I want to welcome all of you to the first multi-institutional Sports Medicine Fellows Conference, and I want to thank you all for joining in. First thing first, I'd like if all of you, and I may end up having to say it during Jeff's presentation, to mute your audio so that everything comes across more clear and less feedback and less interruption. This is being recorded, and what we're going to do at the end of each week of these conferences, and these conferences are going to be Monday through Thursday, we're going to be putting them on to the AOSSM, and the following week they'll be available on the Learning Management System for the AOSSM if you and others in your program want to review the talks. Also, for questions, if you would go ahead and submit that using the chat button on the bottom to submit your questions on the chat, and then we'll be able to answer them at the end. It's my distinct honor to introduce our first speaker, who's a good friend and helped me put this together, Jeff Douglas from ASMI in Birmingham, Alabama. He's going to be talking about the technique that he's essentially perfected, introduced and perfected. How's that, Jeff? I'll start drinking now, I'll let you go ahead and talk. But thank you all for joining in, and I want to thank actually all the fellowship directors and members of the fellowship, who are really volunteering their time, because we know it's a difficult time for our fellows from an educational standpoint, and hopefully, this will help lessen the load of not having the opportunity to operate for a few weeks. So, I want to thank all the other faculty that are participating in this and making this available for the fellows. So, without further ado, Jeff, take it away, man. Well, thanks. I appreciate that, Mark. I appreciate the opportunity to do this, and I hope you all are staying safe. So, as always, there are disclosures. I am a consultant for Arthrex, and I receive a royalty on a kit that was created to support this technique. And with that royalty, I could probably buy all the people on this conference call a cup of coffee. So, I appreciate that. ASMI receives lots of support from lots of people. So, I think it's important to make sure we learn from history. And so, I'm a fan of history, and I always want to know how we got here. If you don't know how you got here, it's tough to move forward. And then, can everybody mute their line, please? Can everybody please mute their line? Shyam? Shyam? Or whoever is listening, Shyam, can you mute your line? We'll just say you get a bye. If you're very comfortable, if Matt can use it, if some other guys can use it, it's not the time to do your first case. I can't mute him, Jeff. I'm going to have to do that next time. Shyam, can you please mute your microphone, please? Go ahead, Jeff. Sorry. All right. Well, we're going to try to overtalk him then. Okay. So, we want to make sure we're not defining insanity here by trying to do the same thing and expecting a different result. Back in 1981, Lyle Norwood was one of the first to publish on UCL Repair, and he had two out of his four patients return to play at the same level. Everybody knows the Conway article, which is Frank Jobe's patients, which was published in JBS in 1992. This had 70 patients in it, and it covered a 13-year time span. What gets lost in historical recall of this article is that in that 70 patients, there were 14 repairs to bone out of the 70 and 56 reconstructions that we all know now as Tommy John surgery. And so, those 14 repairs didn't do as well. They did okay, good to excellent in 71, but only two out of the seven at the major league level got back to the same or higher level of play. So, pretty poor results at the highest level of baseball, whereas three-quarters of the reconstructions got back. So, on the basis of this, Dr. Jobe very wisely decided that he was going to stick with reconstruction as repair did not seem to do well. Now, keep in mind, remember, many of you guys that are listening to this weren't alive in 1974 when this was done. And the technology we had available to us in terms of anchors and sutures and certainly an understanding of the operation wasn't available. Dr. Andrews then looked at his group of patients and published on 91 patients with reconstruction or repair in 2000. These were done over the first 20 years of his career, and repair did not fare well at all either. Again, less than 30% of the repairs getting back to the same or higher level of play. So, on the basis of these two experiences of two world-class and to this day, two of the best elbow surgeons who ever lived, UCL repair was largely abandoned with good reason. The results just did not warrant continuing that. Well, that went on until Buddy Savoie kind of delved into some things back in the mid-2000s. Now, keep in mind, by the mid-2000s, we had anchors that were made out of things other than metal. Well, we had anchors at all. We didn't have those back in the 70s and 80s. Those didn't come around until the 90s. And then we had better anchors and better sutures, and we had a 20-year history, maybe a 30-year history with the operation. So, Buddy went back and just repaired in female athletes, softball, gymnasts, and tennis, and got 16 out of 17 back in under three months. That's a pretty skippy return. This was published in AJSM and went largely unnoticed. Most people, myself included, did not pay much attention to this. And so, he was encouraged to go back and do it in overhead athletes, which he did and published in 2008. He had 60 overhead athletes, most of them male, and had 58 out of 60 return to the same or higher level of play at an average of six months. This is very different than what we typically see with the reconstructions, but not necessarily in a better or worse level. But we're talking about a different operation here. And maybe we're talking about a different pathology here. So, Buddy, and I have to give Buddy a lot of credit in this process because the first person that I called when I had this idea was Buddy Savoie. And Buddy was very gracious about it. He had been doing this repair since 2008, and this was in 2012 timeframe when I started talking to him about it. And Buddy very graciously was helpful and encouraged me to keep going with this and do some basic science and keep going. So, I got to give a lot of credit to Buddy, and he and I have talked through this for almost 10 years now. So, with less than 200 cases before 2017, you know, the peer-reviewed literature basically didn't support the use of ulnar collateral ligament repair. There were generally poor outcomes compared to reconstruction, and so Buddy kind of changed the game. This went largely unnoticed, as I said. So, there was a renewed interest with newer technology and more experience in the operation. And so the question was, are we defining insanity? Are we redefining insanity with trying to do a UCL repair? Keep in mind that for my institution, you know, Lyle Kane and the rest of us published on over 1,200 reconstructions, all done with the modified Jobe technique, and ulnar nerve transposition was carried out in every patient. And the average return time in that group was nearly 12 months, but 84, 85% returned to play at the same or higher level with a low complication rate. So, this has kind of been the benchmark study that we've all looked at, because it was such a large number of patients and covered such a broad timeframe. This is 10 years ago. There have been a lot of techniques, and they're all good. I actually learned to do this operation from Dave Olchek at HSS back in the late 90s, and that's a great technique and works very well. There are hybrid techniques that have been developed. All of these have similar results and outcomes and are accepted as industry standards and can be used very successfully. And you should always do what works best in your hands. And so, you know, when you're asked how you do this or why you do this, you know, people will become very dogmatic about you should do this and you should do that. And I'm not a big fan of that. I think that you should do what works best in your hands and definitely take to heart what you've been taught and evaluate those things. And always guarantee the outcome as best you can. Don't take it because somebody else does well with something that you're going to. So revision UCL reconstruction has actually not been a very good operation. There are much poorer outcomes. Return to play rates as low as the 30s. And this may speak to the healing potential of trying to get a graft to heal in a bone tunnel the second time. The length of recovery that tends to be more of a 15 to 18 month recovery with a loss of velocity, stamina and control. So it's very rare for a starting pitcher at a high level to go back to being a starter after a revision. Stan Conti and company looked at this and has published on this repeatedly using the Major League Baseball data. Return to play average time was 21 months and 31 Major League pitchers. And only 42% were able to return for at least 10 games. This is significantly worse than what we see in primary UCL reconstruction, which is a really predictable and good operation. So the question becomes, is reconstruction necessary in all these people? And a lot of these kids that we see, the average age for youth welfare is in the late teens, mid to late teens. And so do all these people need a tendon graft or can we get by with a lesser operation? And this was the whole genesis of the idea. And so in some of these people, maybe we didn't need to be doing as big an operation with as long a recovery. So our question was, does UCL repair necessary in this population? So over the first 10 to 12 years of my career and after working with Dr. Andrews for so long, we'd cut into several thousand of these ligaments over time, over a 15 year period. And through that period, we really only had one answer. They were all reconstructed in some form. And so the question was, are we doing too much of an operation for some of what we were seeing? And could we do something different in these lower grade injuries or endovulsions? And then secondly, could revision reconstruction be improved by this technology as well? So this is the internal brace. And this is built by a guy named Gordon McKay, who is a foot and ankle surgeon from Scotland. And basically he took two 3.5 millimeter corkscrew peak anchors, put a collagen coated fiber tape between them. And we added the super suture zero fiber wire on the end of anchor one. So you see that coming off on the right side of the construct there. Then we did a cadaver study. So I wanted to make sure this was going to work in a cadaver before I tried it in a live human with a pulse. So we took this and did 10 match pair cadaver specimens and did some cadaver testing. I wanted to make sure I was on solid ground before I offered this to a patient. So we basically looked at this and at time zero, it turns out that the gap formation is at least as good as the reconstruction. It turned out better than the reconstruction, but that wasn't the point. And I've been very cautious not to say that as the outcome of the study. I wanted just to know that it was at least as good. If it was at least as good, then I felt good about offering it to a patient, and it was. Then we took it and looked at it and compared the two. This is kind of a graphic representation of the data you saw on the previous slide. But basically the repair very nicely recreated the normal condition, which is in blue. The green is the procedure. The left side of the screen is the reconstruction. The right side, the repair. So then we did a cyclic study. Chris Jones, one of our fellows a few years ago, went and looked at cyclic behavior. And basically this showed that at 500 cycles, the repair held up very nicely relative to the reconstruction. And so this is how we felt we could definitely rehab these guys a little quicker and push them a little harder. The construct of the internal brace is obviously very stable and very strong with the tape. And bone fixation on each end. So it is a strong construct. And that does allow us to push these guys a little quicker. So then the question became, well, who's a candidate? And so if you look at the slide on the left, the picture on the left, this is a 17-year-old thrower with clearly an end avulsion of what is otherwise good, healthy ligament tissue. That's about as normal appearing a ligament as you're going to see if it wasn't avulsed from the sublime tubercle. And that's very different than what you see in the right-hand slide, the right-hand photo, which is a gray crud that used to be ligament tissue. And this is just gelatinous looking stuff along with a big projecting osteophyte. This guy is not going to be a candidate. This is a 34-year-old thrower. This person is not going to be a good candidate for repair because the quality of that tissue is going to be so bad. And this person is going to have a big defect when you take that bone, that enthesophyte out on the sublime tubercle. So that person is very much going to have a tissue deficiency and need more tissue, whereas the one on the left, that's, to me, a very good candidate for repair. What about bone problems? You know, the one on the right, you see this, again, huge, almost touching enthesophyte coming from the sublime tubercle. When you take that off, there's going to be a huge hole. This person needs about as big a tendon graft as you can find to make them a new UCL. The one on the left, not so much. There's really no evidence of any real bone there. There might be a little calcification in there, but nothing that's going to be a real tissue deficiency when you cut into that ligament. So I think it's always important to look at x-rays with these things, and you get x-rays before you get MRIs. You can save yourself even a little bit of time by doing that. If you get the x-ray on the right, the word UCL repair probably does not need to come out of anybody's mouth. That's a bad idea, in my opinion. So this is a short video, about a four-minute video, and so we make the same incision. We use a posterior approach rather than a muscle-splitting approach. We find the antebrachial cutaneous nerve. We isolate the ulnar nerve. I went through a period where I was not transposing the nerve in all of these, and we'll talk about that in a minute. We elevate the muscle from the ligament, and so we're kind of coming in from the backside of the muscle layer rather than going through it. And so this is the ligament here from sublime tubercle on the left. We'll start with this cut. We'll go to the apex of the sublime, and we're going to go towards the medial epicondyle, being careful not to go posterior. I want to stay in the tissue of the ligament. This person has a distal tear. You can see this is all lifted off of the sublime tubercle. I shouldn't be able to see that bone there. There's actually a piece of bone that came off with it in the posterior. That's the posterior leaflet of the ligament. But this person clearly has a distal avulsion. So we're going to put our first anchor in right there at the apex of the sublime tubercle. You can see the anchor go in with the corkscrew anchor and the super suture in addition to the tape. So we're going to maintain the position of those two things and advance the anchor. So the anchor, first anchor is always put in on the side of the avulsion if we're dealing with an avulsion. And the anchor is put in all the way down, flush with the bone. And then we use the super suture to do what Buddy did. When Buddy Savoie did this, basically he put an anchor down there and just sewed it down with a suture. And so in talking to Buddy, I wanted to make sure I did this at least as well as what he did. So that's why I added the super suture. I was thinking initially of just doing the tape. And after talking to Buddy, I certainly didn't want to take any chances that what we were doing wasn't going to be at least as good as what he did. And so we took the suture on there and we did a repair on the side of the avulsion. Very careful to protect the ulnar nerve back there. And this zero fiber wire is placed through here. And we're going to tie that ligament back down to the bone. Now I did do a little bit of bone prep there before I tied it down just to make sure I had a bleeding surface. And then I'm going to sew up the split that I made in the ligament. So this is a zero tichron. This is a permanent suture using a size zero kind of ultra strong suture. And then as I get close to me of a condyle, I'm going to make sure that I still have access to it. And then I'm going to put the second anchor. It's important not to be too distal here. And Mike Ciccotti is going to talk about this tomorrow and some pearls for this operation. We want to make sure we're on the face of the medial epicondyle, not being way down distal and posterior. That's probably one of the big no-nos. And Mike's going to tell you more about that. We use a little bit of an oversized tap on the second hole because there's actually four limbs of fiber tape that's going to go into this. Then I take it and I advance it into the tunnel. And I purposely made this one a little short so I didn't size it right to show you that if it's too tight, you won't be able to flex the elbow up and that tape is going to indent the underlying ligament. So if that's the case, you want to pull this back out, which I'm going to do here. And I usually do that by pulling on the sutures and I'm going to advance it down and then reinsert it and check it again. And I want to make sure that I get that anchor down and make sure that I can flex the elbow up all the way and that it does not indent the underlying ligament. I usually start with about the second or third thread on the anchor at the origin of the tunnel or at the entrance to the tunnel. And I want to make sure there's no tension at all on that tape as I flex it. I don't want to capture the elbow. And so far that hasn't been a problem, but I think this is a really important check here is to make sure that that tape is never tighter than the underlying ligament. And I want to impart one piece of advice to you. Do not put this thing in too tight. It's a really strong construct. So now I've got the second anchor in and now I'm going to sew that down with a couple of super sutures just to sew it to the underlying ligament. That's important because I don't want the tape to windshield wiper over the underlying ligament in the event that it's not isometric. So we're going to come back to that video I just showed you there. That's five months post-op from the alpha patient. So with the recent success by Buddy and then the basic science study we did, that patient you just saw had his surgery on August 8th, 2013. And we did a follow-up study on 128 of them done through December of 2016. We've now done nearly 400 of these in Birmingham, and it's estimated over 2,500 have been done worldwide to date. This is an Arthrex estimate. It seems to be growing. We lost 17 of the 128 to follow-up, making our follow-up study available for 111 or 87% follow-up, with mostly 96%. The average age was 18 and a quarter, so these are mostly high school and college age kids. They were all dominant arms, and this was only in throwers that we were reporting on. So these were baseball, softball, javelin, and football throwers. All the football kids were quarterbacks. And it's important to know that the level of play, as you would expect, would be younger. Again, these were indicated because the quality of the tissue dictated it. So two-thirds of these kids were high school, and most of the rest of them were college. There was one pro, or a couple of recreational athletes, and a middle school kid. Before we talk about scores and outcome scores, it's important to get a scale of what we're dealing with here. So Jamie Franz, who was one of our fellows a few years ago, did this study when he was in residency, looking at KJOC scores and reported norms. The normal Major League Baseball player that's healthy has a KJOC score of 97. This is somebody that's never been injured, never had surgery. Healthy minor leaguer, about the same, about 97. The average professional pitcher, however, is only 91. And if you had a history of an upper extremity injury, it was 86 1⁄2. If you'd had surgery, it was 75. So those are important numbers to remember when we get to looking at KJOC scores. So at our 87% follow-up at 12 months, all 111 of them attempted to return to play, and 92% were able to return to play at the same or higher level. So this was very similar to Buddy's data. The KJOC score after 12 months was 86. So just to remind you, that was the same as the people where they had an upper extremity injury and greater than by 10 points of the people that had had surgery. And at 24 months, their score was 91, which is more commensurate with somebody that had never been injured. And so the throwing athletes rated their elbows at almost 96 at 12 months, and the average return time was about 6 1⁄2 months. So this was considerably different than what we see with reconstruction. But again, it's a different patient population overall. These people have less pathology. It's also important to look at what other things, what other factors could have influenced the outcome. So we looked at ulnar nerve transposition. We did ulnar nerve transpositions in all 1,200 and something of those we published in 2010. And as I started doing this, I started making smaller incisions and thinking maybe I didn't need to transpose the nerve. Transposition of the nerve made no difference in the outcome. The p-value was 0.3. I was transposing, I was not transposing many of them, but I've gone back to transposing a lot of them because I've had to go back and transpose about nine or 10 of them. And I think that's because of the approach that we use. Because we do a posterior approach, we are exposing the nerve, and that probably leads to some scarring around the nerve in some patients. And I think that's why I've had to go back and transpose those people. So I've gone to transposing all of them at this point and haven't had to go back and had any problems with that, no longstanding neuropathies. And so the question becomes, you know, why don't you go to a muscle splitting approach? Well, number one, I don't do the muscle splitting approach. And that's, so this is what works best in my hands. And number two, I haven't had any reason to think, gosh, I wish I didn't transpose that nerve. So we transpose all of them. That's just the way we do it here. People that are very successful doing the docking technique and doing a muscle split should stick with that, because that's what works best in their hands. And there's nothing wrong with that whatsoever. And that's my advice there, and that's why I'm doing it the way we're doing it, because that's what works best in my hands. So I have had several that I wish I had transposed. So I've never had a patient I wished I had not transposed, but several I wish I had. What about proximal and distal? That didn't make a difference either. The P value is 0.7, so no difference in proximal and distal. There were four tears with both proximal and distal components, but there wasn't enough N to compare. But it was about the same. Partial and complete, again, did not make a difference. The P values were high, and there was no difference in those. So basically, there was no difference in the outcome, whether we did a nerve transposition or not, whether it was proximal or distal, or whether it was partial or complete, the outcomes were basically similar. There were no major complications. I did have to remove a retained subcuticular stitch, and that person went back to competition in about three months after the second operation, 10 months after the first operation. We had to remove heterotopic bone from one athlete on multiple occasions, and I'll come back to that one in a second. I had to go back and do an ulnar nerve transposition in two. One of the people, this is just in the early part of the study that I did not transpose, and I'm sorry, two of those that I had not transposed, I had to go back and transpose. And then one, I had to do a revision as he ruptured his sling that held the nerve in place. They all returned to play. I had one high school pitcher who underwent a UCL repair after his ninth grade season and then played his next couple of years. And in April of his senior year, he re-tore it. He re-tore through the whole thing, the ligament and the brace. But his original injury was distal. His second injury, his revision injury, was proximal at the medial epicondyle, which is where most re-tears occur. He declined revision surgery and was not planning to continue to play baseball in college, and he has not decided to have it fixed to my knowledge. And he was asymptomatic when I had seen him a few months after that. What about revision to reconstruction? The one player that had HO, we did two resections of his heterotopic ossification, including radiation therapy, and he re-grew it a third time. And I talked to Chris Ahmad up in New York about him. This is a kid who plays in the mid-Atlantic region in a D1 college. And he actually pitched a season after the first HO excision. He pitched a whole season, but continued to have some motion loss. So he came back, and we did it again, and he was unable to get back and took a red shirt. And so we, Chris and I talked about it. I wanted Chris's opinion, and our opinion between the two of us was that he should be revised to a reconstruction. And he elected to do that. So we'll come back to him in a second. As a general rule, the patient's post-op course is pretty uncomplicated. They get their range of motion back pretty quickly. This is actually the second patient that I did. She was a gymnast and had an elbow dislocation, and I had to fix her lateral side. As you can see there, she had disrupted the whole lateral side and required surgery was flipped up into her joint. So I did the medial side as well with the internal brace. This was about four and a half months post-op, and she was getting ready to go back to tumbling as a gymnast. So she achieved full range of motion by six weeks. We're doing plyos. Our normal post-op protocol, you start doing plyos after week six. We do two weeks of two-handed plyos followed by two weeks of one-handed plyos, and we generally initiate a throwing program or a weight-bearing program for tumblers and gymnasts and grapplers after week 10, start of week 11. And the average return time to get back to baseball was just over six months. Tumbling was a little left. So this is our alpha patient again. This is my good friend now who I've gotten to know pretty well. He's now a fireman. He pitched two years of junior college. He was a senior in high school coming up after his summer where he tore it in June of 13. He rested eight weeks, and we talked about a PRP or repair to quit. He was a pitcher only. He elected to go with this after a long talk with he and his mom about, you know, the fact that we hadn't done this before. This was definitely new, and this video was taken on January 11, 2014. So just over the five-month period post-op, and I tell people when I got this video from the athletic trainers, they're about two and a half hours south of here, I about threw up. I thought they were trying to crush my idea by having this kid thrown as hard as he was. Off of a mound, you can see there, five, not even, barely over five months post-op. And they told me, they said that we just can't hold him back. And he went on and pitched and won nine games his senior year and got a junior college deal to pitch. Super good dude, and I've enjoyed continuing to follow him along. So limitations of these things, obviously, this is largely collegiate and high school kids. George Palletta did the first major league guy, Seth Maness, in June of 2016. Seth returned to competition in March of 17 at the minor league level and then made it back to major league baseball in May of 17 at 11 months. So far, we've done 10 major league baseball players, not all of them pitchers, but people who have made it to the major league level. Lots of people that pitched in the College World Series and in college, but obviously, there's no control group to go with this relative to our known experience with UCL Reconstruction. In our other group of patients at that point where we followed this one up, there were eight gymnasts and 12 cheerleaders from the same time frame. Those people tended to return a little bit earlier, so did wrestlers and some other athletes with other needs. Volleyball, I think, is a little bit tougher than some of these other ones, and maybe I would hold them until the six-month time frame. Tennis, again, maybe a little bit longer. But the grappling sports and tumbling sports, they tend to get back a little quicker. What about revisions? I've revised five prior UCL Reconstruction using this technique. Four out of five had to modify a joe and one had a docking. They all tore at the medial pecundal or origin. I used a larger anchor on the medial pecundal for all these guys. Three of them have returned to play at the same or higher level. Two of them are in the process, one of them at the major league level. And so there's a lot of interest in this right now because revision UCL is such a not great operation. So there seems to be a lot of interest in this. One of my recent revisions, this is one of the major league guys, is a 39-year-old who was playing last season. He had his UCL Reconstructed in 11 and pitched seven seasons since then, got a free agent deal and signed a free agent contract twice, actually. He had the onset of symptoms in the summer of 19 and couldn't complete the season. And you can see here, you know, he's got this obvious avulsion of this large mass of tissue. I don't know if you can see my cursor there, but this is typically what you see with a re-tear of a reconstruction. So there's this big gap up here and this, the thickness of this tissue is the combination of his normal ligament, his native ligament, and his graft. So this is going to be a large piece of tissue in there. So I had to find his nerve. He had had his nerve transposed before, so I had to find his nerve. And then you can see in the center, this big hole. I split the ligament and you can tell that there's just a giant hole right there where all that tissue used to be attached to the bone. So we abraded his bone and got a really good, thick repair of all that tissue back to bone and then added the tape, as you can see there on the right-hand side. And so we did the internal brace repair for this revision. Lots of reasons for that, and we'll be talking about that next couple of weeks when Mike and I, Mike Ciccotti and I talk about this together. So my thoughts are that as with other ligamentous injuries in the body, end avulsions can be repaired back to bone and partial thickness tears can be augmented. The addition of the ultra-strong tape and good anchor technology and a lot of experience with the ligament help us. It's important to know this is not a ligament replacement. The tape will not likely hold up to what we're going to put it through if we think of this as the ligament. This is a ligament augmentation and a repair. It is not a ligament replacement. It may be a better option for revision than reconstruction, as we know that reconstruction has not been a great operation in those settings. And I don't know if the tape is just structural or if it's simply a scaffold for healing, but it should never be the primary restraint. We can talk about ulnar nerve transposition, but as I said, I've gone back to doing most of those. People have asked about my opinion about revising somebody that's had a repair, and I can only tell you what Chris's experience was because he did that kid that had DHO. I have not had the opportunity to revise one that has had a repair before, and neither have any of my partners here in Birmingham, and Dr. Andrews has not as well. But what Chris said and what I would expect is, number one, there's less bone loss. These are plastic anchors, so there's no reaction, and I would encourage you not to use absorbable anchors in these settings. So there's no soft tissue in the tunnels. It's just plastic, easy to drill through. I call that fellow proof. It's tough to screw it up. You can drill through it. You can remove it. It's fellow proof. So you should have good bone stock to work with. That way you can create good tunnels for doing a revision to a reconstruction. In talking to Chris, he said it was a very easy revision because of that, because there was no bone loss, and he also said that he saw the tape and the internal brace were intact. I think this kid had an underlying, obviously, a bone metabolic thing that we didn't get ahead of early enough, and his revision has actually gone quite well. He was pitching earlier this year before the cessation of the season due to the coronavirus without any problems and had regained his motion. So the revision actually worked great, and he's doing quite well. So I have cautious optimism in patients with partial thickness injuries and end avulsions. I would not likely use this technique in somebody with a nutritional rupture and poor quality tissue. A tissue deficiency demands more collagen. They need more tissue. They need a graft. I have, however, been talked in doing a few of those patients recently within the last 12 months because of a necessity of a shorter recovery. Basically, people coming to me saying, I want it repaired. I understand it might not work, but I can't go through a reconstruction. Again, I don't have time for that, or I don't have time to go through a reconstruction at all, or I'll miss my opportunity. So people understanding the risk of having not great tissue with this. I have to say, stay tuned on that. I'm not expecting that to work as well in these people, and I should be getting some of those people back to some answers on that this summer. And now we're moving into higher levels of sports, and obviously there'll be more outcomes to follow. So I've been very cautious not to say that this fits a specific level of athlete. This is definitely more about the level of pathology that we see. And I also will say that UCL reconstruction is a very predictable, very reliable, very reproducible, excellent operation in my hands and the hands of others that do this. And we continue to use that operation. This is another option for people that have a certain level of pathology. So with that, I'm going to tell you, since we are in a crisis, how do you help out in a crisis? So if you don't know, I own a distillery here in Birmingham. You can follow us at DreadRiverCo. It's DreadRiver.com and DreadRiverCo on the social media. This is our hand sanitizer that we started making. Our people pivoted very nicely a few weeks ago and started making hand sanitizer out of the stuff we would normally throw away every week. And we're giving that away to healthcare workers and frontline people and ambulance companies and, you know, nursing homes and the homeless and everybody else. So interestingly, this batch here smelled a little bit like tequila. So with that said, I will say thank you, and I appreciate the time and the opportunity to speak to you guys. I hope you're all staying safe, and we'll take some questions. So we'll take some questions. You guys, it's great. If you can actually type your questions on the chat, and I'll keep everybody muted so that we don't have problems with reverberation and being able to talk over noise. And while we're doing that, Jeff, you know, you had said you want good quality tissue. You don't want chronic damage tissue. You've got, and usually it's, again, it's off either the sublime tubercle or off the medial epicondyle, but, you know, you look at the studies looking at MRIs of high school pitchers, and they all have change within their ligament. How is it that you decide it's too much intrasubstance change or not enough? You know, I'm not a fan of making the decision to operate on these things based solely on the MRI. I think MRIs can be very misleading. I think the quality of the MRIs we see are anything from strip mall MRIs to really good MRIs. So, I think you have to incorporate the history, the physical exam, and the imaging. I'm a fan of dynamic ultrasound in some of these people to see if there's instability. Most of the people that we're thinking about doing repairs on don't have dynamic instability unless they have a true end of vulsion like the MRI that I showed, and even that person might have a millimeter, millimeter and a half of increased opening. In the gymnasts and things, the people that really tear these things in two you're going to see a little bit more. So, I think that with the, you know, the interstitial signal that you see, a lot of that is typically proximal or mid-substance. I like non-surgical management for that until you just can't go any further. I like PRP, especially if it's proximal, you know, mid-substance. Not as good for distal, but I really want to make sure that these people have rested, and rest to me means absolutely shutting it down for six to eight weeks, no activity that's going to put stress on that ligament. I don't mind putting them in a brace if I think they're not going to follow instructions, and then getting them back through some plyos for a couple of weeks and then a throwing program. So, even that is going to be a three-plus-month, you know, return with a strain or something like that, a grade two strain is going to take a few months. If somebody fails that, then I'll consider doing a repair if they're, if they failed, you know, that kind of thing, and I really believe they've taken the time to do the non-surgical stuff. So, here's a question for you from Joe Cooper. It says, how often, thanks Dr. Dukas, how often do you plan a repair based on the MRI and then pivot to reconstruction interoperably based on what you see? So, you plan to go in to do the internal brace and then you decide that it's not going to work and you switch to a reconstruction. Have you had to do that, and how often? Yes, I have, and honestly, more frequently I've gone that direction than the other direction. So, when I have somebody that I'm even considering doing a repair, we consent them for both operations every time, unless the person has said absolutely I don't want a reconstruction. I've had other people say I don't want a repair, and then we only consent them for one. But normally, we're consenting them for both if we're discussing a repair. And I think our most recent numbers is we're about 92% accurate on our prediction of being able to do a repair when we've thought that was the better option based on the imaging and the history. So about 8% of the time, about one in 12, we're gonna have to do a reconstruction. And, you know, we have prepared them for that possibility. And that speaks to the fact that the MRI is not the window into the soul that we'd all like to think that it is. And you have to make that decision at the time of surgery. We have been very dogmatic about making sure people understand we are making that decision based on what we see and feel. Great question, Joe. So Will Workman out here has a question that actually is something that I've encountered as well. He said he struggles a little bit with getting the second anchor started. I'm assuming he means the medial epicondyle anchor. Says he seems to need to re-tap, re-do, and just is there any technical tips? And with that, I would put in the direction of drilling to put in that anchor as well for your, you know, any tips with regard to, you know, making sure people aren't blown out the back but in all realities when I'm trying to get at, especially if they're not moving the nerve. Yeah, for sure. So I think tunnel position on the humerus is probably the most important technical aspect of this operation that determines outcome. And I think a lot of us that work in the UCL world believe that failures more often than not occur in the operating room with the primary and over the next, you know, six or eight weeks, the graft doesn't heal. It's not isometric or even close and you get a non-healing graft or something along the biology is not very good there and you have a problem. So I think that that humeral tunnel, and there've been several studies that have shown this in different ways. The humeral tunnel is less forgiving than the ulnar tunnel. And the most unforgiving position on that is to be distal and posterior. Mike Ciccotti is gonna talk about that and you're gonna hear me say how much I agree with that. So I think having a good trajectory and having a good plan for the humeral tunnel, I put my index finger, I almost create a guide between my thumb or the drill guide and my index finger. There are guides that are available. I think there are a couple of companies that make a drill guide for this, but I like the idea of making sure that the humeral tunnel and I'm very kind of back and forth. I wanna look at it a couple of different ways and make sure I've got it in the right plane before I drill that tunnel. When I'm doing a proximal repair, the humeral tunnel gets drilled first. When I'm doing a distal repair, the distal tunnel gets drilled first. But whichever side is the second anchor has more tape going in and out of the tunnel because there's two limbs going in and there's two limbs coming back out. So in the kit that we have, there are two taps to do this because of that. The first tap is the same as what's tapped on the first side. The second tap is a little bit larger and I can find out what the number on that tap is, but I believe it's a millimeter bigger or a half a millimeter bigger or something like that than the first tap. It's not a full millimeter, it's like half a millimeter. But that's really important to start in that second one, especially in people with really hard bone. I've had to re-tap those things. I've broken the anchors in the second tunnel. I've had all those same things. And again, the good news about that is these are plastic anchors, so you can always drill through them. But I do sympathize with that. I went through all those things and having that second tap definitely makes a big difference. So I encourage you to either make a second tap or get one that's a little bit oversized from the first one. Okay, here's a question. Jeff, how do you counsel the patients? This procedure in insured rehab, really, the baseball players telling them that it's gonna be a year or whatever for the reconstruction and this is something earlier. It can be very, as was stated here, Dr. Sakati says, truly intoxicating. So how do you navigate those who come in and are really just adamant about wanting the repair but may not be a true candidate? I think we have to be as honest as we can be about that. I feel the same way. I can get intoxicated by seeing how well this goes. And I've been tempted to do some repairs in tissue that you get in there and you think, okay, well, it's not the best tissue, but it's not the worst tissue. You know what? I think that if it's not good tissue, do the gold standard. I really, I sleep well at night because I have really stuck to those principles and not expanded it. You know, I know that we're probably gonna expand it and people are gonna expand it, but I just didn't feel like I could be the person to do that early on in this process. And obviously I've done a bunch of these and did a bunch of these before I even did this technique. So when you've seen thousands of these things, you know what good tissue looks like and what it doesn't. If you're not sure, the safe thing to do is to reconstruct it. That is the gold standard still and should be, you know, it has a right to be the gold standard. So I think that I would counsel people not to take chances with something that doesn't have the proven track record if you're not comfortable that you're doing it for all the right indications. Certainly we know that reconstruction works well. So I think it's, there's no question, it's easy to get to get swayed by that. You know, we took a slow approach to this and I think that helped. So here's actually on the anchor issue, actually, Dr. Roth says, when you said you'd use a 4-5 anchor for UCL reconstructions that you revise with the repair, do you mean a 4-5 anchor from both sides of the brace or just the side you repair? Thanks, Dr. Durbin. That's a great question. Hey, Travis. No, I'm just using it on the humeral side because all the revisions have been off the humerus. So I don't have the issue on the distal side, on the sublime tubercle side, or I haven't. Now, I wouldn't mind using a bigger anchor, but I haven't felt like we needed that. And, you know, the other thing is, so I'm just using that 4-5 anchor on the humeral side because that's the side that has all the bone issues from the previous tunnels. And look, I don't think that a 4-5 anchor, I've ever had a problem with it holding well. It's not like the bone is destroyed from the previous surgery, but there is soft tissue in there. And so we are asking, you know, for a little bit of an issue. We are asking that bone to hold an anchor. And so a little bit bigger anchor, I don't think hurts anything. When I first got into this, Arthrex actually thought that the 4-5 anchor was what we had to use. They didn't actually think we could do it with the 3-5 because they didn't think we could get the fiber tapes through it and make it work. I went down there and I showed them, I thought we could do this with a certain size tap and things. So I actually had to kind of talk them into the 3-5s. I like the 3-5s. I think they hold perfectly well in the kind of bone we're dealing with. The other thing I'll say is that John Conway, another fantastic elbow surgeon, has kind of gone to doing a hybrid along with doing a reconstruction. He adds the internal brace on top of it in some cases and moves the tunnel distal on the ulna. And I think that that's perfectly okay, whether it's at the apex of the sublime tubercle or distal to it, as long as it's in line with the fibers, it should be fine. And if you look at some studies on the insertion of the UCL, some of those fibers go several centimeters down the ulna along that ridge. So I don't think there's any problems with being distal. I would caution you not to be too close to the articular surface. So I would say apex of the sublime or distal. And so in somebody that's had a reconstruction, you could always go distal to the previous tunnel. Okay. Here's one from a guy named Bob. He says, thank you, Dr. Douglas. At what degree of flexion do you fix the second side of the internal brace? Well, thanks, Bob. That's a good question. We tend to do it at about 10 to 15 degrees of flexion. So almost extension, you know, 15, 20, something like that. I think that with this technique as with reconstruction, again, the humeral tunnel is going to dictate your isometry and the graft behavior more than anything. And so I know George Palletta does them in more flexion. Dr. Andrews taught me to do them. And I think Dr. Olchek does them this way, do them in a little bit more extension. You know, I think it's a little bit easier to get flexion back than it is to get extension back if you're not isometric. But that's the way we've done them here for my 20 years in Birmingham. So probably about 15 to 20 degrees of flexion. But again, I'm checking the tension on that thing throughout. Okay, so I'm waiting to see any more questions. If there's some more out there, please chat them to me. But let me ask, you know, your progression, Jeff. So, you know, what are you doing now as far as when do you let them start to do their light toss? When do you let them start to throw on flat versus mound? And when do you let them start to bat, both, you know, controlled and then against live pitching? So we get through the first six weeks in a brace. So we make them use a hinged elbow brace for the first six weeks. They're in it 24 hours a day, except for bathing and doing what their therapist tells them. We send them to therapy starting somewhere between days three and day five. I think it'd be okay to wait another couple of days if you had to, but we're usually in the first week at least. And then we start them on range of motion exercises. So my goal is for them to have a full range of motion by the end of week six. And I'm usually seeing them back either in person or by video, Skype or something like that at the end of week six, because I need to know that they have full motion. And so if they do, then we'll progress on to the next phase, which is the plyometric part of it. If they don't have full motion, I'm not letting them move on. So this is a very tiered rehab and they've got to get through the first part of it before I'm gonna let them go to the second part. So if they're good at the end of week six, I'm assuming their tissue is healed down to the bone and the tape is still intact. And so it's protecting them and now we can push them a little bit. So we're gonna start a two-handed plyometric program, 50% stress on each hand. And over two weeks, we're gradually gonna move to one side, the affected side. So we've effectively gone from a two-handed plyo to a one-handed plyo over a two-week period. And we're gonna do that from multiple angles, passing back and forth a medicine ball or something like that. And then we're gonna do one-handed plyos for two weeks. So that'll be increasing in stress as well from bouncing balls on walls and trampolines and dribbling and things. And towards the end of it, they're throwing them off a trampoline, which is very much more mimicking the throwing motion. So then I wanna hear from them again and make sure they're not having any problems. I don't necessarily need to see them at the end of week 10, but I want them to call the office or text me or something and let me know that they're still feeling okay before I give them the okay to start the throwing program. So then we start the throwing program and the hitting program if they're a position player. We start those at the same time. We tell them to go six days a week, Monday, Wednesday, and Friday throwing, Tuesday, Thursday, Saturday hitting, and they take Sunday off. If they're a pitcher only, I'll tell them to throw Monday, Wednesday, Friday, and they can keep going. They can go every other day. So they can go Monday, Wednesday, Friday, Sunday, Tuesday, Thursday, Saturday, and so on. If they're a position player, they gotta do the others and take a day off. I also caution them not to do any other upper body lifting during the throwing period. So the only thing I want them doing is their bands, their throwers 10 exercises with their bands. And I want them to do that after they throw. I want them to do it after they throw because I do not want them to throw with a fatigued shoulder. That's one of the deaths to a throwing arm and one of the big injury risks to an elbow. So I want their shoulder to be in good shape every time they pick up a ball. So I tell them do not do any other upper body lifting, no bench press, military, deadlift, power clean, none of that stuff. Only do your bands, do it after you throw. And that way you give yourself the most time between fatigue and the next time you pick up a ball. I also tell them, make sure they throw to a target. Every throw, throw to a target because rebuilding that muscle memory of throwing is important. And I tell them to maintain the arc under the ball. So I'm not throwing moon balls, but I'm also not throwing balls on a line. I want there to be a gentle arc under the ball. We're just playing catch. And that arc stays the same all the way out throughout the throwing program in the first phase, which is the long tossing part. Once they get past phase one, again, I want to talk to them then because that's when they get on the mound portion of the program, that's phase two. And then I want to make sure they're not having any problems after phase one. Once they get through that, they go to phase two, which is the mound part of the throwing. And the only change I make in that is once they get past 75 throws on the mound, I want to spread them out to three days of rest in between throwing sessions. Great. And is there any other, are you drinking some of that whiskey right there? I would never. Any other questions from the fellows that, that was a great presentation, Jeff. I'm looking forward to see the flip side of the coin tomorrow with Mike Ciccotti, that'll be the big lead into when you guys actually have your true debate. Well, I want to say that Mike's a great friend and obviously he's a great leader. Mike is another person that has been a great resource for me and a supporter of me through this process. And Mike and I have talked about this a lot. So I'm sure he's heard me say this before, but I have the utmost respect for him. He's a good friend and I appreciate his support through this process. Actually, I'm sorry, there's another question in here from Tim Wang, who's here at Stanford. He says, hi, Jeff, thanks for a great talk. How much of the improvement do you think is the repair itself versus the internal brace, as well as your thoughts on the effect on ligament remodeling over time? I think that basically we are repairing a ligament that no different than any other ligament in the body that we are repairing, whether it's an MCL in the knee or a glenohumeral ligament in the shoulder or anything. We're repairing a ligament back to bone and ligament to bone healing is very reliable and reproducible and easy to get the normal body mechanics back to the way they were intended to be. So I really think this is an indication thing. And that's why I keep harping on the idea that the tissue quality is so important. If you're dealing with good ligament tissue, really this should be as successful as any other ligament repair in the body. And that seems to be the case, but it's so important to know what that ligament tissue is and what the quality is. So I think ligament remodeling is important. I do think that the tape serves as a scaffold as well as a delivery mechanism. We're using a collagen dip tape, which obviously in Europe, a lot of the European countries won't allow that, but we're using a porcine collagen dip tape, which I think also delivers some biology there. And so is it possible that that plays a role? Is it possible that the tape is providing a scaffold and that early rehab makes a difference in the vasculature of that tissue becomes a little bit better than without it? Those are all great questions that I hope somebody smarter than me will figure out. But I do think that the general gist of this is that if we're repairing good tissue back to where it came from, we're recreating the normal biomechanics as opposed to substituting with it with a graft. I always say to patients, if we're putting it back the way God made it, that's a lot better than substituting for it. So it's only possible if you have good tissue. So that's just my way of looking at it. Okay, excuse me, one last question here. Weller versus Pappy, what's your go-to? Weller, 100%. So I'll give you a little lesson on bourbon since I have the floor. I'll do a brief two-minute bourbon lesson. So I didn't know a lot of this, just so you know. I was not a bourbon connoisseur until the last couple of years. So Weller and Pappy's, Buffalo Trace is the manufacturer. They're the parent company over all these distilleries. They have about 20 or 25 distilleries and they're all really good. Eagle Rare and Blanton's and all these other really good bourbons. And so they make three products. They make three liquids. Mashbill One, the Mashbill One is a low rye bourbon. Mashbill Two, which is the high rye bourbon. And then we did Mashbill. And so of their 25 or 20 or 25 different lines that are all different companies that they've purchased over time, they use those three and they go into different barrels in different places and become the different spirits. Only two of them are used the weeded Mashbill and that's Pappy and Weller. Those are the only two that use the third Mashbill. And so those products are manufactured on the same stills. They go into the same barrels, get loaded on the same trucks, go to the same warehouse. And the only difference between them is Pappy's aged on the fourth floor and Weller is aged on the third floor. And obviously they age them for different lengths of time, but those are the only differences between them. And quite honestly, and I've got some of both and had both, I am a giant Weller fan. I think what they make, and when we started our distillery, that's what I told them I want. When they asked me what I wanted it to be like, I told them, if you make me something close to the Weller Special Reserve, we've home run this thing. And that's what I wanted. So I am a huge Weller fan. There you go. Well, I will say the Dread River is quite, having tasted, it's outstanding. So I think you're, I'm not the connoisseur, but to my simple tastes, it's two thumbs up. I agree. Until I'm about halfway in the bottle, then I can't get my thumbs up anymore. Oh, that's too funny. All right. Well, thank you guys. I appreciate the opportunity and I look forward to tomorrow night. That's right on time. Thanks, Jeff. We look forward to everybody for tomorrow. I'm sorry if there was any audio-visual linkage issues. So trying to work my way through this and get a bit more savvy. So, but thanks, Jeff. And thanks everybody for participating and look forward to Michael Ciccotti from Philadelphia tomorrow, giving his ulnar collateral ligament reconstruction counterpoint. So thank you all very much. Bye.

UCL repair

sports medicine

ligament

internal brace

cadaver studies

surgical technique

patient outcome

tissue quality

ligament remodeling