reconstruction crazy or is where we're going to go? My disclosures are important because much of the work that I've done has been with Arthrex and so the tools and the equipment that you'll see are primarily related to Arthrex so I want you to be aware of that. We know these are our major source of morbidity for baseball players as we've heard. We use our imaging studies to try to determine when the injury is significant enough that we might have to do something for these individuals. The MRI is really our workhorse in terms of the imaging but ultimately has already been stated it's when they fail the clinical management that we perform the surgical procedure. Mark has helped us with his group to actually predict who's going to fail so if you have a complete tear particularly distal you're kind of wasting your time on conservative management. Some of the others especially proximal may have a very good result so you've decided to reconstruct it you really have to understand the anatomy. Brandon did this nice study at HSS and then Mark and his team have really spent a lot of time trying to figure out exactly where the insertion point is and how we can reproduce that surgically. That's really the key. We know the insertion point is broad like it is with many other ligaments. Where's the right spot to put it to try to reconstruct these? You've already heard that graft choice doesn't make a difference in outcome but most people are using the palmaris longus as their first graft choice and that's what we're doing for these hybrid reconstructions unless it's not available. You've also heard that surgeons have learned how to do this a variety of different ways and some techniques report return to sport rates very high but when you look at return to performance rates as Mark said it's about 80 to 85 percent for all of the different techniques that are currently being used and Chang did a nice sort of summary paper a few years ago talking about that and the favorites were that people were putting a tunnel on the ulnar side, docking on the humeral side, muscle splitting, move the nerve only with symptomatic. So that's the summary you've already heard this morning. We asked the American Shoulder and Elbow Surgeons well what would you do? What was remarkable is we only had 159 out of 661 members that responded and 77% of them did less than five UCLs per year and so not necessarily the Major League Baseball team physicians but these people are have in thought process and they came up with essentially the same answers. This is the scary part is when we first looked at this and we were criticized heavily by the way we looked at this, it was a return to sport was about 20 months and of course there's breaks in the season and everything else but just putting the numbers together that's what came up and everyone said you're full of crap, they get back much faster than that, that's not the right answer and then this paper in 2019 she speedy was on it 20 months. So there's different ways to slice it. We think that after reconstruction that many of them are back competitively by 12 months sometimes a little earlier but to say that they're back to same level performance it's 15 to 18 months and they'll tell you that. So the internal brace really Jeff deserves credit for bringing that. Buddy Savoie had repairs a series and others have too but Jeff has brought this to the forefront and we've already heard from Brandon what the key criteria are. Jeff has a nice video online, Chris has a great video online if you want to have a backup reference to know how to do this the right way and the early paper showed what was really remarkable how fast they could get back and they were doing well if you chose the right patient. The complication rates were really not different and maybe even a little bit less in certain areas but they're there and they're real and you have to share them with your patients and the biggest problem continues to be the ulnar nerve and how we manage it so be very careful there. That being said this is caught on like wildfire. So if you look at the trends and collegiate baseball players the repair was 10% in 17, 20% in 18, 25% in 19, it's probably higher than that 20, 22. So people believe in this and it's working well but what happens if it's off the distal end you go in to repair it there's no tissue there there's a gap well how do you do repair you just gonna put synthetic tape over it that's not gonna work but what if it's mid substance and you can't really pull it back together so what about doing the repair but you have to have college in there so let's do the collagen and maybe add the repair on top of it and as Mark already stated there is some basic science work that's already been done to show that if you add that tape as you would expect it makes it much stiffer than just using the tendon and it matches closer to the native UCL as Matt Smith and his team showed. So what we thought is like is there a way with modern-day tools and techniques that we can combine these two ideas and make this work properly and not cause any harm to our patients and we did the biomechanical studies and it was really quite remarkable as what Mark just showed it this is published it's it's online but it's not completely published yet so it's but you can get it online and we went through this series of steps to come up with the fact that if you did this augmented double docking you clearly had improved stiffness at time zero the gap formation was back to normal UCL and the torque failure was even stronger so these are all significant improvements and if we can do this and we don't harm the biology of that graft healing we may have a winner here this might be our future so briefly going through the technique we have to find the point that Mark's talking about it's not so straightforward so we use the native ligament to give us a guide but he's right it's just that that junction of the sublime tubercle on the ridge and we want to aim away from the joints about 15 degrees distally so that you don't go into the joint if you aim straight across you're going to come into the joints and some of these people so you have to aim down and our first drill is a 3.5 but what we found out different than our cadaver study these kids bones is like cement and sometimes that's not enough and if you're going to use an anchor with two tape limbs and a suture for repair and a graft what we do is we put the 3.5 hole down and we over drill slightly then we put the 4.0 down just enough so we make sure we have enough room at that level people say well you're going to make it too loose believe me it's still going to be tricky to get that anchor in there with two limbs of the graft two tapes and a suture and you're putting in a 3.5 screw so definitely do this because that'll make it easier the bone is so hard there and then once we've made that hole we put in our fiber tag guide and we drill across the entire ulna so you have to be gentle and go across but you have to go out because you're gonna have to put your anchor in there and then seat it and pull on it make sure it's locked into place this is how strong that anchor is you know when you think about having a soft anchor how strong it is you lift the arm off the table it's strong enough and these are knotless so what you do is that you make your loop you pass it your working stitch through the loop you pull on it so you have the loop and you put your graft in the middle and you pull on it and it sinks right down into place and so this is what that looks like so all through the same single socket we're pulling on the stitch and we put that on you can use you know forceps to guide it in a little bit better when you lock that into place it's unbelievably strong and that graft is fixed now hopefully in the right spot and you've not caused any of the problems but you can see how rigid that is so you've got your graphics you cut your working stitch now you put your anchor over the top your anchor has two fiber tapes and if your tears on the ulnar side another collagen fiber wire suture for the repair and once you have that in there you have your tape your anchor and your graft and everything's ready to go that's your ulnar side now you got to go the humeral side as Mark mentioned we have some guides that help us like Mark if I'm not transposing the nerve I don't want to do much with it but you I do like like Mark just showed you to put the holes on both sides so I free up the nerve enough above the medial epicondyle so you can just place it out of the way safely now here's another one where you put a 4-5 drill in there but in this really really hard bone you have to be prepared because oftentimes you need a 5-0 and that seems big but it's just one opening that we're doing this and then we have to do first we have to do our reconstruction so exactly what Mark said no difference now the one difference is is that he can see one end of the graft and then slide the graft you can't do that so you have to do the preparation of the the graft and both ends and we use a suture on there but we have to measure the length and make sure that it's correct but you have to do that twice instead of once like Mark showed you because you don't have the ability to slide the graft and you're only doing two limbs not three limbs with this technique theoretically you should need it with the additional augmentation then we just pass it through just like Mark showed you we tie the knot and then once that's fixed we take the tape and we move it over the top of the graft and we put it in the hole and again this is one where when I have really hard bone I'll you drill a five instead of using the three five I'll use a three nine swivel lock because I have two tapes especially if it's the humeral side I'm gonna have two tapes I'm gonna have another collagen coated suture in there and I've got to go past two limbs of the tendon and so we've upgraded it to a five and that's because the cadavers were soft enough it wasn't a problem but in these kids they're so they're bone so hard you have to go up if you're going to do the repair on the humeral side and add an additional suture on that side and this is what it looks like when you're done and just like you know Brandon said we take the arm through a range of motion we make sure we get full extension and we have this nice all graph and what everything's in place we do usually three you can do two but one in the middle and two at the two edges of a 90 degree circumferential stitch around this to make it all one unit so in 2022 internal brace as Brandon showed you is a great option for the younger athlete detachment lesion is a reconstruction enough I it is the gold standard we're not better than that but it may be in the next couple years that you'll hear more and more surgeons doing this three-in-one technique with the ability to get our athletes back possibly possibly as much as six months earlier from if they just had a straight reconstruction so we're hoping that that's what we'll see and it's going to take a few years to really know that for sure thank you very much

UCL injuries

surgical techniques

ulnar collateral ligament

anatomy

internal brace technique