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On this episode of the sports physical therapy podcast, I'm joined by Dr. Jeff Dugas. Jeff's an orthopedic surgeon at Andrew sports medicine and the American sports medicine Institute in Birmingham, Alabama. Just one of the pioneers of the new internal brace procedure for Tommy John repairs. It's an exciting new procedure that we've seen great results with so far and a faster return to pitching. And this episode, we're going to talk about the history of this procedure, the selection criteria, the benefits over a traditional reconstruction, and so much more about Jeff's experience.
Mike:Hey Jeff. Thanks so much for joining us on the podcast today. How's it going?
Dugas:Great to be here, Mike. Thanks for having me all as well.
Mike:You're one of the pioneers of this newer procedure, the internal brace procedure for ulnar collateral ligament repairs. And it's really awesome to see its growth over the last several years. And it's super exciting to have more options for our overhead athletes now. Why don't we jump right in and start talking about that. Can you explain a little bit about what exactly this new internal brace procedure is? And then maybe give a little context, maybe a little bit about the history of UCL repairs in general.
Dugas:Sure. So I'll start with the history part, cause that gets us to the other part, but the. Tommy. John was a pitcher with the Dodgers and the Yankees. And in 1974, Frank Jobe, who was one of the pioneers of, of elbow surgery and in our country. And one of the real fathers of sports medicine did his owner collateral reconstruction. And, uh, he swore that it was a total failure. He, he said, Cause Tommy, John got an owner nerve palsy that didn't come back for two years and another operation. And, uh, so he, uh, uh, so he basically said it was bad and he didn't do another one for five years. And. Yeah, it's crazy. And Khatami, John came back to win more games after his surgery than before, uh, Lao, Norwood published the first study on this in four patients and only two of them got back. But remember, back in the day, when people were repairing things, Norwood was the first to publish on repair it in 1981. And only two of them got back there that was before suture, anchor technology, advanced and suture technology, advanced four. We really knew anything about the operation. So fast forward, John Conway wound up being the Texas Rangers doc for a long time. And one of the more gifted scientists in the elbow world and the practices in Texas, fantastic surgeon, he published when he was a fellow on job's. Uh, first 74 patients that he did reconstructions on it. Tommy John was the first one. And in that group, 75% of major league baseball players got back to major league baseball with reconstruction, but only 30% of the repairs that he did eat 14 repairs, seven major leaguers, and only two of them got back. So based on that job said repair was bad and reconstruction was good, which was right. And then Andrew's published in. 2000 with Fred ASR, who was a fellow when he pulled the data together on his 90 patients or so, and he had the same outcomes, you know, 80 something percent of the elite baseball players got back, but only 30% of the repairs because he had done some repairs early on, got back. So as of 2000, there were 160 patients that were. Published on reconstruction, which is hard to imagine over a 26 year period, we only published on a hundred to 60 patients,
Mike:That's crazy considering how much I know Dr. Andrews alone did.
Dugas:Right. I mean, and then over the next 10 to 15 years, the whole thing exploded. So 2000 is when I was finishing my fellowship while, and I, and so we started and we were doing all these cases with Andrews, you know, hundreds of thousands over the course of 10 years. And we cut into these ligaments and we reconstructed all. And, and so we were doing a reconstruction for every one of these patients, regardless of what their level of pathology was. And some of these things, you cut into these ligaments, and they're just not that bad. I mean, you look at these things, you think, gosh, it's a shame. We got to do this 12 month operation for this and this high school kid. And of course, the years, as the years went by the ages got younger. It went from being a professionals operation, which was a lot of the patients in job. And Andrew's study to a smaller number over time. And now the vast majority of them are high school kids. So Andrews was pushing us to say, look, this is terrible. We have to do these things. So that was the Genesis. And in that timeframe, there were so much advancements in technology with suture anchors and tapes and suture technology and biologics and all these other things. Plus our understanding of the operation after doing thousands of these things with multiple centers across country, doing lots of these things. So. Uh, a guy named Gordon MCI, who is a foot and ankle surgeon at Scotland was the first one to use the concept of the internal brace. And the internal brace is really a construct using two small plastic anchors with a, with a tape, a suture tape, a fiber tape, which is spread between them. And we, we use the college and coated fiber tape. In the U S because we can get it. Some places in Europe won't allow you to do any kind of college, but what we can. So we use that. So that was the internal brace. I remember going down to the company that made this and they didn't think we could do it. And the elbow using these small anchors, they thought the tape was too big. And I said, no, no, no, no, we can do this. I went down there and I showed them in a cadaver. We could do it. And. And so then we, we proved that we could do it. And so that was the Genesis of it. And then it was just a matter of doing some basic science studies, which we did prove that it was at least as good as what we were doing every day. And then, uh, I had the right patient walk in and we could talk about that if you want, but the right patient walked in and the summer of 2013 and we did the first one.
Mike:Isn't that amazing. Right, And, and, you know, for, to give a little history too, you know, you mentioned your fellowship in 2000, I just, you know, just to, just to reflect on that too. Um, you know, I don't think a lot of people know that, um, we were doing our fellowships at the same time. That was me down there and the PT world and, and you and Lyle down there in the, uh, in the surgical world. So you, you brought back some memories there, but you know, it's amazing to you. You also mentioned too. I remember when. You know, back in our fellowship days and our early career days, remember like Tommy John's used to be like 35 year olds that work towards the end of their career. right, Or,
Dugas:right.
Mike:30 year old professionals. And then now their kids they're high school kids or college kids. So, you know, to be able to do.
Dugas:high school kids. Now it's terrible.
Mike:And I like what you really said right there, where you said, like, sometimes you go in there and you're like, gosh, the tissue's not that bad. I wish we didn't have to do a full reconstruction. That's amazing. So, uh, so, so you alluded to this a little bit about, you know, the 12 month it takes in a Tommy, John reconstruction, what are the, what are the main benefits of the internal brace? If it's a similar, if it's a similar strength, does that, what changes this? Like why would you go an internal brace over a traditional Tommy, John.
Dugas:Well, let me just say, as I start that, you know, thank God for Lyle Caine. You know, we've been side by side for a long time and we, we, we re I think we get anxious when we're more than about 50 feet apart. So as you know, it's, he's been a vital part of this. I don't want to overlook saying that about LA. Um, so. You know, when we do a reconstruction, reconstruction means you're substituting for what was there, whether it's ACL reconstruction, UCL, reconstruction, whatever. So you're putting a piece of tendon in asking it to become a ligament, tendon and ligament are similar, but they're not the same. And so when you put that tendon graft in there, it has to heal in the bone tunnels. And we know from Scott rodeo, You know, studies in the nineties out tended to bone healing, tend to know all these kinds of things work. And, and so that tendon has to heal first and then it has to undergo a process of ligament disease. So that tendon has to actually reorganize into ligament like tissue to function like a ligament and tendon would not survive in the ligament mode as a tenant. And that's very different than the repair with the internal brace, where you have ligament and you're asking ligament to heal to bone and then augmenting it, that ligament tissue is already ligament. It doesn't have to change just as to heal. And that's really the major difference in the two operations. And we repair every other ligament in the body. There's no other ligament that we don't. Uh, and so as long as the tissue is good and that's really what it boils down to with the internal brace is if the tissue quality and quantity are there, if the ligament tissue itself is okay, it's just detached. You can reliably repair ligament to bone and ligament to bone healing is very robust and reliable and reproducible. And, and, and so. The augmentation with the internal brace. And I do think the college and makes a difference. You're putting a backstop on this so we can rehab them quicker. And we did some studies looking at cyclical loads and all these kind of things to know that we could push these people. Um, so we rehab them a little quicker. Uh, Kevin, you and everybody else that rehabs these things, I'm sure you would say the same thing. Kevin does the internal brace people get their range of motion back.
Mike:Right.
Dugas:have less, it's less of his operation. There's less bleeding, there's less swelling, there's less pain, but they also get the range of motion back quicker. And that's because it's a very, very stable and rigid construct so we can push them pretty quickly. We don't have to worry about pistoning and the tunnels and the graph, not healing and things like that, that we worry about with the reconstruction. So we have to go slower. So we were able to rehab them quicker, heal quicker, and become the tissue that it's supposed to be, which had already is. Faster. And then it's just a matter of building up their strength or endurance and getting them back in the game. So
Mike:W
Dugas:it literally cuts the rehab time in half.
Mike:Right. And that's, and I remember when, when, when you guys first started doing this, you know, Kevin and I, you know, we, we hopped on the phone and, and we were both saying, we were like, wow, like this seems really fast. We're kind of nervous. And I think we're still, we're S we're still nervous. Every time we go through the procedure, it's almost, we're still nervous, but I get admit the outcomes have been fantastic.
Dugas:They have been, and I have to give a lot of credit to buddies. Yeah. I got to give a lot of credit to buddy Savoie. Who's another one of the real geniuses of, of shoulder and elbow surgery. Uh, today is Dr. Andrews 80th birthday. And he was our presidential guest for the fellowships side of this weekend. But, you know, buddies actually. Doing these, and he's getting them back and four or five months,
Mike:Wow.
Dugas:which, you know, I, again, I think, you know, that's fine. We're probably pushing the envelope of what we can do rehab wise. But, um, I remember the very first one, they sent me a video. I think I showed you this. We did the surgery on August 8th, 2013. And on January 10th, they sent me a video of this kid pitching off the, now that I thought, why are you trying to kill a good idea? It's going to fail and we're never going to do another one of these, this, why are you doing this? And I called the therapist and the trainer, and I was like, what are you doing? They said, we can't hold them back. You know, he, he, he feels great. He's pitching. And, and he went on to pitch his whole senior season in high school.
Mike:And it isn't that historically too with like things like ACL's like from the transition, from the eighties to the nineties where sometimes our, our, our advanced rehab progression was just, uh, it was just feeding into the noncompliance of our patients. Right.
Dugas:Absolutely. Absolutely. I get it. I get texts and emails all the time about, Hey, so-and-so hit. And again, I got, I got one the other day where somebody was hitting in a game at 10 weeks post-op and I was like, oh my God, I told you not to do that. You know? And they're like, oh, it feels great. He's hitting. And I was like, okay. I
Mike:That's, but it's funny. I I, well, I I'm glad that you are also nervous when you hear things like that. Cause we still are, but, but you know, but you know what it's but it's been great. And you know, like you said, I mean the concept of not having to go through. Uh, ligamentization process and then not having to deal with, with, um, you know, some of the issues like the bony tunnels, healing and all those things, and just, it's just, it's really exciting. So, so rehabs faster. W when do you let an internal brace start throwing? Let's start with that. When do you usually start that?
Dugas:So my typical routine is I give them six weeks to heal in a brace. We get the range of motion back. We start them PT day three, and, um, we rehab them, keep them in the brace. Six weeks they come out of the brace. They start doing pliers. We do four weeks apply. I was starting with two handed pliers for two weeks. Gradual progression over that two week period to the, to the effected side, you know, we're basically going from 50, 50 to a hundred percent on the effected side. Then we do two weeks of one-handed pliers, gradually rapid ramping up the intensity and things like that. So by the end of it, they're throwing a Plyoball off the trampoline, which is just like throwing and then they start throwing programs. So we usually start the throwing program and we collect, um, you know, start a week 11. And there's a couple of phases to that as there always is. And, uh, generally speaking, it's about a six to seven months, total recovery time
Mike:And total recovery, probably just because we have to get people off the mound and pitching again. So w in position players would be even faster, like when do you let Position players. get backed in.
Dugas:I think most position players are back at about five months. Um, you know, they're they're um, those guys can hit, usually you're hitting live by four months. We started the hitting progression at the same time and the hitting progression is only six weeks. So they're done with the hitting thing by 16, 17 weeks. That's four months. So usually they're back hitting and, you know, or playing first base, you know, if their first basement, I could probably play in a game at four months, uh, you know, a left side of the infield or probably five months outfielder, probably five months catchers. I've been a little bit more cautious with, cause they have to throw from so many angles and they gotta throw hard and they're throwing all the time. So I think catchers and pitchers probably about the same, uh, You know, interestingly, one of the groups that were a little bit concerned about this is true for reconstructions. Two is javelin throwers. Jack chaplain throwing is really not an easy one to get back to. And I think when we looked at data, the javelin throwers are probably not going to do as well in general, regardless of which procedure you do, um, as the, as the baseball and other overhead asks.
Mike:Yeah, the torque's enormous with, with, you know, such a large way to implement that's that's, it's, it's totally different. right. And, and to give the listeners some perspective again, too. I mean, we're starting to throw after a Tommy John reconstruction now at About month five now, so it's about 20 weeks or
Dugas:20 weeks. Yeah. About 20 weeks.
Mike:And they're getting back, which is actually slower. We slowed that down, which I don't know. That's probably another topic of conversation, but you know, we've slowed that down from 16 to 20 because people were failing. I don't think I was necessarily, you know, you know, the fault of the procedure, but, um, and they're not back until give or take about 12 months. Some teams are even delaying long. Again, I don't necessarily agree with, but you know, that's a big difference, like you said, it's about half the time. And man, when you, when you're talking about a collegiate athlete, are you talking about somebody with a very specific timeline? That is, that is. very impactful for them And
Dugas:is. And I think that some of the data on return time obviously has seasonality built into it. You take a fair amount of seasonality out of it when the total recovery time is half,
Mike:right.
Dugas:because you have so much time to make those decisions. Whereas if you get somebody hurt right now, uh, you know, at the pro level, They probably won't come back till the all-star break. You know, they might not be back in April or may, even though they might be able to the proteins, you know, the major league teams are going to be very patient with these things because they have an investment in these guys, whereas at the college level, You know, they're going to be pushing them a little harder cause they don't have the time high school kids don't have the time. So, you know, the seasonality of it really makes a big difference in terms of that statistic. So we always look at, you know, return time relative to seasonality and seasonality is a much bigger factor in the reconstructions than the repairs.
Mike:Yeah, big time. And, and, and everybody has different goals depending on their level. I mean, at the professional level where we're often mapping out like a two year progression and that includes return time, but sometimes we delay them on the way back because we want them strong towards the playoffs or, or something like that. You know, it's just the
Dugas:Right, exactly.
Mike:All Right. So, so based on that, then somebody comes to your office and they see you, who who's the best candidate for this? Like how do you make your, your algorithm, your clinical algorithm of whether you go for a full reconstruction or this new internal brace repair. Look what goes through your mind?
Dugas:Well first it's, it's always their preference. You know, I worked for. They don't. I, you know, I saw, I always say that, look, I work for you. You're hiring me to do a job for you. And my job has to be to achieve your goal. That's mom, we have a shared interest. So my urgency, my, my recommendations have to be based on your goals, not my goals. And. So I have people that come and they say, you know, whatever you do, I want the internal brace and I can look at them and say, yeah, your tissue looks terrible by MRI. I think that's a bad idea. I've had people say that, like, I don't have time for the reconstruction. I want the repair. If it doesn't work, that's okay. I have other people that could look great for repair and they're like, I, I, I'm not on a timeline. I want the goals to. Just, just do the reconstruction. That's fine. It's their choice. It's their elbow. The vast majority of them come in and we consent them for both operations. And that's because while MRIs are good tests and it's the best test we have. So I think some of it starts with a good history. Good x-rays and a good MRI contrast, no contrast, whatever. Just a good quality MRI, not a strip mall MRI. You know, not one where the person was trying to escape the magnet. You can't see anything but a good quality MRI. So if you get good at, if you get good imaging and good x-rays and get a good history, you can get a pretty good feel. I think we've been about 92% accurate and saying what procedure we're going to do if we have the option of doing either. So there's about one in 10 or 12 or so. You changed based on what you see when you're in there. Um, because ultimately it has to be based on what you see and feel. And so I think good quality imaging is what you're looking for. And on the imaging, if it looks like the tissue is healthy and it's just detached, which is a lot of these. They're good candidates for the repair and in our study that we published, and this was the early 130 of these, there was no difference whether it was proximal or distal, partial or complete did a nerve transposition or not. None of those things made a difference in the outcomes. So there was no reason to shy away from doing whatever we felt was best at the time.
Mike:That's great. That's great. So, so the number one thing is tissue quality. It has to have the right type of tissue quality. So if it's too degenerative, it's probably not going to take, and you're going to go full reconstruction.
Dugas:Correct
Mike:Right. And
Dugas:or quantity, you know, if somebody's got a big obstacle in their ligament and, uh, you know, like a big former avulsion or something where. You know, they'd pulled something off when they were 10 or 11. There's a big piece of bone. And when you cut it out, they're going to have a deficiency. Those people need more tissue, they need more college. So if you have a deficiency of either quality or quantity, we're probably doing a reconstruction.
Mike:that makes sense. And that's probably why, you know, with, with the, the mean age of people needing these procedures, you're getting younger and younger. That probably means the tissues better. So we're going to see more potential candidates. Is that accurate?
Dugas:I would say that's very accurate. You know, the, the UCL world is probably 70% high school kids.
Mike:Right. Yeah. That's that's crazy. So can you share with us what have been the outcomes so far? I know you've probably studied this and seen some of the most in the country. Uh, how many of you performed, give or take now and what do you think the outcomes have been so far compared to.
Dugas:We've done about 600 of these in Birmingham over the nine years we've been doing it. Um, and, and it's accelerating. I'll probably do, you know, somewhere in the neighborhood of 200 of these this year. So it's accelerating, which is, which is expected, you know? I would say that around the country, there's probably been somewhere between three and 4,000 of these done. Um, some of the other studies buddy published on 40 or 50 of these and had, um, about the same outcomes we did about 93%. Good and excellent return to play at the same or higher level. You know, those statistics that we have to, we have to track and. They it's been the same. So everybody seems to be reporting kind of the same numbers somewhere in the low nineties. If you look at at standard reconstruction and these are data from, you know, Andrews and, and job and us, we published that big study on, you know, 1200 of these things. Um, it's about 85, 80 8% good, excellent return to play at the same or higher level. And I tell people those statistics and everybody says, well, we want the repair. And I said, look, that's not how you should look at it because remember we're cherry picking
Mike:Right.
Dugas:and we're cherry picking the ones that are, that are less injured, less tissue issues. No, I don't have to take off a big piece of bone and, you know, the only thing holding the elbow together as a graft and you know, stuff like that. So I think that it's not fair to compare them and say one is better than the other. That was never the goal. And nor should it be reconstruction is still a great operation. And. And people with good healthy tissue. I'm sure it's higher than 85, 88, but in the, in the studies we have looking at all comers. Those are the numbers. So I don't necessarily think it's a fair comparison.
Mike:Do we have any, uh, assessment on longevity yet of these NDA?
Dugas:We're looking that up now. So we're looking up the five to seven year results. Um, you know, the real acceleration of this happened around 2016, 17. And, and so if you look at the numbers as you'd expect, that just keeps growing and getting bigger. So we will probably publish the five to seven year results, you know, minimum five-year followup. Probably in the next two years, probably when we get to about 10 years, total experience, we'll publish the five to seven year data. We're collecting it now. And it looks about the same. It still looks like it's about 93%, which is what you would expect. But you know, then you've got to look into, you know, how long are these people playing? And that has a lot in it because a lot of these high school kids wash out and they don't have the opportunities or they're not good at. You know, and, and so one of the things we have to ask. Were you able to pitch to the level that you w was your elbow, the reason you didn't go further or was it something else? And that's going to really play into the numbers in that, but, um, we've got them all the way up to the major league level. Most of the major league clubs are now comfortable with this. Um, a lot of the agents are comfortable with it, the players, but you know, there's still no room to say that reconstruction is a bad operation. Now, interestingly, Dr. Andrews on this panel, we had this weekend with Kevin and me and, and uh, buddy Savoie and Lyle, and we were all sitting there. We were talking about all this. And Dr. Andrews said that he thinks it will not be long before every UCL surgery is done with internal brace. And we were talking about hybrids with, you know, reconstruction with the internal brace and all that. All of us are kind of nervous about putting extra tunnels in the bone, doing that. Some people are doing it and the outcomes will be, you know, some people around the country are doing that personally. I think it, it seems interesting, but I don't know that it's gonna be. Better. Um, there, there will probably be some studies published on that. I think it will be at least as good, but I'm a little nervous about drilling extra holes in the bone and, uh, and creating some more stress risers, especially on the medial epicondyle side.
Mike:Right. especially w with the internal brace doing so well, I, I don't know, if we've, if we've warranted a need for that yet. It's not like the internal brace is failing on its own with just a repair,
Dugas:No, no. We rarely see somebody tear the tape. I've seen. nine years of doing this, I may have seen two or three, two people tear the tape. In fact, one of them, two of them out of the, maybe three that I've seen tore the tape and the ligament, but it was on the opposite end of their initial injury. And it was like four years after the fact,
Mike:Crazy. Right. and and who knows what led into that? Yeah.
Dugas:Right. And revisions, you know, revision UCL surgery is probably one of the least successful operations I've ever done. You know, there are things that we do in medicine that, that work really well. And anytime you're revising, you wouldn't expect it to be as successful as the primary. But revision UCL is really one of the worst operations in the history of sports medicine with a success rate of like 40%, you know, I mean, it's really bad and it's a hard operation to do, and it takes forever. I think at the major league level, the average return time was like 21 months. So it's a forever operation. It's terrible. And so right now, most of us are revising previous reconstructions with internal brace and revising failed internal races with reconstruction because you don't have any bone problems, so you can do it like a primary. And, um, so those seem to be revisioned now seems to be a better operation because we have the internal brace as an option post recontract.
Mike:And the people we've seen. I mean, I've, I'm two of them right now. The people we've seen are, are doing great. So,
Dugas:Oh, yeah.
Mike:The future is bright and it's people like yourself pushing the envelope and, and a lot of your colleagues, Dr. Kane and everybody that's really helped in this procedure. So, um, you know, thanks. Thanks for doing all this. And Jeff, thanks so much for taking the time to share your experience with this. And, and heck I mean, 200 this year. I mean, there's no person that I probably want to talk to him more than you because you know, with that much volume at you're seeing a wide spectrum of people, it's great experience to share with everybody. So thanks for taking some time out today to share that with.
Dugas:My pleasure, Mike, it's great to see you. And then obviously keep doing what you're doing. I appreciate all that you do. You're one of the real scientists in what you do and you're leading the field and between you and Kevin and people like Russ and others, you know, I mean, it's just, uh, we don't get there without you guys. You know, I, Andrew said this and we always said, I can do a perfect operation, but if we don't get the rehab, it's, it's going to fail. We only give them an opportunity and. And you guys are vital to what we do and the outcomes we get. So I appreciate you've been a real pioneer in the rehab of this, and I really appreciate your work.
Mike:Yeah, thanks. And for any orthopedic surgeons that may be listening. Cause we do have those too. I want you to notice how in tune Jeff is with the rehab process. Right? I mean, he, he was listening that out as if he was the PT working with the person every day. So it takes a team, it takes a collaborative effort and, you know, getting to even do podcasts like this just shows, you know, your willingness to do that. It just helps outcomes. And that's, what's, that's, that's what we're doing it for us. Right. And trying to maximize people, getting back to what they love. So thanks again, Jeff. Hopefully get you out on a future episode.
Dugas:happy to do it. Mike, take care.