Elbow injuries in the throwing athlete. Difficult diagnoses and surgical complications

Ultrasound assessment of the lateral collateral ligamentous complex of the elbow: imaging aspects in cadavers and normal volunteers

OBJECTIVE

The Lateral Collateral Ligamentous complex (LCL) is an important stabiliser of the elbow. It has a Y-shaped structure with three components. In this study, we sought to describe the ultrasound aspect of the individual components of this ligamentous complex and to evaluate the performance of ultrasound in both cadavers and in normal subjects.

METHODS

Ten cadaveric elbow specimens underwent high-frequency ultrasound. Two specimens were sliced and two were dissected for anatomical correlation. Ten elbows of normal subjects were also evaluated by ultrasound. The findings were compared.

RESULTS

The three components of the LCL could be visualised in all specimens and normal subjects with the exception of the proximal portion of one specimen. In 80% of the specimens and 100% of the healthy volunteers the proximal portion of the LCL could be separated from the extensor tendons.

CONCLUSION

High-resolution ultrasound can assess all components of the LCL of the elbow and can distinguish them from surrounding structures.

A biomechanical evaluation of ulnar collateral ligament reconstruction using a novel technique for ulnar-sided fixation

BACKGROUND

Techniques for ulnar collateral ligament (UCL) reconstruction have evolved since its original description.

HYPOTHESIS

Ulnar collateral ligament reconstruction using the ZipLoop for ulnar-sided fixation, as combined with the humeral docking technique supplemented with an interference screw, will restore valgus stability similar to that of the Jobe technique and the native ligament.

STUDY DESIGN

Controlled laboratory study.

METHODS

Kinematic testing was performed on 8 matched pairs of cadaver elbows with an electromagnetic tracking system through an arc of motion for the intact, disrupted, and reconstructed states of the UCL in an unloaded and loaded condition. From each pair, the docking technique using the ZipLoop for ulnar fixation and humeral docking technique supplemented with an interference screw and the traditional Jobe technique were performed with matched gracilis allograft tendons. After kinematic testing, both reconstruction groups were tested to failure at 70 degrees of flexion.

RESULTS

Kinematic results for the unloaded condition showed that both reconstruction techniques significantly overcorrected (less valgus angulation) the specimens between 40 degrees and 120 degrees of flexion when compared with the intact ligament (all P values < .027). Under loaded conditions, the ulnar trajectories for both reconstruction techniques exhibited significantly greater valgus angulation (undercorrection) at 20 degrees of flexion (Jobe, P = .0084; ZipLoop, P = .0289) when compared with the intact ligament but were not significantly different over the remaining arc of motion. Failure testing resulted in no significant statistical difference between the 2 reconstruction groups. Failure testing demonstrated that humeral tunnel egress, midsubstance elongation, and ulnar tunnel egress of the ligament were similar between the reconstruction techniques.

CONCLUSION

The docking technique using the ZipLoop for ulnar-sided fixation is biomechanically equivalent to the Jobe technique for UCL reconstruction. Both reconstruction techniques restore valgus stability similar to that of the native UCL ligament.

CLINICAL RELEVANCE

This modification in the docking technique restores elbow kinematics while eliminating the risk of ulnar bone bridge fracture, and it allows for retensioning of the graft after cortical fixation.

Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers

BACKGROUND

Although elbow pain is common in throwing athletes and golfers, posterolateral impingement from a hypertrophic synovial plica is a rare but possibly underdiagnosed condition.

PURPOSE

To evaluate the clinical results of arthroscopic treatment of symptomatic lateral elbow plicae in this athletic population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twelve patients, 9 male and 3 female, whose mean age was 21.6 years (range, 17-33 years), were reviewed. There were 7 baseball pitchers, 2 softball players, and 3 golfers. All patients had diagnosed isolated lateral elbow plica; none had lateral epicondylitis, instability, osteochondritis dissecans, arthritis, loose bodies, or nerve conditions. The mean time from onset of symptoms to treatment was 9.25 months (range, 3-24.5 months). At a mean follow-up of 33.8 months (range, 24-65.5 months), patients were evaluated with a questionnaire and examination, based on the American Shoulder and Elbow Surgeons standardized elbow assessment and previously reported elbow outcome score.

RESULTS

Posterolateral elbow pain was present in all patients. Fifty-eight percent (7 of 12 patients) complained of clicking or catching, whereas only 25% (3 of 12) experienced swelling or effusion. At elbow arthroscopy, a thickened synovial lateral plica was debrided in all cases. Ninety-two percent (11 of 12 patients) reported an excellent outcome with a mean elbow score of 92.5 points (maximum, 100 points). Return to competitive play averaged 4.8 months (range, 3-9.5 months). One patient with a fair outcome developed medial elbow instability that later required reconstructive surgery.

CONCLUSION

Posterolateral elbow impingement from hypertrophic synovial plicae can cause significant pain and disability in throwing athletes and golfers. With careful diagnosis and exclusion of other elbow problems, treatment with arthroscopic debridement and focused rehabilitation is highly successful and allows these athletes to return to their previous level of play.

Posterior olecranon resection and ulnar collateral ligament strain

Valgus extension overload is well described in the throwing athlete. The surgical treatment involves posterior olecranon osteophyte resection. It is not known how much of the posterior olecranon can be resected before increased stress is placed on the ulnar collateral ligament. Ten cadaveric arms underwent posterior olecranon resection in 4-mm increments. After each bone resection, three different valgus loads were applied to the elbow at 70 degrees and 90 degrees of flexion. Ulnar collateral ligament strain significantly increased with each load. Significantly more strain occurred on the ulnar collateral ligament at 90 degrees compared with 70 degrees of elbow flexion. This difference may be the result of the relative importance of the ulnar collateral ligament and the posterior olecranon at different positions of elbow flexion. The strain on the ulnar collateral ligament was slightly higher after the 8-mm and 12-mm cuts but not statistically significant. This study suggests that at moderate quasistatic valgus loads, ulnar collateral ligament strain is not significantly increased with posterior olecranon resection.