Any questions from the audience? Sir. Jim. I know you're explaining how you use the technique on the O-sign, can you just clarify that again? Are you using a tunnel or are you using a... Most surgeons that have done this for a while are just absolutely fix it, they have to do a tunnel. They feel really, really that's important. And so one of the MLB team physicians who does a lot of these still does that, and then he puts a separate hole for his anchor and his tapes kind of in between that and does that as a third essentially hole into the bone of the sublime tubercle. We thought it would be better to consolidate all of that, so we try to identify the best point on that ridge of the sublime tubercle in line with the rest of the fibers. We look at it very carefully from the work that Mark's done, the work that Braden's done, we try to identify what looks like going to be the most central portion of that ligament and two starting points. And when we get down to the sublime tubercle, we find that ridge and we drill that hole, and that hole is big enough to take the anchor. The anchor has a suture and a tape on it, and it can also take a palmaris graft into it. And so we have to drill the hole, then we have to take out the guide and drill slightly deeper so that we can sink it in, and then it basically locks it in solid. Does that make sense? Yeah, so you'll take a piece of a tensionable device, you'll put the permanent suture around the tape and around the way? You can. You can. So originally we did it as we just drilled the hole and then we tapped it and prepared it for the anchor, but then we drilled a little bit deeper so we could get the graft all the way in there. And then we put the drill hole all the way across for the loop of the soft anchor, and we just pulled the graft in there to fix that firmly. Then we took the anchor, which has the tape and the suture, and just put that right over the top of it in the same hole. But some people have been just skipping the anchor and put it all in the loop and pulling on it like that. We didn't test that, but that's what some people have done. They've eliminated the hard anchor and just done it all with the loop of the soft anchor technique. I see another hand. Yes, sir. I only heard the word partial once today, and I came here to learn about how to manage that partial. One thing that I think is really important to mention when you talk about a partial tear is partial tears on the distal side, I think we have a better understanding of than partial tears on the proximal side. I think partial thickness distal tears, and you know, Dr. Shignates helped us show us this, are a worse actor than partial tears on the proximal side. And we actually have less agreement as to what a partial thickness proximal tear even looks like on an MRI. And we've done a couple of studies of that where we can't even, if you show people at this table the same MRI, some people will say that's a proximal tear, and other people will say that it's not. So I think for partial thickness distal tears, certainly you could try a PRP injection, and I think a literature would suggest, our literature is kind of all over the place, but if you look at the comparative evidence published using the MLP database, it's probably about a 45% return to play, and it's maybe not better than, you know, not using PRP. And certainly for those players, a repair works quite well, and you don't need to do full reconstruction. I would just comment that you should read Dr. Shigadant's two papers on this using MRI classification, which as Peter said, may not be perfect, but it gives you a starting point and gives the predictability of whether the athlete is going to require surgery for surgical management. That's been very helpful. So with that in mind, I would ask Mark, do you take each of the six different categories and treat them differently or give them, I'm assuming of course if it's, you know, a complete tear, that's a different story, but these partial tears, distal, middle, or proximal, do you have a separate rehab for each of those? We don't necessarily have a separate rehab. I mean, we have a separate approach, you know, for all those, but, you know, every situation is different. So we're treating the entire athlete, right? So it's level of play, it's expectations, it's career length, it's timing of the season, there's all sorts of things that kind of go into this decision making. The ones that are easy are the ones that Peter's talking about. The complete pull-offs on the distal side, those don't do well. I mean, very rarely do those do well without an operation. So the question there isn't, are we going to treat this non-operatively? It's, okay, how are we going to treat it operatively? And that's where, you know, where this discussion comes in, you know, you're going to try to repair that if you can, do reconstruction if you need to. A lot of us, myself included, are doing some hybrid type, you know, reconstruction. So repair plus reconstruction in that situation. Also to Peter's point, the proximal ones, they're tricky. I frankly find the proximal ones very difficult to repair when compared to the distal ones. It's a different animal. And that one's a little bit tougher. More likely to take all other things being equal. If I've got a low-grade proximal injury, I think that's got an 85% chance of getting better without an operation. If I've got a grade three, what we call a 3B distal complete avulsion, I think that's got about an 85% chance of failing if you don't do an operation on that one. So we try to look at the whole thing, you know, as, again, look at the entire package here and what it is you're trying to do. Yeah? On that low-grade, lower-grade proximal, there's tons are coming in line. And they failed rehab. They're painful but not necessarily unstable. Yeah, I think I... The ones that are still burning. Yeah. Yeah. That needs repair. That needs surgery. What surgery? Again, it depends on the situation, depends on the athlete, depends on the expectations, who they are, where they are in their life. That all goes into that discussion. I don't think... It's not a cookie cutter. It's not, okay, you've got a partial proximal injury that's this great. This is the operation you need to be doing. It's not like that. For me, most of the time, that's going to be a repair with internal brace. Yeah. Yeah. I'm the same with that. Yeah. And I would say, the three-month thing, I don't know that... I mean, we can actually have a discussion on this, how long you wait to pull the trigger on somebody. Three months for me is probably a little bit long. So I usually, I'll see them, whether or not they have imaging or not. I'll shut them down for somewhere around four weeks or so. See them back, make sure they're asymptomatic. And when they're asymptomatic and we've optimized some of the shoulder, hip stuff that Greg talked about, I'll have them start a return to throwing program. And if they can proceed through it and they do fine, great. If they can't make it through the return to throwing program, then I think you have your answer. You don't necessarily wait three, four, or five months to see what the answer is. The other thing you can do is if you're concerned about those and they have pain, but you don't think they're unstable, you can get a stress ultrasound on those players and you can see if they have some joint gapping. It's hard to do because only certain places do it, so it's not readily available. But if you have access to it, you can definitely do a stress ultrasound, have to compare to the contralateral side. And if the MRI is equivocal, you can say, okay, this is gapping more than normative values. I should repair or reconstruct this. Or it's not really gapping much. It doesn't look bad on the MRI. We should try PRP, try some other things. That's a great point. And I apologize for not bringing that up. The stress ultrasound is fantastic in these cases like this. Because like you said, I think I challenge any of us clinically to really diagnose low-grade instability. I mean, it's a really difficult thing to do. And to Brandon's point, for me, if they're not better in four weeks, they're not going to be better in six. So I think you can move them along probably a little quicker than that timeframe. I would also comment that although we're not there yet, I think we'll be able to treat more and more of those with orthobiologics in the future. I really do. I think if their stress ultrasound is equivocal and they're still hurting, we just haven't figured out the right mixture to make this work. But I think it's a healing issue. And if we can shut them down and get the right healing environment, that's going to be a winner for us. But we're still not there yet. Yes, sir. Any other? Yeah, go ahead. We didn't discuss the graft selection very much for psilocybin versus palmaris. It looks like you're taking decision-making there. Tony or Brandon, you want to comment on that? Yeah. If you look at the data, it shows that there's no difference. For me, if they have palmaris on both sides, then I'll take the ipsilateral. If they're missing a palmaris, sometimes the tendon length is actually a little bit short. So if they only have a palmaris on one side and you take it, sometimes it's not a great graft. If they have a palmaris on the other side, I'll usually go to a gracilis. The important thing about the gracilis, if you take it, is that if you're going to do the hybrid technique that Dr. Romeo talked about, you really have to thin that graft out because it's fine for a palmaris to do that technique where you're doing a double docking. But if you have a gracilis and you're trying to dock it on both sides and you're having it looped over, you really need to shrink it down. Because I've had a couple of times where I've taken a gracilis and it's been hard to get it to sink properly. And I've had to kind of trim it a couple more times. So just keep that in the back of your mind. But from an outcome perspective, there's no difference. Side of hamstring, whichever one you take, it doesn't matter. Ipsilateral, contralateral, palmaris, it doesn't matter based on the literature. Someone asked yesterday about an allograft. Do you want to talk about Cohen? So Mark Cohen at Rush is a great elbow surgeon. He's kind of a psychopath, but he's one of the best surgeons I've ever operated with. And he does an allograft probably 75% of the time. We looked up his results compared to Dr. Romeo's and Bush Joseph's and everybody. There was no difference in allograft to autograft. I will tell you that I have yet to use an allograft. Not in a player. I've had a couple of patients who preferred that. I mean, that's what their family wants, so we did that. I think the evidence is not, there's no evidence that it will be a higher failure rate if you use an allograft. But I don't think there's enough scientific evidence to say that it's equal to or better. It's just not inferior to as far as we can tell. Yeah, Buddy Savoie's got probably the best paper on that, on allograft. His results were great in that one series. There's also data from Paletta. So the thing about allograft that I think is really nice is that you don't have to take the patient's own gracilis. And we do have EMG evidence that suggests that gracilis is doing something in that player when they pitch. There's a lot of activity in the hamstrings normally during the throw. The thing that I think is interesting about the allograft-autograft debate is so much of what we think we know comes from the ACL, where the graft is passing through the middle of the knee in a totally non-vascularized environment. This is not an ACL. You're placing it directly inside of a muscular, well-vascularized sleeve. So I actually use an allograft very liberally. If the patient doesn't have a palmaris in my hands, I just use an allograft. I don't think there's any evidence you can use to knock me off that post. Peter, and you use a gracilis allograft? Yeah. Really? Cool. It's MIT. Yeah. Interesting. Okay. Other questions? I learned something. Thank you. So, Tony, I have a question for you. Yeah. How much material do you think we need to have when we're doing our hybrid reconstructions to make a difference? In other words, do you have to put in an internal brace? Can you put in something smaller? Should we be putting in something bigger? Yeah. I think the sweet spot is unknown, but based on the work that Matt Smith has done and some others have done, these ultra-strong sutures seem to have very similar biomechanical testing results. So I think that the thing that I like about the tapes is the serendipitous finding that your tissues kind of grow into it. It kind of integrates into your tissues well, as opposed to a round suture that, especially if it has a coating, you don't want to have any coating other than collagen on it or no coating at all. It's nice to have it integrate into the tissue, and that's one of the things that we've seen with the tapes. But we use a two-millimeter tape, and I wouldn't be surprised if you go down to a one-millimeter tape or something smaller and probably have very similar results. It's the same like with the gracilis. There was a thinking that if they're six foot four or taller and they're throwing 95, you've got to put a hamstring in there because there's no way their palmaris is going to tolerate that. But two out of every three Major League Baseball pitchers get a palmaris and seem to do just fine, so that they get the Tommy John surgery. So I think that the answer to your question is that we're probably slightly overdoing it right now, and there may be a sweet spot where we could put something a little bit smaller and just as effective. Anybody else have any thoughts on that? Yeah, I just have a question real quick. So those of you who have seen failures with the repairs, how are they failing? What do they look like? Have you seen any? I've revised one of Dugas's, not because the ligament failed, but because the guy who you know, who we met with on some research stuff, felt like the elbow wasn't stable. His stress ultrasound was a little bit loose, maybe, but I've got to tell you, when I did his reconstruction, and I did it just as a regular reconstruction, when I drilled out his humeral side, it was right through the anchor that Jeff put in, so I don't think it was in a bad spot. So he subjectively felt like he couldn't get back. He was a Minor League Baseball player, and I will tell you, the revision was not difficult once you get the nerve and stuff out of the way from all the scar tissue, but the revision was not hard. You? I have two, one that I did where it was the exact similar thing, it was an outside surgeon did a repair for a collegiate javelin thrower, and when I got in, his tape was loose. His tape had not been tensioned, and I think the surgeon who did it was probably concerned about over-constraining the elbow, so they basically, they didn't tighten the tape. They put in the anchors, they left the tape loose, and they just sutured it in place. So I think that there probably is a role for making sure the tape is tight, and to do that obviously you need to be confident that your tunnels are in the right place. So I have gone to the same thing Brandon's done. I don't put a free under it, I put it in as tight as I can get it in. The second one is one that I have not yet revised, but it's a player that, a high school player who did a repair, he got back to full play and was very happy with the elbow, and then subsequently re-tore it in a different location from where the original tear was. So that's the original, that's like the Dugas failure. He's on the schedule for two weeks from now, so if you ask me next year, I can tell you what I actually did. Hybrid or full reconstruction, what are you going to do? We're going to do full reconstruction. So I've done a few, and each case I felt like it was a technical problem from the original surgeon. Misplacement of an anchor, improper tensioning of the graft. They fail a little, at least in my experience, they fail a little differently than the reconstructions. The recons tend to fail at the humeral side, as you know. So I think, and my next question to our panel here is, along those same lines, are we repairing ligaments that would probably heal if we didn't have this tool? If you look at that Texas study, it's a pretty easy operation to do, and that scares me a little bit when you've got a few guys out in the community that, hey, this is pretty easy, I'm just going to throw an anchor in this thing and a piece of tape and I'm going to be good. I don't have to do a full recon. Are we over-treating this a little bit now? I think that gets to Peter's point before about how do you diagnose a proximal partial thickness tear. And I think everybody here, and I think everybody in the room will understand that you want to make sure that you are, in that four to six week period that we're treating them conservatively, you want to make sure that you optimize everything else that can be causing their elbow pain, right? Because if you don't do that, and you go and do the repair, they're still not going to do well when they come back from it. So you have to make sure that you've corrected the problems that led to that potential elbow pathology in the first place. But I think that we probably may pull the trigger a little soon on proximal partial ones. I think the distal ones get pretty clear for the most part. Those are pretty easy to see. But to Peter's point, I think the proximal partial ones are, I think you're right. Any other thoughts? Yeah, I would agree. The distal ones are pretty reasonable to, if they're partial, try a brief period of non-operative treatment. And higher grade distal ones or full thickness distal ones, I think moving faster towards surgery has been borne out from Dr. Schick and Dent's work. I think that making sure you have a good conversation with the patient about realistic goals and risks and what the surgery entails. And on these ones that are a little more of a partial proximal, really giving them a good period of rest and assessing their goals and expectations before jumping straight to the surgery is the right thing to do. And I think that if you don't do that and you just say MRI, tear, need to repair it, then you're going to jump in and do too many surgeries. And that's going to lead to some problems and complications. Am I the only one who's had people referred in with normal MRIs? All the time. Will you please do a reconstruction on this? The player comes in saying, I'd like to see a reconstruction on my elbow, and I'm like, you have a normal MRI. I'm sure everyone else has seen this in clinic. Don't operate on that person. I think that's one where getting a stress ultrasound and saying you have no laxity, you need to rehab your elbow, is really valuable. Completely agree. I think that your point is typical of many of the things we do. I mean, I think for quite a while we over-operated on superior labral tears because it was very easy. It's an easy part of the shoulder to see. It's an easy part to put the anchors in. We do that for partial thickness rotator cuff tears. There's a lot of repairs of partial thickness cuff tears that don't need to be done, but they're being done. And I think this will be the same. One of the things that's particularly seductive about this is that even if it doesn't need to be done, there's very few complications for it. So if you do it, and whether they need it or not, typically the person will do fine. Or they won't get, their failures, they just can't get back to throwing. But it's not that they have a high infection rate or nerve injury or any of those kind of things. So that makes it even more seductive to say, eh, you know, four weeks he's been hurting and it's still bothering, we're just going to fix it. And not really put a time and effort in to try real non-operative management. Yeah. Can you clarify, when you get a stress ultrasound, partial, proximal tear, is it after the end of four to six weeks when they're still complaining, or is it on the initial? Yeah, so for me it sort of depends where they're at in the process. If they're coming in kind of de novo and have elbow pain, and it's just more of a chronic thing and we're just going to rest them for four weeks, I'll probably do that first. If they're coming in and they've had an event and we're getting an MRI, for me the ultrasound comes in. If the MRI is equivocal, then I'll go ahead and get a stress ultrasound. And, you know, the fever view is another MRI view that's coming out that radiologists are becoming more familiar with. It may kind of take the place of that if you don't have a great ultrasound person. It is dependent, but if you do have somebody that can do the ultrasound, it's a great way to either confirm or to rule out that injury. So for me, if it's an equivocal MRI or if it's a partial tear and they're not progressing, then I'll go ahead and get the ultrasound. I don't know what you guys do, but I don't jump to an MRI right off the bat in the non-professional, non-seasonal timing issue player, right? So I'll rehab them first for a month, and if that doesn't get better, then I'll get the MRI and go down that route. And it's not until after the MRI is questionable that I would get the stress ultrasound. So I don't usually image them right off the bat. I don't know if you guys do, but if they're a high school or college kid comes in without a really significant acute pop, then obviously MRI. But if it's a kind of dull, vague, medial elbow pain, they're positive movement valve distress, positive milking maneuver, I'll start them in rehab and then MRI them if they don't get better. I generally don't do PRP for this, but I'll leave that to the other guys. Again, if you were at the meeting on Wednesday, you probably heard this, and the evidence is not very strong that we can take a person prior to injection and predict who's going to respond to that. But we have a couple of studies that have suggested it works very, very well by some prominent baseball people. One of the first ones bothers me to this day that it was published because they suggested that the average amount of laxity in the UCL was about two to three millimeters and that their athletes were more like five to seven, and when they injected them with PRP and rechecked them, the laxity was reduced, which I think is not true. But that's in the paper, and you can see that. And that's one of the papers that people use as a reason why you should try to inject these. But when we looked at a large series in the Major League Baseball Hits database, you can't tell who predictably is going to get better. So what I suggest to my athletes is that, depending on the level of nonoperative management they want to go to, is that here's what we would typically do. If you want to essentially have no stone unturned, then I would suggest in the early phase where we're keeping you out from throwing that you may consider a PRP injection because there is some suggestion in some athletes that'll work. I just can't tell you whether your son or you are going to be the one that it works for. But I know Peter's had examples of that. I've had examples where we've done these injections. They've gotten remarkably better. We have no idea why, but it's unpredictable. And our biggest problem, of course, is that you can't really correlate the professional athletes who don't have a cost concern with our normal patient population where the cost can be anywhere from $750 to $1,500 or more for these injections, which is a lot for a lot of people. Peter? I'm with Brandon. I think the best part about them is that it forces them to rest and do the rehab in a lot of situations. And cost is a big issue for a lot of the kids I see. So I never push them that direction. If somebody is really into it, then I say it's probably not going to hurt you. I do think if you're going to do it, probably the best outcomes are with Buddy's paper. And if you read that paper carefully, he did two injections separated by, I think they were separated by at least a week. And then he put the players in a brace for six weeks. And I've often wondered if the brace is part of the reason it works for exactly the reason you're talking about, that it's really just more rest. It's a more effective rest period to say you have to wear this brace for six weeks to make sure the PRP works. Just a brief word about stress ultrasound. I also use it in my practice. And I've been using the Fever View as well. If you read the Fever View paper carefully, it's of normal pitchers. And they had laxity up to four millimeters in normal pitchers in that paper. So we've done our own study recently that I've just finished writing up where we looked at high school and collegiate pitchers. And we did stress ultrasounds before and after throwing. And after throwing, there is half as much laxity as there is before. So I think when you look at laxity, you've got to be really careful that you are looking at a combined product of both the UCL and the Flexor Pronator, and that players have different abilities to activate their Flexor Pronator and relax it. So you are not necessarily looking strictly at the UCL when you do that study, when you try and measure how much laxity is there. And so for that reason, it may or may not be as useful diagnostically for determination of a full or partial thickness UCL tear as you may like it to be. Great points, great points. So our results on this operation. Yes, sir. Sorry. If you don't have access to dynamic ultrasound, any belief in your gut practices still remaining about intervarsal stress x-ray? Anybody using a... Yeah, there's a paper by Luke O, and there's an old paper from the Andrews Group. Lead author is Bruce. Both of them suggest there's a limited clinical utility. And it's painful. It's painful. This is good. I'm not an anesthesiologist, obviously, but are you looking for a two millimeters difference between sides compared to the wrong side, or are you looking for the ligament peeling off, or what are you looking for? It's funny, I don't think there's an exact answer. I think Sakati's got a lot of the baseline data on this from a study a few years back. We've been doing this for years in the Phillies players preseason. The best data, obviously, is if you can have a pre-injury understanding of what their UCL is, which we have in our guides, but obviously in the majority of people we see, you don't. I think a side-to-side difference is probably what you're looking for. But Pete can probably comment better than I can on amount of absolute laxity. Yeah, I mean, this is what I, after I read that fever view paper, I was like, four millimeters difference? Well, I'm like, I'm never gonna see that in an ultrasound. I mean, that's almost half the field of view of a small transducer. What I was gonna say is, you know, if we look at our literature, return to play outcomes following UCL reconstructions over the past 20 years, the number really hasn't moved a whole lot. I mean, it's between 80 and 85% return to play. What are we not doing here? Tony, I know you've got some pretty strong opinions about this. Yeah, I think, my opinion is, is that we're doing everything that we can except psychological retraining of the athlete. And that is, you can't just throw hard all the time. You've gotta be a four pitch pitcher to be effective. And I think that the other thing that we saw with the Tommy John surgery is the primary reason that their careers ended was their problem with their shoulder after Tommy John surgery. So it's the entire kinetic chain. And I think that when the elbow goes, some of them have been on the precipice of having problems with their shoulder, the rest of their kinetic chain, their scapula's not right. And then it just, it basically becomes relevant or the sentinel finding of the collapse of the kinetic chain is that they tore their UCL. So we repair that, but we don't have the ability to fix all the rest of it. And so that's that 10 to 15% who they can come back, but, and maybe they can throw pretty well, but they, their shoulders start to bother them. They start to say there's other things that are not quite right. They don't feel quite right about their elbow. So I personally think that we're doing pretty well in terms of reconstructing this ligament. So we have to look away from the elbow to see how we're gonna close out on that last 15%. Great answer. Anybody else have any thoughts? I think it sums it up beautifully. Okay. You don't have any thoughts on that? I have the exact same thought you had. Good answer. Peter, I'm gonna quit. I probably heard Peter tell me that. We talk about low effort throwing. Is there concern of change in mechanics in these guys? And one thought is, of course they throw 80% because that's just how they feel naturally. It just feels good to them, right? And they feel it's so easy for them to throw a quote 80%. If we're forcing them to drop down to 50, are we messing with their mechanics a little bit? A little bit. Or a lot? I don't know how many of you have thrown from a mound. It's a different feeling. I mean, throwing from flat ground and throwing from a mound, when you get really comfortable throwing from a mound, it just becomes like a fluid movement and you wanna go. It's really hard to shut it down to 50% when you start throwing from the mound. I think it's easier on flat ground to kind of maintain that. But once you get on the mound and you get that leverage, you start getting your stride length, it's really hard to not just wanna let it go. And so I think that we do the best that we can, but it is really hard to get them to throw at 50% and have really good mechanics. I think they do have a tendency to adjust the way they're throwing to go that slower speed. And I think somewhere around 70% or higher is where they get into their groove. And it's that last 30% where they really get up to their maximum potential. So I don't mind if they go a little bit higher than 50%, if as long as they feel comfortable, it's not hurting them. Peter, what do you think? Yeah, I mean, I think it's a major concern. I think the real interesting thing to me about it is we were doing it with them, with us telling the throwers and then throwing 80% for years before we ever measured with the radar gun. And it's not like that was the major cause of that 50% failure. So it doesn't matter. And I put up that slide and I've thought about taking it out because I've thought, why am I like, I think it's interesting, but I also wonder maybe if telling the player that, providing the player that information is not so useful in terms of preventing recurrence. Again, it's one of those things, it's a little hard to understand, but if you're on the field or if you're at a stadium and you get a chance to throw in a pitching thing where you get a radar gun and you're not a pitcher and you throw as hard as you can, doesn't matter how athletic you are, you'll be lucky to hit 70 miles per hour. And these guys may not even be as athletic as you might be and they can just pop 85, 90, and it's just the whole mechanism. So it's such a fluid mechanism when they start getting to those speeds that I think it's hard to put the brakes on the entire thing to say, just throw 50% of that. I think it just flows by the time they get to that level. Other questions from the audience? We've got a couple minutes, we're gonna do a case. Brandon, why don't you take us through this? Oh man, all right. So this is a 12-year-old kid, middle school baseball player, friend of a friend from a couple states out. Currently throws in the mid 80s, he's 12. Had some elbow pain last few months and then also had some discomfort while he was wrestling because he doesn't just play baseball, good for him. He was kind of managing it and then the last week his pain went up significantly. Really talked about pain kind of posterior or medial aspect of his elbow. Also had some pain when he was trying to extend his elbow. So exam wise, gently trying to get him to full extension did not hurt him, but as you start to snap them straight, this is usually my test to see if they have something going on in the back of their elbow, he didn't love that. You can do an arm bar, you can do a bounce test, whatever you're comfortable with. I usually do a bounce test. And then he was missing about 15 degrees of extension. So passively as you got him there, it didn't seem to hurt him. He stopped 15 degrees shy and as you bounced him there, it bugged him quite a bit. Flexion wasn't an issue. Had some medial discomfort, usual positive UCL tests. Some discomfort with the tunnels at the elbow and then you always need to make sure, and we didn't really mention this, but whenever you're doing elbow surgery on the inside of the elbow, you really need to know where the ulnar nerve's sitting and make sure it doesn't subluxate. So in every one of my exams on these guys in my note, I dictate whether or not the ulnar nerve subluxates. I think that's really important. And then for purposes of this, he did not have a palmaris on that side. So you see his x-rays here, right? Concern you, not concern you? He's 12. Oh, but it is. Oh, but it is. So he has some fragmentation of the medial epicondyle there and sort of an open olecranon physis. Those are kind of the two main things that I see. Looks like the medial epicondyle is a bit gapped relative to the normal site there. So I think he may have some side-to-side difference if you got a contralateral x-ray. Yeah, so I have contralateral x-rays. When do we expect that olecranon physis to be closed? Anybody know that answer? Crito, C-R-I-T-O-E. Usually, yeah, usually it's a little older than 12. It's usually 14. Correct. So that, right, so I said, oh, maybe this is just normal because he's 12, this should be open, right? There's his other side. He's got that disease where they age rapidly. That's his other side, right? So that looks very different, right? So the point of this in the adolescence is get the other side, right? Because I'm not smart enough to know what's going on with that elbow. Get the other side. It tells you what it should look like. This is his other side. He is 12. So there's his other one. So clearly got some problems here. Yeah, so then we get an MRI on him, obviously, right? Because he's 12. He's a high-level thrower. He started in the mid-80s. And this is what you get, right? You have that giant oscle that we talked about. You get some edema within his olecranon. As you go towards the back, the sagittal view here, take a look at the back. You see quite a bit of edema there. Some sclerotic bone. Some cysts that have formed there. Pete, what do you think, man? You liking this? You're not liking this? Yeah, I mean, there's obviously, there's obviously a challenge because there's two things going on at the same time. You know what I mean? There's the UCL and there's also the olecranon. And based on your exam, it really sounds like both of them are symptomatic. They are. So I would suggest if you're going to shut them down, you're probably going to want to fix both at the same time. Yeah, and not to mention his nerve was symptomatic. So we'll call it a three. His nerve was symptomatic? Nerve was symptomatic. Great, so you've got three problems. So, you know, we kind of talked about this a little bit. He's 12, right? So he's been through this for quite some time. You can shut him down, see how he does, right? Maybe just fix the olecranon issue. Shaq, you think if I just fix the olecranon, he's going to do well? No. I don't think so either. No. Then maybe we address the UCL at the same time. And then when you're talking about the UCL, we just had a great discussion this day. You know, how do you fix it? Is this a guy where you can try to repair that? He's 12, right? I kept harping on younger guys, you can do a repair. But that obstacle makes me really, really worried. Would you try to repair that, Dr. Romeo? You know, I mean, I would say that we're going to take a look at it, but I would be prepared to do the full reconstruction. And if you want, do the hybrid. So again, we talk about the hybrid like it's already standard of care, but it isn't. There's some things about it that we're still learning about. And I think that, you know, if you can't do a repair, then the next answer is a reconstruction. And if you're doing these operations on a regular basis, and you're comfortable with some of the newer ideas with regards to doing the internal brace, and you want to do a hybrid, that might be an effective thing. So I think you talk to him about the possibility, at least take a look at it and see what you have. But most likely the ligaments on that far end of that bone ossicle, and if you're going to remove that ossicle, you're going to be short, you know, five millimeters or more, so. Yeah, that was kind of my concern. So, Shaq, I guess, what's your plan? What are you going to do for this guy? Well, you know, first of all, the answer is no, you don't fix that fragment. That's just get that out of there, for sure. One of the cases I was going to show shows one of those going badly, but I agree with Tony. I think you have the discussion. It's going to be short. You're not going to be able to do a repair. I'd probably do, and he doesn't have a pulmaris, so probably looking at a gracilis graft, I wouldn't do an allograft. Probably do my little hybrid operation that I do. I'd probably use his gracilis. I'd take it from the opposite side. I'd probably fix his olecranon, move his nerve. That was the plan. And so, you know, a repair by itself is probably a 30 minute procedure. If you add in an ulnar nerve transposition with a reconstruction, we have to get the gracilis and fix this group. It's a lot of surgery for this elbow. I mean, this took me over probably an hour and 20 minutes to get this whole thing done. So we discussed it quite a bit, and so I agreed. I thought you couldn't just fix one of the three problems. I thought you had to fix everything at the same time. So based on some of the EMG study that Peter's done, we took the gracilis from the opposite leg, right from his landing leg, because we know that that's less valuable from the pitching mechanics. And again, I talked to you guys before about trimming that gracilis down. This is the one where I really learned in that you have to trim it down. He was only 12, but he had monster gracilis. So had to spend quite some time trimming that down to make sure it could fit into the 3-5 hole that we drill on the ulnar side to do the hybrid technique. So I can show what the next one is. So which of these variables drives his rehab? Great question. So for me, it's the hybrid technique, the nine to 12 month recovery. The olecranon doesn't change anything for me outside of not trying to hyperflex them early. So I limit their flexion a little bit sooner. That's the only thing I try to protect from the olecranon perspective. Then I treat it just normally like a reconstruction. So I usually do one per screw placement. You can use a washer or not. This is a four-oh screw, partially threaded. I thought we got a reasonable fixation there. After I kind of drill, I take a drill tunnel and I kind of drill out the area where the fracture site is just to try to stimulate healing a little bit in him. Certainly I had his medial elbow exposed. I wasn't concerned about hitting his nerve when I did that. I shelled out some of the oscle that was there. The other part of it, I just left in place because it wasn't in my way when I was putting his tunnel in. So he's, do I have six months on him? I don't think I have six months on him yet. Great. Did I send you stuff? Did I? Yeah. I'll just show you this because this is an interesting case. This is one of mine. So he's, I had that because I plan on updating this live when he's six months, but he's three months out now. I haven't started him in throwing yet. He's asymptomatic. His elbow feels great. He's got full range of motion. So from a doing well so far perspective, he's great. But the reality is he's 12 and just had a monster elbow surgery for a thrower. So I had a long discussion with him and his dad about this is something that doesn't happen usually until somebody is much older and the likelihood of him doing well is tough. But skeletally, he is much older. No, I know, but like for his career purpose, I mean. So if you think about, we have a finite length, not to say we do, but if you do a reconstruction, we have good data that says they can play five years after their reconstruction, but he's 12. So he plays five years after his reconstruction. He's a junior in high school. No, I'm with you. I'm just trying to say that like this kid's ceiling is not as high as you think it is because he's already skilled enough. Oh, oh, I understand what you're saying. Yeah, it makes sense. So he had a 15 degree flesh and contracture preoperative, correct? He wouldn't extend, yeah, he wouldn't extend 15 degrees shy being fully straight. I think that was partially pain mediated. So that's my next question. What do you think you did in surgery to correct that 15 degree? Yeah, so once I fixed his olecranon, once I had him examined for anesthesia, he went totally straight. So it wasn't an issue. To your point of, if you would have scoped him to clean up the back a little bit, yes, if I couldn't get him fully straight when he was asleep, then I would have done that. You wanna do one more? Yeah. So this is a 24 year old female crossfitter. She's, yeah, all of our favorite patients, right? Attempting a personal best overhead press with 250 pounds. Came to see me pretty shortly thereafter. Medial sided elbow pain, nothing on the lateral side, nothing on the ulnar nerve. Very markedly positive exam for the UCL injury. Interestingly, she had a prior right elbow sprain two years ago, sort of a similar thing. I didn't see her for that. And that one still bothers her a little bit. So here are x-rays. Limited view. Something going on on that ulnar side. Yeah, she's had something going on for a while. Yeah. Here's her MRI. That's the problem. Any thoughts on that? It's a problem if you're a thrower, not if you're a normal human. Yeah, just tell her that she shouldn't lift weights overhead anymore. Yep. We tried that. It didn't work. So, you know, you see a complete proximal, or I'm sorry, a complete distal avulsion off the tubercle. A lot of edema around, and so it looks like an acute injury to me. Obviously, probably has some chronic changes from just all the activities she's been doing over the years. So here she is at the time of surgery. Little capsular defect there. Yeah, that's, every time I go in for a repair with internal brace on a distal tear, I always, always, always tell them that I have a graft available because we may be tissue deficient. No matter what the MRI says, because that, you can see this, where sometimes in the MRI, you don't appreciate it as much, especially, you know, we can't always get the, we get four millimeter cuts, and a lot of them, especially if you come from outside, and you may miss this, and it's a gap, but I can't just put tape over the top of that and expect that to work. So for me, that's, they have to have at least a reconstruction, and then you can discuss whether you should add a hybrid to it or not. Yeah, we had just a long discussion before surgery, and she absolutely insisted on having the fastest thing that she could do because she wants to get back to throwing these silly weights up over her head again as fast as she can. She really didn't want anything to do with a recon, but yet, this is what we found. I would have been burned pretty good on that. I would not have thought I would have seen that going into this. Yeah. Can I ask you, repair versus reconstruction of this player, is it gonna change how long it takes before she returns to weightlifting for you? No. So, because you just mentioned she doesn't want anything to do with a reconstruction, it's a longer time to return to play. She's not trying to throw a baseball. Yeah, no, I agree, I agree. So on the other side then, you're right, she's not trying to throw a baseball. How much do we need to do here? I mean, do we get away with just doing, I don't know the right answer. Just fixing it? Yeah. I don't know either. I don't do a lot of UCL reconstructions or repairs in crossfitters. I, again, I guess based on her request, if I was asked to do this without using a graft, then I would try to elevate the surrounding tissues as best as possible and bring it side to side and put a tape over the top and just tell her that I'm not sure this is gonna work effectively for you, but we did what you asked her to do. Which is exactly what I did. Yeah. What you just said. Yeah, and maybe some of these will work, but for me, I would sleep more comfortably if we put more collagen in there, so. I think it's the same idea as if somebody has a repairable meniscus tear and they say, I do not want this fixed. And you have to, I mean, you can't, you do what you think is right, but you have to do ultimately what they want. I mean, you can send them somewhere else if you don't want to do it, but if you agree to do something, I think you have to do it. So I would have done what you did if she said, I don't want a reconstruction. Do what you can. You can do what you can. That looks pretty freaking good. Actually came together pretty nice. And she's back working out. I'm just wondering, you know, I'm just wondering if you went ahead and did the hybrid technique and just moved her along faster because of her sport and stuff, whether that would have given both of you the result you were looking for. Could have been an interesting case study. You know, CrossFitter returns to overhead lifting two weeks post-op. Yeah, I agree. This really looks great. But for all of them, I will consent them for a graft and for somebody that's not trying to throw a baseball, this situation, if the tissue's deficient, I think it's a good option for a hybrid to kind of add the collagen plus get the early biomechanics of the tape. But it looks awesome. Yeah, thanks. That's great. In this type of athlete, would you use a J.J. Watt brace or something? I think you could. I think the literature doesn't support the use of bracing or not. So I probably wouldn't do it. But if she wanted it, you could. Would you go back to the sport? Yeah. Yeah. Well, obviously we don't have any studies on this, but it would just be a matter of, I suspect she'd be relatively non-compliant with many of the lifts that the CrossFitters do. It's just gonna feel awkward to her. But there may be some more that might give her the support that she needs to feel just a little bit better about her elbow. I wouldn't discourage her from trying to wear some kind of sleeve or something around her arm as a proprioceptive device as she goes back. I think a lot of athletes really appreciate that. They have a better sense of where their joint is at. And even though we don't have evidence that it stabilizes the joint, I think they feel their neuromuscular control is better. So I would treat them in that regard. Absolutely, and she did use a sleeve. But to your question, I don't know the rules in CrossFit. In competition, she may not be able to wear something like that. I don't know. No, we pretty much let her go. She didn't do much rehab. All right, we're done. Shocker. Anybody else? Great, thanks everybody.

elbow injuries

UCL injuries

distal side

bone drilling

hybrid technique

partial thickness tears

stress ultrasound

PRP injections