Thank you. My presentation today is on all the collateral ligament injuries of the throwing elbow. This is the so-called Tommy John's procedure, and I'm going to talk to you about how to decide. I don't have any conflict of interest disclosures. Tommy John's procedure, what about the beginning? Well, it started off with Frank Jobe. He did the first Tommy John procedure in 1974. Unfortunately, there was an ulnar nerve palsy, seconded to the transfer of the ulnar nerve submuscular, and it took the nerve symptoms about 18 months to resolve. Dr. Jobe was distraught with that, and he swore he would never do the surgery again. Fortunately, Tommy John's returned to win more games after surgery than before. It took Dr. Jobe five years before he agreed to do another UCL reconstruction. What about the Tommy John's procedure and the summary, and I'll present to you the summary of various early techniques. Of course, the original Jobe procedure was popularized by Dr. Jobe, and then I modified it, called the Andrews Modification Technique, which put the nerve subcutaneously under the skin and not under the muscle. Then we had the Docking Technique, which was a procedure popularized by David Olchek, and then the Dane Technique by Olchek and Eltrosh, which was a modification of the Docking Technique. These are the various early operative techniques. On your left is the modified Jobe procedure. On your right is the Olchek procedure, and then the modified procedure by Olchek and Eltrosh below. What about the surgical indication for this procedure? Well, number one, acute or chronic complete tears of the UCL is obvious. Partial tears after failure of conservative treatment is also a surgical indication for this procedure. Note, though, is that it is usually not necessary to operate on UCL injuries if the athlete has no future in baseball or if he's retiring. This is especially true in a casual young high school baseball player or the college senior not talented enough to play pro ball. What about decision-making? Well, the most difficult thing in decision-making is making the diagnosis and determining the severity of the injury. As we've stated above, failure of conservative treatment is hard to determine. Because of our good results today, we're more aggressive to surgically reconstruct the injured UCL in a promising and mature baseball player than we were in the past. Again, you must remember that partial tears of the UCL don't necessarily heal conservatively. How many heal? Good question. The answer is 50-50 or flip a coin. Let me go over with you the technique of the injuries modified Jobe reconstruction that I've done through so many years. This obviously is a modification of the technique described by Frank Jobe and all in JBJS in 1986. On your right is an illustration of the of that technique with a graft and drill holes. In the technique I'm describing, materials and methods, we had from May 1988 to December 2006, we had 1,281 UCL reconstructions that I did and 942 of them had at least a two-year follow-up. 34% of these Tommy John's procedures or 320 of them were professional baseball players. All patients had all the nerve transposition performed. 30% had excision, also of post-immediate electronin osteophytes. This is a surgical technique, and the first thing we'll show you is the medial skin incision with all the nerve dissection. We have to free the nerve up and transfer it or at least free it up to be able to get underneath the flexor muscle mass to the ulnar collateral ligament. So transferring the ulnar nerve is something I did routinely. Next, the flexor pronator mass is elevated but not detached for UCL exposure. As seen in this illustration on your right. Bone tunnels are then drilled in the usual fashion as described by Dr. Joe. This modified job technique utilizes a split in the Tommy John's ligament itself right down the mid-portion of it so we can see the drill holes on both ends. This allows us to see the deeper tear of the Tommy John's ligament by splitting it longitudinally. Following that, the graft is passed and crossed in a figure-eight fashion as seen here. It's then sutured side to side over the proximal back part of the medial epicondyle with appropriate tension at about 20-30 degrees of elbow flexion. It's then the split in the native ligament is closed and imbricated and a repair of the tear of the ligament is also repaired. At that point, the graft is enclosed side to side as seen here. This shows the completion of the procedure with the sutures in place. Post-operative care is pretty straightforward. You use a posterior split for five to seven days. You try to control edema and begin progressive range of motion at about five to seven days and you want to have full motion by at least six weeks and you usually discontinue the brace anywhere from four to six weeks post-op. At week eight to fourteen, you begin advanced strengthening exercises including shoulder exercises and core strength exercises and scapular exercises. At four to six months, depending on how the patient has progressed, you begin an interval throwing program. At 12 months, you hope you have the recovery or sometimes it takes more than 12 months. It's like the rainbow. The follow-up results in this series, we had 942 patients at a greater than two-year follow-up. 743 of the patients were contacted at 79% with a 36-month average follow-up. What about the return to sport? 84% of the reconstructions were able to return to the same level of competition or higher. 90% of major league baseball players were able to return to the professional level. That is the professional level. To critique this further, only 75% made it back to the actual major leagues. So, in summary, the reconstructive procedure is tried and true in reconstructing the ulnar collateral ligament. The reconstruction has been called the gold standard. It then began with Joe, then Andrews, and then with the other authors that I have mentioned to you. By the way, very, very early attempts at direct repair were also tried by Dr. Andrews and Dr. Jobe, and there was a dismal failure of a direct repair of the ligament without augmenting it. So, let there be progress. Over the last 50 years, there's been a lot of progress through experience in the Tommy Jones procedure. There's been a lot of annotation, a lot of improvement, through experience in the Tommy Jones procedure. There's been a lot of anatomical, surgical, and very operative experience, including rehabilitation and study of the actual footprint of the ligament, both proximally and distally. Recently, there's been progress through technology, especially suture and anchor technology. And also, there's been, hopefully, some progress additionally through biologics, which hopefully enhances the healing ability. That hadn't been proven yet, though. There are newer techniques, particularly with the flexor tendon split approach. In this approach, you do not have to transfer routinely the ulnar nerve. The docking technique was seen on the upper right, was developed by Dave Olchek in the 1990s, and it's a widely accepted technique with excellent outcomes. The hybrid technique was also a technique using docking and tunnels by Olchek, Eltrosch, and others, and it's an accepted technique with similar outcomes. Again, the advantages of all of these procedures that I'm showing you here is that they do not routinely transfer the ulnar nerve, nor do they have to transfer the ulnar nerve. Let's go to the new kid on the block, and that is in the use of the internal brace by Jeff Dougas. From 2011 to 2013, the internal brace for the UCL was developed. Initially, there was a lot of skepticism. Arthrex said the tape won't fit through the eyelet. Dougas said, let's find out. Arthrex said, not sure this will work. Dougas then said, let's try it in a cadaver and do some basic science work to see if it will work. Then Arthrex said, this is going to replace UCL reconstruction. Then Dougas said, no, it will work for some, but not for all. What about UCL repair history? Well, that has a place in our discussion of UCL's injuries also. Buddy Savoy was the first to really push for UCL repair. He published this in the Journal of Sports Medicine in 2008 and was somewhat forgotten in the literature. He had 60 overhead athletes, 47 males and 13 females. They were relatively young. Average age was 17.2 years. His mean follow-up was good, 59 months. In this series, 51 of the 60 had suture and anchor repairs. 9 of 61 had sutures pass through drill holes. In the follow-up result, 93% had excellent, good to excellent results. This was amazing. 58 of 60 returned to the same or higher level of play at average six months, not a year or a year and a half, six months. That has progressed to the repair and augmentation with the internal brace by Jeff Dougas. In that particular procedure, Jeff took the advantage of the information that was passed on from Buddy Savoy and continued to work on it. He used two corkscrew peak anchors, as you see on your right, with a collagen-coated fiber tape, which made up the internal brace. This was size zero, super suture. And also, important thing was Jeff did some basic bench research on the UCL repair with internal brace augmentation at time zero and found out that it had excellent tensile properties. Initially, the indications for a direct repair with internal brace by Jeff Dougas was a relatively young or lower level throw with minimal injury. He had a partial tear approximately, or perhaps distally, with good quality ligamentous tissue still remaining. So he was picking his cases pretty carefully to try this on. Here's some of the repair candidates that he had. On your left here is a distal avulsion of the ulnar collateral ligament with good tissue. That's one he picked to do the direct repair in the internal brace on. On your right is one that shows a partial tear in the upper third of the Tommy John's ligament that still had good tissue. And actually, in that case, he didn't really make up his mind what to do until he got in and looked at the ligament itself directly. And indeed, he did a direct repair with an internal brace on this particular patient. Here's a video that shows an actual repair using the internal brace and a direct repair of the ligament. We're working here on the distal part of the ligament attachment. On the distal part of the ligament attachment, there's the tape and the anchor. It shows us driving the anchor into the sublime tubercle. To your right is the hand. It shows here the actual suture. Repairing the ligament itself with a Xeroticron suture. Repairing it on up from distal to proximal, back up toward the medial epicondyle. Now we're going to drill a hole in the appropriate insertion of the Tommy John's ligament to the medial epicondyle. We'll thread the end of the tape over the anchor, and then drive the anchor into a position with appropriate tension. Check for range of motion, and finish it. I'm about to publish results of the internal abrase which were published by Dr. Dugas in 2019. He was encouraged by the recent success obviously of Savoy with allocollateral ligament repair when he did this series. And also, as I said earlier, Dugas' basic science report showed time zero success. Dugas' first patient underwent UCL repair with internal abrase augmentation on 8-8-2013. A total of 129 were performed through 2031 and 2016. Now nearly 700 total have been performed at the Andrews Sports Medicine in Birmingham. An estimated over 5,000 have been done total to date, and that's an arthritic internal estimate. As rapidly ongoing support and experience with nearly 25% of NCAA UCL surgeries are now being utilized with the internal abrase in 2019. The results of 111 athletes with internal abrase and direct repair by Dr. Dugas, there was an 87% follow-up at a minimum 12 months. All 111 patients attempted to return to play. 102 of the 111, 92% were able to return to play at the same or higher level. KJOC scores for patients after 12 months averaged 86.23. KJOC scores of patients after 24 months averaged 91.07. Throwing athletes related to their elbows is 95.6% normal at 12 months post-op. This was the important thing. Average time to return to competition was 6.68 months post-surgery. That return has revolutionized the Tommy John's procedure. What about complications? Well, there were no known major complications in this series. There have been five reoperations, one to remove or retain subcuticular stitch, and he had full return to high school baseball at 10 months post-op. There was one to remove heterotopic bone, a full return to high school baseball at 10 months post-op also, to perform secondary subcuticular ulnar nerve transfer. These are secondary subcuticular ulnar nerve transfers. One returned and had to have the nerve transferred eight months after the UCL repair. Both of these returned to play at four months post-ulnar nerve transfer. There's one to perform a revision ulnar nerve transfer for nerve instability after ulnar nerve transportation, and he returned at four months post-revision UNT ulnar nerve transfer. All of these returned to play, though. What about revision UCL reconstruction? The previous published follow-up papers have shown poor, very poor results, outcomes in overhead athletes with a return to play rate related to revisions to be equal to about 30% return to play, and I guess the question is, what is the healing potential for these re-dos? And also, the other thing is, what's the length of recovery? It has a tendency to be longer. It has a tendency to be more than 15 months recovery when you do a re-do reconstruction. And by the way, it's known by all the baseball doctors as one of the worst procedures we do from an outcome standpoint. This is my own series of outcomes after ulnar collateral ligament revision reconstruction in baseball players, and it was published in Journal of Sports Medicine in 2020. I had 65 revision cases from 2004 to 2016. Sixty-two percent were able to be contacted with a minimum follow-up for 22 months. Ninety-five percent of them were pitchers. Fifty percent overall returned with a 20 to 40, in other words, 20 of 40 of them returned to play. We had 10, in this series, 10 Major League Baseball pitchers. The good thing was that 8 out of the 10 baseball pitchers returned to Major League Baseball. Look what it took, the length of time it took them to return though. Pitchers returned an average of 12.8 plus or minus 3.7 months, just about a year and a half to return. And as an overall result in this series, certainly wasn't 30 percent, but only half of the baseball players were able to return 50 percent. What about newer revision procedures using a hybrid technique and or a hybrid direct repair plus internal brace? These are all newer techniques, and I'll show you an example or so. This is a new, recent revision technique case example. There's a 39-year-old Major League Baseball pitcher who previously underwent a UCL reconstruction with Palmeiras autograph using a modified joke technique in 2011. This is actually one of my patients. He pitched seven seasons as a Major League Baseball pitcher since Tommy John's initial procedure. He began to have the onset of ulnar collateral ligament UCL symptoms in the summer of 2019, and he was unable to complete the season. On your right shows you, the yellow arrow shows you the pre-operative MRI of the torn UCL graft. You see where the bending moment is, and you see where it's all disintegrated approximately. This is a case follow-up of a direct repair in this particular case with an internal brace, a direct repair with an internal brace. A direct repair was done in November 2019 with the internal brace, and on your left again is the pre-operative MRI with the yellow arrow, and on your right is the post-operative MRI of the torn UCL graft healing at six months post-op. Marked difference of the direct repair and an internal brace. This particular Major League Baseball pitcher returned to play in June of 2020, seven months post-op, not a year and a half. He's been a starting Major League pitcher since then and was pitcher of the month of May in 2022 season. He is now 42 to 43 years old and throwing 80 to 90 pitches a game. What about the latest direct repairs plus internal brace revision results? That was just one example. Dr. Dugas and Keith Meister have been doing these. Dr. Dugas has now revised eight prior UCL reconstruction using this technique. To begin with, five of the eight had modified jaw procedures, and three of the eight had docking procedures. Seven of the eight, or most of them, were torn at the medial epicondylar origin of the UCL where the bending moment is. One out of eight was torn at the ulnar attachment, which is unusual. They used a 4.5 millimeter anchor on the side of the injury for all repairs. Five of the eight have returned to play at the same or higher level. Other three are less than eight months post-op. And there's been an increased interest in direct revision with internal brace over the last year or so. As a matter of fact, I think Dr. Dugas has seen four patients regarding revision in the last two months. As a matter of fact, I think Dr. Dugas has seen four patients regarding revision in the last two months with this particular procedure. So what about some thoughts on the use of the internal brace? Well, first thought is cautious optimism in patients with partial thickness injuries and devulsions. I'd like to use this technique in those who have additional ruptures and poor quality tissue in the native UCL. We all think that tissue deficiency demands more collagen. Now the revision cases is an entirely different ballgame. Decision to perform a UCL repair with internal braces and intra-optive, one in the vast majority of cases, is usually made at the time that you look at the actual quality and quantity of the ligament tissue that's uninjured and there. We also look at the level of play, the velocity that they throw, the age, all the nerve transfer, the fact that it's not or has been transferred. If it's been transferred, it makes the procedure doubly hard to go dig it out. Also, the location of the ligament is important and the degree of the tear can be important, but really in most cases it's shown no effect on outcomes of UCL repair with internal brace. Just makes the procedure much harder. Thoughts, in addition to this ultra-strong biologic enhanced tape and modern anchor technology may provide protection to the repair while healing and a backstop over time after healing. And I would say without argument that it is not a ligament replacement. A revision surgery, a direct repair with internal brace may be a better option than a redo reconstruction. We don't know if the tape is structural or simply a scaffold for healing. It is never the primary restraint to valve or stress. And the other thing that we're learning is that perhaps the ulnar nerve does not need routine transfer with any of these new procedures. So, in conclusion, there will always be a need for the gold standard Tommy John's reconstruction with a tendon graft. On the other hand, in the future, all Tommy, I think that in the future, all Tommy John's surgical procedures will probably be augmented with an internal brace. In other words, every Tommy John's procedure will probably have an internal brace done with it at some time in our future. Thank you for allowing me to present this information to you and good luck in your future careers.

Tommy John procedure

UCL injuries

surgical techniques

post-operative care

internal bracing

athlete recovery