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Rich Hill Elbow Surgery Discussion Heezy 1323 Happy Supposed-To-Be Opening Day everyone. Since the baseball season is (unfortunately) on hold due to the coronavirus pandemic, about the only recent baseball-related news to report has been that both Chris Sale and Noah Syndergaard (in addition to Luis Severino earlier this spring) are in need of Tommy John surgery. I covered some information about Sale’s injury and some discussion regarding techniques used in UCL reconstruction in previous blog posts. In the comment section of the latter post, TD user wabene asked an astute question about Rich Hill’s surgery and how it is similar or different from typical UCL reconstruction. Hill’s surgery is indeed different from a typical Tommy John surgery, and I thought a post about it might be interesting to some readers. As usual, my disclaimer: I am not an MLB team physician. I have not seen or examined Hill or reviewed his imaging studies. I am not speaking on behalf of the Twins or MLB. I am only planning to cover general information about this type of surgery and my take on what it might mean. Twins Daily contributor Lucas Seehafer posted an excellent article about Hill’s surgery back in January that was a good look into the surgery basics and some background about UCL primary repair. There was some additional discussion in the comments as well. Since Lucas did such a nice job covering the surgery, I won’t go into excessive detail in this post, but I’ll give my version of the basics, and then cover how Hill’s surgery is similar and different. Basics of UCL Primary Repair As covered in my post about Sale, the UCL is a strong ligament at the inside of the elbow that resists the stretching forces that occur when trying to throw a baseball. Obviously, hurling a baseball 90+ mph can take a toll on this ligament and it can, in some cases, result in a tear. These tears can occur at the top (humeral) end, bottom (ulnar) end or in the middle (called midsubstance). The figure above is from a study we did when I was in fellowship indicating the location of the ligament injury in 302 patients who had undergone surgery with Dr. Andrews. The most common areas of injury are at either end of the ligament, with the humeral end being slightly more common (at least in this series) than the ulnar end. These patients all underwent UCL reconstruction, which is the standard operation to treat these injuries when non-surgery treatments have failed to result in adequate improvement. More recently (I would say within the past 5-7 years), there has been emerging interest in performing a different operation for a subset of these patients called UCL Primary Repair. This operation differs from UCL Reconstruction in that when the repair is chosen, the injured ligament is reattached back to the bone at the site of the injury using special anchors. There is typically also a strong stitch called an ‘internal brace’ that is passed across the joint along the path of the repaired UCL as well. I often refer to this internal brace as a ‘seat belt’ stitch. The idea behind the internal brace is that early in the healing process, before it has re-developed strong attachments to the bone, the ligament is susceptible to reinjury which could cause failure to heal (or compromised strength of healing). The internal brace (theoretically) helps protect the healing ligament and allows for development of a stronger attachment back to the bone. Once healing has occurred, the internal brace is thought to act like ‘rebar’, adding some strength to the ligament (though the exact magnitude of this contribution is unclear). This figure illustrates the repair technique with the blue ‘internal brace’ also in place. This is different from UCL reconstruction, where tissue from elsewhere in the body (typically either a forearm tendon called palmaris or a hamstring tendon called gracilis) is passed through bone tunnels and used to create a ‘new’ ligament. One of the reasons for the interest in primary repair of the UCL has to do with the length of time needed for recovery from UCL reconstruction. As many of us know from having watched numerous pitchers undergo (and subsequently return from) Tommy John surgery, there is usually around 12-18 months needed for full return to pitching at the major league level. There are a number of reasons for this long time frame, but a major contributor is that this is the amount of time needed for the graft to fully heal. Recall, we are taking a tendon (which normally attaches muscle to bone) and putting it in the place of a ligament (which normally attaches one bone to another bone). Though tendons and ligaments are similar, there are differences in their microscopic structure. Over time, as the graft starts to heal and have new stresses placed on it (namely throwing), it begins to change its microscopic structure and actually becomes a ligament. In fact, there have been animal studies done that have shown that a biopsy of a sheep ACL graft (which was originally a tendon) over time evolves into what is nearly indistinguishable from a ligament. We call this process ‘ligamentization’, and it is probably the most important part of what allows the new ligament to withstand the stresses of throwing. This process, however, takes time. And because of this, the recovery from UCL reconstruction is lengthy. With primary repair of the UCL, this process of conversion of the tendon to ligament is not necessary since we are repairing the patient’s own ligament back to its normal position. Some healing is still required; namely the healing of the detached ligament back to the bone where it tore away. But this process does not typically require the same amount of time as the ligamentization process. So why, then, wouldn’t everyone who needed surgery for this injury just have a primary repair? In practice, there are a few issues that require consideration when choosing what surgery is most suitable for a particular athlete. The first brings us back to the first graph from this post regarding location of injury to the UCL. It turns out that asking an injured ligament to heal back to bone is a much different thing than asking a torn ligament to heal back to itself. Specifically, trying to heal a tear in the midsubstance of the UCL (which requires the two torn edges of the ligament to heal back together) results in a much less strong situation than a ligament healing to bone. That makes those injuries that involve the midsubstance of the UCL (about 12% in our study) not suitable for primary repair. It can only be realistically considered in those athletes who have an injury at one end of the ligament or the other. In addition, there is significant consideration given to the overall condition of the ligament. One can imagine that repairing a nearly pristine ligament that has a single area of injury (one end pulled away from the bone) is a different situation than trying to successfully repair a ligament that has a poorer overall condition. Imagine looking at a piece of rope that is suspending a swing from a tree branch- if the rope is basically brand new, but for some reason breaks at its attachment to the swing, it seems logical that reattaching the rope to the swing securely is likely to result in a well-functioning swing with less cause for concern about repeat failure. Conversely, if you examine the rope in the same situation and notice that it is thin and frayed in a number of places, but just happened to fail at its attachment to the swing, you would be much less likely to try and repair the existing rope. More likely, you would go to the store and buy a new rope to reattach the swing (analogous to reconstruction). Similarly, when we are considering surgical options, we examine the overall health of the ligament on the MRI scan, and also during the surgery to determine whether repair is suitable or whether a reconstruction is needed. If there is a significant amount of damage to the UCL on MRI, primary repair may not be presented to the athlete as an option. Also, consideration is given to the particulars of an athlete’s situation. For example, let’s say I see a high school junior pitcher who has injured his elbow during the spring season. Let’s also say that he wants to return to pitching for his senior year but has no interest in playing baseball competitively beyond high school. In this case, the athlete is trying to return relatively quickly (the next spring) and is not planning to place long term throwing stress on the UCL beyond the next season. If this athlete fails to improve without surgery (such that all agree a surgery is needed), and his MRI is favorable- he is a good candidate for UCL primary repair. This would hopefully allow him to return in a shorter time frame (6-9 months) for his senior season, which would not be possible if a reconstruction was performed. Indeed, this is the exact type of patient that first underwent this type of surgery by Dr. Jeff Dugas at American Sports Medicine Institute in Birmingham, AL. Dr. Dugas is a protégé of Dr. James Andrews and has been instrumental in pioneering the research behind UCL primary repair. As you can probably imagine, the longer players (and pitchers in particular) play baseball, the more likely it is that there is an accumulation of damage to the UCL over time. This is the factor that most commonly eliminates the option of primary repair of the UCL in many of these players. So how does any of this relate to Twins pitcher Rich Hill? Let’s discuss. Hill underwent UCL reconstruction of his left elbow in 2011. He was able to successfully return from his surgery but has certainly faced his share of injury concerns since then (as described nicely in Lucas Seehafer’s article). This past season he began to have elbow pain once again and was placed on the 60-day IL as a result. He then underwent surgery on the elbow in October 2019 by Dr. Dugas (noted above). The procedure performed was a repair procedure, but in this case instead of repairing Hill’s own UCL, the repair was performed to reattach the previously placed UCL graft. I don’t have any first-hand knowledge of Hill’s surgery, but my best guess is that the technique was very similar to what was described above for a typical primary repair with internal brace. To my knowledge, this has not been attempted before in a major league pitcher. There is data showing a relatively good return to play rate with primary repair that is very similar to UCL reconstruction. However, most UCL repair patients are much younger than Hill and the vast majority that have been studied to this point are not major league pitchers. There are a couple of ways you can interpret this data when it comes to Hill. One perspective is that he had a repair of a ‘ligament’ (his UCL graft) that was only 8 years old (since his TJ was done in 2011), and as such it likely doesn’t have as much cumulative damage as his UCL might otherwise have if he had not had any prior surgery. An opposing perspective would be that this is his second UCL operation, and even though his most recent surgery was not a reconstruction, the data that would be most applicable to him would be data regarding athletes who have undergone revision UCL reconstruction (meaning they have had a repeat TJ procedure after the UCL failed a second time). This data is less optimistic. Most studies would put the rate of return to play after normal UCL reconstruction around 85% (depending on exactly how you define successful return to play). In most studies, the rate of return to play after revision UCL reconstruction is much lower, around 60-70%. There are two MLB pitchers that I am aware of that have undergone primary repair of the UCL (Seth Maness and Jesse Hahn). Maness has yet to return to MLB and Hahn didn’t fare very well in 6 appearances in 2019. Finally, my last input on this topic as it pertains to Hill is to imagine the specific position he is/was in. He is likely nearing the end of his career (he turned 40 in March 2020). He had a significant elbow injury that was not getting better without surgery. Presumably his choices were four: 1) Continue trying to rehab without surgery and see how it goes, understanding that the possibility exists that rehab may not be successful. (Perhaps a PRP injection could be tried) 2) Retire. 3) Undergo revision UCL reconstruction with its associated 12-18 month recovery timeline, likely putting him out for all of 2020 with a possible return in 2021 at age 41. 4) Undergo this relatively new primary repair procedure with the possibility of allowing him to return to play for part of the 2020 season, but with a much less known track record. In fact, a basically completely unknown track record for his specific situation. If that doesn’t seem like a list filled with great options, it’s because it isn’t. If I’m being honest, I think Hill probably made the best choice (presuming that he still has a desire to play), even with the unknowns regarding his recovery. He obviously couldn’t have seen this virus pandemic coming, but that would seem to make the choice even better since he is not missing any games (because none are being played). For Hill’s and the Twins sake, I hope his recovery goes smoothly and he is able to return and pitch at the high level he is used to. He sure seems like a warrior and is certainly the kind of person that is easy to root for. But based on what we know about his situation, there is an element of uncertainty. If I were Hill’s surgeon, I likely would have told him that he had around a 50-60% chance to return and pitch meaningful innings after this type of surgery. Let’s hope the coin falls his way, and also that we can figure out how to best handle this virus and get everyone back to their normal way of life as soon and safely as possible. Thanks for reading. Be safe everyone. Feel free to leave any questions in the comment section.

Chris Sale Tommy John Q&A Heezy 1323 It has been reported that Chris Sale of the Boston Red Sox will undergo UCL reconstruction surgery, also known as Tommy John surgery. Sale has not pitched in a live game since August 13, 2019. He then went on the Injured List on August 17 and did not return for the remainder of the 2019 campaign. He was reportedly seen at that time by several of the best-known US surgeons who care for pitchers and a decision was made to hold off on surgery, and instead try a platelet rich plasma (PRP) injection. He finished the 2019 season with a 6-11 record and ERA north of 4.00, significantly below the standard he had established throughout his excellent career. This is on top of the fact that Sale has yet to even begin his 5-year, $145 million contract extension. Sale will now miss whatever portion of the MLB season is played this year, as well as potentially some part of the 2021 season. A number of questions can often surround a decision such as this, so let’s cover a few things that readers may find helpful. (Disclaimer: As per the usual, I am not an MLB team physician. I have not examined Sale or seen his imaging studies. I am not speaking on behalf of the Red Sox or any other team. This article is for educational purposes only for those who might want to know more about this injury/surgery or about how these types of decisions get made.) Question 1: What is this injury? How does it occur? The ulnar collateral ligament (or UCL) is a strong band of tissue that connects the inner (medial) part of the elbow joint. (Figure 1) Though it is relatively small (about the size of a small paper clip), it is strong. The native UCL is able to withstand around 35 Nm (or about 25 foot pounds) of force. However, by available calculations the force placed on the elbow when throwing a 90mph fastball exceeds this, at around 64 Nm. How, then, does the UCL not tear with each pitch? Fortunately, there are other additional structures around the elbow that are able to ‘share’ this load and allow the UCL to continue to function normally (in most cases). The flexor/pronator muscles in the forearm are the most significant contributor. The geometry of the bones of the elbow also help. In many cases, the UCL is not injured all at once (acutely), but rather by a gradual accumulation of smaller injuries which lead to deterioration and eventual failure of this ligament. When the ligament is injured, it obviously does not function at 100% of its normal capacity- in which case the other structures around the elbow are required to ‘pick up the slack’ in order to continue throwing at the same speed. This is why when a pitcher reports a ‘flexor strain’, there is concern that the UCL is not functioning properly – the muscles of the forearm are being forced to work overtime to compensate for a damaged UCL. There are also cases where the ligament does fail suddenly. These are often accompanied by a ‘pop’ and immediate significant pain. Question 2: What do players report as the problem when their UCL is injured? Most commonly, players report pain with throwing at the inner part of the elbow as the most pronounced symptom. However, other symptoms can also be present including loss of throwing control/accuracy, inability to fully move the elbow, swelling, numbness or tingling of the hand and more. Symptoms can be significant almost immediately, or they can begin very subtly and slowly increase over time. Once they have reached higher levels of baseball, most players are aware of this type of injury (thanks to efforts toward education for coaches, athletic trainers and others) and are able to recognize symptoms and report them to the appropriate personnel. Question 3: Once the player is concerned about an injury to the UCL, what happens next? Most commonly the player will be examined by an athletic trainer or team physician to assess the injury and direct further treatment. Often, xrays will be performed of the elbow to assess the bones of the elbow joint for any abnormalities. There can sometimes be bone spurs, small fractures, bone fragments or other findings on these xrays. However, much of the time the xrays are normal and an MRI may be performed to further assess the situation. An MRI allows us to see the soft tissues around the elbow in addition to the bones. Specifically, we are able to look more closely at the actual UCL itself, the surrounding muscles as well as get a closer look at the nearby bone. (Figure 2) The MRI helps the treatment team get a sense of the integrity of the ligament, which allows for the next step in the process: deciding how to treat the injury. Question 4: How are UCL injuries treated? This is where the challenges often really begin. Much of the time, the UCL will appear abnormal on MRI. There are a handful of grading systems that are used to classify these injuries (one of which, incidentally, I helped create), though there isn’t one that is universally used or agreed upon. Generally speaking, they try to separate injuries into those that are partial tears or complete tears and also try to identify the specific location of the damage. The damage can occur at the upper end of the ligament (called the humeral end), the middle (called midsubstance) or at the lower end of the ligament (called the ulnar end). In those cases where there is a complete tear of the ligament (meaning that the ligament is no longer in continuity and attached at both ends), there is near universal agreement that surgery is typically necessary to allow that athlete to return to competitive throwing activities. The problem, however, is that most MRI’s show a partial injury to the UCL. These injuries can be extremely difficult to predict how they are going to respond to a chosen treatment. In addition, athlete A can have an MRI that looks much more abnormal than athlete B, yet the symptoms of athlete B are substantially worse. This is the basic cause of the uncertainty as it pertains to treatment for this injury. There has been tremendous research performed attempting to quickly identify ways to reliably separate those throwers that are going to need surgery from those that will not. Indeed, with pitchers such as Sale, there can be tens or even a hundred million dollars plus at stake. However, to date there is not a perfected method that can be used for every athlete to make this surgery vs. no surgery decision. Question 5: What non-surgical options are available? There are primarily two non-surgery options available to these athletes, and I’ll attempt to briefly cover them here. A) Physical therapy- the commonly used ‘rest and rehab’ method. This is probably the most important component of any treatment plan, and a good therapist who has specialized training in the care of overhead athletes is critical. Often, the athlete is prescribed rest from throwing in order to allow the UCL an opportunity to ‘settle down’ any inflammation and perhaps perform some healing of the injured tissue. In addition, as we discussed above, the muscles of the forearm contribute to stability of the elbow joint. Strengthening these muscles (along with a number of other muscles throughout the body) contributes to ‘protecting’ the UCL from further injury. As the recovery progresses, a return to throwing program is initiated, usually starting with a small number of throws from a short distance and gradually progressing to longer throws with greater effort and eventually throwing from the mound (for pitchers). This hopefully results in a more well-balanced and mechanically sound athlete who is more evenly distributing the forces of throwing across the various anatomic structures involved. B ) Platelet rich plasm (PRP)- This is a product that is obtained from the athlete’s own blood which is drawn and then spun in a centrifuge to separate the blood into its components. The portion of the blood which contains the platelets is then taken and injected at the site of injury to the UCL. This injection includes a number of chemical signals (called cytokines) that regulate healing and inflammation (along with many other things). The injections are thought to help with healing of these partial UCL injuries. The available data on this is mixed, with some studies showing improved results with PRP and others showing no difference. In the linked study, the rate of ‘successful’ non-surgical treatment was 54% (including both PRP and non-PRP athletes). Question 6: How is the decision to proceed with surgery made? This is probably the most challenging part of the evaluation process of UCL injuries. There are a tremendous number of factors which play a role in this decision. These include the specific characteristics of the athlete (such as age, position, role, contract status, stage of career, desire to continue playing and several others); exam and imaging findings (understanding that these are frequently ambiguous); as well as response to previous non-surgery treatment (to name a few). Often more than one expert opinion is sought, particularly when it is a big name/big contract player. Usually, surgeons will speak with a number of people when considering options including the athlete and family, team doctors and staff, team officials, and other experts (who may or may not have seen the patient themselves). In my experience in these situations, the vast majority of the time there is a consensus amongst those involved how best to proceed. Occasionally there will be differing opinions, in which case the athlete often has to make a choice on how to proceed. Question 7: Why didn’t Sale just go ahead with surgery last fall? I suspect that this is a question that many Red Sox fans are wondering about right now. As discussed above, these decisions are typically difficult and have many contributing factors. While it may seem as though ‘rest and rehab’ never works and everyone should just go ahead and have Tommy John surgery at the first sign of trouble, that is not really borne out in the data. There is some variance depending on the definition of ‘successful return to play’ used in any particular study, but for the most part the rate of success of Tommy John surgery in pitchers is around 80-85%. That means about 1 in 5 never make it back to pitch. This may not seem like bad odds, but I submit that your opinion might change if it was your elbow (and livelihood/contract) at risk. As they say, hindsight is always 20/20. In the case of Sale, I suspect that the season being shortened by the unusual circumstances of coronavirus this year likely also played a role. Once it became clear that a full season would not be played, the decision may have been easier. I think I’ll stop there for now (if anyone has continued to read this far…). If people are interested in technical aspects of how the surgery is performed, please let me know in the comments an I’d be happy to do another post about it. I have spare time currently, as you might imagine. Stay safe everyone, and please listen to the medical professionals who are trying to help us combat this virus. It is a serious threat to our way of life, and we need to treat it as such in order to minimize the damage. Thanks for reading.