The circumferential graft technique for treatment of multidirectional elbow instability: a comparative biomechanical evaluation

Evaluating the efficacy of hinged elbow braces in reducing passive valgus forces after ulnar collateral ligament injury-A biomechanical study

Purpose

This biomechanical study aimed to investigate the effectiveness of a hinged elbow orthosis in reducing passive valgus forces following medial ulnar collateral ligament (UCL) injuries of the elbow joint. The hypothesis tested was that a hinged elbow orthosis reduces these passive valgus forces.

Methods

Eight fresh frozen cadaveric elbow specimens were prepared and tested under three scenarios: intact ligaments, simulated UCL rupture and application of a hinged elbow brace after simulated UCL rupture. Valgus instability was assessed using a custom testing set-up and the Optotrak motion capture system. Statistical analysis was conducted to compare the results across scenarios.

Results

Intraclass correlation (ICC) calculation showed that the testing set-up was reliable in investigating valgus deflection across all levels of applied force. The hinged elbow brace reduced passive valgus forces after UCL rupture. The reduction in valgus instability was consistent with close approximation to the native state, although not reaching its level.

Conclusion

The hypothesis-that a hinged elbow orthosis significantly reduces passive valgus forces in the elbow following UCL injuries-is not supported by the data and therefore has to be rejected. Nevertheless, the study demonstrates a tendency that a hinged elbow brace could mitigate these forces, at least in an experimental cadaveric model with static study conditions.

Level of Evidence

The level of evidence of this study is level IV.

Elbow lateral ulnar collateral ligament reconstruction by transposition of the local extensor fascia septum: surgical technique and preliminary results

The lateral ulnar collateral ligament (LUCL) is a primary lateral stabilizer of the elbow that originates from the isometric center of the capitulum and inserts into the supinator crest of the ulna. LUCL injury may be due to trauma, chronic strain, or iatrogenic lesion. In patients with symptomatic LUCL insufficiency and recurrent posterolateral rotatory instability, surgical reconstruction can restore elbow stability. In primary acute treatment, the injured LUCL is reattached to the lateral epicondyle with transosseous sutures and anchors placed at the isometric origin of the ligament. If the ligament quality is poor, patients with chronic elbow instability may require reconstruction with a tendon autograft or allograft. Alternatively, the LUCL can be reconstructed by transposition of the local extensor fascia septum, a local flap that exploits the common extensor fascia connected to a thin strip of extensor digitorum quinti or the extensor digitorum communis intermuscular septum. We describe a new LUCL reconstruction technique based on the transposition of the local extensor fascia septum and report the preliminary result in a series of patients aged 50 years or less.

The role of the brachialis muscle in elbow stability with collateral ligament injury: A biomechanical investigation

BACKGROUND

The brachialis muscle lies in close anatomic relation to the anterior capsule of the elbow joint. The contribution of the brachialis muscle to elbow stability has not yet been fully investigated. Therefore, the aim of this biomechanical in-vitro study was to analyze its influence on joint stability.

METHODS

Nine fresh frozen cadaveric elbows were evaluated for stability against valgus and varus/posterolateral rotatory forces. Brachialis loading was measured indirectly using strain gauges. Three distinct scenarios were analyzed: A) with intact lateral ulnar and ulnar collateral ligaments B) with a ruptured lateral ulnar collateral ligament C) with ruptured lateral ulnar and ulnar collateral ligaments.

FINDINGS

In all scenarios, an increased strain was observed under posterolateral rotatory/varus forces. The maximum measured strain occurred with elbow flexion of 30° and pronation of the forearm. The strain was significantly higher with dual-ligament rupture (mean - 210.5 μm/m; min. 97.8 μm/m; max. -310 μm/m; SD 107.8 μm/m; p = .034) compared to intact ligaments (mean - 106.9 μm/m; min. -32.51 μm/m, max. -287 μm/m; SD 100.2 μm/m) and single-ligament rupture (mean - 109.5 μm/m; min. - 96.7 μm/m; max - 130.4 μm/m; SD 18.2).

INTERPRETATION

A strain of the brachialis muscle was observed under varus/posterolateral rotatory forces with a pronated forearm and the strain increased significantly in the event of a dual-ligament rupture. This suggests that the brachialis muscle may influence varus/posterolateral rotatory stability of the elbow. Hence, a concomitant tear of the brachialis muscle might result in pronounced instability following simple elbow dislocation.

LEVEL OF EVIDENCE

Basic Science Study, Biomechanics.

The flail elbow: Every surgeon's nightmare

A flail elbow joint has an excessive or abnormal degree of mobility resulting in loss of function. Such a situation can arise from structural damage or loss of neuromuscular control. Structural damage may be in terms of loss of integrity of bony, ligamentous, or both components, and this is commonly caused by trauma, failed arthroplasty, infections - either in the native joint or associated with the above, or inflammatory arthritides. Arm paralysis from any cause may also leads to a loss of muscle control making the elbow flail. The management of the condition varies according to etiology; and concurrent issues like infection and instability need to be addressed in addition to the structural problems. Treatment can be non-surgical with the use of orthotics to support the elbow, and maybe more appropriate in certain circumstances. Surgical treatment can involve fixation, repair or reconstruction. Often the deficiency is not amenable to these methods and arthroplasty has to be considered. The situation becomes more fraught in case of failure of arthroplasty and/or infection, where reconstruction can be challenging. In this review we have considered diverse clinical scenarios that fall under this broad umbrella, with a focus on those encountered commonly in practice.

LUCL internal bracing restores posterolateral rotatory stability of the elbow

PURPOSE

Posterolateral rotatory instability (PLRI) of the elbow occurs from an insufficient lateral collateral ligament complex (LCLC). For subacute LCLC injuries, lateral ulnar collateral ligament (LUCL) internal bracing rather than reconstruction may be a viable option. The purpose of the study was to compare the stabilizing effects of LUCL internal bracing to triceps tendon graft reconstruction in simulated PLRI.

METHODS

Sixteen cadaveric elbows were assigned for either LUCL internal bracing (n = 8) or reconstruction with triceps tendon graft (n = 8). Specimen were mounted and a valgus rotational torque was applied to the ulna to test posterolateral rotatory stability. Posterolateral rotation was measured at 0°, 30°, 60°, 90° and 120° of elbow flexion. Cyclic loading was performed for 1000 cycles at 90° of elbow flexion. Three conditions were compared in each specimen: intact elbow, LUCL and radial collateral ligament (RCL) transected, and then either LUCL internal bracing or reconstruction with triceps tendon graft.

RESULTS

Transection of the LUCL and RCL significantly increased posterolateral rotation in all degrees of elbow flexion compared to the intact condition (P < 0.05). Both LUCL internal bracing and reconstruction restored posterolateral rotatory stability to the native state between 0° and 120° of elbow flexion, with no significant difference in improvement between groups. Similarly, LUCL internal bracing and reconstruction groups showed no significant difference in posterolateral rotation compared to the intact condition during cyclic loading.

CONCLUSIONS

At time zero, both LUCL internal bracing and reconstruction with triceps tendon graft restored posterolateral rotatory stability. As such, this study supports the use of internal bracing as an adjunct to primary ligament repair in subacute PLRI.

Chronically unreduced elbow dislocation treated with box-loop ligament reconstruction: The first case series

OBJECTIVES

Describing our initial experience of performing box-loop ligament reconstruction in patients with chronically unreduced elbow dislocation.

DESIGN

Retrospective review.

SETTING

One tertiary referral centre.

PATIENTS/PARTICIPANTS

Six patients treated with box-loop ligament reconstruction from 2015 to 2018 were included in this study.

INTERVENTION

Box-loop ligament reconstruction.

MAIN OUTCOME MEASUREMENT

Quick disabilities of the arm, shoulder and hand (Q-DASH) and Mayo elbow performance index (MEPI) score.

RESULTS

All subjects exhibited substantial increase of range of flexion-extension motion of the affected elbow, from a mean of 24.2° initially to 119.2° postoperatively during the follow-up period (median = 14 months, range 12-31 months). The subjects recorded an average MEPI score of 82.5 points, and average Q-DASH score of 16.2 points. There were no complications that occurred.

CONCLUSIONS

This is the first case series of patients with chronically unreduced elbow dislocation treated with box-loop ligament reconstruction. Using this technique, all subjects had excellent outcome without any complication. Further studies with larger samples and better methodology are required to investigate the safety and efficacy of such technique.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

BACKGROUND

Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures.

METHODS

This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case.

RESULTS

The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision.

CONCLUSIONS

The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

[Chronic ligamentous instability of the elbow]

BACKGROUND

Chronic ligamentous instability of the elbow is an important pathology as it is accompanied with pronounced dysfunction. Moreover, it represents an established risk factor for the development of osteoarthritis. Posterolateral rotatory instability (PLRI) caused by insufficiency of the lateral collateral ligament (LCL) is the most common type of chronic elbow instability and is usually a sequel of traumatic elbow dislocation. Chronic overload can lead to insufficiency of the ulnar collateral ligament (UCL) with subsequent valgus instability, especially in overhead athletes.

DIAGNOSTICS

Subjective instability and recurrent elbow dislocations are not always the main symptoms but elbow instability is instead often characterized by pain and secondary joint stiffness. Many clinical tests are available yet eliciting them can be difficult and inconclusive. A "drop sign" on lateral radiographs as well as the detection of collateral ligament injuries and joint incongruity on MRI scans can support the suspected diagnosis. In some cases, instability can only be verified by diagnostic arthroscopy.

TREATMENT

Reconstruction of the lateral ulnar collateral ligament (LUCL) for treatment of PLRI generally leads to good clinical results, yet recurrent instability remains an issue and has been reported in 8 % of cases. UCL reconstruction for chronic valgus instability leads to a return-to-sports rate of about 86 % in the overhead athlete. Ulnar neuropathy, which is seen in approximately 6 % of patients, represents the most common complication. On the rare occasion of multidirectional instability, the box-loop technique can be used for simultaneous reconstruction of the LUCL and UCL with a circumferential graft. 15 cases with promising results have been reported in literature thus far.

The Circumferential Graft Technique for Treatment of Chronic Multidirectional Ligamentous Elbow Instability

Introduction

The circumferential graft technique^1,2 represents a potential option for the treatment of multidirectional ligamentous elbow instability using a single tendon graft (Video 1).

Indications & Contraindications

Step 1 Perform a Medial and Lateral Approach

Approach the elbow joint through either a single posterior skin incision or separate lateral and medial incisions.

Step 2 Drill the Bone Tunnels

Create humeral and ulnar bone tunnels for circumferential graft placement.

Step 3 Place the Graft

Use a plantaris allograft, which we recommend; however, a semitendinosus autograft may also be used.

Step 4 Close the Wound

Ensure that meticulous wound closure is achieved as it is key to preventing postoperative complications such as superficial or deep infection and persistent seroma.

Results

As multidirectional instability represents a rather rare complication following ligamentous elbow dislocation, clinical data regarding the circumferential graft technique are scarce^1,2.

Pitfalls & Challenges

Annular ligament reconstruction with the superficial head of the brachialis: surgical technique and biomechanical evaluation

PURPOSE

The purpose of this study was to perform biomechanical testing of annular ligament (AL) reconstruction using the superficial head of the brachialis tendon (SHBT) as a distally based tendon graft. We hypothesized that posterior translation of the radial head following AL reconstruction with an SHBT graft does not significantly differ from intact specimens.

METHODS

Six fresh-frozen elbow specimens were used. The stability of the radial head against posterior translation forces (30 N) was evaluated in 0°, 45°, 90° and 120° of elbow flexion. Posterior translation was obtained for the intact AL, the sectioned AL and the reconstructed AL. Cyclic loading (100 cycles) in 90° of elbow flexion was performed for the intact and the reconstructed AL.

RESULTS

Posterior translation of the radial head decreased during elbow flexion in native specimens. Sectioning of the AL significantly increased instability over the full range of motion. AL reconstruction with the SHBT restored the stability of the proximal radius but-other than the native AL-was not influenced by elbow flexion. In 120° of flexion the native AL provided significantly more stability when compared to the reconstructed AL. Cyclic loading did not provide significant differences between native and reconstructed specimens.

CONCLUSIONS

We provide a feasible technique for AL reconstruction using the SHBT. The biomechanical results obtained in this study confirm the efficacy of the procedure. AL reconstruction restores the stability of the proximal radius, yet it cannot fully mimic the complex features of the intact AL.

Functional anatomy of the lateral collateral ligament of the elbow

INTRODUCTION

The aim of this study was to analyze the functional anatomy of the lateral collateral ligament complex (LCLC) and the surrounding forearm extensors.

MATERIALS AND METHODS

Using 81 human cadaveric upper extremities, the anatomy of the forearm extensors-especially the anconeus, supinator and extensor carpi ulnaris (ECU)-was analyzed. After removal of aforementioned extensors the functional anatomy of the LCLC was analyzed. The origin of the LCLC was evaluated for isometry. The insertion types of the lateral ulnar collateral ligament (LUCL) were analyzed and classified.

RESULTS

The ECU runs parallel to the RCL to dynamically preserve varus stability. The supinator and anconeus muscle fibers coalesce with the LCLC and lengthen during pronation. The anconeus fibers run parallel to the LUCL in full flexion. The LCLC consists of the annular ligament (AL) and the isometric radial collateral ligament (RCL). During elbow flexion, its posterior branches (LUCL) tighten while the anterior branches loosen. When performing a pivot shift test, the loosened LUCL fibers do not fully tighten in full extension. The LUCL inserts along with the AL at the supinator crest. Three different insertion types could be observed.

CONCLUSIONS

The LUCL represents the posterior branch of the RCL rather than a distinct ligament. It is non-isometric and lengthens during elbow flexion. The RCL was found to be of vital importance for neutralization of posterolateral rotatory forces. Pronation of the forearm actively stabilizes the elbow joint as the supinator, anconeus and biceps muscle work in unison to increase posterolateral rotatory stability.