May 5, 2021

TRANSCRIPT

Interviewer: Yeah. So, if you have some elbow pain while you're pitching, there is something you can do about it and actually something you should do about it. And there's a new procedure that might be the thing that you need.

Dr. Peter Chalmers is an orthopedic surgeon. He's an elbow specialist. He's also the current team physician for University of Utah baseball and Salt Lake City Bees Triple-A baseball. So if somebody does have elbow pain while they're pitching, where do you start with that diagnosis, Dr. Chalmers?

Dr. Chalmers: Yeah. Absolutely. So elbow pain during pitching, it's not normal to have really, really a sore elbow with pitching. And there can be a couple of different causes, and some of them can be problematic for the future for a pitcher. So, definitely, I think it's worth, after a period of rest, if the pain doesn't go away, seeing someone to be fully evaluated with, you know, having someone take a look at the elbow, and then potentially getting an MRI to take a look at the cartilage and the ligaments within the elbow.

Interviewer: All right. And if the condition happens to be something called an ulnar collateral ligament injury, then there's a procedure that's been used for a long time called Tommy John surgery. Tell me a little bit about that, and then we're going to talk about the alternative, which could be better for some patients.

Dr. Chalmers: Yeah. Absolutely. So, for a long period of time, if you tore your ulnar collateral ligament, the ligament on the inside of the elbow that basically holds the upper arm and the lower bones together when you pitch a baseball, if you don't have that ligament, those bones try and fall apart, and it's basically not possible to pitch a baseball. If you tore that ligament, historically, then your career was just over.

And there was a pitcher named Tommy John, who had that injury, and he went to a surgeon who said, "Well, there's got to be something we can do," and they invented this procedure to reconstruct or rebuild the ligament using a tendon graft. And that actually works pretty well, but it has a very long recovery. It takes about a year to get back to play because the new tendon has to become a ligament over the top of the old ligament. And that process is very slow.

So that was the historic way that we would treat ulnar collateral ligament injuries, and the pitcher that first underwent it, his name was Tommy John. So they're commonly referred to as the Tommy John ligament or Tommy John surgery.

Interviewer: And now there's a new procedure. So I've heard that considered called reconstruction, and now there's a new procedure that actually just repairs the ligament and has some better outcomes. So tell me a little bit about that.

Dr. Chalmers: The good thing about many of these ligament tears is often the ligament is torn right off of either the upper arm bone or lower arm bone side. And the ligament itself is still good quality tissue. So, historically, we would replace that whole ligament with a new tendon graft.

The new procedure is to repair the patient's own ligament and allow their own ligament to serve as their ligament going forward. That has a much quicker recovery and can get pitchers back to play in six months. So that's been a huge advance in our treatment for this injury and has certainly, for a lot of our players, granted them ability to get back to another season or even sometimes to get two seasons in depending on the timing.

Interviewer: So, when you're working with a pitcher, how do you determine which one of these two that you're going to use?

Dr. Chalmers: So there's a number of factors that go into that. Certainly, the appearance of the ligament on the MRI and the location of the tear play a role, but often during surgery, we'll also assess the quality of the tissue. And if the tissue is robust enough, then we can use the patient's own tissue to do the repair.

Interviewer: If it is an option, then is it just as good as the Tommy John surgery? You said, definitely, you could get back to playing faster. Is it as a robust of a repair?

Dr. Chalmers: It may be better.

Interviewer: Oh.

Dr. Chalmers: Some of our early data suggests that the rates of return to play may be higher after repair than they are after reconstruction.

Interviewer: And I understand another advantage of the ligament repair is if you have a younger athlete, that this would be an option where Tommy John surgery would not be an option. Tell me about that.

Dr. Chalmers: Yeah. Definitely, younger athletes have the highest capacity for healing. And so, in a younger athlete, this surgery can work very, very well, and that's who it's been performed in mostly to date. But in someone who's really young, if they have open growth plates, you may be concerned about performing a surgery with a ligament graft, where we may have to drill tunnels in the bone that may disrupt the growth in the future. So this is a nice option for that patient population.

Interviewer: And what does the recovery look like then? You said that the recovery is faster. You know, Tommy John surgery could take up to a year. How fast is this recovery, and what's the rehabilitation process like?

Dr. Chalmers: So as early as two weeks out from surgery, the patient begins moving their elbow. About a month from surgery, they begin strengthening. And the whole goal here is that you have to start strengthening early because as early as three months out from surgery, the pitchers will start throwing again.

Interviewer: Wow.

Dr. Chalmers: And the goal then is to get back to full play with full velocity, pitching full games by six months.

Interviewer: That sounds pretty amazing. Is that pretty amazing from your perspective as an orthopedic surgeon?

Dr. Chalmers: It's a huge advance. It's a huge change over the year, sometimes 18-month recovery we saw historically with reconstruction surgery.

Interviewer: Are there downsides to this type of repair?

Dr. Chalmers: Well, it's a relatively new option, and so we don't have 5 or 10-year outcomes with it so far. But so far, it appears to have few downsides as compared to the reconstruction. There had been some concern that if you do this surgery, it may make another surgery in the future more difficult. And so far, those have not appeared to be true, but there have been very few of those performed because it works so well.

Interviewer: And it sounds like this is a very specialized procedure still at this point. What advice would you have for somebody choosing an orthopedic surgeon to do this type of procedure?

Dr. Chalmers: Well, I think that one of the most important things patients need to understand is that surgery itself is a technical skill, and it's important to find a surgeon that you feel like performs enough of those procedures to feel competent at it. So, as a result, I think when you look for a procedure that's less common like this, you need to find a surgeon that feels comfortable and performs enough of them, that they'll have already worked through the kinks and make sure that they're not going to have any problems performing this procedure for you.

That's one of the benefits of coming to a place like the University of Utah, where you have specialists in a large variety of areas. It allows each of us doctors to find a smaller niche and then, as a result, to be better at what we do.

Interviewer: I want to talk a little bit about this procedure. So what is, in your mind, the youngest patient that you would do this type of a procedure on?

Dr. Chalmers: One of the things that is unique about this area of the elbow is that right above the ligament is a growth plate. So for people who are skeletally immature, it's very rare to have the ligament be injured. And the vast majority of those that are skeletally immature, the growth plate itself sees most of the injury, if there is an injury. As a result, we very rarely perform this procedure for anyone under the age of 14 really.

Interviewer: Is there anything else about this procedure that you feel that a patient or a patient's parents would be interested in hearing that I missed?

Dr. Chalmers: One of the things that I think is really interesting about this procedure and really important for people to understand is that we've talked historically about the reconstruction and the tissue within the reconstruction as though we can make you a new ligament. But I will tell you that the tissue that we bring in from somewhere else is not the same as what you were born with. It doesn't have the same nerve fibers. It doesn't have the same pressure fibers.

And we demonstrated that actually pretty elegantly recently in a study we did with the Angels, where we looked at the changes in reconstructed ligaments as compared to non-reconstructed ligaments over the course of a single season or off-season on ultrasound, and found actually that the ligaments that had undergone a prior reconstruction respond differently to stress than native ligaments. And I think that's probably because they don't have all of their normal sensors within them.

So one of the big benefits of this procedure is that it preserves all that. It preserves all the normal pressure sensors and nerve fibers within your own ligament and allows it to respond normally to stress in the future. So that's a real benefit of this procedure over the reconstruction, and one reason why I think we're probably going to head more and more in this direction in probably a lot of areas of our field in the future.

For Patients