Dr. Neal ElAttrache: Tommy John concept 'hasn't changed' much over last 50 years

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In September 1974, Frank Jobe, MD, performed the first Tommy John surgery, which is now one of the most common procedures among baseball players. And in 2024, one of Dr. Jobe's students, Neal ElAttrache, MD, is looking ahead to the procedure's next evolutions.

Tommy John surgery, which is used to repair a torn ulnar collateral ligament, has saved the careers of several MLB athletes. Today, more than 25% of MLB pitchers have had or need Tommy John surgery, Dr. ElAttrache said. 

"The operation itself has changed in small detailed ways," Dr. ElAttrache told Becker's. "But the overall concept and philosophy primarily has not changed. It's remarkable that over 50 years, the concept really hasn't changed very much."

Another thing that has changed is how baseball pitchers throw, and it's something Dr. ElAttrache and his peers are watching closely.

"The demands of the patients that we're doing it on have changed," he said. "Some of the ways that a few of us have enhanced the operation is in response to the increasing demands and forces and the violent nature of what's happening to a greater degree to that ligament in the athletes that we're dealing with."

When Dr. Jobe developed Tommy John surgery, baseball teams had a handful of pitchers throwing balls at average speeds of mid-90 miles per hour, Dr. ElAttrache said. Now MLB teams have several players who regularly throw balls at at least 100 miles per hour.

It was previously more common for baseball teams to strategize when pitchers would unleash their maximum effort, Dr. ElAttrache said. But now he's also seeing baseball players adding spin to their fast throws by either sharply pronating or supinating their forearms, adding force to their elbows.

"The ability to throw harder with higher velocity has increased since 1974," he said. "The potential damage to that ligament has increased. The incidence of injury to that ligament has increased, and the potential for failure and retear of the reconstruction after you've done it has increased."

As the demands of pitchers evolved, so has the way orthopedic surgeons think about Tommy John surgery, Dr. ElAttrache said.

"We're continuously looking for ways to enhance the operation to make it more durable and do it so that it's strong and that the graft tissue that we're putting in there doesn't have to experience all those forces all by itself," he said. "So we're looking for ways to share the load produced by pitching or throwing between other materials to help share the load so that as the graft is maturing, the tendon is maturing and turning into a ligament. It's not getting damaged in the process."

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