So, Jeff should be complimented for the work that he's doing in this area and teaching us all about that. I was asked to speak about why a reconstruction is still the best procedure that we have available for our athletes who have this problem that you've heard about this morning. Let's see what's going on here. And of course, we're talking about that ligament there. These are my disclosures, which are updated regularly at the American Academy of Orthopaedic Surgery website. When we looked at the return to pitching and performance in Tommy John surgery, it was very easy to see, as Dr. Oh just showed you, the incredible increase in the amount of athletes who are undergoing ulnar collateral ligament reconstruction. And it was particularly evident when we looked at the Humana database and a large population of patients that this was true for our college and high school athletes, and it was very concerning for us in terms of this dramatic increase that we've seen. So what are your options when surgery is indicated? Well, most are going to do the reconstruction, but now we have a pretty strong argument for repair, and it started with others, and Buddy deserves a lot of credit for a decade ago what he reported, and of course Jeff's added the internal brace or this special tape that reinforces this repair. And this is the study in 2008 where there were 60 patients that Dr. Savoie did a primary repair, and it's very clear he stated that this is indicated when it's a humeral or ulnar attachment avulsion. It wasn't for mid-substance types tears, and the rehabilitation was accelerated to see back to sport at about six months, and the results were outstanding, very similar to what Dr. Dugas is also reporting. And when we looked up a group of these that have been published over the last 10 to 20 years, it really didn't add a whole lot more to the information, only to say that in the right hands with the right indication, a repair is definitely a viable option in terms of management, as you see here when we group together the four studies that were available for this. And these were mostly done in collegiate and high school athletes, not our professional athletes. But why is the clear winner the ulnar collateral ligament reconstruction? It's because the injury often causes tissue deficiency. There's a safe approach, and new instruments can make it reliable. It's the gold standard in terms of knowing what the outcomes are in hands of many surgeons, not just one or two. And the long-term results, we know what they are, and we'll have to wait and see what they are with the repair. Number one, injury often causes tissue deficiency. There's no question our younger athletes, in particular, as you saw from the repairs, they'll get the avulsion off of one side or the other. But many of our athletes will undergo an attritional change. The forceps are right on a hole in the distal part of the ulnar collateral ligament that you can't just put a synthetic piece of material over that and expect to get the same result. And that's because it's very thin distally, as Dr. Schickendance and others have pointed out to us, and that's why it doesn't heal so well in that area. So we have to be aware of that ahead of time. So I'd strongly recommend that you read your own MRIs and understand when it's not just an avulsion or a liftoff, as Dr. Duga showed you, but there's actually tissue missing down there, and a simple piece of tape over the top of that is not going to make a difference. Number two, there are a variety of different ways of doing it, and with the approach through the muscle and or lifting it up, as the ASMI guys have shown for many years, and with some of the new instrumentation, many surgeons are able to get reproducible results. And the two most popular procedures that have been published and followed are the ASMI technique and then the docking technique, particularly on the humeral side. And kits like this have been helpful to make sure that surgeons can be consistent in where they place their tunnels and how they pass their grafts, and this has improved the reliability in many surgeons' hands. There's a number of different ways of doing this, but the key is making sure that the graft is in the best spot possible, which again, you're guided by some of the instrumentation and of course your own knowledge, and then adding that collagen and going through the proper rehabilitation. Most are still using the palmaris longest, and the second choice is the hamstring autograft. The results are the same. And in terms of other surgical variables, when you look at it, whether it's college, high school, or professional, again, a variety of different techniques, and with the current docking technique or the ASMI technique, the results are essentially the same. Graft type, palmaris or hamstring, same. Surgical technique, same. So that's one of the nice things about the reconstruction is that, again, it's reliable in a lot of surgeons' hands to get very good results. And then this study here also pointed out, which we'll learn from Dr. Dugas and others about the repair, how important it is where you put the elbow at the time of the reconstruction, but this study suggested where many people were putting it about 30 degrees of flexion, maybe slightly higher degrees of flexion would be the best place to do it if you're doing a reconstruction. With the graft or with the tape, this may not be as forgiving, and so this may actually over-tension. It is the gold standard to do a reconstruction. It's the most reliable. It's the most predictable. We have outcomes. Dr. Dugas and his team at ASMI have shown us in a very large series how well these patients do. The average time to full competition was almost 12 months, and that's one area where he is showing significant differences with the repair and internal brace. And when they looked at their adolescent baseball players, which many of the patients that are in the internal brace and repair series, this is the group that you would compare to the most for right now, you can see the results with the reconstruction are quite excellent and, again, very reliable with 98% returning at just under 12 months back to their sport, and you can see the vast majority were able to get back to the same level of their sport. When you look at the professional athletes, the ones who are going to put the tremendous amount of torque and throw that ball over 90 miles an hour routinely, what we saw as return of sport was 97%, 83% the same level and no significant decline in performance over time, which is really very, very remarkable when you look at this. And then when we also looked at how revisions come about, some people are worried that the graft may stretch out or it needs a lot of time to heal. You've heard about people being delayed in how many innings that they have to, they're allowed to do their first year back, and we went and looked at this very systematically and whether they did 150 innings or 180 innings or any amount of innings, there's no threshold. So each athlete is different, but the point is it's a very reliable procedure in the highest level athlete and, therefore, should be in our lower level athletes too. Our experience at Rush reflected exactly the same thing. The one area we struggled with was the gymnasts, and I think when you look at Buddy's work and Jeff's work, maybe the internal brace will really help us in that environment. Finally, long-term outcomes and durability. Here is an athlete who had UCL reconstruction in 2010 and then eight years later won the Cy Young Award. This young kid to the right, who's a high-level high school baseball pitcher, if he has a repair, an internal brace, what is he going to be doing in eight years? We have no idea today, but we can pretty much predict what he might be doing if he had a reconstruction, and what we saw is the average length of the career in Major League Baseball after the UCLR was about four years, and this is very similar for an age-matched group cohort. That's about four years from the same time that they have surgery, so this did not affect their longevity. Ninety-two percent of the patients were able to throw without pain. Ninety-three percent were satisfied in this for the competitive baseball players at ten-year follow-up. Ten years. That's the gold standard, so let's bring it home. The injury often causes tissue deficiency. I don't think you can replace that with synthetic material. Beware of that. It's a safe approach now through the muscle or lifting the muscle up as the ASMI team has shown us, and there's new ways to do this with techniques and devices that help us. It's the gold standard in terms of return to performance and the longevity, and the long-term results are very clear. We'll find out from the brace how that's going, but I want to thank Jeff and Buddy for their pioneering work and helping us improve the way we take care of our athletes. Thank you.

ulnar collateral ligament reconstruction

Tommy John surgery

ligament injuries

athletes

reconstruction procedure