Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon in Los Angeles, CA and the inventor of DoubleButton Tommy John™ — a UCL reconstruction of the elbow that uses a single bone tunnel on each side and fixes the graft with a metal button at each end. He published the original description in 2012, the surgical technique in 2021, and clinical outcomes in 2020. Surgeons from around the world — including from the institutions where Tommy John surgery was first performed — have come to learn this procedure from Dr. Mirzayan.
To find out if you are a candidate, call (310) 746-5918 or request a consultation online. Virtual consultations are available for patients traveling from Las Vegas, Long Beach, Henderson, Phoenix, and Scottsdale.
What Is Tommy John Surgery?
Tommy John surgery is the common name for ulnar collateral ligament (UCL) reconstruction of the elbow — a procedure that replaces the torn or degenerated medial ligament of the elbow with a tendon graft. The UCL is the primary stabilizer of the medial elbow against the valgus stress that occurs with every throw. In baseball pitchers, the ligament absorbs forces that approach or exceed its structural limits with every pitch — and over time, in acute injury or through gradual attrition, it tears.
The surgery is performed far beyond baseball. Any overhead athlete — softball players, javelin throwers, quarterbacks, tennis players — can sustain UCL injury requiring reconstruction. So can manual laborers and non-athletes with specific injury patterns.
The procedure carries the name of the first patient who had it. The surgical problem — and the solutions available to fix it — have evolved substantially since that first case.
Why Dr. Mirzayan Developed DoubleButton Tommy John™
Dr. Mirzayan was not satisfied with the fixation available from standard UCL reconstruction techniques.
In the Jobe technique, the graft is woven through bone tunnels in a figure-of-eight and then sutured to itself. The construct is only as strong as those stitches. In the docking technique, sutures attached to the graft are tied over a small bridge of bone on the medial epicondyle. That bridge can be thin, and modern high-strength sutures can cut through bone. In laboratory testing of reconstructed ligaments, the most common mode of failure is at the suture-graft interface.
The second problem is the bone tunnels. Both techniques require two bone tunnels on the humeral side and two on the ulnar side. Drilling small bone tunnels close together risks having them converge into one another, collapse, or fracture the bone between them. Bone tunnel-related problems account for a meaningful share of reconstruction failures.
Dr. Mirzayan wanted fixation that did not depend on knots or bone bridges, and a construct that used a single bone tunnel per side. That is what he built.
How DoubleButton Tommy John™ Works
The palmaris longus tendon is harvested from the forearm through three small stab incisions. If the palmaris is absent on the injured side, the contralateral palmaris is used. If neither is available, a gracilis graft from the landing leg is used — the leg that absorbs force during the pitching motion. Dr. Mirzayan strongly prefers autograft and has used allograft only a handful of times in his career. The graft is folded over itself to create a thicker construct and loaded onto an adjustable-loop button.
The ligament is approached through a muscle-splitting approach that leaves the flexor-pronator origin intact. The ulnar nerve is not routinely moved or released. Dr. Mirzayan only transposes the nerve in patients who already have nerve symptoms before surgery.
A single bone tunnel is drilled in the medial epicondyle, and a single bone tunnel in the ulna at the sublime tubercle. The graft is passed through the humeral bone tunnel until the button flips and seats flat against the anterior surface of the medial epicondyle. That position matters — it reproduces the natural origin of the UCL so the graft runs in an anatomic line toward the ulna rather than making a sharp turn.
Once the button is seated, Dr. Mirzayan can grab the graft and pull on it hard enough to shake the patient's entire body on the table. The construct does not move. That is the whole point of the design. Fixation that secure means the graft is holding load from the moment surgery ends, rather than depending on knots or a bone bridge to hold. It is also why patients come out of the postoperative splint at the first visit and are not placed in a brace afterward.
The ulnar button is passed through the bone tunnel and flipped on the far cortex of the ulna, where it sits buried under muscle. Patients cannot feel it and it is undetectable to touch. Once the button is flipped, the graft is pulled down using a tension-slide maneuver and tensioned with the elbow at 90 degrees of flexion. The graft can be tensioned, assessed, and re-tensioned before anything is locked down — a meaningful practical advantage over techniques that require the graft to be sutured to itself. An interference screw is then placed in the ulnar bone tunnel for additional compression, and the native ligament is repaired over the top of the graft.
The Internal Brace — Built In, Not Added On
The suture tape internal brace is built into DoubleButton Tommy John™ rather than added as a separate step. The tape passes through the same humeral button and down the same ulnar bone tunnel with the graft, secured by the same screw. Every patient gets it. It is not an optional add-on and it does not require additional tunnels or additional fixation hardware.
The internal brace provides immediate mechanical support to the reconstruction while the graft is healing and undergoing ligamentization — the biological process by which the tendon graft is converted into a functioning ligament. This is the same principle driving the use of suture tape augmentation in ligament surgery across other joints, and it is one reason Dr. Mirzayan's patients are out of their splint early and progressing through rehabilitation faster than the traditional timeline.
What the Evidence Shows
This is not only an impression from the operating room. A cadaveric study comparing bisuspensory fixation against the docking procedure found that both restored valgus laxity to the intact state, with no significant difference between them in stiffness, ultimate torque, angle at ultimate torque, or energy absorbed. Separate biomechanical testing has shown that button-based fixation outperforms interference screw and Jobe-type reconstructions in load to failure and in the number of loading cycles survived before failure.
Who Is a Candidate?
DoubleButton Tommy John™ is appropriate for overhead athletes and active patients who have sustained a complete UCL tear or have a chronically degenerated UCL that has failed nonoperative management. Candidates typically include baseball and softball pitchers and position players, javelin throwers, quarterbacks, tennis players, and other overhead athletes with medial elbow pain and documented UCL insufficiency.
Not every UCL injury requires reconstruction. Dr. Mirzayan treats the majority of throwing athletes with UCL injuries nonoperatively first — rest, rehabilitation, and in appropriate cases, platelet-rich plasma injection. Surgery is recommended when nonoperative management has failed and the patient wants to return to overhead throwing at a competitive level.
For patients with a partial UCL tear, Dr. Mirzayan evaluates the injury pattern, the tissue quality, and the patient's goals before recommending a path. An acute distal UCL tear — particularly one with a sudden pop in an elbow with no prior chronic symptoms — may be a candidate for primary repair rather than reconstruction. He determines tissue quality intraoperatively using what he calls the SPOT test: sutures are placed through the ligament and pulled. If they rip through, the tissue is poor quality and he proceeds with full reconstruction instead of repair.
The distinction between repair and reconstruction is one Dr. Mirzayan explains to patients using a simple analogy: repairing a torn UCL is like patching a new tire — the structure is fundamentally sound and worth saving. Reconstruction is like replacing a bald tire — the tissue is degenerated and cannot reliably hold a repair. Only one of those two surgeries makes sense for each situation, and the decision requires direct visualization of the tissue.
What to Expect
DoubleButton Tommy John™ is performed as an outpatient procedure under general anesthesia. Patients go home the same day.
The elbow is placed in a posterior splint for the first one to two weeks. At the first postoperative visit, the splint is removed and active range of motion begins immediately — no prolonged bracing. This early motion protocol is made possible by the security of the button fixation.
Formal physical therapy begins in the first weeks and progresses through a structured rehabilitation program. Light throwing begins at approximately four to five months. A progressive interval throwing program is initiated at five to six months. Return to competitive pitching or overhead sport occurs at approximately nine months in Dr. Mirzayan's published series — meaningfully earlier than the twelve to eighteen months commonly cited for traditional UCL reconstruction.
Dr. Mirzayan will give you a personalized timeline based on your sport, your position, your level of competition, and your rehabilitation progress.
Published Outcomes
Dr. Mirzayan published outcomes on 36 baseball players who underwent DoubleButton Tommy John™ with a minimum of two years of follow-up and an average of more than four and a half years.
Mean return to play was 9 months, with a range of 6 to 16 months. 83 percent returned to playing baseball, with 67 percent returning at the same level or higher. Kerlan-Jobe scores improved from 33.2 to 89.7 and SANE scores from 20.7 to 93.6. 69 percent had an excellent Conway score and another 14 percent a good score. 94 percent were satisfied or extremely satisfied and would have the surgery again.
One patient required revision reconstruction and returned to play. One required removal of the humeral button. No medial epicondyle or ulnar fractures occurred.
The complication Dr. Mirzayan is most pleased about is one that did not happen. No patient developed new ulnar nerve symptoms after surgery. Published rates of postoperative ulnar neurapraxia after UCL reconstruction range from approximately 2 percent to nearly 21 percent — and in the largest series ever reported, it was 16 percent. In Dr. Mirzayan's series it was zero. He attributes that to the muscle-splitting approach and to leaving the ulnar nerve alone unless the patient has a pre-existing reason to need it addressed.
Of the six athletes who did not return to baseball, only one stopped because of the elbow. The other five graduated high school or lost interest and were not seeking to play at a higher level.
These were high school, college, and minor league players — not Major League pitchers. It was a single-surgeon series without a randomized comparison group. Dr. Mirzayan states that plainly rather than presenting the results as more than they are. What they demonstrate is that a reconstruction fixed with buttons on both ends produces excellent function, a low complication rate, and a return to pitching at around nine months.
Frequently Asked Questions
What makes DoubleButton Tommy John™ different from traditional UCL reconstruction?
DoubleButton Tommy John™ uses a single bone tunnel in the humerus and a single bone tunnel in the ulna, with a metal button at each end to fix the graft. Traditional techniques — the Jobe and docking procedures — require two bone tunnels on each side and rely on knots tied over bone bridges or sutures attached to the graft itself. Button fixation is mechanically stronger, eliminates the knot-tying and bone bridge risks, and allows the graft to be tensioned and re-tensioned before anything is locked. The result is a construct secure enough to allow early motion without bracing from the first postoperative visit.
What is the internal brace and does every patient get it?
The internal brace is a suture tape that runs alongside the graft and provides immediate mechanical protection while the graft is biologically incorporating. In DoubleButton Tommy John™ it is built into the construct — passing through the same humeral button and down the same ulnar tunnel with the graft, secured by the same interference screw. Every patient receives it as part of the standard procedure. It does not require additional bone tunnels or fixation hardware.
How long is recovery?
In Dr. Mirzayan's published series of 36 baseball players, mean return to play was 9 months — meaningfully earlier than the 12 to 18 months typically cited for traditional UCL reconstruction. The splint comes off at the first postoperative visit and active motion begins immediately. Light throwing starts at approximately four to five months, with a return to competitive throwing around nine months.
Can my UCL be repaired instead of reconstructed?
Possibly — for patients with an acute tear in a previously healthy ligament, primary repair may be appropriate. Dr. Mirzayan determines tissue quality intraoperatively using the SPOT test and makes the final decision at surgery. Every patient consented for repair is simultaneously prepared for reconstruction in case the tissue quality does not support repair.
Does Dr. Mirzayan see patients from outside Los Angeles?
Yes. Dr. Mirzayan welcomes patients from Las Vegas, Long Beach, Henderson, Phoenix, Scottsdale, and from around the world. Virtual consultations are available. Call (310) 746-5918.
Is Dr. Mirzayan in-network?
Dr. Mirzayan is an out-of-network provider. Many patients with PPO insurance plans have meaningful out-of-network benefits. His office will verify your coverage before your consultation so you understand your financial picture before making any decisions.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon, the inventor of DoubleButton Tommy John™, and one of the most experienced elbow surgeons in the United States. He developed DoubleButton Tommy John™ because he was dissatisfied with the fixation available from existing procedures — and then published the technique, proved it works in a peer-reviewed outcomes study, and taught it to surgeons from around the world, including from the institutions where Tommy John surgery was first performed. His published series demonstrates a mean return to play of nine months, an 83 percent return-to-baseball rate, and zero new postoperative ulnar nerve complications. For overhead athletes who want a UCL reconstruction built on the strongest available fixation, with an internal brace built in and a recovery timeline ahead of the standard, Dr. Mirzayan is the surgeon who invented that procedure. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Long Beach, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
References
Mirzayan R, Benvegnu N, Sidell M, Acevedo DC, DeWitt DO, Lowe N, Singh A. Functional outcomes of ulnar collateral ligament reconstruction with a novel double suspensory fixation. J Shoulder Elbow Surg. 2020;29(8):1530-1537.
Mirzayan R, Schoell K, Acevedo DC, Singh A. Ulnar collateral ligament reconstruction of the elbow with double suspensory fixation. Arthrosc Tech. 2021;10(2):e303-e309.
Acevedo DC, Lee B, Mirzayan R. Novel technique for ulnar collateral ligament reconstruction of the elbow. Orthopedics. 2012;35(11):947-951.
Jackson TJ, Adamson GJ, Peterson A, Patton J, McGarry MH, Lee TQ. Ulnar collateral ligament reconstruction using bisuspensory fixation: a biomechanical comparison with the docking technique. Am J Sports Med. 2013;41(5):1158-1164.
Armstrong AD, Dunning CE, Ferreira LM, Faber KJ, Johnson JA, King GJW. A biomechanical comparison of four reconstruction techniques for the medial collateral ligament-deficient elbow. J Shoulder Elbow Surg. 2005;14(2):207-215.
Cain EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426-2434.
