Brian Lau:
Hello. Welcome to the Arthroscopy Journal Podcast. Brian Lau from Duke University and today I have the privilege of speaking with Dr. Brandon Erickson from Rothman, New York. He's a assistant professor at NYU, one of the assistant team doctors for the Philadelphia Phillies, as well as a member of the Major League Baseball Research Committee. We're going to be talking today about his paper published in Arthroscopy on the elbow ulnar collateral ligament tears, a modified consensus statement. Brandon, thanks for joining us and how's everything going in Philly?
Dr. Brandon Erickson:
Good man. I'll tell you, Brian, I appreciate you guys having me on. I try to do the couple games down in Philly a year and then I always cover the Phillies and they come up here to New York so I don't have to travel too much, which is not too bad. Started with Rothman up here a couple years ago when they opened up in New York and been doing a good amount of work on the UCL and trying to figure out exactly what we should do for some of these tears. Hopefully this paper will give some answers. Probably didn't answer every question that's out there, but hopefully gave some answers to some of the questions surrounding UCL tears.
Brian Lau:
Yeah, obviously UCLs get a lot of press with baseball and there's a lot of misconceptions with it amongst the general public and with players and coaches and so I think the more we can understand about it and the more we can disseminate accurate information, the better. I think the first question is, it's a unique setup that you guys did for this paper in terms of the modified consensus statement and maybe just speak a little bit of how that was formed, how the group was formed and the process a little bit just so we have a bit of an understanding of the methods of how this process took.
Dr. Brandon Erickson:
Yeah, so I'll tell a lot of this work, Eoghan Hurley, who's actually with you now as a resident, did while he was a research assistant at NYU and they had started doing this modified Delphi statement for patellofemoral issues and for some shoulder instability. I was part of that work group that did it and I was pretty excited about trying this for a UCL tear since again, it's one of those black box things where we don't have all the answers for. What we did was, we came up with a group of 26 surgeons and rehabilitation either therapists or docs that work in the rehab sector and we formed these four groups, four working groups. We had a group that was tasked with the non-operative treatment of UCL tears, one that was tasked with the operative treatment, one that was tasked with rehab and return to sport and one that was tasked with just diagnosis in general.
We divided the 26 members up in those groups. Obviously all the rehabilitation people were involved in the rehabilitation section. The other surgeons were all sports and/or shoulder and elbow trained either from the United States and we had some of our international colleagues, including some of our colleagues, Dr. [inaudible 00:00:35] from Japan was involved in this as well. What we did, we set up a group of questions for each group and then the people that were involved in each working group went through and answered those questions and then we did several rounds of questions to get down to specific statements that were then either agreed upon or not agreed upon by the members of the entire working group. When you see in the paper we have the percent agreement that's with everybody within the working group, all 26 people weighing in on that.
Brian Lau:
It seems like you basically had the working groups do an initial breakdown of different questions, but everyone, the whole committee had final say on the final consensus. Is that right?
Dr. Brandon Erickson:
On the statement, yeah. The statements got developed by the working groups based on some questions that were asked to everybody and then the entire group of 26 people gave the consensus answers to those statements.
Brian Lau:
Yes. Was this done in an in-person meeting or zoom and how many iterations of these questions at times did you go through it?
Dr. Brandon Erickson:
Lot of REDCap surveys, my friend. None of this was really done in person. We had some email chains that went around and then we had a lot of REDCap services so that all the answers to everything could be anonymous. The entire thing was anonymous for everybody and it just depended on how many times we had to break down each question to get consensus amongst the group before we posed the statement to the entire group. It was somewhere between sometimes three to four rounds of it just adding and subtracting based on what the working group thought was appropriate.
Brian Lau:
There is always that balance of having discussion but also keeping things anonymous. I think you guys did it. This technique is really, really good and obviously Eoghan who's here has been a real pioneer in this and trying to push us for some of other different things as well. I thought maybe we'd go through the paper the way you guys did in your working groups and just talk about each of the four different topics a little bit.
Dr. Brandon Erickson:
Sure.
Brian Lau:
We'll start with diagnosis and maybe you can comment on a few things that you thought stood out and then you can go from there.
Dr. Brandon Erickson:
Yeah. I think there were only a few statements in our working group that had unanimous consensus, meaning everybody agreed upon and a lot of the statements were in the 90 percent range, but there were a couple in the diagnosis group that hit 100 percent just looking at patient history factors that you should ask about looking at injury mechanism, acute versus chronic, previous elbow injuries, things like that and list out a couple of things that the working group and everybody involved thought was very important. I would say it's a good take home point from when you're thinking about trying to make a diagnosis here about questions you should be asking to your player. If you look as far as advanced imaging was concerned, most everybody agreed, again, 100 percent consensus saying that we should be obtaining advanced imaging, usually an MRI or an MR arthrogram, although we didn't necessarily specify within the group which of those you should obtain.
There are some people that would say you can see everything on an MRI and that probably has to do with how good of a scanner you have whereas some people still like to get arthrogram through this and I don't think that's a wrong answer depending on what scanner capabilities you have at your institution or at your surrounding areas where you get your MRIs done.
Brian Lau:
I think the key thing that I took out of it was a real consensus on the physical exam things you should be looking at, your classic exam five. I didn't think there was anything too special. A couple of things that stood out was the stress radiographs. There was some consensus for it, but then a second question there said maybe you shouldn't. What's your take on it? Should we be doing stress radiographs or what's the role in using that in the diagnosis phase?
Dr. Brandon Erickson:
Yeah, Brian, great question about the stress ultrasound and stress radiographs. What I would tell you is, in my opinion, if we have pre-injury data on these players, I think the stress radiographs and stress ultrasounds are really, really useful. Just as a one-time point measurement, they can be helpful but not quite as significant. If you look at some of the work done by Mike Sakati and the group from Philly a couple years back, they produced some normative data on what the amount of gapping on the inside of the elbow should be with these stress radiographs and stress ultrasound, usually using a Telos machine through a stress ultrasound with one of the radiologists. They came up with some normative data.
If you get a stress ultrasound on somebody and they're well under what the normal amount of gapping is, you could say, okay, this person probably doesn't have a UCL tear, but if they get into that plus minus normal range, the question becomes, is this an injury and if you don't have pre-injury data on them, it can sometimes be difficult to interpret that? I would say for the Phillies and things like that, we have pre-season stress ultrasound data on these players so it's really beneficial for us in that setting, but if you don't have that pre-injury data, sometimes it can be a little bit harder to interpret.
Brian Lau:
Gotcha. You're saying for the Phillies, you guys are doing stress ultrasound exams on all the pitchers or all the players or who are you guys doing that for? I think that's very interesting that you're able to do that. That's really novel.
Dr. Brandon Erickson:
We collected a lot of information in spring training on a lot of our pitchers. Certain guys don't do it, but the majority of our pitchers we have stress ultrasound data on and so we can actually go back and look at some of that data, which is something we're doing now looking at predictive factors for potential UCL tear. More to come on that as we analyze that data a little bit further, but it's really beneficial and I would suggest that people that take care of teams, whether it's high school, college, pro, it's an interesting data point to collect before the season starts.
Brian Lau:
Yeah, there's stuff you guys get out of that because I think that could be really interesting. I think your point, in isolation, any kind of stress related gap is really difficult. What do you think about comparing to the controlador side? Sometimes we do that in the knee, but in the elbow with throwing arm and non throwing arms, it's probably quite different. Have you noticed that in your evaluations?
Dr. Brandon Erickson:
Yeah, it's very different. We definitely see some increased laxity in the throwing arm of pitchers and we see some changes in the ligament from a thickening perspective as their workload goes up. Some of Pete Chalmer's work touched on that. While we definitely can use that from a KT1000 and things like that in the knee, from a elbow perspective, I don't think it's super relevant.
Brian Lau:
I think that makes sense. I think the other really interesting part that came out of the diagnosis here, the one that had the least consensus was MRI or MRA and it's interesting, obviously if you do a MRA, you've got the time of the anesthesiologist. It might take a little bit longer to get because you have to have it be done in working hours and you have to have fluro to get that injection in there. I know it depends but how are you deciding between getting the MRI or getting the MRA or is there certain times when you're deciding, okay, an MRI is good enough or how are you deciding?
Dr. Brandon Erickson:
I'll tell you, I did my fellowship at HSS and I spent a lot of time with Dr. Potter learning how to read elbow MRIs and so just in case he listens to this, I will tell you I do not get MR arthrograms on anybody.
Brian Lau:
That's good.
Dr. Brandon Erickson:
The reality is, you have to shut those guys down for a little bit with an arthrogram. I think if you have a good scanner, certainly a 3T is great, but if you have a 1.5T where they do a good job and get the cuts in the correct plane, I think you can usually see what you need to see with an MRI. I actually do not routinely get MRAs. I have patients that come in from other places with MRAs that obviously we read, but if the dye is not put in the right spot, you can sometimes get some edema around the plexor pronator that may look like an injury if dye leaks out or they didn't get it in the right spot, you can think that something else is going on that may not be. I personally don't get MR arthrograms, but I don't think you're wrong to get it. I don't personally do it though.
Brian Lau:
Okay. That's good to know. I think especially because now 3T standards are coming more and more commonplace, those are probably pretty good, I would imagine. This wasn't one of the consensus questions, but you talk about in your discussion a little bit was the risk factors and you talk about total arc of motion versus just GERD itself. Obviously we've all in residency learned about GERD and the risk factors for shoulder and elbow injuries, but let me get your take on this evolution, maybe it's not just internal rotation but total arc of motion and your thoughts on that?
Dr. Brandon Erickson:
Yeah, that was a really good thing you picked up on and Kevin Wilk to his credit, is absolutely outstanding as a therapist and a huge source of knowledge for me and he did some really great work a couple of years back looking at total shoulder arc of motion or risk of elbow as well as shoulder injuries in a lot of professional players over the course of a few seasons. What he actually found was that total arc of motion was a much more significant risk factor for sustaining shoulder and elbow injuries and actually if you're looking at arc of motion in general, if you break it down between internal and external, a bigger risk factor was actually not gaining enough external rotation. If you compare the two shoulders side to side, throwing and non throwing, you want to see at least a five degree gain of external rotation in your throwing shoulder. If you don't have that, that's a huge risk factor.
I'll tell you, anybody that comes into my office, obviously we're trying to see a lot of patients and be very efficient in our office day, but something I do in all of my throwers is a very quick easy exam where I have them lay on their side like I'm doing a sleeper stretch and so their scapula is basically pinned against the bed and I check their internal and external rotation just to get a quick and dirty sense of are they really tight or are they pretty loose? If they're getting close to 170 degrees of total arc of motion, I think that's pretty good. If it gets to be less than that, I get a little bit worried.
Brian Lau:
That's a really good point and a very important physical exam part that you were mentioning there so thanks for bringing that up.
Move on to the next part of here is the non-operative management. Touching a little bit on that with the sleeper stretching and stuff like that and I think the general good consensus here that you guys had, but was there anything in the non-operative part that stood out to you as you looked at the results?
Dr. Brandon Erickson:
No, I think the non-operative treatment of these is pretty straightforward in the sense that a lot of our players that have partial thickness tears, whether that's proximal or distal, we're going to try a course of non-operative treatment with a couple of the guys in Cleveland Clinic that had tears so we have that conversation with our players to try an extended course of non-operative treatment or not. We have to treat these players conservatively, but a lot of my practice is high school and college stage players. Unless they have an acute full thickness tear or an acute very high grade partial tear, most of my players are getting a course of conservative treatment.
Brian Lau:
Conservative as they're talking about if they're just having no [inaudible 00:13:13] tear but some soreness and pain over there, getting them to stretching, look at the pitcher mechanics. Is that the pathway you're using normally?
Dr. Brandon Erickson:
Yeah. I usually use a four to six week timeframe of shutting them down, not having them throw it all. We start physical therapy, we work on total arc of motion to shoulder like we talked about, scapular mechanics, scapular control. I also have them focus on contralateral hip range of motion so landing leg, hip range of motion because we've done some work looking at risk factors for shoulder and elbow injuries and we know that if you can't properly internally rotate over your landing leg, that puts you at risk for injury because it puts more stress up the kinetic chain and there's a good study out of Japan that looked at that.
I harp on shoulder motion on their throwing side and hip motion on their non-throwing side and we'll see if their exam is back to normal. If they don't have pain with the moving [inaudible 00:13:59] stress test through a [inaudible 00:14:01], their elbow has quieted down and they feel pretty good, I'll them start a return to throwing program. If they're still positive on their exam, then either we'll give it a little bit more time or we'll have them throw, but we have a real conversation with them saying, "Listen, if your exam is still positive, the chance that you're going to be able to successfully throw is much much lower."
Brian Lau:
If I get this right, you're saying people who come in with a tear, you're going to try these non-operative measures that you've just discussed or are these people who come in maybe not a frank tear, but some increased signal and some soreness or are these also for the people with the full tears?
Dr. Brandon Erickson:
A lot of times these are people that will come in with elbow symptoms that are consistent with a tear and then we don't necessarily just jump to some advanced imaging right away, especially if they're a high school athlete. We try not to push the MRI on them too quickly because chances are I would treat them conservatively anyway. I'd usually start with this and then if these things didn't work, then I would wind up getting the MRI. Sometimes they come in with the MRI, but if they haven't already come in with it, then I'll usually start slow.
Brian Lau:
Gotcha. Okay. Another question that came up is the role of biologics or PRP and you had a really good discussion about that and just see if you can expand on that, the role of PRP and when you use it in these elbow injuries?
Dr. Brandon Erickson:
It's interesting. We had a lot of discussion back and forth about the biologics as far as non-operative treatment goes and I would tell you if you synthesize all the data that's out there, we did this study looking in the major league baseball hits database and saw that it didn't necessarily make a difference in an ability of guys to get back to return to play. If you look at some of the case series that are out there, Podesta, Dines, et cetera, they do show a good return to play rate with the PRP injection. The downside to the study that we did in the Hits database was we didn't have access to the number of PRP injections they had all the time or the makeup of the PRP injections, whether the leukocyte regimen was poor so that was definitely a weakness in our study.
If you look at some of the case series, obviously you're just having a case series of people that had UCL tears and had PRP, so you don't have a control group to see if they would've gotten better without the PRP anyway. I think the data that's out there is plus minus so I think there isn't anything wrong with doing PRP for these patients. I don't necessarily push it on my high school and college-aged players. Certainly some people come in asking for it and I'm always happy to get them set up for it. I don't do them myself, I'll them see one of my partners to do it under ultrasound guidance. I don't think it's wrong to do it. I just can't tell you with a hundred percent certainty that if you get a PRP injection for this, it's going to make a difference.
Brian Lau:
Right. I'd say that we see the same thing here at Duke. A lot of our collegiate players that come in asking for PRP when they have some elbow pain and stuff and it's always hard to have the answer that, but you're right. I don't do them myself either and have my partners do them. There's a period of shutting them down after the PRP so maybe that helps. There's still, like you said, a lot to learn about the role of PRP and the concoction that you're going to use. It's interesting.
Dr. Brandon Erickson:
You're right, the shutdown period is exactly part of it. You're doing the non-operative treatment anyway, so it's hard to parse out how much the PRP plays a role unless you MRI them pre and post and things like that and do a really good controlled study on it.
Brian Lau:
Right. Right. The third category that you guys had was the operative management, which I thought was really interesting. It seems like the overall pretty strong consensus on most things, but I just want to get your sense after reviewing the questions with the group. Anything that stood out to you?
Dr. Brandon Erickson:
I think the stuff you'd expect people to agree on, people agreed on. Who should have a UCL reconstruction, who's a good candidate for UCL repair. Jeff Dugas put out some great work on UCL repairs and I would tell you the majority of patients that I see are good candidates for UCL repairs at this point. The interesting part of this and is the allograft question of should we be using allograft at all in these players and the group thought, "Yes. In a revision setting that may be worthwhile," but again it was a relatively low rate of agreement at 86 percent.
Where I did my training at Rush, Mark Cohen does quite a few ulnar collateral ligament reconstructions and he uses a double docking technique and uses an allograft in more than 50 percent of his cases and I would tell you that having spent a good amount of time with him in residency, his patients do quite well. I have not had the fortitude to use an allograft in any of the players that I've done this on yet, but I don't know that it makes a difference if we use an autograph in allograft. We pulled all of his patients when I was at Rush, we pulled all the other guy's patients for Romeo, Burma, CBJ and we didn't see a real difference in their ability to return to sport based on graft type. This may be something that we need to look into going forward similar to an MPFL reconstruction using allograft versus autographed, it's an extra extra-articular ligament. Does it make a difference if we use donor tissue with our own tissue?
There can be problems with harvesting the palmaris. We've seen case reports of median nerve harvest or if you go to the gracilis, potential hamstring issues down the road. It's just an interesting thing to think about. I think it should generate some discussion as we learn more about it.
Brian Lau:
I would say I completely agree with you. I've done a couple of these allografts and those patients seem to be doing very, very well and I think there's definitely more to learn and it's something to think about as an option, especially those patients that don't have a palmaris.
Dr. Brandon Erickson:
I was going to say I did one yesterday and it was a younger kid and he didn't have a palmaris on either side and I've learned that if they don't have a palmaris on one side, usually the palmaris on the other side is not great so I tend to not go to the other arm if they don't have an ipsilateral palmaris because I get worried that it's not going to be a large tendon. They'll probably have a low lying muscle belly and may not be usable. I just did a gracilis on him but I was thinking afterwards, I'm like, "Gosh, this kid is pretty young. I'm taking gracilis from his landing leg where he doesn't have any issues and is it the right thing to do?" I think it's the discussion point that we have to have going forward.
Brian Lau:
Yeah, I totally agree. The next question was, you know mentioned it in one of your responses just now and also in the survey and also in the discussion was about repairs. UCL repairs are becoming much more popular and you mentioned that even for most of yours, you're seeing that people are candidates for UCL repairs and how do you think that evolution has come? I know Jeff Duggan has done a lot of work showing that, but how did you evolve with that? Did you do a lot of that in fellowship or is that something you've learned in practice here?
Dr. Brandon Erickson:
Yeah, honestly I didn't do many in fellowship at all. It had just started to get popular when I was finishing up my fellowship so it was not something I did in fellowship and then learning from Jeff and talking to Jeff about this a lot and getting his tips and tricks on it.
When I started, I saw a lot of patients that I thought based on his data were really good candidates for repair - full thickness or high grade partial thickness, proximal or distal tear with an otherwise healthy ligament. I said, "Listen, I'm going to start to adopt this and see how it goes," and I'll tell you, I've had, knock on wood, very good success with the repair. If somebody is tissue deficient like the kid I was telling you about yesterday, I don't think a repair in isolation is the best option at this point. I think we still have more to learn about it. A repair is very viable. I think major league guys that maybe have some more miles on their elbow and they have a ligament that has been beaten up or they have a large osteophyte within it and by the time you shell that out, you wind up with a ligament that's not totally healthy, those are not the ones that you want to really repair.
The ones who have good quality tissue, I think a repair is a great surgery. You just have to make sure you get the tape isometric.
Brian Lau:
Gotcha. Yep. I think that's definitely key. You're saying you're seeing a lot of proximal or distal evulsions more or are you doing this for mid-substance tears as well?
Dr. Brandon Erickson:
No, I haven't done the mid-substance one yet. I know Jeff has done a couple and he's been pretty happy with it and George Poletta has also done quite a few of these and he has great results to them as well. I don't honestly see a lot of mid-substance tears. Most of mine are proximal or distal, but when I do have the mid-substance or I am tissue deficient, I've actually moved away from a standard reconstruction. I've started to move more towards a hybrid technique. Tony Romeo had a great idea of adding in an internal brace with a graft and so what I've migrated to and what I think a lot of surgeons are doing some form of, although the techniques probably differ a little bit, is doing a graft but also adding in an internal brace and repairing the native ligament.
I think that's probably the way things are going to move and I think the rehabilitation process will speed up a little bit as we do this rather than it being the 12 to 18 month return from a full reconstruction. I think it'll get in that nine to 10 month range, so a little bit longer than a repair but not quite as long as we've seen with a full-fledged reconstruction.
Brian Lau:
Yeah. There's been so much evolution since the first time [inaudible 00:22:41] obviously and another thing that came up that I was thinking about as we were looking at this was their approach to it, too.
Muscle split versus elevation. It looks like both of them are listed and it was consensus that one of the two. Want to get your thoughts on which one you like to do and what the discussion points we should be thinking about with one or the other?
Dr. Brandon Erickson:
I think that as long as you do your approach well, you can do whichever of those two approaches you like. I personally do a muscle split, that's how I was trained and it's how I've been comfortable doing it for the last five or six years. I would tell you that if you do an elevation and you do the ASMI technique and you transpose the nerve every time, there's nothing wrong with that as long as you do it the right way. Part of the step you saw on the paper was if you have a technique that's reliable for you, do it that way. If you're an elevation person, then do that. If you're a muscle split person, do that.
I tend to do a muscle split and usually there's a nice thick white [inaudible 00:23:33] that you just can split right down and you can spread down to the ligament. You don't really have to cut much, you just spread with a couple of elevators and it gets you right down to where you need to be most of the time. For me, that's been really reliable but I don't think you're wrong to elevate.
Brian Lau:
Yeah, you can identify people who do either ones and feel very passionate about the others, but I think your point is right, your point is good. Whatever technique you do and you do it well, I think either one would be a good.
Dr. Brandon Erickson:
Do you split or do you elevate, Brian?
Brian Lau:
I split. Just move on to the last one here for the rehab and return to sport, anything that stood out to you in terms of rehab? I think [inaudible 00:24:15] discussion and I agree that there is still a lot to learn about how we should do the return to sport, but was there anything that stood out to you?
Dr. Brandon Erickson:
There is a lot to learn and I would tell you we picked the people that we thought were the absolute experts in this. Kevin Wilk, Mike Ryanal, Dan Conti, just everybody who rehabs a ton of these to get their opinion on and you can see that again, there was a lot of places where we had some pretty strong consensus and a couple of places where we didn't have great consensus. A lot of the places where our consensus wasn't great was in the timing of when we should allow people to throw and get back to sport.
I think the bottom line is we don't know. There are some guys that progress a little bit faster than others and trying to put an absolute timeframe on this is probably not the right answer. There are other factors that go into this obviously, how much work do you have to do on their kinetic chain? Are you changing their arm slot? How's their velocity progressing? Do they have anything else done? Do they have an osteophyte that was taken down or another nerve transposition at the same time? I think that's what we have to figure out going forward and there is probably some part of this that has to be individualized to each person. Let's say I do a UCL repair and I tell them before surgery, "In about six or seven months, I'd expect you to be very close to if not throwing off a mounted game competition," and there are some people who at four and a half, five months feel like they're ready.
There are some people who take eight to nine months and I don't think there's a right or wrong answer. I think we just have to listen to that person's elbow as they go through the rehabilitation process and see where they're at.
Brian Lau:
Yeah, I agree. It's so hard to know the timeframes and everyone always asks, "How many months out? How long away?" It's so hard to say within an exact science because we just don't know so your point is taking an individualized approach to it. One thing that is definitely in the return of sport and literature that's gaining a lot of traction not just in elbows but throughout sports medicine is the psychological aspect of it. What are your thoughts on that with UCLs?
Dr. Brandon Erickson:
I think that's a great point and something we don't talk enough about. I had a pretty good size injury to my ankle when I was in college. I had an open fracture dislocation in my ankle so I had that treated relatively quickly and then it took me a while when I was back to full speed and everything to be able to run across the middle of the football field and not think that I was going to get lit up and have my ankle broken again. I empathize with these guys that have a traumatic injury, how bad the trauma was, you can debate, but it's a traumatic injury and for them to trust their body to go back to do that again can take some time. We see, if you look at the return to sport, not so much for UCLs but other things, ACLs, things like that, a lot of times in the second season somebody's back, they do a little bit better.
From a UCL perspective, I think that's something we need to consider. The question is how do you measure somebody's readiness or mental toughness to get back to going or their grit as Bernie Bach, Dr. Bach liked to say. I think we still have to learn how to do that, but I think you're exactly right and that there should be some kind of measurable effect of us to do that to let these guys go back.
Brian Lau:
Yeah. I agree, too. I think it's something we just don't know as much about and need to study more. The last question I have is what's the future? When you think of the future, say five, 10 years from now in UCLs and if there are two things you can point you to crystal ball and say, "This is what we should be looking at or thinking about whether that's return to play or surgery techniques, what do you think it is?
Dr. Brandon Erickson:
For me, I think we're going to see a much higher growth of UCL repairs and I think as long as we continue to do them in the right person, we'll see really good results with that. There are indications from that we'll probably expand a little bit and I'm anxious to see how the results go from that. The questions I'd like to see answered that I don't think we have the answer to yet are exactly what you said and it involves return to sport. Can we get these guys back faster or do we really need to wait as long as we need to in that 12 to 18 month mark for reconstructions? I think some of that will parse itself out as we get into doing more of the hybrid techniques and seeing how long it takes those guys to get back.
If the hybrid technique works well and whatever hybrid technique you're using, if that works well and it does what we think it can do with the internal brace backing it up, I do think we can accelerate these players getting back. I will say in having seen a lot of these and rehabbed through some of them and dealt with players at different levels, if you rush guys back too fast from this, they don't tend to do well. If you're erring on the side of being a little slower or a little faster, my personal opinion is to be a little slower. Players don't always love that, teams don't always love that, but you're looking for the best long-term health of the player and so if it takes a little while longer to get them back, I think you go with that.
Brian Lau:
Yeah, I agree. Exciting stuff and this is a great paper. I think it goes over a lot of the questions that a lot of us have who do these type of surgeries and I think it's a must read for everyone. Again, I just want to thank Dr. Brandon Erickson for taking the time, but also his co-authors, Eoghan Hurley, Edwards Mojica, and Dr. Laith Jazrawi and the rest of the owner collateral Ligament Consensus Group. This is going to be in Arthroscopy and thanks so much for taking the time for joining us. It was a lot of fun, learned a lot, and I look forward to doing more of these with you hopefully.
Dr. Brandon Erickson:
Brian, that was awesome. I really appreciate you having me on the discussions. I'm really excited to hear what people think about this and if they do things differently, please feel free to drop us some comments or email us or text or whatever. This was 26 people that do these a lot, but there are a lot of people around the country that also do these, so would love to hear their thoughts.
Brian Lau:
Perfect. Thanks so much and all right, we'll talk later.
Dr. Brandon Erickson:
Great. Thanks, Brian.
The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association nor the Arthroscopy Journal, and they're not necessarily meant to be used as treatment recommendations for patients.
Medical Disclaimer:
The information and opinions discussed herein, including but not limited to text, graphics, images, and other material contained in this podcast and its referenced paper are for informational and educational purposes only. No material in this podcast or its referenced paper is intended to be a substitute for professional medical advice, diagnosis or treatment. Specifically, all content and information in this podcast and its referenced paper does not constitute medical advice. Always seek the advice of your physician and/or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you were exposed to from this podcast or its referenced paper. The information discussed in this podcast and its referenced paper may not apply to every individual and may cause harm.