The new Tommy John repair with an Internal Brace is an exciting option for UCL injuries.
But is everyone a candidate for this new procedure?
In this podcast, we talk about some of the factors to go into deciding who is the best candidate to have a great outcome.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 314: Who is a Candidate for the Tommy John Internal Brace Procedure?
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Show Notes
• UCL Internal Brace Surgery with Jeff Dugas
Transcript
Nancy :
All right, so Tom from Arizona, “I’m starting to see more of the UCL repair with internal brace procedure in baseball pitchers. I want to be able to know when to recommend this for my patients over the traditional Tommy John procedure. How did the surgeons decide which procedure to perform?”
Mike Reinold:
Good one, Nancy. I like the Arizona accent that you added this time too. I’m just kidding. Is there an Arizona accent?
Lisa Lowe:
What does that even sound like?
Mike Reinold:
That was amazing. That’s a great question. We’re definitely starting to see this new procedure, or newer procedure, using an internal brace to help repair a Tommy John ligament. We’re talking about this in elbow, but this is being applied to other ligaments elsewhere in the body too. I haven’t seen a ton of these yet in other body parts, but we just see so much baseball. We are definitely seeing it more.
I like this question. How do you know which one to perform? There’s a couple buckets to talk about here as one is, obviously, the patient’s desires. The other one here too is… I’ll start the episode off with this, and then maybe we’ll kick it off to Lenny for some more details. I do know that our friends that do this procedure, the surgeons that do this procedure, they get the patients’ consent for both procedures before the surgery. You’re agreeing to either of them. They do make a decision oftentimes intra-operatively on whether or not you are a candidate to do this internal brace. They do get you to consent that if they don’t like the ligament, for example, the way it looks, that they’ll perform a traditional Tommy John reconstruction, not a repair. I will say that the surgeons prep everybody for that.
Len… If you want to know more, I’ll talk about this now, but I did a great podcast on my other podcast, the Sports Physical Therapy Podcast with Dr. Jeff Dugas from Birmingham, Alabama. He’s one of the ones that really started pushing this a little bit more. You should go check out that podcast episode too.
Len, so let’s start it off with this. Who’s a candidate for this and why? Why don’t we start with that, and I’ll give you an open-ended thing to run with.
Lenny Macrina:
Oh, okay. Yeah. I think everybody starts off as a candidate. You have medial elbow pains….
Mike Reinold:
Yeah. How unfair.
Lenny Macrina:
…Then you come and they determine you have a UCL sprain, and then the MRI shows something going on. Now you’re a candidate and now it’s intra-operatively. We work a lot with Dr. Chris Ahmad, who’s the Yankees team doctor in New York City. It’s usually… Previously, Luco at MGH in Boston and now Matt Leman. We have a bunch of surgeons that we have good relationship with, including Jeff Dugas. We get all this information from them.
It’s usually an intra-operative thing that they are deciding, kind of like, on the fly. I feel like it’s evolving. Every time I think I understand when they’re going to do an internal brace, it’s evolved into “we’re going to do an internal brace as a hybrid now,” which means they’re going to reconstruct it and do the internal brace. Previously, it was “is it a tear on either the proximal or distal end?” Not a mid-substance tear. Mid-substance tears cannot heal on their own. You can’t sew the fibers of the UCL back together and then put a piece of the fiber tape or the internal brace on top of that. They try to and it just doesn’t work well, but if it’s proximal or a distal tear, meaning on the sublime tubal distally or on the medial epicondyle proximally, they can fix that, put that back down to the bone, and then put the internal brace on top of that.
A lot of doctors are saying, “you know what? Wait, there’s more. We can do better. We can reconstruct it with your hamstring or palmaris graft, and do the internal brace on top of that, along with repairing the ligament first.” You have a repair of the ligament that was torn on your native ligament, they take your palmaris or hamstring, and they put the internal brace on top of this. Now you have this sandwich of delicious tissue that is going to protect that medial elbow, at which point you get back to throwing. I think, in the doctors that are still… Which is a good chunk of them… Still doing just an internal brace, it’s more of an off-the-bone tear versus a mid-substance tear.
Mike Reinold:
I like that. I think that’s a great first place to start right there. If it’s torn in the middle, an inter-substance tear, you can’t just repair it. You have to reconstruct it. The hybrid procedure that Lenny alluded to, I think, that changes the conversation. That turns it back into a traditional Tommy John, you just added some internal brace on top of it.
Lenny Macrina:
Right.
Mike Reinold:
All the benefits of the internal brace are out the window at that point. You’re not going to be able to get back faster. That’s something that I think some surgeons are trying. I’m not sure if that’s going to be the future or not. I don’t know.
Lenny Macrina:
Yeah. I don’t know.
Mike Reinold:
We’ll see. We have some that we’ve seen. They seem to be a little tighter at first. I talked to one of the surgeons, Keith Meister in Texas, that’s doing a lot of these. I said, “Yeah. He is really tight. His elbow feels really tight the first time I saw him.” He’s like, “Oh yeah. They’re super tight.”
Lenny Macrina:
Good.
Mike Reinold:
I’m like, “Oh, yeah. Great.” I was like, “Oh, all right. Okay. That’s the point.” It’s helpful to understand that. I like that that’s intra-substance tear.
Tommy Johns are evolved. When I first started, these were 30-year-olds plus that had chronic crappy ligaments that over time, tore. You had to have this big reconstruction. I think what’s happening now is we’re seeing a lot of younger people that have insufficiency, and it’s not as degenerative maybe of a ligament. The ligament’s not completely trashed. I think there’s more people that might be candidates to do this internal brace. Maybe we’ll throw this to Mike a little bit, because I know Mike sees a lot about this too. I want to hear your thoughts in general, but how much of this is an age thing? Is this a younger person procedure because their ligament is not as messed up? I don’t know. Lenny talked about the status of the ligament, but what about the patient themselves? When does that start to factor into who is a good candidate?
Mike Scaduto:
Yeah. I would say I’ve seen it both ways. I’ve seen this performed in younger people with potentially better-quality ligament tissue. Although they have a UCL sprain, it’s not as degenerative in nature. Then, I think, I see it as well later on in college students, like juniors and seniors that want to play one more season and this is their chance to get back for that year. Maybe, they’ve already used up a red shirt year, they don’t have 12 to 16 months to undergo a full UCL reconstruction recovery, and this internal brace enables them to at least have a chance to come back for that final season.
I’ve actually talked to one of the top doctors and he says that people will come in and say, “I don’t care what the ligament looks like.” This is the patient talking to the surgeon. “I don’t care what it looks like. I want you to do the internal brace, because I need to come back to play.” I think that’s super interesting.
Mike Reinold:
Right.
Mike Scaduto:
A lot of the conversations that I have with patients and particularly patients’ parents is they’re starting to hear about this new procedure. A lot of people are referring to it as Tommy John Light. I think that’s interesting. They think they have a choice as to “should we just get to Tommy John Light?” As Lenny and you discussed, this is the decision that’s made intra-operatively. I think it’s interesting to see that there’s this option out there that potentially can get people back a little bit faster. There’s probably going to be some pressure from parents on kids’ surgeons, PTs, maybe to move in that direction to get their kid back a little bit faster. We’ll kind of see how the outcomes change over time as we get more data about it. So far, it seems like it’s been promising and good outcomes.
Mike Reinold:
Yeah. It’ll be interesting. The whole reason why there’s still two procedures is, I think, that the traditional Tommy John reconstruction is still considered the gold standard. Sometimes gold standards exist because of longevity and a lot of outcomes over time. We know we have something that is reliably successful in a large amount of people. It’s not that there’s two different options and you have a light one versus the big one. It’s more about as we learn more, hopefully, this replaces the gold standard. We don’t know that just yet, but I will say, I don’t think anybody on this podcast would disagree either, we’re seeing great outcomes. We are not seeing bad outcomes with this internal brace. We’ve seen it in kids, we’ve seen it in major league big leaguers, we’ve seen it for revisions, we’ve seen it for first-time surgeries. We’re seeing it and they work. It’ll be interesting to see down the road how that goes. There’s always going to be people that aren’t candidates for this, because their ligament quality’s not quite there, so they can’t just repair it. I think that’s interesting.
Dave, what are your thoughts? Or did you have something on this with your patient population? Or even the non-baseball players in general? Obviously, gymnasts are one, but this is more than just baseball players.
Dave Tilley:
I guess I have a question for Mike and for Lenny and for anybody else around. How does this translate to the non-baseball throw? It does make sense if you have a mid-substance tear in an overhead athlete. You can think of javelin, you could think also baseball, right? Makes sense that a full repair might be ideal for longevity. I actually see a lot of, we call them Tammy Jane’s in female gymnasts who fall and they blow through the ligament, unfortunately, once. A hyperextension. That makes sense, but we also see a lot of repetitive overuse-type stuff come up from a distal tear because of hyperextension and impacts. That’s where my question is. I actually have a high-level, level 10, gymnast who has a confirmed distal end sublime tunical tear. It’s not full and it’s not a sprain, but she… We’ve seen Olympic weightlifters or people who just over time get through their UCL.
I guess it’s more of your thought, do you think that’s someone who might be a candidate for an internal brace? This girl that I’m thinking of, super high level, wants to get a scholarship next year going into junior year. If we can get her back in whatever, the month for it is three, to compete and get a scholarship versus the 9 to 12 it might take to skip a whole junior year and a recruiting cycle. They’re doctors. She’s six weeks into rehab and she’s getting better. If it doesn’t get better and she still has issues, they’re going to talk about surgery. I think that’s a really an important conversation of should we try a brace in a non-confirmed, no-research person? Or is it go for the classic full repair and go? She has high-level traction forces and high-level compression forces that are coming for possibly five more years.
Mike Reinold:
Yeah. For sure.
Lenny Macrina:
I would say she’s definitely a candidate. Sorry.
Mike Reinold:
Yeah. No. I was going to say the preliminary research has shown that the strength of the internal brace is there. It’s not weaker. That’s the first thing I thought of when you said it. Like, “Man, this person has to withstand a lot more forces potentially than a baseball player.” I think it’s there, but I don’t know. What do you think Len?
Lenny Macrina:
I would say if this was my patient and I would have that in my back pocket. I would not necessarily advertise it. They may want to jump into surgery and skip the rehab altogether. Just say, “I failed rehab.” In my head, I would know that if they are still having symptoms, even instability or pain, and we think it’s from that ligament tear that at 6, 8, 10 weeks, and we have to now count backwards, and when we need to be ready for blah, blah, blah that I think this is a viable option for a gymnast. I was skeptical initially that we were going faster with these.
I’m like, “This isn’t native tissue. How are we going faster? How is it stabilizing quicker than a reconstruction?” I think that’s the fact, that it is not our native tissue. It doesn’t have to ligamentize and become a ligament from a tendon, I think, is a benefit for a lot of people. Including a gymnast, a weightlifter. Somebody like that who’s not going into a valgus torque all the time throwing a baseball. I think they can get back a lot faster than a baseball player. I think, the positive hope for a gymnast and anybody else that you mentioned.
Mike Reinold:
Yeah. My concern would be the traumatic nature of some of these injuries. A gymnast, a wrestler, the traumatic injuries from falls like cheerleaders that fall on outstretched arms, those sorts of things. There’s lots of athletes that get this more traumatically. Weight lifters… If it’s very traumatic and the ligament itself is beyond repair, that’s going to always be a problem because you have to repair the ligament to put an internal brace on it. I think that’s the integral part.
Lenny Macrina:
Oftentimes those scar down and heal too.
Mike Reinold:
Yeah.
Lenny Macrina:
The weightlifter who snatches, and that gets that hyperextension… Those heal. Wrestlers, I’ve seen a bunch of wrestlers, they heal. They don’t need Tommy John, because they’re not constantly going into valgus. For somebody, the person who can’t heal, didn’t scar down well, and is still having pain instability, I think, that’s definitely a good candidate for this.
Mike Reinold:
Especially if you’re putting weight on it. Right?
Lenny Macrina:
Right.
Mike Reinold:
I go back to the gymnast. The wrestler that falls on it once is one big thing, but if your activity is weight-bearing.
Lenny Macrina:
Repetitive type stuff.
Mike Reinold:
Yeah. Dan, what do you think?
Dan Pope:
I was going to ask a question for you guys, because I don’t see this quite as much with my population. I tend to see… I have an athlete, as Lenny said, Olympic weightlifter and he had the decision whether or not to do surgery and he’s gotten back to all his lifts. He’s sitting new PRs, doing well without it. I don’t know if that’s the best long-term solution. We’re always trying to figure out what’s best for folks long-term. Since that’s the question.
One of the things that pops into my mind, and this is what the surgeon has said, “You’re going to lose range of motion with this surgery.” I guess, I think, John was talking about this prior, we have issues with people losing range of motion at the elbow after these surgeries. For some of these athletes, having symmetrical lockout is incredibly important. For an Olympic weightlifter that would potentially lose range of motion going through one of these surgeries, I guess, that’s in the decision-making process of whether or not they want to go through with that. If they’re lacking a little bit of lockout, that’s going to make it extremely hard for… Lockout is so vital for that sport.
I guess, my question for you… Is there a difference with the internal brace versus the reconstruction for range of motion?
Lenny Macrina:
I don’t think so.
Dan Pope:
…For those folks?
Lenny Macrina:
There shouldn’t be.
Mike Scaduto:
It doesn’t seem like it. Yeah.
Lenny Macrina:
They should get their motion back. Baseball players don’t get their motion back because they didn’t have the motion before the surgery. They all have flexion contractions from throwing. If you had good motion and you don’t have a stiff elbow going into the surgery, you should be fine. Mike Scaduto, I don’t know if you want to say…
Mike Scaduto:
I was going to say, generalizing, the type of body characteristics that Olympic weightlifter has is generally more hypermobile, probably has a good amount of elbow hyperextension. Probably wouldn’t be super worried about restoring elbow extension after the internal brace in that type of population. Probably comes down to the specific person.
Lenny Macrina:
Right.
Dan Pope:
Thanks, you guys.
Mike Reinold:
Yeah. When they’re doing the surgery, they bring it through a full range of motion to assure that they didn’t over-tighten it. It shouldn’t limit the range of motion. It’s not designed to limit the range of motion and it shouldn’t. Yeah. Poor rehab or somebody that chronically was losing it before, but Olympic weightlifters aren’t that. I wouldn’t use that as a reason to not do it. That’s a post-operative complication that would be bad for them. I totally get that. I don’t think that’s something that should happen. Hopefully, we prevent.
Dan Pope:
Right.
Mike Reinold:
I think, an Olympic weightlifter, some of these other sports we talked about, javelin, even tennis, softball, because it’s mostly position players, those types of things, they don’t stress it as frequently as a baseball pitcher. Baseball pitcher, it is valgus, valgus, valgus over and over again. It’s a little bit more demanding for that athlete. If you’re doing this here and there, right, then let it scar down, see if it works, or do this type of thing. I do think Dave’s population throws us a bit of a curveball or a cartwheel. Throws us a bit of a cartwheel. Did that work?
Dave Tilley:
Courtney and I cringed internally.
Mike Reinold:
You say throw us a curveball.
Dave Tilley:
We’re close, but you threw a slow ball over the plate, so it didn’t really get there.
Mike Reinold:
Okay. There we go.
If you going to throw a cartwheel at somebody though… The force generated through weight bearing with that amount of impact. That does worry me a little bit, I’ll be honest with you. If the ligament’s not torn in half and it’s not a huge dislocation type thing, then it’s probably still a candidate to an extent.
Well, hopefully, that helps. If you deal with some of this patient population, you’re going to be faced with this question. Oftentimes we talk to our patients before they get to the surgery and they’re asking us questions. “Is this an option for me? Is this not an option for me?” I think the indications are expanding and as we get to use this more and more, this is going to be refined over the years. For now, I think this is a great start and it’s great to have two options for these people. Like Mike said, somebody that doesn’t really want to commit to the 12 to 16-month outcome that this could be really good.
Be sure to head to my other podcast, the Sports Physical Therapy podcast. My episode with Jeff Dugas was great because he talks about a little bit of this too from his perspective, from the surgical side. You can learn more about this procedure, but it’s really neat. Anyway, really appreciate it. Great question. Thanks for asking. Head to mikereinold.com, click on that podcast link if you have a question like that, and we’ll be sure to answer. In the meantime, please rate, review, subscribe to us, Apple Podcasts, Spotify, wherever you listen to your podcasts, so you can keep getting new episodes when we release them. Thanks so much. See you on the next episode.
