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

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

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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 potental trailblazer.

Maness is a week away from returning to the mound and expects to be ready for opening day, just seven and a half 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 12-month 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 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?”

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