By Jane Ehrhardt
For two years, Jeff Dugas, MD tested an idea on the elbows of cadavers that would offer an alternative to the Tommy John surgery, which is a reconstruction procedure that replaces the damaged ligament with a grafted tendon. Instead of reconstruction, Dugas, an orthopedic sports medicine surgeon at Andrews Sport Medicine, wanted to develop a reliable repair.
“Repairs were done early on by the big elbow surgeons—Jobe, Andrews, Lou Yokem,” Dugas said. “But they had poor outcomes compared to replacement.” However in the last 20 years, advancements in the understanding and technology of anchors, sutures, physical therapy, and throwing programs, rejuvenated the interest in repairs in the mid-2000s.
By 2013, Dugas had honed his findings into a procedure that repairs the ulnar collateral ligament (UCL) back to bone. The UCL internal brace, inspired by the work of Scottish ankle surgeon Gordon Mackay, produces outstanding outcomes with up to 93 percent of patients returning to play at the same or higher level.
The procedure uses collagen-coated FiberTape to attach the damaged ligament’s ends to a pair of 3.5 mm Polyether ether ketone (PEEK) anchors drilled into the bone. “You’re able to repair the ligament back to bone where you can expect it to heal, and you’re augmenting it,” Dugas said, referring to the tape. “So you’re better off than when you started.”
Around 900 procedures have been performed at Andrews Sports Medicine alone in the past decade on athletes at every level, from high schoolers to pros. “It doesn’t seem to matter how old you are, what position you play, what level you play at, or how hard you throw, the success rate is around the same 93 percent,” Dugas said.
That has made the UCL internal brace a popular choice for injured athletes. In addition, recovery time averages seven months, according to a 2023 study in Arthroscopy Techniques that analyzed 350 athletes who had undergone UCL internal bracing over a three-year span. Some sources report recovery as short as four months. That means five months faster than the year needed after Tommy John reconstruction.
Though baseball pitchers top the list for UCL damage, the type of athletes facing that injury range from javelin throwers, gymnasts and swimmers to cheerleaders and wrestlers. “I had a WTA tennis pro in yesterday,” Dugas said, adding that UCL injuries result from overhead motion. “So we see all the throwers, tumblers, and grapplers.”
The majority are also not professionals, but high-school age. “Because so many more athletes are playing sports in high school. And probably only one percent go on to play college and only one percent of those go on to pro,” Dugas said.
But not every UCL injury is eligible for an internal brace. “The number-one criteria for repair with the internal brace is not having tissue deficiency,” Dugas said. “Of course, this also bolsters the outcome numbers in comparison to reconstructions because repairs are only being done on healthier tissue. We’re not dealing with a lot of chronically diseased ligaments. Most of the time, the injured 35-year-old baseball pro who’s still throwing hard more likely has only reconstruction available to them with its 12 to 18 month recovery time.
“But I’ve been pushed into doing it in some cases. For example, an injured pro baseball pitcher with tissue deficiency in his UCL came in for an internal brace. He said at 39, he didn’t have 18 months for recovery from a reconstruction, and that if it didn’t work, he’d retire. In the end, I think people make good decisions when they’re faced with the data.”
Since its arrival a decade ago, the UCL internal brace procedure has taken on multiple variations. “I think people use ‘internal brace’ in different ways than I describe it,” Dugas said. “We use a fiber tape coated with collagen. It’s a thicker, robust construct. Others use types like suture tape, which is still strong but not nearly as strong as FiberTape, which holds up to more stress.”
“There are some hybrid procedures that have emerged where they combine an internal brace with reconstruction. They put in an anchor where the ligament tore off and sew the ligament back down, then put a reconstruction over the top of that. So it’s a hybrid procedure, but not a hybrid internal brace.”
“I think there are about five or six hybrid techniques in use. We don’t know if they’re better than reconstruction or the internal brace alone. I don’t think any of them are dangerous or a bad idea, but we don’t know yet if it improves the outcome of what we have.”
Dugas blames the recent increases in UCL injuries in baseball pitchers not on the pitch clock, the spin or the velocity being applied these days, but the ball. “They took away the tack. It’s smoother, so you have to grip it tighter to spin it,” Dugas said.
