presentation, Brennan, thank you. So we've decided to do a reconstruction. How do we go about doing that in 2022? I still use a traditional docking technique. You know, the graph pass through the owner drill holes, although we're looking now a little closer to single point fixation on the owner. Tony seems to have figured some of that out right now, which is which is great. I think we've been interested in that for quite some time now. The other options at this point are, you know, traditional job three ply interference screws, both distal and or proximal suture anchors, suspensory buttons, and something that Tony's gonna talk about and that Brennan just touched on here briefly is the hybrid reconstructions, which are to me quite fascinating. I'm looking forward to hearing Tony's thoughts on that. You know, if we're doing a traditional reconstruction, palmaris, ipsilateral palmaris is still probably our go to graft the vast majority of the time. Other choices include the gracilis and less common anymore, the plantaris, Achilles tenon, toe extensors, allograft, all these things have been described but are not very widely used. I use a tenon stripper and harvest the palmaris through a single incision. The younger the athlete, the more likely you are to run into some some fascial bands that spread, that connect between the palmaris longus and the flexor carpi radialis, so you need to be careful with this. If you do get some resistance as you're using your tenon stripper, by all means, you know, go up the forearm, make a small transverse incision, pull the graft through to help you to get a good quality graft without transecting it and leaving yourself short. As Brennan pointed out, we always look for the medial anabrachial cutaneous nerve, usually runs with that big vein that comes right through the middle of the operative field, but that's a highly variable anatomy here, so just kind of keep an eye out for that. It may not be quite as obvious as it is sitting right here. And then as Brennan pointed out, we split, we don't typically lift and we're exposing and not transposing. You know, the muscle splitting approach between the FCU and the FDS has been popularized over the last 20 years. It's the way I do it. There are other ways to do this as well. This is, at least in literature, a safer way to do it in terms of minimizing trauma to the ulnar nerve. So we split it like that and we just get enough exposure of the ulnar nerve to protect it. I don't move the nerve unless there's neuropathy or instability of the nerve. If it's just transient neuritis, secondary to some instability of the elbow, that by and large goes away after you've reconstructed them. Go distal, when distal, we know that the ulnar collateral ligament has a very long ulnar attachment along the medial ulnar collateral ligament ridge, so it does extend down about a centimeter or so further than what was originally thought to be the insertion point. So we want to get down nice and far. I try to find the spot between the transition of the sublime tubercle as it sort of tapers into the ulnar collateral ligament ridge. That's kind of the sweet spot for us, and that's what this looks like. So that's the sublime tubercle there. The ridge is distal to that, and that transition point between the tubercle and the ridge is where we place this commercially available guide. It's a guide that Dr. Romeo was very instrumental in creating. Years ago when we first started doing these, it was always a scramble to get the instruments to do this operation, and now we've got good guides that help us do this. So I always use a curved curette to make sure I've got good continuity and a true tunnel here. Another trick you can use is get an angiocath and run some water through it, run some saline through it, make sure that you've got a patent tunnel, and then you can use a little curved needle to pass some sutures through that, and that will assist in passing your graft through the ulnar side. Stay lateral when proximal. What does this mean? Chris has done a nice job looking at the true anatomic insertion points of both the ulnar side and the humeral side. It's interesting. We think about the ACL and these great guides that we have for getting everything in the right position, and it's been studied extensively. It hasn't been studied very much around the elbow. Nonetheless, this is probably the best article out there talking about where your tunnel should be. This is where the medial tunnel should be ideally. The mistake that most surgeons make is putting this too posterior and putting it too medial. So you want to be lateral and you want to be a little anterior, as Chris has pointed out in this study. And this is what, for me, an ideal docking hole or socket on the medial epicondyle looks like, a little guide that we use there. So we'll clean this off, and this is pretty aggressive in this case, coming down and getting good exposure of the bone. It's almost down at that little corner where the epicondyle sort of transitions into the rest of the humerus there. Right down in that little corner, get yourself a curette, flatten that out, get a nice starting point. And in general, a good direction to go is along the course of the medial intermuscular septum. If you're not exactly sure where you ought to be going, that's going to keep you out of trouble if you stay there. And come on with the curette, and we use this little guide that'll help us drill the small holes that we're going to use to pass our docking sutures. And then once we get that done, once again, we're going to check with an angiocath, make sure we've got good flow, and we'll use some passing lasso-type devices to pass our sutures, and then we'll pull our graft up in. And I'll run through that. So when you do a docking, you want to make sure that you've got enough length in that second limb of that graft to come back and fold it back over onto itself. This is just some further pictures of how this looks as we're going along. So rather than transect this and cut it short, it's nice to be able to fold this back onto itself and make a three-strand reconstruction. And that's what that looks like. If it's really tight, you don't really want to overstuff it. Most of the time, a polymerous graft will fit. And then you sew those things together, and off you go. So as Brandon pointed out, post-operatively for these, typically not throwing our reconstructions until about 16 weeks or so. We try to push that up a little bit, but it doesn't seem to work very well. So hence the idea behind the hybrid reconstruction and the repairs, being able to go a little bit quicker. So how are we doing? How do reconstructions hold up over time? Biomechanically, Glenn Fleissig did a nice study looking at biomechanical parameters following ulnar collateral ligament reconstruction and found that biomechanically, our athletes are getting back. So that's a good thing. Long-term outcomes, longest study out there, minimum 10-year follow of Andrew's cases, 83% return to play at about a year. A nice study by Brandon Erickson and Tony looking at rate of return in Major League Baseball. Again, 83%. You're going to see that number coming up a lot here. Does graft type or tunnel configuration matter? Good question. The answer is no. There was no significant differences in the time to return to play or time to same level of play based on the reconstruction or the graft type. So it's similar for both docking and the modified job. Return to sport outcomes after ligament reconstruction with the palmaris versus hamstring, does that matter? No. So there's no significant difference in return to same level of play between either the hamstring or the gracilis graft. So it doesn't seem no matter what type of graft you're using, although allografts may fall off on that a little bit. What about performance after Tommy John surgery? This is a good study out of the K-Job group. These are Neal's cases. Technique performed, graft type used did not affect performance. So it doesn't seem to matter how we do this or the type of graft that we're using. What about subsequent injuries? Looking at this versus a palmaris or a hamstring, again from Brandon and Tony, looking closely at this, no difference again, return to performance or return to same level of play with regards to either a hamstring or a palmaris. So there's a persistent theme here as you can see. What about docking technique versus a modified job technique? So what about if you elevate the flexor pronator group and move the nerve? If you control for how the flexor pronator group and the nerve is handled, there is no significant difference in overall outcomes. So that's important to know. Again, if you're comfortable doing a modified job technique, you're going to get good results and equivocal results to a true docking technique as long as you're not doing much with the flexor pronator group. What about revisions? Brennan briefly mentioned that. Historically, they've not done very well. You know, this is the first article on revisions that came out of the Kerwin-Jobe group. If we look at the techniques that were done that were revised, you had 11 Jobes and 3 Danes. Dane TJs weren't repaired. Only 33% return to play. More contemporary literature results are a little bit better. More 65% return to play at the highest level of play, although they did no fewer innings pitched and fewer wins following revision surgery. So this kind of leads us into a segue with what Tony's going to talk about. There's a lot of interest in this hybrid type reconstruction. There is some pretty good basic science literature out there. There is zero clinical literature out there with regards to augmenting a graft. And I'm very interested to hear what Tony has to say. This is the study that Brennan just brought up. Another study that was recently published in the American Journal of Sports Medicine. Again, showing basically the same stuff that Tony's showing with his double docking augmentation. So, you know, if we look at the literature right now, over the last 20 years, our results really haven't improved. We're about 80% return to play across the board for the last 20 years. And if you look carefully through the literature, surgical technique and graft type don't seem to matter. So there's a lot of interest in this evolving technique with graft augmentation that might lead to even greater success. Try to get us above the 80% mark. So I'm really interested in hearing what Tony has to say. So thank you very much.

Ulnar collateral ligament reconstruction

Hybrid reconstructions

Graft choices

Nerve damage prevention

Post-operative care