Hey, good morning. I talked about maybe some things that go along with UCL injuries that we should be aware of. Here are my disclosures. I'm going to start with two of the most common things you have to do in addition to the ligament reconstruction and one is arthroscopy for valgus extension overload. This is a condition where the elbow going into full extension sees shear and compression in the posterior aspect at the olecranon and you get problems. That abutment, that shear, that repetitive force creates osteophytes and also some chondral issues and there's an interplay because the valgus forces are not just imposed on the ligament. It's also on the bony articulation and so if you have some laxity in your UCL prior injury, a sprain, even if you were young, over time that can contribute to the exacerbation of this posterior impingement process and so you have to be aware that there could be some laxity. How do I know this? I did it in a laboratory. I took cadavers and I loosened the ligament and I put some pressure sensitive film in the back of the elbow and if you have a loose ligament, you get this saddle shaped joint that kind of rotates and you get peak loads right at the posterior medial aspect of the olecranon. So there's a real biomechanical rationale for loose ligament, exacerbates, valgus extension overload in the posterior compartment. Here's some study that says that this problem is the most common diagnosis at least in the late 90s for baseball players. So it's extremely common. In fact, every baseball player that you see that says it hurts here, you should examine this. If it hurts here, you should examine this. We'll go over that. Check out this study. 72 professional baseball players, 65% had posterior medial ophthalmopathy, 25% had a posterior debridement that went on to need UCL surgery. What this is saying is if you do an arthroscopy in the back of the elbow, there's a high chance that in the future they're going to need a ulnar collateral ligament repair reconstruction or some type of treatment. So keep that in mind. This is John Conway's study. It's not published, but I find this very interesting. He was doing some valgus stress x-rays and he was seeing that some players have a little laxity. If you have some laxity on valgus stress, you have a higher chance of having osteophytes in the back of the elbow, really about double. Here's this picture again with the film going in just to emphasize that intact ligament night distribution, go all the way to a full tear, you get these peak loads in the back. So what's the summary of all this? Check the UCL and patients who complain of posterior elbow pain. Okay. I think we hit that pretty good. Examine the posterior part of the elbow or the medial part of the elbow. Posterior impingement is like this. It hurts back here. It hurts in follow-through. How do you know it's follow-through? You ask them, does it hurt before you let go of the ball or after you let go of the ball? It hurts after I let go of the ball. That's follow-through. Then they get stiff. They get effusions. They get swelling. It's hard to warm up. It's catching and popping. So as we said, check the UCL and we're going to talk about ulnar neuritis. We're going to check for ulnar nerve issues. I'm going to do this a couple of times. I had a patient, second opinion, scheduled for a triceps tendon repair that had a bone spur in the back of the elbow. And the reason is on the MRI report, it said something like a small partial tear of the triceps. The radiologist was seeing this. These players don't have triceps tendonitis, but a lot of athletic trainers will be treating players with triceps tendonitis because they say it hurts here and it actually hurts with the extension. But anyway, if you see or smell triceps tendonitis, hunt the spur. It's there. Here's the exam. Push on the posterior aspect of the olecranon, posterior medial aspect. If they got a spur like this, you see on the CT scan, they don't let you do this because it hurts too much. So you balance them into full extension, they'll only let you do it once. This patient doesn't actually have a spur. This is an arm bar test, so you just put them in full extension. I like having the patient slide down. They get comfortable and they're just more relaxed than if they're, say, sitting or standing. And then this, you see on the MRI scan, we talked about osteophytes on the olecranon. This is a cartilage lesion on the trochlea. You can get some cartilage lesions on the trochlea. And if you do a moving valgus stress test, which is great for UCL, around 70 to 120 degrees, if you do that moving valgus stress test closer to extension and it hurts, that's suggesting they have a posterior medial problem on the trochlea. And sometimes the MRIs underestimate it. So keep that in mind. Extension hurts, posterior medial trochlea. CT scans, great for this. 3D reconstructions are great. Here's that osteochondral or chondral issue that's going on. If you see cysts or little signal patterns, it's hard to see the cartilage, right? If you see that cyst, almost always there's a cartilage problem. And that's because the cyst is developing because of the cartilage issue. All right, I'm going to go over a little bit of technique. Technique is fun. I've showed this before. I've showed it at this meeting twice already. I'm going to keep showing it. I'm going to show it today. I'm going to show it to anybody who wants to watch. This guy's going to have an elbow arthroscopy. Of course, when you do elbow arthroscopy, you have to be so aware of where the nerves are. This patient's ulnar nerve lives anterior to the epicondyle. It is not in its normal position. It didn't have surgery. It's acting like it's been transposed. Anyway, if you accidentally don't know where the nerve is, you make an incision there, it could be a catastrophic issue. So before arthroscopy, always check where the nerves are. This is a patient who's going to get a combined arthroscopy and a UCL. My staff hates this. You know why? They've got to set up for arthroscopy. Sometimes I do a couple of these in a day, and they'll be like, please, no arthroscopies today. And they ask, is the next case an arthroscopy? And then if I say yes, they've got to get all the stuff. So anyway, check out the setup. Patient's on supine, hand table, ready to do the reconstruction. You just lift the arm up, hold it in a positioning device. The same device I would use for shoulder arthroscopy in the lateral position. And then you keep the elbow, the more vertical the humerus is, the easier it is to do it. And about 45 degrees of elbow flexion, you outline all the landmarks, you've got the ulnar nerve, you know where it is, it's in situ in this particular patient. You see where the portals are for elbow arthroscopy. One is lateral to the triceps, about a centimeter proximal, and then you have a direct posterior portal. I like injecting. You take the elbow joint and you distend it. And a lot of elbow distension for arthroscopy is to get the nerves out of the way so that you have less chance of nerve injury. This actually is just to distend it so you can cut the skin in the capsule. If you cut the skin in the capsule, it's like popping a balloon a little bit, the scope will fall right in. Sometimes it's hard to get the scope in. If it's hard to get the scope in, it's because the capsule is so loose, you just can't get through it because it's so, you know, there's so much, you know, call it patchlessness to it. All right, so we got the scope in and then we're going to isolate our posterior, direct posterior portal. And it's good to visualize this because this portal, if it's in a good spot, makes the surgery easy. If it's not in a good spot, you've got to fight angles to get on the olecranon. So you don't want to be too far away from the olecranon, otherwise it's too steep an angle to work on it. And if you're too close, it's just too tough to get an angle over the top. Okay, we got the right spot. Do a little bit of ablation to clean up the capsule off of the olecranon. And I've heard people get concerned about triceps issues. I mean, you're really far away from the triceps, unless you're using heat in a different way, you're not going to take the triceps off. But more importantly, you should be careful of heating that part of the elbow because you'll get an injury to the nerve. So it's a lot of taps on the ablation device. It's not sustained. And we use some instruments like freers and things to loosen it up if it's a fractured osteophyte. And then we can shave and keep working on it. And this is what it looks like from the arthroscopy video capture. And then we get the piece out. You grab it and you do a little bit of contouring. Check this out. This is a valgus stress test. I was never able to make an elbow open that effectively with just stressing it. But if you take your camera and you lever on the humerus, you can create valgus stress more effectively. Because when you try to stress it yourself, you're actually externally rotating the humerus. You just can't get it. But if you lever it, try that. If you lever it, you'll see you're not damaging the elbow. And then now we're going to close the portals. And this is the beauty of this setup. Once we get the portals closed and the co-band off, you just lie the elbow on the hand table and then go to work. I usually don't put the tourniquet up for the elbow arthroscopy. Now that we're going to start the reconstruction, we can put the exsanguinae, put the tourniquet up and go forward. There's not a lot of literature on this, but the literature is encouraging. In fact, one of the, I mean, it just feels so good. A guy's got a bone spur in the back of his elbow that hurts, it's like taking out a splinter. They feel great afterwards. I mean, they really do. Maybe you have to rehab them, of course, a little chance of stiffness. Here's some research. Look at the numbers. They're so small. I mean, there's only so many patients in these studies. So this deserves more attention in the literature. This paper has been referenced already, outcomes not influenced by graft type and ulnar collateral ligament surgery. But they looked at some of the concomitant procedures in this large cohort study. Arthroscopy for loose body and posterior medial impingement, it's a relatively common procedure. All right. That's why we started with it. Arthroscopy. It happens a lot. Here's the trochlear cartilage. It's just similar to cartilage restoration in any part of the body. You clean up all the damaged cartilage and you can just leave it as abrasion chondroplasty. Sometimes they do that in the 35-year-old picture who's got a really beat up elbow. Younger patient, we try to do some cartilage restoration. This just happens to be drilling for marrow stimulation. Okay. Return rates are not so great. I actually think this is a challenging problem. I have a lot of patients with this. Some of them, they don't even know they ever had a problem. Some, it's tricky, can't get over it. We're doing physical supplementation, PRP injections because of the cartilage. Just like cartilage in any other part of the body that has ligament tissue. All right. I'm going to tell you a case. Who cares about what's on the slide? I'm going to tell you this guy. I love him. He's 37. He's a great player. His elbow's killing him in the back. He's got a bounce test. It hurts when you do this. His UCL is okay. Doesn't look okay on x-ray. He's a mature player. He's been around for a long time. Look what he's doing to his UCL. He's a position player. Anyway, we're going to ignore that because it doesn't hurt, but he's got this. It's got a crack in it. This is mid-season. Professional player. Mature. He's going to want another contract. Who's going to put the camera in right away? Okay. I didn't put the camera in right away. I gave him a cortisone injection, and then I gave him another one, and the reason is out of the few places that cortisone can be helpful, the inflammation, the synovitis, the pain, you can get by with a little bit of cortisone. I know there's a mechanical thing in there, but the purpose of this presentation is some players who need to play, it's not unreasonable to give them a cortisone injection, get them through the season, and then you fix them at the end of the season, took the piece out. Nothing different than the previous cases. He goes on. He does well. Okay. Check out this patient. He's 17. He's got a positive posterior elbow exam. His UCL is, look at this x-ray here, can't point, but you see the fracture at the sublime tubercle there. You can see it on MRI scan. He's got a UCL tear, posterior medial impingement, so we're going to do basically the procedure I just showed you from a technique aspect, and we'll do a little bit of repair work on that fractured fragment, because we don't have to take it out, but we'll do a reconstruction, and the reason why I'm showing this particular case is because not all UCLs are the same, and we think of it as UCL. He's got a UCL. We'll just do a UCL reconstruction, like they're all the same. They're not all the same. They're all tricky. All right. Let's move to the second most common concomitant procedure. I'm going to check time so we can go over some questions afterwards. All right. He's a kid, plays, outfielder. You guys see that? He's got a little something going on. I've shown this case before, because it's a fun case. By the way, I know you guys know this, but putting these cases together, it takes time. I was on the flight, putting a case together on the way here to Denver, and the guy sitting next to me said, I had a hard time sitting next to you on this flight, I have to tell you. I was at, hey, I was supposed to go to a faculty meeting thing. It was at a restaurant. I got there early. I was working on a case. The manager of the restaurant came up to me and said, you're making our patrons very uncomfortable. Can you put the computer down? Okay. This is what I was doing. He's making this case, and then we make an incision. Check out this nerve. It is all over the place. I cut the skin so delicately, it's thin. I just don't want to do anything to the nerve. This is concomitant procedures. He's got what's called a subluxing ulnar nerve. It snaps, it hurts, they get tingling in their fingers. They got all the neuritis features of it. Check out the snap. Find these snapping ulnar nerves. They hurt, and they do so well with the stabilization of the nerve. This kid's got something else also. I just show this because if you're not aware of it, the triceps is snapping also. If you just transpose the nerve without doing anything to the triceps, they will still snap, and it will be a failed surgery. You got to do something to the triceps. This is a big snapping tricep, so we actually cut the medial aspect of the triceps, and then we're going to reposition that aspect of the triceps back into the main aspect of the triceps. I'll put a video on this if you guys want to see it, and then we put it back into the triceps. It's just an old suture technique, and then you can see no more snapping. Okay, here's the question now. We need to stabilize the nerve, and there's a few ways to do it. We can do it with the inner muscular septum, which has to be taken out with an ulnar nerve transposition. You got to take out the inner muscular septum, but many surgeons leave the inner muscular septum on the epicondyle and use it as a sling to stabilize the nerve. If you guys haven't seen this or done this, this is really cool. This is a little bit of flap you create in the adipose tissue on the anterior skin flap, and you use the fat with a little bit of the denser fascia underneath it, the so-called scarpus fascia, and you can use that to stabilize the nerve. For me, it's like putting a pillow on the nerve instead of putting something that is maybe going to irritate the nerve. I also have videos on this if you guys want to see the technique. It's really soft on the nerve. I use the inner muscular septum sometimes. Ulnar nerve dissection, I'm just going to show you a little bit of it. Ulnar nerve dissection, going on two heads of FCU. I'm going to jump up. We got the nerve dissected, and then this is the intermuscular septum. This is a big inner muscular septum, so you can see how the inner muscular septum can be used as a sling, but here's the little thing that I do, I might as well share it. If you use the inner muscular septum and don't do what I'm doing here, the nerve sits right on the epicondyle. If it's sitting right on bone, it's very sensitive. I got a bunch of players that they cannot sleep, they get ulnar arrhythmias just because they get pressure on their nerve. If you sew the inner muscular septum to more position, the nerve transposition anterior gets off the epicondyle. You guys know what this is? I'm seeing more of these things. It's an onconious epitrochlearis. Check out this muscle. It's an accessory muscle. I use a dictation system, and when you dictate an onconious epitrochlearis, I can't tell you what comes up on that thing. You got to type it in. This muscle compresses the nerve and causes nerve irritation, and I see it in gymnasts a lot too. I see it in swimmers, I see it in all kinds of athletes that use their arm. It's hard to see on MRI scans, so you don't always get the diagnosis. You just cut the thing. You can see it right here. This is this cut muscle, and then you can do your ulnar nerve transposition. I looked this up. Basically, if a patient has an onconious epitrochlearis and they get treated for it, for the symptom of ulnar neuritis, they actually do much better than the patient who has just ulnar neuritis without the muscle. Maybe it's a good thing from a treatment standpoint. It's not a good thing because it gives you ulnar neuritis. We did a little bit of work on this on the ulnar nerve systematic review. It's so easy to quote a systematic review because it gives you all the information right away. There's a fair amount of ulnar nerve issues after UCL surgery, and it happens more commonly if you do obligatory ulnar nerve transposition. Obligatory meaning you elevate the flexor muscle going through the two heads of FCU to get to the UCL, and then you have to transpose the nerve. Otherwise, it'll be stable. You have more chance of having a ulnar nerve problem. This is a study again. Check this out. There are a lot of ulnar nerve transpositions. If you're going to be a Tommy John surgeon, you have to be pretty good at handling and managing the ulnar nerve. Okay, I'm going to jump through this a little bit and maybe just show two more things to be aware of. Like I said, not every Tommy John surgery is the same. Check out this x-ray. This guy's losing motion, and it hurts, and can't throw. The issue with this is we're going to be taking out all this bone. There is no native tissue. We're talking about fixing the native tissue, and repair, and good tissue. There is no tissue left of the ulnar collateral ligament when you got ossification like this. You find it, you cut it, osteotome, sometimes bring in C-arm, you get that thing out, and right away their motion is improved. And then the reason why I showed the hamstring graft is because there's no native tissue. You want to use a very good quality, large caliber graft, and if they even have a palmaris, maybe it's not good enough or big enough. And if you use palmaris, try to get four strands, otherwise just use a gracilis. So every patient has their unique, say, pathology. In fact, this case in 2022, this would be one where some people would do the hybrid because there's no native tissue, and if it's only relying on your graft material, maybe it needs a little extra help. All right, we went over a little bit already of this. I love Mark Chikendance's work on this. He already talked to us about it so I jumped over. Okay, here's a, you guys will see this. It's part of the whole valgus extension overload. This kid's a college pitcher. He's got these x-rays. Felt a pop. You guys see this? He's got an olecranon stress fracture. There's different types for time constraints. I'm only going to show this. It's called a transverse proximal. What are we going to do? He's got a bad ligament. We're going to take care of both of them. If you guys haven't taken care of olecranon stress fractures, they're not that hard. It's a percutaneous approach usually. You put some pins in and you can put some screws across. I'm going to pause on this one because you want to make sure the screws are not in the joint. And so getting an axial view like this can be helpful because you'll see that the screws are not in the joint and then you put some screws in and you compress this. These things can heal very nicely and then you do a ligament reconstruction. All right, thank you guys so much. I think we have some time for questions. No, we're good where we're at. Any questions? Yes. The non-baseball activity after UCLA, the repair and construction, so playing field first base and batting, would you guys allow that? When can we go back to batting? Batting and then first base. So Brandon looked at that for Major League Baseball through the HITS database and what we saw, Eric, was a basement effect and that is nobody let them go back before three months. So most of them are back batting or starting back by three to four months and we did not see any increased injury with that. Now our trainer that retired, Kirk Steiner, said he saw one or two people tear their UCLs batting. I've never seen that in my life. I don't know, Chris, have you seen that? I've never seen it. So I don't know if that's old school or whatever, but you don't get UCL tears batting. So most of our guys that are not pitchers are swinging a bat without us knowing within four to six weeks because they're almost filled. As soon as they get out of the brace or whatever they start, we tell them not to. So generally we start about three months but just really by four and a half months they can swing away. That's what we did. I don't know what you did, Mark. Yeah, that's true. I think it's that same paper. We talk about that. In general, position players come back at about the same rate as pitchers. Interestingly, catchers are a little less, but it's about 75% in catchers. They come back a little bit quicker, not a whole lot quicker. I might as well offer a different opinion. First, you have position players who are tearing their UCLs, and why are they tearing their UCLs? It's a 17-year-old kid and they want to get back to playing as a position player at just the age. First, all of the rehab for throwing compressions is necessary to make the ligament work well. They have to go through the ligamentization process. Hitting is just for fun. All the kids want to hit because they want to get back into it. I don't like hitting at the same time as you start throwing. Most of the extremely talented and experienced surgeons, they just don't like it because of the kid's enthusiasm. Some kids hit, they go into the cage, they hit like crazy. So you're trying to temper hitting with controlling throwing, and some of these kids throw too hard, it's so easy. So I say, go hitting until you see how your throwing is going. I need to see or hear that your throwing is going smooth. So I always delay hitting or throw. And then if the kids really want to get back into the age, so you're going to make a choice whether you're going to hit or you're going to throw. I don't like doing it at the same time. And the issue of the military and UCO, hitting is real, but guys can get posterior impingement from hitting. Lead elbow and follow through, you get extension, it hurts when they go into extension like this. So if they're a left-handed hitter, right-handed thrower, it's a combination on the elbow and posterior impingement. Great point. Just to clarify, the paper was only to try to identify a threshold at which you might increase the risk of a UCL tear going back to batting. We just didn't find that. So I think each team position can direct the care. Chris's points are very valid in terms of trying to separate out those two important return back to performance. I think it could differ at different levels of play. High school player may be necessary to their team getting back to batting. Professional players are a little more specialized. So we have to kind of individualize it there. One more comment. Sure, Chris. We work backwards from the time that they need to be ready. Like, I got a flight in a little bit. I'm driving fast. I'm going to make a flight and get to Denver Airport. I don't know what the driver's going to be like. If my flight, my shift's flight, is not for another three hours, drive slow. We work backwards from when their season is going to start. We've got a lot of time to go slower. It just makes sense. And some of the data on the professional athlete, why it takes you so long, it's because we're working backwards. There may be not a reason to get them back. I got a bunch of guys who could potentially get back in 2022. Some of them are like, why are we going to risk it? We'll just see in 2023. And all of a sudden, it's been five months on their data profile from our return to play. They were ready. But we just wouldn't want to rush for, like, two games. Could you guys talk me through your thought process on treating the acute UCL injury in a non-future? I specifically treat a lot of wrestlers with these injuries. And I'm always a little bit, you know, when should I be considering an acute repair for a higher grade complete involvement versus non-operative management? And when you're non-operatively managing it, how long are you bracing them and when are you letting them go back to contact? Greg, you want to jump on that? Yeah, I think that the higher grade injuries in the wrestlers or football players, I think a lot of them can do well in non-operative management. They don't put the same stress on their elbow. And typically, if they fail that and they need surgery, I think a repair is sufficient as long as it's not just an injury. I think that's a great population to examine more and take care of a lot of wrestlers. I have more failed surgery in wrestlers than others, particularly in shoulder instability. A massive range of motion, stress that they put on them, I have more failures in shoulder instability in wrestlers than any other population. And then the elbow, the internal braces change things because it's seasonal in career timing, like we just talked about, it's an impact. So if they need to get back in season, usually give them a trial because they can recover with non-operative treatment, but there is a failure rate. And then the internal braces change things because the recovery time is so short and the ability to eliminate the so-called failure of non-operative treatment and have a more predictable success rate. So if we have a college wrestler who's got mostly a year because of COVID, because the season was off, he's not going to go to graduate school and he has one more year to wrestle and you can fix him and make it more predictable, these kids will say, please fix me. I want that population and I use more internal braces now on wrestlers than I would say two years ago. Yeah, I agree with that. I think the way we handle it now has definitely changed than it did three years ago. I can tell you, gymnasts don't tolerate ulnar collateral ligaments very well, non-op. At least that's been my experience. John Conway has kind of the world's experience in taking care of gymnasts. You can talk to John about it. He's pretty aggressive at getting those reconstructed and or repaired. And I agree with Chris, with the internal brace, pretty easy to fix, pretty easy to fix. Tough athlete and I also agree that they're the most failures that I've got, particularly in the shoulder. They're impervious to pain. Basically you know if it's going to work, you check how much colic they've got in their ears. It's like every qualifier, the prognosis is better. The gymnast is interesting because they're really hard-pulling because they train so much. Valgus in a gymnast is real and they get their injuries closer to full extension. The pros get their injuries closer to flexion. So if you check a gymnast's valgus, it's probably the only population where you end up doing bilateral. Gymnasts do it on both sides. And they've got the tiniest little bones. So you've got to get different drills and you can't use the big drills that Tony's doing. You've got these tiny little bones. And non-operative treatment has a high failure rate. They're typically like 13 and 14-year-old kids. Maybe you've got to do a reconstruction on a 13-year-old and you end up doing it. So my young people say, well it's the youngest only collateral ligament you've ever done. It's always on a gymnast. I know this is like 10 or 11. I think if you elect a non-operative course, you need to really truly do good non-operative treatment. It's not going to get better in seven days. Right? So I think you need to Well, you know, so for a thrower, so for every week down, it's a week back. So like if he's a throwing athlete, you shut him down for six weeks, six weeks return to throw. I suppose that that would be reasonable. If you're going to shut a wrestler down for six weeks and then build him back up for six weeks, I think that's probably reasonable. But as Chris said, they all want to get back sooner than that. Mike. Yeah. Awesome presentations. I'm just curious. Do all of you harvest palmaris, the ipsilateral ligament? Or do you do a contralateral? Just for... My preference is ipsilateral. Yeah, mine is too. And Chris taught me, if you've got a deficient palmaris on the ipsilateral side, the other side's the same way. So don't go to the other arm if you think because you can't use the ipsilateral, you're wasting your time on the other side. And unfortunately, usually it looks like it's there, but it's always short. That's been my experience. You tap it on one side and try to harvest the other one. I didn't listen to Chris. And so it'll be less than 15 centimeters will be short if you get anything. I agree. And I agree with Priscilla as well. Yeah. I got a funny patient who goes like this. He doesn't have the palmaris on his normal side. He's got it on the opposite side. And every parent says this, use mine. And their dad who says use mine, he doesn't have it on his not normal side, but he's got it on his opposite side. So I took a picture of them like this. They were weird images. And they both only had one palmaris, but on opposite arms. That's funny. There's some practicality to it because I try to make nights with the anesthesia team. I buy them breakfast every once in a while. I do all that kind of stuff. I really want to have a good relationship with them. We've got this IV stick on the other side, so we've got to deal with all those things. And I do a lot of these surveys. Priscilla's kind of an artist. It's not that challenging. I like it. It's just a little more prepping and training. So Michael, you asked the question, that must mean that you... No, I do ipsilateral, but with all this grip work that I'm doing, I don't, I just, in the back of my mind I think to myself, even though it seems that the return is great at 83%, but do we slow things down, even though it might be a clean harvest, because you are, and even though it's... Some of the new studies looking at spin and everything, it looks like they're getting it back, even though most of them are still two-thirds or more, they're at a grand harvest. So somehow they're figuring it out. A little bit. Tissue thing. What about biologic, if you guys are going to use a biologic on a partial thickness proximal? It seems more and more, we know that it's the hardest thing to find. Is that truly pathology? And we can treat those non-operatively more often? What do you guys use right now? Well, if you're going to do it, ultrasound guided, first of all. We don't, I don't do that. I've got primary care sports docs that do those for me. They're using PRP. The thing about the PRP injections is, if you do PRP injection, you're truly committing them to some time, right? I think you've got to let that rest, let that work a little bit. So it almost slows them down a little. I'm not sure, I don't know which ones we should be doing biologics on. I don't even know if it works. But we're using PRP. And ultrasound guided. Yeah, and I agree, ultrasound guided. And the controversy is, a lot of the work's been done with leukocyte core. But from most of the basic science work, if you're working on tendons, you should be using leukocyte ridge. So it truly is, if it goes to the orthopedic surgeon, many of them do leukocyte core. But if it goes to our primary care docs or PM&R docs, they do leukocyte ridge. Because that's what the evidence would suggest is the better option. You're going in the joint with a leukocyte core, you're going for the tendon with a leukocyte ridge. So that's what we've been using as an option for our athletes. But again, because it's out of pocket, if they're not on a professional team, I won't do it for them with ultrasound guided, because I don't want any concerns that it wasn't exactly in the right spot. And we have people that specialize and do those injections all day long, so I let them do those for us. Switching gears a little bit, guys. How many of you in the audience have had experience using Euflexa-type products in these VEOs, like Chris was talking about, these cartilage lesions and these more mature players? Anybody using any VSCO supplementation with any success? I've used it once in a master's level thrower to help them through the season, and their joint was not in good shape, so we were just trying to get them through. And it seemed to help a little bit, but I have not used it in this younger patient population. Chris, it seems to be popular in Japan. Japanese players come to New York and it's part of their routine. There's no real downside to it, except if you're in the season and they all come out of the dark. Back to the work of biologics. I use stem, so-called stem cells, we call them stem cells, or what we should call them, in one setting that's a Tommy John reconstruction that's started not too long ago. And I'll share with you honestly, my results are going down. They're not getting better. I have all these techniques, and I think it's because, why do these guys have to throw so hard? The velocity of every player at every high school, college, one of our college draft picks on the court, throws $104 an hour. The amount of velocity that's going up, we can't compete with our surgical techniques, so the Tommy John's that used to work, are not working, so that's why what Tony's doing is very exciting. Occasionally we'll get a guy in an immediate, probably the day he's starting a mental health program or something, he's getting games, and he's getting sore, and he can't memorize, it's going to have signal, and that signal is going to be in the proximal part of the graft, and that graft insertion into the embryo compound, and it looks like that's the tough part to heal. And then if you shut him down and you do some therapy, or some type of stem cell, that's probably the only time that I use stem cell, because there's so much at stake, and so forth, and the players really want it. And here's the funny part about these Tommy John's that are optimal. If you have a failed Tommy John, and you need to revise it, you can revise it with a repair, with the brace, internal brace, repair. If you've got an internal brace that fails, you revise it to a Tommy John. There's some irony there. Jim, have you guys revised any internal brace yet? Yes. And with your anchor at the subline tubercle, are you just going, do you have to dive any deeper, or do you just use your same guy? Generally, Stu, can you work around it? Yeah. I've revised a number of these. I just ignore it. Even if it's just part of the anchor. Yeah. Just because, like, in CC with the reconstruction, you don't have as much of a stress riser as you think, because you've got a typically a peak anchor that's holding that stress riser neutral. So I do try to go a little bit this way. That's probably a movement that I'm doing, but all my tunnels are getting more distilled with every case, because I do hybrids different than Tommy. I do a hybrid where I put all my tunnels toward this tunnel and put a pair of anchor right at the meat of the center of the subline tubercle. There's enough space there around the big guy. I just took care of the kid this week on Tuesday. 6-7, he wanted to take a photo with me. It was like this. You know, he's got to go like this, and I've got to go like this. He's got to go like this. He's got to go like 6-7. His arms have to go to the big guy. That's the case for right off the chest. It's a hybrid. Yeah, so usually surgeons that are doing the internal brain are putting it just past the joint line. So you've got a lot of real estate distally to still work with. So hopefully that's where they put them. You just take out the tape, and like Tony said, you just drill. On the humeral side, you drill right through it. And on the ulnar side, you typically just leave the thing alone. The tape gets kind of caught up in the drill a little bit, but it's okay. We good, guys? Any other questions? Thank you for coming.

UCL injuries

elbow

ligament reconstruction

valgus extension overload

impingement issues

non-operative management

PRP injections

acute repair