Well, we'll switch gears back to the UCL, and this lecture is entitled Lessons Learned, but I think it could also be called Mistakes Made by me. We've had excellent talks from Luke, Jeff, and Tony looking at UCL, and this will be sort of a summary of the salient points that they really put together, I think, quite well, and this is sort of just to continue on with that a little bit. Looks like my disclosures have not changed in seven minutes, so we'll move on for that. One lesson that I've learned is if I have a real question about the elbow, I usually ask my partner, Bernie Morey. That usually works. That's a good way to learn a lesson. The other is if I think I'm clever, if I think I have a new idea, I check with Buddy Savoie, and he's probably already done it, so that's another lesson I've learned. Another one I've learned is sometimes it's easy to diagnose instability. I'm pretty sure what ligaments are torn here, a little bit of MCL is still attached, I guess. But moving on, today, the lessons were discussed, what have we learned, what do we do about the torn MCL? What are the perceptions out there? It's amazing. The baseball media, 25%, a quarter of them think that reconstruction is a performance enhancement. Even collegiate athletes, one out of four, think that a recon without injury, patients without injury, will help performance. Let's do it. I'll pitch faster. We know that's not the case, but that's the perception. So what are risk factors for MCL injury? Well, one, I love to say, is not living in Minnesota. It's greater rates in the south, for good reason. It's good weather. You can pitch year-round with higher velocity. You can lose a total arc of motion. That's been shown to potentially lead to this. It's the shoulder, it's not the elbow. And pitching more than 100 innings per year. All the things you can do down here when the weather's beautiful. But there are really no studies yet showing that trying to preventive programs, prospective studies, will decrease the rate of surgery. And the slides that we've seen from Tony and Luke, the increasing number of surgeries that are performed. So we're really not sure. We don't have good data that a risk reduction program, we think it will work. We haven't proved that yet. Imaging studies, the gold standard's always been an MR arthrogram, but the MR techniques have gotten better. That's one thing I've learned, is that you don't need to do the arthrogram. And the dynamic ultrasound has also gotten better. So that combination, I think you don't need to do the arthrogram techniques. Mike Ciccotti looked at ultrasound again, and it's interesting. They just looked at these players, not players having surgery, but you can see the dominant arm was about a millimeter more, and this was significant with a large number of players, a millimeter. So if we're talking about shoulder instability, knee, ACL instability, a millimeter's nothing, right? And so it's interesting how a millimeter can potentially make the difference. But it's also well known that if you keep throwing, you will have laxity of the ACL over time. That's not pathologic. That's just something that occurs. So it makes it hard to really define which of these players are going to be at risk. Jeremy Bruce at the University of Tennessee in Chattanooga was able to find that over six millimeters, which is still not a lot, was associated with a full thickness tear in these patients. But part that I thought was interesting is 31%, almost a third, had less opening on the injured side than the uninjured side, and that there may be no difference in the laxity of an asymptomatic pitcher versus the pitcher who goes on to a UCL reconstruction. So imaging studies, whether it's ultrasound or MRI, it makes it hard to identify that at-risk player, which is who we really want to try and identify. And in some cases, it's not the elbow, it's the shoulder. We should be looking at the entire mechanics of that player. And this is a study that Dines and Luyocum looked at, that the total range of motion is less in the injured group, and there's GERD also in these players, and that you should consider the shoulder and the chain of mechanics, and not just the shoulder, you look at the whole body of these patients as they move, which can contribute potentially to an elbow injury. Surgical approach has been discussed. We also start with, of course, the flexor-pronator split, identify the ulnar nerve, get exposure of the subline tubercle, but then what do you do at that point? Well, in my practice, what I've gone to, and I've tried all these, is a single-strand double docking technique. The single docking technique is probably the most popular now, along with the JOBE. And here's an example of a pitcher of mine using the screw technique with a very stout graft doing well, return to play. And this is the double docking with anchors, buttons, which I do now on these players, and get them going sooner, potentially, with this technique. Graham King and I collaborated on a study looking at the double docking technique and found it stronger than interference screw fixation in this cadaver study, very strong fixation compared to some of the other techniques. Results, I think we know, non-operative treatment, early study by an arthritic, but his study included full thickness tears, partial tears, sort of a mixed bag, but that was the lowest at 42% for conservative treatment. If you look at many studies, as this study looked at, about 80%, a little over 80%, excellent result. And that's what we've seen in Tony and Luke and Jeff's presentations, about 80% getting back to play. If you look at in-game performance, and this is over 1,000 pitchers, again, just over 80% return to their play. But look at the amount of time, 17 months. In most of these cases, if you're doing a full out reconstruction, double docking, single docking, JOBE technique, it's going to be over a year before that highly competitive player gets back to the mound. Again, fewer innings pitched after reconstruction and decrease in velocity. Now, what that's not, if you get granular about it, a lot of those starters are relievers, so they are going to pitch less innings. And if you injure your elbow once, you're maybe going to change your pitching mechanics a little bit to go to a different pitch, not just a fastball pitcher, so you're going to decrease your velocity anyway, even if you feel like you're doing fine. But most of the studies show a prolonged recovery and a decline in performance overall. That's the data that we have. Another study looking at large number of players, again, over 80%, regardless of the type of surgical intervention, as Tony mentioned, but again, showing decreased innings pitched and decreased fastball velocity after reconstruction. This is another large study looking at the hits system from Major League Baseball. Again, about 80% starts to sound boring or repetitive, 80% return to play at the same level, which is what's most important, not just returning to play, at 71%. Again, no difference based on the reconstruction technique or graft used. But if you follow these patients, almost 50% had a subsequent elbow injury and 13% of those underwent further elbow surgery. So if you follow these patients long enough, it's not all fine and dandy at 80%. Things do change over time. What about non-operative treatment? Timo looked at some of the series coming out, and since each of the conservative treatment strategies was different, whether using PRP or not PRP, a brace, offloading brace, and there's currently, and this is something that we should be working to work on, and hopefully some of us are, there's no current prospective, just case series studies in the literature looking at the treatment of partial tears. I think we could do better in that regard. And as we've heard, in non-operative treatment, 66%, which is better than the 40% that Rettig had, but again, 81% of these are successful return, non-operative proximal tears. So we just focused on the proximal tears. Maybe we can go from that 40% of Rettig to 60%, maybe to 80% with non-operative treatment potentially. So that brings us to PRP. The study looked at 34 patients, single shot, leukocyte-rich, which is better, leukocyte-rich, leukocyte-poor, you're going to get more of an inflammatory response with the leukocyte-rich technique. The return to play was 12 weeks, three months. And at six years, long-term follow-up, almost 90% have returned to the same level of play, but again, no control group in the series. We got PRP, Josh Dynes looked at this. Again, if you notice the PRP players tend to be a little more conservative, or these are the younger players. Look at the ages. They're all in their PRP, all about 17, 18 years of age. One to three injections. How many injections? I don't know. Some players, 22 patients had three injections of PRP. But look at this. Sounds similar. Meantime return to competition, three months. Kato, who I spoke to about this a few weeks ago in Japan, 34 baseball players, now leukocyte-poor. And 26 of 30 are able to return to pre-injury level at about, guess what, 12 weeks. With increase, or decrease, which is good, in the DASH score. And Buddy's group and Michael Bryan looked at this also. And they were very aggressive. These are 25 patients. These are varus unloading brace, structured physical therapy program, two injections, leukocyte-rich, separated by about two weeks, done under ultrasound. But 96% were able to return to play at the same or higher level, an average of 14 weeks. Now the players were released to go to competition at six weeks. That's early. But look at that. Similar to the 12 weeks we've heard. So about three months, which is a huge change in these players going back to sport at a similar level that they were going at before. So will PRP be a game changer? Perhaps. It's something that we need to have prospective studies with the control group. But if we're able to get players back at three months, that's a lot better than over a year, I would say. So suture augmentation, as Jeff presented, is this also a game changer, as PRP may or may not be? And we've heard Jeff's excellent presentation. And look at the average age, 18. We're always a little bit hesitant. I know I am. I want to do this on patients that have good biology, high healing, and don't have a $2 million or $50 million contract. But look at the results that Jeff presented. 92% of patients returned the same or higher level of play at six months. So now we're starting to see that we've gone from the 12, 17 months to having that to six months or so using a heavy suture technique. But it's interesting, as Jeff mentioned, there was no difference in outcome based on the location of the tear, proximal or distal, or complete or incomplete. So I think that's kind of interesting that patients did well. So we need to also sort out who are the best candidates for this technique. Here's a case, probably an extreme case of mine. This is a weightlifter in competition, had an audible injury when his elbow exploded on the left. You can see his expression there, and his coach said he could hear, and it was not fun to hear. This does happen. This is at the 2016 Olympics. Same expression, notice, on the guy's face. These are almost open dislocations. It always goes out medially, always goes out in my practice, open dislocations go out medially. He's got a little bit more weight than my patient there. So terrible, everything's torn. So this is using a heavy suture technique. I did the medial side, which is what we're talking about today, but it was so bad I had to go on the lateral side and did the same heavy suture and anchor technique that Jeff talks about. Bilateral repair in this patient. So he was very aggressive, very smart, well maybe smart and weightlifter aren't really going together, but he comes back in five weeks, he's doing well, he's got great range of motion. I said, okay, now we can start you moving on 10 to 15 pounds of weight progressively. He starts smiling and started laughing. I go, what's so funny? He says, can I show you a video on my phone? I said, sure. So this is what he showed me, if this runs. I said, that's you. That's actually you. What are you going to do with that? Are you going to push it with your feet? You're not really going to lift this, are you? Oh my goodness. So I said, yeah, so I guess that 10 to 15 pounds, we can go up to 20 to 25 pounds progressively will get you eventually up to 100 pounds and then we'll eventually get you to the bar and get you back in the gym. Thank you for coming. So again, this is an extreme example, but showing that an aggressive early treatment and potentially we can accelerate our patients getting back to play, whether it's baseball or weightlifting. So there's always what's next to learn. I'm always trying to learn. So two weeks ago, I was at the Japanese elbow meeting, which is in conjunction with the hand meeting and I'm having dinner with Professor Abasaki, that's Scott Wolf, the other Caucasian you can see from HSS, you can see on the left. And one of his colleagues started drawing on the back of a napkin what they're doing now in his group and using bone pegs, graphs, a minimal suture, no anchors, very intriguing. Perhaps that's the future. Perhaps we'll hear some papers from Japan in the future about what we can learn about UCL reconstruction. So thank you very much.

UCL injuries

reconstruction

risk factors

surgical techniques

PRP