These are my disclosures, really nothing pertinent for this talk. UCL Reconstruction remains one of the most successful operations in sports medicine, returning athletes to play, restoring performance and longevity in their sport. Examples of Dr. Jobe's original technique have been developed decreasing surgical trauma to the flexor pronator, the ulnar nerve, sublime tubercle and medial epicondyle. However, the main features and concepts remain remarkably similar to the Tommy John surgery of 1974. The only study which includes UCL repair and reconstructions in the same cohort is actually the landmark study by John Conway and Frank Jobe in JBJS in 1992, 50% of those repairs in that study returned to play versus 68% of the reconstructions. With the evolution of fixation methods including attractive anchors, implants and suture material along with earlier diagnosis and treatment of UCL injuries before more extensive joint pathology can occur, repair of the UCL with suture augmentation has become an attractive option for some tears. Currently, however, there are no outcome studies which directly compare these modern augmented repairs to reconstructions in the same cohort. However, there are features of these repairs regarding native ligament preservation with tissue-friendly sutures for load sharing that are very attractive to me in my efforts to maximize the performance of my reconstructions clinically and under ever-increasing demands. While the demands that we're seeing that are increasing are not only in the professional ranks but also at the high school level, and while the actual top-end pitch velocity may not have changed very much over the past hundred years, the number of players able to throw 95 to 100 plus miles an hour has exploded, including in high school players. In 1974, Nolan Ryan's fastball was over 100 miles an hour, but he threw it less than 20% of the time. The average pitch velocity of a team in 1974 was just under 90 miles an hour. In 2021, however, the average velocity is over 94 miles an hour, and every team has multiple pitchers that can touch 100. The increase in demand and exposure really gets my attention. I have a young Major League Baseball pitcher in his first full season post-UCL reconstruction who just threw a record 38 pitches over 100 miles an hour in one game two weeks ago. So I'm always on the lookout for ways in which I can enhance my reconstructions. Last year, we studied our results in the 54 Major League pitchers who we reconstructed between 2012 and 2016 and for which we could obtain performance data for three years before and after surgery. With regard to return to play, 96% returned to professional baseball and 82% returned to the 40-man roster. The average time to return was 13.7 months. With regard to performance, we see workload, earned run average, whip, and velocity. Whip is walks plus hits per innings pitched. So the lower the whip, the better. And velocity all improved post-op compared to the three seasons pre-op. Well, how do they perform compared to age-matched controls in the major leagues? We see that post-surgery, they compare favorably with regard to win percentage, ERA, whip, and average fastball velocity. Our single institution experience has been slightly more positive than prior pooled data for MLB pitchers undergoing UCL reconstruction. This is the age-matched controls. So this is my technique. What I've done is I've borrowed the really attractive features of the repair that you saw that Chris so nicely described, and I've incorporated that with the reconstruction. I've been doing this over the past three years. So typically split the flexor, as you've seen. Now on this image, you see the ulnar nerve. See if I can get this pointer. See the ulnar nerve here, the ligament. This is the medial ulnar ridge. This is a very important landmark because the sublime tubercle can have a lot of misshapen things like you saw with the fractures of the sublime tubercle. It can be deformed, but if you find the medial ulnar ridge and extrapolate a line right from the medial ulnar ridge, it'll take you to the center of attachment for the ligament on the tubercle. So that's an important landmark. So I make an incision in the mid-fiber of the anterior bundle of the ligament in line with the medial ulnar ridge going to the epicondyle. And on this one, you see that the more proximal part of the ligament, just like it showed on the MRI scan pre-op, was where the problem was. There was attenuation, and that was where the real injury was, was in the proximal segment of the ligament. So then I make my typical drill holes anterior and posterior to that midline that extrapolated from the medial ulnar ridge. And then in the epicondylar attachment site, I love the paper that came before us that showed the problems with getting isometry on the epicondyle. That is very true. So then you're writing out, I make a larger drill hole posteriorly and a smaller drill hole underneath the pronator. Then what I've done is I've incorporated this part of the repair. I take the braided collagen-coated suture, and if it's a proximal tear, I'll begin distally and I'll shoelace the sutures from distal to proximal so that then the sutures are finally exiting the proximal ligament where it's torn from the epicondyle. So this would be the construct. So then I mirror image the posterior limb of that suture so that the sutures are coming out proximally here. And if it was a distal tear, I would have done the exact opposite. I would have started proximal and go distal. Then passing the graft as usual through the sublime tubercle drill holes, and then taking a clamp, and I haven't tightened down those suture loops in the native ligament yet. So I take a clamp and I go underneath those suture loops, and I pull the first limb, the anterior limb of the graft underneath. So you can see what's going to happen here. We're going to pull that limb underneath, save that, and then we're going to size the opposite limb, fold it upon itself, and then suture it and pull that underneath the suture loops also. So I'm going to have both free ends of the graft through there, and I've pulled them through with the sutures that were in the native ligament. Then I tension the suture loops, and I pull the graft tight, and I tie the graft sutures first. Then I pull these suture loops from the native ligament, and what that does is it repairs and retentions the native ligament tissue on the side that it's torn from. So it brings it up proximally, and it envelops then my three strands of the graft. I brought my third strand of the graft down distally and put it back into the sublime tubercle. So I have the benefit of load-sharing sutures in the native ligament that I know are in an anatomically good position because I didn't detach the native ligament, and I'm incorporating that tissue around my graft. So in conclusion, the UCLA is still the gold standard with high return to play and return to performance rates and high demand throwers. Modifications continue to evolve as demands on the reconstruction continue to increase. UCL reconstruction incorporating features of UCL repair with suture augmentation may enhance the performance of the reconstruction, but further studies on repair versus reconstruction and reconstruction versus reconstruction plus repair are warranted. Thank you.

UCL Reconstruction

Tommy John surgery

sports medicine

UCL repair

suture augmentation