Dr. Jeff Dugas has scrubbed in for about 2,000 surgeries on the ulnar collateral ligament of the elbow. He reconstructs the injured ligament with a tendon grafted from the patient's forearm or leg. All sorts of athletes come in for the operation—wrestlers, javelin throwers, gymnasts—but most frequently they are pitchers. The surgery is even named after a pitcher, Tommy John, the Los Angeles Dodgers southpaw who had the first successful procedure in 1974.
Four decades later, organized baseball is in the midst of an epidemic of arm injuries as a result of overuse, according to the American Sports Medicine Institute. Front and center is the UCL. Tommy John surgery has almost become routine in professional baseball. As Dugas started opening up more and more elbows, he would look at the UCL and think, Why are we here?
While an MRI might reveal something wrong with the UCL, it would not always reveal the severity of that problem, meaning that surgery would be required and doctors like Dugas would have no choice but to completely reconstruct the elbow. Big league pitchers were missing whole seasons because of partial tears. It was like repainting the whole car because of a scratch on the hood.
In general, pitchers are eventually able to regain their velocity after Tommy John, but it's a long and laborious process. The inserted tendon, which formerly made its living attached to a muscle, must learn to behave like a ligament and adhere to a bone. Nevertheless, elbow reconstruction has been the path for 43 years, leaving scores of pitchers with the telltale scar shaped like a smiley face on the inside of their elbow.
In 2012, the same year a record 36 pitchers had the procedure, Dugas started to wonder if a less invasive surgery were possible. Could there be a repair of the ligament that would cut rehabilitation to five or six months, instead of the usual 12 to 18?
Dugas has an undergraduate degree in chemical engineering from North Carolina State, and he decided to put it to use in order to try to find out. If he succeeded, it would change the game.
In January 2013, 17-year-old pitcher Mark Johnson began to feel pain in his left elbow just prior to the start of his junior season at Carroll High School in Ozark, Alabama.
"Like someone shot me with a little BB," he said.
That season, Johnson noticed that his velocity had decreased. This was a dire predicament for Johnson, who was obsessed with baseball. He was not a professional prospect by any means, but that hardly mattered.
"I had no other hobbies but baseball."
After the season, when he tried to pitch American Legion summer ball, Johnson's elbow throbbed with pain. By July, he couldn't even throw a ball, much less pitch in a game. He feared the worst. Without much of a professional career to look forward to, losing his senior season to major surgery likely meant losing the last bit of real competitive baseball he was going to play for the rest of his life.
In August 2013, Johnson set up an appointment with Dugas, who had performed shoulder surgery on him the year before. During that appointment, Dugas did mention that Tommy John surgery was a possibility, but he also raised the option of a new experimental procedure. What if they repaired the ligament instead of replacing it? Dugas explained that such a procedure was likely to cut recovery time in half.
Obviously, Johnson was receptive.
There was uncertainty, Dugas told Johnson. The doctor wouldn't be sure that Johnson's UCL could be repaired until an incision was made and he got a closer look at the injury. Moreover, Dugas had never performed the repair procedure on a pitcher before. The last time UCL repairs had been tried on pitchers was in the 1980s, and it failed.
Still, Johnson would not be dissuaded.
Dugas had been a pitcher himself in high school and walked on at North Carolina State. He mostly threw batting practice for the Wolfpack, but he enjoyed the game so much that it was fine with him to just practice and have a place on the bench for games. After N.C. State, he went to medical school at Duke.
In 1999, after training at the Hospital for Special Surgery in New York, he accepted a fellowship with the man who would become his mentor: Dr. James Andrews. Andrews is a household name in the baseball world, and considered a foremost practitioner of Tommy John surgery. Now Dugas and another surgeon, Lyle Cain, are partners in Andrews' practice in Alabama, Andrews Sports Medicine & Orthopaedic Center, which is where Dugas decided to finally do something about over-reconstruction of torn UCLs.
Dugas credits Dr. Felix "Buddy" Savoie of Tulane University for developing a method to repair the UCL using anchors. Savoie published two papers on the procedure, in 2006 and 2008, but they did not receive any mainstream attention.
Dugas called Savoie in early 2013. Another surgeon over in Scotland, Gordon Mackay, was using a supporting tape in ankle surgery, an innovation known as the Internal Brace. Could something similar be done using Savoie's anchors and a different type of tape in elbows?
Savoie believed that it could. That February, Dugas and King started testing a construct of anchors and a bovine collagen tape that is strong enough to pull a car. Using elbows from cadavers, they put the anchors-tape construct through maneuvers on a machine that tests stress and tension.
They completed their experiments in June. The machine tests showed Dugas that an anchors-tape construct could be "at least as good" as the full reconstruction of an elbow with grafted tendon and anchors.
At that point, Dugas said, "I just needed the right patient to walk through the door."
By "right person," Dugas meant a pitcher, or another athlete, with a moderately diseased or worn UCL. It couldn't be too messed up—a UCL that was a gelatinous pile of crud would have to undergo reconstruction, not repair. Due to the limitations with imaging that caused the rash of TJ surgeries in the first place, Dugas would have to make a game-time decision on which patients could be candidates for the experimental procedure. You have to see the ligament exposed to know whether you can repair it or you need to reconstruct.
"What we were looking for was a way to fix these things in younger, less injured, less clinically affected elbows that would give them the ability to return to play a little quicker," Dugas said. "TJ is 12 months plus."
And that's when the 17-year-old Johnson came in.
A gym rat of a baseball player, Johnson lived to pitch for his high school team, but his elbow injury had jeopardized his senior season. A reconstruction—traditional Tommy John surgery—would have meant missing the season. A repair meant he could play.
Dugas wouldn't know which would be possible, however, until he started operating. The date was set for on August 8, 2013. Prior to surgery, Johnson's mother had to sign two consent forms, which would allow Dugas to either repair or reconstruct the elbow, whichever was needed.
When Dugas opened up Johnson's left elbow, he was elated. The UCL was repairable. Mark Johnson would be Patient No. 1 for Dugas' procedure.
Just five months later, Johnson was throwing full velocity off a mound at Troy University, where a team of trainers was aggressively rehabbing his elbow.
"They sent me a five-minute video of Mark throwing full velocity at five months," Dugas said. "I wasn't ready to see that. I almost threw up."
Johnson recovered enough to be the starting pitcher for Carroll High School in their season opener in January 2014. He pitched in nine games that year.
"He saved my senior season," said Johnson, now 20 and a firefighter in the Ozark area. "I could have never gotten that back. I have memories now of my senior year pitching. And I can pitch batting practice to my (youth) team now."
Johnson's swift recovery challenges the conventional wisdom about surgery on the UCL. Since Tommy John had the first reconstruction while he was with the Dodgers, recovery has typically been 12 to 15 months. Some major league organizations are now stretching TJ rehabilitation to 18 months, just to be sure the elbow has healed properly.
Two years ago, Oakland Athletics general manager Billy Beane sat down next to Dugas at the Southeastern Conference baseball tournament and asked Dugas why he had not operated on high-profile pitchers. Dugas told Beane that more data had to be collected and there had to be caution.
"Good answer, Doc," Dugas recalled Beane saying.
"I wanted to make sure we would get these people back before we did any more," said Dugas. "I didn't do another one for six months. Mark Johnson was pitching full velocity in five months with no pain. We would normally not let a Tommy John throw for 18 weeks. This kid was back on the mound doing bullpens before that."
Research by American Sports Medicine Institute has found that about 80 percent of pitchers who undergo UCL reconstruction return to the same level of performance pre-surgery. Dugas expects the success rate of the new procedure to be as high or higher. At the same time, he emphasized the need to be realistic about what the repair can do.
"We have very, very carefully said this is not the greatest thing ever and that this is going to replace Tommy John surgery, we are not saying that," Dugas said. Often, major league pitchers may have too much disease in the elbow for a repair to work. "If it never helps a major league athlete, fine, because 75 percent of the ligaments we are operating on are not major league baseball players or high-level D-1 pitchers."
Dugas says he has done 160 repairs to date. He flipped through his phone to read thank you notes from parents whose children in other sports have been brought back to full health sooner, and just as safely.
Now Dugas' taping technique is making its way into Major League Baseball. Seth Maness, a 28-year-old relief pitcher in the Kansas City Royals organization, had the surgery in August 2016. Dr. George Paletta, a friend of Dugas', performed the operation.
The Royals have since called Maness up to the big leagues. He pitched for the first time on May 14, less than nine months after his UCL repair. He gave up a home run, but was credited with a win.
"We are watching him very closely," Dugas said.
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