So, thanks to the AOSSM and our program chairs for inviting me to present this. I have no disclosures in regard to this topic. It's already been highlighted that UCL injuries and reconstructions and repairs are going up year by year. So we know radiographic diagnosis, x-rays, MRI, MRI arthrogram. We use stress ultrasound in Philadelphia quite a bit. So this is the real issue. When you have a young player who has a specific traumatic injury, maybe one pitch, but typically in relation to a specific injury where they have a partial or a complete tear from one side of the ligament. So this is a highlight of a distal ulnar collateral ligament tear. So what are the treatment options? So obviously we want to evaluate is this a complete tear versus a partial tear? Is it acute versus chronic? Is it professional or an amateur athlete? Our treatment options are non-operative in many settings, particularly in partial tears. Personal reconstruction, you can augment this with an internal brace as John mentioned and I think Neil will highlight as well. You can do a primary repair with an internal brace augmentation and you can augment this with a graft. So I'm not really sure what to call some of the procedures now. Are we doing a primary repair with a graft augmentation or are we doing a reconstruction with a primary repair augmentation? So I guess we can hash that out somewhere down the road. So who are the repair candidates? So typically again these are relatively acute injuries. These are either proximal or distal avulsions with good quality tissue. These can be in the throwing elbow but also can be in the non-throwing elbow, particularly in gymnasts or in wrestlers or in lacrosse players. So you have a specific acute injury. What about other potential repair candidates? And Neil published a study not too long ago looking at patients that have had a prior UCL reconstruction that had a one-sided graft tear. What we know is that typically when reconstructions fail, they typically fail from the proximal side. So you can consider doing a UCL repair with an augmentation with an internal brace. Neil did this in a group of six professional athletes and found that there was four, they got 67%, so four out of the six, back at 17 months. So this is another option for consideration for a repair. Again, contraindications for a repair, you may argue a professional versus a non-professional athlete, but really a physiologic older ligament and obviously a mid-substance tear. So Jeff Dougas did a study looking at the biomechanical aspects of a repair and found that a time zero reconstruction was similar to the repair. How about the approach? Well, I think it's very similar to what everybody else is doing, a muscle splitting approach. So we're going to split the flexor pronator, do an intramuscular split down to the ligament, which you can see here. Then you're going to get down to the ligament and assess the tear, assess the quality of the tissue and the location. This is a left elbow here, so the shoulder is up top, the hand is down below. This is a proximal UCL tear. I think we're missing a video back. That's not good. So this is an example of a distal tear. So we're going to go ahead and put the anchor in distally first to do the repair. Once you've exposed the ligament, assess the quality of the tissue, then you'll do a primary ligament repair and closure. So we'll go ahead and put the anchor or do the repair stitch at the area of the tear first. So in the setting of a proximal tear, we'll put the proximal anchor first. Do a primary repair of the ligament to the proximal end of the... Wow, the screen went off. And then do your primary repair of the ligament. After you do this... We're missing three more videos. So then after you do that, then you'll go ahead and put in your opposite side anchor. So you will, if it's a proximal tear, you'll put your distal anchor in. Take your tape, tension it appropriately. One of the key factors when you're doing this is really to consider double tapping the anchor because as you do your repair and put both your limbs of your suture tape in, it's really tough to get your anchor in there. So you'll double tap it, put your tape in, tension it appropriately, put a little bit of varus. I typically, as Jim Bradley taught me, put a freer underneath. Make sure you're not over-tightening it. Try to get as isometric as you can and then finish your repair. So looking at a clinical study, Jeff published their data in 2019 of 111 athletes, 92% of those got back just under seven months. I think that in general, if you're doing quite a bit of these, you're probably looking at about eight to nine months of getting back to full participation and return to play. Whereas obviously in the reconstruction, as Michael mentioned earlier, it could be as early as 10 to 12 months, but typically you're in the 14 to 16-month time period. So you're looking at probably about half the time. I think that's probably a pretty safe number if you talk to your athletes about when you can get them back. So 92% around just under seven months. And this is looking at some of the complication rates. Again, a fairly low complication rate when you do this study, when you do this procedure, no major complication rate, just under 4%. Rehab, somewhat similar, but a little bit different than a reconstruction. So splint for seven to 10 days, brace for another additional two to four weeks. You can start batting at about three months. You can start tossing somewhere between 12 and 16 months, depending on your athlete and your repair. So generally, at least you should be going at four months, throw them from the mound somewhere around six months, which gives you a return to play, again, somewhere around eight to nine months. So in 2023, which of these patients are getting repairs versus reconstruction? So a chronic tear, you want to evaluate for whether it's an acute episode. Again, initial treatment non-operatively may consider some type of biologic injection. For an acute tear, determine the location, the severity of the tear. We use ultrasound again to look at laxity. If the ligament quality is good, then consider a primary repair. For a complete tear, again, if it's a mid-substance tear, we know that the UCL reconstruction is the gold standard. If it's an amateur athlete, and they're really just looking to get back to, you know, their last high school season, their last college season, and they are not looking to advance their career, and they have one chance to get back for one season, then a repair may be an option for you to consider. So some tips and tricks, again, you're going to do a muscle splitting approach. As mentioned before, I will leave the nerve alone in case of symptoms. Again put your anchor in, the first anchor is in the location of the tear. Tap it twice. Use a 3.5 and a 4.5 tap. Place sutures through the ligament, then close your ligament split. Tie your suture repair. Then place your second anchor on the opposite side. Again tap twice. Find the tension of your internal brace and don't over-tension. Thank you very much for your attention.

UCL injuries

reconstructions in athletes

diagnostic methods

treatment options

surgical approach