Good evening. Welcome to the AOSSM Fellows webinar series, featuring tonight's topic, UCL repair versus reconstruction and non-operative treatment. A point-counterpoint discussion with presenters Dr. Michael Ciccotti and Dr. Jeffrey Dudas. Dr. Ciccotti is president-elect of the AOSSM and chief division of sports medicine and director of sports medicine fellowship and research at Rothman Orthopedics and the Sydney Kimmel Medical College at Thomas Jefferson University in Philadelphia. Dr. Dudas is chair of the AOSSM fellowship committee and practicing surgeon and program director at Andrews Sports Medicine and Orthopedic Center in Birmingham. This webinar will cover decision-making of UCL injury and the throwing athlete. Dr. Ciccotti and Dudas will take you through several cases that illustrate the entire spectrum of non-surgical and surgical management, including surgical options for primary and revision surgery. To submit a question online, on the GoToWebinar panel on your screen on the right-hand side, click the questions drop-down arrow on the right-hand side of the panel. This slide here shows you where you input your question and click send. I will now turn this over to Dr. Michael Ciccotti. Thank you, thank you, Meredith. So I would like to welcome you all to our continuing 2020 fellowship webinar. And tonight, what we'd like to do is discuss the treatment of ulnar collateral ligament injury in the throwing athlete, uh, current concepts in 2020. Jeff Dugas and I have had the good fortune of talking about this topic in a variety of ways in seminars over the past several weeks, and what we'd like to do tonight is look at it in a different way to, to really touch on the most important topics in terms of non-operative, uh, operative treatment with reconstruction, operative treatment with repair in terms of case presentations. And there's no doubt that every time I, I listened to Jeff, I learned a lot. So I'm looking very forward to, to all of this. See here. There we go. So I'd like to begin with a case presentation. Uh, these are my disclosures, none of which have any direct conflict with this talk. So we have a 25 year old right-hand dominant minor league pitcher, uh, right elbow pain and stiffness after four or five innings, but really able to recover by each start and still effective. The pain that he describes it's posterior, it's medial. And on his examination, he has a little bit of swelling. His tenderness is over the olecranon tip. He's got some restrictions in his range of motion, but he feels stable to exam. His flexor pronator is intact. Uh, he has, uh, an intact ulnar nerve, but he has a positive arm bar test. And as you see here, a test with the arm abducted 90 degrees, uh, the shoulder internally rotated, extending the elbow with the pronated forearm on the shoulder of the examiner. And then hyperextension is pain in the posterior aspect of his, of his elbow. These are his plain x-rays and not particularly revealing. We could debate if there's a little bit of change in this posterior aspect of the, of the, uh, olecranon. And then here's his MRI. So Jeff, when you look at this, is there anything in particular that, that strikes you on this? You know, uh, Mike, it's, there's a little bit of signal down in the olecranon also, and I can't tell if that's a line down there or not, but there's some thinning of the proximal UCL, but really his UCL looks intact. I don't really see a, you know, you could argue that there's maybe a little partial tear there where the positive radiology symbol is, but the substance of his ligament looks pretty good. Yeah. And that was, that was our feeling. You know, we felt pretty confident. We thought his flexor pronator looked intact. His ulnar collateral ligament looked intact. And I see what you mean down here. Our radiologists were not particularly concerned about that. Um, so in terms of your differential diagnosis now, what are your thoughts? I mean, do you think it's pretty straightforward? What, what, you know, what, what ideas do you have in this, on this athlete? You know, I think that this looks like a typical throwing athlete with, um, you know, we look at a lot of these MRIs and, and is this just a normal MRI for a thrower and who knows how long this guy's had this, these findings, these could have dated back a while. So, you know, to me, it's the worst case scenario for this is that he's got a small partial tear proximally. And I think he's got a lot of options. I think I would, uh, be thinking about the possibility that he has a acute or acute on chronic partial proximal tear. That would be kind of the worst case scenario for him. Okay. And, and so worst case scenario, but you're thinking, you know, he does have maybe some degree with his examination of, of whatever we want to term it posterior medial impingement or valgus extension overload, correct? Oh yeah, for sure. No question. He's got the posterior medial impingement. Um, and, and I didn't hear what you said about whether he had any, any nerve symptoms. I think you said he did not, but, um, you know, he certainly has, uh, he certainly would be concerning for some valgus extension overload, um, you know, with that constellation of findings. Great, great. And I want to add too, as we go through these cases, just anyone in the audience, please feel free to send in your questions to Meredith and we'll answer them as we go along. We're going to be asking questions of each other when we may actually answer your questions, but please feel free to, to, as we move through this, ask questions. So, so our diagnosis, our working diagnosis was posterior medial impingement. You, in this scenario, you know, he's still effective. What are your thoughts on treatment for him? So, you know, rest, obviously I think he goes through the non-surgical stuff first. I certainly would not think anything surgical right off the bat for this. Um, I would say rest him, uh, active rest, non-steroidals. Um, if we really felt like he needed to get back in season, he was having more poster medial symptoms, I would consider a corticosteroid injection once. You could talk about a biologic injection. People have tried that. Um, you can go with no injections and just some rest. You can look at his mechanics. There's, there's a bunch of different ways to, uh, to go about this, but I would certainly be thinking non-surgical at this point. And so that's, that was our feeling. He was effective. Uh, we held them off from throwing for roughly about three weeks or so. Uh, three to four weeks. We focused on his kinetic chain, looked for any deficits, felt like we corrected them. He went through a short toss, long toss mound program, uh, and attempted to get him back to, to perform. But he felt like his symptoms were persisting. And in fact, they were worsening. Uh, he got to the point where he felt like his velocity was diminished. He felt like his control was not precise and he really wasn't effective anymore. And it was interfering with his ability to participate. And, and in fact, in his words, he felt like he couldn't compete. So in that scenario, you know, what are your thoughts now? So where does he report the pain in the course of throwing? Is it more at the top of the windup or is it more at ball release? Can you distinguish between the two? Great, great question. So where he, you know, where he reports the pain is really important, right? And, and if he's back, if he's like cocky and early acceleration, we might be thinking more ligamentous. If he's near ball release, we might be thinking that it, it really is a source of posterior medial impingement or valgus extension overload. So his pain was as he was releasing near the end, when he was finishing his pitches, he felt that pain. Right. So, you know, you're thinking at this point that it's probably more of a posterior problem and less so of a medial problem, and obviously you have to be careful with those things. Cause they can be chicken and the egg a little bit. Um, but, but I would be thinking about, you know, some more, some more aggressive non-surgical management. If we didn't inject them back four months ago, I would certainly consider that now. And it might be post-season at this point, if it's post-season, you know, maybe you think about injecting them and giving them a couple of weeks to see if he can get past it and throw some more. If not, maybe we're considering scoping him and, uh, and debriding that posterior medial osteophyte. Great. All great points. So it was towards the end of the season. We gave him an injection, didn't help. Now the end of the season, he's not effective. We really felt like, well, you know, the pieces of the puzzle were fitting together. The way he described the pain when in his throwing mechanism, it was bothering him. His exam was pretty straightforward. He failed non-operative treatment. So this is what we did. We brought him to the OR and we took off a Lecron on spur and everybody clapped in the operating room. And so you can see there, hopefully you can see the X-ray, you know, uh, there, the amount of bone that we, you know, that, that we resected. Can you talk a little bit about, about bone resection in this, in this scenario? Absolutely. And, and looking at that, I would say that's a really good X-ray because you didn't take too much. And, and too much is too much. You, I think you can get by in these operations with taking too little, but taking too much is going to create some problems. So there, there've been a couple of studies. We did a couple of studies. I think there've been four or five studies on this, but you know, as you look at it, we, we really shoot for that three to four millimeter mark. And, and that was based on our numbers, but just in our, in our experience too. I think you go above that and you're starting to really potentially create some instability and put more stress on the, on the ligament. So, you know, those bones first take a long time to form. Uh, this didn't come about overnight. So, you know, taking three to four millimeters of bone off of this guy is going to give him plenty of time. And as you said, there, there are several very good studies that have documented increasing stress on the collateral ligament, as you take more of the, the posterior, posterior medial aspect of the olecranon off. So to be, you know, minimalistic, I think is really the key here, taking what, what is abnormal and the burrs that we use, you know, three millimeter, four millimeter burrs. You can use that as a, as a gauge, anything that looks irregular, uh, take that off, but being very, I think very, very prudent. And, you know, Jimmy published one of the early landmark articles on this 72 professional baseball players with valgus extension overload. And the early results were just great, you know, 90 plus percent good or excellent, but very sobering and in longer followup, right. You know, under 50%, uh, at two to five years with recurrent medial elbow pain and 25% that developed valgus laxity that required UCL reconstruction in the future. And, and a variety of studies have shown this. So with that in mind, how do you counsel these athletes? You really think it's valgus extension overload. Um, but what do you tell them about the future? Pardon? Still there, Jeff. I think he just mentioned he had to switch phones. Oh, okay. Yeah. So no problem. So, so, I mean, I think the important point here is that we need to be really prudent in how we counsel them to let them know that, that we really think this is the issue, but, but in throwing athletes, the UCL can be an overload. But in throwing athletes, the UCL can be an underlying aspect or a problem. And in the future, they run a risk of having an issue down, down the road. So he completed his post-op rehab and he returned and he was just lights out. I mean, he was just great. So effective, uh, and really just someone that was clearly rising towards the major league level. And then at about just about a year and a half, close to two years, he had some recurrent elbow pain and on his examination, pretty similar to before little bit of restrictions in his range of motion, his ulnar nerve was intact. He had no discomfort with resisted wrist flexion and forearm pronation. Uh, and now he had a positive milking test, uh, and, uh, tenderness along the ulnar collateral ligament and their variety of tests that have been suggested for, uh, for valgus laxity, milking, dynamic milking tests that seem to be the most popular tests utilized. Uh, and then, yep. Yeah, I'm back. I had to, my phone died. Yeah, no worries. So, so he got back, he was lights out. And, and then a year and a half later, and I'm presenting it now, he just had some recurrent medial elbow pain in his exam now he's got a positive milking test and now Jeff, here's his MRI. So do you have any, any, any comments on that? Well, I wanted to go back to where we were before for just a second. You know, when we talked about how much bone to resect and what are your thoughts on whether or not the ability to make that bone requires them to have a little bit of micro instability, which may mean they have a little bit more natural laxity, you know, we know that throwers can have a little bit more laxity than non throwers. And do you think that the people that make these spurs are the ones that maybe are on the upper scale of that? And maybe that's why they're so sensitive to, to over resection of these things. I really think Jeff that you're on it. And I, and I think though that we do everything we can to treat them non-operatively to kind of navigate them around, whether it's, you know rest and anti-inflammatories, the injections you talked about, kinetic chain evaluation, but you know, if they can't perform and they have localized pain, you know, we, we, we do this type of procedure, but I think we just have to be so minimalistic and we have to counsel them that this could happen in the future. Yeah. And I think that's the real value of that is, you know, before we go and take that spur off, like you said, you have to try non-surgical stuff first because you can get into trouble even taking a little bit like you guys did. And who knows whether this caused this or not, but now he's he's a year and a half later and he's still having symptoms and he's got that signal in his, in his proximal ligament, you know, and you could certainly make the argument that that's a partial tear, a strain, a high grade strain, if I was going to call it a strain, I would say that's a pretty high grade strain or a partial tear, there's probably still some fibers left there, you know, intact, but it's definitely a ligament that's got some stress on it. Okay. So it's changing and we've, we've looked at this, we published a stress ultrasound as another way of evaluating our 10 year experience, over 350 players over 10 years, and we looked at thickness, partial thickness, tears, calcification, and joint space width with rest and, or at rest and stressed. And we found those players that had even as little as a millimeter and a half to two millimeters difference between stressed and unstressed, they may be at a higher risk for UCL injury and may more likely require UCL surgery. And then we looked at this combining it with MR arthrography, 150 athletes with medial elbow pathology. And we looked at the sensitivity, specificity, and accuracy of just stress ultrasound, just MR arthrography. And when we combine them and we found that we significantly increased all three of those sensitivity, specificity, and accuracy when we combine the studies. So we've combined those in terms of this. So we did a stress ultrasound on him. And to the, to the left here, we can see this is the medial ulna right, or medial humerus right here. The cursors are at the joints, joint space. This is the, the ulna and the sublime tubercle. His ligament is here. The flexor pronator is up top, and then here's him being stressed. And with stress, he was over that 1.5 millimeter gapping. And when we compared him to the opposite elbow, which was 0.3, he clearly was in that range where we were concerned about him having instability. So, so your thoughts here, you already talked about it. I mean, he's really somebody that is moving towards at least partial UCL injury. And then the question would be, what, what are your thoughts now on his, his treatment? He was, he had the scope. He was very effective for a period of time. He's now had some new onset symptoms. You know, where would you go from here? So to me, this is a guy who, who probably had a little bit of hypermobility in his elbow to develop the post-remedial impingement. And we take that away to relieve his symptoms and he goes back to throwing well, but he's now got that elasticity. So that ligament, while there's still fibers there, is moving a little more than it should. His, his elbows gap and open more. And that's clearly, it's like swinging a kettlebell. You know, you're going to put more stress on that thing as he, as he gets to the apex of his throwing motion, the, the late cocking and early acceleration phase as he, as he really tensions that ligament. So I would counsel this guy that this is a ligament at risk for sure. And it's not likely that this is going to go well over time. He's going to have a problem and it becomes a matter of how well you can manage him without surgery. But I would tell this guy at some point in his throwing career, if he's going to keep throwing, it's likely he's going to need a procedure on that ligament. So let's, let's talk about that because it is important. We're, you know, is non-operative treatment appropriate? And I, and I would say to you, maybe one of the questions to begin with is, are there specific types or degrees of UCL injuries that can be well-treated non-operatively? And we looked at, with a stressed ultrasound evaluation of a cadaveric model, different types of commonly seen partial thickness UCL tears. And what we found was that some of these partial tears, they acted stability-wise just like the intact ligament. Some of them had intermediate amounts of stability or instability. And some of these partial tears acted just like a complete tear. So depending upon where they were geographically, they had either more or less stability. And then we took it one step further and we did a collaborative study with the Stabbing Group looking at the variations in blood supply in a cadaveric model. And we found that the proximal UCL had a very dense blood supply from the epicondyle and the flexor pronator. But as you move distally, it became relatively hypovascular and quite hypovascular or avascular near the sublime tubercle. So perhaps that variation in vascular supply might be a factor as well in the relative healing capabilities of these partial tears. So there may be certain types of partial UCL injuries that can be well-treated non-operatively, those that have a better blood supply, those that are inherently more stable. So he didn't want to have surgery. He really wanted to navigate through this non-operatively. So we went through a non-operative program. And in terms of non-operative treatment, there are a variety of suggested treatments, you know, resting for a period of time, three to six weeks, making them feel better, starting range of motion, strengthening, and then progressively working them back to what they do. And in baseball-wise, swinging a month, month and a half, a throwing program can start at that point, but it can be three months of non-operative treatment. And I would say to you that the tendency in the past has been to be very myopic. But I think that it's very important that we need to really be broad and think about that entire kinetic chain that so many authors have focused on, legs, hips, core, scapula, shoulder, cardio. And in doing so, we're optimizing their outcomes. And then we have to return them to what they do, right? So they throw a ball, short toss, long toss. We could debate how far out that they need to throw a ball, but essentially then a pitcher goes to the mound and throws fastballs first with increasing effort. And then they field, right? So fielding to the player initially and then full fielding of their position and they hit, so dry swings, hitting off a tee, light front toss, and then maybe live hitting and batting, but it doesn't end there. Once we have them go back to play, we really have to continue to watch them, to look for what might be injurious biomechanics and avoid them, help them avoid them. Do you have any thoughts on those non-operative milestones, Jeff? Yeah, I think those are all exactly right. And I think that one of the keys is, you know, we talk about getting the body ready. You know, does this person have the flexibility in their core, in their back, in their legs to use the power that they've got in their musculature? And a lot of times it's really a balance question. Ben Kibler's taught us a lot of that stuff. You know, a lot of the strength conditioning guys now in baseball really understand the connection between flexibility and power and the ability to use that weapon of an arm when they have that connected body. And so I think really managing that whole body, that whole body unit in terms of flexibility and power, and then obviously throwing mechanics play into that with the pitching coaches. So, you know, going back to the building blocks, I think is important at that point. So he was treated non-operatively. OK, here's the question. Here's the big question. What are your thoughts? What are your thoughts on biologics, PRP, stem cells, a combination, steroids? Just what is your feeling and what are your anecdotal experiences with this? Well, I think there is a role for biologics in these, especially in a case like this. So we know that proximally with the blood supply and the thickness of the ligament there that the biologics do a little better than distally. And so in for whether you're talking about a high grade strain or a partial tear proximally and certainly in somebody that's going to get some non-operative time, the addition of a biologic there certainly can't make it worse. I think that looking at Podesta's numbers, which were really, you know, Lou Yoakum's patients where they said 88 percent with the partial thickness tears, I think most people have been unable to recreate that. And a lot of the studies through Major League Baseball and the HITS data, that has not really borne out in other ways. And it doesn't mean that they were wrong. I think it means that they didn't necessarily drill down in that first group of patients that Podesta had on what partial meant. So I think partial is a big word. And I don't think we got granular enough in that one study. I think we're still trying to get there. But I think in a picture like this with this athlete, I would certainly consider a PRP. I think that would be simple to do with ultrasound guidance. So we have our people that do that. And stem cells are doing BMAC or something like that. I'm not sure that we have enough data on that. And I'm not sure that that's not overkill for this. So I think I would stick with PRP here. I think we have enough data to support that. So you're right on it. I agree completely with you. So Lou Podesta's study was really the first study, right? 34 MRI documented partial tears. They all failed some form of non-operative treatment. He had appropriate metrics, single ultrasound guided PRP injection. They returned roughly about three months and all of their metrics improved. And to their study, 88 percent returned to prior performance. So that's pretty optimistic. But a small, a small study. And that's been repeated. Josh Steins, Neil Elitrosh, as you see the authors here, Jim Bradley, Chris Ahmad, 44 partial tears. They had a variety of PRP injections. They started throwing about a month and a half, but also returned at about three months. And again, 73 percent excellent or good, but a small study. And so that's what prompted us, as you already alluded to, Jeff, to look at the Major League Baseball experience. And we looked at 544 non-operatively treated partial tears. 133 had traditional non-operative treatment with a biologic. The other 411 had just traditional non-operative treatment, no biologic. They were statistically similar with respect to all aspects, both groups. And so what did we find? Well, we found in terms of just picking up a ball to start throwing, there was no statistically significant difference whether you had a biologic or not. And the only difference was that it took roughly 10 to 14 days longer to start if you got the biologic. And we felt that that was probably just the scheduling of the biologic and any kind of soreness they might have had post injection. In terms of actually playing in a game, they were statistically more likely to play if they didn't have a biologic than if they did. And if we looked at the ultimate question, failure of non-operative treatment and requiring UCL reconstruction, there was no statistically significant difference whether these players had a biologic or not. And when we carried it out in a survivorship analysis, we found that, again, no statistically significant difference over three years. Now, there are limitations to the study. It's retrospective. There were a spectrum of PRP techniques, multiple radiologists and a percentage of the athletes either retired or they were released. But if you look at this data for what in this population, the use of biologics, it prolonged the time to return to throwing. It did not increase the percentage to return and it did not decrease the need for subsequent UCL reconstruction. So you could you could step away and you could say, well, OK, it doesn't work. And what I would say to you, having lived and breathed that that this data is that I think it just means we as researchers haven't done a good enough job yet. We really haven't figured it out because there are so many different PRP and biologic regimens and activating agents and the sequence in the post injection rehab. And we really need to carry out more precise research to answer that question. And it sounds like you're pretty much on the same page with that, Jeff. Yeah, completely. And I would say anecdotally, my experience with that, with our guys, has been in the 50 50 percent range, you know, 50 to 60, maybe at best. So I think, yeah, I agree completely. I think it's we're not I think it's seeing us and we're not seeing it, you know, kind of thing. And we just need we need to drill down a little further on that. But it's, you know, for a professional player, it's like pocket change. Right. But for a high schooler, hard to look them in the eye or their parents in the eye and say, you got to pay a couple thousand dollars, depending upon where they are, for something that we just don't have evidence for. But he's a pro player, you know, so he got the PRP, but his symptoms persisted. So so what are your thoughts now? Partial thickness tear, failed non-operative treatment. Where are you going to go? I don't think he's got anywhere to go. I think we've covered the gamut here. I think if he wants to keep being a thrower, you kind of kind of you kind of got to bite the bullet and go fix it. I would guys like this. You really can't argue with them. You know, they'll walk in and say, OK, you know, Doc, I've had it. You know, we've done it all. What do you want to do? And I don't think you've got too many places to go here. So so these are some of the indications of clinically high grade injury in a thrower. If we have imaging evidence of, you know, instability or damage to the ligament, a non-thrower or a recreational athlete that maybe has symptoms of daily living that is unresponsive to that non-operative program. And that's allowed us and others to to sculpt an algorithm that we use for for identifying when it is appropriate to treat these athletes. And in terms of the surgical options, though, you know, and I know you're going to touch on this a little bit later to Jeff, but the early data strongly supported reconstruction over repair. And so the majority of the studies early on really evaluated outcomes of various reconstructive techniques and the surgical approach. Well, pretty straightforward for the majority of these are splitting the flexor protein and mass at the junction of the middle and posterior thirds or lifting it forward as you do down, I know, down on ASMI and not detaching it. That is splitting then the ligament valgus in the joint to confirm the instability and then choosing a graft, you know, palmaris longus hamstring, most common. We have a question here from from Ian. Jeff, your thoughts on graft type of graft you would prefer to use. So I think it depends, you know, I think you see a number one, I do prefer autograft. I've not done any with allograft. So I have to say I'm biased towards autograft. But I think you look at the palmaris and see what it looks like. There are some people that have a ACL worthy palmaris and then there's people that it's so thin and small that you think maybe we need more tissue. So there's no question that the gracilis tendon is bigger. It's more collagen. We tend to go there for when we know we're going to have a tissue deficiency, like with a piece of bone that's got to come out or obviously if somebody doesn't have a palmaris. But some people have really good sized palmaris and I think there's absolutely nothing wrong with that graft. Right. I think I think that if you have palmaris and it's, you know, four to five millimeters or more in width and it's appropriate length, depending upon the technique you're using, it just it's just flattened. It slides through very easily. You know, gracilis, you trim down and it gets it's a little more challenging, you know, to pass it through. But there are, you know, a variety of other grafts that have been utilized as well. And we know the original Frank Jobe technique, lifting off the entire flexor pronator mass, drilling into the cubital tunnel, which necessitated transposition of the ulnar nerve. And then it was modified to split the flexor pronator, drilling from the supracondylar ridge so you didn't have to transpose the ulnar nerve. And then Dave Olchek making the proximal humeral tunnel smaller and just passing sutures through and a variety of alternatives. But there's no doubt that by far the most commonly performed procedures in the world are modified figure of eight and the docking. And so here's just a video in terms of the tunnel. So the ulnar tunnel is the same for both. And we're just using a commercially available guide. You can use drill three, five drill bits, but five, seven millimeters, eight millimeters from the articular surface with a one centimeter bridge and care to maintain that that bridge. And then you can smooth that bridge with a we have a small tile clip here. You can use carets. So really being careful to preserve the bridge, but doing these simple things that can help the graft to to slide through more easily. This is, I would say, arguably is the most important tunnel of all the distal humeral tunnel. And what we like to do is make a bovie mark midway between the base of the epicondyle and the tip, just along the anterior surface. And there are several anatomic studies that have identified that spot, which is very consistent. And then we pass the suture ethabonds through the ulnar tunnel and we with a hemostat hold it on that spot. And it's almost always right there. Sometimes we'll shift it one way or another, depending upon the suture. And then we take a four or five drill bit and we're palpating the the epicondyle and the intermuscular septum, slightly angled 30 degrees and into the column so we can preserve that that epicondyle. And then in terms of the modified job techniques, splitting the flexor pronator mass at the junction of the anterior and middle third and drilling two 3.5 tunnels that converge on the 4.5. We have a hemostat in the 4.5. And as soon as we tickle that, then we know that we've connected and we'll slightly widen it and we can use a towel clip. We can use purets to again help graft passage. And then we'll be sure to elevate off that flexor pronator so that we can maintain a one centimeter bridge between those two tunnels. And we're palpating the epicondyle where the ulnar nerve is. And again, as soon as we tickle that that hemostat, then we can do the same things with the towel clip and the and the curette to make graft passage smoother. For a docking, it's a smaller tunnel, a two millimeter tunnel. This is just a commercially available guy. But you can just use a burr too, placing it in the 4.5 tunnel. And it allows you to figure out where you want to split that flexor pronator mass. And it's actually a smaller split here than what's needed for the modified Joe. Just elevating it so we can see the two those two tunnels. And then we'll use that that guide, placing it in the 4.5 tunnel. And we'll drill two two millimeter tunnels. And we're maintaining, again, at least anywhere from five to ten millimeters of a bridge. And here we can see in a moment the the bridge that we have between those two two millimeter tunnels. So which one's better? Which of these two techniques? Well, we looked at this and published a review of all the literature in the throwing athlete on UCL reconstruction. We looked at all the job techniques with clinical outcome and modifications of Joe. We looked at the docking technique and modifications of the docking technique, clinical outcome studies, all the alternative techniques with clinical outcome. We reviewed the three systematic reviews and then the biomechanical studies. And if you if you sift through that information, the current research indicates increased return to play, particularly in the overhead athlete with respect to UCL reconstruction. If you split the flexor pronator mass or lift it, not detach it. And if you minimally handle the ulnar nerve. But there's really no optimal UCL treatment that's been identified. The figure eight in the document, the most common in the systematic review, suggests perhaps the docking has lower complication rates, increased return to play, but it's not statistically significant. And there's really been no prospective match study. And so that's what prompted us to do our current prospective randomized study of these two techniques, single surgeon, single graph or same graph, same rehab. So in the midst of completing the study and we've found no statistically significant differences to this to this point. And then and then enters in Jeff Dugas with ulnar collateral repair and internal brace. And I know you're going to touch on this, Jeff, but this idea of a collagen coated and enhanced brace that might help speed up the rehab is is is incredibly intoxicating. And and I know you're going to review this. I won't steal your thunder. But you have been very meticulous about both biomechanical and clinical evaluation of this technique. And it's it's, again, very intoxicating because of that short recovery. But I will say that you have been so particular about the indications, you know, a complete or partial evulsion of the UCL, proximal or distal. But the quality of the remaining tissue is is is good. It's not poor quality. And maybe you could I know you're going to speak on that a little bit later, too. But this may actually be a smaller percentage of the UCL tears we see in the overhead or the or the throwing athletes. So we understand we've got reconstruction, we've got repair. And, you know, is it sort of like, you know, that we need to go to the sexy, trendy, new procedure, the traditional established procedure, you know, each of them has aspects to them that are very important to consider when we're developing our treatment algorithm. But I would say to you, it's not a debate as to which one is best. It's really a debate as to how they each fit into our treatment algorithm. And we need to continue to do research. So, you know, we reconstructed if it's a high level thrower, attritional degenerative changes. So a physiologically older UCL, maybe a non thrower that that fails, not operative treatment. And that may be actually a larger percentage of the UCL tears in the in the at least the elite level. But we'll consider repairing it if it's a high level thrower, a proximal or distal evulsion, physiologically youthful and maybe and you're going to touch on this. I know older thrower, perhaps at the end of the career of of his career that has a short window to maybe to return or perhaps in revision. But that in this era of sports specialization where these throwers start throwing as soon as they exit the womb, it may be a smaller percentage. Can you comment on, you know, on those indications, Jeff, your thoughts on those? Yeah, you know, in Mike, you and I have talked about this for years and I'll get into that in a minute. But I think that the biologically or as you called it, physiologically youthful UCL is really the place for these things. And I don't think that it necessarily matters what level of play they're at or how hard they throw. That has not seemed to make any difference. So I don't think it's a matter of whether they're high school or college or pro. I think it's a matter of how youthful their UCL is. And, you know, I think that the timing of things does make a difference. It is intoxicating to do these shorter things. But I think we've been really dogmatic about the indications. And let's be clear, UCL reconstruction of whatever form works best in your hands, be it docking or modified job or whatever, is still the gold standard. And the gold standard is the gold standard for a reason. And nobody should go away from that, especially in light of how intoxicating the repair can be. We all we almost ought to be more careful with that. But I do think that, you know, long time from now, when we look back at this, I don't think that the level of throwing or the or the quality of the throwing is going to make a difference. I think it's purely going to be a matter of the pathology and the biology. So that's just my love that I'm going to have these important aspects. Right. We need to tip our hat and really, really put them into our algorithm. So when we looked at this athlete, we thought he had a significant amount of degenerative changes in the ligament. He had a significant undersurface tear, as you pointed out. So we decided we would do a reconstruction. You know, in terms of your post-op rehab milestones, I mean, these are some of the common, generally accepted milestones. Can you just comment on that? Completely agree. And I think in talking to Kevin Wilk, who's our kind of guru on this stuff around here, we've moved away from the throwing or we've kind of lengthened it a little bit. We used to try to throw at 16 weeks. You know, I think we're more in the five to six month range, 18 to 20 weeks now, maybe 24 weeks. We used to try to get out to 180 feet. Now we're just going to 120. I think most of the clubs are going a little shorter on their long tossing program. And I think that that was in response to some failures that we were seeing, you know, within that first 12 to 15 months. So I hopefully we're in the 12 to 14 month, you know, 15 month time frame with most of these guys. I think we've all seen some people get back in 10 to 11 months, but it's tough to promise that, especially at the higher levels. So I think the one thing I would add is, you know, we're really kind of pushing the throwing out a little bit more. I agree. I agree completely. Taking a longer time, allowing, knowing that it's individual, each athlete and this idea concept of kinetic chain, of course, vitally appropriate. So just to follow up here, his rehab progressed smoothly. He was just doing great. And then at eight months, I mean, he was like gum on my shoe. At eight months, he just developed this vague recurrent right elbow pain. And his examination here, same range of motion, flexor pronator seemed fine, ulnar nerve was fine. He felt stable. Imaging, it's really hard postoperatively, right? So we did an MR arthrogram here and it looked like it was intact. It looked like there was continuity, thickened tissue, but it looked like it was in continuity. We did a stress ultrasound and with stress, he was under that 1.5 millimeter or threshold. So we were feeling better about it. So what are your thoughts at this point? You know, some vague pain, doesn't, we can't, we can't find a, you know, it's structurally to have a source. Yeah, I would be begging the GM to trade this guy at this point and see if he could fix your problem anymore. But if that doesn't work, then, you know, I think you really have to look at mechanics. I mean, this guy is a three-time or four-time, you know, in your office with what clearly looks like a good UCL at this point, nothing bad. I think you really gotta look at what's causing this and go back to those building blocks. Yes, so we did, we looked at that and here you've got some player, I mean, the point is even at the most elite level with trainers working with them, I mean, there's still things that can happen, right? So his scapula was a little low, he had some core weakness, he was a little soft, then he was corkscrewing. And so we felt he had identifiable kinetic chain deficits. Do you have anything in the office that you use, any kind of technique that helps you when you're trying to impress the idea of kinetic chain on, you know, a thrower and or his or her family or coaches? Yeah, so I start with their legs, I see if they can do a single leg squat, I wanna know what their hip, you know, and core kind of strength is. I'll also look at, I wanna examine them without their shirt on, I wanna see what their scapula is doing, I wanna see how much control they have of their scapula. So really those two things, you know, and just overall physical conditioning, you know, is this somebody that has the body to throw as hard as they want to, or are we dealing with less than a full loaf of bread here? Right, exactly, and so we use single leg squat tests, which if you're gonna show it to them, you have to practice it so you do it well, but it is, I think, can be powerful when you're trying to at least show them that these young athletes that feel like they're really so well conditioned and they can't stand over their leg and their corkscrew and twisting, so I think that's an appropriate test. So he underwent a focused kinetic chain rehab, the throwing mechanics were really scrutinized, the symptoms resolved, and then finally he advanced to MLB. So how do you put the pieces of the puzzle here? Well, this is important, particularly in baseball, you should consider not opt for certain types of injuries that are stable and have a good blood supply, we can think about repair in the younger athlete, we can augment it, but follow-up continues for precise indications, but reconstruction does remain a standard of treatment and there's no difference, at least to this point, between modified job and docking, but we have to be really precise in terms of evaluating our outcomes. So that's our non-operative treatment and reconstruction, now Jeff is gonna teach us all he knows about repair. Hey Mike, let me ask you a question about that last little bit, in that guy also, the other thing I would say to him is, let's look at your conditioning program, I think you and I both see people that are doing too much in the weight room and that's putting their elbow at risk, how do you counsel people about that, in terms of not burning out their shoulder and putting their elbow at risk? Yeah, I mean, we really do have, we have to kind of back them off sometimes, right? They get very aggressive with what they're doing and an inherent imbalance that occurs, so I think we have to monitor them very, very closely to get them to where we think they need to be from an entire kinetic chain standpoint. Right. I think Meredith is gonna switch us now to the other slides. Got it. So while she's doing that, let me say that, through this process of this UCL repair stuff, how valuable Mike has been as a friend and colleague and that's the sign of good leadership. He was probably one of the first people that I went to when I had this idea and as a surgeon and friend that I respect in this elbow world, I can't thank him enough for the support that he's given me. We've had probably counting on 1,000 conversations about this over the last 10 years and he continues to be a great resource for me, so I appreciate it, Mike. I tell people when I give this talk that I am a consultant for Arthrex and I make about enough money on that that I could buy about 10% of the people on this call a cup of coffee, so thank you for listening. Let's see. Is it gonna let me advance? There we go. So my case starts with a 17-year-old high school junior javelin thrower with collegiate aspirations. Two-week history of medial elbow pain after a meet in March, so this is the spring competition when it's kind of the prime time of their deal. Felt pain with one throw. Didn't recall a pop. No neurovascular symptoms and pain with throwing since the episode, so he's not been able to return to throwing. Meredith, I don't really think I have control here. There we go. On inspection, he was pretty normal. No swelling. Range of motion was good. Good strength. Stability was normal, but he did have pain with a moving valgus and a milking test. Pain to palpation in the medial elbow near the sublime tubercle. No other real issues. His pain was definitely at the top of his motion and not at ball release, and these are his x-rays, which are pretty normal. Nothing really posteriorly, and so with that, Mike, what are we thinking about this? Where do you go with this at that point? What is in your differential? I mean, the way you're describing it is there's concern, obviously, about him from that ligament standpoint. These x-rays really look pretty clean, right? I mean, there's not much on them from a plain x-ray standpoint. He doesn't have a lot of the changes that would make us think. I mean, he's obviously a young person chronologically, and by x-ray imaging, he doesn't have some of the concerning osteophytes or traction spurs that we see that would make us think he has ligamentous deficiency. Right, exactly. So we went on to get an MRI and with intra-articular contrasts and arthrogram MRI, and you can see with the positive radiology sign here. What appears to be an otherwise pretty healthy ligament and some signal dyspnea, and people have called this a T sign. I'm not sure that I like that comment from radiologists because there are some normal variants, but what do you take on that and what do you look for? What are your thoughts on this, and in particular about the surrounding edema, and what do you think about that? So, I mean, when I look at that, I mean, obviously I have concern that there is some stripping of the ligament distally. As you said, I agree with you, the remaining part of the ligament looks actually very good. I mean, you might argue maybe there's a little of undersurface change approximately, but it looks like the injury is more distal and there's some periligamentous edema there too. So, and I know, again, as we've talked about that that's a relatively hypovascular area, so less likely to heal if we were to treat that non-operatively. Right on, and I think, you know, when we see that kind of halo around the outside of the ligament there, you know, sometimes we'll get radiology readings saying that the contrast is leaked out all around the ligament. I think that this represents more just edema. Like you said, periligamentous edema. You could almost think it's a deep flexor strain, you know, overlying the ligament to go along with that injury. Maybe those things go together. So, you know, non-surgical versus surgical, same discussion we had before with all the findings in a healthy 17-year-old who's in season. So where do we go? So let me ask you, on his exam, though, you did say he had a milking test, right? Milking positive moving valgus stress test. So we have a question here about which tests you think are the most beneficial, if you think milking, dynamic milking, and utilizing those tests. What are your options and your thoughts on those? I do find that dynamic milking tests and milking tests are helpful. I like to do it in a supine position where I feel like their scapula is stabilized and I can control a little bit better and I'm pure to their elbow, but your thoughts? Yeah, I think the dynamic milking test is a better test than the moving valgus stress test in terms of, you know, picking up the more subtle things. If somebody hurts when I stress them just at their side and valgus and just pull on their arm, that tends to be a little bigger of an injury to me. You know, those are, you're not really putting as much stress on it as you are with a milking maneuver. So I think if they hurt with that, you know, test at the side with the moving valgus test, that probably is, you know, a little bit higher level injury. But to go back to your question, to me, you know, we could certainly treat this non-operatively. He's a young thrower, we could treat it non-operatively or think of it, the rest of the ligament, it looks very good, but I have great concern about these distal tears, these avulsions, for the reasons we talked about, biomechanically more unstable and less vascular. So if he's a high level thrower, you know, I would be thinking about some of the surgical options. Yeah, I agree with you completely. And let's see if I can get that to advance. There we go. So we tried to rest him because he was in season and he was trying to get to the state meet. So six weeks of rest, Plyos, the whole interval throwing program, he actually returned and competed at the state invitational in late June and he was able to train to get back to that point. So now we're three months later. We did not do a biologic on him because it was distal, because we didn't feel like the success rate with that was great, but we wanted him to be able to get back for this because this is what he wanted, was to be able to compete in this meet. And so he got back, but again, he had a re-injury. He was fine before it, then this time he felt the pop. So same exam with the addition of some neurologic findings. He had the ulnar neuritis that lasted about a week after the pop and a little bit more fullness in his forearm. So now where are we? I'm thinking at this point, you tried him on a non-operative course. He has a lesion that's less likely to heal anyway, non-operatively. I think you're, if he wants to get back to where he was before, then I think you're obligated to think about surgical treatment. And he's fitting into this, the very precise indications you've defined for consideration of repair with augmentation. He repeated his MRI because I wanted to make sure that he didn't have another, an injury at a different location along the ligament. I was pretty convinced that he was gonna have a ligament problem, but I wanted to make sure he didn't have two ligament problems, more or less, and that he didn't have any bone edema or anything else that I could hang this on. So this was his second MRI, which I'm sure you'll agree, pretty much the same distal tear. He probably did heal it down a little bit, get some scar around it, and then he clearly pulled it back off. So any thoughts on that? Nothing really different for me. No, no, no, I agree with you, yep. So again, I think you're right, and this is what we found. So this is without any dissection here on the left, and I'm gonna, I don't know if you can see my cursor, but this is a bare sublime tubercle. There's no ligament attachment to that area right there. And you can see into the joint, normally the joint is very conforming. This is a fairly unstable situation. But good, healthy tissue. You can see within the forcep there that the thickness of the ligament tissue itself is very good, and there's no real tissue deficiency. So we went ahead and did the UCL repair with the internal brace, and that's the picture at the end. We felt like his tissue quality and quantity was good enough to warrant that, and so that was the final result there. And he went back and this past year was able to compete prior to COVID, so he was doing well as of six weeks ago. So just historically, repairs, they didn't come around recently, nor would did them a long time ago, but so did Frank Jobe, and Dr. Jobe and Dr. Andrews being two of the real pioneers of this stuff, they both tried to do repairs, and that goes back to 1970s with Dr. Jobe. And John Conway, our friend in Texas, was his fellow at the time and wrote these up, and this was published in 92. But what gets lost in this publication is the 14 repairs that were part of that group of 70. And the reason that everybody went to reconstruction rightfully was that 75% of the Major League players in this article got back to the Major League level, whereas only two, or 30%, 29% of the repairs did. Now, keep in mind that that was in the age of not great technology. We didn't have some of the technology that we have now. Azar and Andrews published on a second group, again, the same results, less than 30% returned to the same or higher level. So on the basis of these two world-class surgeons, UCL Repair was kind of banned, and rightfully so. And remember, these guys were and still are some of the best. So along with Mike Ciccotti, I also have to give Buddy Sabwa a lot of credit. Buddy published two articles that really, I have to say, went largely unnoticed, even though they were published in our trade journal back in the mid-2000s. The first one in female athletes. Now, this is in 2006, so this is with more modern anchor and suture technology and a lot more experience, 20 to 30 years worth of experience with UCL surgery. And these people were getting back in three months. Not much attention to that, and these weren't really overhead throwers, so he redid the study in 60 overhead athletes, mostly male high school and college baseball players, and 93% of them, good to excellent, 58 out of 60, back to the same or higher level of play in six months. But again, not many people paid much attention to this. And so there were poorer outcomes in the overhead athletes with return to play rates as low as 30% in revisions. So revision surgery has been kind of a problem, and we thought maybe this would be another place for the repair. At the major league level, revisions can take a year and a half plus. This is almost 21 months. That's a year and nine months from surgery with really not great outcomes. Revision UCL surgery, Mike, I don't know about you, but that's one of the least gratifying operations I do, and I never feel good about telling the person they should expect to get back. What are your thoughts on that? Well, I agree with you completely, and this is perhaps one area where what you're describing may have a real indication here, because straightforward revisions are just poor outcomes. Or so, like the one that we showed before in the case, cases like this on the left may be good candidates for that, whereas the ones on the right with the beat up ligament and the bone spur, those are not good candidates. And so this is just a quick video of doing it. We use approach through the posterior side, so we elevate the muscle belly rather than splitting it. We're protecting the ulnar nerve after we find the medial anabrachial cutaneous nerve, so you can see the ulnar nerve there. We elevate the muscle belly off without detaching it, and then we split the ligament from the sublime tubercle up to the medial epicondyle. So we always start on the sublime. There's the ligament there. We're gonna split starting on the apex of the sublime tubercle and go proximally. It's important not to go posterior here. If you tend to follow that linear edge where the tendon started, where you took the tendon off, you'll end up posterior. So here's another one of these big distal detachments, and plenty of good tissue there. There's nothing wrong with the quality of the ligament. So we're gonna drill the first tunnel. The anchor one always goes in on the side of the injury. So in this case, it's a distal injury. The anchor goes in with this tape and a super suture through the islet. We advance this 3.5 millimeter anchor, and then we're gonna use that suture to basically do what Buddy did, which is repair down the flaps of that ligament tear. So that's basically doing what Buddy did, which was just a simple anchor repair. So now we've repaired the tear down, and that's what we're gonna see here in a sec. We're gonna repair that tear back and then close up the split before we drill the second hole. So we're passing it through the anterior leaflet, and then we'll pass it through the posterior leaflet. And you can tell I'm protecting the nerve there very carefully, making sure we don't damage the nerve. For some reason, the video's stopped. There we go. There it goes. You're very careful, I can tell, about the position of the nerve, though. Gotta be careful with the nerve. I think that's key, especially with this approach, with any approach. I mean, the nerve just has to be protected. So we close up the split, and then we're gonna drill the second tunnel. And as Mike said, a lot of the determinant of the function of a graft or this repair is gonna be based on where the humeral tunnel is placed. The humeral tunnel is clearly more important. You have less room for error on the humeral side. So you gotta be on that anterior face. You can't be distal. So once we find the spot we wanna go, we're gonna drill, we're gonna stay in the column, make sure that we're not on the distal tip. We're more anterior. You can kinda see we're more on the anterior face. I think it's better to be a little bit towards the joint than a little bit towards the tip. I think it's a little more forgiving to be a little bit in the ligament or just deep to it, rather than being way outside of it. This is an oversized tap. And then we put the second anchor in. And I'm purposely gonna put this in a little tight on this video just to show you. So when we put it in and it's too tight, the tape is gonna constrict the ligament and you're not gonna be able to flex the arm up without it pulling the anchor out. So this should not happen. We gotta redo that and pull the anchor back out and repass it. So we're gonna give ourselves a little more length. The benchmark that I typically use is I start at the second or third thread and see what happens. And now the tape is not constricting the underlying ligament and I can advance that anchor in there without increasing the tension. And so it's important to check this and make sure that there's not too much tension and it doesn't restrict motion at all. There should be no restriction to motion and no indentation of the ligament by the tape. That would be a sign that we put it in too tight. So that's the one caution I have is make sure you check this to make sure that it's not too tight. So with the recent success, we underwent a clinical study. We looked up 128 of these that we did through December of 16. We've now done about 400 of these and there's been a couple thousand of them done around the country. We lost 17 of them but we followed up about 87%. Most of them males and all in the dominant arm. Mean age about 18. So these are all mostly high school and college throwers. Baseball represented the vast majority. Two thirds of them were high school. The rest of them were collegiate except for middle school or recreational and pro. So these are lower on the age scale and it's important to know when we talk about KJOC scores what the norms are. And I'm gonna tell you to pay particular attention to the history of upper extremity injury and the professional pitcher one. So we looked at our follow up at 87%. We had 92% return to play at the same or higher level with their KJOC scores being 86 at 12 months and 91 at 24 months. And an average return time of between six and seven months post-op. So we were coming close to the norms of people that were throwing at the highest level and only about a six to seven month recovery time. So we looked at whether or not anything else in there made a difference. Did ulnar nerve transposition make a difference? It did not. Whether we transposed it or not. We transposed all of them in the big study we did with UCL Reconstruction. And I was doing that in the beginning and then I went away from it. Now I've kind of gone back to it. I've been transposing more of them lately. I think I've had a few that I wish I had done. So I've never had a patient I wished I had not transposed but I've had several that I wish I had. So I've kind of gone back to transposing them. Proximal versus distal, no real difference there. There were four tears of both but it didn't seem to matter. Partial versus complete, again, P value, no difference statistically. So no difference in outcome whether that was proximal or distal, partial or complete and whether or not we did a nerve transposition. Keep in mind this is only 100 or so patients. So this is patient number two. This was a gymnast. So she had a lateral and medial injury. I had to fix the lateral one. It was in her joint. Her whole lateral side was in her joint and I decided to do the internal brace. This was six weeks post-op. Most of these guys are gonna get their motion back pretty quick. They don't have, they don't tend to be as uncomfortable. And for a throwing program, we wanna start them throwing in week 11 if they can, if they've achieved their range of motion and done their plyos. And so the average return time for baseball is just over six months. For the other sports, it's been a little bit less. On revisions, I've revised five or six of these. Most of them had a modified job. One had a docking. I have used a little bit bigger anchor to accommodate for the bone loss from the previous drill tunnels with the grafts. Three of them have returned. Mike, what's your thought on this? I mean, you and I both share the idea that revision of these things is just not fun and I'm gonna show you a case here in a minute, but you said before, you just don't like doing them. I can't stand that operation. Yeah. Well, I mean, it's a challenging procedure, no doubt. And at least what we have to this point, the data suggests a really low rate return, 30 plus percent that really return, return to prior level for a sustained period of time. So we haven't hit the nail on the head with our traditional techniques. That's why I'm saying this might be an area where perhaps augmenting with an internal brace is helpful, but there's so much there. Are the tunnels in the right spot? Are there any, what's the harbor that was there before? The graft itself, maybe we need to excise the tissue that's there, leaving too much tissue. Do we use a hamstring graft? I mean, there are all kinds of questions that we just haven't figured out yet that make this not a reliable procedure. No doubt. So this was a recent revision. I did this one last fall, a 39-year-old major leaguer with a bunch of time. He'd had a UCL reconstruction with Modified Job in 2011, and he threw seven seasons through two free agent contracts. So this guy's well paid. He was 39 and he pitched through the summer, but he had pain and he wasn't able to complete the 19th season. And this is his MRI that was sent to me. And I think, Mike, I think we both looked at this. I think a bunch of us looked at this one. And what do you see? Tell us what you see in terms of what we see with these revisions and re-tears and things. Yeah, I mean, so you can look at, at least distally, you see that there might be some ossification that's occurred distally. The tissue itself is incredibly thickened, right? So, and it looks like it's detached, at least in several of the cuts, approximately, and what's left is this amorphous, degenerative type mass that really doesn't probably give any substantive support. Right, and he had tried PRP to get back to compete, complete the season. That didn't work. He had a couple of different MRIs, but they just kept looking like this. So we went and revised him. And so I had to find his nerve, which is never a fun task. If you've had a nerve transposition, relocating and neuralizing that nerve is never fun. That took more time than doing the repair. But you can see that hole, and you can see just the detachment of all that tissue. And I want to point out how thick that tissue is. It's like having two ligaments there. He's got his native ligament, and then he's got his reconstruction there. And so tacking that back with that bigger anchor, and then the tape you can see on the right. So he is about six months post-op now, six to seven months. And with the revision, I kind of want to look at these guys at about nine months, not at seven. I'm having a hard time slowing this guy down. But so my thoughts in general are that, as with other ligamentous injuries, some of these things can be repaired. And that was really the genesis of this. And as I said, Mike and I talked about this along with a lot of other people going back a long way. I want to point out the tape is not a ligament replacement. It never should be the ligament. It should be there to support the healing, provide the biology with the collagen. But you got to be really careful not to over-constrain these things and really be picky. I think that the experienced UCL surgeon knows where this fits. And I really want Mike's comments on that because I think that's one of the most important things that you can get from these things is you got to do what works in your hands and what your training teaches you. So Mike, with that, I'll see what your thoughts are on that and then how important it is to have some experience to do these things. Jeff, excellent talk. And you've really been so methodical in defining this technique, doing appropriate biomechanical studies before you actually did it in anyone in the operating room, and then being meticulous in your follow-up and also figuring out where it fits into our armamentarium. And it's absolutely in the armamentarium that we have. So to your point, to your question, I think if you really look through the data that's available, whether you do a docking or some modification of it or a job modification of a job, there's data that's there, retrospective case series, designer series, and even some prospective data that shows that there's probably no statistically significant difference. So if you're confident in what you do and you do it the right way, you know that you're providing your athlete with a good surgical procedure. So I think you can do both and do them both well with great outcome. We have some great questions here, and I just wanna get your thoughts to go through the questions. Just going back to the idea of MRI, do you always use contrast, Jeff? What are your thoughts on that? I think MRIs are a mixed bag. So I always like to say that MRIs, number one, are not the window into the soul that everybody thinks they are. And there's a lot of components to the MRI. There's the technique, the thickness of the slice, the magnet, the person who's reading it. And so I think if you have Hollis Potter at HSS or a gifted musculoskeletal radiologist that just knows their stuff and they're used to looking at their MRIs, I don't think it matters. Whether you get contrast or not, you can go either way. But I think if you don't have that and you're dealing with a low-quality magnet or you're dealing with a brain radiologist, I think you're better off getting the contrast. So we order it when we can get it. If we're making the decision, we order it. I think on good-quality magnets, on a good 3T magnet with a good radiologist, you probably don't need it. But we do tend to order it because we don't always get those good ones. What are your thoughts? No, I agree with you completely. And I would say to you that it's putting the pieces of the puzzle together. What they tell you historically, their examination, the imaging studies are helpful, but we can't hang our hats on them. We have found that stress ultrasound helps us, particularly in these partial injuries, particularly in those that have failed non-operative treatment or a revision situation, but they're all pieces of a puzzle and you have to fit them together. And we do use contrast often, but we have radiologists that can read them whether there's contrast or not. So it's really, I think the person who's interpreting it with you is really important in their comfort level. For you aged fellows out there, you can tell Hollis I said that. Yeah, there was a question about physiologically youthful. We use that terminology. And I would say to you that the reason that that terminology is important to think about is that we can have a chronologically young athletes that have physiologically old UCLs, right, Jeff? I mean, they're just thrown from their youth, right? Yeah, I would think that your first case that you showed had a physiologically not youthful ligament. That's a young person. But how do you figure that out? And I would say to you that in that scenario, we're often dependent upon how we interpret our imaging studies. They give us some clues as to that physiologically older UCL, whether the plane x-rays that show the traction type of ossification or the MRIs or stress ultrasounds that show incompetent degenerative type ligament. No doubt, and I think it also means you've cut into a bunch of them, you know? I mean, you've cut into thousands of these things and so have I, and you know what it feels like and looks like. So again, I would tell all of the fellows on the call, you know, get off to a fast start of doing what works well in your hands and what you've been trained to do. Don't step out on a limb your first couple of times doing this. Make sure you know what you're doing before you change up what you're good at. Next great question was about hamstrings, hamstring graft. Do you prefer ipsilateral or contralateral if you're using a gracilis? I prefer contralateral for two reasons. First and foremost, because I don't want the fellow on my back when I'm doing the case, I want them on the other side of the table taking the graft. And second, because I think that they don't, are not as bothered by having it on their, by their front leg, their landing leg, as they are on their push-off leg. Their push-off leg is so vital to generating power that I, just in my experience, they're bothered by it less when they get back to baseball. How about you? What do you think? I agree. I think that's a great question. And there are a variety of people have looked at this. Brendan Erickson has done a variety of studies. He polled Major League Baseball team physicians and 75% chose the contralateral gracilis. He then did an EMG study looking at this and found that the contralateral gracilis was far less active during pitching than the drive leg or the gracilis on the drive leg or the ipsilateral leg. And yet, if you look at epidemiologic data in baseball, the contralateral hamstring is more likely to have an injury or pitcher's more likely to have an injury in his career in the contralateral leg. So if you're gonna take it from that leg, if they're more likely to get injured. So I think the data kind of is a little bit back and forth, but there's no question it's logistically easier in the OR. So our tendency is to take it contralateral. Yeah. Yeah. A couple of questions on the repair technique. So how do you judge if it's not too loose? How do you determine it's not too loose? So you're focused on not making it too tight. How are you sure it's not too loose? Well, if I put it in the first time, if I put the anchor two in and I dunk the driver into the tunnel and I flex it and then extend it and there's just too much slack in it, then I'll tighten it up. And I wanna be able to get through an entire range of motion without over constricting the ligament. I also, and I didn't show this in the video just for time sake, I always sew the tape, I whip stitch the tape down to the underlying ligament with two or three simple sutures just to make sure that it moves as a unit. So I do wanna make sure that it's tight enough. There's no point in having it in there if it's not gonna at least help out the native ligament. So I want it to be, I'm looking for what we showed in the video. I'm working on some ideas to see how I can make that a little more scientific, but I would say at this point, it's still a little artistic. Yeah, got it. A gestalt that you have. And then lastly, the question about using an internal brace with a reconstruction and is that just now, are you just thinking about it in terms of a revision situation or how about a primary reconstruction? What are your thoughts on that? So I think that George Paletta and John Conway and some of those guys have done more work on that than I have. I have done one of those at this point and I can't say I have enough data to say it's a good idea. And so basically I augmented a repair or a reconstruction with an anchor on both ends. Whether or not I think that that's valuable, it's more stuff in the tunnels. It does have some biology to it. Is it a conduit? Is it a carrier or a scaffold for biology? I think that John and George are probably gonna have some data on that for us hopefully this year. I think you and I just got invited to speak in New York and I think we're gonna hear some data on the hybrid techniques with that in New York. So I think that that's possible and not a bad idea. I think that there's gonna be more iterations of that coming out and we'll see what that does. But I don't have enough information to say it. What are your thoughts? No, I mean, I agree with you and I do think, I really do think that it's gonna have some benefit in a revision situation. Whether, if it's additive to a reconstruction, obviously the biomechanical aspects and biomechanical studies can be done and give us some, can substantiate that to some degree and they can be done. I'm not sure if that'll translate into a clinical significance on a primary, but in a revision, I really do right now think that it's gonna be helpful. I think it's gonna be helpful. Yeah, this is great. You know, Jeff, every time I talk with you, I learn a lot. So I appreciate this and I know this is helpful for so many people. So thank you for what you do, for educating me and for other people. So thank you on this. And I wanna say to you that I do think that the internal brace is like one of your greatest accomplishments. But I actually think Dread River Distillery might be even a little bit higher on that list. So there you go. So from Jeff and I, we wanna thank all of you for participating tonight. Thank you for your attention and your time and be sure to check in to our, with our next in the upcoming AOSSM webinar series. I just wanna say thanks, Mike, as chair of the fellowship committee. You know, this was something we wanted to do for the fellows across the country. And to have you, the incoming president, speak at this was a big deal. I know you got a lot going on right now and I appreciate the time and as always, the guidance and the teaching. So thanks for the time. And we will look forward to seeing everybody next week for the next one. Meredith, back over. Thank you, Dr. Ciccotti and Dugas. Thank you so much for presenting tonight's material. The fellows on the call tonight, you will receive an email from AOSSM Research asking for your participation in the AOSSM member-sponsored survey. And next week's webinar is on ACL outcomes update on MOON. Thank you again for participating. Thank you, Dr. Ciccotti and Dugas. Good night, all. See you guys. Bye.

UCL injuries

throwing athletes

UCL repair

UCL reconstruction

non-operative treatment

biologics

surgical techniques

internal brace

rehabilitation process

diagnosis

MRI usage