Faculty for all they've taught me about the elbow over the last several years. Everybody's from New York and I'm coming at you from New York. I apologize I can't be there. And I'm gonna talk to you a little bit today about the ulnar collateral ligament repair in 2022. Basically, who are the patients we should be doing this on? How do we get these guys back to playing? I don't have any disclosures that are relevant to this talk. And so the question is, why are we talking about UCL tears? We've heard a little bit today about the increasing number of ulnar collateral ligament tears and reconstructions that have been performed. You can see some studies that have been done showing a sharp increase in the number of UCL tears and that it's the sixth most common injury that caused Major League Baseball players to miss time. The problem is, this is not just a problem of our Major League athletes. We're also seeing an issue in our younger athletes, as you've heard, with a significant number of UCL injuries in our 15 to 19 year olds. So this is an issue, okay? So let's talk a little bit about UCL repair and what's the history behind this. Well, we can thank Dr. Conway and Dr. Joe for really pioneering ulnar collateral ligament reconstruction and ulnar collateral ligament repair. If you look back at their study from the early 90s, they looked at 70 patients that had a reconstruction or a repair and they showed the outcomes of these patients. Average follow-up for them was about six and a half years. And what they did for the UCL repair was they basically directly repaired the anterior bundle of the UCL, okay? No suture anchors back then. And this is kind of what their technique looked like here when they did the UCL repair through these bone tunnels. This is what their reconstruction technique looked like with the modified Jobe technique. And what they found was, was that the UCL reconstruction group did quite well, but in 71% of the UCL repair group had an excellent result compared to 80 in the UCL reconstruction. But the problem was only 15% of those patients that had a UCL repair were able to get back to sport at the same level versus 68% in the reconstruction group. And if you look at the Major League Baseball guys, only 29% in the repair group were able to get back to playing in Major League Baseball compared to 75% in the reconstruction group. So there was a huge difference here. And so because of this, UCL repair dramatically fell out of favor, fell out of favor pretty quickly. And the problem is we kept seeing these increase in the number of UCL injuries and UCL reconstructions. But then there was a pioneer that brought back the UCL repair and kind of rose it from the dead like a phoenix. So Buddy Savoie back in 2008 put out a great study looking at 60 patients that had a UCL repair and basically included the techniques that he suture plicated the repair to bone drill holes or use the suture anchor. And he found outstanding results. 93% of these patients had good or excellent outcomes. 97% were able to get back to sport at six months after surgery. You can see the scores here. And so we started to look into this a little more. We did some systematic reviews and we saw that, okay, maybe repair can be an option for these players in getting back and maybe those that don't need a reconstruction. And so along comes Jeff Dugas talking about maybe adding something called an internal brace to the UCL repair. And so we found Dugas as one of the proponents for this. And then we also needed some players that were willing to try it for the sake of getting back faster to return to sport because you have to have some people who are willing to take a leap of faith in order to have a new technique start to work. And so if you look at some of Jeff's work, he did a great biomechanical study looking at the UCL repair, compared it to the modified job technique and basically found that a UCL repair with an internal brace replicated the time zero failure strength of a normal ulnar collateral ligament reconstruction and actually was more resistant to gapping, which is extremely important. Nick Verma did a study essentially looking at cadavers and compared UCL repair without an internal brace, UCL repair with an internal brace and UCL reconstruction and looked at torsional stiffness, gap formation and residual torque. And basically what they found was that UCL repair with the internal brace compared to the other two groups had significantly higher torsional stiffness and higher residual torque and actually had less gap formation. So kind of similar to what Jeff saw was what Nick saw in his studies. And you can see here just showing how much better UCL repair with the internal brace was compared to his counterparts in this cadaver study. So then Jeff put out his initial results of this and he had results on 128 overhead athletes and he had a one year minimum outcome. And basically what he found was that 87% were included in his followup and the average age of surgery was about 18 years and the majority of these were baseball pitchers. Now, important in this study was that the majority of these players, essentially all of these players had avulsions of the ulnar collateral ligament from the medial epicondyle or from the sublime tubercle and all had very good tissue quality. Okay, this was not done in players with ligaments that had beaten up over many years with poor tissue quality. And what he found was, was that 92% of these players were able to get back to playing but importantly they got back at 6.7 months after surgery which is significantly different from reconstruction. We know reconstruction gets guys back at about 83 to 85% but it takes 12 to 18 months and the complication rate was very low in the study. And so while this was kind of early outcomes of Jeff's work, this really kind of catapulted us all into thinking maybe we had a new technique on our hands that might be very viable for these players. You can see here based on location of the tear, all these players did quite well. So the things I wanna really harp on with you for UCL repair are that at least based on Jeff's work and at least in my own personal anecdotal evidence is that most of these have to be proximal or distal injuries in order to get these guys back successfully. You really wanna have good tissue quality kind of like this MRI right here and you wanna see these in younger athletes because older athletes tend to have ligaments that have been a little bit more beaten up over time and so it's unclear whether or not they would do well with a repair with an internal brace. Not to say that they wouldn't but we just don't have the data on this yet. So at least based on the current data, proximal or distal injuries with good quality tissue in younger players, that's who you're looking at for a UCL repair. And we did a study, kind of a modified Delphi consensus statement looking at all their collateral ligament tears and we asked the group made up of over 20 surgeons from around the globe, what are the indications for a reconstruction versus a repair? And basically when they talked about either damage to the ligament on both the humeral and ulnar side or if there was a mid substance tear or insufficient tissue, of course the patients wanted this, this is when you consider a reconstruction. But in the other patients, you'd really wanna have a repair, right? Partial thickness tears, isolated, proximal or distal revulsions, no chronic changes in the ligament and again, patient preference. And so at least based on this consensus group we're starting to see a theme here of who might benefit from a UCL repair. Now of course, imaging comes into play a lot here, I showed you the MRI before, we always get x-rays on our guys that come into the office and you shouldn't see anything on the x-ray in somebody you're gonna do a repair in. If you start to see a big sublime tubercle enthesophyte or you start to see a loose body within the ulnar collateral ligament or an ossification that's formed, that has to make you think that that tissue quality might not be great and that may not be the best candidate for a UCL repair. So you have to really take a hard look at that. And again, this is the MRI that Player showed you before but this is as we scroll through it. You can see that tissue quality is great. He has a complete full thickness proximal tear, a ton of peri-ligamentous edema, no injury to the flexor pronator mass, no posterior impingement, the rest of that elbow looks pretty darn good and so this is the ideal candidate for this. This is a college freshman pitcher. And so let me walk you through a little bit how I do a UCL repair with the internal brace. So incision on the medial side of the elbow, okay, it doesn't have to be quite as big if you're not moving the nerve. So if you're not moving the nerve, it does not have to be more than five or six centimeters. You make a skin incision, you get down to the flexor pronator fascia and you isolate the medial antebrachial cutaneous nerve. You take a lab sponge and you kind of push this tissue forward so you can really just keep that nerve within the fat tissue there and you shouldn't really encounter it during the case. If you're gonna see it, it's gonna cross distal in the incision. We split the flexor pronator to get ourselves down to the ulnar collateral ligament and we spread the muscle fibers to get down there. We don't really cut it, okay? And once you get down to the UCL, then we incise the UCL in line with its fibers, okay? And when we incise this, we oftentimes see that there's some gapping at the medial joint line. You should not see any gapping here in a healthy ligament. And of course, we know in this player, he has a high grade partial thickness or full thickness tear. This is when we're performing the surgery. This is not a great quality video, but you can see how loose this ligament is here. This isn't a player that had a complete distal tear. I'm showing you a video and a technique of a player that had a distal tear, not a proximal tear. But this is the distal tear and you can see that that tissue was simply not attached there and it's very flimsy. And so what we do is we place our first ankle distally where the tear is, okay? If the tear is proximal, the first anchor will go proximal. And we put this just a few millimeters distal to the joint line, because we know that based on some of our catabaric work, the part of the ulnar collateral ligament that attaches to the sublime tubercle, the most proximal portion of this is what provides the most restraint to valve distress of the elbow. So this is what you wanna create when you redo this. So first we drill and then tap for our anchor. And then we place our first anchor with our internal brace and then we repair our ligament back down. So you can see these are the high tensile sutures that are placed through the ligament tear. And this is what we're going to tie down. Now, once we've tied that down, then we wanna perform a side to side repair of the ligament that we split in line with its fibers, because we want the internal brace to lay on top of the native ligament. Once that's done, we locate the isometric point by holding the tape up to the medial epicondyle and taking the elbow through a range of motion. And if you start to see that it gets loose or gets too tight, you have to adjust where your spot is. You want this ligament to, you want the internal brace to be isometric, okay? So we drill for our anchor, we tap, and then we place our high tensile tape, our internal brace into our anchor and we place this in. And then what we do is we repair and suture the internal brace to the ulnar collateral ligament on our way out, so that you've basically made one thick wad here and then you check the range of motion to make sure that the patient has full range of motion, that the elbow does not get caught or stuck at any point here. You can place a freer under the internal brace when you're putting it in to avoid over tightening it, but I have not seen any of these players that have been over tightened. And now this is just an image to show you this is a different patient, but if we're gonna move the ulnar nerve, cause I do a split to get down to the flexor, a split through the flexor pronator fascia, the nerve then gets moved in front of the medial epicondyle and gets sewed in kind of with a fat patch posterior to this to help prevent it from subluxating backwards. And this you can see after we've done the repair, the nerve will sit nicely anterior here because it's not under any significant tension. And so the reason that repair is so enticing to many of us is because the rehabilitation following this is significantly faster than a UCL reconstruction. This slide is courtesy of Ken Wilk and you can see here kind of when we get to that three month mark, it really starts to diverge. Repair starts to throw, reconstructions need much more time, and repairs are getting back to playing at about six to seven months, whereas reconstructions are taking 12 to 18 months, okay? Now just thinking about the rehab after this, and you wanna make sure your players are hitting all their benchmarks, you really wanna make sure that guys have full range of motion by the six week mark here, okay? So I usually see them back at two weeks and if I'm concerned about them at all, I'll see them back two weeks after that. If they look good, then I'll see them back at the six week mark, but you wanna make sure you get your range of motion back relatively quickly. And then as we said before, most of us are letting these players start a throwing program in about three months after a repair with an internal brace. And as far as a minimum amount of time from surgery to letting them go back, I don't think that we've really figured this out yet. Most of us think it's gonna be in that six to seven month range. We kind of asked five to six months in this study here, and you can see it had less than 80% agreement. So a little bit longer is probably a little bit better, but really in that six to seven month range is probably ideal. Now the question is, can we improve a UCL repair or can we find a technique that we can use in players that have those mid-substance tears or those ligament deficient players? And so Dr. Romeo and I did a cadaveric study a little while back looking at a new type of UCL repair with an internal brace. We called it the double docking augmentation group, and this was his idea. And basically what we compared was we compared a modified docking group to this double docking group that did not have an internal brace, and then to a double docking group that did have an internal brace. And we ran it through the same testing that you've seen in the biomechanical studies before. And this is what our modified kind of double docking augmentation group looked like. We had a suture anchor that was placed distal, and we had an anchor that was placed on the far cortex of the ulna. And so we docked a graft on that side and secured it both with a fiber tack anchor through a loop, a knotless fiber tack, and then we placed a anchor in this, basically a swivel lock in that hole that we had drilled to secure the graft in place through a single distal fixation point, and that anchor was loaded with fiber tape. And then what we did was we performed our modified docking technique on the humeral side, similar to the way you would do, and we secured our graft, and then we placed the internal brace over the top here. So you can see you perform both a reconstruction and a repair with an internal brace in these players. And this is what it looks like after we had finished. And so similar to a modified docking on the humeral side, but adding in this internal brace augmentation. You can see we compared it to our double docking technique without the internal brace, and also to a modified docking technique. And basically what we found was, was that this double docking augmentation group actually did quite well and actually outperformed the modified docking technique in a lot of the parameters that we looked at. And so the question is, is this something that we could potentially use in our athletes that have tissue deficiency or have some of those sublime tubercle enthesophytes or calcifications within the UCL? Is this an option for them? And can we get guys back faster because we're using both the collagen as well as the internal brace to help them maybe accelerate the rehabilitation process? I'll tell you, Dr. Romeo is studying this right now and a few of the patients that he's done. And just anecdotally, he knows and has reported that these patients are doing quite well at the nine month mark. And a lot of these guys are getting back at about the nine month mark after surgery. So not quite as fast as an isolated repair, but much faster than a reconstruction. And so if we kind of, you know, bring this home here, you know, UCL injuries are going up. We all know that, okay? Repair is very much a viable option and repair with an internal brace has done quite well in these overhead athletes. Right now, we wanna see good quality tissue, proximal or distal injuries, younger patients. You know, that is who the ideal candidates are for UCL repair with an internal brace. But we have to look a little further into whether or not this works for mid-substance tears, whether or not this works for players that have some tissue deficiency, or do we need to go to a different type of repair plus reconstruction where we're adding in collagen so we are both performing a repair as well as a reconstruction and can maybe get those guys back a little bit sooner. Now, what I have to tell you, the caveat to all of this is that all of this is short-term, okay? If you look at Dr. Jobe's studies and a lot of the studies from Dr. Andrews, we're talking about 20 years of follow-up on these guys, even more than that, actually. If you're looking at the repair data, this is not quite as robust. This is a much shorter timeframe. So I can't tell you whether or not this works at five or 10 years because we don't have that data yet. We still have to continue to follow this. But what I will tell you is that in my own anecdotal evidence and what some of the other faculty here today have spoken about is that revising a repair to a reconstruction is actually not nearly as difficult as revising a reconstruction again. So something to keep in mind when you're doing the repairs, this may be a very good option. This is just an interesting app that we've done some webinars on talking about UCL injuries. This is for surgeons, kind of almost like an Instagram for surgeons to share cases and share videos. And in case you want some further reference, there's a very good chapter in our book about the elbow about UCL reconstruction and UCL repair where Dr. Dugas goes over his techniques and Dr. Rolchek talks about his techniques as well as Dr. Romeo. So thank you very much for your time. I'll be here through the phone to answer questions as we continue along. Thank you very much.

Ulnar collateral ligament

UCL repair

Internal brace

Recovery times

Surgical technique