Of the 4,000 ulnar collateral ligament reconstruction surgeries that have been performed on Major League Baseball players since the procedures inception in 1974, nearly one-third of them have been performed in the last five years, but industry-wide the field is in the middle of an innovation cycle.
For total UCL tears, surgery remains the only option, but the future of partial reconstruction could look very different than it does today.
Neal ElAttrache, MD, of the Kerlan-Jobe Orthopaedic Clinic; Steve Jordan, MD, of the Andrews Institute for Orthopaedics and Sports Medicine; and Luga Podesta, MD, director of sports medicine at St. Charles Orthopedics in Port Jefferson, N.Y., shared their thoughts on what the future of partial UCL reconstruction could look like.
The current state of Tommy John isn't drastically different from when Frank Jobe, MD, performed the first procedure in 1974. Advances have been made and techniques have drastically changed from when Dr. Jobe performed the first surgery, but the treatment for total UCL tears remains the same; surgery.
Surgery has been successful, and in the MLB it's the gold standard when it comes to total tears. That is because its success has been replicated and documented. A pitcher can go in, get the surgery, recover and — if everything goes right — be back on the mound in the future. Baseball teams know the time table related to Tommy John surgery and the recovery process remains somewhat consistent with variation on a case-by-case basis.
Treatment for partial UCL tears is where orthopedic surgeons are starting to innovate. Platelet rich plasma and stem cell treatments are being used in an experimental basis to treat the tears, and regrow the UCL ligament with the body's own tissue.
"It's experimental but exciting," Dr. Jordan says.
Like any new treatment it isn't without its critics. Dr. Jordan says skeptics of PRP often refer to the treatment as "promising rarely proven." Although some orthopedic surgeons are seeing success rates in the 80 percent range, the entire process is still a big question mark, because of differing approaches to the treatment and a lack of published studies.
"Nobody really knows how long to make guys wait," Dr. Jordan says. "Right now it's about 12 weeks before a person starts throwing, and nobody knows exactly how many shots to do. Is it one shot every three weeks, or is it something else? That's the thing we're still trying to sort it out."
Dr. ElAttrache echoed Dr. Jordan's statement. "We are uncertain about how long we should wait to return to pitching after injection, and how long and how well the ligament will withstand the stress of returning to pitching."
Dr. Jordan says the Andrews Institute is in the midst of a study that shows when the UCL tear is a lesser grade tear, stem cell treatment is a reasonable option with a 75 to 85 percent success rate.
Dr. Podesta and Dr. ElAttrache both mirrored the comments that PRP or stem cell therapy is complicated, but both see upside with the treatment.
Dr. Podesta had a study published in 2013 in the American Journal of Sports Medicine where he demonstrated PRP was an effective option in treating partial UCL tears in athletes. In the study, he treated 34 baseball players from a range of ages, and saw an 88 percent success rate. He admitted that his study lacked a traditional control group, but he went back and treated a patient in a traditional manner and the results were not nearly as successful as those treated with PRP.
"The formulation of the biologic therapy will make a difference in the results of either PRP alone or in combination with Bone Marrow Concentrate," Dr. Podesta says. "Our preliminary results using a combination of PRP with concentrated bone marrow derived stem cells has been very good with an 80 to 85 percent healing rate resulting in returning to throw competitively at 12 to 14 weeks. However, as with the Tommy John reconstruction, the post biologic treatment and rehabilitation is critical. Cell lines and biologic grafts need to be allowed adequate time to absorb and grow, facilitating collagen deposition, cross linking and ultimately tissue proliferation and growth."
Dr. Podesta says he has been recommending the treatment for younger athletes because "We can get that tissue to heal normally … and we're seeing a quicker and stronger response with it."
Dr. Jordan and Dr. ElAttrache have both seen hybrid approaches to the treatment that utilize stem cells.
Dr. ElAttrache has seen a procedure done to younger arms where a surgeon will take a braided collagen-coated ribbon-like suture and use it to create an internal brace. The procedure takes "some of the stress and strain off the healing tissue with this thick ribbon-like suture."
Dr. ElAttrache believes the future of partial tear treatment could be in biological methods, but the procedure still has too many question marks and uncertainties. He says the field needs better studies with valid control groups to accurately assess the value of biologic injections for partial tears.
"When pitching is providing an education or livelihood for an athlete, these patients often have a narrow window of opportunity to recover and return to competition when they get injured," Dr. ElAttrache says. "We must be as educated as possible that our treatment, whether non-operative, biologic or surgical, optimizes their safe and successful return to play without wasting critical time."
Dr. Jordan says injections will continue to work with partial tears, and he feels that they could even benefit the new grafts used in total tears. But the entire treatment still has to clear one final hurdle.
"We've got to get to the point where we can prove it's better than a Tommy John," Dr. Jordan says. "We want to prove that you're going to do three months of therapy and be good to go."
Becker's Spine will publish a follow-up story featuring Dr. ElAttrache, Dr. Jordan and Dr. Podesta examining the rise in Tommy John surgery and the efforts to combat next week.
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