So, I want to thank everybody for joining us for the second Multi-Institutional Sports Medicine Fellows Conference Lecture. Again, please keep your microphones muted. I have that ability to help today, so that'll be good so that there's no ambient noise that'll interrupt Dr. Sakati. Again, this is being recorded, and the lectures will be transferred to the ASM Learning Management System, and so the one from yesterday and from today will go to the ASM, and the ASM will have it available for re-review starting next week. As far as questions, if you have questions, submit them on the chat. More than very much would I like to encourage the fellows to ask questions, as this is for you guys. Also, for the faculty of the different fellowships that want to participate and add to the conversation and even make comments or questions, I'm happy to unmute you. Just let me know, and I'll unmute you to ask questions. I muted Michael Sakati yesterday because it was beyond my technological capabilities, but I've grown since yesterday, and so I'll be able to get you guys involved. So we're very fortunate today for I have Michael Sakati, who's the Chief of Sports Medicine, Director of Sports Medicine Fellowship and Research at the Rauffman Institute, and the Medical Director of the Philadelphia Phillies. I've known Michael for quite a long time. He's always been a tremendous role model, and he's got some other perspectives on the collateral ligament injury management, and so he's going to talk about the Pearls and Pitfalls in 2020. So I will have Dr. Jeff Dougas, who helped me with this whole program, is going to help also moderate and give some perspectives. So without further ado, Dr. Sakati, take it away. Well, thank you, Mark. It's absolutely an honor and a pleasure to be part of this great program that you've created here, and I'd like to start first by saying that I hope that everyone and your families are okay during this absolutely challenging time, but this will end, and we will get through this, and there will be sports again, and to that point, it's important that we continue to do these types of things, that we collaborate with each other, we do research with each other, we learn from each other, and this program, and I applaud you, Mark, for creating such a great program for all of our fellows, types of things that we're doing in our own space for education, the webinars that AOSSM has created, all of them are testimony to the fact that there are a lot of people out there who care greatly about your education. When I say that, I mean our fellows' education. So Mark, again, I applaud you for putting this together. Last night, Jeff Dugas started us off with an outstanding talk on UCL repair. I had to pay Mark Safran a lot of money to follow up so I could have the last word on this topic. So it's my task to talk about ulnar collateral ligament reconstruction in the throwing athlete, pearls and pitfalls, and how we might compare it to UCL repair. So these are my disclosures, none of which have any direct conflict with this talk. 25-year-old professional pitcher with chronic right medial elbow pain, now some functional disability. A 20-year-old javelin thrower with progressive right elbow pain and stiffness. A 17-year-old high school pitcher with acute abrupt right medial elbow pain. What do they all have in common? Well, they all have some type of injury to the ulnar collateral ligament. And that injury occurs, and so then the next question is, what are the treatment options that we have? Specifically, what are the operative treatments that we have? We heard last night, again, an outstanding talk by Jeff Dugas, and he outlined this very new and trendy, sexy repair. And my task is to talk to us about the traditional and longstanding reconstruction technique. Well, the early data strongly supported reconstruction over repair, as Jeff indicated, and the majority of studies, particularly the studies that have looked at clinical outcome, have focused on that, on reconstruction techniques. And yet, there absolutely is more recent data that suggests that repair is a viable alternative. And so, we have new techniques, we have new, sexy, trendy repair, we have the traditional reconstruction, and both of them have certain things that we continue to understand as being important in how we treat these types of athletes. And so, my job, then, is to focus on the reconstruction side. And we all know that in the beginning, there was Tommy John. And with Tommy John and Frank Jobe's original procedure, where he lifted off the entire flexor pronator mass and exposed the entire medial peccondyle, and in drilling, the direction he drilled his tunnels, had to transpose the ulnar nerve, there was a significant amount of morbidity that was associated with that for the athletes. And so, Lou Yochum modified that by splitting the flexor pronator mass in two areas and changing the directions of the medial peccondyle tunnels, not having to transpose the ulnar nerve, and even Jimmy Andrews' modification of just shifting anteriorly the flexor pronator mass, not lifting it off in its entirety. And Dave Olchek, making smaller tunnels in the proximal tunnels in the medial peccondyle, and passing the graft in a docking-type fashion. And there are alternative procedures, a variety of them, that have been proposed. But there is no doubt that, by far, the two most commonly performed procedures for reconstruction are the modified figure of eight and the docking. So we'll focus on those two. What are our surgical indications for reconstruction? Well, clinically high-grade injury in a thrower, MRI evidence of a high-grade tear with significant degenerative changes throughout the ligament, so poor-quality ligament with a larger serratia being recorded. We've done a significant amount of research with stress ultrasound, and that has helped us unquestionably. So high-grade tears on stress ultrasound, with over two millimeters difference from stressed to unstressed in the injured elbow, or a millimeter to a millimeter and a half of difference in the deltas from the injured to the uninjured elbow. Even in a non-throwing athlete, a recreational athlete that has symptoms with daily activities that are unresponsive to non-operative treatment. And that has allowed us to develop an algorithm that really directs our treatment for the spectrum of UCL injuries that we see. Well, the surgical approach is the same for these reconstructions. Splitting the flexor proteator mass at the junction of the middle and the posterior thirds, and right underneath it is the ulnar collateral ligament, exposing that ligament, then splitting the ligament in line with its fibers, and valgusing the joint just to confirm the instability. And then we choose our graft. Palmeris longus certainly was the initial graft used, but gracilis hamstring is another very popular graft option, but there are a variety of other grafts. One, two, three, is not available. In terms of the modified figure of eight, well, drilled two 3.5 millimeter tunnels in the ulna, one anterior and one posterior to the sublime tubercle. Then a 4.5 millimeter tunnel in the distal aspect of the medial epicondyle. Then splitting the flexor proteator mass and drilling two 3.5 millimeter tunnels with a one centimeter bridge that creates a Y configuration, and then passing the graft through. Pretty straightforward. The docking technique, well, it's exactly the same on the ulnar side, two 3.5 millimeter tunnels, anterior and posterior to sublime tubercle. The same 4.5 humeral tunnel, a smaller split in the flexor proteator, two smaller tunnels, two millimeter tunnels, and then docking the graft in and tying it over a bone bridge. Again, seems pretty straightforward, but actually if you step back from those two procedures, there are nuances that are important for us to understand. What I would like to do is to take the next few minutes and go through some of the pearls that we have utilized that we think have helped us to be more consistent with this procedure and our outcomes more reliable. We're going to walk through 10 pearls of UCL reconstruction. The first one, don't make me nervous. Don't make me nervous. Well, the medial antebrachial cutaneous is the first nerve that we identified. It lies directly on the flexor pronator fascia, and it most often runs with the adjacent vein, and we'll pass a vessel loop through it. We'll identify it and protect it through the case. It's not infrequent that it may be right over the area that we want to split the flexor pronator mass, so we'll be careful and cautious with it. Most often, it's one main nerve. There may be branches that we have to protect as well. We'll try not to do any harm to it. Injury to that nerve does cause dysathesia or loss of sensation along the posterior medial aspect of the forearm, and though it doesn't interfere directly with function, it is certainly an annoyance to these athletes. But the ulnar nerve, that's the nerve, of course, that we're most focused on. We know that it's in the cubital tunnel, and it's adjacent, directly adjacent to the posterior aspect of the sublime, so the sublime tubercle. So here, the sublime tubercle and the perineural fat can often be seen very close and several millimeters from where we're going to drill our tunnels. Current research has indicated that there may be increased return to play, particularly in overhead athletes, when the ulnar nerve is not transposed, and a variety of authors have identified that, and yet we heard an excellent lecture last night from Jeff Douglas about transposing it. Jimmy Andrews routinely transposes it, so that can certainly be done, but if it is done, there has to be care taken in terms of preserving the vascularity of the nerve, making sure there are no areas of compression on the nerve, and the standard treatment is some type of stabilization of fascial sling, either over the nerve or in the subcutaneous tissue, to maintain that nerve in a subcutaneous position. Okay, split, don't lift, split, don't lift. Well, the original Jobe figure of eight lifted off the entire flexor pronator mass, and there's no doubt that that made the anatomy much more easily seen. The tunnels could be drilled, you could see anterior, posterior, you could identify where the ulnar nerve was. So, in many ways, the surgical technique was easier in that fashion, but there absolutely was morbidity associated with it to the athlete. And so, Leocum's modification with splitting the flexor pronator mass, unquestionably though, it makes the procedure technically more challenging, because visualization is limited by those splits, or Jimmy and Jeff's modification where they shifted anteriorly, those procedures are technically more challenging, because you can't see the whole medial epicondyle, but there is certainly less morbidity to the athlete, as you see here, just splitting it. And the current research indicates increased return to play, particularly in the overhead athlete if you split or gently lift and not detach the entire flexor pronator mass. Appreciate the sublime, appreciate the sublime. So the sublime tubercle has a variety of morphologies, it can be peaked, it can be rounded, it can be flat. And we drill our tunnels anterior and posterior to the sublime tubercle, five to seven millimeters from the articular edge. And there are several good anatomic studies that have shown a broad base of insertion along the sublime tubercle that can run a centimeter to a centimeter and a half. And so, exactly the distance from the articular surface may not be as important as the distance between those tunnels. One centimeter bridge, maintaining those tunnels anterior and posterior to the sublime tubercle and maintaining and protecting that bony bridge. And if the bridge fractures, then we have several options, a transosseous button can be utilized, a biocomposite interference screw. So here in this video, we've already drilled the, this is a commercially available guide that can be used, the sublime tubercle is the right elbow. We've already drilled the anterior tunnel and holding it in place, and now the posterior tunnel. And you can see here, they're anterior and posterior to the sublime tubercle. You can use a towel clip, either a small or medium-sized towel clip and or ring curettes to soften the curve, to create a smooth transition for the graft to glide through. All this, making it easier down the road for the graft to slide through these tunnels. But it's important always to protect that bridge when we do this part of the procedure. Find the right spot up top. Find the right spot up top. Arguably, this may be the most important of all the pearls. So studies have suggested that there may be an isometric-like spot that is predictable, midway between the base and the tip of the epicondyle, the base and the tip of the epicondyle. Just anterior to the edge, okay, that dividing line between anterior and posterior surface with a 30-degree angulation. Dr. Samad has done a good amount of work with CT-based studies looking at this position. You can use a suture. You can pass a suture through the ulnar tunnel and also use that as confirmation of that isometric-like spot. So here in this video, again, a right elbow, midway between the base of the epicondyle and the tip, just along the anterior surface. And we'll mark that with a bovie, as you see here. And then we've passed an ethabond through our ulnar tunnel, and then we'll just place it on that spot, and we'll range it back and forth. This takes 20 seconds, 30 seconds. And the large majority of the time, it is spot-on, it's reproducible, but sometimes it may be a little bit anterior or posterior, and we'll shift it accordingly. Drilling this tunnel is very important. We feel for the intermuscular septum. That's a line that we would focus on. And we're feeling where the cubital tunnel is, the anterior and the posterior aspects. This is a commercially available drill guide that has a stop on it. But you can use a 4.5 drill. You have to be sensitive, though, to that far cortex. You do not want to violate that far cortex. Show me the ridge. So show me the ridge. Show me the supracondylar ridge. So exposing the supracondylar ridge is important. Splitting the junction of the anterior and the middle thirds of the flexor pronator mass, and then exposing it for the tunnels. So making proximal lateral tunnel first, or drill hole first. This is the more challenging tunnel or drill hole to make because of the soft tissue mass. Often these athletes are larger, their upper extremities have a lot of musculature, so it's harder to make that tunnel. So we make that tunnel first, but that allows us then to make our second tunnel and maintain a one centimeter bone bridge. And we can shift that around the corner as well. This video shows us with a figure of eight. So we have a forceps in the 4.5 tunnel. Again, this is a right elbow. My finger is on the position of the ulnar nerve. And I'm drilling that more proximal lateral drill hole. And as soon as that tickles the forceps, then I can help soften that with a towel clip and or a small curved curette, again, to help the graft to pass through more easily. And then if I need to, in order to maintain a one centimeter bridge, if I need to elevate any of the flexor pronator, I can. And once again, feeling the position of the ulnar nerve, that cortex there. And as soon as it tickles the forceps, then I know I've met that tunnel. And then again, with a towel clip and with curettes, just gently softening that tunnel so that we can have our graft pass through more easily. How about with the docking? Well, this is a commercially available guide, but one that is reproducible in that the drill point is just three millimeters beyond the tip of this guide. It's placed in the 4.5 millimeter tunnel. It helps you to assess where you need to split the flexor pronator mass proximally. And you can expose that part of the suprachondrular ridge. And then once you've adequately exposed that area, then you drill your tunnels. As you see here, again, this has a stop on it. You can use a small two millimeter drill or a burr. And then you can see that there's a one centimeter bridge that's maintained between them. The wrist or the knee? The wrist or the knee, where will we go? Well, Frank Jobe first described palmaris longus, and that was the original graph that was utilized. And there was certainly convenience on the ipsilateral side to use that graph. But as we know, upwards of 20% of patients may not have a palmaris longus. And in some cases, it may actually be diminutive. Optimal graph width is between four and six millimeters. And so because of that, the chrysalis has absolutely increased in popularity. It's always present at the knee. It though often is larger than that optimal four to six millimeter width, and so it requires us to trim it. That can make it a challenge as we pull the graph through, particularly in a modified figure of eight, where it can fret and fray, and we can find it challenging to pull it through. Overstuffing can be a concern with a larger graph. Heterotopic ossification has been noted, and Jeff Dubious and his group have published on that as well. And there's a debate over whether we use ipsilateral or contralateral chrysalis graph. Brandon Erickson did a poll of Major League Baseball team physicians and found that over three quarters use the contralateral chrysalis as their graph source, and has also done EMG studies that have identified less or lower hamstring activity in the contralateral leg. And yet, we know from an epidemiologic standpoint that the ipsilateral leg in a thrower is more likely to have a hamstring injury than the contralateral leg. So there is debate over whether we use ipsilateral or contralateral chrysalis. Can it be too short or can it be too long? Can the graph be too short or too long? Well, yes, it can. And if we think about the modified Jobe procedure, the standard graph length is between 15 and 18 centimeters. Well, if the graph is too short and it's a palmaris, you need to harvest another graph. You have to harvest a chrysalis. You can suture the graph end to the adjacent graph length, or actually convert to a docking procedure. So rather than having the graph pass through a figure of eight, if the graph is too small, you've already drilled 3.5 tunnels, but you can nearly suture, like in a docking technique, if the graft is too short, the sutures will come out through the 3.5 tunnels and you tie it over that bridge. If the graft's too long for a modified job, well, you just pull the graft through into the adjacent tunnel and you suture it to itself. Again, if it's a gracilis, it's hard to pull through sometimes, and so you can also alternatively just cut off the excess and re-suture it. Well, how about if we're doing a docking procedure, eight to 10 centimeters of graft is required, unless you're using multiple limbs with a docking procedure. If the graft is too short in a docking procedure, well, you have to harvest an alternative graft. If the graft is too long, though, the UCL reconstruction will be lax. So you measure the depth of the 4.5 millimeter humeral tunnel. It's usually somewhere between 10 and 15 millimeters, and you bottom out your first limb, pass the sutures through the first limb, pull them out proximally, you bottom out that, you lay the second limb over the elbow joint and apply a slight varus so the joint's reduced, and you mark where the graft passes over that 4.5 humeral tunnel, and then you add anywhere from seven to 10 millimeters, place your suture, remove the excess, and if it's still too long, well, then you have to remove the suture, re-measure, and re-suture. So it's important to really think about this concept, particularly in a docking procedure of how you might not have the graft be too long, and then your reconstruction is lax. Why not make the passing smooth? Why not make it easier to pass the graft? Well, a larger graft with sutures through it may bind as it passes through the ulnar and the humeral tunnels, and again, the optimal width is between four and six millimeters. So we can trim the gracilis graft, as already mentioned, that absolutely helps, and to do it meticulously, is important, particularly the leading edges of the graft. And additional techniques that may help passing the graft more smoothly, well, they include puretting, as I showed in the videos, the cancellous bone within those tunnels. We can trim excess tissue at the suture ends of the graft as we sequentially pull it through. That graft can fray, so we can remove any of that excess tissue, and you can use mineral oil on the leading edge of the graft as well. So which way will you fix me? What's the fixation technique that you'll use? Well, traditional fixation is with sutures, and that's our preference. Modified job, the graft is sutured to itself. The docking, the grafts are sutured over a bone bridge. The high-strength sutures can certainly be utilized, and yet there are alternative fixation devices that have been proposed, suture implants, and yet there's some concern with perhaps graft healing or coaptation of the graft to the bone surface with suture implants. Interference screws have been utilized as well, but reported post-operative fractures have occurred, particularly in the medial epicondyle. And then most recently, cortical button with Sal Frenjemoor and Mark Schickendance, just publishing in AJSM, using a cortical button distally, 30 degrees angled distally, 60 degrees posterior in order to avoid the posterior neurosseous nerve. So under or over with the native ligament? Under or over, which way do you place it? Well, the native UCL can be repaired actually either way. You can place it under the graft prior to graft fixation. This prevents graft abrasion on the ulna or the humerus, but it doesn't allow you to assess the joint reduction or how stable the joint is. You can suture it over the graft after you have fixed the graft, and that's our preference. This allows direct visualization of the joint while you're reducing it and while you're tensioning your UCL graft. This doesn't protect the graft from any potential abrasion, bony abrasion, but if you're careful with where you place that tunnel, midway between the base and the tip of the epicondyle, then an abrasion may be less of a concern. And then you close the flexor pronator splits. Okay, so those are our 10 pearls, but because this is a very special group, we're gonna throw in a bonus pearl. Don't forget the chain. The chain, how important is this chain, this concept that Ben Kibler and others have talked about? We cannot be myopic. We can't stay focused just on the elbow. We have to think of these athletes from the ground up, legs, hips, core, their scapula, the rest of their upper extremity. We have to do that, and we have to identify deficiencies and improve those deficiencies, doing it in a slow and steady fashion, and then that way we optimize their return. But what is the rehab after this procedure? This is just a very general protocol here you see, bracing them for four to six weeks, starting early range of motion, strengthening six weeks. From a baseball perspective, swinging a bat somewhere between three and four months, tossing maybe somewhere between four and six months. A pitcher may not get to the mound until six, so maybe upwards of 10 months. And for a position player, it can take 10 to 12 months to return. A pitcher can take a year or a year and a half, so it is not a short period of time, definitely longer than the rehab after a repair that Jeff outlined last night. But they go back to baseball, and what do they do? Well, they throw a ball. So short toss, long toss, mound programs, progressive tossing, 30 to 180 feet. We could debate how far. There are some throwing programs that go higher than that, two to 300 feet. But a position player is essentially done at that point, and then a pitcher goes to the mound. They do a mound program. Fastballs first with increasing effort, and then they add their off-speed pitches. But we focus on technique throughout. They also have to field. So grounders and fly balls directly to the player, and then full fielding of their position. And at the most elite levels, they can then progressively increase their exposure to competition, gradually increasing it, and then eventually return to play. The swing of bat too. So dry swings, hitting off a tee, gentle front toss, then live hitting, then batting practice, and then eventually return to play as well. Does the end justify the means with this very elaborate procedure that takes so long? Well, we looked at this in terms of the throwing athlete. We did a current concepts review on all the literature looking at the throwing athlete after UCL reconstruction. We looked at all the clinical studies that documented outcome after the various Jobe figure of eight procedures, the original Jobe through the modifications. We looked at all the studies that have outlined the clinical outcome after docking procedures, the original docking and modifications of the docking with extra limbs. We looked at all the outcome studies after alternative techniques. We reviewed the three systematic reviews that are out there, and we looked at all the biomechanical studies. And if you put that information together and you sift through it, the current research on UCL reconstruction indicates good results anywhere from 63 to 95%. But if you look at the more recent procedures, those results after reconstruction are much higher, 80 to 90% range. 10% complications with ulnar neuropathy by far the most common. And those studies indicate increased return to play in the throwing athlete. If you split the flexor pronator mass, you don't detach it completely. Either you split it like Lou Yoakam has suggested or like Jimmy Andrews, gently lifting it up, but not detaching it. And if there's minimal handling of the ulnar nerve. But there's really no optimal UCL reconstruction technique that has been identified. Absolutely, the modified figure of eight in the docking are the most commonly used in the world. And the systematic reviews suggest that docking has a lower complication rate and an increased return to play, but that is not statistically significant. And previously there's been no comparison studies of these two techniques. We'll then enter Justin Arner and Jim Bradley with a very important study. The first real direct comparison of these two techniques for reconstruction, the modified job and the docking. 51 patients undergoing UCL reconstruction, 25 modified job, 26 docking, single surgeon, minimum two year followup with appropriate metrics, a variety of graph sources. And they found no statistically significant differences between those two techniques with respect to their scoring metrics at a minimum of two years. And no differences with need for future surgery. The palmaris longus graphs had slightly higher CAGEOC scores than the gracilis graphs. But this wasn't a prospective randomized study. It's really two sequential case cohorts. And it's not randomized with multiple graph sources, but a very important comparison study on these two techniques. Because before this point or to that point, the majority of clinical studies or virtually all the clinical studies were designer series or disciples of designer series. So beginning to compare them is important. And that's what prompted us to carry out our prospective randomized comparison of these two techniques. So we're in the midst of a prospective evaluation, 80 throwing athletes with UCL tears diagnosed by history exam, MR arthrogram, stress ultrasound, single surgeon, randomized to modify figure of eight or docking, the same graft in all patients, the same postoperative rehabilitation program in all patients. And the followup you see here with exam, appropriate scoring scales, return to play milestones, patient reported outcomes, throwing metrics, following them up to five years with MR and stress ultrasound at a year and two years. So to this point, we have 73 athletes currently enrolled, 27 with two year followup, 46 with one year, 96% return to play with no complications. And we have found no statistically significant difference in any of the followup metrics, return to play milestones or any of the imaging. And the only difference is that docking has a significantly shorter tourniquet time. But we do need to continue this followup. The point being though, that if you compare these two techniques, there really seems to be no statistically significant difference. So whatever technique you are most comfortable with, you know that you're providing that athlete with optimal care. Okay, so there we go. There's what we know about reconstruction. What about repair? Well, in comes repair, this very novel, trendy procedure that we heard about last night from Jeff Dugas with an internal brace, this collagen coated enhanced tape that allows for a much more aggressive rehab protocol and an earlier return to play than traditional UCL reconstruction. Well, is it sort of like when we find something that we've never seen before and we say, wow, that looks pretty cool. Let's check that out. Well, if we step out of that and we really look more closely at it, their evidence is really compelling. They've done an outstanding job with this in terms of their research. So from a biomechanical standpoint, we heard this last night, match pairs of cadaver arms with cyclic valgus rotational torque to the native UCL, the surgically torn UCL, and then either surgically treat it with repair and internal brace or the modified JOBE, no statistically significant differences, yet resistance to gapping was greater in the repair than the reconstruction. And the UCL repair with internal brace replicated the time zero failure strength and the UCL repair with internal brace was more resistant to gapping at low cyclic loads. But the authors are very specific to say in cases of acute proximal or distal insertion injuries or impartial fitness injuries. Others have looked at this biomechanically as well. So at MedStar in Georgetown and Inova, match cadaver elbows with no statistically significant differences identified between repair with internal brace and the docking procedure. And then out at Curlin and JOBE, researchers looking at cadaver elbows, finding that the UCL repair with internal brace restored valgus and rotational stability and the docking with slightly higher load to failure strengths and the repair in the internal brace. On the clinical side, they've followed their biomechanical studies up beautifully as well. And again, Jeff outlined this, 111 patients undergoing repair with internal brace. Their indications of vulsion injury with otherwise healthy tissue. Minimum two-year follow-up with appropriate metrics, 92% returning at six to seven months, six to seven months. And yet it is a case cohort study, no controls or comparison group. And their early results are with phone surveys. But the point is that looking at this biomechanically, looking at it clinically is vitally important. And the authors are so precise to say that the indications are a complete or partial avulsion of the UCL from either the sublime, tubercle or the medial epicondyle without evidence of poor tissue quality in between. So essentially a healthy ligament that has a localized area of injury, a localized site. So repair, reconstruction, reconstruction techniques are important. They both have aspects that we need to tip our hat to. And so what have we learned from all this? Well, the 25-year-old professional pitcher, the 20-year-old javelin thrower, the 17-year-old high school pitcher, they all have some type of injury to the ulnar collateral ligament. But how we treat them is going to be specific to who they are, where they are in their career and the type of injury that they have. The options we know, reconstruction, repair. Well, the debate is not really 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 really need to continue to do focused research to be granular with this, to really define precisely where they fit into that algorithm. So for us, we reconstruct it. If it's a high level throwing athlete that has degenerative changes throughout the UCL, that's physiologically an older athlete, older UCL that is, they may be chronologically young, but they may have a lot of mileage on their UCL. Or a non-thrower or recreational athlete that's failed non-operative treatment. And this may very well be a larger percentage of UCL tears overall. But we'll consider repairing it if it's a high level thrower that has a proximal or distal avulsion that's physiologically youthful in terms of their UCL. Localized injury. They have healthy tissue with a localized injury. A non-thrower or recreational athlete that's failed non-operative treatment. Or even in terms of indications, and this is part of the getting more granular and thinking about this, this may be an ideal procedure for that older thrower that's at the end of his career, the twilight of his career, that can't wait a year or a year and a half to get back to playing. And that six month or shorter rehab with a repair may give that athlete the opportunity to get back. But this may very well be a small percentage of the UCL tears that we see overall, particularly at the elite level. Because in this era of sports specialization where we begin playing baseball as soon as we exit the womb, we have a lot of chronologically young athletes who have physiologically old UCLs because of the mileage they put on. So how do we put the pieces of the puzzle together? UCL repair may be indicated in younger athletes with no attritional or degenerative changes. Repair with augmentation has been proposed, but follow-up continues and the precise indications are being determined. UCL reconstruction remains the standard of operative treatment with comparable outcomes for both the modified job and the docking. Outcomes and return to prior level must be determined for both repair and reconstruction in order that we provide optimal care for our injured athletes. But I will say, I'll end with it, as exciting as the UCL repair with internal brace technique is, I would dare say that it's not likely Jeff Dugas' greatest contribution to us. Thank you. Wow, Mike, it's Jeff. Can you hear me? Yes. That's a great talk, Mike. Thank you so much for doing that. And Mark, again, thank you for doing that. Mark is taking the questions at this point. So if you have, well, maybe I can see it. Let me see if I can look at this question. We'll go through some questions on the group. I can ask them. I got it, Mark. So this is from Peter Deluca. Thanks so much for the excellent review, Michael. Are you aware of any studies that directly compare the use of autograft to allograft for UCL reconstruction? Any thoughts on the difference in tensile strength? Yeah, so Peter, that's a great question. And Jeff, you touched on this last night too. I mean, Buddy Savoie, we tip our hat to Buddy as well for a lot of things. And Jeff, you said last night that he sort of refocused you on the whole idea of repair. But also, he's a brave guy and he has published a group of patients that he's used allograft on. I will say that that has not had a lot of traction and the large majority of surgeons that do this on a regular basis and take care of elite athletes are using autograft tissue. Jeff, I don't know if you have any other comments on that. Yeah, I agree. We have not gone the allograft route. I like the idea of autograft. I just think allograft introduces a variable that I don't ever recall somebody not getting back because of their graft site problem to throwing. So I just, I think it introduces a variable that is unnecessary. I will say, I'll add though, that different than the intra-articular environment in a knee with an ACL reconstruction where there's synovial fluid. I mean, this graft that we're using and the reconstruction we're doing is, it's essentially perhaps intra-articular one side, extra-articular on the other, well vascularized by all that we're doing in terms of drilling the tunnels. So you could argue that it may be a much, a better environment for an allograft tissue than for ACL reconstruction. For sure. Yeah, I agree with that. Next question is from James Liu. Thank you, Dr. Scottie. If the bone bridge around the sublime tubercle is fractured, what is your preferred fixation method or surgical techniques and does this change your postoperative protocol? So the bone bridge around the, on the sublime tubercle? Was that the question? Yes. Yes. That's a bad thing. Yeah, I mean, that's why just be so, I'm so careful with that in terms of the videos I showed, I went through quickly, but we're really careful with those tunnels. And so you're kind of, you walk a tightrope, I think, because you need the tunnels to be large enough to pass the graft through. And we'd like a sizable graft, but if they're too large, then you could obviously violate the bone bridge. But I would say that on the ulnar side, I think the ulnar side is much less of an issue than the humeral side, the distal humeral tunnel. You talked about this last night, Jeff. That distal humeral tunnel is much more important to me. So if on the ulnar side, if the bridge were to fracture, the two options I mentioned, you could use a tenodesis-type screw, or you can use a button. The button would be my preference, and that's had just recently published out of the Cleveland Clinic. Again, Mark Shickendance and Sal Frenjemoor published on that, and that's a very viable treatment option. How about your thoughts, Jeff? Yeah, I agree. I've used that distal button. I think the instructions you gave, the 30-60, 30 distal and 60 posterior is right to avoid. Obviously, I try to barely get through that distal cortex and not plunge through there, but I think using a button on that side is good. I have used the interference screw on a revision setting where the bone was kind of rooted out from the previous graft, and I didn't have a great tunnel, and so I drilled a little bigger tunnel and used the interference screw. I think probably if I was doing that same case today, I would use a button. But I would say, Jeff, too, though, that that's a technique. I mean, there are people who use screws on both sides. That's right, right. So it's absolutely a technique, and if you think about fracture, the stress risers that might be created because of a fracture, I mean, the higher incidence is on the meat alpacondyle side with an interference screw than it is on the ulna. Of course, it could happen on the ulna, but it seems to be less of an issue on the ulnar side. No doubt. Brandon Erickson weighed in. Hey, Brandon. He said they did a study at Rush comparing algraft to autograft, no difference in outcome. Thanks for typing that in, Brandon. The next question is from Mike Pullen. Thanks for a great talk. Given the talk yesterday and the promising results with internal brace, what are your thoughts on incorporating an internal brace for patients undergoing a reconstruction? Do you think this may shorten the rehab process, I'm assuming, for reconstruction? Yeah, so you talked about this a little bit last night, Jeff, and there are some people that are looking at that and doing that. We have not done that. And in my mind, just because of the limited real estate in that area and drilling tunnels for reconstructions, and not that it couldn't be technically coordinated and can be done, but we haven't moved in that direction. But as perhaps an early stress shielder to some degree that may benefit it. But I think that my sense is that the end might not justify the means with that at this point. Perhaps in a revision situation, but not necessarily in a primary. Yeah, I think so, too. I haven't done it either, Mike. And I know George has done it a little bit, and I think John Conway may have played with a couple of different constructs with that. But I think George has done kind of a hybrid like that and probably got a small series of those as well. But I think that to do that, it would be an interesting question. It's an interesting question, the one that certainly first from a biomechanical standpoint could be looked at, just in piggybacking on the biomechanical studies that are out there. And it would be just another variable to add to look and see what it does. Yeah, absolutely. I don't know if this is Mike Freehill to everybody else. Excellent talk, Michael. I know you do traditional, but I was wondering if anyone has had an issue with suture stack and modified over the medial epicondyle. I haven't had any times where I thought we put too many sutures up there personally. I don't know about the docking guys, if with the suture stack tying it up there over the medial epicondyle, because we do a more traditional figure of eight. But have you run into that with the docking? Second. So in terms of, I'm assuming the question is about the sutures themselves and causing post-operative irritation, correct? Yeah, I would think so with the stack up there where the sutures from the docking technique. I will say to you, Jeff, that I have seen that a very small number of times and to the point where it was very localized discomfort. And in fact, in two throwers that I gave localized injections to that resolved the symptoms. And one of them that had really a true discomfort that was a functional disability that I had to go back in and make a small incision. This was well past the reconstruction, having healed and excised the knot and the symptoms resolved. So I think it is a real entity. I think it's very infrequent in my hands, but it is something that can happen and we should be aware of. All right, and Mike confirmed that was exactly what he was talking about and said, thanks. Next question, William Workman. Dr. Scottie, thank you. It looks like your incision is anterior to the medial epicondyle. Was I seeing that correctly? And if so, am I making mine on the wrong side? Thanks. No, you can make the incision anterior or posterior. And so what I would say to you is that I think that maybe the most important thing is not to make it right over the medial epicondyle because of where we rest our arm. So make it either anterior or posterior. We're not transposing the ulnar nerve routinely. So I can get to the ulnar nerve if I need to, but we prefer to make the incision anterior. Jeff, now you're transposing the ulnar nerve. Do you make your incision posterior to the epicondyle? We do, we go on the posterior side. So I think either way you can do it. And perhaps what you might be planning on doing with the ulnar nerve might direct you. I would just suggest not making it right over the epicondyle from a, just from a, you know, a sensitivity standpoint. I agree with that. Next question is from Travis Roth. Great talk. Thanks a lot. With a muscle splitting approach and not mobilizing the ulnar nerve, how do you access posterior medial osteophytes if necessary? Yeah, so great, that's a great question. So we will do arthroscopic approach. And so we can do, we feel like we can address that arthroscopically. So we'll do, we don't routinely do arthroscopy pre-reconstruction, but in certain situations, if there's a loose body or posterior medial impingement, we will do that. We have alternatively though addressed it through the incision, but those are in the cases where we would also be transposing the ulnar nerve. And you can speak to this too, Jeff, you know, to get through that posterior medial capsule that the nerve is so close that you're almost obligated to do something with the nerve. Absolutely, and it's like I was saying last night, I really, I started not moving the nerve for a period of time and making a smaller incision and really thought I was on this, you know, an easier way of doing this and not messing with the nerve, just pulling it posteriorly and, you know, not going past the medial epicondyle approximately. And I found that I was having to go back and transpose a few of them because I think I generated enough scarring around the nerve because I was going posterior to L of my, my split is posterior to get to the ligament. I think I could avoid that by making a true muscle split in the mid substance of the muscle belly, but obviously then you have to make the decision to go back there and deal with the nerves you have to. So I think it's our approach that caused that problem, not the nerve itself. Yeah, and I would, you know, I would say to you too that it's interesting because the way I think of this is that ulnar nerve, so in your group, I mean, obviously you routinely transpose the ulnar nerve and you are so careful with, you know, the things that I mentioned in this talk, you're maintaining that vascularity to the ulnar nerve, making sure that when you transpose it, that you're looking at the intermuscular septum and excising the intermuscular septum and scalloping that fascia over the flexor carpi ulnaris, that there's no points of impingement and then in some way keeping it anterior. So you're very meticulous about it. And that's really important. When this procedure was first defined by Frank Jobe, so many of these throwers went for so long with ulnar collateral ligament instability that they, so many of them, a high percentage had secondary ulnar neuritic symptoms as well. And in that case, ulnar nerve transposition was very commonly performed. I think that as we've gotten much more confident with diagnosing this and in our surgical treatments and our postoperative rehabilitation, I think the large majority of those athletes, they never get to the point where they're, where they develop such severe ulnar neuritis that they have to have an ulnar nerve transposition. But obviously, if you choose to do it, you can do it well as your group does, we just have to be really careful. Yeah, I completely agree. And one of the things that we saw when we looked up that large number of patients, that 1,200 and something is, we had one out of those with a longstanding ulnar neuropathy. And so, when we talked about complication rate, some of those larger studies that we looked at that said that the way we were doing it had a higher complication rate, a lot of those were post-op ulnar neuropraxias that resolve within hours, days, weeks, and don't create any long-term problem, but they were still listed as complications, we all listed them. I think we gotta be careful when we're listing complications as something that anybody, if you mess with the ulnar nerve, you're likely to get a little bit of a post-op neuropraxia for a couple of days in a fairly, 10 to 15% of those people. I'm not sure I think of that as a complication. I don't know about you, but you think we gotta get on the same page about that. That's not something that's for this group or anything, but I think that we, that's just one of those. Let me follow up with a question, Jeff, on that in terms of the ulnar nerve. And we've talked, you and I have talked about this in the past, but I think it's an important point. What you do to the ulnar nerve, and Frank Jobe used to do a submuscular transposition. He had lifted off the entire flexor pronator mass, transposed the nerve, and then he brought down the flexor pronator over the top of it, so a submuscular transposition. And gosh, going back in on those cases was, if they had any ongoing ulnar nerve symptoms was absolutely terrible. I mean, a really hard case. And I think that's what shifted us towards performing subcutaneous transpositions, but the concern is you wanna stabilize the nerve. Your thoughts on using a fascial sling, just like I showed in one of the pictures, do you suture it to the fascia, the subcutaneous fascia, so it's less impinged upon? Do you use two slings? What are your thoughts on that? We use one sling. I don't think there's anything wrong with using two slings, but we've used one. We went from using a fascial sling, which was how we did it for the first, I don't know, 10 or 12 years that I've been in practice to the last probably eight years or so, we're using the intermuscular septum as the sling. And in doing that, we're keeping it a little bit higher, I think, because it's attached to the medial epicondyle up there. And so I think that our priority when we teach the fellows is to make sure that the nerve moves very freely. Watch it, stick an instrument under there and make sure there's enough room for two nerves under that thing, so that you know that the sling itself is not causing any compression. You're not gonna keep it from creating scar around the nerve, and some people are gonna get a big hematoma. You know, those are the ones that I worry about having ulnar nerve problems, is the ones that swell, that we don't do a good enough job with hemostasis. I think as you take the septum down, there's that leash of vessels up there. I think being really cautious not to get a big hematoma post-operatively can really prevent you having some ulnar nerve problems. Yeah, agreed. I got another question from the audience here. Sean Sitton says, great talk, Dr. Scottie. What's your thought process on treatment algorithm for those athletes who start to have ulnar neuritis or ulnar nerve type symptoms post-op, especially as they start to get into their return to throw program with or without a transposition? Right. I will say that I just anecdotally, my perspective is that is very infrequent, very rare, but it can happen. And so in terms of our treatment algorithm, our treatment algorithm is stopping them from throwing. We will give them a prescription strength non-steroidal anti-inflammatory for two to four weeks. While they're not throwing, we'll focus on all the things that we talked about that are important. We all understand their kinetic chain. And then we haven't used a brace, but you can use a brace. You can use a splint. We haven't done that. And then quieting them down and then re-initiating their throwing program. But, and in the large majority of that small number of cases that has been effective. But to kind of step backwards a little bit, it depends upon really what is the source of the ulnar nerve issue. Was it, is it an ulnar nerve that just is inherently stable, but just was irritated perhaps from poor mechanics? Is it an ulnar nerve that because of the reconstruction that you've done, distally might have some scar tissue around the posterior ulnar tunnel that might be putting some type of pressure or compression on the ulnar nerve that is millimeters from that. And we've seen that as well. So it really depends upon what it is. And if it's in that case, that scenario, you can look at it with a ultrasound. Ultrasound has been very helpful for us to kind of identify what area, if there's any area of scar tissue that has occurred along the ulnar nerve. And if it's localized to that area, that's distal, you can use an ultrasound guided injection in that tissue. And in one case, we had one patient, we had to go back and actually debride the thickened tissue that was adjacent to that posterior ulnar tunnel that was compressing the ulnar nerve. So that's a great question. You mind if I ask, have Steve Cohen kind of comment, one of the things you brought up was the return to play of the mid 60% to greater than 90% and no real difference between the different graft types and different approaches. But something that always comes up is return to play, really return to play versus return to performance and metrics. And I know Steve Cohen, your partner, has done a fair amount of work on that. Steve, do you wanna comment for a sec? Yeah, sure. Thanks, Mark. Michael, obviously, great job. And Jeff, good job moderating. Return to play is very different when you compare a professional athlete to a high school and a collegiate athlete. The likelihood is that if you're a high school athlete and you're a sophomore or a junior, and you have this injury, you likely were one of your top players or a upper level performer. So getting back to a high school level is very common. And the same goes for even college, you're a scholarship athlete. And the likelihood is you're gonna get back at some point in time. And one of the things that we looked at specifically was if you're a professional baseball player, do you get back at the single A level? If you were a double A player, do you ever get back in those levels? And I think it's really important to look at it specifically, because you don't just say, okay, well, this professional athlete got back to pitching to some level professionally, but when you were a triple A guy and then you came back and you never got higher than single A, that's really not competing at a similar level. So it's really important to analyze that return to play at previous level, not just return to play, period. Steve, that is a great point. And yes, I remember vividly that study that we did, and it was a very sobering study. When we looked at return to play after UCL reconstructions, and we looked at return to play and return to prior performance. And some of those UCL reconstructions were done, they were done on professional baseball players. And some of them were done in our organization. The others were done by surgeons in the country that you would want to do a UCL reconstruction on you. And it was very sobering. The actual return to prior performance, it was not nearly as good as we thought it would be. And I think that might've been one of the studies that has really focused us since on the difference between return to play and return to prior performance. And clearly a difference between just walking out on the field once or playing and playing at that pre-injury level for a sustained amount of time. And the literature that has, there has been more recent literature that's focused on return to prior performance using performance metrics. And Brandon Erickson has published that with suggesting improved metrics. There's another study by Macney that's looked at the metrics having maybe decreased. So there's a little bit of debate yet, but your point is a very important point. We need to be as granular as possible when we critique ourselves, okay? We have to be as objective and as honest as possible. And we have to use metrics that are appropriate. An ASES score, well, gosh, that's a score that just evaluates your ability to brush your teeth or comb your hair. But a KJAC score is more sports specific. So we have to use metrics that are appropriate to the activity. We have to use metrics that are specific for the sport. And then that way we're really gonna grade ourselves on how well we're doing. And I think if we do that, we're gonna see we're probably not quite as good as we think we are, but that's what pushes us to improving diagnosis and our techniques and our rehab. So that's a great question and a great point. So I think Mike Friel made a comment basically looking at statistics and on what they are and what are variable. And I think more granular statistics, as you said, and performance are gonna be key because I just wanted that point to get out there because you sit there and you look at a lot of the more current literature and everybody's got 90 plus percent return to sports rate. But again, it's not necessarily at the same level. And I think we need to be more detailed in what we are describing as return to play versus return to performance. So that's great. So it's four o'clock here, seven o'clock on the East Coast. I wanna thank Jeff and Michael for, Michael, a fantastic talk as always and Jeff, great talk yesterday as well and great moderating today. And I wanna thank you all for participating and we're gonna start up again on Monday and next week at the beginning of the week is on the telephemoral types of issues starting with Latul Farrow from the Cleveland Clinic. But again, this will be available on the AOSSM Learning Management System next week. And again, I think you all please have a safe weekend. Thank you, Michael. Thank you, Mark. Thank you again for coordinating this, outstanding. And Jeff, thanks for your words of wisdom, your sage advice. Thanks, Mike. Thanks to all you guys. We appreciate you, be safe. Okay. Thanks everybody. Have a good night.

UCL injuries

surgical techniques

UCL reconstruction

modified figure of eight

docking procedures

autograft

allograft

ulnar nerve

comprehensive treatment approach

return to play