Understanding Alex Kirilloff's Wrist Surgery

[Lucas Seehafer PT]

The Minnesota Twins announced Sunday morning that promising first baseman Alex Kirilloff will be undergoing his second wrist surgery in as many seasons later next week in California and will miss the remainder of the season.

The Pioneer Press’s Betsy Helfand—among others—relayed that Alex Kirilloff will have his ulna bone shortened during the procedure. The ulna is one of the two bones of the forearm and sits on the inner side when your palms are facing forward and hands are at your side. 

Kirilloff recently received a cortisone injection into his right wrist in an effort to reduce the pain he experienced while swinging and underwent surgery last summer to “separate a bone” from his ulna due to the forearm bone being atypically long as well as the presence of cartilage damage.

The Twins and Kirilloff had been adamant since Spring Training that there has been no evidence of damage in his wrist since he underwent his first procedure despite lingering pain. As such, he was likely dealing with ideopathic ulnar impaction syndrome, a condition in which an individual experiences ulnar-sided wrist pain and reduced wrist range of motion despite a lack of anatomical damage.

As a left-handed batter, Kirilloff’s right wrist undergoes ulnar deviation during each swing. This action pushes the bones of the wrist—specifically the lunate and triquetrum—against the ulna. Additionally, a structure known as the triangular fibrocartilage complex (TFCC)—a mix of dense cartilage and ligaments—sits between the lunate, triquetrum, and ulna. In essence, the TFCC gets sandwiched between the three bones and is subjected to shearing and torsional forces during each swing, which increases the odds of tearing. An abnormally long ulna would only serve to increase the force placed on the TFCC, at least in theory.

The most likely procedure that Kirilloff will have is known as ulnar shortening osteotomy, during which the ulna is fractured, manually shortened, and re-connected with plates and screws. (He will likely also have the TFCC either repaired or shaved.) This procedure reduces pressure on the TFCC and should, again theoretically, reduce the pain Kirilloff experiences with each swing. 

Ulnar shortening osteotomies have shown good promise in the general population, but there exists a dearth of evidence among athletes. As such, it’s unclear how long Kirilloff will remain sidelined, though the Twins are reportedly hopefully he will be ready by Spring Training 2023.

Kirilloff joins Royce Lewis as top Twins prospects who have had back-to-back seasons compromised by season-ending surgery. Kirilloff also missed the 2017 season with Tommy John surgery and the 2020 campaign due to the Covid-19 pandemic.

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[Bob Twins Fan Since 61]

Sucks for Alex and the Twins.

[Linus]

Thanks for this article. Very helpful in understanding this issue. 

[jmlease1]

Really helpful to understand what's going on with Kirilloff and what this surgery means (and doesn't mean).

It's a shame he's having to deal with this. He's a really talented hitter and had a big future with the team either in the OF or at 1B, but if he can't swing the bat effectively for more than a few weeks without pain making him ineffective again that role diminishes quickly. Hopefully this medical intervention will resolve it so he can resume his career as intended. 

Hate to lose him, and we need the offense he can bring when healthy, but if you're injured, you're injured. He wasn't going to be able to have much of an impact if he had tried to keep playing through it and we're too far away from the offseason to make waiting until then a realistic option. Better to deal with it now and hopefully this procedure will be a long-term solution that will keep it from cropping up every few months.

Good luck, Alex. Glad the medical team has come up with a plan!

[Mike Sixel]

Good luck to him! It would be great if he can play baseball.... But I just want him healthy for his sake. 

[Squirrel]

Thanks for the info. Wonder if our resident doctor has more to add? Calling @Heezy1323!

[Kummel]

Such a promising talent.  Best wishes to him and for his full recovery.

[Doctor Gast]

Too bad they hadn't anticipated this specific problem the 1st time as to not have another surgery done and delayed his progress. Speedy recovery to him.

[ashbury]

18 minutes ago, Doctor Gast said:

Too bad they hadn't anticipated this specific problem the 1st time

Doctors generally try the less invasive approaches first.  Cutting off some bone?  Pretty much anybody's last choice.

[D.C Twins]

As I've said in previous posts, his career is in jeopardy. The wrist is a complex and delicate anatomic area which is obviously under repeated stress with MLB swings. 

The hard part of this will be for the surgeons to estimate the accurate amount of shortening needed to optimize (an educated guess no matter how talented they are and there is no way to gauge success until well after the surgery is done). 

 I wish him the absolute best, but am very worried for his future

[gman]

It does sound like last option. A failure with this to me means an end to a very promising career. Good luck to Alex and the doctors with this procedure.

[Doctor Gast]

49 minutes ago, ashbury said:

Doctors generally try the less invasive approaches first.  Cutting off some bone?  Pretty much anybody's last choice.

You are probably right on that. But like Phil Hugh shoulder problem  they've discovered that they weren't cutting off enough, so they end up cutting off more now, w'/ great results. I'd hope that they've learned and try harder to solve the problem than prolonging one's totally 100% recovery

[Game7-91]

Sad and worrisome news. Thanks Lucas Seehafer for excellent explainer. Very much sounds like last thing to do to fix it, but also appears no other option. All the best to him, hope it works.

[Trov]

If it helps him stay on the field good for him.  I wonder why they did not look into this last surgery or why it just started to be an issue in his early 20's.  My guess his bone did not get longer just this past year, I could be wrong not a doctor or anything.  Either way I hope all the luck to him on his recovery. 

[wabene]

9 minutes ago, Trov said:

If it helps him stay on the field good for him.  I wonder why they did not look into this last surgery or why it just started to be an issue in his early 20's.  My guess his bone did not get longer just this past year, I could be wrong not a doctor or anything.  Either way I hope all the luck to him on his recovery. 

Probably a condition that wouldn't have appeared if he was wasn't the son of a hitting coach who has swung a bat millions of times. 

[roger]

Best of luck to a young man who has the potential to be one of the best hitters in the game.

The Twins have four special young hitters, AK, Lewis, Larnach and Miranda.  We are seeing Miranda every day.  Can you imagine what this team will be like after all four get healthy with a year’s experience behind them?

[sftwinsfan]

I was wondering if any other players have had this done before, but that pretty much answers that. To break a bone is one thing but shortening a bone and needing plates and screws in there could have some impact on things. Hopefully this will not only solve his pain issues but that he can regain full range of motion and not have his swing impacted. Between the prior Tommy John surgery (as an OF/1B) and this he could sure use some luck to go his way. 

[Heezy1323]

6 hours ago, Squirrel said:

Thanks for the info. Wonder if our resident doctor has more to add? Calling @Heezy1323!

Not sure how much help I will be here, but I'm happy to put in my $0.02. 

I don't see many wrist issues in my practice, so this topic is out of my area of true expertise. Lucas did a great job covering this topic in the article.

I tend to think of the TFCC much like the meniscus in the knee. It is designed to function as a cushion or shock absorber for loads across the wrist. Since most of us don't walk on our hands, the wrist 'meniscus' sees much less stress that the meniscus in the knee. This is why this type of injury/problem is uncommon in the general population. 

However, certain movements or activities (such as swinging a bat/golf club/tennis racket) do cause additional stress on this area. In a perfect world, the TFCC is up to the challenge of withstanding these stresses. However, some people have an ulna that is a shade longer than ideal (and we really are talking about a difference of just a few millimeters here). This can add enough stress to the area that the TFCC can begin to break down. As in the knee, when the meniscus is not fully performing its normal 'shock absorber' function, that stress is then transmitted instead to the surrounding structures. In this case, that is the cartilage of the small bones of the wrist (which is what it sounds like was addressed at his original surgery). 

Often, going in and 'cleaning things up' and repairing the TFCC injury is all that's needed. It is just unfortunate that in this case the more simple procedure didn't turn out to be very durable (meaning its positive effect didn't last very long). I also tend to agree with the option of trying a cortisone injection or two, to see if that can alleviate the problem as well. 

When things don't progress as we would like, and people still have pain in the wrist, the next option is to try to do something to change the mechanics of the area to lessen the stress. In this type of situation, that means shortening the ulna to offload the TFCC and cartilage in the area. The surgery is typically performed (at least as I understand it- I don't do this type of surgery) by cutting the bone, removing a small wafer of bone, and using a plate and screws to bring the bone edges back together. In this type of surgery, you are essentially 'creating' a fracture, and the body needs to do the work of healing the bone, just as it would a fracture that happens if someone was to fall and hurt their wrist traumatically. 

If it sounds like this is a significantly more aggressive surgery than the first type, you're right. Any time you perform a more complex surgery, it introduces additional risk of complications. If an athlete/surgeon had a crystal ball and could know in advance that the first surgery was not going to be totally successful, obviously neither would choose the first surgery. But that luxury doesn't exist, so we constantly have to balance risks and benefits when making these difficult decisions. I would be willing to bet that this possibility was discussed with Alex at the time of his first surgery, and he was perhaps even given the option to do the more aggressive surgery first (this is pure speculation on my part). 

I completely agree with Lucas that the success rate of this type of surgery on athletes is not well-studied. This makes it challenging to recommend it as a first-line procedure, particularly for professional athletes whose livelihood depends on milliseconds of reaction time and the generation of tremendous force. 

It's definitely unfortunate that Alex needs to have additional surgery, but as best I can understand the issues from the information available, the history leading up to this point and the plan going forward make a lot of sense to me. Fingers crossed that he can heal up and get back to mashing baseballs soon. 

Happy to try and answer questions if people have any. This was probably all clear as mud...

Nice job, @Lucas Seehafer PT. Another tough topic to cover. 

[Heezy1323]

4 hours ago, wabene said:

Probably a condition that wouldn't have appeared if he was wasn't the son of a hitting coach who has swung a bat millions of times. 

I suspect this is precisely correct.

[Heezy1323]

5 hours ago, D.C Twins said:

As I've said in previous posts, his career is in jeopardy. The wrist is a complex and delicate anatomic area which is obviously under repeated stress with MLB swings. 

The hard part of this will be for the surgeons to estimate the accurate amount of shortening needed to optimize (an educated guess no matter how talented they are and there is no way to gauge success until well after the surgery is done). 

 I wish him the absolute best, but am very worried for his future

I would humbly suggest that this part is actually the easy part. We know how long the ulna is 'supposed' to be, relative to the radius (the bone next to it). A fairly straightforward calculation can be made to identify the amount of bone that needs to be removed to 'normalize' the length. And there are jigs that can be used that account for the amount of bone, thickness of the saw blade (kerf), etc to obtain a precise removal. 

In my view, the more challenging things here are:

1) Deciding when to pull the rip cord and go ahead with the surgery 

2) Predicting for Alex exactly how his body will respond and what effect this will have on his swing mechanics going forward

3) Identifying a timeline for recovery (as this can sometimes vary substantially from patient to patient)

4) Worrying about potential complications that can arise

For the most part, as a surgeon I feel like the surgery is the thing I have 'control' over, where as so many of these other things are out of our control (either partially or entirely). I tend to stress about things I can't control (rightly or wrongly, I suppose one could argue). 

[jimbo92107]

Shortening an arm bone, my god, that's drastic. Poor kid, he doesn't deserve crap luck like this. Let's hope the surgery and recovery go as well as possible. Good luck, Alex!

[USAFChief]

1st: thanks Lucas and Heezy for your great help here.

2nd: for either or both: assuming normal recovery and rehab times, is it likely he will meet the Twins "hopes" and be physically ready for spring training?

[MMMordabito]

Thanks, Lucas (and Heezy).  To me, these are the types of contributions that help set this site apart from others.  It makes me question some reporting that Alex' surgeon didn't know why the injury was flaring up.  My take away is that every person responds to disease, injury and then surgery and treatment differently.  Let's hope Alex responds well this time.

[Reptevia]

Well researched. I hope it works. Without him, we have huge holes at 1st, LF and arguably C.  RF is a bit of a ? Too. Max has been a little fragile…

[RpR]

2 hours ago, Reptevia said:

Well researched. I hope it works. Without him, we have huge holes at 1st, LF and arguably C.  RF is a bit of a ? Too. Max has been a little fragile…

LOL - Here he comes to save the day,, means that mighty AK is one his way.? but then , Caesar Tovar played every position.

 

[Heezy1323]

On 8/8/2022 at 9:51 AM, USAFChief said:

1st: thanks Lucas and Heezy for your great help here.

2nd: for either or both: assuming normal recovery and rehab times, is it likely he will meet the Twins "hopes" and be physically ready for spring training?

I'd be speaking out of turn if I said I am intimately familiar with the rehab of this surgery, but February puts us about 7 months from surgery. I think that's a very reasonable time frame for something like this. It's possible I'm wrong here, and there's more to it than I know, but I feel comfortable with that timeline. 

[glunn]

8 hours ago, Heezy1323 said:

I'd be speaking out of turn if I said I am intimately familiar with the rehab of this surgery, but February puts us about 7 months from surgery. I think that's a very reasonable time frame for something like this. It's possible I'm wrong here, and there's more to it than I know, but I feel comfortable with that timeline. 

Thanks for your very educational posts.

Do you think that it could be helpful if he could find a batting glove that absorbs more of the energy when he makes hard contact?

 

[Heezy1323]

13 hours ago, glunn said:

Thanks for your very educational posts.

Do you think that it could be helpful if he could find a batting glove that absorbs more of the energy when he makes hard contact?

 

That's an interesting question. My assumption has been that the force generated at the wrist is primarily from the swing itself, not necessarily the contact with the ball. But I would say I don't honestly know the difference in forces across the wrist on a swing and miss vs. a swing that makes contact. My best guess (and I would call it a guess) is that the gloves probably wouldn't make a difference unless they were quite thick/cushy, in which case they probably aren't realistically useful for an MLB hitter. Would be an interesting study...