Doctor revolutionized Tommy John surgery, much to Rangers’ benefit
ARLINGTON, Texas — Last June, the Texas Rangers acknowledged what had become undeniable: Jacob degrom, the ace starter to whom they committed $185 million in free agency, required elbow surgery.
What neither the Rangers nor degrom, whose words were couched in tears, specified at the time was exactly what kind of surgery. In particular, they never referred to the procedure by its colloquial name — Tommy John surgery.
With good reason. It wasn’t.
Well, not exactly. Degrom became the latest pitcher to undergo a procedure that takes traditional career-saving Tommy John ligament reconstruction and combines it with an extra layer of protection from a synthetic internal brace suture. It is essentially two procedures. It doesn’t have a catchy name. But it has become the calling card of Rangers team physician Dr. Keith Meister. He’s revolutionized a revolutionary surgery.
The Rangers team physician for the last 21 years, Meister, 62, has become perhaps the world’s foremost authority on pitching elbows. His “hybrid” procedure has become the industry standard.
“I asked him what he would advise if I was his son and this is what he suggested,” degrom said recently. “From my understanding, it’s almost like your body turns [the sutures] into ligament over a period of time. It’s just that much thicker and that much more protection. He’s the best elbow surgeon in the world. When he explained it, I was all in.”
Maybe someday, the Meister maneuver will have a fancy name. In the meantime, he’s too busy to come up with one. He started performing the procedure in 2018, taking a twist on traditional Tommy John, an “internal brace” suture and adding it to the elbow reconstruction. It offered two layers of protection in one.
Business is good. As the hunt for velocity and increased spin advances, pitchers are blowing out in record numbers. Meister said he could do 12 procedures in a week if he wanted. As it is, he now has three offices, including the 21,000 square foot TMI Sports Medicine and Orthopedic Center in Arlington. He is regularly sought out by pitchers across the country the minute elbow pain arises.
Degrom wasn’t even his first Cy Young Award winner of last summer. He did Seattle’s Robbie Ray five weeks earlier, then occupied himself with Rangers prospect Kumar Rocker and eventual Ranger Tyler Mahle. And those were just the more notable guys.
Even branched out to football and performed the procedure on San Francisco quarterback Brock Purdy.
According to Jon Roegele, who tracks elbow procedures online (because everything is tracked online somewhere), Meister has done at least 118 elbow procedures on drafted players or those already in pro baseball. And that’s just the pro guys. Since Dr. James Andrews retired in 2023, it makes Meister the active leader. All in, Meister said he’s done over 300 of the hybrid procedures since he first started doing them in 2018.
“He’s a big believer and develops relationship with players when they’re healthy, so it’s much easier to trust him when they become hurt,” said Rangers senior director of medical operations Jamie Reed, who as head athletic trainer recruited Meister to leave the University of Florida for Texas in 2003. “He takes time and that’s a separator.”
HYBRID PROCEDURE
September will mark the 50th anniversary of the first Tommy John procedure on, fittingly enough, Tommy John. At the time, it was called Ulnar collateral ligament reconstruction.
John, a left-hander, had seemingly reached the end of a moderately successful MLB career with what was basically referred to as a bad elbow. In short: The elbow ligament ruptured and there wasn’t a way to repair it. It’s what forced Sandy Koufax to retire in 1966 at age 31.
Dr. Frank Jobe, who became the Dodgers team physician two years after Koufax retired, devised a procedure in which a graft from another tendon, harvested from either the wrist or leg, could be sewn in to repair the tear. It took John another year to return to pitching after the surgery, but he went on to have another 13 years in the big leagues. By the time he retired, John had become the namesake of a ground-breaking, game-changing procedure.
Over the years, the procedure has evolved. It needed to. Travel and elite baseball mushroomed as an industry, preaching that kids needed to play year-round in search of college scholarships or a pro contract. That put more stress on the elbow.
The hunt for more velocity put more stress on elbows. Likewise, the search for increased spin. More guys’ ligaments failed at younger ages. Pitchers’ reconstructed ligaments started tearing, too.
In the last decade, the “internal brace,” pioneered by Dr. Jeffrey Dugas, became an option. A surgeon can use sutures to simply repair a ligament that hasn’t pulled completely off the bone (known as avulsion). It’s slightly less invasive. The rehab can be a bit shorter. It’s a great option for non-pitchers.
Meister decided elbow repair didn’t have to be an either/or proposition. Why not reconstruct and reinforce the new ligament at the same time? He could, to quote, the Six Million Dollar Man, make it “better, stronger.” If only pitchers still cost only $6 million.
The idea for the hybrid procedure was born.
“I married the two,” Meister said. “I felt like there was enough basic science and biomechanical data to do exactly what I was thinking about doing.”
If the procedure should be named for anyone, then it is probably Kyle Cody. He was the first. In 2018, Cody, then a Rangers minor leaguer, tore his ligament. But when Meister looked at images, there was also a chunk of bone where ligament was supposed to be. He had a huge calcification growing. Meister needed to better anchor his repair. And, well, Cody could use some extra ligament.
Cody represented a perfect test case. He suggested the idea to Cody. What did the minor leaguer have to lose?
“For 85-90 percent of people, one procedure works just fine. But then what about the 10 percent or 15 percent that it doesn’t? How do we adapt, do it better?” Meister said. “At the elite levels, we are talking about Ferraris. You don’t take care of a Ferrari the same way you do a Toyota.
Cody missed all of 2019, then reached the majors with the Rangers for parts of 2020 and 2021. The elbow has held up just fine. It was eventually his shoulder that gave way. The Rangers released him after 2023.
Not everybody ends up as a namesake.
A SOLID FIX
The bottom line: The hybrid has proven so far to be a solid fix.
While traditional Tommy Johns have started to fail more often as pitchers have had their first procedure earlier, the first five years of hybrid data are promising. Meister said that he’s seen about a 1% failure rate among the 300 or so he’s performed. It’s still relatively early in the data-gathering process. Degrom had his first elbow surgery — a traditional Tommy John reconstruction — in 2011. It held up for a decade and two Cy Youngs.
But pitchers are throwing harder, earlier, leading to stress on still developing ligaments. Year-round youth baseball is an issue. And don’t get Meister started on the art of pitch design. It leads to pitchers applying “death grips” on the ball, creating extreme stress on the ligament, to exert extra spin and movement.
“With all these designer pitches, we’re seeing a lot more stress on the medial elbow, so we’re seeing very predictable injury patterns as a consequence of these pitches,” Meister said. “Probably the worst of all of these is a sweeping slider. It’s a great swing and miss pitch.”
“But if you got a guy that you control for six years, what do you think the likelihood that you’re going to actually get six years of use out of this guy? I can tell you it’s almost zero. These guys are ripping up their elbows as a consequence of so many of these pitches.”
The Rangers have listened. They just don’t throw the pitch. MLB’S Statcast system delineated the sweeper from a traditional slider in its metrics in 2023. The Rangers ranked 30th in usage, having thrown the pitch just 256 times. Jon Gray threw it 151 times, down from 733 in 2022. The other two pitchers who threw it — Glenn Otto and Alex Speas — are no longer with the organization.
This has become something of a crusade for Meister. He presented to MLB at its New York office over the winter. He was asked to join a task force to investigate the dramatic rise in pitching injuries.
“I get it; performance is important,” he said. “But there has to be a performance metrics that we marry with a health metric. At some point, we have to say, ‘OK, we know if you throw this pitch more than this percent of the time, the chances that you’re going to get hurt, are exponentially greater.’
“We have all that data now. So that’s what I’ve been just kind of crying and screaming for. Let’s take all this data that we have, and let’s try and keep our guys healthier.”
The New Age approach Keith Meister collects mementos.
Inspired to become a doctor by his grandfather, a doctor himself, Meister started by keeping every thank you card a patient has ever sent him. Thanks to smartphones, he takes pictures of the interior of every elbow he operates on to have as a reference. Now, he takes photos of the pitch grips of every patient, too, to better understand what stresses they are creating.
These days, he’d love to maybe declutter a little. Maybe not have so many thank you cards or so much space on his phone taken up by photos of exploded elbows. He’d even be happy to do with a little less business.
You listen to him talk and you’d think you are talking to an old-school baseball scout, reminiscing about days gone by, when controlling the strike zone mattered much more than RPMS and velocity.
“You know, the New Age coaches will tell you the perfect inning is nine pitches,” Meister said. “The old school coaches will tell you, no, the perfect inning is three pitches, right? That’s the frustrating thing. Let’s get back to pitching to contact. Maybe you don’t have to pull pitchers after four or five innings.”
“Maybe you don’t have to put close to a $1 billion in salaries on the [injured list]. It’s gone from like $550 million in 2016 to $880 million last year. You want to save money, right? You are worried about doing a line by line budget. And you’ve got all these pitchers hurt.”
In the meantime, he’ll keep on collecting mementos and hoping his New Age approach to a 50-year-old procedure will help limit his return business.