The “Docking Technique” was first described by Dr. David Altchek. This technique reconstructs the UCL by looping a single continuous graft loop through converging Ulna bone tunnels and “docking” the sutured graft ends through two humeral tunnels, after which the two ends of the UCL graft are tied with non-absorbable suture over a bone bridge. The Docking technique can be performed using the Arthrex ElbowUCL Reconstruction Instrument Set. FiberWire and FiberLoop may be used to stitch the graft ends and for final fixation over the humerus bone bridge.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Ulnar Collateral Ligament Reconstruction Using the Docking Technique

Hi, my name is Doctor Anthony Romeo. I'm from Rush University Medical Center in Chicago, and today we're going to demonstrate a ulnar collateral ligament reconstruction in a 16 year old baseball pitcher. We'll be using a hamstring autograft for our graft choice. Our plan is to perform a tunnel for the ulna fixation. And then to dock the two ends of the graft on the humeral side. We will be using the Arthrex ulnar collateral ligament reconstruction tray that was specifically designed for this operation. It has a number of very valuable features that includes the fact that there is a V guide for the ulnar drill holes that allows us to create a tunnel with the first time through, not by hand, but with a guide system that will allow the easy passage of a graft at the sublime tubercle. And in addition, there is a humeral guide system, which allows us to create a socket of socket of approximately 15mm, which is the appropriate size for docking the graph, and then also to have that an articulated arm for the humeral guide. That will allow us to drill two holes that are two millimeters in diameter so that we can pass sutures through at the medial epicondyle ridge and then dock our graft into the humeral socket. So here's our graft. It's a hamstring graft that we trimmed down to fit appropriately for the size. And we'll slide this through. We'll try a 4.0 just to show that it easily goes through the 4.0. And it slides through the 3.5 without a problem. So I think this graph size is good for what we're planning on doing when we're making our ulnar collateral ligament incision. We we want to be careful not to put our incision directly over the prominence of the medial epicondyle. So here's our medial epicondyle. And our ulna of course will be just below this area here. And our ulnar collateral ligament will go from the medial epicondyle down to the ulna. And what we're particularly careful about is the ulnar nerve. So we can feel the groove, the cubital tunnel. And we know the nerve will wrap around in this direction. So we want to be careful, particularly on our ulnar side, to protect against an injury to the ulnar nerve. And the incision could be made either through the cubital tunnel, particularly if we're going to move the ulnar nerve or can be made more anterior to the medial epicondyle to stay off of the area of the ulnar nerve. And the medial epicondyle. We need to get exposure on the ridge of the medial aspect of the humerus, distal humerus, so that we can put our two drill holes that we'll use to dock our graft. And we need to get down to the ulna. Our major neurovascular concerns distally will be the antebrachial cutaneous nerves of the forearm. So we have to be a little careful about that. So here's one of our antebrachial cutaneous nerves. And we'd like to preserve that. So they don't experience numbness on their forearm or develop an aroma which can be painful. So we have to free this up just a little bit. Let's have a couple of sends, please. The plane to identify our ulnar collateral ligament is going to be in this fascial plane with the muscle behind it and the muscle in front of it. And that will be our muscle splitting approach to do our reconstruction. And so here's the tip of our sublime tubercle. So now we're going to make an incision in the capsule of our joint and expose the joint of the elbow on the medial aspect. Which one of these is a 3.5 diameter drill guide, and it will sit on both edges of the sublime tubercle. So we will slide this in. And we'll drill our two guides. There is a peg that will go inside once we're done with this drill. Charlie, can you put that in there for me? So this will hold our position accurately, and then we'll go ahead and drill our second drill hole. And then we're going to take a 4.0 curette and slide in. And we're going to connect our two. Make sure our two tunnels are connected. And the guide is set up so they are connected. This just helps to smooth off the edges and to take out any irregularities. So it'll be easier to pass our wire passing guide. And we'll go ahead and chamfer our hole so that it's it's the graft is well tolerated and slides through nicely with no edges to the bone. So there's a suture passing wire in the UCL reconstruction kit, which will help us to pass our graft through the ulnar tunnel. And then we'll do our best to identify that on the opposite side. And it should pretty easily. And that just makes it easier for us to pass our graft through this level. So the next thing is we'll take our graft. And once we have the sutures from our graft in place, then we can take our wire loop. Let's have a hemostat. Let's free that up a little bit on the back side here. Okay. So now we're going to lead the graft through. Do you have some mineral oil. Okay. And then we have a little mineral oil. Okay. And this should pass our graft through. Like that. So by using that wire loop and planning this all out ahead of time, we avoid any problems with our graph passing. And we have a nice solid graph with a tunnel that's a centimeter or more separated and very solid way of doing this without compromising any of our bone on the ulnar side. So now we'll go to the humeral side. And for this tunnel we need we have a 4.5 drill guide. And again we don't want to put too far medially or all the way in next to our articular surface. But we pick a point right in the middle in the center of the medial epicondyle. And we'll drill our tunnel. We have a drill that has a stop on it. So this should create a socket of about 15mm. And we'll take our chamfer again. So that'll be our socket that we're going to dock our graft into in just a moment. Now we're going to take the adjustable humeral guide that we use to place our tunnels that we'll pass our sutures through. And typically speaking, after we center this in our socket that we created, we'll then identify the proper position. Now surgeons sometimes will put both of the tunnels on the anterior aspect of the medial epicondyle. But you can put one anterior and one posterior as long as you watch out for the ulnar nerve, of course, or both of them on the anterior position. We're going to take our drill bit, which is a 2.0, and create our two tunnels one anterior, one posterior. Now this guide is set up so that once you've drilled the tip of this drill, will hit the tip of the inserted guide through the socket so that your tunnels are connected. We'll take our 2.0 drill guide and we'll go through the. The medial epicondyle ridge. And again this has a stop on it. So then we're all the way down. We should be in good position there. Okay. All right. Now we're going to go ahead and drill our second tunnel. So we'll go ahead and reposition this and pull back on this edge here. Let's extend that up just a little bit. Safer zone. Good. We're in good shape there. Okay. Great. All right. And then once we're done with that, we can then take our sked. We'll go back to we'll keep this in this position. We'll take our Cricut and just open this up enough so that we can see our tunnel, our socket that we created. We'll take our sked and we pass that through all the way in, and we aim towards the actual tunnel that we just created. So we pass it in, make sure it's seated and then aim towards the tunnel. Then we take a micro lasso. We put it down through the tunnel that we just created with the 2.0 drill. And what we'd like to do is we've got to be careful to aim towards our actual sked that we placed, and if it all lines up, the wire will hit the sked and bounce out and then be easy to pass. And because we're not quite done yet, we're going to go ahead and just put a suture in this position here. So if we can have a number two FiberWire. So you can if your graft is ready to go and you've already closed your ulnar collateral ligament, you can just use your wire loop to pass this through. But we'll go ahead and put a suture in place here to secure this down. And then we have to go ahead and also secure down our tunnel posteriorly. So we have a hemostat please. And again we'll go through the same sequence of events. We'll look for our tunnel. We'll make sure that with our micro lasso it goes through. And then we aim our skid directly towards the tunnel that we created. We just made a slight adjustment in our micro lasso. And sure enough, here comes our wire loop. We'll take an additional suture, so we'll pass this on through, take our skid out. And they're the most complicated part of this procedure For most of us is getting our tunnels established and making sure that we can pass our graft through. And that was simplified by the drill guides and our exposure. We'll take a hemostat, please. Okay. Next stitch please. The first limb of the graph, which is coming out posterior through our anterior tunnel. So we'll take this here and we'll use our suture as our suture passer. We'll just make a loop in our suture and pass this on through. And then we'll figure out the distance that we need to cut off our other side of our limb, of our graft, so that we can dock the graft and make sure that both limbs of the suture are nice and secure. So we'll pull on this and line this up and go through as we see here. And we'll pull this nice and secure. So it's all the way that's buried in. So we know that that's the greatest distance it can go in. So now what we have to figure out is where do we want to cut this graph. So we'll take a hemostat. And this is the opening to our tunnel right here. And then if we need the if we know that the tunnel is 15mm, we have to guess. We have to judge a little bit less than 15mm to make sure that there's room for both of the graphs to bottom out. So we typically choose about one centimeter. That should give us some play. So that we have about five millimeters of space available that we can rotate or shift our graft to make sure that it fits securely. We'll take a FiberLoop for the final limb, and we'll start at about the level where we think the graft will enter into the socket that we've created, and usually with the with the last. Right after the last one, we'll come back on the graft again to lock that last stitch in place. And once we're convinced that our graft is in a good position, which looks good, we'll take a knife. A fresh plate with a fresh blade, and we'll cut our graft. We'll take our remaining suture that we're using as a suture passer. Make our loop. Pull our second end of our tendon graft through. We'll get the suture through first. And now here's where we actually dock our graft. So we'll take an adson elevator. We'll back out our opposite graft. So we take a little tension off our other graft. We'll make sure that this graft will enter in appropriately as we see there. Almost. That looks tight. Yeah. Okay. So now. I'll tighten it down even more. We'll see the side. Yeah. We definitely we want to incorporate it into his native Mcrl2. So this is our our final reconstruction. The graph goes from the sublime tubercle. It's been placed through a tunnel and then brought together and reinforced and incorporated in with the patient's native ulnar collateral ligament. And it went through a tunnel in the medial epicondyle. And then it was fixed over the top of the epicondyle ridge with our sutures. So we have a nice secure graft. As we take this through a range of motion. You can see it's isometric. You don't see any change or stretch in the ligament. And it's a very secure graft. It's a tight graft that lines up well. And we'll be an excellent reconstruction. Allow them to get back to throwing a baseball. So now we'll go ahead and perform our closure. And our closure, as you can see is relatively straightforward. We'll take some number one bike roll. So this is our intramuscular layer that we've closed. We maintained our nerve Our cutaneous nerve to the forearm. Looks nice. Okay. Okay. So our next layer of wound closure is the. Is the subcutaneous layer. And we're using A20 monocryl. And then we'll finally put A30 monocryl with steri strips for our final wound closure.

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Epaule & Coude

Kyle Anderson, MD, (Detroit, MI) discusses tips and tricks for elbow arthroscopy. Topics covered include operating room set-up, patient positioning options, portal placements and the relevant instruments and equipment available from Arthrex® to complete each procedure. Dr. Anderson also shows imaging options to best diagnose pathology and common arthroscopic elbow procedures.

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Advances in Elbow Arthroscopy Techniques

Elbow always seems to get thrown in at the end, even though I love it. In terms of positioning, I think we've already seen a couple of things that can be really useful. I like the idea that Bill presented with the TRIMANO for prone positioning. I find myself doing mostly supine positioning. Because most of the elbow arthroscopy I do is with something else, like a ligament or something like that. And I've used the TRIMANO for the supine position and can bring it down onto the hand table pretty quickly. We have a little extender at Beaumont that raises the clerk up, so that the TRIMANO gives you a little bit more excursion with that, but it's kind of nice and simple. I think we've all seen that if we're going to scope the elbow, obviously the proximity of our neurovascular structures is a greater issue than other joints that we deal with. So distension can be quite important regardless of position. And Lynch back in 86 showed us that we can have tremendous improvement in that safety if we get the elbow distended for a neutral position. So I don't want to ever lose sight of that. I was trained and still like the proximal lateral portal for my initial portal. I know a lot of us in the room like a medial portal as our starting portal, but this one gives me a lot of flexibility. I think the safety factor is is quite good, so I like the proximal lateral portal just anterior to the supracondylar ridge just above the epicondyle. Nice little soft spot there. And and again, quite safe. Everything that I do in the elbow. One of the exciting things for me is everything that I do arthroscopically can be done in either the arthroscopy tray that Arthrex now has, or the UCL tray that gives us a variety of options and for UCL reconstruction. But for the elbow arthroscopy, I've got everything in one set and that makes it really nice. Probably our most common indication for elbow arthroscopy is loose body removal. I think that's the bulk of what we do in an isolated arthroscopy arthroscopic procedure. And and so I guess it's fitting to put this first here, you see one in the anterior compartment right in there. I will use occasionally a spinal needle to localize it. I'll still go back and sometimes use outflow from the from my grasper cannula to bring the loose bodies toward me. I think it's a simple little thing to do that can make things quite nice. So we either have to do some dilation, which in the elbow can be dangerous. So there is a way of, of doing this more safely now with the dilation instrumentation that you see here. And again, I think that's quite nice. But I prefer to just break these up sometimes with a scissor. You can see we're going through with the one here. And then just take them out and fragments. And again, the Arthrex set has nice graspers that will let us take those out quite easily. Probably for me, the second most common excuse for elbow arthroscopy would be posteromedial impingement. This is almost exclusively with ligament reconstruction. I'm really hesitant to do any kind of decompression. In a thrower who is not also having a ligament reconstruction, I think it's a set up for a problem. We've seen that the stresses across the UCL go up, especially if we're removing normal bone. So I, I think it's a it's a UCL problem until proven otherwise. But fragmentation is notoriously negative on imaging. And even in when I was with David Walczak, we found that 38% was even missed on the MRI. So sometimes we'll get lucky and see it on this hyper flexion external rotation view where you see this little fragment here. And it's almost like a little mini nonunion. I'm going to skip through some of some of this very quickly. So we'll I really want you to use caution when you're doing any kind of resection of bone in the on the posterior medial olecranon, especially if you're not reconstructing the ligament. But I'll do the work through trans triceps portal while we're viewing from posterolaterally just lateral to the triceps tendon. And what we'll frequently see is this little fragment that again, it's almost like a little mini nonunion. It can be very easily missed because it becomes covered in fibrous tissue. If you see here, we'll kind of get in and look posterolaterally this one there in the obviously a supine position. And we'll this arthroscopic view will pick up in a second. You see where the spinal needle I don't know how well that this is kind of an old video, but you see that little fragment can move around and look fairly normal on your imaging. But yet I do think that causes a lot of grinding and a lot of pain. So I think it's really important, at least for me to look back here on every ligament that we do, we'll take a take a peek in the back, and then we'll come through and and debris that again trying not to remove a whole lot of normal bone. I think we've got pretty good evidence now that that's dangerous for our ligament. But those can be those can be very elusive. And also one of the things that we want to make sure we're doing is, is checking for a good valgus test. As soon as we do our initial assessment of the elbow. And very few of them are as obvious as this one here, where it really opens up quite a bit with, with with pronation and valgus stress. But in my hands, any opening basically is showing any significant opening. Here is a is a positive test. The problem is that you can have a symptomatic UCL and they don't open up a great deal, but you're reproducing their pain. So it's different than than our comparisons in the knee. Tennis elbow. I have to admit, is one thing that I go back and forth between whether I want to do this arthroscopically or open. I think it's compelling since the majority of the pathology is on the deep surface. Plus, we get to assess for other pathology. It is nice to do an arthroscope, but it's also quite gratifying and very simple to do it open and put a little split and then we can get a nice repair done open. Like excision is another one that's not extremely rare. For me and Neil and others have done some good work to show that golfers are a group that we see this in. I find it easiest to work through a posterolateral portal or I'm sorry, look through a posterolateral portal and work through a mid lateral portal. To to breed this. And actually the Torpedo shaver is great for this one. Just the entry is really nice with that. And so we can get that out of there and get rid of that painful clunk. And then lastly OCD lesions are something that less commonly need. At least for me. I'm not doing a great deal of this, but it's nice to do a microfracture of these. Again, working for me, mostly posterolateral because they're distal and addressing these. If I'm doing plugs, I'm usually opening for that. So but something that I certainly think in the right hands can be done. Arthroscopically. And then lastly capsule release or contracture release. I still like to work off of the humerus. I know there's a lot of people that can be very aggressive in removing capsule, but to me, if we if we're coming off of the humerus, I think our safety factor goes way up rather than what you see on the right, coming across straight across the capsule anteriorly. I don't think that the brachialis provides the protection that some people rely on. So we go ahead and do those capsule releases off the humerus. And again, I think the safety factor is much better for me. That's it. Nice and quick.

Dr. Scott Steinmann from the Mayo Clinic (Rochester, MN) describes helpful tips for operative set up, patient positioning as well as methods to establish safe portals for common elbow arthroscopy procedures. Several new products are highlighted to assist surgeons in elbow positioning, tissue retraction, capsulotomy, and novel instrumentation for osteophyte removal. Dr. Steinmann also presents an interesting approach to traumatic elbow dislocation injuries that may provide better patient compliance and outcomes.

Elbow Arthroscopy and Arthroscopic Tennis Elbow

Thank you, Brian. Thank you. Reinhold. I would like to echo what Gus was saying about the UCL. Said. I think it's really made a big, big difference. And I use it on the lateral and medial side of the elbow. And the last thing we're working on is making a smaller Chinese finger trap to help pull it through. I think a lot of us have had trouble. You put the whip stitches in, you try and pull the graft through and it gets caught. And with the Chinese finger trap, you can pull it through a lot, a lot easier. So I don't think that'll that'll really help. And as you heard, there's a lot of new new products coming out. Arm holders. And what I'll talk about is I'll kind of go through the arthroscopic part a little, little bit quick. I think we kind of have an idea about elbow arthroscopy, and I'll just focus on some, some new things that we can do with, with some of the new products. Well, it's obviously becoming more common for elbow arthroscopy with the continued advancement in techniques, I think we're becoming much better at dealing with arthritis in the elbow and dealing with all areas of arthritis in the elbow. There's still a real risk of neurovascular injury with elbow arthroscopy. I think that's the key thing that we've been trying to do is to try to try and make this technique safer, and therefore more available to more surgeons that don't do arthroscopy, the elbow that commonly. Typically you see an x ray like this, but if you actually get a CT scan, it gives you a real roadmap of a 3D CT to kind of see what you need to go osteophytes in the railhead, fossa loose bodies by the coronoid, and then posteriorly you can see osteophytes coming off of the sides of the electron. And I'll show a video in a little bit. But the, the new PoweRasp that was developed primarily for the shoulder, actually, I think is a great new product for the elbow because it makes taking out that osteophyte there safe, whereas I typically use a round bur which can easily wrap up the ulnar nerve that lives right, right over here, and we'll be able to see that later. Not wrapping up the ulnar nerve, but I tend to use general anesthesia in the in the lateral decubitus position. Here's a typical setting. You can see the armhole that we'll talk about tilting the table a little bit toward the surgeon itself, trying to get that dependent arm out of the way of your knee and hip so you can actually get into the patient a little bit more ergonomically. And the ability to move this arm holder both in and away and up and down. So if you have a female patient you can adjust it. And a male patient and potentially a fairly inexpensive product for most hospitals. You can see here we're tilting the patient toward the surgeon as something I've sort of noticed over the years that as you do a long case, the patient will tend to pull backward from you, and then suddenly you'll have the arm holder in the antecubital fossa, which is obviously inhibiting your ability to get anteriorly in the elbow. And you want to make sure also that you can actually flex the elbow up. Particularly important when you're working in the back and in the back of the elbow. I always like to say the elbow should be the highest thing in the room. So when you're prepped and draped, if you have a shaver in here, you're not banging against the side of the body, but you have 360 access to the elbow, and the elbow is not down here, in which case your shaver, your camera bangs into the side of the body. Looks like that just before you're about to start. There are no wrong portals in the elbow. You kind of have to have a imagine a three dimensional view in your mind of where the nerves are. It's all about avoiding the nerves. As long as you're not going through a nerve or an artery, it's a safe portal. And so it really doesn't matter to me whether you start medial, lateral or posterior. I'll start in the back of the elbow. If there's more work to do in the back of the elbow, usually it's more to do in the front, but if there's more to do in the back based on the CT scan, that's that's where I'll start. There's no limit on the number of portals, but I think it's best to try and just make the portals you need, just as in the shoulder, to avoid blowing up the blowing up the joint, and to mark out all your potential portals. First we're looking at the lateral side there. I tend to do an anterolateral portal first, because that's the portal that's going to be closest to a major nerve, the radial nerve. If I get that portal done out of the way before the elbow swollen at all. All the elbow portals are easier to start from that. I think insufflating the elbow is a very important aspect. I don't do that in the shoulder and you can see why here. If you don't insufflate the elbow and you come with your trocar, you will slide across. Most of the time, the capsule inflating the joint just allows you to pop in. It doesn't move the nerve further away. It's still right on the capsule, but allows you just easier to get in and get started. Typically easier to do that right over the radar BioPatella joint itself. And so that's where we typically do the anterolateral portal first. If I feel I'm in the joint just to speed things up, I'll just push straight across and then take a scalpel and cut down on that side. You can see here we're just. I can tell that. I can tell that I'm in the joint. So I just immediately cut down and then we're off and going and get things started. Thinking about the elbow arthroscopy set that makes it makes us all a little bit, a little bit easier. Do a switching stick to get to the to the other side. I find this articulating retractor that's also in the set that we developed. Helpful, particularly to get the ulnar nerve sort of out of the way. If you're in the back of the elbow, you can bring that in close to the nerve and lift up rather than just lever down. And I think that's very helpful when you're working, particularly if you've got osteophytes on the medial side steps. We kind of went through anterolateral portal first, at least in my practice. Do your bony work first. Here you see a burr, which is obviously we'll talk about the PoweRasp in a little bit. Take out your loose bodies, then do a capsular resection. And I've learned that it's not important to take out all the capsule, but I usually leave a large postage stamp, so to speak, over where the radial nerve is coming down over the radial head. I think that's important. There's really no no need to take out all the capsule just off of the humerus and off of the insertion down onto the ulna. Protecting your radial nerve as you do that. Now, switching this is actually looking in the posterior medial gutter. So this is posteriorly. Right behind the PoweRasp is the ulnar nerve right behind the capsule. Now imagine having a burr right there. Yeah it'd be scary. But with the with the PoweRasp you can see this osteophyte just melts away. And it's important to get these osteophytes out if you really want to do a good job. Taking just a tip of the electron as it comes into olecranon fossa is not enough. You go down both sides of the olecranon to really clean it, clean out the elbow, and you can see here we've. We have the ulnar nerve on the other side. And then if this was a stiff elbow then I would release the capsule here exposing the ulnar nerve. But don't do that until you've finished taking the osteophytes off. So I'm not worried about the ulnar nerve. We're just a short while ago I would be. So I think that's a that's a big help toward making elbow arthroscopy a safer for for all of us. You can watch it again if you want. And again, as I mentioned, just above the radial head, there's a fat pad. You can see that at arthroscopy. And the radial nerve is right there. This is not always part of a standard part of the elbow arthroscopy formula. But you can you can see radial head down here. The radial nerve. Truly when you do a complete capsule ectomy as I did here kind of it almost doesn't want to go back, see. But it just wants to hang out there. That's when you see that fat pad. That's when you need to slow down and preserve that part of the capsule that's right there. On the nerve. As I was showing the PoweRasp, I was working down here and you can tell the ulnar nerve is right on the other side there. So you need to preserve that OCD just briefly. These lesions are often hard to get. People complain to me. It's hard to get there. It's really not that hard to get if you if you do an ergonomic 9090 approach going underneath the anconeus, giving you a view such as that so you can look at your lesion and very easy to microfracture and debris that if you just go under the anconeus the head up into. That region and just. Briefly on on tennis elbow. Some people say it should be called Rover's Elbow because it was described actually the sculling way before people were playing lawn tennis or whatever tennis was called back then. I think this is an important article by Marty Bowyer and Jill Hastings. If you think of the attachments on the lateral side of the elbow between two sides of a mountain, the sort of the safe side where the CRB and EDC complexes, that's what we're supposedly reading. And the lower half you can see here is the danger zone. This is where the lateral ligament would be. And you want to avoid taking that down. But just concentrating on the upper half of the capitellum when you're doing a release. I think we've kind of seen this. I'll just show the very, very beginning. But if you want to see from the medial side is this, and you want to be coming in reading the tissue off the lateral capitellum there, and that will give you a good, a good. Exposure. And just to finish up just something we've been we've been doing actually just for the past past few weeks. But if you have a traumatic patient that has a very traumatic dislocation of their elbow. Just to switch from arthroscopy for a moment, typically we've been using external fixers to hold these patients in place, and we've argued whether we should be using a hinged or static ex-fix as I've moved on just to static. Much easier, easier to put on, but I think using some of some of the techniques that we've learned, maybe this InternalBrace. But this is this was an elbow from a traumatic car accident. I didn't do any dissection. The patient did it themselves. Very unstable, exploded both the medial and lateral aspects of the elbow. But by putting a in this case we used a 3.5 SwiveLock with two FiberTape. And what we're going to do is pull that up and then put a 4.75 SwiveLock in here. This is an elbow that in the old days, which was not long ago, I would have put an external fixator on statically for just about 3 to 4 weeks. But here we're using this very strong fixation. Pulling that up. Repairing. Even putting an extra, extra number two FiberWire through. And we'll use those two number two fibers to secure the soft tissues. Using this as an internal ex-fix or brace to hold the elbow together, anticipating that it's not going to last, you know, six, eight weeks. But I don't really want it to. I just want to last until the soft tissues here heal. And we're going to stitch the muscle back together. That was all exploded. And then look at the medial side of the elbow, but very stable right out of the box. And this patient actually went back. You can see an open wound over here for some plastic surgery procedures. And multiple times at least two times back to the Or undergoing anesthesia. And you worry obviously about them pulling the elbow out during that time frame. I just saw her back in the clinic and she was doing fine. So I think I think potentially we were just in the lab a little while ago working on that. So I think this might be, in certain instances, a way to avoid using an ex-fix for the very traumatized elbow situation. Thank you very much.

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