Tag Archives: graft

What is Tommy John surgery?

Baseball card of Tommy John for the Los Angeles Dodgers
From Zellner, “A History and Overview of Tommy John Surgery,” Orthopedic & Sports Medicine Specialists

In July of 1974, Tommy John, pitcher for the Los Angeles Dodgers, felt a twinge in his throwing arm, and could no longer pitch. Dr. Frank Jobe tried a new kind of surgery on John’s elbow, and after missing only one season, Tommy John returned to the mound in 1976 and continued pitching until 1989.

How?

The surgery which bears Tommy John’s name is by now a common buzzword in the baseball community. Over 500 professional and hundreds of lower level players have received this treatment, but even the most avid fan may still be unsure what it means.

Tommy John surgery is the colloquial name for surgery on the Ulnar Collateral Ligament (UCL). This ligament is vital to the elbow, especially in the throwing motion. Injury to the UCL accrues over time; fraying and eventual tearing occurs after repeated and vigorous use. Baseball pitchers, throwing around 100 times per game and at speeds upwards of 100 mph, put themselves in danger of UCL injury.

Location of the Ulnar Collateral Ligament in the human arm, shown on a baseball pitcher.
Image from Wikimedia Commons.
Tendons in the elbow joint, with the Ulnar Collateral Ligament marked
Image from Wikimedia Commons

What can be done when a player injures his or her UCL?

Prior to 1974, not much. Ice and rest, the most common suggestions, would do little to improve serious UCL damage. A “dead arm” spelled the end of a player’s career. Dr. Jobe would change that. 

Jobe removed part of a tendon from Tommy John’s non-pitching forearm and grafted it into place in the elbow. John’s recovery required daily physical therapy before slowly starting to throw again.

Since Jobe’s pioneer surgery on Tommy John, most patients undergo a similar kind of reconstruction procedure. A tendon from either the forearm (palmaris longus) or the hamstring (gracilis), is looped through holes drilled in the humerus and ulna, the bones of the upper arm and inner side of the forearm. In some modern cases, the hope is to repair the UCL with a brace that lets it heal itself rather than total replacement. This allows for faster recovery time because the new blood vessels that have to form in traditional ligament replacement are unnecessary. In either case, athletes recovering from UCL surgery, a procedure which itself takes less than two hours, typically require at least a year to restore elbow stability, function, and strength.

Some misconceptions about Tommy John surgery exist. One 2015 study found that nearly 20% of those surveyed believe the surgery increases pitch speed. However, increase in pitch speed may be affected more by the extensive rehabilitation process rather than the new tendon itself.

The study also found that more than a third of coaches and more than a quarter of high school and collegiate athletes believe the surgery to be valuable for a player without an injured elbow. This perception of Tommy John surgery makes it seem like a superhuman kind of enhancement, as if out of The Rookie of the Year, or worse, it becomes like a performance enhancing drug. In reality, a replacement UCL at best replicates normal elbow behavior. A procedure capable of creating a superhero might be attractive, but for now, Tommy John surgery just helps players get back in the game.

 

For further information:

 

How Many MLB Players Have Had Tommy John Surgery?

Brace yourself… You might need surgery

A surgery? For my PCL? Could be more likely than you think.

Usually hiding behind it’s annoying and commonly ruptured brother the ACL, the PCL (posterior cruciate ligament) is a durable ligament that usually doesn’t cause problems for athletes… until it does.

Because of the strong nature of the ligament, injuries that tear the PCL are usually sudden and traumatic. Think car accidents, falling hard on a bent knee… you get the picture. When enough force is applied to the top of the tibia, the tibia can be pushed backwards, past the threshold of the PCL. Even though the PCL does its best to hold your femur and tibia together in the right spot, it just doesn’t hold up to the brute force of a dashboard. These injuries can usually be diagnosed by the presence of a “sag.” When your doctor holds your bent knee up, it looks like your shin bone is sagging underneath your knee. This is your torn PCL crying for aid.

A photo showing the location of the PCL and ACL inside of the right knee. The ACL crosses from left to right over the PCL. Both are attached at the top to the femur and at the bottom to the tibia.

When it comes to fixing these injuries, the nonsurgical approach has typically been recommended for low-grade tears that don’t totally rip the PCL apart. These braces are attached to the leg right above the knee, and are supposed to hold the bottom part of your leg under the knee in place. This prevents from your knee from going too far forwards and backwards, and allows scar tissue to build up over your PCL. While your body tries to heal itself with scar tissue, you will work with a physical therapist to build up your quad strength and restore your range of motion. Over 80% of athletes are able to return to play after bracing their knees.

A PCL brace is shown in place on a knee. There are two stabilizing straps above the knee, and two below the knee. They are connected by a metal frame that meets at a hinge joint over the side of the knee.

However, surgery, which was once only reserved for extreme PCL tears, is now seen as a viable, cost-efficient option for even low-grade tears. PCL surgery is intended to restore normal knee biomechanics and stability to about 90% of their post-injury strength. Sometimes, a part of the Achilles tendon is used to create a graft, or a “new” PCL. This is called an allograft, and results in safer and shorter surgeries (8). Within a month, the athlete can walk and bear their own weight. After six months, athletes are able to return to sports.

In theory, surgery sounds like the most “permanently good” option there is for fixing your PCL. However, no scientific studies have yet been done that can accurately compare the return-to-play rates, or even the relative healing of people in braces versus people who immediately got surgery. When people don’t comply with their treatment plans (aka, take off their braces early, skip physical therapy after surgery, etc.) the data for comparisons between bracing and getting surgery aren’t clear. While your PCL may be out of commission, so is the jury on this one. At the end of the day, the best treatment method for you is dependent on the mechanism of injury, severity of your injury, and whether you plan on listening to your doctor or not!

For more info on PCLs:

Posterior Cruciate Ligament Injury

Management of PCL tears

ACL Reconstruction: Which Option Is Best For You?

200,000 ACL injuries occur each year, and ACL reconstruction is the 6th most performed surgery in the United States, so to come back bigger, faster, and stronger, the right recovery path is critical.

The anterior cruciate ligament (ACL) is a critical part of the knee joint that connects the femur (‘thighbone’) to the tibia (‘shinbone’). Its main functions are to support the knee joint during side-to-side motion, such as cutting, shuffling, or pivoting, and to prevent the tibia from moving too far forward relative to the femur. When an ACL ruptures, it is very common to reconstruct it to bring someone back to performance level.

Location of the ACL inside the knee joint with other labeled bones and ligaments with another diagram showing a ruptured ACL.
Image from Wikimedia Commons “Anterior Cruciate Ligament”

The basis of ACL reconstruction is using living tissue, also known as grafts, to replace, and function as a substitute, for the torn ACL. There are four types of ACL reconstruction surgeries that use different types of grafts. Those four types of surgeries are classified as autograft reconstruction, allograft reconstruction, xenograft reconstruction, and synthetic reconstruction. Autograft surgeries require one’s own grafts to repair the ACL, allografts require a cadaver’s grafts to repair the ACL, xenografts require an animal’s grafts, and synthetics require manufactured materials. Additional articles on xenograft reconstruction and synthetic reconstruction can be accessed here and here.

Each surgery requires the removal of the damaged ACL, and then the incorporation of a new substitute by tunneling the newly selected graft through the femur and tibia. Within the autograft group, the two popular grafts for reconstruction are patellar tendon and hamstring tendon, with quadricep tendon being another, less popular, choice. The patellar tendon surgery takes the middle third of the patellar tendon, a tendon that connects the kneecap to the tibia, and makes sure to include the bony ends.

The hamstring tendon surgery takes two small slivers of each of the two hamstring tendons, connecting the hamstring muscle to the tibia, coils them up, and then finally bundling them to increase strength.

A knee joint with bones, ligaments, and tendons labeled.
Image from Wikipedia “Knee Joint”

For the allograft surgeries, a surgeon may select an Achilles, patellar, hamstring, or quadricep tendon from the donor.

It is very important to choose the right surgery. While the determination of which surgery and technique to perform falls heavily on the surgeon’s and patient’s preference, there are advantages and disadvantages of each technique which tend to persuade the choice of surgery. The main concepts surrounding the decision of which surgery to perform are the activeness of the patient, muscle strength, and previous knee injuries. Depending on the job, sport, or activity of the patient and the desired return time, one technique may be a better fit.

For a patient participating in low demand activities, allograft surgery may be the best fit due to less post-surgery pain and quicker surgery time, however it is very expensive and offers less tensile strength compared to autografts. As for autograft surgeries, patellar tendon reconstruction allows faster recovery time due to the bone-to-bone bonding and offers a strong substitute for a torn ACL, however future knee pain is very common. Hamstring tendon reconstruction requires more recovery time; however, the post-surgery pain is significantly less than the patellar tendon reconstruction and the tensile strength of the hamstring tendon is the strongest possible substitute.

Additional reading and comparisons between the popular autografts and allograft techniques can be accessed here and here.

The Spinal Fusion that Reignited a Legendary Career

Can you imagine being the best player in the world at a certain sport and one day, aggravating an injury that not only put your athletic career in doubt, but also did not allow you to do normal daily activities? This is the challenge that faced Tiger Woods.

Tiger Woods is one of the greatest golfers to ever play the sport but has been plagued with back issues over the past few years that have prevented him from winning and also playing in golf tournaments. A golf swing applies a significant amount torque to one’s back. Repeating this motion as many times as Tiger has, through practice and tournaments since he began his career, caused him to have chronic back issues that had to be dealt with. In order to deal with these back issues, he had three back surgeries over the course of three years. After these, he was still unable to not only golf but also do daily activities without pain such as get out of bed, or play ball with his kids. Tiger was at a crossroads, and decided to get a spinal fusion surgery.

An image of the spine with the three regions labeled: cervical (upper region), thoracic (middle region), lumbar (lower region)
Taken from Wikimedia Commons

The spine has three regions: cervical, thoracic and lumbar. The cervical region is in the upper spine near the neck, the thoracic region is in the middle of the spine and the lumbar region is in the lower back. The lumbar region takes the majority of force in a golf swing and is where Tiger had his fusion done. In the spine, discs are in between each vertebra. The disc acts as a shock absorber and allows for slight mobility of the spine. Tiger had a severely narrowed disc in between two of his vertebrae in the lumbar region due to the previous three back surgeries he had. In order to be pain free, that disc had to be removed. This brought about the discussion of him receiving spinal fusion surgery.

 

Spinal fusion surgery is a process which removes the problematic disc from the spine and inserts a bone graft in place of the disc. A plate with screws is then placed in the vertebrae above and below the bone graft. The plate helps with the healing process and over time, it will heal as one unit. The essential goal of spinal fusion surgery is to take two vertebrae in your spine and make them act as one. When these two vertebrae become one through the surgery, it eliminates motion in between them and hopefully, removes the pain as well.

This is an image of a spinal fusion surgery with screws helping to hold the vertebrae together
Image taken from Wikimedia Commons

This spinal fusion surgery was a huge success for Tiger and allowed him to keep playing golf at a high level. Through his win at the 2019 Masters tournament, it’s safe to say that he has at least a few more years of winning tournaments and playing competitive golf before calling it a career.

Additional information and sources used can be found here and here. 

 

Can we 3D print our own skin?

Can you imagine a world where amputees receive replacement limbs which are able to detect temperature and pressure like an actual limb? How about a world where when you get a cut, you can 3D print some of your own skin to patch the wound?

To the average citizen, this might seem like something out of a science fiction movie. To researchers at the Graz University of Technology, the Wake Forest School of Medicine, and the Universidad Carlos III de Madrid, this is a reality that they are helping bring ever closer. Both of these scenarios are discussed in a recent article by Mark Crawford, who investigated the recent breakthroughs in 3D printing human skin and creating sense-sensitive artificial skin.

photograph of an arm reaching into the sky to feel the rain in the palm of their hand
photo by Alex Wong on Unsplash

At the Graz University of Technology, researchers are working on creating an artificial skin that can sense temperature, humidity, and pressure. Currently, artificial skins can measure one sense at best, but with the use of the nanoscale sensors that these researchers are developing, sensing all three at once could be possible. This is achieved through the materials that the nanosensors are created out of: a smart polymer core and a piezoelectric shell. The smart polymer core can detect humidity and temperature through expansion, and the piezoelectric shell detects pressure through an electric signal that is created when pressure is applied. With this technology, prosthetics could be made which could allow the wearer to retain some of their lost senses.

At the Wake Forest School of Medicine, researchers have created a handheld 3D printer which produces human skin. This device could be used to replace skin grafts, as it can apply layers of skin directly onto the wound. Through the use of bioink, this handheld printer can create different types of skin cells. After scanning the wound to see what layers of tissue have been disrupted, it can print the appropriate skin needed to correct the injury.

Photograph of the 3D skin printer created at the Universidad Carlos III de Madrid, which is still in its prototype phase.
modified from Crawford, ASME January 2019

At the Universidad Carlos III de Madrid, researchers are also 3D printing human skin using bioink. They are creating both allogenic and autologous skin to create the optimal skin, which is a combination of the patient’s own cells and cells created from a stock. Although they have managed to print functioning skin in its natural layered state, it is tricky to create the cells in such a way that they do not deteriorate.

It is also tricky to correctly deposit the product. To illustrate, more research needs to be done on the mechanical properties of artificial skin before it could be used on humans. The artificial skin must be able to stretch and react to tension in a similar manner to the real skin it will be connected to. Additionally, researchers must figure out how to safely send the signals the artificial skin is detecting to the brain.

Overall, both advancing artificial skins and 3D printing human skins could largely impact humanity. Even though we have yet to use these skins on people, they are already being used in industries, such as L’Oreal, to limit testing on humans and animals. Already, these skins are being used on robots, as seen in this video, to help prepare the skin for human transplant:

 

Interested in seeing more? Check out some more articles on the advancement of artificial skin from Caltech and Time.

Exciting Advance in ACL Repair

Anterior Cruciate Ligament (ACL) injuries are among the most common in sports, with nearly 100,000 tears annually. Additionally, the rate of pediatric tears has been increasing at a rate of 2.3% each year for the past 20 years. The high incidence of this injury is in part due to the structure of the knee complex, where the ACL is located. The ACL helps connect the two longest bones in the body and is responsible for rotation and transferring body weight to the ankle. Specifically, the primary functions of the ACL are to prevent the tibia from sliding too far in front of the femur and to provide rotational stability to the joint. This rotational motion, combined with a lack of muscle support at the knee, is why so many athletes tear their ACL. A recent paper looked into how a team of doctors led by Dr. Martha Murray at Boston Children’s Hospital have come up with a promising new approach to repairing the injured ligament.

Two side views of the knee joint, one showing a healthy knee and one showing a complete ACL tear.
Photo by BruceBlaus on wikimedia.org

Due to its environment, ACLs do not repair on their own like other ligaments do. The synovial fluid, which resides in the knee complex to reduce friction in the joint, limits blood flow to the ACL and PCL (posterior cruciate ligament). When injuries occur to these ligaments, the lack of blood flow prevents clotting. In most other ligaments, clotting would occur and would function as a “bridge” for the two ends of the torn ligament to grow and heal across. Due to ACLs not being able to undergo this process, the current method for repair is to take a graft from the patient’s hamstring or patella and replace the torn ACL with the new graft. While this method is typically successful, Dr. Murray’s team estimates that the re-tear rate is about 20% and up to 80% of patients develop arthritis in their knee 15-20 years after the surgery. To combat this, Dr. Murray drew inspiration from how other ligaments heal and developed Bridge Enhanced ACL Repair (BEAR). The premise of this technology is to take a “sponge” that is composed of proteins that are naturally found in the ACL, and insert it between the torn ends of the ACL.  Using sutures, the sponge is moved into position and the two ends of the ACL are pulled into the sponge. Blood is then drawn from the patient and inserted into the sponge. This environment acts as a blood clot and stimulates the ACL to repair itself. Clinical trials have shown that the sponge resorbs completely after 8 weeks, at which point the two ends of the torn ACL have begun to join back together. While the BEAR treatment is still relatively new, early results are encouraging with patients seeing similar results to patients that undergo traditional ACL reconstruction. Though it is difficult to predict the rate at which patients who receive BEAR treatment will develop arthritis, animal testing has shown lower instances of osteoarthritis development, which is promising news for those who suffer from this common injury.

For more information about the BEAR technology check out Boston Children’s Hospital website or this recent article. A short video detailing the technology can also be seen below.