Tommy John surgery: Cutting edge to commonplace

Tommy John surgery has become such a success, it's almost fashionable for pitchers to have elbow reconstruction.

Originally Published: August 13, 2003
By Jayson Stark | ESPN.com

Last week it was Ryan Dempster and Mike Fetters. The week before it was Denny Neagle. Before them it was Rick Ankiel's turn. And before him came Paul Byrd.

What do they have in common? They've all visited their friendly neighborhood Tommy John surgeon during the last month or so. And there will be more just like them -- next week, the week after and even more weeks after that.

Tommy John
Tommy John underwent an elbow ligament transplant in 1974, then won 164 games.
It's so commonplace now, this trip to the rebuilt-elbow shop, it's amazing that Major League Baseball hasn't created a new weekly award for it. You'd have your Player of the Week, your Pitcher of the Week and your Tommy John Patient of the Week.

John Smoltz. Kerry Wood. David Wells. Tim Worrell. Mariano Rivera. ...

There are so many esteemed "alumni" of Tommy John U. in the big leagues these days, we could put together a special Tommy John portion of the Cy Young ballot.

Tom Gordon. Scott Williamson. Rod Beck. Matt Mantei. John Franco. Billy Koch. ...

Are there any bullpens left in the big leagues that don't have at least one prominent arm fresh off the ever-churning Tommy John surgical assembly line?

A.J. Burnett. Bob Wickman. Scott Strickland. Brian Moehler. Seth McClung. ...

They're all out there doing their rehab right now after having Tommy John surgery in the last year. Heck, it's hard to believe we even put the "news" of these operations in the notes or transactions columns anymore -- because it's getting easier to keep track of which pitchers haven't had this surgery than which pitchers have.

So isn't it amazing to think that it was only 29 years ago that Tommy John headed into Dr. Frank Jobe's operating room to become the first ligament-transplant guinea pig?

Back then, what Tommy John was doing was almost as revolutionary as landing on the moon. Now, all these John Smoltzes and Kerry Woods later, it's almost as routine as going to the dentist. What a world.

Chad Fox, the just-released Red Sox reliever who is actually in the rarified Two Tommy John Surgeries Club, still laughs when he thinks about how cavalier his surgeon, Dr. James Andrews, was when he told Fox he was going to need his first operation, back in 1996.

"He acted like it was a walk in the park," Fox chuckled. "He goes to me, 'Ah, we'll just fix you up and you'll be fine. About a year or so, you'll be all right.' And then he left the room. I was like: 'This guy's acting like it was nothing, like I was getting my teeth cleaned.' "

Chat wrap: Tom Candiotti
Tom Candiotti took your questions about Tommy John surgery in chat.

Oh, it's not, of course. But only because there's a better chance of something going wrong with the teeth-cleaning machine than there is of something going wrong when Dr. Andrews or Dr. Jobe is borrowing some tendon from your wrist or hamstring to replace your blown-out elbow ligament.

There are no guarantees in medicine, but Tommy John surgery is about as close as it gets. Jobe and Andrews now estimate there is a 92-to-95-percent chance patients will recover from Tommy John surgery as good as new. Maybe better.

And when the patients hear that, laughs Andrews' rehabilitation specialist, Kevin Wilk, "they like those odds."

Which is more than could be said for Tommy John.

One in a hundred. Those are the odds Jobe gave John. But Jobe admits now they weren't even that good. After all, there was no Plan B back in 1974.

"He realized," Jobe told ESPN producer Jim Witalka, "that the options were to go back to Terra Haute, Ind., or to have the operation, with a high risk of failure."

As we all know now, that operation was a success. The day he had his surgery, John owned 124 career big-league wins in 355 games. He won 164 more games after the surgery, which prolonged his career 405 more games over 14 years.

And that's how this monster was born.

It's a beautiful thing. But in some ways, it's not. Sometimes, we aren't sure which. So we'll let you make up your own mind:

The Beautiful
Any invention that keeps John Smoltz's career alive and well can't be all bad.

Any invention that means Kerry Wood's career isn't over at age 21 has to be a good thing.

Any invention that allows the great Jose Rijo to return to a pitcher's mound after losing six years of his career -- after appearing on the Hall of Fame ballot, in fact -- has to have its merits.

We don't dispute any of that.

Tommy John Alums
Pitchers who have had Tommy John surgery:

IN THE PAST YEAR
Jon Lieber
Denny Neagle
Bob Wickman
Paul Byrd
A.J. Burnett
Ryan Dempster
Rick Ankiel
Scott Strickland
Brian Moehler
Mike Fetters
Seth McClung

HAD IT TWICE
Darren Dreifort
Jose Rijo
Chad Fox
Nate Bland
Lance Carter

PAST AND PRESENT CLOSERS
John Smoltz
Mariano Rivera
Jason Isringhausen
Scott Williamson
Billy Koch
Matt Mantei
Jeff Zimmerman
Mark Wohlers
John Franco
Tom Gordon
Kerry Lightenberg
Tim Worrell
Rod Beck
Lance Carter

STARTERS
Kerry Wood
Matt Morris
David Wells
Odalis Perez
Paul Wilson
Kris Benson
Garrett Stephenson
Scott Erickson
Corey Lidle
Adam Eaton
Pat Hentgen
Steve Sparks
Paul Wilson
Sterling Hitchcock
Kevin Jarvis
Joe Roa

SET-UP MEN
Jason Christiansen
Cal Eldred
Doug Brocail
Lance Painter
Michael Tejera
Danny Patterson

MOST WINS AFTER
TOMMY JOHN SURGERY
David Wells, 197 (through 8/13)
Tommy John, 164
Tom Candiotti, 151
Before Tommy John surgery, there would have been no second chapter for any of those men -- or any of the 75-100 other pitchers currently walking around the major leagues after having their elbows reconstructed.

Think about all the great pitchers we never got to see, 40 and 50 and 60 years ago. Think about all those guys whose careers ended the day they heard their elbow pop.

"In those days, when someone did that," Jobe said, "they were just sent back to the farm -- and they would get another pitcher."

So we're all for technology marching on, especially when it allows people to chase a dream they never could have chased without it. And that's Tommy John surgery at its best. It is medical science's way of preserving dreams -- and careers.

"Too bad," said Tommy John "graduate" Tom Candiotti, "they didn't have this back with Sandy Koufax."

If they had, at least Koufax wouldn't have to talk his way onto the operating table like Candiotti did back in 1981. As a minor-league pitcher in the Brewers' system, Candiotti has to convince Jobe he was worthy of being operated on.

"I'll never forget what Frank asked me at the time," Candiotti said. "His words were: 'Are you a prospect?' I guess he probably didn't want to do this operation just to any guy that came into his office. He said he'd done eight of these operations previously -- 'and the only guy that's come back has been Tommy John.'"

But Candiotti talked the doc into it -- and was pitching in the big leagues not much more than a year and a half later. In his second start, he even faced -- and beat -- John, in what the newspapers described as the "Battle of the Reconstructed Arms." Candiotti kept pitching for another 17 years -- and now sends Jobe a Christmas card every year, which he signs: "Your Prospect."

Candiotti is part of the reason the world of Tommy John surgery has come so far so fast, because there are so many success stories just like his.

Andrews says he now does more than 150 Tommy John surgeries a year, that he recently performed seven in one day. We know of five pitchers who have been on big-league rosters this season who have even had it twice: Rijo (Reds), Fox (who just signed with the Marlins), Lance Carter (Devil Rays), Darren Dreifort (Dodgers) and Nate Bland (Astros).

The true measure of exactly how far Tommy John surgery has progressed isn't any of those guys.

It's Jon Lieber.

It has been one full year (plus a few days) since Lieber walked off the mound at Wrigley Field for the last time, knowing something was very wrong with his elbow. He had the surgery a week later, on August 8, 2002. The Cubs waved goodbye after the season. He is under contract with the Yankees now.

Lieber hasn't thrown one pitch for them yet. But in one way, Lieber might be looked back upon some day as the pitcher who changed the world of Tommy John patients almost as much as John did. Why? Because last winter, only five months after his surgery, the Yankees were so confident it would transform him back into the 20-game winner he used to be, they gave him a two-year contract.

It was a condition Lieber and his agents, Rex Gary and Jim Turner, asked for, because they knew that if he'd taken only a one-year deal, he'd have been under pressure to do the one thing Tommy John patients are told never to do -- rush it.

Lieber
Lieber

"I just didn't want to be put in that situation," Lieber said. "So I was looking for something that was comfortable, where we knew this year, if there was no way of me pitching at all, so be it. The main concern was having me healthy for the 2004 season."

As sensible a concept as that might be for the patient, it seemed a lot to ask in the buyer's free-agent market of last winter. But the Yankees had no problem with it. They signed Lieber to a deal that included a $500,000 signing bonus, a $2.45-million salary for next year and an $8-million option for 2005.

"When we looked at Jon Lieber," said Yankees GM Brian Cashman, "we knew he'd be done most, if not entirely, this season. But we were looking at our rotation and how it's set up for the 2004 season, and we recognized that we had three potential free agents in our rotation this year, in Andy Pettitte, David Wells and Roger Clemens. ... So you look for alternative ways that could assist you and lower your payroll, and you take a little chance with a high upside.

"In Jon Lieber's case, coming off the Tommy John surgery, the success rate of those guys coming back is extremely high. We felt, if we moved on him like we did this past year, and rehabbed him ... it would actually be a low-risk, high-reward type move, that we could have a bird in hand in this rotation and at least fill one of those three slots."

So Lieber's contract now figures to become the benchmark for all veteran pitchers with any kind of track record who have Tommy John surgery in midseason. And the reason is as basic as a 2-and-0 fastball: Just do the math.

It normally takes a year for a pitcher to make it back from the surgery -- and often a year and a half before he's pitching like himself again. So anybody who has the operation in the middle of a season and then signs a one-year deal would feel that clock ticking.

But a two-year contract means the rehab becomes the priority, not the comeback date. So if Burnett, Dempster and Strickland, among others, don't ask next winter for a deal with an almost identical structure to Lieber's, something's wrong.

A two-year contract for a Tommy John patient isn't a sign that baseball contracts are now officially like hitting the lottery. It's a sign that the procedure has become probably the safest bet in modern sports medicine. And that's good ... but maybe a little too good.

The Not-So-Beautiful
They come streaming into the offices of orthopedic surgeons from coast to coast. They're not just asking if they're candidates for Tommy John surgery. They're practically begging to have it.

"The big joke in the locker rooms now," Candiotti quipped, "is that, hey, when they sign this kid, you might as well send him right to Dr. Jobe now, or Dr. Andrews, have him do the operation and get it out of the way early."

Well, it hasn't quite come to that yet. But we're getting there.

We're not just talking about major-league pitchers and minor-league pitchers having this surgery anymore. We're talking about Little League pitchers.

Going under the knife
In repairing a torn ulnar collateral ligament, better known as Tommy John surgery, doctors replace the torn ligament in a person's elbow with a healthy ligament from either the person's hand, wrist, or forearm.

Dr. John Bergfeld, executive director of Cleveland Clinic Sports Health, told drkoop.com: "... the principle of the surgery is the same: to repair a ligament that is frayed and torn with an accessory tendon from the arm."

The accessory tendon does not have a useful function otherwise and is usually taken from the hand, wrist or forearm. According to Bergfeld, 12 percent to 13 percent of patients do not have such a tendon in either arm, in which case one is taken from the leg or toe.

The ulnar collateral ligament is a band or sheet of fibrous tissue that connects two or more bones and supports the arm muscles used while throwing a ball. The ligament is located on the inside of the elbow. If the ligament is torn or damaged, it's impossible for a person to gain velocity while throwing a ball.

Andrews said he recently performed Tommy John surgery on a 14-year-old -- "and now it's not unusual at all to see a 16-year-old being reconstructed every day that I operate."

Now we ask you: How can anybody consider that a good thing?

"We've got a problem, a big problem in our young baseball players," Andrews told Witalka. "They're really getting mature baseball injuries before they really get to be (mature) baseball pitchers. And the reason is, they're overpitched -- (all because of) year-round baseball."

But it's too simple to say that year-round baseball is the only problem here. The larger problem is that we live in a world in which people think modern medicine can fix anything. And when the line blurs between a stomach ache and a blown-out elbow ligament, we've officially tumbled out of control.

"They come in," Andrews said, "and the younger the kid, I mean, they're just dying to get this operation. I think some of them think it's like wearing knee braces to protect your knees -- (so) if you get your ligament fixed, you'll have a stronger elbow. Of course, that's not true. So we have to be very careful."

One of the great myths that has grown up around Tommy John surgery is that undergoing the operation is like getting a brand new arm, so you'll actually be a better pitcher after surgery than you ever were before. But ask Kris Benson if that's true. Or Mark Wohlers. Or Pat Hentgen. Or Pete Harnisch. Or Scott Erickson.

Do some pitchers come back and throw harder than they used to? Yes. John Smoltz and Chad Fox are living proof -- but only because they're now throwing without pain, and all the rehabbing has made their arms stronger, not better.

"I was consistently a 92-93 (mph) guy," Fox said. "Now, all of a sudden, I come back (after his first surgery), and I was consistently 94-96. After my second one, I'd rushed it up to 98, and now I'm 94-96, and no problems at all. ... People are like, 'Why don't you go back for a third?' "

Sure. And then a fourth and a fifth and a 12th. Fortunately, some doctors are now imposing a two-TJS limit. So we'll never live to see the magic of a 10-time Tommy John patient pitching some night against an eight-timer.

What we might see, some day, is the next generation of elbow repair -- a fix-it right out of the Sci-Fi Channel.

"We may be able to develop gene therapy," Andrews hypothesized, "so that we'll be able to inject a substance into a young kid's ulnar collateral ligament and develop it twice as strong as mother nature would. We would hope that we could grow ulnar collateral ligaments in the lab -- and exchange parts."

And who among us can't wait for that. Our kids traded baseball cards. Our grandkids will trade elbows.

But that's a saga for another time, way out there over the horizon. The saga of Tommy John surgery, on the other hand, is now one for every time -- every day, every week, every month of every year, seemingly until Dr. Jobe, Dr. Andrews and their orthopedist brethren run out of elbows to operate on.

Jayson Stark is a senior writer for ESPN.com.

Jayson Stark | email

Senior Writer, ESPN.com

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