April 1, 2004
Under The Knife
Special Report: Advances in Labrum Surgery Discovered
For the last decade, pitchers have not feared elbow surgery as they once did. Advances in surgical techniques and rehabilitation have made what was once a career-threatening condition a routine procedure with a predictable outcome. Return from Tommy John surgery has been reduced from two years in the late '70s to a mere nine-to-12 months today.
The same cannot be said for shoulder injuries. Instead of surgical repair, the best techniques have been those of prevention. Dr. Frank Jobe's "Throwers Ten" program has led to a reduction in the number of rotator cuff injuries at all levels of baseball, but at the same time, there has been an explosion of a new type of injury--the labrum tear.
As pitchers fell to this new menace, surgical techniques and rehabilitation seemed useless. Most doctors had given way to 'conservative management,' a practice of non-invasive treatment of symptoms in hopes that a pitcher could somehow remain effective just a little bit longer. Some players, especially older ones, began thinking that the outbreak of labrum tears was some kind of gimmick. "You know what causes labrum tears?" asked Hall of Fame pitcher Jim Palmer. "MRI scans. No one had ever heard of labrum tears before these things. We didn't even know we had labrums. I don't think I have one now."
In the face of unacceptable losses to the injury and a dearth of advances, teams struggled to address the issue. Some use denial, while others try to prevent the injury with strict pitch counts. Research across the country failed to find results even while surgical techniques were standardized.
But in July of 2003, a study was released in a medical journal, The Journal of Alternative Protein Structures, hitting the sports medicine community like a Roger Clemens fastball to the head. Researchers at St. George's University had discovered a technique to grow and insert an artificial labrum that both filled in tears and bonded to the existing cartilage. Early reaction was denial and disbelief, but only weeks later, the techniques described in the study were recreated by the Gstaad Institute in Switzerland and at Tarkio College in Missouri.
The Gstaad Institute's confirmation of the technique, fossal ortho-layering, was first used on skiers. Labrum injuries often occur when a skier or snowboarder falls and has the shoulder forcibly externally rotated. While the mechanism of injury is not the same as occurs in pitchers, the technique worked and several teams sent physicians to Gstaad to learn more about the technique. Using cartilage from cadavers, patients lucky enough to be admitted to the initial study had only one minimal problem. Some patients experienced rejection of the foreign cartilage and the matrix of newly grown tissue had to be removed.
As the Swiss researchers and physicians perfected the ortho-layering technique using microsurgical techniques, the team at Tarkio saw an opportunity to use a technology they had invented several years previous. To avoid the rejection, Dr. Madhu Satyanarayana used a soy-based protein polymer to build the protein matrix that was layered into the glenoid fossa. The matrix was then stimulated with an enzyme filtered from yet another agricultural product, the lentil. Support from the USA Dry Pea and Lentil Council and the American College of Orthopedic Research, the technique rapidly was perfected. The first human use of the soy-lentil protein was performed in December 2003 on an unnamed high school pitcher.
This pioneering pitcher, his identity still guarded due to his age, was able to begin a normal rehab just days after the procedure. Ultrasound scans showed almost complete fusion of the soy-lentil matrix with the remaining undamaged labrum. After three weeks, the resultant structure was scarcely differentiated from a healthy labrum.
Further refinement of the technique and studies on the best--or in this case, least invasive--methods of introducting the soy-lentil protein matrix into the affected shoulders is ongoing, but in February, the first fossal ortho-layering procedure was performed on a professional baseball player. This surgery, performed at St. George's University Medical Center under the supervision of Dr. Robert Lennon, was controversial, but early results for the patient, former major league pitcher Jose Rijo, have been encouraging.
Through a translator, I was able to speak with Rijo about the procedure. "I just want to play ball again," he said. "I've had every other surgery, so when the doctors told me this was an experiment, I didn't mind so much." Our translator told me that Rijo compared the scars from his multiple elbow surgeries to the small, puncture like marks on his shoulder. Looking more like pimples than evidence of a groundbreaking procedure, Rijo was able to move his shoulder through a nearly complete range of motion.
While I was not able to get to the Dominican, our translator was able to sit with scouts as Rijo went through a bullpen session. Afterwards, he lit a victory cigar as his representatives discussed a comeback with several teams. With his velocity in the upper 80s, Rijo may not be able to make it back to the majors, but he's serving as quite a proving ground for the procedure.
Two more fossal ortho-layering procedures are scheduled for early April, this time with younger players currently in the minor leagues. The teams involved are attempting to stay anonymous, but sources indicate that at least one is a top pitching prospect. Dr. Lennon will do both procedures at St. George's with team physicians observing.
One of the more remarkable parts of the story is the way that the patent, filed by Tarkio and its researchers, is not being used to enrich anyone. The technique of creating the matrix was put into the public domain in hopes that increased usage of the product would lead to increased demand for lentils, a mainstay of the northern Missouri and southern Iowa agricultural economy. "The soy-lentil matrix is the peoples," said Dr. Satyanarayana.