what does that look like in 2023? Well, repair's the hot topic, so we're gonna try to spice up UCL reconstruction a little bit. We're gonna start with this history and this player and tell me what to do. So 31-year-old pitcher, so sort of old for a pitcher, and he pitches a lot, a lot of innings per year. He's 154 innings into the year, he's doing really well, and all of a sudden he feels a pop in the elbow. He tells you, it's the strangest sensation I've ever known. The body is moving forward, but my left arm is out in right field. He has pain on the inside of his elbow, he can't control it, he has decreased velocity. He's had previous shoulder and elbow injuries once you ask him, and he has demonstratable laxity on exam. So he's failed conservative treatment and he comes to you for treatment. What do you decide to do? Well, you say he has a deficient UCL and repair, so he's relatively old, he's been pitching a lot of innings, probably not gonna be a great repair candidate. So what about reconstruction? What options do you have? What type of graft? What is the durability gonna be? And what are you gonna do with that ulnar nerve? He wasn't having symptoms before. Well, if you haven't caught on yet, this is Tommy John in 1974. Frank Jobe created this procedure and he gave him one in 100 chance of return and said that he didn't see many major league pitchers with scars on their arms back then, which so much has changed, of course, today. And he used the palmaris, which had been used in other hand-type procedures and repurposed that for the elbow for the first time. Well, it worked, and that's why we're sitting here talking about it today. He returned about two seasons later. He did have a complete ulnar nerve injury that had to be later addressed, but he was able to play 2,500 more innings. He won 164 more games and competed in three World Series. So as you've kind of seen, the incidence is rising. Really, that first 20 years, only about a dozen were performed, believe it or not. And then over the next five years, that number really upticked, as you'll see, some of the procedures became more popular. And now, as mentioned, 20, 25% of major leaguers and 15% of our minor league pitchers have had UCL surgery. And it's been described as an epidemic among our youth athletes. So how are you gonna do the perfect UCL reconstruction? Well, you want the stiffest construct, right, to resist that valgus stress. You wanna maintain range of motion. You can't lose anything there. You wanna be able to rehab them as quickly as possible. You want as high a return to sport as possible. It needs to be durable. It needs to try and spare bone. And this is something we think about with why do a repair versus a reconstruction, if you can, is that even if the tissue is maybe marginal, is that you can save bone. It's gonna be no difference, or at least very little difference when you go down to do a reconstruction later. So trying to spare bone is important. Limiting soft tissue disruption. And of course, keep the nerve happy. So to think about where we're going in the future, I think it's important to take a look a little lens into the past. And most of us learn one way to do it, and then that's it. But I wanna show you a couple things because some of these trends and some of these techniques will recirculate over time here. So going back to the figure eight, this was your classic job. And the two things that he did that have since changed in most approaches is that he detached the flexor pronator and then eventually incorporated the submuscular ulnar nerve transposition. You can see the return to support was okay. 63 to 68% and high ulnar neuropathy right after. And this was about over 10 years since he did his initial one. Took him about that long to write it up. Then the next one was about a decade later. ASMI came up with this approach and the FCU split, and then they went to subcutaneous ulnar nerve transposition and then you see those results really start to bump up. And then the modified job later, where they split the flexor pronator mass and these then tended to match those results. So these are your figure of eight techniques. And this is kind of what they look like where you have the graft coming over a bone tunnel on the humerus as well as the ulnar side. And then the docking techniques. So early 2000s, the decreased, the docking technique which allowed us to take less bone from the humerus, very high return to support rates. And these have been modified into the three and four stand techniques. And then we see suture anchors come onto the scene around the late 90s and also good return to support. And that's what these constructs look like. And this is what a lot of us are familiar with, the docking technique. And then you can see that hybrid technique with the suture anchors starting to be used. Then we have the linear techniques. And these are your interference screws, your endo buttons, graft links, double docking, I'll check, elotrache, docking on the humeral side and ulnar side interference screw fixation. Then the more recent anatomic technique that really tries to maximize the ulnar side of fixation with suture anchors. And so that's what these techniques look like. And you can see just that kind of linear construct taking less bone than some of the older techniques. And then the anatomic down here, which really exemplifies that elongated ulnar sided. So which technique do you use? Well, studies have tried to compare these. And really, if you take out the flexor pronator disruption that was in the early Jobe studies, there's really no clinical difference. Some of this data was just presented yesterday as well. So really no difference in clinical outcomes when you control for these things. No difference in complication rates, ulnar nerve, et cetera. So what you wanna do is what we always do is put the anatomy back where it belongs. And so this is a great paper that came out a couple years ago and really exemplified where these attachment sites are. And you can see just that really long three centimeter, I think is about what it was, insertion on the sublime tubercle. And that's why the anatomic folks are moving that direction. But also, on this view, let's see how close towards the trochlea that anterior bundle comes off. So I think if you put the ligament or the repair, whatever you're doing in the anatomic position, you can't go wrong in that situation. So what about the ulnar nerve? Well, again, it doesn't look like there is any difference in clinical outcomes or return to sport. This was a study where they looked at 100% of the people in the transposition group had symptoms and 13% of them still had symptoms after transposition. So that's something you can tell patients is that, yeah, there's a 10% chance or so that you may have symptoms even if we transpose the nerve. But 0% of the people in the non-transposition group had symptoms. And so it's unlikely that if they didn't have symptoms before that they're gonna continue afterwards. So where are we in 2023? Well, clinical data is still to be seen, but what we're starting to see, and Dr. Romeo is gonna be talking about this probably in a second here, is that we can add suture augmentation to reconstructions. And if you don't have great tissue and you need to do a reconstruction, there's potentially a benefit in adding suture to that. Potentially we can rehab them quicker and decrease the stress to the ligaments to prevent re-tears. So biomechanical studies are looking good so far. This is from a group out in Crillon-Jobe. And then this is Dr. Romeo's group, two different techniques. Double docking was used for this one. So 2023 I think is gonna look like a continuum. I think at one end you're gonna have your good healthy tissue, your younger athletes, the right kind of tear. You're gonna be doing a repair. You don't need to take bone there. You wanna save that bone and you're gonna do a repair and you're gonna probably put a suture augmentation in there. At the other end, you've got a mid-substance tear, you got bad tissue. You're gonna do a full reconstruction and you may put a tape in there to help backstop that. And of course clinical outcomes are still to be seen. But then you're gonna have this kind of mix in between where maybe you can add some level of graft to the repair. And so I think it's really gonna look like a continuum moving forward based on the quality of the tissue, the type of tear and the level of the athlete. So thank you and we look forward to hosting you all in Nashville in two years.

UCL reconstruction

Tommy John surgery

history of UCL reconstruction

advancements in UCL reconstruction

techniques in UCL reconstruction