Authors: Jeff Passan
Dr. Steve Shin worked as a hand surgeon at Kerlan-Jobe, and ElAttrache needed his precision. Shin looked into the exposed elbow and prepared his one assignment: move an eight-inch portion of Coffey's ulnar nerve, a tube of fibers that originates at the spine, snakes down the arm, and controls fine-motor movement in the hand. The ulnar nerve allows you to pinch, make a fist, type. A hand is a hand, and not a claw, because of it. Even the slightest bit of irritation to the nerve can have a profound effect; since Coffey's first surgery, the numbness in his ring finger and
pinky hadn't abated. Not only could mishandling of the nerve set back his rehab schedule, it could leave him with permanent damage barely five minutes into the surgery.
Shin wore a pair of jeweler's loupes in order to distinguish the nerve and its tiny branches from the surrounding scar tissue. During Coffey's first operation, the surgeon, Dr. Timothy Kremchek, had brought the ulnar nerve to the front of the elbow, laying it over the reconstructed ligament, a procedure that in the dozen years since had fallen out of favor. Shin, a kind of neural cat burglar, carefully lifted the nerve away from the disarray inside Coffey's arm and fastened it temporarily to his skin with three sterile rubber loops weighted down by clamps. The ulnar nerve would rest there, a spectator to the rest of the operation, which at ten a.m. was barely under way.
Now ElAttrache could gauge the true damage, and it was grim. An MRI provides a working theory on an arm's condition, though it rarely tells the entire truth. In 2012, Minnesota Twins pitcher Scott Baker went in for surgery on the flexor-pronator mass, a bundle of muscles in the forearm, and went out with a new ulnar collateral ligament, too. ElAttrache feared Coffey's flexor mass had ripped away from the bone and torn his flexor tendon, and his suspicion was correct. Now an already trying surgery would prove a test of ElAttrache's patience and stamina as much as his technical know-how.
“Stan, look at this,” ElAttrache said, calling over the Dodgers' trainer, who had scrubbed in. The last twelve years of pitches had turned Coffey's elbow into spaghetti, and the flexor tendon tore because of what Stan Conte calls “shearing force”âthe minute stresses that, when repeated thousands upon thousands of times, can cause ligaments and tendons to fray and, eventually, to snap.
ElAttrache wasn't exaggerating when he called this his toughest surgery. Hundreds of Tommy John operations have earned him the title of the fastest gun in elbow reconstruction, powering through some UCL repairs in as little as sixty minutes. His
preferred technique requires drilling holes to create new pathways in the humerus (upper arm) and ulna (one of the lower-arm bones) through which he can slide the tendon until perfectly taut. Over the next two years, the new tissue slowly undergoes a process called ligamentization, in which tendon cells called tenocytes modify their function and how they secrete the regenerative protein collagen, and, after about two years, change their entire form. In adapting to its new role holding the upper and lower arms together, the tendon actually morphs into a ligament, connecting bone to bone.
ElAttrache went to work, asking for pickupsâmedical tweezersâand a scalpel. The last track of a Counting Crows song strained through a subwoofer and two cube speakers. Conte stepped away from the table. He had sat in on plenty of surgeries, and he never tired of what they represented: a miracle of modern medicine that could give injured pitchers a new lease on a baseball career. Even with Tommy John's success rate, he didn't shrug it off as some routine procedureâ“almost like a root canal,” as Atlanta Braves manager Fredi González once called it.
“A lot of people talk about Tommy John, how you're back in twelve months,” Conte said. “It's not that easy. There are complications. There are issues. There are a ton of decisions to be made in the OR that can change things. It's like we're walking up to the tee right now and the hole is five hundred yards away. This is our tee shot.
“And I hope nobody shanks it.”
E
VERYBODY IN THE ROOM STOOD
except for Neal ElAttrache. He sat in blue scrubs on a swiveling stool, a green surgical mask over his mouth. Although Todd Coffey's arm was flayed open, all eyes were on ElAttrache, who happens to have movie-star looks and a clientele to match. Earlier in 2012, a picture of Arnold Schwarzenegger and Sylvester Stallone resting in adjacent hos
pital beds had gone viral. ElAttrache had done their surgeries back-to-back. Schwarzenegger went to him on the recommendation of ElAttrache's brother-in-law: Stallone. He is married to the model Jennifer Flavin, and ElAttrache to her sister Tricia, a nurse he met on his first day at Kerlan-Jobe twenty-five years ago. Tricia doesn't see much of him, nor do their three daughters. He misses parent-teacher conferences and lets mom handle boy trouble. Sleep is a luxury for ElAttrache, golf a rarity. He is fifty-four, in the prime of his career, the prime of his life, and he spends most of his time tending to other people's problems. When Los Angeles Lakers star Kobe Bryant blew an Achilles, ElAttrache fixed it. When Los Angeles Dodgers ace Zack Greinke fractured a collarbone, ElAttrache mended it. He performed both of those surgeries the same April day in 2013. Hundreds of millions of dollars ride on his scalpel.
“I always have to take care of my patients and do surgery and do that well. That trumps everything else,” ElAttrache said. “That level of intimacy, that relationship you make with a patient, celebrity or athlete or not, is almost like a sacred thing. I tell the guys we're training: if that privilege doesn't strike you right in the chest, to have that given to you, you're missing the most beautiful thing about what we do. It doesn't matter how famous they are. It's that you can really be involved in someone's life.”
Orthopedics called him, as it did his father, Selim, who attended Jesuit school in Lebanon as a kid, studied medicine in France, and came to Chicago in the mid-1950s to complete his residency at Northwestern University. He didn't know much English, so he learned by joining a local YMCA for three months. He met a nurse named Vera, got married, graduated, moved to Utah, started a family, and relocated to Pittsburgh, where he took care of the United Mine Workers. Three of his children would grow up to be doctors. Neal was the famous one. When he gave lectures around the country, his father sometimes showed up unannounced and snuck into the back row for a listen.
“My first day in medical school, my first class in anatomy, I knew I had been blessed to find maybe the only thing I'm any good at in my life,” ElAttrache said. “I feel very, very fortunate to have been able to find it. I immediately knew I was home.”
More than an hour into the surgery, ElAttrache laced sutures through the holes he had drilled in Coffey's humerus and ulna to help guide the graft and, ultimately, hold it in place. The ends of the sutures stuck out like guitar strings that hadn't been clipped.
ElAttrache conducts his team like he's leading an orchestra, his hand movements signaling exactly where the other half-dozen people should be and what they should be doing. When he opens his hand, his scrub tech, Ken Newmark, knows what instrument ElAttrache needs. When he releases a tourniquet, Leslie Quinn, his nurse, is standing over the wound with a suction instrument. When he readies to drill into a limb, his equipment tech, John Hale, hands him a tool loaded with the proper bit. The movement of the team is balletic.
At 10:44 a.m., with the ulnar nerve resting safely to the side and the preliminary holes drilled and the sutures strung, ElAttrache started spelunking for whatever piece of the gracilis might be left. He ran his scalpel along Coffey's thigh. Tourniquets allowed the flesh inside to remain a pearly white. ElAttrache wasted no time in jamming his index finger into the hole. As he rooted around, ElAttrache pushed the skin of Coffey's leg out from the inside. “It's all feel,” Conte likes to say. ElAttrache wasn't feeling much and asked for help. Shin and a surgical fellow each pulled back one side of Coffey's leg to give ElAttrache a better look. When doctors need something, they will MacGyver it. And if it meant Coffey's leg was going to hurt like mad when he woke up because two grown men were playing tug-of-war with it, well, he's the one who rejected the dead man's tendon, and that's what pain meds are for, anyway.
The extra leverage proved no help; no matter how much ElAttrache searched, he couldn't find what he was looking for.
“I shouldn't have to dig this out,” ElAttrache said.
“It's melted down,” Conte said.
Quinn, the nurse, knew what that meant. She went over to a workstation near the operating table and came back with two eight-and-a-half-by-eleven sheets of paper and showed them to ElAttrache.
“There are two choices here,” she said. “You like any one better?”
She held one piece of paper in her left hand and the other in her right. ElAttrache scanned the left first, then went to the right.
“Give me that one,” he said, pointing to Quinn's left hand.
As Quinn left the room, ElAttrache dug back into Coffey's leg. It was 10:56. He had already spent twelve minutes fishing. He wanted to search one more time so he could tell Coffey he made every effort. Quinn walked back in, holding a blue bedpan filled with warm water and a plastic bag with a long, white strand inside.
“You want it open?” she asked ElAttrache.
“Not yet.”
A minute later, he found what he was looking for: the last remnant of Coffey's left gracilis. ElAttrache slung his fingers behind it and pulled the tendon out of the wound to show the onlookers.
“I can see through it,” ElAttrache said.
“That's not great tissue,” Conte said.
“This would be the weakest link of our operation if we went with that,” ElAttrache said.
Nothing is as critical during Tommy John surgery as the length and diameter of the graft. Having a good piece of tissue emboldens a doctor. Had ElAttrache used Coffey's remaining gracilis, it may not have been enough to tie even a single loop, let alone the double-stranded approach ElAttrache prefers. He gestured toward the bedpan and said to Quinn: “Open it.”
At 10:58 a.m., she sliced through the bag and pulled out Todd Coffey's new elbow ligament. Quinn dipped it in the water and
let it continue to thaw as ElAttrache stitched together Coffey's leg and laid a few Steri-Strips over the sutures. Six minutes after its water bath began, the allograft was ready.
If Todd Coffey wanted to pitch again, it would be with the semitendinosus tendon of Donor ID 101079556, a twenty-four-year-old male who'd died in a car accident. Nobody in the room knew his name. Coffey's new tendon (cost: three thousand dollars) had arrived vacuum sealed from RTI Biologics in Gainesville, Florida, packed in dry ice inside a cooler stuffed into corrugated cardboard, just another brown box among the many dropped off at Kerlan-Jobe, a frozen miracle to undo what years of pitching had wrought.
The tool kit for ElAttrache's standard UCL replacement includes sutures made of collagen-coated, polyester-wrapped plastic polymer, stainless-steel alloy drill bits manufactured to eat through bone without burning it, chamfers to round off sharp edges of bone that could slice the fresh tendon, and the battery-powered Arthrex 600 drill. ElAttrache stood above Coffey, ready to begin the most delicate phase of the surgery: drilling two holes in the ulna that intersect like a V in the middle of the bone. The graft would come in one side and out the other. Then both ends would slide into a 5.0-millimeter tunnel on the bottom of the humerus, where two smaller drill holes on the top of the bone would create separate paths for the two ends, which would be yanked taut by the sutures ElAttrache laid earlier. Once the tension was correct, ElAttrache would knot the sutures together on the outside of the bone, stabilizing the new UCL.
The tiniest error could end Coffey's career. During Coffey's first Tommy John, this was a ho-hum portion of the proceedings, but in a revisionâparticularly one lasting this longâmaintaining bone integrity presented the greatest danger. Forget baseball being a game of inches. Surgery dabbles in fractions of millimeters. The drill holes from Coffey's first surgery left his ulna in danger of cracking. ElAttrache needed holes small enough to ensure the
bone's stability and large enough to accept the thick graft. Already he had shaved down the semitendinosus to accommodate it. He took a deep breath, sucking in his mask, and leaned in toward the ulna, ready to fix Coffey's elbow using the docking method, a variation on Jobe's original surgery.
As he depressed the drill's trigger, ElAttrache used a guide to stop the bit from plunging too far. “I have to be careful on the ulnar side,” he had explained earlier. “I don't want to break the bridge.” The bridge is the area between the two holes. The bigger the bridge, the less likely the bone is to crack. If the bone did fail, ElAttrache could attach the UCL with a metal button or screw, an inferior solution. Broken bone meant no more baseball.
Immediately ElAttrache knew the 3.5-millimeter holes in the ulna were too small. He took away the guide and free-handed one hole to a 3.6-millimeter width. He tried to pull the graft through. Not even close. He didn't want to thin it any more, either. Most blowouts leave most of the original UCL in place; the surgeon can tie the new tendon on top of it, using the native ligament's collagen to help in the healing process. Coffey's had practically vaporized, the remaining pieces infinitesimal.
ElAttrache asked for a 4.0-millimeter bit. As Hale prepared the drill, ElAttrache debrided tissue from the bone. Shin, the hand doctor, suctioned away the refuse. ElAttrache wanted a closer look. The bridge was getting smaller by the moment, the peril growing larger.
“I'm ready,” ElAttrache said. He widened the holes to 4.0 millimeters and tried to pass the graft again. It wouldn't budge. He was getting pissed. In a normal surgery, he could drill the ulnar tunnel with his eyes closed. He asked for a 4.5-millimeter guide but kept the 4.0-millimeter bit. The slightest mistake meant total failure, and ElAttrache was inviting it by free-handing the drill to expand the tunnel's opening by that fraction of a millimeter.