Over the last several years, we have seen the growth of the new repair of the ulnar collateral ligament with an internal brace procedure. It’s been awesome to witness such great success with this new Tommy John procedure, and patients have been doing great.
Here’s an update on our experience so far, some clinical pearls on rehabilitating these athletes, and the differences we sometimes see with traditional Tommy John UCL reconstruction.
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#AskMikeReinold Episode 330: Rehabilitation After UCL Repair with Internal Brace
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Show Notes
• UCL Internal Brace Surgery with Jeff Dugas
Transcript
Kaylee:
So Tom from Florida is asking, “I have my first patient coming in next week that has undergone the new UCL repair with internal brace procedure. What has your experience been with these so far? What are the main differences with this and a normal UCL reconstruction? And do you have any tips for me?”
Mike Reinold:
Awesome. Great job, Kaylee. Tom, great question. I think when we all saw our first one, we all probably had some butterflies too. Right, Len? Like about this procedure here. We have a new procedure that’s supposed to be faster. I don’t know if I can say better, but equally as good, faster… Equally as good, exciting new procedure. Yeah, I think we were all a little nervous with this, like how is this going to go? But now I think we get a bunch of reps under our belt. Is that the right phrase? We have reps. Anyway, we have experience. We have had a lot of experience with these now, and I think we’ve had some good experiences. So Len, why don’t you start off? What do you think of this UCL with internal embrace? How’s it been going? How do you think it’s different? Any rehab pearls that are different between this and a traditional Tommy John? What do you think?
Lenny Macrina:
Yeah, so I was working with Dr. Dugas down in Birmingham, Alabama when this first came out, so I’ve been seeing these for about 10 years now. And even he was shocked, because the first pitcher he did this procedure on was a Troy University baseball pitcher, and they started throwing crazy early and he was not happy, but the kid did really well. And like our ACL protocols that eventually evolved, it evolved because of people that cheated and did well, and we’re like, huh, I guess we can go faster than we thought. So with that, we go faster with it, which initially did not make sense to me, because you have a tissue you’re putting in that’s not your native tissue, and you need that tissue to grow into the elbow essentially and stabilize the elbow. Like an ACL, if you had a cadaver graft or some kind of outside tissue, you would go slow with that person, but not so with the elbow. It has held up, they suture down really well, they repair the ligament underneath as well, and going faster did not affect anything.
So going faster means starting to throw maybe a month or so early, maybe 6 weeks early. I fight the tendency to go as slow as a Tommy John reconstruction because I still have visions of Tommy John dancing in my head of how to go, because we used to stop throwing at 12, 14 weeks out of surgery with a TJ, and now we’re throwing at 12 weeks with an internal brace. So they do well, their motion comes back pretty easily, unless it’s a hybrid. If they do a reconstruction with an internal brace, which is a hybrid approach that some doctors are doing, they tend to get a little stiffer into flexion, I feel like, and even extension a little too. They lose some extension, and so you got to be cautious with that. So you got to know, is it an internal brace? Is it a hybrid or isolated internal brace?
Otherwise, it’s the typical range of motion progression early on. The problem is, we go so slow. Not slow. We go relatively slow early on and then it’s a 6-week window to get their strength and function back, and then to start throwing. And that’s what always throws me off, is we have that get the motion back for 5 weeks, get a strengthening condition program going, start throwing 12, 14 weeks, and then they get back sooner. So I’m a little torn with it. They do well. I’m no longer a skeptic, but I still am cautious and still revert to my Tommy John ways every once in a while. I don’t know if you feel the same way, Mike.
Mike Reinold:
I like that, you’d revert to your Tommy John ways.
Lenny Macrina:
Yeah, the traditional reconstruction ways.
Mike Reinold:
Dan, what do you think?
Dan Pope:
I also had a question for you, Lenny. We have a million kinds of return-to-throwing programs. Do you shorten those up at all or are you keeping the same length?
Lenny Macrina:
No, I keep the same program because you still need to get a ramp-up time for the athlete. And we build all that in. It’s not like I’m shocking them. It’s literally, all right, when do you need to be ready? How much time do we have? When do we know we can, at the earliest, start to throw? And then I’m educating from the beginning that we’re going to need 8 to 12 weeks for long toss and then another couple months easily for pens. But we’re starting to throw at 12-ish weeks, depending on if their motion is good, their elbow is quiet, we get clearance from the doctor, their strength numbers are good, meaning we’re testing their cuff which I usually don’t start testing that until maybe 8 to 10 weeks with the UCL at the earliest. So I feel like we kind of rush things a little, and I’m curious how this plays out, because we don’t have long-term data on how well they do.
We rushed our ACLs, and then next thing you know, we’re pulling back and going back to traditional numbers of not starting to run until 4 or 5 months out of surgery and waiting 9 months to function. So I’m curious if this takes a similar approach once we start seeing the data coming through and they’re happening at 4 or 5 years out of surgery instead of 8, 9 years out of surgery with a UCL or something like that. I don’t know. But I mean, they seem to do well. It’s a solid procedure. It’s a procedure done for somebody who has a distal or proximal tear. So they got to be able to repair it back down to the bone to get the ligament reattached, and then they can do the internal brace over that. If they have a mid-substance tear, then they’re typically going to just do reconstruction with a palmaris or hamstring and hopefully not a cadaver, which you’ll see every once in a while. It’s usually a palmaris or hamstring for a reconstruction. But the tear has to be in a certain position. They won’t know that until they get in, and then the decision is made by the surgeon, just so everybody is aware.
Mike Reinold:
Dan, I would say my traditional return to throw with a Tommy John full reconstruction, is close to 7 months. I’m not against going a couple months faster with these internal braces, but oftentimes we don’t. And I think that’s kind of my input on this question I think from Tom here, is that you don’t have to rush through the program just because you can. So I think Lenny said that kind of well in his part there. But oftentimes we don’t need to go faster, meaning there’s no point in being game-ready in November for any baseball player, theoretically. So what we do is we often take a step back and we think with the end in mind when we build these throwing programs. It’s great that they could potentially throw earlier and come back sooner, but sometimes we don’t need to rush that program. So it’s not just like a cookie cutter with that. So we take everybody into consideration.
I’m in agreement with Lenny. I think the outcomes have been fantastic actually. I think I can finally say that, and I am comfortable and confident in them. I mean, we’ve talked about internal bracing on the podcast several times now over the years. I don’t know if we’ve ever said that. So it’s the end of 2023, almost 2024 right now, and I think we’re confident in it. We have success. We have success with people for years. We have success in the big leagues. We have success in kids. It seems good. And remember, we’re all better, and even our surgeons are better. They’re not just doing random surgeries because they’re cooler or they’re the new thing. This is the right surgery for the right person at the right time. And I think that’s why these are doing better, is we now have 2, you could argue 3 options with the hybrid. We have multiple options on what’s best for this kid. So maybe in the past when you only had one option, maybe that’s why they didn’t do great, but now you can choose between a couple.
For my rehab pearls, I think the first month is very similar between the 2. From kind of 4 weeks to 12 weeks, to me, I think is the critical time point. The physicians oftentimes want to say they can start throwing at week 12, and man, I don’t want to put a number on this because I haven’t been tracking it, but I would say 50/50 for me, if I actually feel like they’re ready at week 12, and that’s been my experience at these internal braces. So let’s say you got a high level collegiate kid, even an upper level high school pro guy, whatever, at 12 weeks, because they weren’t too bad going into surgery, they may look okay and they might be all right. But I would say the last 2, the 2 current ones I have on my schedule tomorrow or yesterday, I delayed them both a couple of weeks because I didn’t think they were ready at week 12 and we had time. There’s no rush. There’s no reason to necessarily do that. We’ll still be on time if we wait 2 more weeks.
But I’ve had a lot of kids, like high school kids, look, they have 4 to 6 weeks where they’re dealing with the trauma of the surgery and healing from that, and getting better, and then in just 6 weeks I have to get them from looking poop to amazing and ready to throw. You could argue that’s not enough time to get them to feel better and to look better, and maybe that’s why they had this injury to begin with. So I think that’s my one caveat that I would say, that one thing that I’m nervous of, especially in the young kids that aren’t huge physically developed, that aren’t going into the surgery with an amazing baseline of strength and stability, and great stuff, is I don’t know if 12 weeks is enough time to get their body right.
So keep that in mind. Take that with a grain of salt, because everybody is different. That’s just one thing that I think about when I’m lying in bed, with some of my patients is like, are they ready to start throwing just because it’s week 12? But other than that, it’s been groovy. I think we’ve had a really good time, nobody’s had any problems. It’s crazy.
Lenny Macrina:
I think there’s very few instances where you have to start throwing at 12 weeks. If you really think about the… Plan it out ahead of time and think of the math, and how much time you need, and build in pick-up time where things will crash and burn. You got to peel them back up and get them back throwing again. There’s very few times you just start throwing at 12 weeks to get them ready for opening day of their high school season. Come on, it just doesn’t happen like that. So you have more time than you think. And you talk about that early on. This isn’t like a 12 week comes and you’re like, nope, you’re pulling the wool out, not throwing today, we’re going to wait another month. You are prepping them ahead of time. You’re testing them, you’re educating them, you’re talking to parents, this isn’t a new thing for them. So you’ve already planned it out, you’ve talked about it, you’ve gotten their input, you felt them out and got a sense of how they feel about getting back at a certain time, and so it works out in the end. You just need to talk it through with them. Communication is the key.
Mike Reinold:
Yep, love it. And the outcome studies that the docs are starting to produce, even some that are officially published and some that are just starting to put their data together, but they’re presenting at meetings, it’s been really good. So I think we’re going to see it more and more, especially in the right person and when this is a qualified thing for that person. So stay tuned. We’re going to start getting more and more of this. But great question, Tom. Good luck with that person. If you have a question like that, head to MikeReinold.com, click on that podcast link, and be sure to go to Apple and Spotify to rate, review, subscribe to this podcast. We’ll see you on the next episode. Thank you.
