Out of the 2,741 pitchers to have Tommy John Surgery, according to Jon Roegele’s database, only one other major league pitcher — Jonny Venters — is a direct comp to have endured three Tommy John Surgeries and return to play.
Drew Rasmussen has endured three surgeries, but the third was a hybrid Internal Brace procedure. Jason Isringhausen (age 38-39) had a third elbow surgery, but it was reportedly not TJ.
Venters (age 33-34) pitched 42.1 innings before retiring after his third surgery (5.31 ERA/4.61 FIP).
Antone was faced with quitting or venturing into largely uncharted waters.
Tommy John surgery is something of a miracle. It’s extended countless careers. But multiple Tommy John surgeries creates nearly an impossible obstacle.
There have been 173 such cases and 59.8% have not returned to play. Those that did return generally had diminished ability.
Why is it so difficult to return?
I asked orthopedic surgeon Jeffrey Dugas — a pioneer of UCL Repair with Internal Brace surgery — last year why having a second TJS reduces the chance to return and performance.
“You’re putting another (tendon) graft on top of an already bulky piece of tissue, and that does change how the joint responds, how it creates tension… and holds the joint stable,” said Dugas of repeat ligament reconstruction. “You also have some healing issues because you’ve already drilled the bone and put tendon in there.”
The joint can lose mobility and become less stable.
Kremchek has performed nearly four thousand Tommy John surgeries at his facility in suburban Cincinnati. Kremchek highlights another reason for the failure rates: Father Time.
“We know that the longevity of a Tommy John at this level is about six years. It just is,” he said. “If you’re a 30-year-old pitcher in the big leagues and have it done, and you last six or seven years, it’s retirement age (if facing a second).”
One thing going for Antone? He was young to have a second Tommy John, let alone a third, at age 30 in 2024. He had more time remaining than many arms.
How have the surgeries changed the inner workings of his arm?
Antone’s first surgery on April 5, 2017 was “pretty straightforward,” he said.
He tore his UCL, and tunnels were drilled — two in his ulna and three through his right humerus to create a triangle tunnel configuration – through which to attach the new ligament graft. He did not have any other related issues.
His second surgery was more complicated.
That injury included an avulsion fracture, which is when a ligament or tendon pulls a fragment of bone away from its main structure. These injuries often occur after a Tommy John surgery as bone breaks from where the tunnels had been drilled in the initial surgery, weakening the bone. He also had a partial UCL tear.
“So, they tried to go in there and stitch that back down, drill the new hole, and reconnect the UCL,” Antone lamented. “Obviously, the second one didn’t work either. There were some issues with it. I think I was getting some fraying from where that bone broke on the flexor, where the flexor was sitting on top of that broken bone – not broken anymore but the fracture of where it was. I think there was some kind of friction happening there, which makes sense.”
That repair held for four years and four months before failing in spectacular fashion.
The MRI last spring revealed the flexor mass had ripped completely off the bone, taking a sliver of his humerus with it. There was no sharp pain because the pain receptors were torn away. The UCL had come loose again, though not torn this time. It was completely detached, freed like a rope that had finally slipped its mooring.
Should he even try and pitch again?
Said Kremchek: “I sat down and we had a heart to heart, tears on both ends.”
But what surprised Antone was how Kremchek remained optimistic even given the severity of the injury. One reason? Kremchek thought they had identified one recurring issue they could address with surgery and rehab: weakness in his flexor mass.
“We can fix the ligament, but I think fixing this flexor mass and getting this to heal properly will take the stress off your ligament and give you a great chance to come back and play,” Kremchek recalls telling Antone. “But I said ‘If it doesn’t, and you can’t come back to play, you can lay your head on a pillow at age 45 and say, ‘I did everything I could.’’”
Antone’s mindset began to become more optimistic. He at least wanted peace of mind. He decided to have surgery. He and his wife also wanted to try and start a family again, and what if, by some minor miracle, his future kids could watch him pitch?
In this attempt, Kremchek said he “threw everything at him the third time.”
Kremchek shaved bone down so that Antone said they could have “a fresh start,” and avoid any fraying. Kremchek drilled new tunnels, and reattached the UCL. He didn’t need a new graft, but he added an Internal Brace for further support. The veteran surgeon added eight anchors to reattach the flexor mass back to the bone, something like rebar reinforcing concrete. For good measure, he also added a collagen patch on top of the ligament to further promote healing.
“Very complex,” Antone said. “A lot going on.”
The repair was a big first step on a long road back. But Kremchek said so much of what got him back to the major leagues was tied to the arduous rehabilitation process, but also evaluating and addressing root causes.
Kremchek said re-injury can often be tied to a pitcher not making any changes.
“And I think that was the big difference,” Kremchek said. “At the end of the day, the rehab was going to be extremely important. And in him understanding his mechanics. If he was going to come back to this level in the game, he’s going to have to fix something.”
Antone would reevaluate how he threw, and what he threw.
When he was well enough to throw again, Antone made his way back to Driveline for an evaluation.