A potential alternative to Tommy John that could cut recovery time in half

[TwistedLogic]

Maness a trailblazer? New surgery for elbow repair cut recovery time

By Derrick Goold, St. Louis Post-Dispatch - 2 hrs ago

 

http://i.imgur.com/63HgADo.jpg

Former St. Louis Cardinals relief pitcher and current free agent Seth Maness works through a throwing routine at John

Burroughs High School in Ladue on Friday, Jan. 6, 2017. Maness is recovering from elbow surgery that ended his season last

year. The seams on the balls Maness threw whistled as they traveled 90 feet away to Cardinals second baseman Kolten Wong

who was playing catch with Maness. Photo by David Carson, dcarson@post-dispatch.com

 

When Seth Maness shut his eyes before a surgeon opened his right elbow, the former Cardinals

reliever was not sure what awaited him on the other side of sleep. The troublesome ligament in

his throwing arm had to be fixed and a complete reconstruction would mean missing an entire

season.

 

He went under unsure.

 

He woke up a potential trailblazer.

 

Maness is a week away from returning to the mound and expects to be ready for opening day,

just 7½ months after surgery, because Dr. George Paletta performed a repair that could

eventually prove to be an alternative to Tommy John surgery for select big-league pitchers.

Until the St. Louis-based orthopedic surgeon saw inside Maness’ elbow, he wasn’t sure if Maness

was a candidate to be the first established major-league pitcher to receive the new procedure,

Paletta said.

 

Now, the doctor and his patient are eager to watch as Maness’ first time toeing the rubber could

be, in their words, “a significant step forward” for the industry. Another doctor who performs

the repair surgery, Dr. Jeffrey Dugas, said there is “cautious optimism.”

 

“It was a game-time decision,” said Maness, a free agent. “I’m going into it sort of expecting

Tommy John and hoping for the other one. You go from looking at missing a whole season to

possibly being back at the start of the year — that’s a big relief. When Dr. Paletta told me, it

was like this little ray of light: There’s a chance.”

 

Maness, 28, completed three sets of throws at a distance of 90 feet on Friday in the John

Burroughs School gymnasium. He is scheduled to take the mound next week for the first time

since his Aug. 18 surgery. He has been encouraged by how his arm feels at every stride in his

rehab, which is accelerated from the usual Tommy John timetable. The Cardinals did not offer

him a contract in early December, making him a free agent — one of the leading groundball

relievers now available to any team. Sooner than expected.

 

The surgery Maness had, called “primary repair,” doesn’t have the sexy name. It doesn’t have

the brand recognition of Tommy John. But it also doesn’t have the lengthy recovery time of its

famous forefather. It is a repair and buttressing of the existing ligament at the bone, not Tommy

John’s reconstruction of the ligament. The scar Maness has on the inside of his right elbow is the

familiar arc of a Tommy John recipient. (Two of the Cardinals’ five starting pitchers have the

same scar.) And the medical code assigned by Major League Baseball to Maness’ profile for

interested teams is the same as Tommy John. As a result, so are the assumptions about the

righthander’s availability for 2017. The surgery he had is too new to have its own code.

 

“It has that potential to be big,” Paletta said.

 

“People are watching this and it’s an interesting thing for all of us,” said Dugas, a managing

partner at the Andrews Sports Medicine & Orthopedic Center in Birmingham, Ala. “There is a lot

that we need to learn from Seth, a lot that we need to learn from all of the guys (who have had

it). We need the data. There are still so many hurdles to go over, but we’re excited to watch

what is going to happen because of what is possible. We’re going to follow him very closely.”

 

“Everyone in baseball should be following this,” said Jeff Berry, Maness’ agent and co-head of

CAA baseball. “He was an outstanding major-league reliever. He was hurt in 2016, was never

right. He has this surgery and he needed the ligament repaired, but he’ll be ready for spring

training, not out for the entire season. Imagine that. Think about the economic impact that has

for the game. Think about what it means to his career.”

 

"Scary Little Thing"

 

Tommy John, pioneered by Dr. Frank Jobe and named for the first big leaguer to receive it, is a

complete reconstruction of the ulnar collateral ligament using a graft. Since its first use, in 1974,

Tommy John has been improved but remained largely unchanged as it became the industry

standard for treating tears of the UCL. The year absence required for rehab has become as

familiar and commonplace in baseball as the one-inning closer and interleague play.

 

Major League Baseball has been unnerved in recent years by a spike in Tommy John surgeries.

By 2015, the proliferation of Tommy John, or TJS, was referred to as an “epidemic,” and

baseball commissioned a study to understand why the rate of elbow injuries had increased at all

levels the game is played, including high school. In 2014, 31 major-league pitchers had UCL

reconstruction – twice as many as the average from the previous decade. Its ubiquity in the

game led to misconceptions, prompting the American Sports Medicine Institute to stress how

“10 percent to 20 percent of pitchers never make it back to their previous level after Tommy

John surgery.”

 

Major-league pitchers know this reality well.

 

They sense it with every twinge.

 

“It’s that scary little thing. It’s always in the back of your head,” Maness said. “You know

anything in that area and automatically you want to avoid assuming any elbow pain is it.

Because, oh man, it’s a career. Today, it’s not a career-ender, but really for a reliever it throws

a little wrench into the scheme of things. I’m expendable. Things can happen.”

 

Paletta, a partner at The Orthopedic Center of St. Louis, is one of the nation’s leading Tommy

John surgeons, with around 600 performed. He has done many of the Cardinals’ elbow

reconstruction surgeries of this era, and this winter the team announced that he would return

as its Head Orthopedic Physician. That came a few months after Maness’ surgery. Maness gave

Paletta permission to speak to the Post-Dispatch about the specifics of his surgery.

 

"The Right Pitcher"

 

About two years ago, Paletta also started doing the “primary repair” option for elbow injuries

that qualified. He has performed more than 50 of these surgeries, and he is working on a paper

about his findings. There have been no failures, he said. Dugas, at Dr. James Andrews’ practice,

performed his first “UCL repair with internal brace construction” in August 2013. Dugas has

done around 150 of these surgeries and does not know of one that had to be redone or led to

Tommy John.

 

For both surgeons, the average time of recovery has been 6½ months instead of Tommy John’s

12 months or more. Paletta said 32 of the pitchers who he helped with a “primary repair”

surgery have now pitched two seasons since the procedure.

 

Mitch Harris and Maness are two of the three pitchers with major-league experience who

qualified for and received the alternative procedure. Dugas described how the surgery has

advanced cautiously from prep players to college players and for it to make this next leap to a

major-league pitcher “it has to be the right pitcher, the right situation.”

 

“In select cases of UCL tears, with this technique, they have the real potential to not miss the

next year,” Paletta said. “This is potentially a huge stride forward in three ways. First, early

results show a high success rate. Second, a return to play is cut by 40 percent. That’s a huge

factor. We are able to accelerate the return-to-throwing (rehab) program for the athletes. With

this technique at the end of 2016 we have a pitcher who is ready to pitch in games by opening

day.

 

“And the third way,” Paletta continued, “as a consequence of this, in the right setting, one would

feel more confident moving to surgery early on.”

 

Paletta had to see during surgery the condition of Maness’ ligament before being certain he did

not need complete reconstruction. The integrity of the tissue is essential, and sometimes a big-

league pitcher’s aged and worn ligament can be as solid as wet toilet paper. The location of the

tear is also an indicator for “primary repair.” A rupture in the middle of the ligament requires

Tommy John. But if the tear is at either end of the ligament, where it attaches to a bone, then

the “primary repair” is possible.

 

The “UCL repair with internal brace construction” – its full clunky name – begins with repairing

the ligament and anchoring to the bone. A bracing system is then constructed out of tape to

help promote healing in the area. That’s the recent advancement, one made possible by Arthrex

tape. Paletta said he and others are borrowing from procedures used to repair ankles and knees

to address an injury in the elbow. The clear benefit of this “primary repair” is that it addresses

the native ligament, and thus doesn’t require a graft and the time that takes for a rebuilt

ligament to assimilate.

 

“We’re repairing the existing ligament and reinforcing it with a scaffold that provides increased

strength for healing from time zero,” Paletta said. “From the get-go.”

 

That also allows for a quicker return to pitching.

 

"The Maness"

 

Three weeks ago, Paletta cleared Maness to begin throwing. For Tommy John pitchers, the long

toss program is eight to 10 weeks. For Maness, it was four. Tommy John pitchers won’t begin

their throwing program until five months or more after surgery; Maness started four months

after surgery. Lance Lynn missed all of last season recovering from November 2015 Tommy

John surgery, and he and Maness are both expected for opening day.

 

From 2013-15, Maness was one of the leading strike-throwing relievers in the majors. Of the

178 relievers in that time who had at least 100 appearances, Maness ranked seventh in walk

rate (4.4 percent) and third in double-play rate (12.91 percent). He led all relievers by stranding

144 of the 215 runners he inherited.

 

The next closest was 91.

 

Throughout 2016, however he felt his arm sag and his results follow. He watched “as my game

just slowly fizzled away,” Maness said, and blamed his mechanics until the damage in his right

elbow was discovered. Paletta outlined several options for him – and one was the dreaded

Tommy John, the vaporization of a year, and the uncertain future. The other was a mouthful, a

surgery that didn’t have the snappy name but offered the possibility of a quicker return.

 

With each throw, Maness is helping baseball study the new technique’s potential.

 

It just needs a catchier name.

 

“Does he need Tommy John,” Berry suggested, “or a Maness?”

[Nafro]

I did my Clinical Biomechanics final project on TJS. This is an awesome post! Thank you.

[G-Snarls]

Damn

 

Nice

[G-Snarls]

Masahiro Tanaka next test case

[Pendleton]

Neat, here's hoping Maness turns out to be a success.

[Brownie19]

TL is on fire...

[TwistedLogic]

Masahiro Tanaka next test case

 

That's exactly who I was thinking of when I read this. Seems like the perfect candidate for it. Yanks should have put him under the knife last year. Wasted recovery time in a rebuilding year.

[glory]

Tanaka can opt out after this coming season, right? Can't see him doing it now. Should have done it last year.

[G-Snarls]

Neat, here's hoping Maness turns out to be a success.

 

I hope so

 

Would be great for him and the game

[G-Snarls]

That's exactly who I was thinking of when I read this. Seems like the perfect candidate for it. Yanks should have put him under the knife last year. Wasted recovery time in a rebuilding year.

 

Sounds like the right type of tear too. Partial tear that can be rebuilt before the whole thing ruptures and TJS is the only option

[G-Snarls]

It seems Matt Harvey might have been well suited for this too

 

Too late now

 

I wonder if he knew about this?? Was it considered?

Edited January 11, 2017 by G-Snarls

[P2F]

It seems Matt Harvey might have been well suited for this too

 

Too late now

 

I wonder if he knew about this?? Was it considered?

Harvey has TOS. I haven't read the article yet, but I'm assuming this wouldn't apply to him if it's geared towards TJ.

[P2F]

Relevant:

 

http://www.fanragsports.com/mlb/garrett-richards-key-angels-2017-season/

 

"Last season, the Angels struggled with both offensive production — despite Trout’s presence — and pitching injuries — losing Richards and Andrew Heaney to elbow ligament tears. While Heaney went on to have Tommy John surgery and will miss the entirety of the 2017 season, Richards has seen some success with an innovative stem-cell therapy program aimed at repairing or bolstering the ligament without the need for straight-up replacement. Per recent reports, Richards is throwing again, and will be ready for Spring Training and beyond.

[TholesWeirdEye]

This article got my dick hard.

[Frag]

Seth Maness surgery has a nice ring to it.

[TwistedLogic]

Seth Maness surgery has a nice ring to it.

 

"The Maness Procedure"

[Krylian]

I'm curious where his velocity compares. For TJ, a lot of times the pitcher ends up throwing even harder?

 

I do remember that Tommy John himself used to be a flame thrower...but was a soft tosser afterwards. I know Maness usually sits around 90 so that's possibly a reason he was a good candidate. It's not like he needs to get back up to 98 or anything.

 

Being the first just means you're a guinea pig. I hope it works out great for him...but I'm worried that he may not be the same. Fingers crossed.

[BTS]

Tanaka has been worth 6.9 fWAR and 8.2 RA-9 WAR over the last two years. You guys sound ridiculous saying that he made a mistake not getting a risky surgery that would have taken him for at least 12 months.

[Krylian]

Tanaka has been worth 6.9 fWAR and 8.2 RA-9 WAR over the last two years. You guys sound ridiculous saying that he made a mistake not getting a risky surgery that would have taken him for at least 12 months.

 

The perception is that he's doing it with smoke and mirrors. I think a lot of people would like to see what he'd do if he had the stuff when he first came over.

[Laika]

I'm curious where his velocity compares. For TJ, a lot of times the pitcher ends up throwing even harder?

 

I believe this is a myth.

[BTS]

The perception is that he's doing it with smoke and mirrors. I think a lot of people would like to see what he'd do if he had the stuff when he first came over.

 

Has the stuff gotten worse? His average fastball velo was 91 in 2014 and 92 in 2015 and 2016.

[Laika]

Has the stuff gotten worse? His average fastball velo was 91 in 2014 and 92 in 2015 and 2016.

 

no. people are stupid.

[John_Havok]

I believe this is a myth.

 

It's a myth for sure. Most people don't take into account that a pitcher usually sees a slow decrease in velocity in the time leading up to the surgery, and therefore come back throwing harder than that. But comparing healthy velocity to hurt velocity is not evidence of anything of course.

 

However, I have read (and I can't remember where now...) an article or two that did show some pitchers throwing harder after the surgery than their healthier earlier career speeds. Thing is, the surgery was not the reason for the increases, but rather the more focused throwing, strengthening and stretching exercises that the pitchers did during their recovery, and continued to do after getting back to their full strength. Basically, they never knew they weren't actually at their full strength before, but maybe could have been if they'd been doing the same exercises before the surgery. And the difference was like .7 -1.2 mph or something.

[TwistedLogic]

However, I have read (and I can't remember where now...) an article or two that did show some pitchers throwing harder after the surgery than their healthier earlier career speeds. Thing is, the surgery was not the reason for the increases, but rather the more focused throwing, strengthening and stretching exercises that the pitchers did during their recovery, and continued to do after getting back to their full strength. Basically, they never knew they weren't actually at their full strength before, but maybe could have been if they'd been doing the same exercises before the surgery. And the difference was like .7 -1.2 mph or something.

 

This is more common and a guy like Delabar is a good example of it. Most of the activities you'll do in your rehab are just good exercises in general to gain strength and precision.

[Nafro]

That's exactly who I was thinking of when I read this. Seems like the perfect candidate for it. Yanks should have put him under the knife last year. Wasted recovery time in a rebuilding year.

 

So you have to understand this is not necessarily a fix to "repair" partial tears in the sense you might think. I have to research more, but it seems that it is a re attachment and use of the new arthrex tape of the existing ligament to the bone. If the tear or partial tear is too far away from where it attaches to the bone; TJS will likely still be required. Point is, it would depend where Manaka's partial tear is, in respect to the bone, to make him a candidate.

[Nafro]

http://www.fangraphs.com/fantasy/primary-repair-surgery-returning-pitchers-to-the-field-faster/

 

I'd like to think my last post described this blog post in one paragraph....