So we're going to get started. All right. So thanks everyone for their interest in elbow on a Friday afternoon. Yes. And yes so I'm the moderator for this session. I'm going to give the first talk but you know the the general theme of this session is to kind of give a sports based sports specific based approach to injury treatment and rehab and return to sport because elbow injuries really are quite different you know depending on the sport that either causes them or that you're trying to go back to. So I'm going to start with the gymnast elbow and I always say I have like really a love hate relationship with treating gymnast because they're very difficult to treat. But I have a really a love of this sport having been a collegiate gymnast myself and I really can relate to these athletes and I kind of know what they're going back to doing and try to use that some of that perspective in this talk here. So I don't have any disclosures relevant to this talk. So as I mentioned my goal here is I'm going to review some of this some information about the skeletal immature elbow. Obviously many of these athletes are very skeletally immature given the age at which people specialize in gymnastics and ascend to higher levels. We're going to talk about some of the mechanisms of injury some of the common injuries that we see and then treatment return to sport. So there are many reasons why gymnasts injure their elbows. One of them being early specialization among all sports that kids participate in. Gymnastics has the youngest age of single sport specialization with average age just under nine years. And then there's really you know overload in the form of training. A lot of times you'll have like a young gymnast doing five six days per week of practice 30 sometimes 40 hours per week at the higher levels. And there's really just biomechanical overload. These are valgus elbows impacting an extension a lot of axial load both in the immature and the mature elbows. And then there have been some rule changes that I'll just mention that have kind of encouraged some high impact extension loading of elbows and younger kids with some of the rules around the change in the vault apparatus. So this is what's called a Yurchenko entry vault. You may hear some of your patients mention this they're doing this at younger and younger ages. It's a round off entry. So they instead of running and hurtling off a leg and hitting the board and then going forwards or even twisting onwards they do like a round off sort of that two legged cart wheel kind of thing high speed into the springboard take off and then as they go up over top they land in a really extended kind of high velocity impact and push off of their arms. And this started to be done at younger and younger ages it used to be you had to be like minimum a level eight to utilize this vault and then the rules changed in 2019 that as low as level six they could be doing this so you have kids sometimes as young as seven doing like timers or like the practice of this maneuver and loading their elbows in this way. And then the other thing that happened was that the vault change used to be kind of skinny and narrow and there was risk of missing the vault but they kind of wanted to make it safer so they changed the orientation of it and made it longer on entry. But what that's really resulted in is people actually approaching it higher and faster with larger forces. So there are less people with catastrophic events but higher load on the elbow. Speaking of that we have many immature elbows in the sport just we need to think about the typical timing of closure of these areas of growth. So the distal humerus you know may and the capitella area may close in girls age 12 to 14. We know that OCDs of the capitella have worse prognosis for healing after fissile closure. Medial epicondyle I know that my colleague Todd Lawrence is going to talk some about evulsions but is vulnerable really up until the age of 14 when that closes. And then radial head fissus closes in girls on average at age 14. And I'll show you a lot of images of the typical kind of stress reaction that the skeletally immature radial head is at risk for in the sport. Highlight this just because it gives you a real cheat sheet at the end I'll kind of reference it back at the end of this talk but I have this paper that we put out to really give all of my non gymnastics partners who end up treating these kids a real kind of template on how to advance people back to sport by load bearing and by event. So you can just kind of choose where you want them to be in terms of load bearing and then kind of give them something to take the gym and I'll show you that later in this talk. So I'm not talking about baseball but there are a lot of overall overlaps and similarities. We see OCDs in both of these groups. We see up convoluted revulsions in the in the skeletally immature individuals but they're different versions of them. Those CDs tend to be more distal. The convoluted revulsions tend to be like less apophysitis more of an acute traumatic thing. And then we see a whole other sort of list of injuries that I'm going to go through here. So this I believe is actually a picture that I've shared I've gotten from Todd in the past but this is his little drawing with the red squiggle showing us that the evolves to meal up a condyle really does take tension off of the UCL which then causes you know further valgus laxity and overload the radiocapitular compartment. And then speaking of the radiocapitular compartment one of the most benign things you can see in a gymnast and I love when this is their only problem is the radiocapitular placa. So there's a lot of hyperextension overload that tissue there can sometimes get hypertrophy and irritated and you can see here see this point this large placa that as we scroll across really all the way over to the ulnar humeral joint is impinging in there. This is someone that I did an arthroscopic placa excision on. So this is kind of an easy fix. They have a pop with extension. See if I'll do it right now but and it's painful. They kind of feel like they get locked but you get the samurai there no loose bodies just a placa. This can be a very easy fix. This is the radial head stress fracture I was alluding to earlier. This is a really classic thing that I see quite frequently and I will tell you in my practice the average age I see this as age 11 or it's almost the only age I see it as age 11. They're always 11. There's always a prodrome for a few months my ankle my elbow has been aching and I was it's always like I went to do the your tank of all and there was a snap and then I couldn't wait there anymore and they come in and oftentimes they have one on one side and then one is brewing on the other and they all have this pattern where the the metaphyseal bone looks like it's become deficient and slopes. They get this little broken dish and then you know if they then go and try again and do another vault or whatever it kind of depresses because you don't have the bone below it to support it so it always has this appearance and these are bad actors they take a long time to heal like a minimum of three months and then they heal with a little bit of a deformity and I really truly believe this has evolved with the changes in rules and your Shanko vaulting loading these really skeletal immature elbows and we know that that that area doesn't close the radial head devices doesn't close until age 14. And so you know I do think there's potential for modifying this risk in this sport but this is a patient of mine again another 11 year old always 11. The acute pain and pop was on the elbow shown here on the left and you can see it's like a little depressed and this one you can see it's and they said my other elbow aches a little bit this one we caught you can see like that's starting to become a little bit less dense. You've got that linear that line right there like that was coming on that one as well. So this person has a few months of non weight bearing ahead of them. This is a patient of mine age 11. I saw them when they were level eight and they were already doing that your tank of well they have this like depressed metaphysis the split in it. They came back to see me for a painful plica more recently and so this is she's now age 15 you can see how it remodels it remodels with a slightly sloped surface and they do I believe get a little bit of post their lateral like subluxation and it's just not a normal elbow even though they heal. So these are bad. The other you know common issue we see is the OCD of the capitellum different mechanism than in baseball which is what we all think of the valgus overload with pitching. This is more of axial load but they do tend to be valgus aligned elbows. And as I mentioned these are different than a baseball baseball. They can be a little bit close to the flexion surface gymnastics a little bit more distal because their weight bearing an extension. And you know typically between the ages of 12 and 14 repetitive axial loading in terms of treatment if you catch this where there's just bone marrow demo and it's not displaced much like an OCD in the knee and they're skeletally immature. There's a good chance you can just offload them take them out of weight bearing for at least six weeks and then maybe add them back into like non flight weight bearing just like you would let your knee OCD start to walk and get off the crutches but you wouldn't let them run or jump. But then you know if you get them too late they've broken off you got a loose piece. Generally these are not repairable once they've broken off and you're looking at either a debridement and or grafting with an osteochondral graft or autograft plug. So if I have a patient who's like you know I'm not going to do this sport anymore but I have obviously mechanical symptoms the loose body. You can remove the loose body. Some of them by the time you get in there they already have a nice layer of fibrocartilage and you're going to disrupt that like those people actually can do pretty well. But then you have patients who have like cystic loss of bone and those are more ones I'm doing an osteochondral plug in. But here's a review if you look at just globally what are the outcomes of arthroscopic management of the pediatric elbow. Many of these are OCDs that have been you know loose by removed debrided you see a high return to sport right. But when you separate out the throwers and you look at the gymnast the outcomes aren't very good. The return to sport is much lower. It's like you know hovering just above 50 percent. However if you kind of look in these small numbers within here you'll see treatment with like osteochondral plug. You know those seem to do actually better but they're small numbers like these in this one series at least the two people that had the osteochondral plugs actually did well. So this is a level 10 gymnast patient of mine 12 year old had a little program of pain on the ball all of a sudden crack pain unable to bear weight in the upper extremity after that comes in obviously has this is not just a surface lesion there cystic changes and some loss of bone block to extension which is common. Her MRI shows this large fragment and her posterior compartment and obviously some bone loss but contained. And so in this situation obviously we want to remove the loose body. She wants to go back. She's a level 10 very talented. She's actually had a medial epicondyle avulsion on the other elbow that she did well and went back from. So in this case I don't think this would be repairable. We remove the loose body and did an osteochondral allograft through an ankylose split through a posterior approach. Here she is one year post-op. It looks really good. She's gone back to sport. I think you know this had some time to mature a little bit and I think she'll be okay but I just have really warned her if you have any elbow pain like do not sit on that. The outcomes of these are generally small series showing mostly in baseball small numbers of gymnasts kind of reported or described or separated out but good ability to return to sport both with allograft and autograft. So this is the table I was telling you about in that paper that I referenced earlier and I really made this or we wanted to put it out there for people who don't know all the terminology when your patient is asking you if they can do like a you know pack salto or you know your chinko entry or whatever. You know you don't know what it is. We listed out by vault bars beam floor non weight bearing partial weight bearing full weight bearing full weight bearing with flight and then full return to sport. And if you kind of want to think about it as like you know non weight bearing on a leg standing walking running jumping I mean that would kind of be like the progression but you could kind of decide where you want your patient to be and which phase you want them to be in and then you could say hey like you could take this to your gym or whatever these are things you can do. Briefly on MUCL injuries and they skillfully mature gymnast these tend to be avulsions not really mid substance repair tears and they tend to be acute and traumatic maybe from an awkward landing on a release move where you land in a hand stand on your upper extremity or maybe you know just an atypical fall or something different than a baseball MUCL injury they tend to be a direct avulsion distally with or without a fragment of bone like this the subacrome with the sublime tubercle avulsion. And because of the obvious laxity and instability these patients have when they try to continue they come in typically with a sense of their elbow buckling inability to return to sport. I don't expect that to heal. So for me if they want to continue in the sport I don't think non-operative treatment is really an option and I have typically repaired these with or without augmentation because the remainder of the ligament is so uncompromised and this is a traumatic event not a traditional thing. I've leaned I've leaned towards repair not reconstruction through an FCU split identifying the joint finding the distal insertion placing an anchor and then whip stitching up and down and tension slide to repair and then typically taking up to an anchor and up a condyle with an internal brace and then rehab for these is a lot shorter than say like return to play for a pitcher that you've done a reconstruction on this is native tissue healing from you know a one off event that was traumatic and so typically they are able to get back to full return to sport by about 16 weeks where we kind of start that full return to sport then. And I have done this on patients who go on to complete you know compete in college high level gymnast they're going back to hard stuff when they're a high level gymnast who's very coordinated. You can think about their level in terms of what could you send them back to do early in terms of like no handed stuff like I can have a level 10 go back do a bunch of no handed front tumbling that's really complicated because they're probably not going to fall doing that if this is like a level seven gymnast a younger gymnast who has this injury you know I'm going to worry about them doing challenging things like that because maybe that's not in their wheelhouse it's stuff they're trying to learn so they shouldn't be trying to learn new no handed things but if there are things that are old hat for them you know they can certainly get back in the gym and do no handed stuff so results of repair. This is a paper by Dr. Richard who's here in the audience. Primary evulsions had great results in throwers there weren't really gymnasts in that paper but they did well and then there are small series of sublime tubercle evulsions again mostly in throwers that did well with repair but there are a couple of references specifically in female athletes specifically with repair and these have shown good return to support to female athletes. MUCLs tend to be a traumatic evulsion and gymnasts at least in my experience they're mostly distal and repairs do well. This is a more recent study looking at operative repair of ulnar collateral ligaments in female athletes did include some gymnasts and some other people who were tumbling again high return to sport with good scores with repair. So it's just a different ideology and outcome. So summary gymnasts have worse outcomes return to sport with OCD debridement than throwers. OCA is a promising treatment for OCD of the capitellum have a high index of suspicion for your skeletally immature gymnasts with unilateral bilateral elbow pain that had a prodrome with an acute pop. This is often that radial head stress fracture the broken dish as I describe it. Remember radial capitella placa is a pretty benign cause of post collateral mechanical symptoms but it's easily resolvable with either debridement or benign neglect that can continue to play through it if they want. And remember the MUCL injuries in these athletes are traumatic and do well with repair. Knowledge of sport specific return to activity can allow less downtime and faster return to sport with safe progression. Thank you. OK so next up is my former co-fellow who's going to talk to us about some topics that overlap but very different baseball. Yes absolutely. Thank you Jocelyn. Thanks for coming. We're the only thing that stands between you and dinner I guess. So I have to say I'm super impressed how many people are here for elbow on a Friday. Oh my gosh. Yes. This is. You all deserve a round of applause for yourself. So yes as Jocelyn said our talks are going to overlap a little bit. My goals are to to review how why the this immature elbow is more susceptible to stress and how the places response to those stress and then talk about three common pathologies we've seen in athletes. So the growing elbow as you know as many growth plates and secondary ossification centers. These growth plates certainly have a different modulus of elasticity and a lower ultimate yield strength than bone making a more susceptible to repetitive stress that repetitive stress actually leads to decreased blood flow down there into the metathesis from the metastatic region which leads to damage to those the end arterial micro Arctic architecture there with subsequent decrease in the amount of calcification. You this process is called PFC elicits and you can see it on x rays and MRI apotheosis is actually from chronic repetitive distractive forces that cause the same pathology And this hurts and the process is fully reversible if you stop the stress. However, the FISIS can show decreased amount of calcification in the hypertrophic zone. So with that foundation, let's start with medial epicondyle injuries. As you know, and Jocelyn reviewed, the onocollateral ligament and the flexor insert onto the medial epicondyle. In the adult, the musculature stress shields the UCL. So the UCL only sees about half the valgus force at the elbow. However, in the skeletal and mature elbow, all the stress goes to the FISIS. And since the medial epicondyle is the last to close, as Jocelyn reviewed, you can have a 14 or 15-year-old pitcher who is shaving who still has an open medial epicondyle. And if these kids are just doing too much, they can develop apophysitis in the medial epicondyle. Medial epicondylitis, as we call it, affects a significant number of youth throwers. And then they all have tenderness to the medial epicondyle that importantly reproduces their pain of complaint, as you know. But if you examine them, you'll find other things like you do in any other thrower. Bilateral external oblique films are really the best way to confirm that diagnosis. And these are basically high-risk stress fractures, as I think of them. And so you just need to tell them that it's going to take a long time to recover from this. And I tell them three months. However, while resting, they can do active, what I call active rest. So they send their PT, and they can work on all the rest of the things in their kinetic chain. So moving on to medial epicondyle fractures. Basically traditional teaching, as Jocelyn said, says that the UCL goes with the medial epicondyle piece. And the musculature always pulls it anteriorly. Unfortunately, biomechanics of the elbow don't really like an anteriorly placed medial epicondyle. That makes your UCL tight in extension and loose inflection, which obviously isn't good for throwing. CT x-rays are enough to make the diagnosis. However, it's hard to see that anterior translation. So people have come up with this axial view, which actually is better at showing anterior translation. Sorry about that. But our techs just can't get it. So we've almost completely abandoned getting this view. CT is actually really good at seeing anterior translation. But it's just a lot of radiation. In a lot of cases, I don't think you need it. And so this is this classic example by Eric Edmonds, where it looks normal on AP, but it's completely displaced. This is another example of a 13-year-old gymnast, actually, who got a post-reduction CT scan that showed a nice intra-articular, a little loose body there. So I was glad we actually got this CT scan, because we were able to take it out, and she ultimately did well. So there are lots of trials currently underway on how to treat this injury. But this is still my current algorithm, where minimally displaced ones don't need surgery. Widely displaced ones I still fix. And then in that middle ground, go non-op for somebody who is not requiring absolute stability to their elbow. But a thrower probably should be fixed. When I get to fixing them, I love this prone position. To fix it, it reduces the elbow and shows you everything you need to see. And then from a surgical approach standpoint, it's pretty straightforward. Approach the medial elbow. You gotta mobilize the ulnar nerve enough so that you can retract it out of the way so that you don't put it into the fracture site, which is basically the bed of your cubital tunnel. I put a couple of reduction stitches in there to help me control the piece, because it's kind of a small piece. And then pass your wire and put your screw in. I like a screw that's no bigger than a third of the piece. And if you want to put a washer in there, put a washer in there. Before the screw is finally tightened, I'll actually tie that little tensioning stitch around the screw, because it gives you a little soft tissue reinforcement of your little piece. And then always do a periosteal repair for rotational control. Comminuted fractures. This is a sportsy group, so use all your fancy sports tricks with anchors and suture passing and whatever you gotta do to get that thing refixed. And then anybody less than seven probably shouldn't put a screw in, and so we'll put two wires. And then post-operatively, our recent data basically says you shouldn't immobilize these any more than two weeks, or they'll get stiff, or you're at increased risk of stiffness going forward. So immobilize them now for like seven to ten days, and then switch them to a functional elbow brace. There are lots of things to watch out for with this fracture. It's kind of the M&M eight mile, like you only get one shot, do not miss your chance kind of thing. But it's basically just my last word on meal pecandals, make sure the ulnar nerve is happy after you fix it. If it's subluxating, if it's rubbing on your hardware, your patient will be unhappy after you fix this. So let's talk about olecranon stress fractures. Jocelyn kind of went over kind of timing of some of these physis. The olecranon physis actually closes fairly late as well. These all present with posterior elbow pain. X-rays are almost always able to get you to this diagnosis. And one clue can be that the medial epicondyle, if it's closed, but you still see a line back there at the olecranon, that's something going on. If it's in a young kid, like this 15-year-old pitcher who's been having pain for two years, we call that an olecranon stress fracture. MRI, I think, can be helpful in these kids to pick up other pathology because the literature says that there's a high likelihood that you're going to find something else going on with them. Nonoperative treatment is always probably the best way to go. If you can just kind of shut them down a little bit, that thing will almost always heal. But if they've been going on chronically like this kid had for two years, a compression screw is like wonders. This is two months after that screw went in and he had already kind of completely consolidated that fracture and was back to sports. So last then is just to say a couple of words about capillary OCDs from the pediatric standpoint. There's some interesting stuff here. So OCDs are basically the proverbial soft spot on an apple. The etiology is still a little unclear, but it almost always has to do or starts with some sort of area where the articular epiphyseal cartilage complex, that cartilage between the secondary ossification center and the articular cartilage doesn't get some good blood supply. It's either because that advancing ossification front takes out a vessel or two, or you get this chronic shear compression force that actually kind of delaminates that cartilage away from that secondary ossification center. And this is good work out of Japan, kind of trying to say that this is how they happen in capillary OCDs specifically. When that happens, you also need a second hit though to stop the repair process. So if you just back off like a lot of the other fissile injuries in kids and don't pound on this, the body will reheal itself. But if you don't and you interrupt that process at multiple different time points throughout the quote unquote healing process, you end up with all of these different types of OCDs, different presentations of OCDs, OCDs presenting at different stages that we see clinically. So as Jocelyn said, most of these are in gymnasts and throwers. Gymnasts have more extension OCDs, throwers have more flexion OCDs. They all have this kind of vague elbow activity related pain. If you think that there's an elbow OCD, get this 45 degree flexed AP view. You will miss a lot of OCDs just like you miss them in the knee. If you don't get a notch view, you'll miss them in the elbow. If you don't get this 45 degree flex view, I call it the Takahara view because he was the first guy to describe it, but most people now just call it a 45 degree AP. Interestingly enough, if you look at the US literature, the US literature says that OCDs in the elbow do really poorly with non-operative treatment. If you look at the literature from Japan, they say you can get these things to heal with casts or splints, but that green dot there that shows 90% healing rate with a cast with return to sport at four to six months, that involves four weeks, a month in a cast and two weeks in a splint. I don't know many people who like to sign up for that, but your other option is to drill them. This is a standard kind of drilling transarticular or you can go retroarticular, whatever you want to do. Salvageable lesions can be fixed. I think these are very few. I couldn't even find the one case I've done in the past 10 years, so it's not up there. Almost all of them come into my office though that I'm operating on, it's unsalvageable things. You have to decide what am I going to do with this lesion. We basically figured out based on how big it is and how deep it is. Smaller lesions that are contained, a debridement and microfracture does really well. Uncontained lesions or high level athletes like Jocelyn said, an OC autograft or allograft, the literature supports more autograft, but I got to tell you in our institution we're doing more allografts do really well too. The breakdown basically, I can't really say, we don't have time to like go into all this debridement versus OC grafting, but basically debridement microfracture works really well at getting patients back to sports, but the results decrease over time. Then you always have an osteochondral graft you can fall back on if they don't do well versus your osteochondral grafting which has more durable results but fewer salvage options. With that, I'll basically just say immature elbows are more susceptible to injury because of all the growth plates there. Thanks. Thank you. Okay, so next we have Mark Richard talking about the mature throwing elbow. All right. Good to see everybody here. I'm going to continue what Todd was talking about and talk about when these kids are a little bit older and their growth plates are closed. Disclosures, none of the consulting ones are relevant except I do some consulting with USA Baseball which is if you had an intact UCL you could hit their office from our old office with a baseball. My other disclosure that's worth something is I'm an unapologetic Red Sox fan so any gratuitous pictures of baseball players, this will be Red Sox players. For me, this is my son plays baseball, I love baseball. He's going from Todd on the left there to me on the right there now that his growth plates are closed and we've got to keep him healthy the whole way. So overview, we're going to talk about the problem, we're going to talk about the risk factors, examine diagnosis, we're going to talk a bit about repair versus reconstruction and where we are with that as far as techniques and return to play and a few slides at the end I'll post your remedial impingement. So this is the thing that gets a lot of kids in our clinic and the misunderstanding of this and what it can do for them is also a big conversation point in clinic. And this is a wonderful book if no one's, if someone hasn't read it, it's older now so I think a lot of people have but this is Jeff Passon, Yahoo sports writer who points out in this nice book that baseball is a $10 billion a year industry, $1.5 billion a year spent on pitchers at the time. It was more than the top 200 NBA contracts and more than five times all the NFL quarterbacks put together. Those contracts have gone crazy so I don't think that's true anymore but this is guaranteed money unlike a lot of them. So when they tear their UCL, they still get their contract and if you look, this is just a couple years ago, numbers have only gone up. These five guys were $1.2 billion worth of money that they're guaranteed whether or not they have and you can see some familiar names there with some UCLs but that's something that everybody's a little bit interested in helping figure out. So MLB experience, they're certainly going up. You look at those numbers there, maybe 10 years ago, 20s, one year at 30. This is this year. The pitch clock is now in play for the last two years. At the current pace this year, they were on track for 52 players which is way more than ever. They were 31 last year which is a record and the 10 years prior averaged about 25. If you look at the timing of injury, I don't know how they calculated that number per se because most of them are in the beginning of the season. I think that's what we feel. These are the kids that are coming in in March, April, May and then it drops off for a while and there's something to be learned there as well, I think, with workload and volume. Most of us don't take care of the professional guys. We get the college guys and the high school guys but it's the same pathology so it's important for us to understand this is local, this is ACC a couple years ago. This is the list of players who started the season with Tommy Johns already done. 41% of them were done in high school so they came into their college already having their Tommy John done. Another study just looking at Tommy Johns in college players, if you look at the numbers in the circles there at each position, 115 in pitchers, no surprise, but about 15% of all college pitchers have had a Tommy John as well so it's affecting those age groups that we take care of as well. So a couple slides on why. Is it technique? Is it volume? It's probably a combination of the two. From a technique perspective, I do think that there are bad mechanics that get drawn through the younger ages and carried into the bigger ages when kids are bigger and stronger. Also Major League Baseball has changed. It used to be this short stride, it used to be this long stride drop and drive kind of delivery like Tom Seaver there, now it's just these big guys throwing downhill. The short stride, so it's a different mechanics than it was before. We all know Tommy John himself had this with Frank Jobe and then played 14 more seasons. You can see all the stats there. Incredible remainder of his career after that and that's what really set a lot of this into motion for the fervor and some of the misperceptions about how good this operation can be. This is one of the, I'm going to talk about two technique things. This is the inverted W, which I have to just, a little aside, I have to just say with a name like Mark, where there's an M that I write every day of my life, a little bit bummed that we don't call it the M because there's a word for that, we don't have to call it inverted W, we call it inverted W. So if they're internally rotated and abducted such that their elbows are high, that's something you'll see if you're watching a lot of baseball. All those guys and then John Smoltz here, all these guys underwent Tommy John, so some thought that that may predispose to undue stresses on the elbow. The other one's flat arm syndrome, which is essentially a low degree of shoulder external rotation or even worse, in some internal rotation at the time of foot strike and really what it is is a timing issue and if you're already at foot strike and your arm's not up, you have to get it up and then get it back down and that changes the mechanics of throwing. So ideally you want to be at 75 to 90 degrees of external rotation at foot strike and then have that sequential transfer of energy. So is that true? This is, these are the team docs for the Nationals who looked at this, they reviewed a lot of MLB tape and identified those two technical syndromes, if you want to call it that, the inverted W and the early trunk rotation and when they went through, they had good agreement that they could identify those two things, but when they looked at the inverted W, the hazards ratio that they calculated did not show an increased risk of upper extremity injury, whereas that flat arm syndrome did. So I'm not a pitching coach, I don't pretend to be a pitching coach, when the kids come in and I try to get them plugged in with the right people, that's one of the things that our PT looks for. What about pitch count and volume? It gets complicated in the older ages because of money. But it is, we have seen a couple entries into it. Matt Harvey, a couple years ago, when his agent put him on a pitch count in the playoffs with the Mets, it didn't go over very well. But we're starting to see it creep that way. This is just a very interesting study from Romeo's group looking at the frequency with which Major League players had Tommy John. And my son plays with the Duke coaches' kids and I think I've annoyed him to death at many, many baseball games asking him about all the things he thinks about. But he always says that their old adage is you want your pitchers from the north, you want your hitters from the south, you want your hitters playing all year round, but you don't want guys coming in that have too many miles on the tires. So he looks for pitchers from the north. And this was a study that really validated that. What they did is they took the 33rd parallel because that's the last temperature in January that is above freezing so theoretically could be pitching all year round. That's that red line. And any state that's in those is warm weather. Anything above it is cold weather. So North Carolina where I live is slightly on the cold weather side. And then they looked at the Major League players from that group and what percentage of them had Tommy John. So if you look, about two-thirds of all pitchers, 65% Major League pitchers were from those cold areas and 35% were from warm areas. But here's the warm weather guys. The blue bars are the percentage of overall players that are from there. See the spike there? A disproportionate number of them had Tommy John. And then if you flip it and look at the cold weather guys, much lower on the red. So the higher proportion of players from the cold but fewer of them were having Tommy John. And then he looked at a couple of other things, age at time of surgery. Pitchers from the warm areas had Tommy John surgery sooner. And then years pitched in Major League prior to surgery, they made it, warm weather guys made it less into their careers before they needed it. So interesting things about volume. Let's just kind of shift towards the clinical side. The anatomy of the UCL I think we're very familiar with. It's really that anterior bundle that is most important to resist valgus stress. And it's about four to five millimeters wide. Posterior and transverse don't seem to add much to valgus stability of the elbow in the throwing motion. There's an attachment obviously on the deep surface of the medial epicondyle. It's a little bit deeper than that superficial if you're looking from medial to lateral. Important to know where that footprint is for reconstruction or repair. And it's about 9.6 millimeters as far as the size of that footprint. And then distally we all know that it's at the sublime tubercle of the UCL. And it's about 24 and a half millimeters in length. It's a little bit more distal to get there when you're operating on these than you typically think about. As far as history and physical exam, these kids will come in and these guys will come in and say that they felt a pop and then their pitches started staying up and they lost velocity. It's because they can't follow through anymore. Their release point is a little bit sooner. The specific, they'll be tender to palpation over the ligament. And then moving valgus stress, which is applying a valgus force over an arc of motion. If they're tender in the mid portion between 70 and 120 degrees of flexion, then that's a positive test. And it's supposedly 100% sensitive. And then the milking maneuver, which I can't do, but you put your thumb out. So you're supinated and flexed. You reach, thanks, Jocelyn, I always tell the kids, that's your udder and you're trying to milk yourself. So get to your udder and milk yourself. And they put their own valgus force on. And if that causes pain, then that's positive as well. Imaging, we get plane radiographs. All these kids who have open growth plates get the contralateral side. As we're getting to the older age groups, you don't see a ton except for maybe some previous wear on the elbow. But MRI and specifically MR arthrogram, so the addition of an arthrogram to an MRI significantly increases the sensitivity and especially the specificity. Look for that inverted T sign that you see there on the right for a distal injury to the UCL. So as far as treatment, nonoperative, this is 20 years ago, but nonoperative treatment in these overhead throwing athletes does not work out very well. Forty-two percent return to sport rate and that's not acceptable for any of the players that we're taking care of. What about partial UCLs? And this is a study out of Curl and Jobe with PRP. To be fair, there's no control group. There's no PRP or the rest in the rehab. But 88 percent return to sport rate. And when you talk to these players in clinic, they are all up for something that's really only risk is to their wallet for the PRP since it's their own blood that's going in there. The actual, when I have these players with partials, this is a paper by Buddy Savoie where he did two PRPs. And I've been employing this one recently and I've been happy with it. What I liked about his study is he did two, two PRP two weeks apart and then he repeated MRIs afterwards and showed reconstitution of the UCL and all those. So guys who don't want surgery and want PRP because of where they are in the season, this is what I offer them with our non-op sports partner who does all this under ultrasound guidance. And here you can see a representative image there with a reconstitution of the UCL on the right. So what about operative, pure ligamentous primary repair, augmented UCL repair and then reconstruction? We'll talk through that quickly. Jocelyn talked about this. We looked up our own series. It was small. It was a lot of athletes, some of who were baseball players. But repair with normal tissue is just different. Around that same time, it was about 15 years ago, Buddy Savoie had a larger series of 60 athletes with repair showing that some of these guys actually do really well. This is before the rage of augmented repairs with the internal brace. But this is the paper I think that we all know out of ASMI with 111 players and a 92% return to sport rate and really very good outcomes. And this has changed the way that we think about a lot of these players and getting them back on a quicker timeline. As far as the popularity and the acceptance in the elbow community, this is a consensus statement. 26 elbow surgeons, three PTs and ATCs, a whole bunch of professionals. Societies validated Delphi method and strong consensus among the group for when you should repair and when you should reconstruct. So I think this is something that our community has accepted. As far as reconstruction, there's been an evolution there with the techniques. And you can see them over the years with the figure of eight and the triangular and linear constructs. And represented graphically here, you can see the different styles. I personally do a docking technique for mine. I think we probably all have little variations on which ones we do. But the good news is that a lot of these work for the problem that we're taking care of. So whatever you're most comfortable with is probably the way to go. So let's just finish with two quick cases here and then a word or two on post-remedial impingement. Partial UCL tear, I'll just kind of take you through a case. This one, the MRI here, has a distal tear. And you can see it there just off the sublime tubercle with that T sign. And you always look at your axial as well because a lot of times you can see it peeled off the sublime tubercle, as you see there. This is a different patient. This is a proximal tear. When you go in, if you've not operated on these before, these are not the ligament torn off just waiting for you to put it back on. You have to make a little leap of faith and actually take down tissue that appears to be intact. And if you look here, this is a proximal tear. As I take this elevator and push up, you can see that there's not good, reliable tissue there. It's not what you would expect. I can easily push into it at the insertion or the origin at the deep surface of the medial epicondyle. And you can see when I put the pickups on it, there's a lot of normal tissue there. But it's not just falling off waiting for you to fix it. So I always identify the only humeral joint with a needle and get an X-ray in there to make sure I know where my sublime tubercle is and my proximal one. Here I am preparing that torn end of the UCL. There's a crack out for that torn end. And we're going to go back in with the internal brace here. And there's the internal brace at the end. X-rays don't really show much other than the hole for the internal brace. UCL reconstruction is an 18-year-old college pitcher who has a rather beat-up UCL, both proximal and distal, and kind of some thinning tissue in the mid-substance. So medial approach, I've gone back and forth on FCU split or just posterior through the floor of the cubital tunnel. I used to, if there were no ulnar nerve symptoms, I would do an FCU split. I'm a hand surgeon. I go for the ulnar nerve all the time. So I have to say it more times than not now. Mobilizing the ulnar nerve and just coming through the floor of the UCL rather than through this FCU split. But here you can see the sublime tubercle. There's the joint there. And it's always a little more distal than you think. I have no conflict here but I do like this from the Arthrex set. That lets you make a little bone tunnel where the ends meet because I do not want to fracture the ulna there. So there it is in play. I always use C-arm to look at this. I like Palmaris when I have it available to me. And there's the passage of the UCL distally. And then they do have a nice little kit that helps you with the docking technique if that's what you choose. And there it is employed there so they can dock it into the medial epicondyle. So what about return to the same level of play? 86, it was 63%. I think despite all these techniques we're now in 86, 87%. That's what we get. But that's not what our kids care about. That's not what the players care about. Baseball is more statistics driven than anything else. So looking at how they do when they get back is important. Return rate by appearance after Tommy John goes down. Return rate by innings after Tommy John goes down. This is the 86% that were successes. Their velocity drops only a mile an hour, but it makes a difference for these guys at the highest level. This is a paper that we actually started doing with one of our residents, but Bill Matsouris in Detroit beat us to it. He took players on the list who had a Tommy John, 168 of them, looked at their statistics for the three years before and their statistics for the three years afterwards. ERA went down. WHIP went the wrong way, went up in that case. Then innings pitched went down as well. So all their metrics go down even though they make it back to sport, and that's important to know. As far as the repair of the ulnar collateral ligament, this is the paper that has the rehab that we all use. It's at five months. I tell these players they get back at six months after a repair. This is the paper for the rehab for Tommy John that I think a lot of us use out of Andrew's group. If you look at the systematic review looking at what all these rehabs had in common, they all had three things, completion of return to throwing program, completion of return to mound program, and minimum time from surgery, typically a year. And in this meta-analysis, it was 12.2 months. Last couple slides, posterior medial impingement. Really the question for me is, is this always associated with UCL instability? It may represent it, but is it always there? That posterior pain and deceleration after ball release and painful mechanical symptoms. This is the biomechanical study that looked at resection of three, six, and nine millimeters of the Electronon to see if it created increased strain in the UCL, which it did. So the take-home point here is only take off the osteophytes, don't get into the native Electronon. If you look at how they do, this is a recent study looking at 49 patients with posterior medial impingement, 13 of them had concomitant UCL insufficiency, 36 did not. 11 of them were before surgery, two of them were during the post-op period. They all did well, though. They got back. These players do a lot better than your Tommy Johns. And when you look at it, 1995, it was a quarter of players had posterior medial impingement associated with UCL instability in their study. More recently, in 2018, it was 27%. So about a quarter of them will have instability, and that's something you need to look out for. Thank you. Okay. All right. That was a whirlwind. It's all right. Almost cut you off. All right. Tyler Pidgeon, also one of my partners here, is going to talk about recalcitrant tennis and golf results. All right. I know everybody needs to get to dinner, so I'm going to try to get through these quickly for you and get to Dr. Klypto's talk. These are my two colleagues. I don't think any one of these is really relevant for this talk. So starting with golfer's elbow or medial epicondylitis, less prevalent than lateral epicondylitis, but it does affect about 3 to 8% of occupational setting workers. Causes of common flexor tendon microtrauma or degeneration, 26% of people will have symptom recurrence after initial successful non-operative treatment. Only 5 to 15% ultimately require surgery for this. The anatomy, common flexor tendon, the most important part of it, there's five muscles, but the pronator teres is the one that's usually involved. The pronator teres is also the active stabilizer of the elbow during throwing motions, so that's kind of important to what we throw back to Mark's talk. If you start losing your pronator teres as an athlete, you can start risking your UCL. It arises from the medial epicondyle, the humerus. There's attachments to the UCL itself. There's also some attachments to the onohumero joint capsule. But again, the pronator teres is the key there. In terms of pathology, we're looking at repetitive eccentric loading of the common flexor tendon. That's usually with wrist flexion and forearm pronation, and ultimately you get an angiofibroblastic hyperplasia, which is essentially a tendinosis and not a tendinitis. This combines with valgus overload of the elbow, particularly in throwers, and you get injury to that pronator teres origin, so you lose the dynamic stabilization of your elbow in an athlete, and you start to worry about further injury to their ulnar collateral ligament. In terms of presentation, the patients will usually describe a medial elbow pain. It usually has an insidious onset over the medial epicondyle. It can be worse and radiate into their forearm, and it's exacerbated by activity. There's no one sport that this happens to, even though we call it golfers elbow. Anybody with overhead throwing can get it. Golf, tennis, football, weightlifting, and bowling as well. And in occupational settings, it's usually associated with forceful grip or heavy lifting. There are two types of medial epicondylitis to be aware of. It's pretty easy. Type one means they don't have ulnar nerve symptoms, and they have a 90% chance of recovery with non-operative management, and then type two, they have ulnar nerve symptoms, and there's a much less chance that they're gonna recover without you intervening. Type 2A means that they have the symptoms, but you can't pick it up objectively. Type 2B means that you can pick it up objectively on exam or with an EMG. In terms of exam, they're gonna have tenderness over their medial epicondyle, or maybe just a little bit distal to it. They'll have pain with resisted wrist flexion and forearm pronation. They have decreased grip strength, and then a lot of them will have normal elbow range of motion. But particularly in athletes, you wanna look out for injury to the UCL. So going back to Mark's talk, you wanna do a milking test and a moving valgus stress test in an athlete. And then everybody, you wanna look for ulnar nerve symptoms. In terms of concomitant ulnar neuropathy, it's a common issue with medial epicondylitis. They'll have decreased sensation over their small finger and the ulnar half of their ring finger. They may have intrinsic weakness in their hand. They may have a positive tunnel sign or a positive elbow compression test. And then you wanna look out for ulnar nerve subluxation on an exam, because that's something that you'd wanna address at the time of surgery if you choose to operate on their medial epicondyle. In terms of imaging, radiographs are usually normal. Maybe 25% or so have some calcification, but it's really not gonna push you one way or the other. Ultrasound has a pretty high sensitivity, specificity, and negative predictive value, but it's operator dependent. An MRI is the gold standard. If you're going to get a test, this is a clinical diagnosis in many people, so you don't have to get one. But if you have an athlete and you're kind of worried about maybe it's medial epicondylitis, maybe it's ulnar collateral ligament injury, maybe it's both, then an MRI can be helpful. In terms of conservative management, it's everything that you might think. It's ice, elevation, activity modification, splinting, et cetera. I think the big one to talk about is what Mark had alluded to for the UCL is PRP or steroid. I think steroids are no-go. This is a tendinosis. It's not a tendinitis, so steroids shouldn't be helpful, and I don't think the literature says that it is. But PRP might be helpful in medial epicondylitis. I won't spend too much time on PRP because we already know what it is, but it's basically autologous blood that's centrifuged down to increase the platelet content. It has high growth factors, and it can stipulate healing. There are some studies that show that PRP is just as good at surgery for something like medial epicondylitis. One of those studies specific to medial epicondylitis is in the OGSM, OJSM, excuse me, 33 patients with type 1 medial epicondylitis. They split them into surgery versus PRP. They had two injections for PRP, and in this study, they essentially showed the same amount of treatment success, but the PRP patients went back to full range of motion earlier, and they had time to pain-free status, which was much quicker. So definitely something you can consider. This is another study on PRP out of the Orthopedics Journal. 26 patients, only eight of those were medial, the other were lateral. But again, they showed about 90% effectiveness. So probably something to think about. In terms of surgical management, you want to have patients that have persistent symptoms for four to six months before you operate. The one caveat to that would be in an athlete that has a definitive tear, you may want to consider operating earlier. In my hands, this is going to be an open debridement with an anchor and repair back. That's kind of how I like to do it. And then if anyone has ulnar nerve symptoms, I'll do an ulnar nerve release. If they have subluxation either pre or post the ulnar nerve release, I'll do a transposition. In recalcitrant cases that fail surgery, 20 to 24% of those patients require ulnar nerve release. So it's probably one of the reasons people have to go back to the OR is that was missed. This is one study that looked at that specific debridement and repair that I talked about, and they showed improvement in elbow scores as well as improvement in pain scale. And then this is another one using that same technique of repair with anchor, and again showed 86% return to sport with older age predicting better outcomes. Both of those studies did demonstrate about 10% to 20% of people needing their ulnar nerve addressed. So going on to the lateral epicondylitis, this has a higher incidence than medial epicondylitis. Also insidious onset, lateral elbow, affecting the common extensor tendon, 97% symptom relief at two years if you do absolutely nothing. So that's important in the counseling. Only 4% to 11% of patients ultimately indicate for surgery, and less than 5% of them have surgery. So that's something to be thoughtful about. For the anatomy on the lateral side, this is the common extensor tendon. There's multiple tendons that insert there, but the one we always think about is ECRB. That's the one that's affected by lateral epicondylitis. That arises from the lateral epicondyle, the humerus. It's very intimate with the LUCL, so during surgery you have to be careful you don't accidentally debride the LUCL. And then it's also intimate with the interlateral elbow joint capsule. I think anybody who does an open release has had that icky feeling where you see the joint fluid coming out, you debride it a little bit too much. In terms of presentation, gradual onset of pain over the lateral elbow, similar to medial epicondylitis except for the opposite side. Patients will have pain when they lift with pronation, and that's a good way to test them. And this is really a clinical diagnosis. For physical exam, again, pain over lateral epicondyle, pain with resisted wrist extension, that's the Thompson test. And then in my office, I'll actually have them grab the back of a chair in pronation and lift it up. I mean, I think that's about 100% sensitive for lateral epicondylitis. I have a lot of pain with that. Imaging, I don't think it's worth talking about too much for lateral epicondylitis. Essentially, less than 1% of cases will change your management based on X-ray. Ultrasound is only about 60% to 80% sensitive. MRI has a higher sensitivity, but it's not very specific. In fact, a lot of times when a PCP sends me one of these patients with an MRI, they say it's an LUCL injury. It's almost never an LUCL injury. It's lateral epicondylitis. So not particularly helpful. Pathology, just like amelial epicondylitis, this is an angiofibroblastic tendinosis, not a tendinitis, so steroids don't help. Under the microscope, you can see apoptotic and autophagic cell death, and type 1 collagen is converted away. You have less type 1 collagen as the disease gets worse, so you have a weaker tendon. Conservative management, there's no clear superiority of a non-operative treatment. There's no one thing that does better than other things. So you can kind of throw whatever you want at it. The big thing is to counsel patients that's self-limited, and a vast majority of people are going to get better regardless of what you do. NSAIDs do have a modest short-term benefit. There's some studies that show counterforce bracing is helpful. There are other studies that show that therapy is more helpful than bracing. And injections, I think, are essentially not recommended. The most recent studies show that patients will get a temporary relief with steroid, and then they come back worse. PRP, on the other hand, I think has some conflicting evidence. I actually, at lateral epicondylitis, I had PRP. I believe in it, but the evidence is conflicting. This is a recent study, JBJS Reviews 2023, where they looked at non-operative treatments, and their grade A recommendations was rest, activity modification, and NSAIDs are helpful. Their grade A recommendation on steroids was they do not provide any significant therapeutic benefits, so do not use steroids. And then in terms of platelet-rich plasma, they said there's similar levels of improvement of pain and function to control. And that was borne out as well in this Cochrane Review. This was done in 2021. They looked at all RCTs and quasi-RCTs for PRP. They had 2,000 patients, and their conclusion is that the data does not support the use of autologous blood or PRP injection in lateral elbow pain. It probably does not clinically provide significant improvement compared to placebo. So I think there are studies that show it helps. There are studies that show that it doesn't help. I had it for my own elbow. But you probably should counsel your patients that it's not the end-all, be-all. In terms of surgery, 2 to 11 percent of patients are indicated for surgery, but only less than 5 percent actually undergo surgery. In terms of indications, they should really fail at least 6 to 12 months of conservative management before you take them to the operating room. And there's a variety of different types of surgery. Debridement, debridement with repair, arthroscopic debridement, and then I'm going to talk to you about ankyneous flap, because I think that's something different I can offer you as a hand surgeon. Just a quick talk about arthroscopic versus open, since this is a sports conference. There's a lot of studies that have looked at them, and there's a lot of studies that have compared them. And the bottom line, if you look at all of these studies, is that both techniques are acceptable. Arthroscopic technique is probably better if you suspect that there's something intraarticular as well. So if you're trying to treat two things, you should do it arthroscopically. If you're trying to treat just the lateral epicondylitis, the patients do about the same. So the ankyneous flap, this is kind of the meat of what I want to talk to you about as a hand surgeon. The ankyneous is this small triangular muscle in the proximal-posterolateral forearm. It's expendable. We use it to cover soft tissue defects over the olecranon. I actually use it when I do bursectomies, if people have finally talked me into removing their bursa, I'll put the flap over to prevent dehiscence. The big thing you need to remember is the medial collateral artery that is the number two up there on the list, you can see that's coming in from posterior. So you can lift that whole triangle of muscle without injuring that artery, and that'll give it a blood supply. You identify the ankyneous just off of the posterior border of the ulna, and then there's a fat stripe between the ankyneous and the ECU that allows you to exploit that area and lift the whole thing up. So here's me intraoperatively. I'm doing an ankyneous flap on this patient. You can see the lateral epicondyle, the ECU, ankyneous, and ulna, and then in the picture on the right there, you can see I've lifted it up. This was a pretty meaty one. They're not always this big, but you can see you get a nice piece of flesh there. And this has been studied. This was actually at Duke where they compared ankyneous flap versus no ankyneous flap in a debridement of lateral epicondyles, and they showed better VAS scores and better DASH scores at the end of the study and the patients that had the ankyneous flaps. There's probably some benefit to it. So I want to get going on to Clipto's talk, but just a very quick case. This is a 51-year-old patient, lateral epicondylitis for many years, exacerbated by using a hammer. You can see he came to me with an MRI that shows that he tore off most of the common extensor, so we took him to the OR. This is my approach. I go a little bit more posterior than you normally would because I want to get to the ankyneous. You can see once I opened up his fascia, he had completely avulsed off everything except for his LUCL, which was nice for me because I didn't have to have an instability case at this point. So I debride all of the poor tissue away. I place an anchor to get ready to repair. And then I mark out that ECU ankyneous border, which you can see in a very subtle fat stripe, which becomes less subtle when you split the fascia. You can see the fat there between the two structures, ECU and ankyneous. And then I raise up my ankyneous, knowing my MCA is coming in from the back, so I just stay deep so I don't injure it. All of that white tissue underneath the ankyneous is your joint capsule and your LUCL, so you just need to stay only on muscle. And then I do my repair, and I flip the ankyneous over. I do the repair, provides it a new blood supply and some padding. And then this is what they'll look like when they're all closed up. Post-op, soft dressing, light strengthening at 6 weeks, return to full activity at 12 weeks, starting early range of motion at 10 to 14 days. Thank you. All right. So Chris Clifto is going to bring us home with the very frustrating management of the athletic but arthritic elbow. And hopefully we'll have a little time for questions. »» All right, awesome. So I'm going to get this pretty quick. But I'm going to be talking about the challenging patient who has elbow arthritis and still wants to get back to sports. So these are my disclosures. So I'm going to start with the case presentation. This is a 38-year-old male crossfitter, SASPOS MVC, had electromagnetic fracture requiring RIF. He was later presented to us with a stiff elbow with very little range of motion, otherwise healthy and referred by an outside surgeon. So here are his x-rays. In the office he had a post-incision, essentially no range of motion, had a fixed contracture but was neurovascular intact. And here is his post-operative or his pre-operative imaging. So as you can see, he has a pretty stiff elbow with a lot of heterotopic ossification. Here's a CT scan confirming that, if it please. So a lot of HO, very little joint space, a lot of OA. So this is an extremely challenging patient that we see more frequently than we would actually like. Here's his range of motion, the OR, very little range of motion, especially for an athlete who wants to get back to CrossFit. So the decision we have to make is, is the elbow able to be reconstructed? What approach would you use? Are there any specific considerations given to HO? What positioning implants, et cetera, do you use? And specifically for a sport, how do we get him back to that? So there are two basic principles. Is it intrinsic or is it extrinsic? And intrinsic causes are usually intraarticular pathology, which are loose bodies, osteophytes, post-traumatic arthritis, or dislocations. And this is an example of a patient that we had that had an intrinsic example of intraarticular pathology. This was specifically a plate, as you can see on the bottom right side, that blocked his motion causing arthritis. Prevention is always the best treatment. We want to do anatomic reductions in the OR the first time around. We want to do the least invasive possible approaches as possible. And these are mainly paratricipital approaches versus electron osteotomies to try and decrease HO. You want to start early range of motion with therapy. You want to support for less than 10 days after surgery. And you want to do immediate range of motion after these fractures for athletes. Mark had a great paper a few years ago showing that perioperative steroids actually decrease HO in patients who are especially athletes. So risk factors for HO. There are two great studies that I found looking at that. Studies show that intraarticular fractures have a higher rate of HO, and they're usually present on two weeks. So you can see these early on and start prophylaxis. And I actually did another study looking at HO patients performed versus patients who just need contracture releases. And HO patients actually outperformed just straight contracture releases. So extras it causes, well, they're typically due to pathology like HO, burns, head injuries, ligament contractures, capsular adhesions, and dislocations. But again, HO is the most common reason for this. The treatment algorithm, if it's less than six months, you would do non-operative treatment which includes serial casting, static or progressive splinting, dynamic splinting, continued passive range of motion, Botox or manipulation. And again, here's the CT scan of our patient versus a 3D reconstruction which shows significant HO and osteoarthritis. So functional outcomes. We all know this. We want to get patients back to 30 to 130 degrees with 50 degrees of pronation versus 50 degrees of supination. Isolated flexion contractures are usually due to tight anterior capsules. Isolated extension contractures are usually due to tight posterior MUCLs. And mixed contractures are the most common. They can be caused by peripheral osteophytes contractures of capsules, HO, or articular step-offs due to dislocations. So when we're thinking about HO, it's usually multifactorial. The elbow and the hip have the highest predisposition of any other joints. Trauma to tissues, bleeding, and head injuries are the most common reason for formation. We know this prophylaxis, but an emethicin of 25 milligrams TID versus radiation therapy are good adjunct therapies for patients that you're concerned about. And again, this is another example of an extrinsic example. You can see calcification HO of the MUCL of the patient at a dislocation. And then these are typically the intraoperative or rather range of motion deficits of these patients have. So the question is, when you have patients that have these contractures, what do you do with the ulnar nerve? And for me, I always do an ulnar nerve decompression and transposition because you can see how tight the ulnar nerve can be on the bottom right side if you don't release it. And here's an example of that patient in the operating room after we did the contracture release. And you can see how tight the ulnar nerve is if you don't transpose it. So when do you transpose the ulnar nerve? Well, this is a great study showing that if you have over 100 degrees of flexion after your release, then you probably should transpose the ulnar nerve. When do you do arthroscopic considerations for OA? Well, typically, we do that for patients that have terminal flexion or extension loss. They have loose bodies. Anterior capsule releases are typically performed. We try to remove bony osteophytes from the olecranon. And we move osteophytes from the olecranon fossa as well. This is a great study showing recommendations for when you should do arthroscopic releases. And typically, patients who have rheumatoid arthritis or lateral condylitis perform the best with our arthroscopic surgeries. This is another great study looking at functional outcomes after arthroscopic release. They found a significant improvement in range of motion arc and relatively low incidence of neurovascular compromise. But when neurovascular compromise does happen, they typically happen at low rates. Roughly 2% of people, the ulnar nerve is the most commonly affected nerve. They found a higher incidence of infections when corticosteroid injections were administered at the time of surgery, so they recommend not to do that. And they said if you're ever worried about the nerve, to do a small incision and evaluate it. So my preferred method for OA in patients who are young and athletes are to do arthroscopically if I can. I try to remove the loose bodies. I do the capsule releases, specifically the anterior capsule, and I remove all osteophytes in the joint. And then I do a mini open posterior incision to remove the olecranon osteophytes, look at the olecranon fossa, and look at the ulnar nerve. So finally, we'll talk about open releases. You know, there are a couple of windows when you're looking at open releases for contractures. I like to do the column approach, which you can see right here, essentially working above and below the LUCL. And you can go anterior, remove the anterior capsule. You can go posterior, remove all the olecranon osteophytes in the posterior capsule. And then I usually move to the medial side and remove the posterior bundle of the MCL after transposing the ulnar nerve. So again, this is a lateral approach, and you can see it's essentially in between the Kaplan and Kocher approach, which is between the ECRB and the EDC, and then versus the ECU and the ankyneus for the Kocher approach. So outcomes, well, you know, for open releases, people do pretty well. There's an improved arc of motion of five years, and they actually didn't use CPM. But I mean, it's not great, right? Like they only get to 98 to 131 degrees of increased flexion, and the arc was only 30 degrees of improvement. And then another study looked at, you know, the total arc of improvement. Again, they looked at 103 patients, and they found only 52 degrees, which, you know, for patients who have very little motion, still isn't great. Again, this is our case presentation of the patient who had the failed OIF. And for this patient, we actually used a dermal allograft for a significant osteoarthritis. And here's his motion postoperatively after we did the release and used the dermal allograft. So just briefly, you know, dermal allografts, you know, we really interposition arthroplasty. You know, they don't do great. This was the best study I found that showed a systematic review. The complication rate and reoperation was 44%. 22% required a repeat interposition arthroplasty, and they had no recommendation for achilles or fasciolata. So, you know, if you're going to do this procedure, expect a high complication rate. So this is our patient six weeks post-op. You can see, again, not great range of motion, but better than he had before. And in summary, know your indications for post-traumatic arthritis, HO versus post-traumatic releases, arthroscopic versus open. 3D CT imaging plays a huge role in determining bony blocks. Prevention is always the best form of treatment. You always have to manage your patient's expectations. They're never going to be normal. You have to tell them that right off the bat. And HO excision does better than capsular contraction. So tell your patients that. And always document your neurovascular exam prior to surgery. Thank you. »» Wow. That was amazing. You did that so methodically. Does anyone have any questions for any of our speakers? It's 6-11 and it's Friday. But if anyone has any specific questions? No? Looking at Gus. Nothing. Okay. »» I'll just use this to say, go Red Sox! »» Yeah. Yeah. That's where we're headed. We're headed to Red Sox. Okay. I did have one. Oh. Did you have a question? »» No. »» Okay. »» I have a question. »» I have one. Oh. Did you? I have one. About the okay procedure. When are you guys, not you, Todd, because you don't do that, but when are people indicating the okay procedure? »» I use it for that person that comes in and they're definitely not a total elbow because they need to bear more weight than five pounds. But they need something. done and they've got arthritis. We don't want to go all the way up to the interposition arthroplasty, but they've probably failed or they're beyond just the simple debridement. And I've actually been really happy with that procedure. I think people do really, really well. Yeah, I would say the purest indication is when they're painful at terminal flexion, terminal extension. So if they have a relatively normal looking joint, but they hurt when they come all the way up or they're carrying something heavy and they have load on an extended elbow, they do awesome. That's the best scenario. Every time I tell someone I want to send you on my partner so they can drill a little hole in your bone so you can bend and straighten it more, they seem to think that's really strange, but I'm like, no, it works. Trust me. All right, well, thank you so much for attending and I think we'll wrap up. So, thanks. When you do a picture.

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