Good morning and thank you. So from a disclosure standpoint, the first disclosure I want to make is that I actually didn't come up with the word Blarney that was given to me. So I am a consultant for Arthrex. I receive a royalty on the kit that was created, which probably creates enough income for me to buy each of you about a half a cup of coffee. And ASMI gets research support from lots of people. So UCL Repair has a long history. It actually goes back a pretty fair distance. Some of the more salient publications include Norwood, but everybody remembers Conway's article on Job's original patients, published in 92. This included Tommy John. There were 70 patients, and of those, the 14 repairs often get lost in the shuffle. Of those 14 repairs, 71% had good to excellent results, as opposed to 80% of the reconstructions. However, in Major League Baseball players, only two out of seven returned to the same or higher level, returned back to Major League Baseball. So about a 30% success rate, as opposed to 75 with reconstruction. Andrews followed that up with a study that Fred Azar did when he was a fellow. And again, the same thing, about 30% of the repairs got back to playing at the same or higher level. So on the basis of those two studies, repair was basically banned with good reason. The outcomes were terrible. And so basically, UCL Repair was abandoned in favor of reconstruction. Remember that these people were and still are some of the best elbow surgeons ever, until my man right there, Buddy Savoie, published a couple of nice articles in the mid-2000s. So Buddy published some articles on simple repair, started with 18 female athletes with great results, 16 out of 17, getting back at three months. This was just using suture anchors or plications back. And then in 2008, and these were both published in AJSM, 60 overhead athletes, male and female, mostly baseball players, 93% good to excellent results, and they returned to the same or higher level at six months. However, and I am guilty of this as well, this largely went overlooked. So this is really good stuff on repair. So the question was, do these younger athletes need a reconstruction if they have good tissue, if they're not beat up? Is UCL reconstruction really necessary in this population? So basically, for the first 35 or 40 years of UCL surgery, we had one hammer for every nail. And maybe there was a better option. So after doing a couple thousand of these over 15 years with Dr. Andrews, we were doing some form of reconstruction for every level of pathology we have. And our thought was, are we doing too much surgery for some of these? Could we do a little better? So with Arthrex's help, and Gordon McKay, who's a foot and ankle surgeon in Scotland, had come up with this idea for the internal brace. We adapted this to the elbow. When I first discussed it with Arthrex, they said, there's no way we can use this tape with two 3.5 millimeter anchors. They were happy to see that they were not correct about that. So we did a base study on cadavers. So we did a basic science study looking at this. We looked at right and left's match pairs. One got reconstruction with the standard modified job technique, and one got the repair. I wanted to make sure that this was at least as good as what we were doing every day, and it was. The point was not to show that it was better, I just wanted to make sure it was at least as good before I did it in a human with a heartbeat, and it turned out that it was pretty good in terms of time zero gap formation. Cyclic results, we went and cycled it, and after cyclic testing, the repair returned back to the more normal condition faster or better than the reconstructions did. So after 500 cycles, the repair looked a little bit better than the reconstruction, and this again was not important for it to be better. I wanted to know that it was the same, and I wanted to make sure it was at least as good as the gold standard. So who's a repair candidate? Well, this image on the left shows what appears to be pretty healthy UCL tissue that's stripped off the sublime tubercle. You don't see any edema in the tissue. There's no proximal injury. This is simply just a degloving or avulsion of the tissue from the sublime tubercle. This is very different from what you see on the right, where basically you expect when you go in there, this is going to be gelatinous crud with this large projecting osteophyte, and that's a totally different situation. What about these little fleck of bone in the ligament versus this almost kissing osteophytes on the medial side? Totally different pathology. With the recent success that Buddy had had in our basic science showing time zero success, we set out to do this. So far, we've done about 300 of these in Birmingham, and we just published in April of this year last month in AJSM our outcomes at two years of the first 128. Arthrex estimates that there's been close to 1,200 of these done around the country to date. So we lost 17 to follow-up. We had 87% follow-up, 96% males, all were in the dominant arm. The average age was 18. Baseball represented the majority of them, a few softball, javelin, and football. And the level of play at the time of injury, as you'd expect, would be predominantly high school. Two-thirds of them were high school, and almost the rest of them were collegiate. There were a few other ones with one professional in this group. Just as a baseline, the KJAC scores of normative data look here. So healthy Major League Baseball players, 97. Professional pitchers, 91. If they've had any evidence of injury, 86, and surgery, 75. So we followed our 128 patients. All 111 of them attempted to return to play. 92% were able to return to play at the same or higher level, with KJAC scores above what you would normally see for anybody at the Major League Baseball level with an upper extremity injury. And they rated their elbows as 95.6% of normal, with an average return to competition time of just over six months. Half of them about had an ulnar nerve transposition. The other half did not. There was no difference in outcomes between those that had an ulnar nerve transposition and those that did not. I try to leave the nerve in place if they have no pre-surgical symptoms, but I don't have a problem moving it if I'm at all questioning that. Proximal versus distal, again, no difference in the outcomes. There were four tears in the group with both proximal and distal, but not enough N to compare. Partial versus complete, again, no difference. So no difference in the extent or location of injury with the outcomes. There were no major complications. We had to remove a retained subcuticular stitch, remove some heterotopic bone, and we had to perform subsequent ulnar nerve transpositions in two, all returned to play at the same or higher level. I had one high school pitcher who went underwent a UCL repair after his ninth grade season. He pitched in his 10th, 11th, and 12th, and in his senior year he re-tore it, but his original tear was distal. His second tear through the tape and his ligament were proximal from the medial epicondyle. Unfortunately for me, he declined revision. I was ready to revise one of these. I have not done that yet. Chris Ahmad has revised one that I did. He was this guy who developed HO, and after several attempts to remove the HO and get his motion back, Chris and I made the decision he needed a revision, and I really wanted Chris to do it. Chris said it was the easiest revision he ever did because there were no bone issues. There were just two 3.5 millimeter plastic anchors in the bone, and he had no problems drilling his tunnels as he always would. All the patients achieved full range of motion by six to eight weeks. As I said, the return time was just over six months. George Palletta did the first Major League pitcher in June of 16. He returned to Major League Baseball in May of 17. So far I've done a total of about 10 professional baseball players, a bunch of NCAA players, and obviously there's no control group. Gymnasts and cheerleaders and wrestlers have all done well with this as well. I've revised five prior UCL reconstructions that had some form of a modified job or docking technique done. All tore off the medial epicondyle. Three have returned to play, and the other two are less than six months, but I will say this is the easiest revision UCL reconstruction or UCL surgery you'll ever do. So my thoughts are that as with other ligamentous injuries in the body and devulsions and partial tears that don't respond to conservative management can be treated with UCL repair and augmentation. It is not a ligament replacement. It may be a better option for revision, and I don't know if the tape is structural or simply a scaffold for healing. And the question of an ulnar nerve transposition is still in question. So people have asked my opinion. I can only go with what Chris said about revising them. It seems to be a pretty easy revision. I encourage you to talk to Chris if you have one. So we're now moving into higher levels of sports. I've been pushed into doing some of these for some tissue deficiencies because of timing. Not sure how that's going to work out. I expect that this will not do as well in those patients if we were to do a bunch of them, but because of some timing issues I got pushed in that direction. So more to follow. Thank you.

UCL repair

ulnar collateral ligament

athlete

elbow injuries

revision surgery