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UCL Reconstruction Surgery Heezy1323 I recently posted a blog about Chris Sale and the news that he was set to undergo UCL reconstruction. That post covered some questions surrounding the diagnosis and decision-making that occurs when players/teams are faced with this dilemma. That post got a little lengthy, and I chose not to delve into the surgery itself, as I felt that may be better presented as a separate entry. My intention with this post is to discuss some of the different techniques that are used to perform UCL reconstruction. This does get fairly technical, and I apologize in advance if it is more than people would like to know. First, we should revisit the anatomy. The ulnar collateral ligament (UCL) is a small but strong ligament on the medial (or inner) part of the elbow. It is around the size of a small paper clip. Ligaments (by definition) connect one bone to an adjacent bone. The UCL spans from the medial epicondyle of the humerus (the bump you can likely feel on the inside of your elbow) to the sublime tubercle of the ulna (one of the two forearm bones). (As an aside, sublime tubercle is one of my favorite terms in all of anatomy). As with nearly any reconstructive surgery in orthopedics, our aim is to recreate the native/normal anatomy as closely as possible. In order to do this, most techniques utilize small tunnels that are drilled into the bone at the ligament attachment sites. The tissue that is used to reconstruct the ligament is then woven through these tunnels and tightened to create a secure new ‘ligament’ that heals and strengthens over time. The primary differences between different techniques are the ‘approach’ (or how tissues are moved aside to see the damaged areas), the specifics of how the tunnels are made and used, the type of tissue (or graft) that is used to make the new ligament, and the way that the graft is secured in place. There are a number of variations that exist, but I’ll cover a few of the most commonly used methods. First, some history may be in order. The first UCL reconstruction was, famously, performed on Tommy John. Tommy John was an outstanding pitcher for the LA Dodgers in the early 1970’s, and had compiled a 13-3 record in 1974 when he had a sudden injury to his elbow and was unable to throw. Imaging was performed, and the diagnosis of a UCL tear was made by pioneering orthopedic surgeon, Dr. Frank Jobe (of the famous Kerlan Jobe clinic in LA). Dr. Jobe had an idea to perform a reconstruction of the UCL, and practiced on several cadavers until he felt he had worked out a promising technique. He told Tommy that he thought he had a 1 in 100 chance of a successful return to MLB pitching. John decided to go ahead. The surgery was ultimately successful, and John returned to pitching in 1976. Though Tommy made it back, he did have a temporary palsy of his ulnar nerve after surgery, which is the ‘funny bone’ nerve that is near the UCL. This caused him significant weakness in his hand at first, but fortunately the strength returned over time and Tommy was able to return to pitching. Interestingly, he won more MLB games after surgery than he did before surgery, and pitched until 1989. There is a story that Jose Canseco hit a homer off John late in his career. Apparently Canseco’s father was Tommy’s dentist, and Tommy said something to the effect of “When your dentist’s kid starts hitting home runs off you, it’s time to retire.” The technique used for this first surgery was termed the Jobe Technique (for obvious reasons). It involved removing the attachment of the muscles to the inner part of the elbow and pulling the muscles toward the wrist to get a good look at the UCL itself. Tunnels were drilled in the bone at the normal attachment sites of the ligament, and a small tendon from the forearm (called the palmaris) was used to weave through the tunnels making a ‘figure-8’ in order to make a new ligament. (The palmaris is a non-necessary tendon that is located in the forearm of about 2/3 of the population. For those patients who don’t have a palmaris, we usually use a hamstring tendon called the gracilis for this procedure.) The old ligament was left in place and sewed into the graft. The nerve was also moved from its normal location (behind the bump) to in front of the bump to take some of the tension off. This is called a ‘transposition’ of the ulnar nerve. This technique was used for a while, but it did have some drawbacks, such as a high percentage of patients having ulnar nerve problems after surgery and some weakness resulting from detaching and reattaching the muscles of the forearm. Because of this, other surgeons sought new ways to perform this surgery. One commonly used technique was termed the ASMI-modification of the Jobe Technique. ASMI stand for American Sports Medicine Institute (in Birmingham, AL) and this modification was initially described by Dr. James Andrews and colleagues. This involved similar bone tunnels, but the main difference was in the way that the muscles were treated. Rather than detaching the muscle and reattaching at the end of the surgery, in the ASMI technique the muscle was lifted up (and not detached) and the work was done underneath the muscle. The ulnar nerve is transposed when this technique is used (like the Jobe technique). The passing and fixation of the graft is essentially identical to the Jobe Technique as well. Another commonly used technique is called the ‘docking method’. There are a couple of main differences between the docking method and ASMI method. First, the docking method utilizes a ‘muscle-splitting’ approach rather than a ‘muscle-lifting’ approach like the AMSI technique (see figure). This means that the muscle is divided between its fibers and a ‘window’ is created in the muscle in order to see the torn UCL and make the tunnels. There is also a difference in the way the tunnels are made. In the ASMI technique, the tunnels are the same size all the way through, and the graft tissue is passed all the way through the tunnels. In the docking technique, the tunnel on the ulna side is the same. But on the humeral side, the tunnels are sort-of half tunnels with smaller tunnels continuing on through the back side of the bone. This is because the graft is fixed in a different way- there are strong stitches that are attached to the ends of the graft that pull each end into the large tunnels. The stitches then pass through the small portion of the tunnels and are tied behind the bone, which secures the graft in place. This technique does not require transposition of the ulnar nerve, which is an advantage because less handling of the nerve generally means less risk of trouble with the nerve after surgery. There are a handful of other techniques that are slight variations on these themes, primarily using different devices such as anchors, interference screws or metal buttons to achieve graft fixation. There have been a number of cadaver biomechanical studies done that have compared methods, and they have been found to be largely equivalent. There seems to be a smaller incidence of ulnar nerve symptoms after surgery when the nerve is not handled/transposed (which makes some sense). The return to play rates are very similar regardless of which technique is used, with perhaps a slight favor to docking technique depending on the study. I trained with Dr. Andrews, and performed nearly 100 UCL reconstruction cases during my fellowship using the ASMI technique. In my own practice, I tend to use the docking technique most commonly. I do this because I would prefer not to transpose the nerve if I don’t have to in order to decrease the likelihood of nerve problems after surgery. We also saw some problems with fracture of the bone near the humeral tunnels when using the ASMI technique, and using the docking technique allows us to make smaller tunnels. This makes fracture in this area less likely. That said, Dr. Andrews has had (and continues to have) tremendous success using this technique. As we have learned more about this type of surgery, it has become clear that it is important that the bone tunnels be made very accurately, as improperly placed tunnels seem to be a risk factor for inability to return to full participation. There has also been some investigation as to whether addition of PRP or other biologics to the reconstruction area at the time of surgery makes a difference in healing speed or strength. At this time, I am not aware that any research has shown a difference. If anyone has managed to make it this far without falling asleep, I hope you found this discussion interesting. Feel free to leave a comment below if you have additional questions. Thanks for reading. Safe wishes to you and your families.

According to my mother, my first word was “go.” I’m not sure I buy it, but if it’s true it certainly explains my predilection for travel. My first MLB game was in 1987 and after moving to Minnesota in 1998, I fell in love with the game. It was almost inevitable my love of baseball and travel would intersect, although I’m not sure when I started intentionally marking off stadiums. Before the season was suspended from the virus, I’d planned to close out seeing all 30 active stadiums in September 2020 when the Twins visit the San Diego Padres. The new Rangers stadium is also in limbo for July. Everyone needs to keep washing their hands and maintaining proper social distance so I can get back to flying and hanging out with 30,000 people on a nightly basis. In the meantime, I decided to take a trip down memory lane and finally finish my write up my experience at each stadium. National League East Atlanta Braves Turner Field My first visit was June 6, 2006 Washington Nationals at the Braves. It was a work trip and a group decided to go see a game. Former Twin Matthew LeCroy was playing for the Nationals at the time. Future Twin Jon Rauch also appeared for the Nationals. I would later be back in Atlanta the summer of 2011 for a work project and attend multiple games, including an August 12, 2011 game when they retired Bobby Cox’s number. I have a Dan Uggla bobblehead from that summer too. It’s only selling on ebay for around $20 eight years later so guess I won’t be retiring early with that gem. The Chipper Jones bobblehead from the same series is going for $36 so if you rate it by hits per dollar, Chipper is a better deal. Turner was fine and close to the airport and downtown which was convenient for me as a visiting fan in those days. But the concourses weren’t open and it hadn’t been maintained all that well by 2011. There weren’t many premium areas either. The Braves closed it five years later and moved to the suburbs where the money was. Trivia tidbit – If you look closely you can spy Turner, now known as Georgia State Stadium, in episodes of IFC’s Brockmire. SunTrust Park (now Truist) By the time SunTrust was built, I was consciously trying to get to all active stadiums, but hadn’t managed to find a time to get back to Atlanta when the Braves were in town. Fortunately a work trip to Atlanta popped up in August of 2018 while the Braves were hosting the Rockies. If they’re going to force me to watch pitchers bat, at least I didn’t have to spring for the plane ticket. The stadium is new and fine and in the middle of a new and fine manufactured village. Parking is not great or cheap, it’s still hot and humid in Georgia, and they didn’t put a roof on it, but there are plenty of premium areas so if you have the money you can get some AC. It has a really nice kids’ area and picnic tables around the concourses so it’s a family friendly park if you can afford the tickets. Pics and more on Twitter. Since I was there in 2018, they’ve unfortunately changed the name to Truist Park. Miami Marlins Marlins Park I’ve been to Florida a zillion times and I’ve seen probably a hundred baseball games there, but until the 2017 All Star Game, they’d all been spring training or MiLB. The Twins were headed to Houston after the ASG break and Royce Lewis was in Fort Myers at GCL so I decided to get two stadiums off my list and squeeze in some MiLB with a Miami-Fort Myers-Houston trip. My first impression of Marlins Park was it looks like a spaceship from the highway. I made it into town in time for the home run derby and saw the ASG the next night. It was July in Miami so the roof was closed both days, mercifully. Inside the stadium isn’t particularly remarkable, but the bobblehead collection is pretty cool and it was the first time I’d encountered signing up for designated driver via iPad. The home run whirligig was still inside in 2017. I’m still not sure if it was hideous or awesome, but it was at least unique. For the actual ASG, my seat happened to be in front of the auxiliary press box which meant I got to hear all the announcements to the visiting press. The AL won 2-1, I took a couple hundred pictures, and then spent an afternoon on South Beach before heading to Fort Myers. New York Mets Citi Field I’d been to the newest Yankee Stadium a couple of times and once saw Shea Stadium from a cab, but hadn’t made it to Citi Field despite being in New York City several times over the years. When I saw the Twins on the schedule early in 2019 with a weekend series before in Philadelphia, the trip practically planned itself. I took Amtrak into the city and then made my way out to an Airbnb in Flushing about a mile from the field. The first game was rain delayed, but fortunately I’d managed to accidentally buy a ticket with access to a couple of the clubs. None that included free food of course, but it was cold and rainy so I was happy to have a warm dry place to hang out after doing a lap around the concourse. There are some weird areas in the outfield from them moving in the fences. The views from the seats are OK, but there’s a dead space between the seats and the wall which makes the area just seem awkward. The condiment carts were exceptional and put Target Field’s to shame. The batter’s eye has an apple that pops up if the Mets hit a homer. The game ended as a 14-8 Twins win and we got to see the apple a few times. The weather had cleared for the second game and I was able to walk the mile to the field. You pass an area that an usher told me used to be a big chop shop area. He said the discussion lately has been about moving the vast parking to the east side so hotels could be built with Manhattan views. The stadium is close to the tennis complex that hosts the US Open so there’s definitely a market for more hotels with better access to transit near the field and tennis complex. With better weather I made my way out to a deck where you can watch flights come and go at LGA. I’d seen Citi Field from planes a few times so it was fun to be on the other side. Game two ended in a Twins loss 9-6 where Twins pitching allowed TEN walks so I finished the game in the Delta Sky360 Club and watched the Islanders play the Penguins. Here’s the Flickr album if you’re interested. Philadelphia Phillies Citizens Bank Park When the 2019 Twins schedule came out with an April weekend series in Philadelphia with the Mets next, I knew it was time to get both off my list. I flew in later Friday night, but not in time for what turned out to be a terrible, rainy, cold game where Jake Odorizzi went 0.2 and gave up five runs. Fortunately, the sun came out on Saturday morning and, after doing the Rocky stairs at the art museum, I headed to the ballpark on a warm April day. Citizen’s Bank Park sits south of downtown in the middle of parking lots that serve the football field, hockey arena, and baseball field. It’s a great feature if you’re driving, but isn’t as convenient if you’re a walker, so I arrived by Lyft. I like brick and Citizen’s Bank Park has plenty of it. They also have trees in the batter’s eye. The bullpens are tiered, which always reminds me of the 2010 game where Drew Butera caught Jim Thome’s homer in the bullpen in a crazy game where the Twins won 13-10 in 11 innings. Out behind left field you can get the Federal Donuts chicken sandwich. There’s no donut involved, but the sandwich is good. I made my way to my right field seat near Bryce Harper for the Saturday game and watched the Phanatic take its laps on its four wheeler. MAX! and La Tortuga had back-to-back homers in the 3rd then and the Twins won 6-3. I opted for a seat in the CBP equivalent of the Legend’s Club for the Sunday game. It has whole walls covered in baseballs. The security guy I talked to says it's like 17-18K baseballs. I didn’t count them so we’ll have to take his word. They've been up since at least 2010 as far as he remembered. The game started out well with a MAX! lead-off homer but the bats went silent and Berrios was human and the Twins lost 2-1. Pictures on Flickr. Washington Nationals Nationals Park A family trip took me to Washington, DC in October of 2019. I didn’t get to pick the dates so no option to make sure we’d be there during baseball so I needed a little cooperation from the Nationals. I’d done the math and new they needed to make the NLCS for us to have a chance to see them… and THEY DID! And of course went on to win the 2019 World Series. There were four of us who decided to make the trip to the game. Believe it or not the tickets for game four were cheaper than a trip back to DC would have been. We picked the outfield right under the scoreboard. Not my usual infield choice, but the price was right and the view was pretty good. We took the Metro to the game. As you come out of the stop for the ballpark, there are restaurants, bars, and condos. I’m not sure what was there before, but the area looks new and was hopping on a playoff game night. The main entrance on the metro side has two large parking garages on either side with large silver baseballs on each side. One garage is the path of a pitch and the other is the path of a homer. Unfortunately, other than the baseballs and nice area across the street by the Anacostia River, the rest of the outside is rather non-descript. They have some history stuff leading up to the homeplate gate which includes the Senators years that are actually the Twins’. Inside the park is pretty standard with open concourses, middle tier club level with suites above it, and the requisite Budweiser party roof/loft/deck in center field. We got to see the Presidents race, sing Baby Shark with the crowd as Gerardo Parra stepped up to bat, and cheer when Brian Dozier entered as part of a double switch. The Nationals scored seven in the bottom of the first. It would be all the offense from them we’d see and all they’d need. They went on to win 7-4, sweeping the Cardinals in four games to advance to the World Series. It was amazing to be in that environment, despite the beer thrown over our section when the game was over. We really need to have a winning playoff game at Target Field. Pictures and some terrible video work on Flickr. Except for Turner Field, the visits to the National League East stadiums came later in my trek to see all parks. I managed to see the Twins at the Mets and Phillies, but the most fun was watching the Nationals win the NLCS. My favorite stadium in this division is a tough choice between Citi Field and Citizens Bank, but the edge goes to Citizens Bank. TCAnelle’s NL East Rankings: Citizens Bank Park Citi Field Nationals Park SunTrust Park Marlins Park Turner Field