Can we start? Thank you, I appreciate it. Because we do have a time frame and without a timer, I'm sure we're gonna run a little long and we wanna make sure we have at least some time for our case panel. So we have four talks and then we'll have a Q&A session. So we'll let our four speakers go first and then we'll have a Q&A and then we'll go into a technique spotlight. One from Dr. Dugas and another from Dr. Ahmad and then we'll have our case panel. Hopefully we'll have enough time left over to do that. And so Steve and I will co-moderate this so we'll kind of go back and forth. Our first paper, paper 19, is on the ulnar collateral ligament reconstruction returns ulnar humeral joint space gapping to normal on post-operative stress ultrasound. That's gonna be given by Mike Ciccotti. Michael. Thanks for pulling that up, sorry. Otherwise you're like staring at your phone. Yeah, yeah. Oh, sorry, I should have put that up for you. No problem, I think we got it. All right, thank you. Five minutes or 10 minutes. So I think this is working. You have to do this first, you gotta click on that. And then it works, I think, sorry. Back there, okay. Perfect. So thank you everybody. I have no relevant disclosures. So thanks to Dr. Frank Jobe and many others, over the last 50 years UCL injury has been transformed from career-ending to often merely career-interruptive. MR has traditionally been utilized for diagnosis. However, this only provides a static snapshot of an otherwise dynamic pathology. Arthrograms improve sensitivity but at the cost of a painful injection. Stress ultrasonography allows for dynamic assessment of the joint. It allows the magnitude of instability to be measured and quantitated by looking at the ulnar-humeral joint space gap. It's been validated as both reproducible and reliable. However, the effect of reconstruction on joint gapping has never been quantified. Reference parameters would be potentially invaluable when assessing for recurrent injury. The purpose of the current study was to evaluate the effect of reconstruction on joint gapping as assessed by stress ultrasound. And we hypothesized that reconstruction would result in a decrease in joint gapping seen on ultrasound at minimum one-year follow-up. Patients were identified within an existing single-blinded prospective randomized trial. Preoperative and postoperative stress ultrasounds were performed by highly experienced musculoskeletal radiologists. Patients were positioned seated with the elbow flexed at 30 degrees and a standardized valgus stress was applied by a TLS device. Ulnar-humeral joint space gapping was measured with electronic calipers with spatial resolution superior to magnetic resonance. The delta was calculated as the change in joint space gapping produced by the application of stress. Standard statistical analysis was performed with SPSS software. 57 patients had ultrasound data available for inclusion. There were no significant differences in terms of demographics or anthropometrics. 70% of patients had a preoperative exam on the contralateral uninjured elbow to serve as a reference population. Nearly 90% had a postoperative exam. The mean deltas were as follows. 2.1 millimeters for the preoperative injured elbow, 0.8 millimeters for the uninjured contralateral elbow, 0.6 millimeters for the post-reconstructive elbow. There was a significant decrease in joint space gapping from preoperative to postoperative. This was true for both of the included surgical techniques. There was no significant difference between reconstructed elbows and uninjured elbows. The current study confirmed that reconstructing does reduce ulnar-humeral joint gapping. This is true regardless of reconstruction technique. And in fact, ulnar-humeral joint gapping is returned to levels comparable to those of an uninjured elbow. The current technique has been validated in a substantial body of literature, including a 10-year longitudinal study of more than 350 professional pitchers, cadaveric studies setting reference parameters, diagnostic assessment showing sensitivity superior to arthrogram. But these papers have focused on the pre-reconstruction injured state. The current study is the first to assess the effect of reconstruction on joint gapping. There's published literature on optimal postoperative imaging after reconstruction. Ware et al have highlighted the limitations of both MRI and MRA. Only two studies have looked at ultrasound after surgery. None have quantitatively assessed joint gapping. Morolla et al performed stress ultrasound at 36 months post-op, but provided only qualitative descriptions. Park used static ultrasound after surgery and reported intact graphs in a small series. One of the most challenging diagnostic scenarios is assessing for possible re-injury after a UCLR. MR is difficult to interpret. Stress ultrasound is an excellent adjunct. And the findings of the current study suggest that if the delta is less than one, the reconstruction is likely intact. If the delta is greater than one, then recurrent tear should be considered. The strengths of the study include prospective data from a well-designed randomized trial. The first to quantitatively assess joint gapping after surgery. Ultrasounds performed by highly experienced musculoskeletal radiologists and performed at minimum one-year post-op when throwers have returned to throwing and many to full competition. We acknowledge limitations. Stress ultrasound may be user-dependent. The anatomy is ideal. High inter and intra-related reliability have been demonstrated, but experienced radiologists may not be available at all settings. Gracilis autograft was used in all patients and this may limit applicability to all graft types. Nonetheless, the current paper shows that reconstruction does return joint gapping to normal after surgery, regardless of reconstruction technique. And by providing reference parameters, it can allow surgeons to better assess for a recurrent injury. Thank you. Thank you, Michael. Thank you, Michael. Our next talk will be paper number 20, Clinical Outcomes of Ulnar Collateral Ligament Repair with Interim Brace versus Ulnar Collateral Ligament Reconstruction in Competitive Athletes. With Jeff Dugas from Birmingham. Thanks. Okay, just push that one to the right there. All right. Okay, thanks. Great work, Michael and the group out of Philadelphia. So thanks for the opportunity to present this. I'd like to thank my co-authors, Lyle's sitting here. I don't know if Benton walked in or not, but this is a large group and it took a lot of people. So thanks to all of them. These are my disclosures. I do get a royalty on a kit that was designed to support the interim brace technique. So UCL reconstruction we're all familiar with. There's a bunch of different techniques that are all highly successful. With different fixation techniques, we published on a large group of these with 83% success returning to the same or higher level, but repairs didn't do as well. It goes back to the UCL history. When Conway wrote on Job's patients, the 70 patients, there were 14 repairs and 50% got back, but in the major league group, only 30% got back. And this mimicked Dr. Andrews numbers as well, about 30% of the repairs, as opposed to the reconstructions did very well. And so on the basis of that, UCL repair died somewhere in the neighborhood of 1992. And then Buddy, who's sitting back here, published two kind of key articles in the mid 2000s, 2006 and 2008, first in female athletes with very high rates of return, 94%, at under three months in females. And then again, 97% in people at six months, mostly male overhead athletes. And this was in 07 and 08, both published in AJSM. The internal brace came around when Gordon Mackay, a foot and ankle surgeon in Scotland, first did this in the ankle, and we took interest in the elbow. It's a construct of two small peak anchors with a fiber tape, with a collagen coated tape, and a high suture, a size zero super suture. And the current study is a comparison of these two techniques. Our UCL reconstruction technique, the modified job, all done by one of the three of us, myself, Lyle, and Benton. And then there were 862 total over an eight year period. We had 92% males. We excluded the ones you see there, including hybrids. We had a 461 complete data set for about a 70% completion rate at a mean age of 19. The reoperation rate was eight and 9%, respectively, between the reconstruction and their internal brace groups. So similar, and there was no statistical difference between them. Interestingly, in the reoperations, the reoperation rate for the reconstructions was 3% to revision. It was 2% to revision in the repair group. Again, no difference. There were a few more ulnar nerve complications, and I think that's because during the middle of this time period, I went to not transposing the nerve, and I had more problems with that, so I went back to transposing them. But there were no statistical significance between the proportions of subsequent elbow procedures in either group with a very high P value. Baseball was the predominance, as you'd expect, but there were others. In the demographics, there were more high school athletes in the repair group, as you'd expect. It was about 54%. Partial tears predominated over complete tears, and the collegiate athletes were a higher percentage in the reconstruction group, with, again, a little bit higher number of complete tears as opposed to the internal brace group. There were 2%. We looked at the people who attempted to return to play. We thought that was probably the most important statistic. Just reporting return to play was less important than those who actually attempted to return to play. We had about 92% and 95% attempt to return, and from those groups, only 2% were unable to return to play in the repair group with internal brace, and 1% in the reconstruction group, for a 98% and 99% return to play for those who attempted to return to play. And the average return time was significantly different at nine months in the repair with internal brace group and 13 months in the reconstruction group. There were no statistical differences whatsoever in any of the patient-reported outcomes that we measured, including the ASES function, ASES pain, KJAK, and the Andrews-Carson score. No difference in any of them. So my thoughts are that, as with other ligamentous injuries in the body and devulsions of the UCL can be repaired back to bone, and minor partial thickness tears can be amenable to this technique, with success rates equal to UCL reconstruction. Addition of the ultra-strong tape and things like that as part of the construct is certainly protective to the repair, but it's not a ligament replacement and shouldn't be thought of as such. I have cautious optimism in patients with partial thickness and then devulsion injuries, but I'm not likely to use this in people with attritional ruptures and tissue deficiency. And as time has gone on, this has been more accepted at the highest levels of sport, including all of the major professional sports in the Olympics. So my thoughts are that the decision to perform this procedure is an intraoperative one in the vast majority of cases, based on tissue quality and quantity, but level of play, velocity, age, what you do with the nerve, the location of the injury, proximal, distal, the degree of the tear, seem to have no influence on the outcomes of repair with internal brace. And revision does seem to be a better option with this than reconstruction, but there's a lot more data needed to prove that. Thank you. Thanks, Jeff. I just want to compliment our first two speakers on staying on time. Thank you. Great job, Jeff. Next will be paper number 21, anatomic medial ulnar collateral ligament reconstruction with internal brace augmentation in throwing athletes by Chris Cramp out of the Mayo Clinic. That button should be good. I think everything should be set up for you. Wonderful. Well, thank you all for your time and attention. It was a fantastic talk with our last two speakers, and Jeff has really sort of pioneered the internal brace and the repair. The question of this study is really trying to report on the outcomes of what happens when we add an internal brace to a reconstruction. Disclosures are available online. None are related to this talk. So here's a quick overview of what we'll do. Talk about kind of how we got here. General outcomes of reconstruction. We'll talk about reconstruction with an internal brace. I'll review the anatomic technique, which is what was used for this study, and then report the outcomes on that study. So the quick version, you've kind of already seen it, but in 1986, Jobe described the, that's when he first published his series, and this was a figure of eight reconstruction technique with an obligatory Ulnar nerve transposition. This was then modified in the early 2000s. So in 2001, we had the modified Jobe published for the first time, which then allowed selective transposition of the Ulnar nerve, still kept the figure of eight technique. And then Dave Altschek published his results of the docking technique in 2022. We have made a few tweaks to this, but ultimately these two constructs are still the main workhorse for UCL reconstruction over 20 years later. So the general outcomes of UCL reconstruction. Jeff just did a great job going through this. Overall, now we have a lot of large robust studies or greater than a thousand patients pulled in them. And if I had to summarize all of them quickly, I'd say the return to play rate for reconstruction is 80 to 95%, which is really good in orthopedics. Return to same level play, 70 to 90%. Also fairly encouraging. The real concern is the return to play time, 12 to 16 months. And so the repair has been really helpful for this in driving that time down. But the question is, can we change that or impact that at all if we had an internal brace to our reconstruction? So why people are talking about this, what's going on in the world right now with the reconstruction? So this is unpublished data that we're looking at in professional baseball. Hopefully we'll have this completed and maybe be able to present it here next year. But just a graph, if you look at all of the UCL surgeries performed in professional baseball, major and minor league, from 2010 over to 2013. The different colors represent the different type of constructs. So the yellow is the repair, the orange are the standard reconstruction. But I wanna draw your attention to this light blue section here. So these are the reconstructions with internal brace augmentations. So the augmented reconstructions are also often called hybrids. So last year, 36% of all MUCL surgeries in professional pitchers were reconstructions with internal brace. So this seems to really be growing, but we don't quite have results yet. The anatomic technique was an attempt to try to move to the next step of reconstruction techniques. It was initially described by our group in 2019 in a biomechanical study. The thought behind doing this was to try to bring the limbs of the graph closer together to make it more anatomic and increase tendon to bone contact. The initial biomechanical study was published in OJSM. A video technique is published in VJSM earlier this year, so feel free to look those up if you're interested. Very quickly, I'll show you here. So a socket is drilled in the medial epicondyle just like you would for a docking technique. The native ligament is repaired back to the medial epicondyle, and then a tightrope is configured around the socket. The graft and internal brace are folded over this and then pulled into the socket. Soft anchors are placed in the proximal ulna. The two limbs of the graft and the internal brace are whip stitched together. This is then tied down at the proximal ulna to give you proximal fixation on the ulna, very similar to the MCL of the knee. And then the internal brace and the tapes from the graft are loaded onto an anchor, which is fixed distally in the ulna. So you get three points of fixation. It's onlay fixation, but it recreates that triangular footprint on the ulna, which matches the native anatomy of the ulnar collateral ligament. Just to recap quickly, so the graft is folded with the internal brace docked on the medial epicondyle. The two limbs are sutured together and then fixed distally. So outcomes of this study. So this study cohort, to keep it clean, this was 41 pitchers. I had it greater than a year and a half follow-up. All position players and non-throwers were excluded. So pure pitchers in this study. Surgery dates were 2020 to through 22. 37 primaries, the rest were revisions. All were using mostly palmaris, so they didn't have it in as gracilis autograft. There were 19 professional pitchers, 22 amateurs, and they were offered an accelerated rehab protocol afterwards. For outcomes, all 37 were able to return to pitching at some point after surgery. Functional outcome scores improved as you would anticipate with this cohort. 92% of the pitchers were able to return in 12 months or less. And I think interestingly, 85% were able to return to the same competitive season the following year that they were injured in. So if they got injured in spring training, this means they were able to get back to games in the next spring training. If they're injured in fall ball, they're able to get back by the next fall season, which I think can be critical for these athletes. And for rehab, they were all able to stay on the accelerated protocol with the exception of one that was flipped over to a standard rehab protocol due to biceps tendonitis and cuff impingement. And then the mean time to return to play was just under 10 months. And I think that this is potentially the most appealing thing of this technique. For failures, there was one patient that failed at three years post-operative. So important note, like most surgeries, these tend to occur late, relatively short follow-up in this group, so they need to be followed longer, but one did experience a re-rupture, and this is a professional pitcher. Number of limitations to this study, obviously lack of long-term follow-up, which is the biggest, it's relatively small sample size. Variability in access to rehab, there are professional pitchers and college pitchers and some high school pitchers in this, which we all know have different access afterwards. Also variability in their level of play, always difficult to return whether, or determine whether or not they return to the same level. It's a very complex question, difficult to answer. And obviously lack of a control group. So we don't know if these results are due to the anatomic technique or the internal brace, or maybe a little bit of both. So ultimately, we really need longer-term follow-up to see if this may be promising in the future. Thank you very much. Thank you. Our final paper presentation for the early part of the session is paper number 22, the natural history of ulnar collateral ligament injuries in professional baseball. This will be given by Joseph Tannenbaum from Northwestern. Joseph. Thank you very much for the opportunity to present today. And I want to say a special thank you to the Herodicus Society for recognizing our work. I know it's probably pretty rare for a resident to be standing up here. And so I really appreciate the opportunity. So my talk today was animated by a study came out about 10 years ago from the San Diego team that looked, that surveyed MLB team physicians and asked them to rate a series of potential draft picks or signings for their risk of recurrence of a series of injuries. And the first was a 22-year-old collegiate pitcher who'd had a Tommy John done about two years ago, had returned to his prior level of performance, pitched a full season without pain. And they tried to figure out what was the general group think about the risk of recurrence for this player. The second one was a similar pitcher who'd had Tommy John done a year ago, had returned to his prior performance and had no pain, but hadn't yet pitched in an actual game situation. And the third was the same 22-year-old pitcher. This player had been diagnosed with a UCL sprain, not well-defined what that meant. That player did not undergo surgery, did a three-month rehab program, did return to the prior level of performance and pitched a full collegiate season without pain. Now, if we look at each of these scenarios side by side, the general consensus was that the first player was labeled a mild to moderate risk. So the majority of physicians rated this player a two or a three on a five-point grading system, one being no problem, five being absolutely stay away. The second was labeled as moderate risk, averaged about a three on that same scale. And that third player was labeled about moderate to high risk, ranging from a two to a four overall in the grading system. And so the question that really animated our paper here today was, what are these risk estimates based on? What do we know about actual recurrence risk or reinjury risk for players when it comes to their UCL? And so that was the question that we sought to address and to do that, we needed to know how often these occur and professional players are perhaps the best group to study because we're able to track them over time and Major League Baseball has gone out of their way to actually help researchers and scientists do this type of work. And so how did we do that? We took data from Major League Baseball's health and injury tracking system, which looked at seasons from 2010 to 21. Now we could have gone further in terms of number of seasons, but we needed to have adequate follow-up for these players. And so every documented UCL injury, a sprain, a tear, anything in between was recorded. Any player who reported an elbow injury that was subsequently diagnosed with a UCL injury was included in our sample. Every player in this database is assigned a unique ID and their injury is given its own identification. So if a player got hurt in 2012 and then hurt the same elbow a couple of years later, their ID would show up in both years, but they'd have a new event ID. So to make that explicitly clear, say that a player tears a UCL in 2018, that player would show up in our data with a unique player identifier, but that injury would also have its own identifier included. That player then rehabs, goes back to playing, wins an MVP, all sounds great. But then five years later, they re-tear the same ligament. That player's ID would be entered again into the system, but the event ID would be a new one, which allows us to track what's actually happening to these players, whether it's a recurrence of the same injury or if it is something entirely different. And we chose to look at the five-year time horizon because that is the median length of an MLB player's career if you average it out over the major and minor leagues. And so when you look at our data and you take all comers, there is actually, it's very interesting that over time, there's a trend toward the recurrence rate going down. But overall, from the 2010 to 2016 seasons, you see about a 10 to 12% overall recurrence rate. Interestingly, if you look at players who were initially treated operatively, again, it doesn't necessarily differentiate between reconstruction or repair, though I would argue with the data that Dr. Camp just put up is probably all reconstructions, that those players have about a five to 7% recurrence rate within five years, whereas players that were initially managed non-operatively had a much higher recurrence rate. And interestingly, when we also looked at what happened to players who had a recurrence, how were they managed, there seems to be, for players that are interested in continuing to play or able to continue to play, about a one-strike-and-you're-out policy that over 50% of those players ultimately underwent surgery for their recurrence, and that that trend over time is going up. So if we look at the initial players from that study that came out 10 years ago, that first player, it is probably appropriate to label them more a one or a two than a two or a three. They're roughly at a 5% risk of re-injury within five years, and likely even lower, although we don't have granular data to say that for sure. The second player, if they are ultimately cleared to return to play, likely also fits into that same bucket of a five to 7% risk of re-injury within five years. That third player, however, is someone we know a lot less about, but our data would suggest that overall, in a five-year time horizon, about a 15-ish percent risk of re-injury. Now, all this is not to say that, the takeaway from this is not to say, well, every player who has some kind of injury or a sprain or a low-grade injury should have surgery. It's just to say that perhaps there should be a little bit more caution for players who undergo initial rehab rather than opting for surgery. So thank you very much. Thank you. for questions. So anybody from the audience have any questions for any of our speakers? Go ahead, Dave. I think you know those numbers you have to look at seasonality you know it obviously plays into it the repair groups if we just look at the repairs the overall time to return was about in the first group we do is about six and a half months but those are all high school kids you know early on and then you get into college and some pros and I think the seasonality affects it but I wouldn't say that the statistics bear out that it's any much that different I think we probably in the higher levels just delay them a little more for anecdotal reasons rather than statistical background correct yeah I think that's true in the accelerated protocol that I offer to these players is essentially the same protocol that I used for UCL repair that that is the accelerated protocol so that's sort of why it lines up but I agree with what Jeff said I think that for high school athletes get back incredibly fast professional athletes not nearly as fast I think the window of effectiveness for a high school athlete is relatively broad and they may be at the top of that when they get injured but they really just have to get to the bottom of that in order to get back to play which often happens pretty quickly I think for professional athlete that window is extremely narrow and so it just takes them longer part of it may be age and youth but I think most of it is a talent problem any other questions from the audience you know Jeff and and when we look at this looking at your data from ASMI and we're somewhere around seven to nine months for the repair and around 13 for the reconstruction there's some prediction that with repair plus reconstruction of the augment is just gonna fall right in between those two is that your sense of what's going on yeah I people ask the question about the hybrid and and Chris's hybrid is excellent it's clearly the best data we have but if you asked all the people to do high-volume UCL surgery what their hybrid is going to be different it can be ten different ones and I think that as time goes by we're gonna find which one of these or maybe there's more than one works really well and what the form of the hybrid is I think the hybrid is here to stay and and I think it fits in a lot of settings we also had return to practice data which I didn't present but the rich because I didn't want to go over time as you mentioned but the return to practice was about six and a half seven months in the repair and it was you know 11 to 12 months in the reconstruction so there was a whether that's valuable return to practice return to play I mean again you get into seasonality but if you're gonna return to practice and you're throwing BP it's probably maybe we ought to be looking at that Chris one quick question about your surgical technique you showed a great example of a proximal tear doing a proper you know repair reconstruction and augmentation with internal brace what are you doing in the setting of a mid substance or distal tear where obviously you can't have a similar situation with your proximal tissue yeah great question the prox was the most common and it's the easiest that's one of the reasons I showed it for the distal tear I do the same thing but you just flip it so the sutures are gonna run up and down and then just take the sutures and pull them into the distal most anchor that's what like I just put in at the end and for the mid substance here actually what I've what I've gone to doing is actually suturing both sides and then the sutures that are in the distal part of the ligament fix them proximally through the socket like I showed in the video and then the sutures that are in the proximal I pull them distally so that way you're sort of taking the two ends and grabbing the sutures and pulling them across each other and then at the end after putting the graft on suturing everything together so it all kind of works as a unit any other questions John Yeah, it's a great question. So I do have three post-op MRIs on this cohort. One was the one who tore, and I honestly was worried about the distal part of this, but the one that had a recurrent tear actually tore proximally, which was surprising to me. And then I have two others that we ended up, they had flexor pronator-related issues, and actually got it and looked at the graph, and the distal aspect had completely healed to the bone. So it's only an N of three, but in those three, the distal part actually healed completely. But I think, again, sample size is small. It's still early. You know, I think we really need more time to know for certain. Great, thank you very much for our speakers. We're gonna move on to the technique section. And our first spotlight video is UCL Repair Plus, and UCL Reconstruction, What to Do and When, by Jeff Dougas. Yeah, and that's all clinically, the stuff that those guys, that's great data to help us every day. So, and that's what we need. So just a little video, and I put this slide up because this is probably the most important slide for anybody that's gonna do, you know, UCL surgery. You gotta know where it goes. And I think that if the technique recreates the anatomy, you're probably gonna be successful. But the sublime tubercle's easy. The medial condyle is not. And so being aware of where that is is super important. So here's a video. This, we go a little posterior. We don't, we never really did the muscle split. There's nothing wrong with it. This is just the way we've done it for so long. Find the musculocutaneous, interbrachial cutaneous nerve, isolate the ulnar nerve, transpose it, don't transpose it. We elevate the muscle, so we do a muscle elevating approach rather than muscle splitting approach. We get the muscle off, and we can see the whole ligament from the sublime tubercle, which is very visibly obvious right there. And you can see that's the outline of the ligament from distal to proximal. We're gonna split the ligament from the apex of the sublime on the distal slope, go up towards the medial condyle, being careful to stay in line with the fibers of the ligament. We're trying to split it, not cut across it. And you can see that this is a pretty obvious distal tear. There's a lot of bone exposed there. This is a big distal avulsion, but the tissue is there, and it's good tissue. And you can see the joint line right above it. So for the repair, and this would be the same for the reconstruction as this approach. For the repair, we're gonna drill the first hole on the side of the injury. So it's gonna be right there at the apex of the sublime, or just distal to it. We dunk the anchor in there with the tape and the super suture, so we lock that in. We tap these holes with a tap that's made for the anchor. This is good bone. I don't think anchor failure is really an issue in any of these things. I'm then gonna take the suture and repair the ligament. So I abrade that bone and make sure it's bleeding. And basically, this accomplishes what Buddy did and showed great results. And I'll point out that Buddy's results are basically the same as what we're doing, even with the internal brace. He had about the same outcomes. So for these endovulsions, doing the repair, I think, is key, and it is a repair with an augmentation. So we're getting a really good repair with a really rigid construct and getting it back down to bone. So this suture is a, we don't use absorbable sutures in ligaments at our place. So this is all non-absorbable suture. This is a zero, very high-strength suture. Name will be withheld. But, and then we close up the split. So the split that we made is closed side to side. Again, we're just trying to recreate the normal anatomy. People say, well, why do you do the split? I wanna know exactly where the joint line is at all times, and I wanna make sure I get good access to the medial epicondyle, because that's the harder part of this. So I'm gonna make sure that I've got good access. I'm through the split there. I'm gonna make sure that I've got my access, and I'm gonna pull the nerve back. I'm gonna drill the second tunnel. The drill goes in. The key here is to know where the bone is. Most of the time, we'll put my index finger up at the top of the bone, and make sure that I direct the drill up the medial epicondyle, not aiming medially, but aiming a little bit towards the ridge above the medial epicondyle. This is an oversized tap, because we have a little bit more tape going into the tunnel because there's two limbs coming back the other direction. And for the purpose of this video, I put this in tight, so I over-tensioned it. There's been some folks that have said, I wanna put this thing in as tight as I can get it. I personally think that's a bad idea. In this patient, I could not flex the elbow past 90 degrees without the anchor pulling out. So to me, that's over-constraining it, and we're over-tensioning the thing, and you're creating some compression on the ligament. So I can take it out. I can adjust the length, and I can redo this. So it's a tensionable construct. I'm gonna get that in there. I'm gonna retest it, make sure I can get an instrument under the tape, and then I'm gonna advance the anchor. And then I'm gonna recheck it, and make sure that the tape does what I think it's gonna do, which is not over-constrain the ligament and the range of motion is complete and free. And then I'm gonna sew the tape down to the ligament so that it all moves as one unit. I don't want any windshield wipering of this tape. It is collagen-coated. I have been back in on a few of these, and it does provide a very robust healing response there. But I'm gonna make sure that the whole thing moves as a unit by sewing those things back together. So you can see there's the construct. So when we're doing our reconstructions, we're gonna drill, you can see the joint line there. This is, again, a right elbow. There's a guide for this, and I've gone to using the guide. You can use the guide, not use the guide. You can convene the tunnels with curved curettes if you don't use the guide. If you use the guide, it does it for you. If you're not gonna use the guide, I usually put an instrument in the first tunnel, make sure that my aim is good, and then I'm gonna hit the first tunnel with the second one. So we're gonna take the drill guide, and again, same approach, muscle-elevating approach, so I can get a good wide view of the native anatomy. I'm gonna pass a loop suture through the curved tunnel there. I've curved them together with curved curettes that I didn't show for the purpose of time, but I'm gonna get a loop suture through that. Then we're gonna move on to the medial condyle tunnel. I've gone to drilling these from distal to proximal rather than proximal to distal, and then you have to make a second limb Y for the tunnels if you do the modified job. If you're doing the docking, you just drill from distal to proximal. It's key not to be interior. That's where the muscle and the tendon are, so you have to aim a little bit posterior, and I will usually put an instrument in there to make sure that I hit it, and then I'll aim the tunnel. Once I get through the cortex, I'm gonna change the angle of my drill and just drill a little bit distal so it's more of a Y and not a T so I don't create a 90-degree angle within the epicondyle. Then I'm gonna pass loop sutures through those using suture passers, and then I'm gonna pass the graft. So this is a palmaris graft. I'm gonna start proximally, so I'm gonna go from proximal to distal through the larger medial epicondyle tunnel. Then I'm gonna pass it from posterior to anterior with the suture loop that I put in there. You're gonna see that I created a little spaghetti here that I have to undo, but ultimately, we're gonna get this thing pulled through the ulnar tunnel. I pulled it inside of itself there, which is not a good idea, but I can easily undo that and get it over the top of that loop, and then I'm gonna pull it through the top of the area. But I can easily and do that and get it over the top of that loop and then I'm going to pull it through. And it will pull the graft through the owner tunnel. If you have a really large craft you can oversize these tunnels or you can see it's been pulled through and now put through the shorter end of the why using the loop that I just showed you and pull it up and you'll complete the construct. At this point you sew the graft to itself or you tie the sutures if you're doing a docking technique and then you can tension it distally by sewing the limbs of the graft together. So one of the questions asked was who's a candidate? Well, the one on the left, this is good healthy ligament that tore off a bone. No different than any other ligament in the body. My classmate in residency, Greg DeFelice, I don't know if he was outside a minute ago, same deal. The one on the right, that's crappy tissue. In Alabama we call that crud. It's a very technical term, crud. That's not good ligament. No matter how you slice it, that's going to be bad stuff. This guy's got a big enthesophyte. He needs tissue. He needs collagen. And a tape is not going to survive long term in that environment, I wouldn't think. So if you're asking who's a candidate, I think it's always wise to consider the tissue quality and quantity as the most important aspects of this in terms of making that decision. Thank you. Thank you. Our next technique spotlight will be given by Chris Hamad from Columbia University on Revision UCL Reconstruction. Thanks, Chris. Good afternoon. I'm going to talk about some difficult cases. We got some tools to take care of these difficult cases. I got three to show you. The first one's a right-hand dominant pitcher who's three years after a repair. So not a reconstruction. He had on the nerve transposition. Now he's got recurrent elbow pain. He was pitching extremely well. You can see the MRI scan. He's got an issue at the proximal attachment. In a revision setting, it's not just about the tear. It's about what were happening with the other tunnels. So we're going to have to manage those tunnels during the new revision configuration. So you can see there's an implant in there. It looks like it's in good position. I do take care of a fair amount of revisions from a tunnel critique on the Epitondal. If there's questions, I get a CT scan. And often the tunnel might be deviated in a way that you have to manage. So low threshold to get a CT scan. This is a typical palmaris harvest. He had a repair, so he has a palmaris available. Not everybody does. 20% do not have a palmaris. You'll see dots on the forearm. In the pre-op area, I outline the palmaris so that when we get in the room, I don't have to question if it, number one, exists. It gives me a little pathway. So three incisions, I like knowing that it's not something other than the palmaris longus. Pretty robust. I do about 90% of my own ulnar nerve work in a revision setting. This patient had an ulnar nerve transposition. Doesn't have ulnar nerve symptoms, so his nerve is healthy. So you have to feel comfortable with ulnar nerve dissection. The principle is go proximal until you feel like you have good control of the nerve. And as you go distal, you're going to encounter all of the stuff that was used to stabilize it. So this is probably the most time-consuming part of a revision operation to an ulnar nerve. You can get a little clever. You can roll the nerve back with some of the tissue off the flexor mass. Okay. Here's the exposure. This prior surgery was a exposure through the FCU heads of the ulnar nerve. So the raffae of the FCU is intact. And so it was a pretty easy exposure from there. And this is where it gets interesting if you haven't had the opportunity to revise a repair. We're splitting the ligament, but there's that super tape in there that's collagen coated. And it's so intimate with the native tissue. So there's real healing characteristics between the synthetic material and the biologic material. But for this particular case, it was a little enlightening. This tissue doesn't look healthy to me. It's fibrotic. It's stiff. I wouldn't leave it. So it's coming out with that collagen coated tape. So more to learn about. I mean, it's a question for all of us who are doing these things. So how are we going to revise this? We're going to do a hybrid reconstruction. We're going to drill tunnels. And these are converging bone tunnels, just like Jeff showed. But it's more distal. Usually you're leaving about a four to five mil bone bridge from the joint line. We're about 12, 13 can get even further down the medial ulnar ridge. The bone is very cortical. So as you get tapered down, as you work distally, sometimes that bone bridge gets a little more narrow, but the bone is so strong. Okay, now we're paying attention to the epicondyle. This is a smaller drill than I would normally drill. It's because we need to get past an implant. So start with smaller drills because a big drill might bounce you around and you may not get the tunnel you like. And you could always just keep advancing to the drill size you want, use a corret, get some of that foreign material out. You can see we're taking special precautions to the ulnar. And then we drill some exit tunnels. This is pretty typical stuff, so we can get past that. Now we're going to pass our graft. And you can't see the joint line here, but it's at least, this guide is about four or five millimeters distal to the joint line. And we're going to put an implant just like you saw Jeff's technique, where we can put the super collagen coated tape. Yeah, I had some thoughts about it, just took one out. Now I'm going to put one back in and it maybe had some interaction with the native tissue that was unusual. After excising the bad tissue that was still native tissue, part of our augmentation strategies, like Chris Camp showed, is if you can repair the native tissue, it's a real advantage. Okay, so now we're going through the exit tunnels with graft and with the tape. Then we're going to take the anterior limb, estimate its graft length, joint is reduced when we do that, and then we'll suture the free end of the graft. So this is standard docking stuff. And then we'll pass the anterior limb along with the tape again. So you like to have a good fit, it's big graft, and now we got tape in there, so sometimes it takes a little bit of maneuvering to get everything nice and snug. Nice fit, I think, is better for healing. So we'll tension and tie the graft first and then we'll tension the augment hybrid suture tape and we'll tie those. And now you don't really see the tape, we're suturing the graft side to side and the tape is below it. So the graft is going to be superficial. Okay, one or two sutures, if you can repair native ligament proximally, there's some tunnel entrance issues with graft healing. Try to get as much fixation proximally. Okay, so that's a revision of a repair. Let's go over this one. That case was about a month ago. I like to show real cases, real time. This case was from last week. So he's 25, he's a professional player, high-VLO guy. He has his first operation in 21, it's a repair, and then he has a problem with it after a period of time of it working and he gets a reconstruction with a gracilis, single point fixation on the ulna. Now we got to make sure we know what happened in the other operations and really read op reports and he had an ulnar nerve transposition and he had some ulnar nerve problems and he had a very unique ulnar nerve operation. He had some commercial wraps put around his nerve and now he sees me and his graft's not working and he's got real neuropathy, not like a sense, his motor function is compromised. So this is what his CT scan looks like. He's got what looks like a typical location for a implant but he had single point fixation of first, likely the first repair that was the implant for the first repair. I looked at it a little more closely, it was a number of years ago. The reason why I bring up this case, this guy's got neuropathy, he's got stuff on his nerve that I'm not familiar with. So I asked my partner, nerve specialist, he puts these nerves that are injured in lacerations and in trauma back together and he was nice enough to help me with this exposure. He told me it would take about 20 minutes. We're about 45 minutes into it and he's still cutting this stuff and I'm glad he's cutting it. And you can see some of this reaction, the tendon is compromised now at the flexor attachment. So revision surgery means you have to be good at managing the nerve. Okay, so we did the same thing as the other case. You can see it looks a little bit more beat up. It's traumatized. I'm not going to go through that part of it. But then we let the tourniquet down and I gave the case back to him and there was a real neuroma in the nerve and he's doing what, it went over quickly, but he's managing a bad nerve with an adipose wrap around it and he feels that's very healthy for the nerve. Okay, last case. Jeff's got a lot of experience with this and I've been following his techniques. So it's really him teaching me how to do it. There's a Division 1 kid. He's three years of a recon that was working, my patient, and I know him. I talk to him. I see him. And then he has recurrent elbow pain. He's got this MRI scan and it hurts. It hurts right where it looks bad on the MRI. He's got positive testing. So we said, you know, we could give you some time off and see what happens or we can repair the graft. Now we're going to repair the graft. Seasonal timing, as Jeff said, seasonal timing is probably more impactful for some of these guys. So the right time of the season you get them back, they'll say, fix it. So this is what it looks like. That's the proximal area of injury. It's the underneath part of it that became off, underneath and deep. And so we can create a stimulation to the bone to get it to heal. We'll put an anchor in at the distal part. And then that suture is an anchor at the epicondyle. So we're going to use a suture anchor. In addition, we're going to suture the graft. Now we'll call it the ligament. And we're going to pass those through bone tunnels and we're going to tie it over a bone bridge. So there's no implant on this side. We drilled across small drill hole 2.0 and you can see two knots there. One is from the repair site and one is from a suture anchor. So that's the time I got. Thanks. Thanks Chris. So we ran a little bit over on those surgical techniques but obviously those are of extreme interest and importance to us. And so now Steve's going to direct us to some questions. And we do have a panel. If the panelists want to come up. We only have about 10 minutes. We'll do the best we can. So I'd like to invite Kevin Wilk and Chris Camp up to the panel. If anybody has any questions for the speakers, please feel free to come to a microphone or raise your hand. And then if not, we'll move forward with some panel discussion topics. So Tony just brought up our, oh Dave you have a question. So I'm going to ask essentially the same question as I did before. So just went through looking at about 300 MRIs, right, just from you guys. If there's a guy who's got a repairable ligament but the accelerated program with a graft and a repair seems to work just as well in the same timeline, what should I tell my general manager when a draft candidate has had a repair without a augmentation? In essence, is there a reason to do just the repair without the graft? Yeah, I think that the nine months that we showed, again, you're bringing in seasonality. The study we did initially, the return time was about six and a half months, which I think everybody would say is if you're just doing a repair, that seems to work. And I don't think it matters what level. I think the hybrids, and I'm doing hybrids as well, I think the hybrid is really interesting. And there's a bunch of different forms like we talked about. I do think that we have teams that go 18 months as their standard for post full reconstruction. Some are more 15 months. Rarely do we see a pro team saying 12 months. I think the hybrids are going to come in, like Chris said, they're going to be 10 to 12 months, and that's a huge improvement over the 15 to 18 months that we're seeing. I don't know that I would say a repair is more or less likely to fail. I mean, we've seen guys, there was a guy pitching last week in the college world series that's going to be a first round draft pick that had a repair as a freshman, and he's throwing 100 miles an hour still and has every year. I don't think we have a way to know that. But what we haven't seen is an attrition rate over time as we've looked at these things. It doesn't seem to be accelerating as time goes by. Dave, great question. I get it a lot. So I don't have the right answer for it just yet, but I think we're getting closer. I think about the hybrid now, people, the players want it, the agents want it, et cetera, and as we work through the indications, there's the ligament tissue quality that Jeff pointed out. It's either bad tissue, it's got ossification in it, it's been beaten up, older player, et cetera, and it may have a diffuse injury pattern that's not satisfying for repair. The second part is the demands on that player's elbow. So if he's 6'6", and he's a high velo guy, and he's going to be stressing his elbow when he's young, and he needs durability along with it, then the hybrid is probably the most common for that type of player. Now, as far as there's a sense, when I look at Chris Camp's video, it's as if he's got a perfect repair, then he's got a perfect reconstruction. So I think what we're trying to say is, can you have the rehab go according to the repair, the repair's going to heal, and you just threw the reconstruction in for added durability, so can you take advantage of having that accelerated rehab? I think it's a little... Jeff calls it seasonality. We often work backwards from the calendar, from a timeline for return to play, based on when they need to be ready, because why don't we soften the length of recovery time? So we don't always... If they go too fast, we got to put a halt on it, but we never say you're going too slow again. No, we just work backwards from it. So I have a hard time when a player is wanting to come back sooner than is what we call medically justifiable. So having said that, I think we all have internal experience when players say, this is my last season playing. I'll give you an example of a javelin thrower. If I don't get back next season in 10 months, I'm never throwing the javelin again, and I trained my entire life to get to this level. What can you do for me? And if you say nothing, that's not satisfying. You say we can try this. So I have a javelin thrower back with an augmented. If you take care of javelin throwers, they take longer than a professional baseball player. This guy was back in 10 months, and he was competing. Jeff, a number of people in this room will help out with evaluating the potential risk of injury when we're going through the draft. If you see a player who's had a repair with internal brace and has returned back to their same level of play, do you deduct anything off of that? Do you think that their elbow is a higher risk of injury as you're going into the draft? I think anybody that's had prior surgery can't be a one. I would never rate them a one. I think if you get the imaging, I would ultrasound it as well and say if it's stable and it's healed and the tissue looks good, I would make them a two. I would do the same thing with the reconstruction. So I think it's procedure independent. If the mass of tissue is well healed and it looks good, then it's a mass. I don't think we could ask for any more than that. I don't think the procedure itself matters. I get asked to review the higher ranking draft picks, and the higher ranking draft picks are the most talented, and none of them have a clean MRI. They are awful. They are terrible. In some ways, if they've already had a reconstruction, it's actually easier on us than the ones that are pre-reconstruction but the high-VLO guys and their flexor tendon's a mess. Everything's a mess on these guys. Nick, how does this correlate with the work you did at Rush looking at MRIs and predicting whether someone's going to get an injury? And it goes along with the velocity of super set-up. You take the high people and the guys. I tell my guys, I tell our guys, you just got to budget in a year at some point. You don't know what it's going to be, but it's going to happen. And just budget it in. To Jeff's point, I think the other side of the coin, we're also starting to see the earlier failures in the high people and the guys in the traditional reconstruction. So there's no such thing as a free market. I think there's just a player who's signed $500 million in two and three years. So I think that the high percentage may be a solution of where we're reaching and what a traditional reconstruction can achieve based on the velocity and size and the skill level of the players that are doing that. And I can give a little sneak peek. We're currently working on going through updated professional baseball data, which is still not finished yet. Hopefully, we'll get it out soon. But it's showing that the revision rates are increasing, which I don't think any of us would be surprised. And the time to revision is decreasing. We used to think that the guys would make it 7, 10 years, and that's no longer the case. And that seems to be true for both the repairs and the reconstruction. So I think that's going to influence those conversations that we have with our GM on draft day. We used to think, OK, they've had it done. They're good. They're going to be set. It's probably not the case anymore. It's going to be more of an issue, too, as we see the guys that are at the draft. They had Tommy John when they were 16. Now they're getting drafted at 18, 19, or even 22. That may not have much life in it. We have a poster out there on revision. It's George Richardson right here. He's the main author. And it's a limited number of patients. But interestingly, 80-plus percent of them come off the proximal side. But as opposed to primary UCL injury, which typically goes from the deep fibers proximally to the superficial, when they re-tear, they go from superficial to deep. And so there's a mechanical difference between how those ligaments are failing. It's obviously still valve of stress, but they're failing from a different direction. And that may play into some knowledge that we don't have yet. We need to figure that out. Re-revision. Yeah, I mean, I've revised all of them since 2017 with repair. I haven't done a revision with a reconstruction. I've sent those to Lyle. We all know how painful those procedures are. But we only reported on 10 of them, and there were four professionals in that group, including two major leaders. And they all got back, and the average return time was nine months in a revision setting. So I just think revision reconstruction is one of the worst operations that we still do. I think when a repair fails, you reconstruct it. And Chris told me he did one of mine. He's like, that was the easiest revision I ever did. When you fail a revision, I think repair is going to prove to be better than what we were doing with revision reconstruction. We were honored enough to have Kevin Wilk with us today. Kevin, can you just summarize for us what are the key things that we need to do for rehabilitation? Repair and tool brace versus reconstruction versus the combined. Are you doing them pretty much the same? And just using time as a variable? Or are there things that you're doing differently that we need to incorporate into our rehabilitation program? Yeah, I think the principles are the same. The time frames change. For me, it depends on who it is as far as the level of the individual. Many times we try to look for deficiencies as we're going through the rehab. What was the causative factors? Is it mechanics? Is there something going on with their shoulder? Young people, it's a lot of hips and legs we try to incorporate. Biomechanics is often the key, obviously. And I always try to look for a cause. Did they overthrow? We talk about velocity. So I'm a fan of sub-max interval throwing programs. I think sub-max, dialing down, longer duration's the way to go. Plyometrics, because the theory is that hopefully that tissue will hypertrophy. Kevin, when are you starting that throwing program? In each of those settings, in the setting of the repair versus the reconstruction versus the revision. Sure. What is your timing from a standpoint of starting to throw? Yeah, and absolutely the surgeon who does the procedure has a lot to do with that. So rely on that and what their guidelines are at the time of surgery. But like for an internal brace, just the repair, eight to 10 weeks. For us, for reconstructions, it's usually four months. For hybrids, there's a little bit of a wiggle factor. As Chris mentioned, a little bit quicker. And will you go like two-handed plyos, one-handed plyos? Always. And a throwing program? Because I think a lot of people in the audience who take care of athletes, if you don't have this wording into your therapist or you're not talking to your patient about, how do I advance to a throwing program? They think they can pick up a ball at eight weeks or at 10 weeks or at three months or four months. And they, I always, they have to be advancing to some level. No, that's a fantastic point. For us in Birmingham, we've always said that for the last 30-something years is even if you didn't do plyos, you're gonna do plyos now, even if it's the timeframe to start throwing because we want to recondition you. And also look at mechanics. So two-hand drills first, close to the body, then soccer-type throws, then getting away from the body, then one hand. But it's a progression as far as the weighted balls too. So we've gone to some weighted baseballs for our plyometrics, like a 350-gram ball, which is slightly heavier than a baseball. And we just try to, again, work on mechanics, but also create some load on that healing tissue, the graft or the internal brace construct. I had a patient's mom demand to have the flat ground throwing program in advance of his time preparation for the throwing. You know, he wanted to study it and all that kind of stuff. Their second post-op visit, the kid says the throwing's going really well, and I fell off my chair. And it turns out they gave the program to their therapist, and week one of the throwing program, when you start throwing is week one, they thought it was week one post-op. Was that a typo? Ouch. Jeez. I think the one thing that Kevin said that we should all take home, and that is in the rehab, the first thing, the most important thing, is to get away from the elbow. You really have to evaluate the shoulder, the entire kinetic chain, and the hips, because those are modifiable factors that may, in fact, prevent recurrence of the injury that we can work on. We have a lot of really clever surgical procedures with really unique implants that are working extremely well, but they're still breaking down. And so we need to look at the things that are modifiable, because we're running out of the surgical things that are modifiable, although Chris showed us a very innovative technique today. So I think Kevin was right, work away from the elbow, and then be patient to getting back to the elbow. And if it's a seven to nine month recovery, I don't know why you have to start at three months. If the kid's completely pain-free and completely asymptomatic, and it was a partial tear that was symptomatic, sure. But I don't think there's any reason not to be patient and wait a little bit longer, and especially on your reconstructions. If they look great at four and a half months, that's fine, but there's no harm in waiting six months, because you know it's gonna take at least a year for them to get back, so there's no reason to push these things, get all the other stuff in order before they really start pushing on their elbow. And I think as Tony mentioned, we didn't talk that much about preoperative physical exam during this session, but obviously it's critical to assess the core and the shoulder. And I think every baseball player, male or female, you need to expose the upper part of the shoulder, the scapula. And when a 16-year-old baseball player comes into the office and you ask them to take the shirt off, and they point to their elbow and they don't understand why you're having them take their shirt off to evaluate their shoulder and their core, that just gives you another example of why they're in your office, because they're really not focusing on the other things. So thank you very much for your attendance. Thanks for the panel. Was there another question, real quick? I was just gonna ask, I walked in late, so you guys might have talked about this, but Jeff and Kevin, can you talk about rehab early-range motion for repair versus reconstruction? I feel like they have more tendency to get stiff, probably because we do a better job constraining the joint than we do a repair-authentic with the brace, so I mean, quickly or exercise-total extension, has that been your experience? Kevin. Yeah, you know, I think the internal brace sometimes can be a little bit tricky as far as range of motion. Many times, for me, it's more flexion, and I don't really push it that much, even with the reconstructions. So I'm a little bit cautious with flexion, hyperflexion in particular, but I think you're right. I think there is a difference with the range of motion. What those reasons are, I'm not really sure. Could be the graph, you know, as you're passing it through. I've heard Dr. Pauletta talk about that as well, that kind of dangerous curve, so to speak. And also, anecdotally, too, I do think that adding an internal brace to a reconstruction runs that same risk. So I've actually, anecdotally, I've observed that. So I've gone to being a little bit more liberal early on. So rather than locking the elbow out at the time of surgery, I actually give them an arc of motion from 70 to 110 on post-op day zero, and let them work through that, and then at two weeks post-op, let them open it up all the way. So I think internal brace, whether you're doing it with a repair or a reconstruction, does run that risk. The other thing is make sure you always get full elbow flexion in the OR before you leave. Jeff showed us that perfectly in his video earlier today. If you don't get that, make some adjustments, because you won't get it later. I think with the internal brace, regardless of whether it's by itself or with a graft, that speaks to why, personally, I think it's a bad idea to max-tension that thing when you put it in. I think if you don't max-tension it, you're gonna have less of that issue, regardless of whether you're doing a hybrid or just a repair. Again, thank you, everyone. I appreciate your attention. Enjoy the rest of the meeting. Thank you. Thanks.

Steven B. Cohen, MD

Anthony A. Romeo, MD

Michael C. Ciccotti, MD

Jeffrey R. Dugas, MD

Christopher L. Camp, MD

Joseph E. Tanenbaum, MD, PhD

Chris Ahmad, MD

Kevin Wilk, PT, DPT

UCL surgery

UCL reconstruction

UCL repair

clinical outcomes

rehabilitation protocols

joint gapping

internal brace

return-to-play

recurrence rates

biomechanical principles