Dr. Brian Lau:
All right. Welcome everyone to the Arthroscopy Journal podcast. I'm Dr. Brian Lau from Duke University, and today I have the privilege of speaking with Dr. Eric Bowman from Vanderbilt University. Dr. Bowman is author on the paper titled “Elbow Ulnar Collateral Ligament Repair With Suture Augmentation is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review” which is published in the Arthroscopy Journal. So on the heels of a great win from Vanderbilt football, rail Bama, congratulations and welcome Eric to the podcast.
Dr. Eric Bowman:
Thank you, Brian, and thank you, AANA, for having me. It's great to be involved.
Dr. Brian Lau:
So we'll get started here. I know you do a lot of elbows and I think your article does a great job of discussing the evolution of ulnar collateral ligament repairs. And briefly describe to our listeners what that is, how that history is, and what the evolution of repairs are with this augmentation that you guys described so well.
Dr. Eric Bowman:
Yeah, so I think the first thing to consider is why are we doing this? Why are we doing repairs? And I think the groundwork is really laid in what we're experiencing is really a UCL epidemic. So if you look at the landscape right now in baseball, if you think about 25% of major league baseball players have had a Tommy John surgery, really new data is going to come out that shows that that's probably about up to a third now, about 15% of minor league players, at least. That is trickling down to the younger age groups and so we are seeing an epidemic at younger ages. So what we want to know is how can we intervene both preventatively, then on the surgical side, what are some techniques that we have that can potentially speed up recovery, limit some of the morbidity associated with a reconstruction and get these players back to playing because this isn't going to change anytime soon.
With early specialization, increased workload, increased velocity, all these things that you're seeing, advancing pitch types, designer pitches, this is only going to become more of an issue down the road as well. So when it comes down to reconstruction versus repair, repair, what essentially we're doing in that circumstance is we're using the native tissue and repairing it back to the bone. And what we try to do is we try to augment that, and so using what we call an internal brace or suture augmentation, we use a suture tape to then act as a backstop for that repair, thereby using the native tissue and saving the patient from a reconstruction, which is using either autograft or allograft to make up that tissue loss or poor tissue.
Dr. Brian Lau:
That's great. So we have a lot strategies, but we also have a lot of patients who look at these, listen to these podcasts. What is the internal brace? What is it made of? What makes it so unique?
Dr. Eric Bowman:
Yeah, so an internal brace is essentially a very thickened, Kevlar reinforced suture that's collagen coated to help with tissue compatibility, and it is a static structure, essentially, that is fixed on both the ulnar's side as well as the humeral side. And what it does is it, as the elbow starts to go into valgus, as you begin to throw, it acts as a backstop. So it doesn't let the elbow go beyond a certain point. So it adds structural stability that the UCL should normally be taking on. And what we're hoping is that over time, that studies will bear this out, is that when the tissue heals back basically, for one, it helps rehab quicker because you're not stressing that tissue as much. But then two, hopefully we're not stress shielding the tissue so that it really develops more in a normal way to adapt to stress down the road. So those are a little bit nuanced parts of this, but essentially, internal brace acting as a backstop to help protect your repair of the native UCL tissue.
Dr. Brian Lau:
I think maintaining the native tissue and then adding something on top as opposed to replacing with this. So I think that's really important distinction and I like to always ask the authors, I think people are curious, so what prompted this study? Was it something a patient you saw? Was it something you guys had discussion with a patient? What prompted you to look into this? Or are you seeing more of these avulsion injuries that are amenable with this?
Dr. Eric Bowman:
Yeah, so I work with a group of other surgeons, elbow surgeons, and we call ourselves the Cutter Group, and we're looking into UCL injuries prospectively. And one of the things we wanted to see was, is what we're doing, as far as repairs, is that essentially equivalent? Are we really doing patients a service? Is this something that is a viable alternative to a reconstruction? So we wanted to look at it from two angles. We wanted to look at it biomechanically, and then, two, clinically. How do these compare?
And so biomechanically, the data's there, good studies, comparative studies, we found that clinically, nobody has really taken the study on to prospectively look at these. And so that's where our study group is taking this to the next step. But we wanted to look and see what clinical data is out there so far for UCL repair so that we can begin to progress and do those other studies to look at it from a prospective view.
Dr. Brian Lau:
I like the name Cutter for those who play baseball. I think I really understand what that reference is, so that's great. Well, you mentioned, too, the two parts you guys looked into; the biomechanical and the clinical. Maybe you can highlight for our listeners what the biomechanical findings were of the study here.
Dr. Eric Bowman:
Sure. So essentially, this was a systematic review and we looked at articles, like I said, biomechanically, and then clinically we searched for UCL repair and or internal brace or suture augmentation is another way you'll hear it described, and then UCL reconstruction. And so we included those search terms, we wanted the minimum of, on the biomechanical side, we looked for data including torsional stiffness, gap formation, peak torque, and failure torque. And so what we found was basically eight biomechanical studies, which we were able to include, and what we looked at was for one was gap formation, and we found less gap formation, meaning when you stress the elbow in valgus stress, there was less gapping compared to a reconstruction. And then essentially, it had equivalent torsional stiffness. So as you rotate the elbow or rotate the arm into valgus, looking at the stiffness failure load, so what load did the construct eventually fail at? And then peak torque, so that torque force, as well.
And essentially we found equivalent values to reconstruction and the native UCL across those studies. So we said that yes, this looked like it was at least equivalent to, if not potentially superior, to reconstruction in terms of those characteristics.
Dr. Brian Lau:
I think that that data was very provocative and I think some of our listeners may be thinking, well, if it's better than reconstruction, should we just repair all of them? And I think maybe you can highlight a little bit, is that indicated for all standard? Is there certain tears that are better for it, certain levels of sport that are better for it? Why would you do a reconstruction if the biomechanical data showing the repairs are maybe better?
Dr. Eric Bowman:
That's a great question, and that's really, I think, where we still need to tease out some of the details because yes, repair does well, but these repairs are generally being done in younger athletes with generally good tissue, and yet there are certain characteristics that are going to be, provide what we believe is probably a better outcome with reconstruction, and then there's going to be characteristics which potentially allow for repair.
So reconstruct, first of all, just so that everyone hears, reconstruction is still the gold standard. We are still doing reconstructions in high-level athletes, especially that ones that have had attritional wear of the UCL over time. So basically, the tissue just isn't great anymore. You're not going to repair bad tissue and expect a good result, so you have to have good tissue to work with. Parenthetically, people are doing what we call hybrid procedures now where you're doing a repair along with a reconstruction and an internal brace. So stay tuned. That's the next level of this.
But just speaking of reconstructions versus repairs, repairs are going to be generally good tissue, they're going to be evulsions, oftentimes off the proximal or distal side. Mid-substance tears appear to be contraindicated at this point based on some other studies that we've done looking at discussing this with groups of surgeons. So mid-substance tears, probably not a good one. Bad tissue, meaning it's really worn tissue, older athletes, and then at the major league level, we don't know what that's going to look like as far as a native repair. Most of those athletes have had attritional wear over a long time and they're going to be either getting a reconstruction or a hybrid. So you got to have good tissue to work with to do a repair.
Dr. Brian Lau:
Yeah, I think that's a really good point in distinguishing that, and I think you say it does go to the second part of the study is the clinical data and highlighting things you guys found, in terms of the clinical outcomes, as well, and return to the sport, as well as complications. So maybe you can highlight some of those clinical key findings.
Dr. Eric Bowman:
Yeah, so it's interesting when you look at the history of UCL repair, you really have to go back to the early nineties and that's when Conway and others were looking at repair, but they didn't have the technology as far as the internal brace and the anchors that we had back then. So repairs didn't do that great. Early on, repairs did not look good, in terms of two out of seven returning to professional sports, so it was really forgotten for a long time. And so really you have to look at before internal brace and after internal brace when you're looking at results.
So before internal brace, repair did not seem to be as viable an option, but after you started including this internal brace, return to sport rates went from 50% up into the mid to upper 90%, and clinical outcomes were essentially at or on par or at least as good as UCL reconstruction. Again, you're not comparing two equal groups. There's going to be bias clinically, and nobody's directly compared head to head a UCL repair with reconstruction. But if you just look at outcomes in the UCL reconstruction group, you're looking at 80 plus percent return to sport.
One of the differences that you'll see is that complication rates are about the same, less than 10%, but the return to sport time is much quicker for repair. So on average, six months versus 12 to 14 months for a reconstruction. So just looking at the historical data of reconstruction versus the clinical data, which we were able to pull out from clinical studies, essentially what we were able to determine were likely comparable clinical outcomes. Again, the caveat there being reconstructions were very heavily done in amateur high school collegiate level players. And so data is yet to come out really at the major league level. And then as I mentioned, those tears that are amenable to repair.
Dr. Brian Lau:
I think that I noticed the difference, obviously as you mentioned, in terms of return to play, some of that is obviously reconstructions tend to be, like we said, more chronic midsubstance injuries. But do you think there's a difference in rehabs or in terms of if you do a repair versus reconstruction, do you think a certain, just, it's maybe less of an injury because it's more of an evulsion? How do you think people's and maybe your return to play protocol change if you're doing a repair versus a reconstruction?
Dr. Eric Bowman:
So a repair protocol is going to be more aggressive in general. We are pretty aggressive with getting range of motion back, and that's one of the technical aspects of this is when folks are doing repairs, you want to put it in snug, but you don't necessarily want to over constrain joints. So you want to make sure at time zero, that they have full motion because if they leave the OR and they don't have full motion, then they're not going to get that back with therapy.
So I generally put them in a brace. I skip the splint, start them in a brace, I see them back within a week to start ramping up the range of motion if they're really keyed in or at the higher levels, they may be able to get with a trainer within a couple of days to start working on things if you trust them, essentially. But a brace for a week or two with it basically locked, and then unlocking it and then increasing the range of motion more aggressively. The brace for about six weeks, and then you start, you're obviously doing your total body, shoulder, core kinetic chain work during that time, and then you start to progress.
So with the repairs, once they have full motion and their grip strength is coming back, their pronation, supination strength is starting to improve, then you can start incorporating plyos, two hand plyos, one-handed plyos. And protocols, some are going to start maybe 10 weeks is on the early side. Mine is generally around three months, as far as starting an actual throwing program. So you can get a field player back even sooner than six months versus a pitcher more on the order of six or seven months.
We were really pushing things at the beginning. I think we've become maybe a little bit more having the player calm down a little bit. And so pitcher, you might tell them it might be nine months before you get back to pitching, let's not rush it. And if they get back sooner, great. It's about expectations set up at that point. Reconstruction, some folks are starting to do, like I said, this hybrid. And so you'll see where before, you were starting a throwing program at four and a half months, maybe you're starting it a little bit sooner, maybe closer to three months to three and a half, so somewhere in between there for the hybrids. But in general repair, you're starting that throwing program probably a month and a half sooner than a reconstruction standardly.
Dr. Brian Lau:
I think that's understanding the differences is important for listeners and for patients. And I think another thing you highlighted here, in terms of, and also earlier, you said position matters, in terms of getting people back, but also sport. Obviously, in baseball is the most common, but other sports like gymnasts or wrestlers are common to get these. In those scenarios, sometimes we may have treated those conservatively because they're not throwing, but now maybe people are doing repairs. Do you think that, how do you counsel those type of athletes, gymnasts, wrestlers, or non throwing athletes who might get these injuries?
Dr. Eric Bowman:
Yeah, I think you're right. It's a very individualized discussion. I have a football lineman right now and he tore his ACL or UCL two months ago, and he's back to playing in a brace, he's asymptomatic. So there's some people that you're going to be able to continue to treat nonoperatively, and I don't think you should necessarily change that for the right patient, otherwise, you have a wrestler, I've had a wrestler before, and they're literally having somebody trying to rip their arm off every time they're out there. So yeah, I think it makes sense to do a repair in that individual. Gymnast too, they're going to be heavily loading the elbow. Quarterback's going to be different than a lineman, of course. So I think those are all things that you need to take into consideration. And honestly, for a lot of our young athletes, it's a great procedure in the majority of those situations.
And you're right, baseball's a little bit different where you just get this attritional wear over and over again that you don't particularly see in a lot of other sports. So yeah, I think it's an individualized approach, you're right. Other sports are going to potentially go back quicker if you're not necessarily working them through a throwing program. But a strength and conditioning program, you can probably get a wrestler back within four or five months. Gymnasts are going to be potentially a little bit longer, six months just with the load they're placing through it, at least. So six months, I wouldn't even be surprised if some of them took a little bit longer, even though they feel really well early on. Swinging, hitting, so even a baseball athlete can hit around that three month mark, as well. So you see even some of the pro level guys get back to field, playing the infield or hitting, certainly within six months or so with even some of these hybrid procedures where they're using an internal brace, as well.
Dr. Brian Lau:
Yeah, definitely. I think Tony's a great example of that because obviously, just hitting this year and doing fantastic, but not back to pitching, yet.
Dr. Eric Bowman:
Yes, exactly.
Dr. Brian Lau:
And then one other thing I wanted ask, you mentioned the complication rates being a little less, 8%, 6% in the study. Any tips or tricks with this internal brace technique to help avoid that, that you've learned about or read about, in terms of preventing complications, particularly that ulnaritis?
Dr. Eric Bowman:
Yeah, ulnaritis is the biggest thing to think about. Although I'll say stiffness is potentially underreported, probably, in some of these studies. Ulnaritis really, if they come in with ulnar nerve symptoms and they're getting symptoms that go down to the fingers and it's more than just a one-time thing, I am generally relatively conservative with transposition of the ulnar nerve, but I think that it is something you need to think about if they're having a lot of consistent symptoms beforehand, doing that along with your procedure. In general, I don't necessarily do a complete neural lysis if I'm just doing a repair, but you have to know where the nerve is, you have to know if they're subluxating. So if that helps you understand where the nerve is better and take that precaution, then I think that's something you need to do.
But I think that a lot of it depends on what their symptoms are ahead of time. Based on the studies. If they didn't have symptoms ahead of time, it's unlikely that they're going to have symptoms post-surgery, in the majority of cases. But yes, some transient ulnar neuritis isn't uncommon, isn't an uncommon thing to see, but you have to know where the nerve is. And then I, like I said, the stiffness is probably under reported in some of these studies. So that's another thing that, like I said, you got to have full motion even before you leave the OR.
Dr. Brian Lau:
I think some of the things you highlighted earlier was make sure you're not over tensioning it, full range of motion before you leave the OR. And then, I don't know yourself and the rest of the surgeons in the Cutter Group, are you guys mostly doing muscle splitting or is there a different approach it, how are you guys, is there some various approaches that you guys are using?
Dr. Eric Bowman:
Yeah, that's a good question. So I do the split. I think most of us probably do. Certain groups, depending on where you train, you're going to do it differently. And certain groups where you have to do more mobilization, you're going to transpose the nerve more often, so you'll definitely see those variations out there. We don't have enough data to really drill down to technique, yet. And since this is so rapidly evolving, there's numerous ways beyond the way even Dugas initially described this in 2018, 2019. There's numerous ways that even beyond that, that are being done to do it now. So it's really hard to tease that out in these limited data sets so far.
Dr. Brian Lau:
Definitely more to come for that. And I guess we're coming up to our time, but my last question I have for you and to help our readers is having now done this study, done this review, how has your practice changed at all? Have you done anything different as a result of this and as a way of those key takeaways our listeners can take from this?
Dr. Eric Bowman:
Sure. Yeah. And I'll just use my experience. I've been out in practice since 2018 and maybe saw one or two repairs in fellowship. And so now that I am doing these in my practice, I would say that almost 90% probably are repairs now. I see a younger population of high school collegiate kids, and they still have good tissue and they're not mid-substance tears, they're evulsions, and they have good tissue to work with, and so we move on with the repair. And I've had great success with that so far. At the same time, I'm not necessarily afraid to do a reconstruction and add an internal brace there either. So I think that gap even between repair and reconstruction is looking different even than when we did this study a year ago, and there's newer biomechanical data coming out there. But I would say that the population I'm seeing, very heavily leaning towards repair.
And if anecdotally you speak to some of the other major league team docs, doing a reconstruction after repair is very much like doing a primary repair. You're not worrying about big tunnels. So honestly, there's not a whole lot to lose, especially in some of these younger athletes that they're trying to make it to the next level and they don't have a year to give up to go through a UCL reconstruction. You might hedge towards a UCL repair in those athletes when yeah, if they would've lost a year, year and a half of playing time, they never would've even had a chance to make it to the next level. So I think this is in the right patient. I think it's a great option and it's really, it's something to add to your toolbox because we're going to need these types of procedures and newer ones as they come along to help treat the variety and the spectrum of patients that we're going to be seeing.
Dr. Brian Lau:
Yeah, I think that, that's a great way to end that. I think what you mentioned is a trend that everyone's noticing there are more and more repairs, and I think that it's helping, probably something to consider, at least for all the patients, and have a discussion with your patients about, so.
Well, thanks so much for sharing your thoughts here, Dr. Bowman, I really appreciate it. It's a great study. And again, the title of the study is The Elbow-Ulnar Collateral Ligament Repair with Suture Augmentation as Biomechanically Equivalent to Reconstruction, and Clinically Demonstrates Excellent Outcomes: A Systematic Review, which can be found in Arthroscopy journal or online.
Thanks for joining us, and as a final part, the views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. So thanks again.
Dr. Eric Bowman:
Thank you.
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