Tommy John surgery has saved the playing careers of thousands of amateur and professional baseball players since surgeon Frank Jobe developed it in 1974. Jobe tried out the orthopedic procedure, technically known as ulnar collateral ligament reconstruction, on pitcher Tommy John, who went on to pitch for 13 more years and retired from baseball at age 46.

Most Major League pitchers (87 percent) are able to return to pro baseball, though most also see a decline in performance after surgeons replace the torn ligament, usually with a tendon from another part of the pitcher's body, according to this 2014 study.

But like a double-header that goes on too long, having the operation a second time doesn't work out nearly as well, according to new research released Tuesday. When surgeons Robert Keller and Bill Moutzouros of Henry Ford Hospital in Detroit looked at 33 pitchers who had the surgery a second time, they found that only 65.5 percent were able to return to pro ball. The ones who did had shortened careers and threw fewer innings than 33 statistically matched pitchers who hadn't had the surgery. Their performances, as measured by baseball's copious statistics, were about the same.

With one Tommy John surgery, "there's a good chance you're coming back," Keller said in an interview. "You're probably not as good as you were before, but you're near to where you should be.

"When you have a second one, you may not come back, and if you do, you won't pitch as much and you won't pitch as long."

The paper has been accepted for publication in the Journal of the American College of Sports Medicine and was presented at the annual meeting of the American Academy of Orthopedic Surgeons this week.

Keller and others have used the word "epidemic" to describe the rash of surgeries needed to reconstruct elbow ligaments injured by the stress of throwing a baseball at high speeds for many years. By one count, there were 36 in 2012 alone.

Pitchers "put a tremendous amount of stress on the inside or middle part of their elbow," Keller said. "It's a huge amount of stress for one pitch, and then these pitchers are throwing so many pitches."

But many fewer players have the surgery more than once (former Cincinnati Reds pitcher Jose Rijo had it done three times), and the new study may help show why. Even if they are able to return to the Major Leagues, the two-timers played 0.8 years less than similar pitchers (3.2 years vs. 4 years) and they threw only about half as many innings as they did before the second surgery. (It's not clear whether that is because they weren't physically able to accomplish the task, or whether managers purposely limited their time on the mound because of the second surgery, Keller said.)

"Anything in medicine, the second time around or a revision surgery ... all of them have increased risk of worse outcomes," said Keller, who has performed Tommy John surgeries himself. In this case, there may be scar tissue in the elbow, the blood supply may not be as good, and tunnels drilled in the bone for the first operation my not be usable, he said.

If pitchers do make it back, however, the study shows that they appear to be able to perform at a Major League level and sustain that level of performance.

Keller said the trend toward specialization in kids' sports is probably behind the rise in ligament tears.

"Little Johnny is not playing baseball, football and basketball," he said. "Little Johnny is just playing baseball." And often he's just pitching, rather than learning other skills.

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