Okay, so we're going to talk about UCL repair, who, what, and when kind of stuff. Who fits, who doesn't fit. So I'm a consultant for Arthrex and I designed a kit that basically has the internal brace in it. And with the proceeds that I get from that, I'm probably up to buying everybody in this room a cup of coffee, so everybody enjoy a cup of coffee on me. So Lyle Norwood was the first one to talk about UCL repair. He published on this in 1981, four players, two of them got back. That was long before the first report by Job. And John Conway, who's here with us, was Job's fellow at the time and he published, he was the lead author on this article published in JBJS 92. There were 70 patients, starting with Tommy John in 1974 and going through 87, they did, what gets lost in this paper is that in addition to the 56 reconstructions, there were 14 repairs to bone. Now those came in multiple forms. There were some suture repairs, some placations, things like that. But out of the reconstruction group, 12 out of 16 at the major league level got back to play, whereas only two out of seven at the major league level got back with repair. So on the basis of this, Conway and Job said, this is a bad idea. Let's go with reconstruction, rightfully so. Andrews then wrote a paper in 2000 with Fred Azar as the lead author on 90 patients. Same thing, about 30% of the repairs that they had done got back to the same or higher level. So the two giants of elbow surgery, Job and Andrews, basically said repair was a bad idea. And on the basis of the data they had, rightfully so. Okay, fast forward now, you know, 15 years or so, and Buddy Savoie publishes two articles in the mid-2000s in AJSM, which I'll remind you is our trade journal. And this went largely unnoticed. People didn't pay a lot of attention to this. The first one was in female athletes, 18 repairs. There were anchors, there were placations, and 16 of 17 got back in less than three months. And then he redid it in 2008 when nobody paid attention to the first one. He did it in overhead athletes, and 58 out of 60 got back with suture anchor repairs, predominantly 93% good to excellent. So keep in mind that those numbers all look better than what we know about reconstruction. And Buddy was doing this long before we ever had the idea for internal brace. So Buddy was one of the first people I reached out to when I had this idea, and Buddy was very encouraging. But remember that before 2017, less than 200 cases of UCL repair had been reported with generally poor outcomes by two of the masters, until Buddy, who went largely unnoticed in the mid-2000s. So I remember Andrews telling me, we've got to come up with a better option. But I also remember thinking, I may be reinventing the failure mode here, or doing the same thing, expecting a different result, and is that the definition of insanity? The internal brace was an idea that was first had by a guy named Gordon McKay. Gordon is a Scottish foot and ankle guy. If you've ever met Gordon, he's the guy with the kilt on most of the time. He's a really fun dude. But he came up with this, and he used it for ankle ligament reconstruction. But it's been used in lots of places, in the knee, the elbow, wrist, and hand. It basically is a construct that has two plastic or peak anchors with a fiber tape in between them. And then we added a super suture on one end, a zero fiber wire type of suture. You could put anything over there, zero anything, through anchor number one. I always put this slide up because I think it's important. If you're going to do UCL surgery, this may be the most important slide. If you're going to do any kind of UCL surgery, you must understand these anatomic relationships. And it is important to really understand how to get to these points. The sublime tubercle is really fairly easy to feel. The anterior face of the medial epicondyle is not quite as intuitive. And you really got to understand where that dot is, and where that face is, in order to get your graft, or your brace, or whatever you're going to do in the right place. So we did a basic science study. We looked at repair with augmentation, compared it to reconstruction. What we found was that the repair was at least as good as the reconstructions we were doing every day. And I wanted to know that before I did this in a live human being. So it turned out to be at least as good at time zero, and I felt good about recommending that to a live person. And Dr. Andrews had challenged me, because we cut into thousands of these ligaments. And I can remember us looking at each other across the table and saying, God, are we operating on the correct elbow? This just doesn't look that bad. Why can't this kid throw? He can't be that much of a puss. What is going on? And we got to come up with a better option for these people. And so that was the impetus for this. So is UCL reconstruction really necessary for this problem, where the ligament tissue is really pretty healthy, and can't we come up with a better solution? And what about revisions? Anybody that does this stuff will tell you that revision UCL reconstruction is one of the worst operations that any of us have ever done. None of us like doing it. The outcomes suck. In one study that Stan Conti published, less than 42% were able to get back for 10 games or more. I mean, it's just a bad operation. So would it be a better option for revisions? So this was our cadaveric study. We showed a little bit less gapping and a significant P-value for that versus the reconstructions. We got closer to the normal condition with the repair. We did a cyclic study. So we knew we could push these things early at 500 cycles. We knew it didn't loosen. So we could push the rehab a little bit. And so who's a repair candidate? Well, the one on the left I would submit to you, that looks like really healthy ligament that just happens to be torn off the sublime tubercle. There's no bone in that ligament. There's no signal in that ligament. It's just ligament that's torn off the bone. And don't we repair every other ligament in the body when it tears off a bone? Why not this one? And the one on the right, this projecting osteophyte with this heterogeneous crud looking ligament tissue, that's probably not as good. Something like this, same idea. When you take that big enthesophyte out on the right, you're going to have a tissue deficiency. The tape should not be the ligament, should not be a substitute for the ligament. So here's a quick video basically going through the procedure. We make the same approach. You can do this through a muscle split. You can do it through posterior elevation. We prefer to do the posterior elevating approach. So we expose the ulnar nerve. We transpose the nerve in each case. We had some where I was not transposing the nerve and I had to go back and transpose the nerve. So here you can see the ligament from start to finish. I've elevated the muscle belly off. Here's the ligament right here from sublime tubercle to medial epicondyle. We've got a great look at it. We'll incise it from the sublime tubercle in its mid-portion up to the medial epicondyle. So now we're looking straight through the ligament. We can see the entire thing and this person had a little piece of bone in the underside of their ligament. You can see where it's torn off, the sublime tubercle there. There's the piece of bone in the posterior leaflet, but bare exposed bone there. This is going to be an easy repair. So we take our drill. We drill our first hole at the sublime tubercle, right at the apex. In goes the anchor and you can see the super suture and the tape through the eyelet. So we're going to advance the anchor down, which fixes the tape and the suture in the hole. Then we're going to take the super suture and we're going to sew down the limbs of the ligament, of the split ligament that we cut. This basically accomplishes what Buddy was doing back in the mid-2000s, which was just a simple suture anchor repair. So by taking an anchor and a suture and sewing it back, we're basically accomplishing what Buddy did. So here comes our suture through the anterior leaf and we're going to do the same thing through the posterior leaf. Come on, Jeffrey. We tie that down and we've repaired the ligament. Then we're going to close up the split. So once we've done this and sewed this down, we're going to close up the split that we made just with some side-to-side sutures, two or three of these in the ligament from top to bottom. Then we're going to drill our second tunnel. So this was a distal tear, so we're going to put the anchor, the first anchor at the site of the tear. So if it's proximal, you do the first one proximal. If it's distal, you do the first one distal. So here's the split. We still got it. We're going to be up on the anterior face of the medial epicondyle. We're going to aim towards the top of the medial epicondyle, make sure we're in bone the whole way. Note that we're not at the distal tip, we're anterior to that. So we're going to tap this hole so we get easy placement of the anchor because now we're going to have four limbs of the suture. This is a little bit of an oversized tap that I had to make for this kit. And I put this in tight for the purpose of the video. So I'm putting this in pretty tight and we're going to flex the elbow up and you're going to see it constrains the ligament. I can't flex it, it's tight. The elbow's a little tight there. So I'm going to pull this back out and I think this is really some of the art of this. You do not want to put this thing in where it over constrains the ligament. The tape should not be the ligament. It should just support it. So it should never be tighter than the native ligament. There's got to be space under that thing. I've had people describe putting a hemostat under it, putting a freer under it, putting something under it to make sure that it is never tighter than what's below it. And I think that is super important and in the eight years I've been doing this, I don't think we've put one in too tight where we couldn't get the flexion back. Now I've heard Keith Meister say he puts it in as tight as he can get it, doesn't worry about it because he thinks it's going to stretch out a little bit. I don't think it's going to stretch quite as much as that, so I don't do that, but I have heard people say that. And then we sew the ligament and the tape together just to make sure they're all moving as a unit. So with the recent success by Savoie, we published a study on our first 128. We've now done a little bit over 500 of these. Interestingly in 2019, 25% of NCAA UCL surgeries were UCL repair with internal brace. That was up from 10% in 2017. I suspect in 21, it's probably closer to a third. So this seems to be growing in popularity at the NCAA level. We had 17 lost to FOP, 87% all dominant arms, average age 18, so predominantly high school and college, virtually all baseball players in this group. And you could see about two thirds of them were high school with the remainder of them mostly college with a couple others in there. We have not seen any difference in the outcome regardless of level of play. Level of play seems to make no difference. And when you talk about KJOC scores, I think it's important to know what the norms are. And I'm going to point your eyes to the professional pitcher at an average of about 91. History of upper extremity surgery, average about 75. So at 12 months, our KJOC scores were about 86. At 24 months, 91. They got back at just over six and a half months, 92% at the same or higher level. So our KJOC scores returned to the average healthy pitcher and were well above the average for upper extremity surgery in both 12 and 24 months. We look back at ulnar nerve transposition. We did about half of them with, half of them without. No difference whatsoever. So if your preference is to not transpose it, doesn't seem to make a difference. I've been transposing more of them because I had to go back and do some. I think that relates to our exposure being posterior. I think we got some scarring around the nerve because of the way we approached the ligament. I think if you do a muscle split, you won't have that. That's just not our preference. Proximal versus distal, no difference whatsoever, P value of 0.7. So it doesn't seem to matter in terms of outcome, whether it's partial or complete, proximal or distal, nerve transposition or not. So no difference in outcome on extent or location of injury. There were a few complications, none of them major. Probably the worst one was a kid who got heterotopic bone. We had to go back. I had to remove a stitch. I had a couple of ulnar nerve things we had to deal with. But they all got back. And this is a picture from one of those ones I had to go back on. And you can see the highly organized, very, very collagenous tissue that forms over this tape. Remember, this is a collagen dipped fiber tape. So very organized tissue. Couldn't even see the tape. It was kind of embedded in there. You could see kind of the blue sheen underneath there, but we didn't cut into it to see it. This was the second patient I did. She was a tumbler. She had a lateral sided injury that I had to operate on. Her whole lateral side was in the joint and I decided to do a repair on her. She was back to full tumbling and gymnastics in four months. Most baseball guys are going to be back in just over six months. We've gotten the tumblers and grapplers back in about four. This was the alpha patient. So they sent me this video and I about threw up. This was five months post-op. And if you're used to seeing people do this at eight and ten months after their UCL surgery and somebody sends you this at five months, you get a little queasy. I called the therapist and asked them what the hell they were doing and they said they couldn't slow the kid down. So limitations wise, you know, this is mostly high school and college kids. George Palletta did the first pro in June of 16. That was Seth Maness. He got back to Major League Baseball in nine months, was competing in seven. There is no control group relative to what we know about reconstruction. There's been a lot more interest in this in the five round draft last year. Two kids that had had this done were drafted in the five rounds. I think we're going to see a fairly, should see about a triple to quadruple number of that this year. There are gymnasts and cheerleaders. They all get back pretty easily. In fact, the non-throwers had a much higher success rate. I don't think we had any failures in that group. I've revised six of these forward modified job two docking. They all tear off the medial epicondyle. Five of them have gotten back, one's less than six months. A recent revision was Rich Hill, 39-year-old Major League pitcher, seven seasons since his reconstruction, started having symptoms in 19, couldn't complete the season. You can see here this big injury where the whole mass of his native ligament and his previous graft had torn off the medial epicondyle. So when we got in there, there was this big hole. I had to find his nerve. His nerve was down for about three or four months because I had to manhandle his nerve that had been previously transposed. His nerve came back and we did the repair basically at the time zero thing. So Rich was named Pitcher of the Month for May of 21 with a 3-1 record and a .78 ERA. One of the things, if you look at UCL surgery and starting pitchers in Major League Baseball, they actually don't do as well getting back to starting. So this is a guy who's been a starter his whole life. He's now 41 and was Pitcher of the Month about a month ago. So he has a nasty, he's got the nastiest curveball you ever saw. So my thoughts are that with other ligamentous injuries in the body, endovulsions and partial thickness tears can be repaired. I think the biologic tape is an enhancement. It's not a ligament replacement. It may be a better option for revision, which is a crappy operation. And you can choose whether you want to do nerve transposition or not. People have asked about revising these. Chris Amad and I and others have done revisions on these. These are the easiest revisions you'll ever do because there's no bone issues. You can drill right through these little plastic anchors and drill your tunnels for a revision right where you always would. And we've all done a couple of these, but the revision rate has been exceedingly low. So I have cautious optimism in people with these endovulsions and partial thickness tears. And now we're moving into higher levels of sport. I'm getting talked into doing a few of these in people that maybe I wouldn't. We're going to follow those people pretty closely. People that have said, no matter what, I want the repair. Whether I agree with that or not, I can't really tell them I decided to do something different when I'm in there. So the decision to perform this is an intraoperative one, and I'll leave you with this. Level of play, velocity, age, ulnar nerve transposition, location, and degree of tear seem to have no effect on the outcomes, and revision may be better with internal brace than what we used to do. A lot more to know about that. So with that, I will say thank you, and I will turn it over to Schick.

UCL repair

ulnar collateral ligament

internal brace technique

Lyle Norwood

Job and Andrews