When pitcher Michael Maness went under anesthesia on the operating table of Dr. George Paletta in St. Louis last August, he wasn't sure what he was in for.
Maness knew the ulnar collateral ligament in his right elbow needed to be fixed. But neither Maness nor Paletta knew just how broken the ligament was, or whether or not Maness would qualify for an experimental procedure known as a "primary repair" that can cut the 12- to 18-month recovery time for traditional Tommy John surgery in half.
"I remember coming to and asking which one they were able to perform, and he told me the primary," Maness said. "I was looking forward to a shorter time to get back on the field."
Maness, who was released by the Cardinals last December, pitched for interested teams just six months after surgery, signed with the Royals in February and made his big league return in just nine months.
The procedure that saved Maness so much time utilizes a 10-year-old product called SutureTape, made by the orthopedic medical device company Arthrex. SutureTape is a flat, braided, ultra-high-molecular-weight polyethylene, bovine-collagen-dipped version of a typically round super suture that looks much like a shoelace. It has been used most extensively for repairs of the anterior talofibular ligament in the ankle by Scottish orthopedic Dr. Gordon Mackay over the past decade. Recently, it has also been incorporated into ligament repairs in the thumb, wrist, shoulder and knee.
Mackay pioneered a technique known as the "internal brace," in which the SutureTape is attached to two screws inserted into the bones at each end of a ligament or tendon, providing a framework against which the ligament or tendon can heal. Imagine a tomato plant (the injured tissue) supported by a tomato stake (the SutureTape). Because the SutureTape is porous, the damaged ligament or tendon grows through the lattice of the SutureTape, and is supported by it.
Prior to the use of SutureTape, elbow UCL repair surgeries in which the ligament was sewn or sutured back to the bone -- rather than fully reconstructed as in Tommy John surgery -- were not very effective. A 1992 article detailed the results of all UCL surgeries done by Dr. Frank Jobe, who was the pioneering doctor who performed surgery on Dodgers pitcher Tommy John. Only seven of 14 patients who underwent repairs returned to their former level of play, and of those 14, only two of seven players (29 percent) returned to MLB.
By dramatic contrast, the well-known and universally-utilized UCL reconstruction now known as Tommy John surgery is 86-percent effective; that is, in 86 percent of cases, pitchers return to their previous level of competition. In a reconstruction, the damaged UCL is removed and replaced with a tendon graft from the patient's wrist or hamstring, and it is the complexity of this procedure that mandates a lengthy recovery. Because of the historically low success rate with UCL repairs, all patients with damaged UCLs have undergone Tommy John surgery, regardless of the status of their ligament. That is, until now.
"The spectrum of what we would see when we cut into the ligaments was so broad," said Dr. Jeff Dugas of the American Sports Medicine Institute in Birmingham, Ala. "Some, you think, 'Gosh, this really isn't much injury and the ligament tissue is good, and it stinks that this little bit of injury is causing this kind of a problem.' And some, you think, 'Wow, this is really crappy tissue, and I can't believe this guy was throwing with this stuff.' And then, there's everything in between. The real conception of the idea for the internal brace was for those lower-level injuries, because we only had one hammer for all the different nails we were seeing."
Based on a UCL repair technique using suture anchors developed by Dr. Felix "Buddy" Savoie of Tulane University, and incorporating the internal brace technique used by Mackay, Dugas developed a procedure that could be used to repair the UCL. But Dugas is quick to point out that this is not a magic bullet and cannot be used in all UCL surgeries; the procedure works well with end-avulsions of the UCL, in which the ligament has pulled away from the bone, but does not work well with mid-substance tears, in which the ligament is torn at its center.
Imagine the UCL as a rope. If it's a pretty new-looking rope that just happened to snap at the end and you'd still use it to tie your expensive yacht to the dock, it can probably be repaired with SutureTape. But if its an old, frayed, salt-crusted rope that looks like it might snap on the next wave, it probably needs to be reconstructed. The problem is, the surgeon needs to see and feel the UCL to make this decision; MRIs just aren't detailed enough.
"We consent every patient for both procedures and then make a game-time decision," Dugas said. "You have to see where the injury is geographically, and you have to know what is the quality of the tissue. If the tissue is good quality, if they have a good ligament and they just tore it, and it's torn on the end, you can repair it and it works well. If the tissue is cranky and has been injured over time, and is just not healthy, I don't think the tape will hold up in that setting."
Dugas did his first internal brace UCL repair in August 2013, and he has done approximately 160 since then. The return time averages six to seven months, because with the internal brace acting as a backup to the ligament, the pitcher can begin moving and start his rehab much sooner than in a traditional reconstruction. According to Kevin Wilk, rehab coordinator at ASMI, rehab speeds up dramatically after the first month of healing. Plyometrics can be done at eight weeks, instead of 12. Single-arm exercises can be done at two and a half months, instead of four. Throwing programs begin at three months, instead of six to nine.
Currently, Maness is the only big leaguer with a UCL repaired with SutureTape, mostly because by the time a pitcher reaches the big leagues and tears his UCL, his ligament is already too damaged for a primary repair, and it must be reconstructed. However, Maness is not the only big leaguer on the field with SutureTape inside him.
Dr. Steven Shin, a hand surgeon at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, has been repairing the UCL in the thumb with SutureTape and the internal brace method for several years. Last May, Shin used it to repair Angels shortstop Andrelton Simmons' left thumb UCL, also with good results and an expedited recovery over the traditional surgery.
"Return to play, depending on sport, position and hand dominance, is usually two to three months," Shin says. "Six to eight weeks would be very fast. We had Simmons sent to his rehab assignment at four weeks. Every day, every game, matters to these guys and to their teams. So to be able to save a month is huge."
Most recently, Shin repaired the left thumb of Simmons' All-Star teammate Michael Trout using the internal brace method. He should be on a timeline similar to that of Simmons.
Dugas and Shin both agree that the internal brace method may also prevent recurring injury ligaments over time, because the SutureTape adds immediate strength and does not disintegrate.
While Maness is a trailblazer, whether he thinks so or not, Dugas is reluctant to dub this procedure the future of Tommy John surgery. It is not, he says, about the level of baseball a patient plays, or how hard he throws or how old he is. It is simply about whether or not a patient has the right injury and timeframe for recovery, because at the moment, the procedure is simply too new to be certain of its long-term success. A pitcher one year into a five-year MLB contract is statistically better off to go with the tried-and-true reconstruction.
"We have a lot more experience with regular Tommy John surgery, which is a great operation with great results, and is proven at the MLB level," Dugas says. "I have been really sticky about who I will do this new operation on, because I don't want to expand the indications to someone with bad tissue or someone with a mid-substance rupture. I don't think this will replace Tommy John surgery, and I don't think it should."