Opening Up the Closer

Eric Gagne restarts the journey today.

The footprints he follows will be fresh, belonging to those of only a few others, the small group of major league pitchers who have had their pitching elbows rebuilt twice.

The Dodger closer, whose electric fastball, fiery fist pumps and unruly whiskers spawned the “Game Over” craze, will undergo the so-called Tommy John surgery, during which a torn ligament in his elbow will be replaced by a healthy tendon from elsewhere in his body.

Again.

Thirty-one years ago, Dodger team physician Frank Jobe and his breakthrough procedure set about extending the careers of hundreds of pitchers, including that of a 21-year-old Canadian right-hander in 1997.

Eight years later, Gagne comes back into Jobe’s operating room the game’s best closer, an All-Star, the Dodgers’ most beloved player ... and in need of another new ulnar collateral ligament.

Gagne joins only a few major leaguers to have the surgery twice -- Dodger teammate Darren Dreifort among them -- and is, by far, the most accomplished. Therefore, after what is expected to be a year’s recovery, he will try to become the first to take his third elbow ligament and rejoin the game’s core of elite pitchers.

“I’m a lot more confident this time around,” he said. “I know what I’ll have to go through and I know it’s only a matter of time. Maybe I’ll come back stronger.”

The process, said Jobe, who today will perform the surgery with Dr. Ralph Gambardella, is expected to be reasonably similar to the first, from locating a hearty tendon, to weaving it through previously drilled holes, to arduous rehabilitation, to pitcher’s mound. The outcome, he anticipates, also will mirror the initial procedure; Gagne will arrive again in about 12 months, with a high-90s fastball and the whole high-powered show.

It could be a matter of time. It is possible he will come back stronger. The body of evidence, however, is thin. No one like Gagne, whose bulk and heaving mechanics are rare in pitchers, and whose role requires him to pitch for games on end, has re-upped for Tommy John surgery, not from the top of his game.

There is no greater authority than Jobe, whose discovery allowed John to pitch into his mid-40s on one end, and has allowed high school pitchers to throw into their senior seasons on the other. Eric Gagne, he said, can be Eric Gagne again.

“I don’t see why not,” he said. “He did it the first time.”

It is the sentiment that carries the two-time survivors, along with Jose Rijo, the 1990 World Series most valuable player with the Cincinnati Reds who had the surgery four times. He missed five seasons in his early 30s.

“They should rename it Jose Rijo surgery,” he said, laughing.

Rijo pitched two seasons after the final operation, then left the game in 2002 at 38. After his second reconstruction surgery, in 2001, Dreifort made 70 big-league appearances. His career is in jeopardy not because of his elbow, but because of knee and hip surgeries last fall. Tampa Bay Devil Ray reliever Lance Carter was an All-Star in 2003, three years after a second Tommy John surgery. Scott Williamson is expected to pitch for the Chicago Cubs this summer, perhaps only nine months after his second surgery.

Though more than three decades have passed since Jobe saved John’s career, and as many as 10% of major league pitchers wear the four-inch scar left behind by the surgery, doctors continue to measure its long-term effects. Timothy Kremchek, the Cincinnati Reds’ medical director who is one of about five surgeons who perform the large majority of Tommy John procedures in baseball, said the medical community was still assessing the effect of the surgery when the second-timers started coming through.

Although he called the procedure and its effect “one of the cool things in sports,” Kremchek added, “We don’t have a track record on these re-dos. We’re all starting from scratch.”

Often, by the time a pitcher requires a second surgery, he is near the end of his career, complicating the analyses. Kremchek said he has opened elbows expecting to perform a transplant, only to find them beyond repair, some stricken by arthritis. Also, as the surgeries stack up, he finds thickening scar tissue has become a deterrent to flexibility, or new holes -- where the new tendon needs to be attached -- must be drilled.

“Technically,” he said, “it’s very challenging. ... We’re learning these things, just scratching at the surface.”

Steve Ontiveros was 35 in 1996 when Dr. Lewis Yocum replaced the ligament Jobe had replaced seven years before. Ontiveros threw only six more innings in the major leagues, but he insisted his elbow was never better when he retired, after the 2000 season. Rijo retired after injuring his elbow -- but not the ulnar collateral ligament -- during a pickup basketball game.

“Dr. Yocum was just trying to get me to a place where I could live life again, playing golf and playing catch with my kids,” Ontiveros said. “I don’t think anyone expected me to pitch again.”

There is also no standard for a transplanted tendon’s lifespan. Philadelphia Phillie reliever Matt Beech blew his in his first inning back from rehabilitation. Williamson went through his in three years. Gagne’s first transplant lasted eight, and could have been complicated by a slight knee injury during the past spring training that caused him to alter his mechanics. Hard throwers such as Gagne are presumed to be higher risks, as are those who throw pitches that require violent arm action, such as the split-fingered fastball. But, Jobe said, the answer may lie in nothing more complicated than a pitcher’s physiological disposition; some people are more physically fragile than others.

“It’s possible they’ve just gone back to the same habits that caused them to break the first time,” Jobe said. “Their [pitching] mechanics are off, or they pitched too much. They still have that same risk with the second one.”

As for Gagne, who pitched 82 1/3 innings in each of the last three seasons, Jobe said, “He does have a 98-mph fastball. Any time you throw that hard, you’re putting really big stress on that ligament. It’s the body breaking down and then building up, basically in balance. If he stumbled or had some change in his mechanics and put a little extra stress on the ligament, all of those things could have been factors.”

It leaves Gagne with today’s surgery and then the recovery and rehabilitation, a year that Tommy John survivors agree is at best difficult, at worst agonizing. Beginning with range-of-motion therapy directly out of surgery, the year is spent dealing with pain, uncertainty and time away from the ballpark.

Ontiveros called it “more mentally draining than anything.”

“No doubt, there is depression,” he said. “It’s one of those surgeries you don’t forget about. Every day you wake up and you work on your arm process.”

Rijo practically made a second career of rehabilitating from Tommy John surgery. While with the Reds, Rijo often recovered away from the team. His occasional visits would be filled with optimism, and usually followed a few weeks or months later with news of a setback.

“Gagne’s got a major, major obstacle now,” Rijo said. “But not the physical part. The mental part. Anybody can go through the physical pain. Gagne, being so tough, he can handle that.

“Believe me, that’s the question Gagne has to answer. It’s going to be such hard work mentally. I know he can take it. It’s rehab for over a year, six or seven months without throwing, just pain. It’s like a war. But I have so much faith in him.”

Paul Byrd, the Angel starter who had Tommy John surgery two years ago, said Gagne has the advantage of a guaranteed contract that takes him through next season. The financial and career stability, he said, will allow Gagne to abide by his rehabilitation schedule.

“He’s established, so he doesn’t have to worry about not having a job after 11 or 12 months,” Byrd said. “The pressure of having to come back right away is off. It affords him the opportunity to take his time and do it right.”

Still, Byrd added, “To go through that again, I’m sure he’ll have questions in his mind. Every day you wonder if you’ll make it back.”

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Times staff writers Mike DiGiovanna and Steve Henson contributed to this report.