the only collateral ligament. We're spending an entire session on this. It's obviously important in baseball. What's really remarkable is all the people that are involved in trying to care for these athletes and all the different disciplines, and we still have a major problem with this injury. And we really have, I have to say, certainly in the last 10 to 15 years, the MLB Research Committee has really tried to emphasize this, and a lot of other programs have too, to try to figure out how to solve this problem. And it still remains a major source of morbidity for our athletes. And we've talked about it in terms of players, but when you start talking about it in terms of money, you can see why the teams wanna figure this out as well as possible. It's really very expensive to have this injury. Kudos to Mark and his team, when you saw that just 2.4 million, whereas the Red Sox spent $72 million last year on players that couldn't throw a baseball. So this is very, very financially important that we figure out not just how to fix these and get them back, but how to do it as effectively and as quickly as possible to save literally millions of dollars a year per team. You heard Eric talk about the different techniques, and without a doubt, this remains the standard of care, but that is certainly shifting. Major League Baseball Research Committee has repair, they have reconstruction, and they've added a third category, hybrid, because of the amount of people that are using that as part of their treatment. When you return a player back to sport, can have some subjectivity to it. We've tried to be more objective, but probably not as advanced as what you see in the league, but that does play a role. And I remember when we published this paper looking at this, and Brandon did the work, and we said that's on average 17 months, people said, well, that's way too long. That's not how long it is, that's way too long. And when we looked at whether you came back early or late or a different level, did it cause a risk of revision? There didn't seem to be any difference. And then this paper is slightly more recent, same thing, 17 months. That's a long time, especially for a young player. Most young players, if they miss two seasons, they're done. They're not gonna be in that sport anymore. So the repair has really been a tremendous advancement for our younger athletes. Is it going to work at the major league level? We're still learning about it, but there's a lot of promise, and maybe the hybrid technique of using this and a ligament may be the right answer. We'll see. Brandon spoke to you about the brace, so I'm not gonna go through that, but you really should have good quality tissue. It's mostly the ones that come off the humeral side of the ulnar side, our younger athletes. This is the ideal candidate. This may not be the ideal candidate. When it pulls off the ulnar side and there's a limitation of tissue, sometimes you get in there, you can't even get it all the way back over to the ulna. You're not gonna just put a synthetic tape over the top of that. You've got to reconstruct it. And the mid-substance ones may not do as well either, although there are reports from Dr. Dukas and others that they can do well. So when you have these cases that are borderline, the one to the left is pretty straightforward, but the one in the middle may be mid-substance, and then the one to the right where there was an injury when he was still skeletally immature, continued to play, now he has persistent pain. If you're gonna take out that ossicle, you're gonna be short on that ligament. Can you just do a repair? It's kind of iffy. Chances are you're gonna be short on your tissue. And so we'd love to do the internal brace when we can. It's a great procedure. We know Dr. Dukas and now many others have reported excellent results, and you see the numbers going up quite significantly. And when you look at the complication rates, interestingly, until just recently, there was no UCL tears that had reoccurred, but one has occurred. But it's really a very, very small number. So it's a remarkably good procedure for our younger patients that have good tissue that we've selected for this operation. But what about the borderline, or what about the ones that need a reconstruction and are gonna take somewhere between 12 and 17 months to come back? Can we do something to move up that timeframe for them? Brandon and others have done some really nice work on the attachment site. And of course, Mark Schickendance and his team have too. And if you look at this carefully, you can figure out a place to place this ligament fixation point pretty close to a single point, but that's another discussion that we can have later on. I would say that many surgeons feel most comfortable with a tunnel on the other side and like that broad insertion, but more and more people are using a single point fixation. There has been some work on this for a while. Matt Smith did some work with using sutures and showed that when you did a reconstruction with a graft and you added additional sutures to the graft, it was definitely stronger. So this internal brace with a graft, which was a suture technique, was better than just a standard reconstruction, especially at time zero. So what about using today's modern day internal brace with a tape, as well as using a graft? And typically the palmaris graft, as we know. It's the same approach. We move the nerve if we have to, and you heard Eric and Brandon both speak about when we need to do that. And then if it's on the owner's side, we'll place the anchor on the owner's side first. And the reason we do that is because when it was designed, the suture to repair was designed to be in that direction. People have added another suture on the humeral side to put a repair on that side, or you can repair that first. I'm not really sure it makes that big of a difference. I think it's important to do something to reinforce the repair at the site where there's the most amount of injury, but I'm not quite sure that it makes that big of a difference. I think the tape still plays a major role in how well this works. And then you place your second anchor. And then what do we do about if we're short on soft tissue? So we looked at this because we've been doing this for a while and some of our patients with their borderline patients, and we wanted to make sure biomechanically it was the right thing to do. It certainly seemed like it was. We used the same equipment we've used all along. We drilled a hole at the sublime tubercle at the point that we thought would be most close to the isometric point. And we use these anchors where you go across and then it's a soft anchor and you pull on it. You see how powerful these things are, remarkably powerful. You can lift the arm off the table with that. And then when you put a loop through that and use a working stitch, you can then pull the graft, you can then pull the graft right down into place and into the socket. So you just pull on that. It's inside of the loop of this locking stitch and you just guide it in. And as you pull in, you'll see it sink into the socket and it's remarkably powerful. Some people have added the tape and taken the anchor out of this. They just put the tape in with the loop as well as the graft and pull on that and lock that into position. And it's fixed, it's secure, it's not coming undone. Then we can, if you like, add that extra anchor with the suture so you could do the repair on the ulnar side if that's where the pathology is primarily identified. And now at that single point, you have the two graft limbs, you have your two tapes and you have your repair suture. You can do this on the humeral side too and if you'd like to do it that way. On the humeral side, we have to make a slightly larger socket to get all of this through that hole but still not all the way up to what Dr. Andrews often used to do, the 5.0. We typically don't go larger than a 4.5 and it can be slightly smaller than that but it does make it a little congested if you make it smaller than that. And then once we have everything all set up and ready to go, then we're ready to do our repair. I personally like to focus on, we'll close the native ligament and then we'll repair the injured part and then we'll do the tendon graft just like we would do if we're doing a typical reconstruction and then we use the internal brace over the top of that to fix that as you see here and so this is what it looks like when it's done. And after everything's in place, usually three sutures perpendicular to capture the native ligament, the tape as well as the graft will then make this very powerful band of tissue that's in place here and it's remarkable, it works well. You check the range of motion and make sure you haven't captured the elbow. If you've captured the elbow, then one of your fixation points is not in the right position and typically the mistake that's made is putting your humal side to posterior so you've gotta really check that to make sure but if you do this anatomically and you get it right, when you're all done, you take it through a range of motion, it's just fine. And again, the biomechanics in this were remarkable and they work in a very positive way and what we found is that when we added this augmentation, we were at time zero, equal to the strength of a normal UCL but stiffer and even slightly stronger to the failure point and you see the markings here so the green and the blue, you see how that's reconstructed. So today in 2023, what should you do? Well, I think if you can, if you look at it carefully to make sense, you do a repair with the internal brace, the recovery time is about six to nine months, I would say closer to seven to nine months. You can do a reconstruction but I think we've become very comfortable in my practice doing the hybrid and we're following up our patients and the recovery time's closer to nine to 12 months. If you do a full reconstruction, our younger patients, we talk about 12 to 15 months and as you know from Major League Baseball, it can be out to 17 months which may play a role because of the being out of season and things like that. So I think within the next couple of years, there'll be enough surgeons that are doing this on a regular basis that will reduce the recovery time down to a very consistent one year so that if you need a graft and you do the hybrid, that's gonna be a consistent result that you can report to your patients which will be very, very valuable, particularly in your non-professional athletes because they'll be able to just miss one season and come back the following season instead of missing two. So I think that's where we're going and I think we have some real strong, promising early data to support that. Thank you.

collateral ligament injuries

baseball

recovery time

athletes

internal bracing