I'd first like to thank Drs. Sabo and Steinman for the opportunity to present at this meeting and hopefully shed a little bit of newer light on some of the approaches that we're now taking with some of the more challenging elbows that we're seeing in the world of throwers. I have nothing to disclose. I think apropos of this talk, I'd first like to provide you with a little bit of history and background as to where we are with Tommy John surgery today and how we got here. We're actually in the 50th year of the Tommy John. September 25th will be Tommy John's 50th anniversary of his own Tommy John. And in spite of a really rather stellar career, he's still not in the Hall of Fame. Ah, but who had the second Tommy John procedure? Well, it was actually the current head pitching coach and extremely well respected head pitching coach for the Arizona Diamondbacks, Brent Strom. I think fortunately, if he had been the first, I don't think we'd be calling it the BS procedure. I think the real question we need to ask first is why do we need to change anything? Our results have been quite outstanding, but I think that failure rates are beginning to increase with the older techniques because of the evolution of the game of baseball. Higher velocity fastballs, more spin on the off-speed pitches is really creating an environment where we're seeing more and more need for revision. And we already know that these revision reconstructions historically have been quite poor. Look what's happened to pitching as a consequence of this huge emphasis on ball velocity. In 2002, the average fastball velocity in Major League Baseball was 88.5 miles an hour. It's now in the current season approaching 90 miles an hour. And the rates of injury are reflecting this. And clearly this increase in trending fastball velocity has lent itself to a significant increase in the number of Tommy John surgeries as a percentage of the individuals now playing the game. 27% back in 2016 versus 35% and probably much greater than that even in 2023. And as we see in life in general, youth follows the example set by their elders. And now we've got a real crisis with our youth. At the National High School Perfect Game, that's 18 and under of the best throwers, best pitchers in the game in 2012, there were only three kids that threw 94 or above. In 2013, there were 17 kids that threw 94 or above. In 2023, there were 54 kids that threw better than 94 miles an hour. And what about this emphasis on ball spin and specifically horizontal ball movement? Anecdotally at least, I can tell you that there's a significant increase in stress on the medial elbow with the hard sliders and the hard change-ups. I don't think we've been able to demonstrate this necessarily in the labs yet, but I do think we'll get there as our acuity improves with respect to motion analysis. And as a consequence of the effectiveness of these pitches, the average number of fastballs thrown is now less than 50% because at the elite level, it's much harder to hit a slider than it is an elite level fastball. And you can see the average batting averages at the major league level. Fastballs run in the 230 to 250 range, non-fastballs about 211. And these are 2023 statistics. And for anyone who really hasn't seen yet what's being created in these motion analysis labs, the ability to measure pitches and develop these so-called designer pitches is really quite incredible. But as a consequence of this obsession with creation of ball movement, it's significantly affecting the shoulder and the elbow. In fact, you can almost tell by the MRI scan, tear patterns that are created by these designers type pitches, these pitches with massive amounts of horizontal ball movement. So as a consequence to all this prelude information I've given you, I really look at reconstruction and repair techniques as either in the pre or in the post brace era. I think that the improvement in our surgical techniques fortunately has coincided somewhat with this precipitous increase in velocity and spin. I do think that there's a surgical advantage incorporating an internal brace into whether it's a primary repair technique or a reconstructive technique, what I like to term as the hybrid. So for me now, there are only two surgical options when I am treating these individuals that come in with failed UCLs. My standard pre-op planning hasn't really changed that much. We get three standard x-ray views, an AP lateral and an axial view. My MRI scans are always non-contrast. I can't remember the last time we actually did a contrast MRI scan. I think it's absolutely critical that you sequence these elbows correctly, however. On the coronal views, you have to get at least a T2 fat suppressed image or preferably a stir image. And that's going to show you the quality of that ligamentous tissue to a much greater extent. I'm not a big fan of ultrasound. I know it's been favorably written up. I just haven't felt that we have the same feedback on an ultrasound exam that we get on an MRI exam. CT scans are not a part of the routine, but if I'm going to map some of the spurs, if arthroscopy is going to be part of the equation, then I do get CAT scans. With respect to imaging, the fever view has been a tremendous step, a positive step, in terms of evaluating and giving us some qualitative assessment on the ligament itself. Dr. Pam Lund, our musculoskeletal radiologist out in Arizona who handles most of our pro baseball imaging, came up with this technique. It's actually very clever. The arm is held in a 90-90 position in the MRI scanner. An eight-pound water bag is placed on the arm to simulate some stress on the on the arm to simulate some stress on the medial elbow. Then an MRI scan is obtained, giving us this 30-degree coronal oblique view of the UCL. It's very consistent in terms of its ability to show degrees of laxity. For me, anything less than two millimeters is stable. Anything in the two to three millimeter range is going to be in the gray zone. Anything more than three millimeters, I'm very concerned about the competency of the ligament. Now, understand that the literature talks about measuring from subchondral bone edge to subchondral bone edge. I actually like measuring from cartilage edge to cartilage edge because that's what I'm going to be looking at when I've opened up the elbow during a surgical procedure. Obviously, ultimately, even though the elbow can be stable under stress view, there's still always qualitative considerations when we're looking at whether or not surgery is an option for these particular individuals. These are my current indications for internal brace repair. I should really start with my absolute contraindications, which are significant soft tissue loss, mid-substance tears, and tears involving very significant degenerative tissue. I think, equivocally so, when I start to see more than three to four millimeters on a fever view, I'm concerned about the quality of the tissue. The proximal tears and high-velocity throwers, I also have a level of concern about. I think that these can effectively be repaired, but I also worry about what the effect of the injury has on the remaining tissue, and is that tissue going to fail for us over the longer term, although proximal tears do seem to be doing as well as the distal tears. I think, overall, we're still kind of exploring, especially when it comes to the elite-level throwers. Now, I have my own technique for internal brace repair, and I call it the docking technique because I do not use an implant on the proximal side. I work in a surgical center, which I'm sure many of you do, and these kits can get very, very expensive. So, I don't need to open kits every time I do one of these. I use a single implant, the 3.5 millimeter swivel lock at the sublime tubercle, and then I use an internal brace tape. I use generic size reusable drill bits, 2.7 millimeters for that distal implant. I have a custom guide that's been made up with a drill stop so that I don't have to open up these kits, and I actually took the taps from prior kits, and I cut the handle off, and I put them into my drill so I can actually power tap. It saves a good bit of time. It also keeps me, again, from having to open up more kits, and then proximally, I use a standard 2.7 millimeter drill bit with a standard drill guide to make my proximal tunnels to dock with, and this is what it looks like. For me, it's a six centimeter or so incision. This is a standard distal tear. You can see I've placed the implant kind of at the apex of the sublime tubercle. I do know where the joint line is. With a distal tear, I'll add a zero fiber wire suture, and then I drill proximally. I move the ulnar nerve out of the way. I release a little bit of the medial intermuscular septum, and then I drill deep. I lateralize that proximal tunnel with two diverging 2.5 millimeter drill holes. Then I go ahead and I repair distally with that zero fiber wire suture. Sometimes I throw those stitches as locking stitches, depending upon the quality of that tissue, and then I use a knot tire proximally to tension down my brace while the arm is being held in 20 degrees of flexion and full supination, and then I add additional sutures across the standard ligament. Now, what you see I do proximally is I actually create a cuff of tissue by drilling deep so that I can pull the existing native ligament over the top of the internal brace. So, as I explained to patients, this is kind of a rebar in concrete or cement type of construct, and then I run the flexor mass with a 2-ovicle suture. To reiterate a little bit, I use this muscle split approach. When you're splitting the fascia though, I split the fascia overlying the flexor digitorum superficialis. So, there's a flap of fascia I can pull posteriorly that protects not only the ulnar nerve, but also protects the flexor carpi ulnaris, and I think that's critical. And then proximally, you want to make sure you don't take down that proximal cuff of muscle because that is the area where these things are going to tend to fail. So, the more you can maintain normal blood flow and normal anatomy, I think the more favorable healing response you're going to have, and perhaps more durable. Some of these things have glossed over already, but just to reiterate, I elevate the ulnar nerve proximally, and I release a little bit of the medial intermuscular septum to help to mobilize the nerve, and also decompress it. The drill holes proximally, I drill deep, and I leave a 4 to 5 millimeter bone bridge between these 2.5 millimeter tunnels, and I lateralize that tunnel. I want to hug the trochlea if I can with this, and then I tie deep with a knot tire. So, the elbows in a 20-degree flex position, full supination, and I throw five throws pushing the knots down with a standard knot tire. With some of these proximal tears, I may actually put this baseball weave with some 1.3 millimeter suture tape to reinforce the tear proximally and help to primarily repair that tissue. And I'm going to reiterate again, you want to hug that lateral trochlear wall with your proximal tunnel. I think it's very, very important to stay away from the flexor tendon and preserve as much of the proximal footprint as possible. 90% of braced and reconstructed grafts fail proximally, so the more we can maintain normal anatomy, the better. I also use that proximal footprint of tissue that I preserve to sew it right over the internal brace, and I think that's a better environment for healing, and it preserves the more normal anatomy. The hybrid reconstruction came into being in 2018, and essentially what I did was marry the two standard Tommy John and internal brace procedures so that potentially we could have the benefits of both. There is no question, there are certain types of cases that presented greater challenge with respect to favorable outcomes, and so I felt like we needed a better procedure to face some of these challenges more adequately. As I mentioned earlier, I felt there was already more than enough adequate biomechanical support that at least theoretically supported this type of construct. And because of this particular biomechanical study that showed that the proximal third of the footprint was the primary resistor to valgus load, I felt that placing the internal brace at that point would give us the most favorable results. This particular study I felt really helped to support utilizing the more distal portion of the sublime tubercle as part of this construct as we modified our distal drill holes. So initially, I only used this technique on the most challenging cases, revision situations, situations where the amount of bone was going to create a significant amount of soft tissue loss, severely degenerative ligaments in elite level throwers, atrophic native ligaments, hypermobile athletes, and as it morphed into a more successful approach, the really high velocity throwers. My graft options really didn't change. I was always in favor of a two-stranded ipsilateral palmaris as long as there was enough tissue there. I would use the contralateral palmaris in the absence of an ipsilateral, but again, you needed to be confident that you had enough quality tissue. Although if the ligament is thin, or I should say the tenon graft is thin, you can use multiple passes with what I like to term the dock loop procedure where I actually loop the opposite end of the tenon graft, dock that, and then bring the remaining portion of the graft around back through the distal drill holes to replicate the pathway of the initial two strands of the graft. The second choice for me is always a gracilis. I thin it down to three to four millimeters in width. It may have a delayed incorporation relative to palmaris. It may have therefore a delay in maturation. That may be a consequence of the girth of the graft rather than the absolute differences in tenon construct. A third choice for me is a semitendinosus. So as I've already mentioned, this is a marriage of two procedures. So my standard internal brace technique I could continue to use, but I added tenon graft and I put the tenon graft tunnels just a bit more distal, really at the concavity of the proximal ulna there, a little bit more distal to where I would normally have gone if it were just an isolated tendon reconstruction, and then the internal brace goes where you would normally put it during an internal brace repair. This is a standard incision measuring approximately six centimeters. I use the FDS-FCU interval. I split the FCU fascia overlying the ulnar nerve. The distal drill holes are 3.5 millimeter converging tunnels, and then I pass sutures right at the concavity of the ulna as I mentioned there. The internal brace gets placed as you normally would, several millimeters distal to the joint line. The proximal socket I drill with a four or four and a half millimeter diameter drill bit, usually 15 to 17 millimeters or so in depth, and then add two diverging 2.5 millimeter tunnels that exit proximally in front of the ulnar nerve protected with that retractor. I'm anticipating placing either two strands of a palmaris or two strands of a gracilis tendon. You can also do a primary repair of the ligament proximally. You may add a suture anchor more medially if there's some flexor tendon involved especially. You can add some suture tape to enhance your repair as well if necessary. Additionally, I put a zero fiber wire suture through the swivel lock for distal tears to repair that, and then I pass the graft through the distal tunnels. For passage of the graft and the brace, I pass the first limb of the brace first, and then the first limb of the graft. I then follow that by passing the second limb of the tendon graft. You can actually dilate the tunnel with a smooth forcep into the tunnel which allows a nice easy passage of the second limb of the tendon graft, and then I pull through the second limb of the brace. I tension and tie it down at 20 degrees of elbow flexion and full supination, tensioning the brace first followed by the tendon graft sutures. As I noted previously, I docked proximally using a number two ortho cord suture with a baseball type stitch, typically four throws. The ligament is then sutured over the top of the graft with a zero vicral suture, and then typically I'll put a single 20 fiber wire suture that incorporates the graft tendon arms with the internal brace and the native ligament. Post-op management for these hybrid reconstructions is what I like to term 5, 8, and 11 for our high school and college kids, and 6, 9, and 12 for our pro guys. The five months or the six month mark, we start our interval throwing program. We start our mound progression at 8 to 9 months, and then our live batting practice sessions at 11 to 12 months with a return of anywhere from 12 to 14 months depending upon the level of play and how the individuals progress. All our throwing programs are velocity based, so each individual gets a velocity chart for their throwing distance based on their own fastball velocities. These are our results using these current techniques. As of December 31st of 23, we've got 322 internal braces. We have 263 more than 18 months out, 48 pro, 134 college, 134 high school, 6 adults. We only have four known internal brace failures that required revision to a reconstruction. Now there may be some perhaps that just stopped playing baseball, but most of our patients we do follow very, very closely to the point at least of return to full activity. We've only had three what I'd call complications, meaning in this case late ulnar neuropathies requiring subcutaneous ulnar nerve transpositions. We haven't had any arthrofibrotic cases requiring any kind of further surgical management. These are our hybrid numbers as of December 31st, 279 primary, 75 revision. You can see an extremely high percentage of elite level throwers in these groups, so they're testing this technique for sure. Better than 18 month follow-up is 91 total as of December 31st, and then in the primary group we've only had four failures, two grafts and then one flexor strain, and then one fracture, which I'll show you that case. Of the 25 revisions, remarkably, we've had 23 return to play, one retired, and one needed an additional nerve surgery. Of the hybrid complications, we've had two arthrofibrotic cases requiring arthroscopy and debridement for a severe fibrotic formation. We had three late ulnar nerve transposition, and we had one somewhat catastrophic distal humeral fracture. I wanted to show you this case to show that none of us are without our own nightmares. This is a 26-year-old right-hand dominant major league pitcher. He was 16 months out from his hybrid ready, actually, to get back for his major league debut and develop this fracture. I'd never seen anything like this before. I've done about a thousand internal brace alone or hybrid reconstructions now with the current technique and haven't had any other fractures. In fact, this is the first fracture I've had at all in my entire career using the techniques that we used, but he underwent ORIF. He's actually back throwing, was seeing hitters. I shut him down because of a repeat MRI showing some increased signal in some of his bone, but it was more precautionary, but he is asymptomatic. We'll see if he can make it all the way back. There's no question this is a rising epidemic in major league baseball, and it has significant financial implications. The results of primary reconstruction have been stable, but I think that the amount of time that these individuals stay well has shortened significantly, and we're seeing guys breaking down at the elite level at the three to five-year mark, so we really have to figure how can we possibly do better, and ultimately, the game is asking us if we can recover these individuals any faster. I think on a positive note, the revision outcomes, which had been characteristically poor, do seem to be improving with our current techniques, but I think ultimately, we're fighting an uphill battle with the evolution of pitching in general. More velocity, more spin is just going to create more injury and some very catastrophic.

Tommy John surgery

elbow injuries

pitching injuries

baseball

surgical techniques

reconstruction methods