We'll talk a little bit about UCL repair now. Greg did a great job kind of laying out why this is a problem, so I'm not going to belabor the point here. I do think that this is actually extremely important when we talk about repair, though. Greg showed you this slide before of how the number of UCL surgeries in our younger patients are going up, and this is probably why UCL repair has become relevant, because it's in these players that repair is oftentimes something that we're going to think about. Chick, I'm still waiting on the ring that you guys have, but this was close enough from last year. So let's talk a little bit about history of UCL repair, okay? We know that this first got talked about back in the early 90s, John Conway, Dr. Jobe, kind of discussed UCL reconstruction, UCL repair, and what they found was that UCL reconstruction in their professional baseball players did pretty well, and 75% got back to play, and this is pretty good for the first go at this procedure. But their repair group did pretty poorly, so they only had about a 30% return to sport rate in their repair group. And so after this study came out, repair was largely abandoned. And so as the number of UCL reconstructions continued to go up, and we saw that the length of time getting guys back to playing in baseball continued to go up after reconstruction, because you're talking 12 to 18 months for a player to get back to playing at the same level after reconstruction, so between one to two seasons missed, the amount of money being missed, there had to be a better option for this. So then Buddy Savoie kind of resurrected the repair, and went over a series of 60 patients, younger patients, mostly males under 18 years old, average age, and he did a UCL repair, didn't hit an internal brace, just a straight UCL repair, either with drill holes or anchors, and he found a great return to sport rate, 93%. And 97% were getting back at, sorry, 93% good recs and outcomes, 97% got back to sport at the same or higher level, and had very few complications. This kind of got our wheels turning, okay, maybe we can revisit this idea of a UCL repair. And so if you take a look at some of the literature at that point, it was pretty sparse. So there was the old study by Conway, then this new Savoie study, one biomechanical study that had come out, and so there wasn't much in the way of literature out there. So then enter Dr. Dugas, who decided to add the internal brace over the top of the UCL repair, so adding a high tensile suture over the top after you've already repaired, whatever suture you choose to do. And so he did a biomechanical study on this, and he compared it to the reconstruction technique that he uses, the modified job technique, and what he found was that his augmented repair, so the repair with the tensile suture over the top, at time zero was actually stronger than the reconstruction. And so another study actually by Nick Verma from Rush kind of reproduced these same results, basically saying that UCL repair with internal brace was actually stronger than a reconstruction and stronger than the native ligament. So at least at time zero, this seemed to work. So then Jeff published his one-year results, and a lot of athletes, so I don't know how many UCL repairs are done in the audience. Myself, I'm probably in the 20 to 25 range a year. He did 128 of these, and he published his one-year file. He does a tremendous number of these. And what he found was in his study, so he only did repairs in players that had a proximal or distal tear, so no mid-substance tears, good quality ligament tissue. And what he found was that the age that he was doing this in, about 18 years old, right, so similar to Buddy's study, and the majority were baseball players. And so when he published his results, you saw that 92% of these players were able to get back to playing at the same level. So that's 92% of baseball players who are mostly high school and college players getting back to playing at the same level. Time to get back, six and a half months. Very different from 12 to 18 months following a reconstruction. Had very few complications from transient ulnar nerve issues, as he transposes the nerve all the time. And then one person, this is actually a little bit of an update, kind of toured their UCL a couple years post-op, but one out of 128 is pretty good if you're looking at results from this. And so if you look at their kind of CAGEOC scores, where the tear was didn't seem to make much of a difference. The majority of these players were able to get back and had a very good CAGEOC score once they got back. And so that was kind of the first study that came out and said, okay, this is probably a viable option of things we can do in the right patient, right, because he restricted his repairs to younger players, good ligament tissue, proximal or distal tears. So then we've started to see trends over the last couple of years. Now we're starting to get into the, you know, database trend studies. And so James Gregory down in Texas basically looked at UCL repair versus UCL reconstruction in the Texas database. And what they found was that obviously the number of UCL surgeries were going up significantly, but back in 2010, repair was only 23% of all UCL surgeries. And by the end of 2019, that was 40%. So the amount of UCL repairs are going up dramatically. Interestingly, they still were doing more reconstructions than repairs. And that's back in 2019. But you can see that the number of UCL repairs were growing dramatically, whereas reconstructions were growing, but not quite at the same level. So they basically found that repair has become a much more common procedure. And I think now that we've seen some good results and we've seen the players that we can do this in, we can start to expand our indications maybe. So we have to kind of take it slow and make sure that the long-term results of this are still good. Because remember, reconstruction, those results came out of a paper published in 92. So we have 30-year results on reconstruction now. We only have five to seven-year results on our repairs. So while we're doing more of them, we just have to keep in the back of our mind that most results are still early to midterm. It's great that people are getting back, but the results are still early to midterm. And so from my perspective, the players that benefit from a UCL repair, so in my practice, the majority of players that I see, because the major league players, the Phillies have, they go to Dr. Cohen, Dr. Scottie, they take trips to Chicago, they take a trip to Cleveland and see one of these guys. So in the college and high school athletes that I take care of, a lot of them have good ligament tissue. A lot of them have proximal or distal tears. Sometimes they're full thickness, sometimes they're partial thickness, and they failed the course of non-operative treatment. But they're younger, they have good tissue quality, they haven't beaten up their elbow, it doesn't look like a bomb went off inside their elbow. And so those are the players that I think benefit from a UCL repair. And Greg showed you some of the consensus stuff we had up before as far as risk factors for UCL injury. Same thing, we asked indications for reconstruction instead of repair, usually two-sided tears, tumor on ulnar side, ligament tissues not great, patient preference, similar things. And then looking at repair over reconstruction, pretty much partial thickness tears, isolated proximal or distal tears, no chronic ligament issues, and then complete proximal or distal tears. And so we think about these players, obviously we always start with imaging when they come in and decide whether or not they're going to be a candidate for a repair. And so we obviously always get elbow x-rays, because sometimes we can see enthesophy, sometimes we can see these little ossicles that have formed inside the UCL. The reason that you get these x-rays is because if you see that ossicle, that's really not a player that's going to benefit from UCL in my practice. Because when you shell that thing out, the ligament's not great anymore, at least in my hands. So for me, that's not going to be a repair, that's going to be a reconstruction, or maybe what Dr. Romeo is going to talk to us in a little bit, maybe a hybrid technique. Usually the MRIs that we get look like this, right? So ligament tissue quality looks good, but you have a full thickness proximal tear. This is a kid that acutely popped this, right? And so you can talk to him about rehab, you can talk to him about non-operative treatment, but the reality is the majority of players that come in with this that want to get back to play, you're going to fix this, okay? And so the way I fix these, right, I don't transpose the nerve unless they're symptomatic, I don't sculpt the elbow unless they have an osteophyte in the back that's causing them symptoms. So we make a relatively small incision because we don't have to get our drill tunnels out the back of the humerus, so you don't have to worry about hitting the ulnar nerve most of the time, you just have to be very mindful of where it is. You protect the interbrachial cutaneous nerve, you make your split in the fashion, that kind of very thick white raffia that's always there, that usually takes you right down to the ligament. And when you get down to the UCL, a lot of times you'll see, this is a different patient, this guy had a distal tear, but you'll see the ligament doesn't always look too bad when you get down to it. And then when you split the ligament, you can see that it gets pretty lax, so you haven't elevated anything off yet, but you can see how lax the joint is, you shouldn't see that amount of gapping in a healthy ligament. Well, that's good. So that's showing you the ligament being a little bit lax. I don't know, the same thing happened to your video, I don't know why. So what we do is we put the first anchor at the tear site, right? So I showed you proximal tear before, this guy had a distal tear. So the first anchor goes distal, and you can see you're just a couple of millimeters distal to the joint line. You just don't want to break out into the joint. We know that the footprint of the UCL is such that the majority of the UCL inserts very proximal to the joint, and then it kind of thins out as it gets distal on the sublime tubercle. So when you're putting this anchor in, since you only have one point of fixation, you want to be as close to the joint line as possible without breaking into the joint, okay? So you drill, you tap for the first anchor, put the first anchor in, and then we repair our ligament, and you can see, this video at least works, so you can see once you're repairing the ligament back, you can restore quite a bit of tension. There's no wear or stress place on this elbow. This is just showing you that that repair stitch that comes in the anchor, that actually can repair it quite well. So we repair the anchor back down, and then we repair our side to side split that we made in the ligament before we put the tape over the top, because you don't want the tape necessarily abrading on the epicondyle. So then once we've repaired the ligament side to side, then we put our proximal anchor in. The tap for the proximal anchor is a little bit bigger than the tap for the distal anchor, because when you're putting the proximal anchor in, you have the fiber tape looped on itself, whereas the distal anchor, you only have two strands of fiber tape through the anchor. Now you have four right coming up proximal. So if you don't use the bigger tap, it's really hard to get this in. That was a change they made a year ago. It was miserable to get that in before. I don't know if you guys had that problem, but it sucked. That was not great. And then once you have it in, you can see that you've laid the brace over the top, and then we throw some, I use fiber, but throw some stitches basically to incorporate the ligament with the tensile suture that's gone over the top of this, and that usually repairs this pretty nicely. And then you want to make sure you check the range of motion. I don't know what this is. But just make sure on the table that you check the range of motion. We used to put a freer, I used to put a freer under the tape when I put it in to avoid making them too tight. It's kind of what Jeff talked about when he talked about his technique. I've stopped doing that. I just put it in as tight as possible, and then they tend to stretch out. So I make sure that I get their full range of motion on the table. As long as I can get them fully ranged, I'm not concerned about it being too tight. So I just put them in as tight as possible. Now, I haven't had a problem with stiffness in these yet. If we're going to move the nerve, obviously we make sure the nerve's out of the way, and then we'll transpose it anteriorly. I just use a little fat flap, a la Mark Cohen, to transpose this nerve anteriorly. And I don't elevate the flexor off if I do the nerve, I make two different splits in the flexor part of the nerve. I haven't had a problem with that. The reason that the repair is obviously a nice innovation that's come through is because of the rehab and their ability to get back to sport. This is Kevin Wilk's slide going over kind of the difference between repair and reconstruction. The difference, the split point, is when they start to throw. So at a repair they start to throw at three months, and at a reconstruction they start to throw at four and a half months, generally. Everybody's a little bit different, but that's kind of general guidelines. With a repair, usually between six to seven months they're throwing off a mound in a game. Reconstruction somewhere between 12 to 18 months. So it's at least half of the time to get back with a repair compared to a reconstruction, and that can kind of vary from person to person depending on how they're doing. And this kind of talked about some of the other consensus statements we came back from about you should make sure that these guys have full range of motion by six weeks. If they are stiff and come back to your office, start thinking about a MedDRAW pack, start thinking about changing therapists, things like that. And then beginning throwing program, like I said, usually three months. Since when I let them go back, I think most of us on the panel let them start throwing at three months after a repair. And then minimum time to get back. There's really not a minimum time. I try to hold the pitchers back for at least six months. The position players, we'll let them go back a little sooner. You saw one of the Phillies position players came back a little early from a repair to DH, right, not to play the field, but he has in his head he is not allowed to slide, he's not allowed to do anything silly that's going to compromise his elbow. It's why we let him go back a little sooner. So thank you guys for listening, and I'll turn it over to Eric.

UCL repair

ulnar collateral ligament

surgical procedure

UCL reconstruction

internal brace