift has led surgeons to look increasingly at ways to share the load placed on a reconstructed ligament while the graft matures.
Internal bracing expands options
Another major development has been the emergence of UCL repair with internal-brace augmentation for select athletes.
Orthopedic sports medicine surgeon Jeffrey Dugas, MD, has been among the surgeons advancing the approach. Instead of replacing the entire ligament with a tendon graft, surgeons can repair suitable native UCL tissue and reinforce it with suture tape.
Becker’s examined the emergence of UCL repair with internal bracing in 2017 and followed Dr. Dugas’ research in 2019. In his 2019 study, 92% of athletes seeking to return to the same or a higher level of competition did so, at an average of 6.7 months.
Repair is not a replacement for reconstruction in every patient. Tissue quality, tear location and chronicity are important in determining which procedure is appropriate. A 2026 review of UCL injury management continues to identify reconstruction as an important treatment for UCL tears while highlighting internal-brace repair as an option for appropriately selected injuries.
Hybrid reconstruction
Surgeons have also begun combining traditional reconstruction with internal-brace augmentation.
Hybrid UCL reconstruction pairs a tendon graft with additional suture support intended to share forces across the healing reconstruction. Orthopedic surgeon and sports medicine specialist Keith Meister, MD, is among the surgeons using hybrid reconstruction in professional baseball.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
