One week after the Red Sox announced that Chris Sale would require Tommy John surgery, two questions loom: When will he have it done, and should he be allowed to have it despite widespread calls by states to postpone elective medical procedures amid the COVID-19 pandemic?
Both topics are enormously sensitive in the game. The Red Sox and Sale’s agent, B.B. Abbott, have declined to say when or if Sale’s surgery is scheduled. Major League Baseball and the Players’ Association declined to comment on the propriety of Tommy John surgery at a time when many states are limiting or banning elective surgeries.
In Massachusetts, Gov. Charlie Baker called for the postponement of elective procedures on March 15.
Three Massachusetts orthopedists contacted by the Globe said the state’s prohibition would include ulnar collateral ligament reconstruction (i.e. Tommy John surgery), and that the operation shouldn’t be performed here for anyone, including professional athletes.
“There’s no question that Tommy John is an elective surgery,” said former Red Sox medical director Thomas Gill, now the director of the New England Baptist Hospital-affiliated Boston Sports Medicine and Research Institute. “A lot of guys try PRP [platelet-rich plasma] injections, try rehab to avoid it, and when they can’t, they end up having surgery. By definition, that’s elective.”
Others disagree with that assessment — at least as a blanket statement. Dr. Jeffrey Dugas, a surgeon with the Andrews Sports Medicine and Orthopaedic Center (the facility founded by Dr. James Andrews) in Birmingham, Ala., believes that there are risks to delaying Tommy John surgery that could reclassify cases from elective to urgent.
“I don’t think it’s that black-and-white,” said Dugas, who estimated that he’s performed thousands of Tommy John procedures. “There are certainly aspects of Tommy John surgeries that, if not dealt with in a timely way in certain people, could have a deleterious effect on the outcome.
“Tissue quality is certainly one of them. If you anticipate a deterioration in tissue quality or bone quality as a result of timing, the timing of dealing with things in a simultaneous way, as opposed to a staged way, protects an athlete from multiple procedures as opposed to one. All of those things are examples of ways that these things could be pushed to a more urgent position.”
For Sale and the Red Sox, there certainly would be on-field consequences to a delay. A typical timeline for recovery for a starting pitcher, chief baseball officer Chaim Bloom said in a conference call last week, is 14-15 months. That suggests that a best-case scenario for a surgery done now would be a return in late May or early June next year. A delay could put into question Sale’s ability to contribute at all in 2021.
But the timetable of his return as well as his team’s competitive outlook would still have to be weighed against the public-health rationale for limiting non-urgent procedures.
“People can make the argument that, well, it’s someone’s livelihood; a professional baseball player needs to get back quickly,” said Gill. “But how do you value a baseball player getting back to his livelihood three weeks earlier, four weeks earlier, when you’re talking about a year to 14-month recovery anyway, versus a construction worker, a small businessman or woman, a mother or father trying to take care of their kids?
"How do you say one is more important than the other? You really can’t.”
Restrictions on elective surgery are driven by several public-health concerns, among them: the preservation of personal protective equipment and ventilators to manage the COVID-19 pandemic; possible exposure of medical personnel to the coronavirus (not just through a patient but also through family members or friends who transport a patient to a hospital); and a desire to allow as many medical personnel as possible to help with the pandemic itself.
But while Massachusetts has offered clear guidelines that would prohibit Sale from undergoing Tommy John surgery here, the situation isn’t necessarily clear-cut elsewhere. In Alabama, where Dugas works, the state is requiring a delay of unspecified duration for elective procedures.
Mets pitcher Noah Syndergaard was scheduled to have Tommy John surgery Thursday at the West Palm Beach (Fla.) Hospital for Special Surgery. While Florida has prohibited “medically unnecessary, non-urgent or non-emergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition,” that standard is being left to the interpretation of doctors.
Dr. Chris Geary, an orthopedist at Tufts Medical Center, said he has “a little bit of skin in the game” when it comes to the dilemmas faced by orthopedists who are trying to assist their patients while also being mindful of the broader context. Geary tested positive this week for COVID-19 and is currently quarantined.
“I guess ethical and legal are two different things at this time," said Geary. “We’re in kind of uncharted waters.”
A doctor in Florida, he said, could be "well within his rights to [perform Tommy John] as long as, on a state-by-state basis, he’s not running afoul of any government mandates.
"But you could look at it from a larger societal level and say, ‘Would it be great if they repurposed everything they had at their surgery center to a larger hospital?’ Yeah, probably. But if he’s not breaking any laws, he’s within his rights to do it.”
The optics, of course, are unavoidably poor. Even if Sale undergoes Tommy John at a surgery center that doesn’t have an ICU and wouldn’t be treating patients with COVID-19 anyway, the mere fact of an athlete receiving surgery at a time when patients are being told that they can’t receive joint replacements would be subject to scrutiny.
“In general, things sometimes get moved around for professional athletes,” said Gill. “That’s not something I agree with, but it’s kind of the way of the world.”
The question of operating on world-class athletes — balancing their long-term care with questions about PPE availability — is one that will weigh on the doctors who ultimately will decide who can and cannot have surgery during the current crisis.
“I don’t think anybody at this point would make the decision to [perform Tommy John] without considering the position we’re in," said Dugas. “I don’t know of any clinician who would be thoughtless enough not to consider that.
“I’ve had to cancel Tommy John surgeries this week, for sure. We’ve canceled our surgeries. But I don’t know that the situations of the people I’ve been dealing with are the same situations that [Syndergaard and Sale] are in, for multiple reasons, biological and ethical.
"We’re all kind of working through that. I have every confidence in my colleagues around the country who do these procedures on a regular basis as they make these difficult decisions.”