1
|
Inagaki K, Ochiai N, Hashimoto E, Hattori F, Hiraoka Y, Ise S, Shimada Y, Ohtori S. Biomechanical Comparison of Stability and Strength After Ulnar Collateral Ligament Reconstruction With Suture Anchor Fixation Versus Bone Tunnels. Orthop J Sports Med 2023; 11:23259671231196135. [PMID: 37693807 PMCID: PMC10492499 DOI: 10.1177/23259671231196135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/04/2023] [Indexed: 09/12/2023] Open
Abstract
Background Ulnar collateral ligament (UCL) injuries occur frequently in baseball players, and UCL reconstruction is performed when nonoperative treatment fails. Purpose To compare a novel all-suture anchor method of UCL reconstruction with a method using bone tunnels (Ito method) by investigating the displacement against valgus torque and the failure strength. Study Design Controlled laboratory study. Methods Eight fresh-frozen cadaveric upper extremities (mean age, 82.0 years) were utilized in this study. To evaluate the displacement against valgus torque, the valgus stability test was performed for 4 anterior oblique ligament (AOL) conditions: intact AOL, resected AOL, reconstructed using the anchor method, and reconstructed using the Ito method. The load-to-failure test was performed to evaluate the failure strength of the anchor and Ito methods. Displacement against valgus load was compared between conditions using the repeated-measures 2-way analysis of variance with Bonferroni post hoc test, and failure strength between the anchor and Ito methods was compared using the unpaired t test. Results Displacements of the intact AOL and anchor method were significantly greater than those of the resected AOL at both 60° and 90° of flexion (intact AOL: P = .005 and P < .001, respectively; and anchor method: P = .024 and P < .001, respectively). The displacement of the Ito method at 90° of flexion was significantly greater than that of the resected AOL (P = .003), but no significant difference was observed at 60° of flexion (P = .109). There were no significant differences in displacement between the anchor and Ito methods at any flexion angle, nor was there a significant difference in failure torque between the anchor and Ito methods (16.3 ± 3.1 vs 17.6 ± 2.3 N·m, respectively; P = .537). Conclusion The displacement and failure strength against a valgus load after UCL reconstruction using a suture anchor on the ulnar side were equal to those using bone tunnels. Clinical Relevance UCL reconstruction using a suture anchor on the ulnar side is simpler and less invasive than using bone tunnels, with similar outcomes.
Collapse
Affiliation(s)
- Kenta Inagaki
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Nobuyasu Ochiai
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Eiko Hashimoto
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Fumiya Hattori
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Yu Hiraoka
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Shohei Ise
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Yohei Shimada
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| |
Collapse
|
2
|
Kerzner B, Kaplan DJ, Khan ZA, Smith SR, Obioha OA, Jawanda H, Jackson GR, Gopinatth V, Sivasundaram L, Verma NN. Ulnar Collateral Ligament Internal Bracing Repair Technique for High-Grade Partial Proximal Tears in the Throwing Athlete. Arthrosc Tech 2023; 12:e1225-e1232. [PMID: 37533907 PMCID: PMC10391346 DOI: 10.1016/j.eats.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/17/2023] [Indexed: 08/04/2023] Open
Abstract
The use of ulnar collateral ligament (UCL) repair with concomitant internal bracing for throwing athletes is a viable treatment option, but must take into account tear location, ligament quality, the expected length of the athlete's career, desire to advance to the next level of competition, and age. There has been increased interest in repair of UCL injuries in overhead athletes due to advancements in surgical technique, as well as improved technologies of anchor and suture material. In addition, return to sport can be accelerated compared to reconstruction. In this Technical Note, we demonstrate an ulnar collateral ligament repair technique, with internal bracing augmentation for high-grade partial proximal tears in the throwing athlete that is reliable, strong, and easily reproducible.
Collapse
Affiliation(s)
- Benjamin Kerzner
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J. Kaplan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A. Khan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shelby R. Smith
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Obianuju A. Obioha
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harry Jawanda
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R. Jackson
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Varun Gopinatth
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Lakshmanan Sivasundaram
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N. Verma
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| |
Collapse
|
3
|
Waterworth R, Finlayson G, Franklin M, Jabbal M, Faulkner A, Gallagher B. Current concepts in the management of "Terrible Triad" injuries of the elbow. Injury 2023:110889. [PMID: 37353449 DOI: 10.1016/j.injury.2023.110889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
Terrible triad injuries of the elbow are complex injuries which can result in long term complications and significant disability. They must be identified correctly, and managed appropriately in order to maximise functional outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This review presents a summary of the relevant anatomy and the evidence for the management of these complex injuries.
Collapse
Affiliation(s)
- Rebecca Waterworth
- Department of Trauma and Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom.
| | - Graham Finlayson
- Department of Trauma and Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom
| | - Marieta Franklin
- Department of Trauma and Orthopaedic Surgery, Whiston Hospital, Warrington Rd, Rainhill, Prescot, L35 5DR, United Kingdom
| | - Monu Jabbal
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - Alastair Faulkner
- Department of Trauma and Orthopaedics Surgery, Ninewells Hospital, Dundee, DD1 9SY, United Kingdom
| | - Brendan Gallagher
- Department of Trauma & Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom
| |
Collapse
|
4
|
Boksh K, Mishra P, Akram N, Abdolrazaghi S, Singh H. Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies. Orthop J Sports Med 2023; 11:23259671231158373. [PMID: 37152548 PMCID: PMC10159257 DOI: 10.1177/23259671231158373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 05/09/2023] Open
Abstract
Background Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads. Purpose To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction. Study Design Systematic review. Methods The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("ulnar collateral ligament" OR "medial ulnar collateral ligament") AND ("internal brace" OR "augmentation" OR "suture tape"). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases. Results After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], -0.34 N·m; 95% CI, -1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, -1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, -0.53; 95% CI, -1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008). Conclusion MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.
Collapse
Affiliation(s)
- Khalis Boksh
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
- Khalis Boksh, BSc(Hons),
MBChB, MRCS, Department of Trauma and Orthopaedics, University Hospitals of
Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW, UK (
)
| | - Pranav Mishra
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nimra Akram
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sina Abdolrazaghi
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Harvinder Singh
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
5
|
Substantiation of safe and effective arthroscopic approaches to the elbow joint in case of enthesopathy of the distal humerus. TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2022. [DOI: 10.17816/2311-2905-1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background: With the development of arthroscopic surgical techniques, diagnostic and therapeutic possibilities have significantly expanded, but they have not become widely used in everyday clinical practice in the treatment of elbow joint pathology. This is due to the small volume of the joint, the close location of the neurovascular formation and the complexity of manipulation. Elbow arthroscopy is a dynamic procedure with a change in the ratio of neurovascular structures and portals in different elbow positions. The risk of damage to neurovascular formations during arthroscopy of the elbow joint is up to 14%.
Purpose: determination of the safest areas promising for the formation of arthroscopic approaches to the elbow joint in the treatment of patients with enthesopathy of the distal humerus..
Methods: To achieve this goal, a complex topographic- anatomical and clinical study was performed on 30 non-fixed anatomical preparations of the upper limb, which included 4 stages, where the topographic and anatomical features of the tendon-muscular and neurovascular structures forming the elbow joint were studied, depending on the angle of flexion of the elbow joint at 3 different levels: level I - 5 cm above the joint space, level II - joint space, level III - the neck of the radius, additionally the above structures were studied using MRI studies in 30 patients.
Results: When the elbow joint is flexed to 90, the brachial artery at level I moves away from the bone and is located at a distance from 27,8 (27.7-28,1) mm to 28,6 (28,4-28,7). The radial nerve at the II level from СMEL is located at 16,4 (16,5-18,8) mm. Median nerve from СMEL by 17,5 (16,6-18,1) mm. The brachial artery is 23,7 (20,522,8) mm distant from the СMEL. The anterior bundle of the MCL has: an average proximal width of 6,2 1,4 mm, an average width of the middle part of 6,5 1,5 mm, an average distal width of 9,3 1,4 mm. The average area of attachment on the medial epicondyle of the humerus is 45,5 9,3 mm, it has a rounded shape. The radial collateral ligament has an average length of 20,5 1.9 mm and a bundle width of 5,2 0,8mm. The average area of attachment on the humerus is 13,6 mm. The average area of ECRB on the lateral epicondyle of the humerus was 53,1 3,7mm. The mean area of the FCR on the medial epicondyle was 58,3 6.3mm. The distance from the entrance of the deep branch of the radial nerve to the canalis sapinatorius to the joint space is 28 (25,529,6) mm.
Conclusion: The results of this study allow the operating surgeon to decide on the choice and placement of arthroscopic access to the elbow joint, which in turn helps to minimize the risk of damage to neurovascular structures.
Collapse
|
6
|
The Role of Ultrasound in the Evaluation of Elbow Medial Ulnar Collateral Ligament Injuries in Throwing Athletes. Curr Rev Musculoskelet Med 2022; 15:535-546. [PMID: 36370301 PMCID: PMC9789266 DOI: 10.1007/s12178-022-09793-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Although ultrasound (US) imaging is commonly used to evaluate the elbow medial ulnar collateral ligament (mUCL) in throwing athletes, significant technical heterogeneity exists in the published literature and in practice. This has resulted in variable and often ambiguous US diagnostic criteria for mUCL injury. This review summarizes the literature on sonographic evaluation of the mUCL and outlines recommendations for consistent descriptive terminology, as well as future clinical and research applications. RECENT FINDINGS Both acute and chronic throwing loads in overhead athletes cause the mUCL to become thicker and more lax on stress testing, and these changes tend to revert after a period of prolonged rest. Stress US (SUS) can aid in the diagnosis of mUCL tears and may help identify athletes at risk of mUCL injury. Variability exists in terminology, elbow flexion angle, amount of stress applied, and technique of stress testing. Recent studies have suggested an injured elbow stress delta (SD-change in ulnohumeral joint (UHJ) space with valgus stress) of 2.4 mm and a stress delta difference (SDD-side-side difference in SD) of 1 mm each denote abnormal UHJ laxity due to mUCL injury. US imaging is a powerful and widely accessible tool in the evaluation elbow mUCL injuries. Sonologists should consider how their US techniques compare with published methods and use caution when applying diagnostic criteria outside of those circumstances. Currently, an SD of 2.4 mm and an SDD of 1 mm provide the best diagnostic accuracy for mUCL tears requiring surgery. Finally, preliminary work suggests that shear wave elastography may be helpful in evaluating the biomechanical properties of the mUCL, but additional research is needed.
Collapse
|
7
|
Vaswani R, Fu MC, Dines JS, Boddapati V, Erickson BJ, LeBus GF, Papaliodis DN, Conway JE, Altchek DW. Hypertrophy of the sublime tubercle in elbow ulnar collateral ligament injuries: a case series of baseball pitchers undergoing ulnar collateral ligament reconstruction with short-term follow-up. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:513-519. [PMID: 37588466 PMCID: PMC10426510 DOI: 10.1016/j.xrrt.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background The ulnar collateral ligament (UCL) of the elbow is subject to repetitive stress in overhead throwing athletes. This can lead to morphologic changes at the bony attachments of the UCL and hypertrophy of the sublime tubercle. The purpose of this case series is to describe the surgical details and clinical outcomes of a series of competitive baseball pitchers with hypertrophic sublime tubercles who underwent UCL reconstruction (UCLR). Methods All baseball pitchers who were treated for UCL injuries with significant hypertrophy of the sublime tubercle on preoperative imaging were included in the series. Clinical history, preoperative imaging, intraoperative findings during UCLR, and postoperative outcomes measured with the Conway scale were described. Results Ten players (average age of 22.9 years [range 13-39]) were included (average follow-up 20.4 months [range 3-38 months]). Five patients also had symptoms of ulnar nerve compression, with 4 requiring transposition at the time of ULCR and 1 at 3 months postoperatively. Bony hypertrophy of the sublime tubercle was confirmed intraoperatively in all cases and excised before UCLR with the docking technique. Of the 7 patients with at least 12-month follow-up postoperatively, 6 had excellent outcomes, and 1 had a fair outcome. Conclusion Although UCLR in the setting of hypertrophic sublime tubercle can be more complex than typical UCLR, excellent outcomes are achievable with preoperative recognition and surgical planning.
Collapse
Affiliation(s)
- Ravi Vaswani
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| | - Michael C. Fu
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| | - Joshua S. Dines
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | | | | | - John E. Conway
- Department of Orthopaedic Surgery, UT Health McGovern Medical School, Houston, TX, USA
| | - David W. Altchek
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| |
Collapse
|
8
|
Melzner M, Pfeifer C, Süß F, Dendorfer S. Musculoskeletal simulation of elbow stability for common injury patterns. J Orthop Res 2022; 41:1356-1364. [PMID: 36203348 DOI: 10.1002/jor.25460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/26/2022] [Accepted: 09/22/2022] [Indexed: 02/04/2023]
Abstract
Elbow stability is derived from a combination of muscular, ligamentous, and bony structures. After an elbow trauma the stability of the joint is an important decision criterion for the subsequent treatment. The decision regarding nonoperative/operative care depends mostly on subjective assessments of medical experts. Therefore, the aim of this study is to use musculoskeletal simulations as an objective assessment tool to investigate the extent to which failure of different stabilizers affects the elbow stability and how these observations correspond to the assessment from clinical practice. A musculoskeletal elbow simulation model was developed for this aim. To investigate the stability of the elbow, varus/valgus moments were applied under 0°, 45°, and 90° flexion while the respective cubital angle was analyzed. This was performed for nine different injury scenarios, which were also evaluated for stability by clinical experts. With the results, it can be determined by which injury pattern and under which flexion angle the elbow stability is impaired regarding varus/valgus moments. The scenario with a complete failure of the medial and lateral ligaments and a fracture of the radial head was identified as having the greatest instability. The study presented a numerical determination of elbow stability against varus/valgus moments regarding clinical injury patterns, as well as a comparison of the numerical outcome with experience gained in clinical practice. The numerical predictions agree well with the assessments of the clinical specialists. Thus, the results from musculoskeletal simulation can make an important contribution to a more objective assessment of the elbow stability.
Collapse
Affiliation(s)
- Maximilian Melzner
- Laboratory for Biomechanics, Ostbayerische Technische Hochschule (OTH) Regensburg, Regensburg, Germany.,Regensburg Center of Biomedical Engineering, OTH and University Regensburg, Regensburg, Germany
| | - Christian Pfeifer
- Trauma, Orthopaedics and Hand Surgery, Innklinikum Altötting, Altotting, Germany.,Clinic of Trauma Surgery, University of Regensburg, Regensburg, Germany
| | - Fran Süß
- Laboratory for Biomechanics, Ostbayerische Technische Hochschule (OTH) Regensburg, Regensburg, Germany.,Regensburg Center of Biomedical Engineering, OTH and University Regensburg, Regensburg, Germany
| | - Sebastian Dendorfer
- Laboratory for Biomechanics, Ostbayerische Technische Hochschule (OTH) Regensburg, Regensburg, Germany.,Regensburg Center of Biomedical Engineering, OTH and University Regensburg, Regensburg, Germany
| |
Collapse
|
9
|
Saengsirinavin P, Ratanalekha R, Wechasil J, Jongthanakamol T, Sriratanavudhi C, Jaroenporn W. Anatomic Study of the Medial Collateral Ligament in Thai Population: A Cadaveric Study of 56 Elbows. Indian J Orthop 2022; 56:1417-1423. [PMID: 35928665 PMCID: PMC9283635 DOI: 10.1007/s43465-022-00648-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to elucidate basic anatomic and geometric features of MCL, providing more accurate and detailed information, as guidance for surgeons, to improve patient's outcome of the treatment. METHODS The anterior bundle (AB), posterior bundle (PB) and transverse bundle (TB) ligament of 56 fresh frozen Thai cadaveric elbows, were measured and recorded, comprise key ligament's geometric features, footprints and dimensions, and its relation to bony landmarks. Sagittal and coronal planes were used in respect of the anatomical position. RESULTS The mean distance between the center of AB origin and the apex of medial epicondyle is as follows: 2.97 ± 2.21 mm anteriorly, 4.73 ± 1.60 mm inferiorly in the sagittal plane, and 4.23 ± 1.13 mm deep from the epicondyle in the coronal plane. Its dimension is 6.23 ± 1.02 mm in width and 45.97 ± 6.75 mm in length. The ligament's insertion triangular shape has its base located 28.44 ± 3.51 mm anterior from the posterior olecranon border, and 22.52 ± 2.49 mm superior from the inferior ulnar border. The tip located 50.79 ± 4.86 mm anterior from the posterior olecranon border and 17.64 ± 2.80 mm superior from the inferior ulnar border. CONCLUSION Apprehension of the precise geometries and distances of the ligament's footprint relative to key anatomical point is crucial. This stereographically comprehended data are useful for surgeon as reference points to obtain stability, motion, kinetic, and kinematic properties of the elbow. LEVEL OF EVIDENCE Level V evidence. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-022-00648-x.
Collapse
Affiliation(s)
| | - Rosarin Ratanalekha
- Department of Anatomy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jaruwat Wechasil
- Police General Hospital, Royal Thai Police Headquarters, Bangkok, Thailand
| | | | | | | |
Collapse
|
10
|
Lühmann P, Kremer T, Siemers F, Rein S. Comparative histomorphological analysis of elbow ligaments and capsule. Clin Anat 2022; 35:1070-1084. [DOI: 10.1002/ca.23913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/23/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Paul Lühmann
- Department of Plastic and Hand Surgery with Burn Unit Hospital Sankt Georg Leipzig Germany
| | - Thomas Kremer
- Department of Plastic and Hand Surgery with Burn Unit Hospital Sankt Georg Leipzig Germany
| | - Frank Siemers
- Department of Plastic and Hand Surgery with Burn Unit Trauma Center Bergmannstrost Halle Germany
- Martin‐Luther‐University Halle‐Wittenberg Halle Germany
| | - Susanne Rein
- Department of Plastic and Hand Surgery with Burn Unit Hospital Sankt Georg Leipzig Germany
- Martin‐Luther‐University Halle‐Wittenberg Halle Germany
| |
Collapse
|
11
|
Jordan DB, Kharlamov A, Schimoler PJ, DeMeo PJ, Miller MC. Valgus fatigue and nonlinear damage accretion of the anterior bundle of the elbow medial collateral ligament (AMCL). J Biomech 2022; 137:111094. [PMID: 35489236 DOI: 10.1016/j.jbiomech.2022.111094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
Failure by fatigue is one mechanism by which ligaments can rupture, with the accumulation of damage gradually degrading the ligament strength. Baseball pitchers who perform repeated high-level throwing continuously subject the medial ligament complex of the elbow to extreme levels of loading, which can lead to fatigue and eventual rupture. This study sought to investigate this behavior and quantify the fatigue properties of the anterior bundle of the medial collateral ligament (AMCL) with respect to valgus elbow torque. Eleven pairs of cadaveric elbow specimens were used for this study. One side of each pair was tested in vertical elongation at four flexion angles and then tested to failure at 90° of flexion. The contralateral specimens were tested in valgus fatigue at 90° of flexion using a specialized apparatus with application of known moments based on the elongation failure load. The average tensile failure load for the AMCL was 595.3 ± 201.9 N. During cycling, the average increase in the maximum valgus rotation angle was 4.77° ± 2.82°. The average maximum stretch of the AMCL middle band increased from 1.066 ± 0.017 to 1.076 ± 0.018 near the time of fatigue failure. The average cycles to failure for specimens tested at 90% and 80% of the estimated failure torque were 3211 ± 4721.33 and 25063 ± 30487.58, respectively. The nonlinear non-dimensional fatigue life and damage accretion results work in conjunction to predict the fatigue properties for a valgus elbow motion of arbitrary torque magnitude at 90° of elbow flexion.
Collapse
Affiliation(s)
| | | | - Patrick J Schimoler
- University of Pittsburgh, United States; Allegheny General Hospital, Pittsburgh, PA, United States
| | | | | |
Collapse
|
12
|
Meyers KN, Middleton KK, Fu MC, Dines JS. Comparison of a Novel Anatomic Technique and the Docking Technique for Medial Ulnar Collateral Ligament Reconstruction. Am J Sports Med 2022; 50:1061-1065. [PMID: 35188812 DOI: 10.1177/03635465221076149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current reconstruction techniques do not re-create the distal ulnar collateral ligament (UCL) insertion. Reconstructing the distal extension of the anterior band ulnar footprint may increase elbow stability and resistance against valgus stress after UCL reconstruction (UCLR). PURPOSE/HYPOTHESIS The purpose was to test a new technique for UCLR, a modification of the docking technique, aimed at re-creating the distal ulnar footprint anatomy of the anterior band. We hypothesize that this novel "anatomic" technique will provide greater resistance to valgus stress after UCLR when compared with the docking technique. STUDY DESIGN Descriptive laboratory study. METHODS Eighteen unpaired cadaveric arms were dissected to capsuloligamentous elbow structures and potted. With use of a servohydraulic load frame, 5 Nċm of valgus stress was placed on the UCL-intact elbows at 30°, 60°, 90°, and 120° of flexion. UCLR was performed on each elbow, randomized to either the docking technique or the anatomic technique. After UCLR, the elbow was again tested at 30°, 60°, 90°, and 120° of flexion. Ulnohumeral joint gapping was calculated using a 3-dimensional motion capture system applied to markers attached to the ulna and humerus. Differences in gapping among the intact state and docking and anatomic techniques were compared using a 2-way analysis of variance with significance set to P < .05. RESULTS There was no significant difference in gapping between the anatomic and docking technique groups regardless of elbow flexion angle. All reconstructed groups showed increased gapping relative to intact, but all increases were below the clinically relevant level of 1 mm. CONCLUSION Ulnohumeral joint gapping and resistance to valgus stress were similar between the anatomic technique and the docking technique for UCLR. CLINICAL RELEVANCE This study provides evidence that the anatomic technique is a viable alternative UCLR method as compared with the docking technique in a cadaveric model.
Collapse
Affiliation(s)
- Kathleen N Meyers
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Kellie K Middleton
- Sports Medicine, Northside Hospital Orthopedic Institute, Atlanta, Georgia, USA
| | - Michael C Fu
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Joshua S Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| |
Collapse
|
13
|
Edama M, Matsuzawa K, Yokota H, Hirabayashi R, Sekine C, Maruyama S, Sato N. Elbow valgus stability of the transverse bundle of the ulnar collateral ligament. BMC Musculoskelet Disord 2021; 22:873. [PMID: 34641828 PMCID: PMC8513277 DOI: 10.1186/s12891-021-04760-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/05/2021] [Indexed: 12/03/2022] Open
Abstract
Background The purpose of this study was to clarify elbow valgus stability of the transverse bundle (TB). We hypothesized that the transverse bundle is involved in elbow valgus stability. Methods Twelve elbows of six Japanese Thiel-embalmed cadavers were evaluated. The skin, subcutaneous tissue and origin of forearm flexors were removed from about 5 cm proximal to the elbow to about 5 cm distal to the elbow, and the ulnar collateral ligament was dissected (intact state). The cut state was defined as the state when the TB was cut in the middle. The joint space of the humeroulnar joint (JS) was measured in the intact state and then in the cut state. With the elbow flexed to 30°, elbow valgus stress was gradually increased to 30, 60 N using the Telos Stress Device, and the JS was measured by ultrasonography under each load condition. Paired t-testing was performed to compare the JS between the intact and cut states under each load. Results No significant difference in JS was identified between the intact and cut state at start limb position. The JS was significantly higher in the cut state than in the intact state at both 30 N and 60 N. Conclusion The findings from this study suggested that the TB may be involved in elbow valgus stability.
Collapse
Affiliation(s)
- Mutsuaki Edama
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Shimami-cho 1398, Kita-ku, Niigata City, 950-3198, Japan.
| | - Kanta Matsuzawa
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Shimami-cho 1398, Kita-ku, Niigata City, 950-3198, Japan
| | - Hirotake Yokota
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Shimami-cho 1398, Kita-ku, Niigata City, 950-3198, Japan
| | - Ryo Hirabayashi
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Shimami-cho 1398, Kita-ku, Niigata City, 950-3198, Japan
| | - Chie Sekine
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Shimami-cho 1398, Kita-ku, Niigata City, 950-3198, Japan
| | - Sae Maruyama
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Shimami-cho 1398, Kita-ku, Niigata City, 950-3198, Japan
| | - Noboru Sato
- Division of Gross Anatomy and Morphogenesis, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| |
Collapse
|
14
|
Biomechanical assessment of docking ulnar collateral ligament reconstruction after failed ulnar collateral ligament repair with suture augmentation. J Shoulder Elbow Surg 2021; 30:1477-1486. [PMID: 33276162 DOI: 10.1016/j.jse.2020.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) repair with single-strand suture augmentation has been introduced as a viable surgical option for throwers with acute UCL tears. For the original single-strand suture augmentation construct, revision UCL reconstructions can be challenging owing to the bone loss at the site of anchor insertion in the center of the sublime tubercle. This biomechanical study assessed a small-diameter (1.5-mm) ulnar bone tunnel technique for double-strand suture-augmented UCL repair that may be more easily converted to salvage UCL reconstruction if necessary, as well as a salvage UCL reconstruction with a docking technique after a failed primary suture-augmented UCL repair. METHODS In 7 fresh-frozen cadaveric upper extremities (mean age, 66.3 years), a custom shoulder testing system was used to simulate the late cocking phase of throwing. The elbow valgus opening angle was evaluated using a MicroScribe 3DLX device for sequentially increasing valgus torque (from 0.75 to 7.5 Nm in 0.75-Nm increments) at 90° of flexion. Valgus angular stiffness (in newton-meters per degree) was defined as the correlation of sequentially increasing valgus torque with the valgus opening angle through simple linear regression (slope of valgus torque - valgus opening angle curve). Four conditions were tested: intact elbow, distal UCL avulsion, primary UCL repair with double-strand suture augmentation using small-diameter bone tunnels, and subsequent docking UCL reconstruction in the same specimen. Load-to-failure tests were performed for primary UCL repair with double-strand suture augmentation and subsequent docking UCL reconstruction. RESULTS With increasing elbow valgus torque, the valgus opening angle increased linearly in each condition (R2 ≥ 0.98, P < .001). Distal UCL avulsion resulted in significantly decreased angular stiffness compared with the intact UCL (P < .001). Both UCL repair with double-strand suture augmentation and subsequent UCL reconstruction showed significantly increased angular stiffness values compared with distal UCL avulsion (P < .001 and P < .001, respectively). On load-to-failure testing, there was no significant difference in stiffness, yield torque, and ultimate torque between the primary suture-augmented UCL repair and the subsequent UCL reconstruction (P = .11, P = .77, and P = .38, respectively). In all specimens undergoing the small-diameter ulnar bone tunnel technique for double-strand suture-augmented UCL repair, failure occurred by retear of the repaired ligament without causing an ulnar bone bridge fracture. CONCLUSION Primary UCL repair with double-strand suture augmentation using small-diameter bone tunnels was able to restore valgus stability. When failure occurs, this technique retains enough cortical bone to permit subsequent docking UCL reconstruction.
Collapse
|
15
|
Clinical anatomy and biomechanics of the elbow. J Clin Orthop Trauma 2021; 20:101485. [PMID: 34262850 PMCID: PMC8258984 DOI: 10.1016/j.jcot.2021.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/20/2021] [Indexed: 11/22/2022] Open
Abstract
The anatomy of the elbow joint had been studied extensively over the last 2 decades. The increased understanding of the anatomy and contribution of the anatomical structures to the elbow biomechanics had enabled surgeons to improve the results of surgical reconstruction and fracture fixation. This review articles intend to summarise the salient functional and clinical anatomical and relevant biomechanical data that had been published recently.
Collapse
|
16
|
Van Trigt B, Vliegen LW, Leenen TA, Veeger DH. The ulnar collateral ligament loading paradox between in-vitro and in-vivo studies on baseball pitching (narrative review). Int Biomech 2021; 8:19-29. [PMID: 33998377 PMCID: PMC8130712 DOI: 10.1080/23335432.2021.1916405] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ulnar collateral ligament (UCL) weakening or tears occur in 16% of professional baseball pitchers. To prevent players from sustaining a UCL injury, it is important to understand the relationship between the UCL properties and elbow stabilizers with the load on the UCL during pitching. In-vitro studies showed that the ultimate external valgus torque of 34 Nm would rupture the UCL, which is in apparent conflict with the reported peak valgus torques in pitching (40–120 Nm). Assuming both observations are correct, the question rises why ‘only’ 16 out of 100 professional pitchers sustain a UCL rupture. Underestimation of the effect of other structures in in-vivo studies is most likely the explanation of this mismatch because the calculated in-vivo torque also includes possible contributions of functional and structural stabilizers. In-vitro studies show that the flexor-pronator mass has the potential to counteract valgus torque directly, whereas the elbow flexor-extensor muscles combined with the humeroradial joint might have an indirect effect on valgus torque by increasing the joint compression force. Accurate experimental electromyography data and a more detailed (musculoskeletal)mechanical model of the elbow are needed to investigate if and to what extent the structural and functional stabilizers can shield the UCL during pitching.
Collapse
Affiliation(s)
- Bart Van Trigt
- Department of Biomechanical Engineering, Delft University of Technology, CD Delft, The Netherlands
| | - Liset W Vliegen
- Department of Biomechanical Engineering, Delft University of Technology, CD Delft, The Netherlands
| | - Ton Ajr Leenen
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, BT Amsterdam, The Netherlands
| | - DirkJan Hej Veeger
- Department of Biomechanical Engineering, Delft University of Technology, CD Delft, The Netherlands
| |
Collapse
|
17
|
Looney AM, Rigor PD, Bodendorfer BM. Evaluation and management of elbow injuries in the adolescent overhead athlete. SAGE Open Med 2021; 9:20503121211003362. [PMID: 33996078 PMCID: PMC8072106 DOI: 10.1177/20503121211003362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7–33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete’s stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.
Collapse
Affiliation(s)
- Austin M Looney
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, USA
| | - Paolo D Rigor
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Blake M Bodendorfer
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
18
|
Wang F, Jia S, Li M, Pan K, Zhang J, Fan Y. Effect of the medial collateral ligament and the lateral ulnar collateral ligament injury on elbow stability: a finite element analysis. Comput Methods Biomech Biomed Engin 2021; 24:1517-1529. [PMID: 33715549 DOI: 10.1080/10255842.2021.1898601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ligaments are the most important stabilizer of elbow. However, the stress of ligaments is hard to measure because of the complex biomechanical environment in the elbow. Our objective was to develop a human elbow finite element model and to validate it by a comparison with previous experimental data. Then several different ligaments injury conditions and elbow flexion were simulated to analyse the elbow instability and to stress the biomechanical consequences. The computational investigation of different effects of ligament constraints of elbow was studied by means of finite element analysis. The stress of the anterior bundle was almost greater than other ligaments in all conditions, which played the most important role during the elbow flexion. The posterior bundle was the secondary stabilizer during flexion after the anterior bundle. The lateral ulnar collateral ligament (LUCL) injury could result in an increase of the ulnar cartilage stress. The anterior bundle and the LUCL were recommended to be repaired in elbow joint dislocations and fractures. This study could help understand the dynamic effects of ligaments on the joint over the entire extension by investigating the tissue stress.
Collapse
Affiliation(s)
- Fang Wang
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China.,Tianjin Key Lab of Integrated Design and On-line Monitoring for Light Industry & Food Machinery and Equipment, Tianjin, China.,National Research Centre for Rehabilitation Technical Aids, No. 1, Ronghuazhonglu, BDA, Beijing, China.,Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, No.1, Ronghuazhonglu, BDA, Beijing, China
| | - Shuoqi Jia
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China
| | - Mingxin Li
- Department of Traumatic Orthopaedics, Tianjin Hospital, No. 406, Jiefang Nanlu, Hexi District, Tianjin, China
| | - Kui Pan
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China
| | - Jianguo Zhang
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China.,Tianjin Key Lab of Integrated Design and On-line Monitoring for Light Industry & Food Machinery and Equipment, Tianjin, China
| | - Yubo Fan
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Chinese Education Ministry, School of Biological Science and Medical Engineering, Beihang University, No.37, Xueyuan Road, Haidian District, Beijing, China.,School of Engineering Medicine, Beihang University, No.37, Xueyuan Road, Haidian District, Beijing, China
| |
Collapse
|
19
|
Matsuura Y, Takamura T, Sugiura S, Matsuyama Y, Suzuki T, Mori C, Ohtori S. Evaluation of anterior oblique ligament tension at the elbow joint angle-a cadaver study. J Shoulder Elbow Surg 2021; 30:359-364. [PMID: 32565411 DOI: 10.1016/j.jse.2020.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ulnar collateral ligament complex, particularly the anterior oblique ligament (AOL), is mainly a static stabilizer controlling valgus. Various studies have been conducted on the kinematics of elbow joints after ligament cutting; however, no biomechanical studies have measured the tension applied to the ligament. Finite element modeling (FEM) is a very useful tool for biomechanical evaluation of the elbow. However, an accurate FEM of elbow joints cannot be developed without information on the potential tension of ligaments applied during the flexion and extension of elbow joints. We believe that FEM of the elbow joint could be obtained by measuring the material properties and potential tension of the ligament applied during the flexion and extension of the elbow joint. This study aimed to measure the potential tension and material properties of the ligament during the flexion and extension of the elbow, by identifying the relation between ligament length and tension using mechanical testing. METHODS We included 10 elbows harvested from 7 fresh-frozen cadavers. The average age of the cadavers was 83.7 ± 5.65 years, and the samples included 8 elbows from 6 male cadavers and 2 elbows from 1 female cadaver. We measured the ligament length at each elbow angle by changing the elbow joint from 0° to 120° in 15° intervals. Thereafter, we extracted the AOL and divided into an anterior band (AB) and a posterior band (PB) and performed a mechanical test to calculate ligament stress. RESULTS The ligament length of the AB gradually decreased as the flexion angle increased. Conversely, the ligament length of the PB gradually increased as the flexion angle increased. AB and PB lengths were approximately the same between 60° and 75°. The average ligament tension and stress of the AB gradually increased with elbow extension. In contrast, the average ligament tension and stress of the PB gradually increased with elbow flexion. The tension and stress of the AB and PB were balanced around the elbow joint at 60°. CONCLUSION The AB was tenser on elbow extension, and the PB was tenser following elbow flexion. Also, the angle at which the AOL stress was equalized was 60°, suggesting that ∼60° is the angle at which the AOL is unlikely to be damaged.
Collapse
Affiliation(s)
- Yusuke Matsuura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
| | | | | | - Yoshiyuki Matsuyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takane Suzuki
- Department of Bioenvironmental Medicine, Chiba University, Chiba, Japan
| | - Chisato Mori
- Department of Bioenvironmental Medicine, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
20
|
THE NONOPERATIVE REHABILITATION OF A TRAUMATIC COMPLETE ULNAR COLLATERAL LIGAMENT TEAR OF THE ELBOW IN A HIGH SCHOOL WRESTLER: A CASE REPORT. Int J Sports Phys Ther 2020; 15:1211-1221. [PMID: 33344036 DOI: 10.26603/ijspt20201211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Injuries frequently occur in competitive wrestling, with the elbow joint representing about 25% of all injuries. Specific to the elbow, the ulnar collateral ligament (UCL) can be injured traumatically from takedowns in wrestling. In athletes with complete UCL tears, surgical management is often recommended with nonoperative management resulting in less favorable outcomes. The purpose of this case report is to present a nonoperative criterion-based rehabilitation program for a high school wrestler with a complete UCL tear of the elbow. Case Description A 17-year-old male wrestler presented to outpatient physical therapy with a complete UCL tear sustained from falling on an outstretched hand during a wrestling match. He presented with limited elbow range of motion (ROM), medial elbow instability, and weakness of the involved shoulder and forearm musculature. A three staged criterion-based rehabilitation protocol was developed for this subject based on specific criteria, including pain, elbow ROM, arm strength, and functional outcomes. Outcomes The subject was treated for nine visits over six weeks, and demonstrated improvements in all strength tests of the involved upper extremity, with elbow flexion strength improving the most by 58%. Return to sport (RTS) tests were used to assess the subject's ability to return to practice. At approximately eight weeks after initial injury, the subject was able to return to full participation in competitive wrestling with no reports of elbow pain or instability. Discussion Through the utilization of a criterion-based rehabilitation protocol for the nonoperative management of an UCL injury, this high school wrestler was able to safely progress back to wrestling without pain or instability in an accelerated time frame. Previously, no detailed rehabilitation guidelines for nonoperative management of UCL injuries in contact sports have been described. Additionally, few studies exist which report on the inclusion of RTS testing following an injury to the UCL of the elbow, as RTS testing is optimal for determining readiness for sport. Level of Evidence 4, Case Report.
Collapse
|
21
|
Marinelli A, Graves BR, Bain GI, Pederzini L. Treatment of elbow instability: state of the art. J ISAKOS 2020; 6:102-115. [PMID: 33832984 DOI: 10.1136/jisakos-2019-000316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 11/03/2022]
Abstract
The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.
Collapse
Affiliation(s)
| | - Benjamin R Graves
- Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory Ian Bain
- Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
| | - Luigi Pederzini
- Department of Orthopaedic and Arthroscopic Surgery, New Sassuolo Hospital, Sassuolo, Italy
| |
Collapse
|
22
|
Luchetti TJ, Abbott EE, Baratz ME. Elbow Fracture-Dislocations: Determining Treatment Strategies. Hand Clin 2020; 36:495-510. [PMID: 33040962 DOI: 10.1016/j.hcl.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.
Collapse
|
23
|
Ikezu M, Edama M, Matsuzawa K, Kaneko F, Shimizu S, Hirabayashi R, Kageyama I. Morphological Features of the Ulnar Collateral Ligament of the Elbow and Common Tendon of Flexor-Pronator Muscles. Orthop J Sports Med 2020; 8:2325967120952415. [PMID: 33015213 PMCID: PMC7509733 DOI: 10.1177/2325967120952415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background: The anterior bundle (AB) of the ulnar collateral ligament is the most important structure for valgus stabilization of the elbow. However, anatomic relationships among the AB, posterior bundle (PB) of the ulnar collateral ligament, and common tendon (CT) of the flexor-pronator muscles have not been fully clarified. Purpose: To classify the AB, PB, and CT and to clarify their morphological features. Study Design: Descriptive laboratory study. Methods: This investigation examined 56 arms from 31 embalmed Japanese cadavers. The CT investigation examined 34 arms from 23 embalmed Japanese cadavers with CTs remaining. Type classification was performed by focusing on positional relationships with surrounding structures. Morphological features measured were length, width, thickness, and footprint for the AB and PB and attachment length, thickness, and footprint for the CT. Results: The AB was classified as type I (44 elbows; 78.6%), can be separated as a single bundle, or type II (12 elbows; 21.4%), cannot be separated from the PB and joint capsule. The PB was classified as type I (28 elbows; 50.0%), can be separated as a single bundle; type IIa (6 elbows; 10.7%), posterior edge cannot be separated; type IIb (7 elbows; 12.5%), anterior edge cannot be separated; or type III (15 elbows; 26.8%), cannot be separated from the joint capsule. The CT was classified as type I (18 elbows; 52.9%), can be separated from the AB, or type II (16 elbows; 47.1%), cannot be separated from the AB. Significant differences in frequencies of AB, PB, and CT types were identified between men and women. Morphological features were measured only for type I of each structure, and reliability was almost perfect. Conclusion: These results suggest that the AB, PB, and CT each can be classified into an independent form and an unclear form. Presence of the unclear form was suggested as one factor contributing to morphological variation. Clinical Relevance: This study may provide basic information for clarifying functional roles of the AB, PB, and CT.
Collapse
Affiliation(s)
- Masahiro Ikezu
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Mutsuaki Edama
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan.,Department of Anatomy, School of Life Dentistry at Niigata, Nippon Dental University, Niigata, Japan
| | - Kanta Matsuzawa
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Fumiya Kaneko
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Sohei Shimizu
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Ryo Hirabayashi
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Ikuo Kageyama
- Department of Anatomy, School of Life Dentistry at Niigata, Nippon Dental University, Niigata, Japan
| |
Collapse
|
24
|
Abstract
Elbow pain can cause disability, especially in athletes, and is a common clinical complaint for both the general practitioner and the orthopaedic surgeon. Magnetic resonance imaging (MRI) is an excellent tool for the evaluation of joint pathology due to its high sensitivity as a result of high contrast resolution for soft tissues. This article aims to describe the normal imaging anatomy and biomechanics of the elbow, the most commonly used MRI protocols and techniques, and common MRI findings related to tendinopathy, ligamentous and osteochondral injuries, and instability of the elbow.
Collapse
|
25
|
Abstract
A sound knowledge of the elbow anatomy and biomechanics is critical to understanding the pathology of various elbow disorders and instigating appropriate management. The elbow joint is a trochoginglymoid joint: that is, it has flexion-extension [ginglymoid] motion at the ulnohumeral and radiocapitellar articulations and pronation and supination [trochoid] motion at the proximal radioulnar joint. Stability of the elbow joint is achieved through static and dynamic components. The aim of this article is to concisely describe the anatomy and biomechanics of the elbow joint relevant to the practice of trauma and orthopaedic surgeons.
Collapse
|
26
|
Iloanya MC, Savoie FH, O'Brien MJ. Nonoperative Treatment of Ulnar Collateral Ligament Injuries. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
27
|
Frantz T, Frangiamore S, Schickendantz M. Anatomical Considerations of Throwing Elbow Injuries. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
28
|
Wigton MD, Schimoler PJ, Kharlamov A, Miller MC, Frank DA, DeMeo PJ. The moving valgus stress test produces more ulnar collateral ligament change in length during extension than during flexion: a biomechanical study. J Shoulder Elbow Surg 2020; 29:1230-1235. [PMID: 32197808 DOI: 10.1016/j.jse.2019.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 12/18/2019] [Accepted: 12/21/2019] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND Injuries to the elbow medial ulnar collateral ligament (mUCL) pose a diagnostic challenge, with the moving valgus stress test (MVST) currently accepted as the gold-standard clinical test. This study sought to biomechanically evaluate the change in length of the ulnar collateral ligament (UCL) during flexion-extension using a null hypothesis that the mUCL will not experience a greater change in length with movement than with static loading. METHODS Seven fresh-frozen human cadaveric elbows were tested with static and dynamic valgus stress. We measured (1) ligament length with a multi-camera optical system, (2) elbow flexion with an incremental encoder, and (3) valgus deviation with an electronic inclinometer. With a force applied to the wrist to simulate a clinical stress examination, the elbow was flexed and extended in a physiological elbow simulator to mimic the flexion and extension of the MVST. RESULTS The simulated MVST produced more elongation of the UCL compared with static stress testing (P < .001). Ninety degrees of flexion produced the highest mean change, and the anterior and posterior bands demonstrated different length change characteristics. Comparison of dynamic flexion and extension showed a statistically significant difference in change in length: The mUCL reached the greatest change during extension, with the greatest changes during extension near 90° of flexion. DISCUSSION AND CONCLUSION The MVST produces significantly more elongation of the mUCL than either a static test or a moving test in flexion. This study provides biomechanical evidence of the validity of the MVST as a superior examination technique for injuries to the UCL.
Collapse
Affiliation(s)
- Michael D Wigton
- Deparment of Orthopaedic Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Patrick J Schimoler
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA; Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexander Kharlamov
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Mark Carl Miller
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA; Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Darren A Frank
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Patrick J DeMeo
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| |
Collapse
|
29
|
Abstract
Ulnar collateral ligament (UCL) injuries can significantly impair the overhead athlete. Reconstruction of the anterior bundle of the UCL (UCL-R) has allowed a high proportion of these individuals to return to their previous level of play. Several techniques for UCL-R are described that produce acceptable results with an overall low complication rate. Transient ulnar neuritis is the most common complication following UCL-R. The rate of UCL injury in young athletes is rising with increased youth involvement and year-round participation in overhead sports. The sports medicine community must broaden its focus to not only treat UCL injuries but also prevent them.
Collapse
Affiliation(s)
- Edward Lyle Cain
- Andrews Sports Medicine and Orthopaedic Center, American Sports Medicine Institute, 805 St. Vincent's Drive, Suite 100, Birmingham, AL 35205, USA.
| | - Mims G Ochsner
- Andrews Sports Medicine and Orthopaedic Center, American Sports Medicine Institute, 805 St. Vincent's Drive, Suite 100, Birmingham, AL 35205, USA
| |
Collapse
|
30
|
Bergmann M, El-Barbari J, Porschke F, Grützner PA, Guehring T, Schnetzke M. Reliability of dynamic fluoroscopy for medial elbow stability in the presence of radial head resection. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s11678-020-00572-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Background
The aim of this study was to examine whether dynamic fluoroscopy is reliable for assessment of medial elbow stability in the presence of radial head resection and different stages of medial collateral ligament (MCL) dissection in a cadaveric elbow model.
Materials and methods
Six intact elbow specimens were measured for joint angulation while applying valgus stress in four examination conditions (Examiner 1, Examiner 2, 1 Nm, 2 Nm) in four different elbow positions (fully pronated or supinated at 0° of elbow extension and 30° of elbow flexion). The elbow specimens were examined for valgus stress in three stages: (1) intact, (2) after radial head resection, and (3) after subsequent dissection of the complete MCL. Anteroposterior radiographs of the elbow were made at each stage to determine joint angulation. Intraclass correlation coefficients (ICCs) were calculated.
Results
In intact elbows, mean joint angulation ranged from 2.2° ± 2.0 (1 Nm) to 5.2° ± 2.3 (Examiner 1). Radial head resection did not increase joint angulation during valgus stress, regardless of joint position and examination condition (Examiner 1: 5.5°; Examiner 2: 5.0°; 1 Nm: 2.6°, 2 Nm: 3.9°). Additional dissection of the MCL led to significantly higher joint angulation during measurements with the standardized torques (1 Nm: 12.4°; 2 Nm: 23.3°). Very good to excellent ICCs for joint angulation between Examiner 1 and Examiner 2 (0.861 to 0.959) were found.
Conclusion
Dynamic fluoroscopy is a reliable diagnostic tool for determining medial elbow stability in the presence of radial head resection and different stages of MCL dissection.
Collapse
|
31
|
Lawton CD, Lamplot JD, Wright-Chisem JI, James EW, Camp CL, Dines JS. State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes. Curr Rev Musculoskelet Med 2020; 13:338-348. [PMID: 32323247 DOI: 10.1007/s12178-020-09621-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW There has been a marked increase in the number of ulnar collateral ligament reconstructions performed annually and an associated increase in the amount of recent literature published. It is paramount that surgeons remain up to date on the current literature, as modern indications and surgical techniques continue to improve clinical outcomes. RECENT FINDINGS Our understanding of ulnar collateral ligament (UCL) injuries, treatment indications, and surgical techniques for UCL reconstruction continues to evolve. Despite the rapidly increasing amount of published literature on the topic, a clear and concise surgical algorithm is lacking. Studies have suggested a trend towards improved clinical outcomes and decreased complications with various modifications in UCL reconstruction techniques. Current sport-specific outcome studies have reported conflicting results regarding the effect of UCL reconstruction on an athlete's performance upon returning to sport. With the rising incidence of UCL reconstruction and growing media attention, UCL injuries, reconstruction techniques, and return to sport following UCL surgery are timely topics of interest to clinicians and overhead throwing athletes. Several technique modifications have been reported, and these modifications may lead to improved outcomes and lower complication rates. Studies assessing sport-specific outcome measures will be necessary to provide a more critical and informative analysis of outcomes following UCL reconstruction.
Collapse
Affiliation(s)
- Cort D Lawton
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Joseph D Lamplot
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Joshua I Wright-Chisem
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Evan W James
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Christopher L Camp
- Division of Sports Medicine, Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
| | - Joshua S Dines
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| |
Collapse
|
32
|
In vivo changes in length of elbow collateral ligaments during pronation and supination on an outstretched arm. Surg Radiol Anat 2020; 42:919-925. [DOI: 10.1007/s00276-020-02451-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/29/2020] [Indexed: 01/26/2023]
|
33
|
Kaufmann RA, Wilps T, Musahl V, Debski RE. Elbow Biomechanics: Soft Tissue Stabilizers. J Hand Surg Am 2020; 45:140-147. [PMID: 31870564 DOI: 10.1016/j.jhsa.2019.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 07/23/2019] [Accepted: 10/09/2019] [Indexed: 02/02/2023]
Abstract
The elbow positions the hand in a stable manner relative to the trunk while allowing flexion and extension as well as forearm rotation at varying shoulder positions. Its ability to perform this task without joint subluxation is accomplished through a combination of bony congruency, ligamentous restraint, and dynamic stabilization. Elbow stability is challenged repeatedly during everyday activities, particularly when the arm is abducted. Traumatic injuries that lead to an elbow dislocation or the microtrauma associated with pitching are frequent situations that destabilize the elbow. This article reviews the soft tissue stabilizers that contribute to elbow kinematics and stability.
Collapse
Affiliation(s)
- Robert A Kaufmann
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Tyler Wilps
- Temple University School of Medicine, Philadelphia, PA
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Richard E Debski
- Center for Biotechnology and Bioengineering, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW The importance of both the static and dynamic stabilizers of the medial elbow for the throwing athlete has been demonstrated in recent studies. Furthermore, recent anatomic studies have demonstrated the insertion of the anterior bundle (UCL) to be more distal and elongated, which has implications for surgical reconstruction of the UCL. The purpose of this review is to highlight recent anatomic and biomechanical studies evaluating the anatomy and reconstructions of the medial elbow. RECENT FINDINGS Recent literature has highlighted the crucial role of the dynamic stabilizers in resisting valgus force, especially during the throwing motion. The dynamic stabilizers of the medial elbow include the flexor pronator mass, specifically the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS). The clinical importance of these findings cannot be under stated, as unrecognized dynamic stabilizer injury can lead to increased stress on a native or reconstructed UCL in the throwing athlete. The medial ulnar collateral ligament complex of the elbow has a crucial role in providing both static and dynamic elbow stability. Most notably, the anterior bundle (UCL) provides the primary resistance to valgus and rotational stresses, especially during throwing motion. An understanding of the humeral and ulnar footprints and their relationships with surrounding structures is necessary to restore the native isometry of the medial complex of the elbow during UCL reconstruction. The flexor pronator musculature plays an essential role in dynamic stability, and the intimate relationship of the FCU and FDS with the ulnar insertion of the UCL should be considered to optimize recovery and outcomes with repair or reconstruction.
Collapse
|
35
|
The Mini-open Plication of Medial Collateral Ligament of the Elbow: A New Arthroscopically Assisted Technique. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2019. [DOI: 10.1097/bte.0000000000000176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
36
|
Kimata K, Yasui M, Yokota H, Hirai S, Naito M, Nakano T. Transverse ligament of the elbow joint: an anatomic study of cadavers. J Shoulder Elbow Surg 2019; 28:2253-2258. [PMID: 31307895 DOI: 10.1016/j.jse.2019.04.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/16/2019] [Accepted: 04/24/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The medial collateral ligament of the elbow joint consists of the anterior oblique ligament (AOL), posterior oblique ligament (POL), and transverse ligament (TL). This study aimed to clarify the structure of the TL, with a focus on the continuity between the TL and AOL. METHODS A total of 42 cadavers (18 males, 24 females) were dissected at Aichi Medical University between 2016 and 2018. Cases of elbow deformity or atrophy were excluded, and 60 elbows (15 males, 15 females) were dissected to assess the fibers of both the TL and AOL using a stereomicroscope. RESULTS The TL could be detected in all elbows and always continued to the AOL. The TL was classified into 2 types. The TLs continuing to the distal half of the AOL (type I) were observed in 44 elbows (73.3%), whereas the TLs continuing to the entire AOL (type II) were found in 16 elbows (26.7%). Type II TLs were significantly more frequently observed in the elbows of females than in those of males (P = .041). Stereomicroscopic observation revealed that the TL fibers entered perpendicularly to the distal half of the AOL in both types. CONCLUSIONS The TL frequently continues to the distal half of the AOL, but rarely continues to the entire AOL. The TLs continuing to the entire AOL were more frequently detected in the elbows of females than in those of males. The TL possibly contributes to medial elbow stability via its continuity to the AOL.
Collapse
Affiliation(s)
- Kentaro Kimata
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan; Department of Judo Therapy, Chuwa Professional Training College of Medical Care, Inazawa, Aichi, Japan
| | - Masaya Yasui
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan.
| | - Hiroki Yokota
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Shuichi Hirai
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Munekazu Naito
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Takashi Nakano
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| |
Collapse
|
37
|
Raducha JE, Gil JA, Harris AP, Owens BD. Ulnar Collateral Ligament Injuries of the Elbow in the Throwing Athlete. JBJS Rev 2019; 6:e1. [PMID: 29406433 DOI: 10.2106/jbjs.rvw.17.00061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UPDATE This article was updated on February 26, 2018, because of a previous error. On pages 1 and 7, in the author byline section, the authors' names that had read "Andrew Harris" and "Brett Owens" now reads "Andrew P. Harris" and "Brett D. Owens."
Collapse
Affiliation(s)
- Jeremy E Raducha
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | | | | |
Collapse
|
38
|
Hooper PO, Warren J, Silko C, Frangiamore SJ, King D, Farrow LD, Schickendantz MS. Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction. Am J Sports Med 2019; 47:2699-2703. [PMID: 31386563 DOI: 10.1177/0363546519864718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined. PURPOSE To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ). STUDY DESIGN Descriptive laboratory study. METHODS Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit. RESULTS The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; P < .001). Three upper limit outliers were discovered: 24.20°, 23.4°, and 21.1°. The mean posterior angle of entry was 40.44° (SD, ±6.18°; 95% CI, 39.22°-41.67°; P < .001). There were no outliers for the posterior angle of entry. Interobserver reliabilities were strong for the 4 measurements. CONCLUSION To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry. CLINICAL RELEVANCE These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.
Collapse
Affiliation(s)
- Perry O Hooper
- Cleveland Clinic Sports Health, Garfield Heighs, Ohio, USA
| | - Jared Warren
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christopher Silko
- Cleveland Clinic South Pointe Hospital, Warrensville Heights, Ohio, USA
| | | | - Dominic King
- Cleveland Clinic Sports Health, Garfield Heighs, Ohio, USA
| | - Lutul D Farrow
- Cleveland Clinic Sports Health, Garfield Heighs, Ohio, USA
| | | |
Collapse
|
39
|
Jordan D, Schimoler P, Kharlamov A, DeMeo PJ, Miller MC. Correlation of Force to Deformation of the Anterior Bundle of the Medial Collateral Ligament Through Consideration of Band Laxity. J Orthop Res 2019; 37:2027-2034. [PMID: 31081556 DOI: 10.1002/jor.24344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/23/2019] [Indexed: 02/04/2023]
Abstract
The anterior bundle of the medial collateral ligament (AMCL) resists the loads that arise at the elbow during overhand throwing and has commonly been divided into posterior and anterior bands. While these anterior and posterior bands have been thought to bear the load at different flexion angles, any transition of the load distribution between the two bands is poorly understood and has not considered laxity (slack). This study considers the AMCL as three bands and quantifies the mechanical response to vertical distraction, simulating valgus-load joint opening, through the sequential superposition of the band responses after the elimination of inherent laxity. Eight cadaveric elbow specimens were used for the study. The intact AMCL of each specimen was tested under vertical distraction in a specialized load frame at four elbow flexion angles and then subsequently retested after two longitudinal transections. The greatest laxity at full extension and full flexion belonged to the posterior (1.9 mm) and anterior (2.4 mm) band, respectively. At the lesser and higher flexion angles, the greatest structural stiffness belonged to the anterior and middle band. The overall AMCL was the most structurally stiff at 60°, with approximately 150 N of force required for 2% elongation. This study shows that the different bands of the AMCL may have different load bearing properties at different flexion angles, causing each band to support different proportions of an imposed load. The presence of the laxity may impose a load-bearing delay, causing load-bearing in each band to begin asynchronously. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2027-2034, 2019.
Collapse
Affiliation(s)
- David Jordan
- Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick Schimoler
- Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania.,Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| | - Alexander Kharlamov
- Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| | - Patrick J DeMeo
- Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| | - Mark Carl Miller
- Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania.,Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| |
Collapse
|
40
|
Lenz R, Bonacker J, Mittelmeier W, Ellenrieder M, Tischer T. [What do orthopedic and trauma surgeons expect from radiologists when interpreting imaging of the elbow?]. Radiologe 2019; 58:968-975. [PMID: 30225771 DOI: 10.1007/s00117-018-0456-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CLINICAL ISSUE The elbow is a complex joint with a multitude of acute and chronic pathologies. In addition to the clinical examination, radiological diagnostics play a decisive role in the further therapeutic management. DIAGNOSTIC WORK-UP/PERFORMANCE While acute traumatic injuries often present with obvious structural changes and the need for rapid treatment decisions, chronic processes can present with less evident alterations. Especially in these cases there is a need for clear communication between the treating physician and the radiologist with respect to managing optimal imaging as the basis for a certain diagnosis and therefore optimal treatment. Basic prerequisites on both sides are detailed knowledge of all elbow pathologies, classifications and the spectrum of radiological diagnostic imaging. ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS From the point of view of orthopedic surgeons the radiologist is responsible for the correct performance and interpretation of the necessary imaging procedures. The aim of this article is to give an overview of important aspects in the imaging of typical orthopedic/traumatic pathologies.
Collapse
Affiliation(s)
- R Lenz
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, 18057, Rostock, Deutschland.
| | - J Bonacker
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, 18057, Rostock, Deutschland
| | - W Mittelmeier
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, 18057, Rostock, Deutschland
| | - M Ellenrieder
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, 18057, Rostock, Deutschland
| | - T Tischer
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, 18057, Rostock, Deutschland
| |
Collapse
|
41
|
Graham KS, Golla S, Gehrmann SV, Kaufmann RA. Quantifying the Center of Elbow Rotation: Implications for Medial Collateral Ligament Reconstruction. Hand (N Y) 2019; 14:402-407. [PMID: 29216764 PMCID: PMC6535941 DOI: 10.1177/1558944717743599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medial collateral ligament (MCL) reconstruction of the elbow mandates precise characterization of where the centerline of elbow rotation projects onto the medial epicondyle (ME). A muscle-splitting approach allows the flexor-pronator muscles to remain attached to the ME and facilitates visualization of the MCL remnant, the sublime tubercle, and the ulnohumeral joint line. Knowledge of where the centerline of rotation intersects the ME relative to the ulnohumeral joint line may assist the surgeon during placement of the proximal drill hole. METHODS Models were created from the computed tomography scans of 29 normal elbows. The centerline of rotation, center of the trochlea, sublime tubercle, and ulnohumeral joint line were identified. Measurements were taken from the ulnohumeral joint line to the center of the trochlea and to the centerline of rotation in the sagittal view and along the course of the MCL. RESULTS The centerline of rotation intersected the ME in a consistent location. With the elbow flexed 90°, the trochlea center and the centerline of rotation are essentially in line with each other. There are significant differences between the distances from the ulnohumeral joint line to the center of the trochlea and to the centerline of rotation in both the sagittal view and along the course of the MCL. CONCLUSIONS The centerline of rotation is located 14.31 mm (1.70) from the ulnohumeral joint line in the sagittal view and 16.54 mm (2.09) from the ulnohumeral joint line along the course of the MCL.
Collapse
Affiliation(s)
| | - Sara Golla
- University of Pittsburgh Medical Center,
PA, USA
| | | | - Robert A. Kaufmann
- University of Pittsburgh Medical Center,
PA, USA,Robert A. Kaufmann, Associate Professor,
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center,
Lilian S. Kaufmann Building, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA
15213, USA.
| |
Collapse
|
42
|
Chronic Medial Epicondyle Avulsion: Technique of Fragment Excision and Ligament Reconstruction With Internal Brace Augmentation. J Am Acad Orthop Surg 2019; 27:e64-e69. [PMID: 30247312 DOI: 10.5435/jaaos-d-17-00446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Medial epicondyle fracture nonunions of the elbow may lead to symptomatic instability in the high-demand or overhead athlete. These injuries are challenging to treat surgically because of the small residual bony fragment, the scarred and shortened chronically injured ulnar collateral ligament (UCL), which prevents it from being mobilized and reduced to its native position. To date, most described methods aim at reducing the displaced fragment and achieving union with the humerus. This usually can only be accomplished by releasing of the scarred UCL to mobilize the fragment. The scarred and attenuated residual ligament is then repaired to restore stability but is often inadequate to sustain high-level valgus loads. We describe a technique of excision of the bony fragment and UCL reconstruction with allograft, augmented with internal brace to provide medial stability to the elbow. The described method allows proper tensioning of the graft and provides immediate and secure fixation.
Collapse
|
43
|
Smith MV, Castile RM, Brophy RH, Dewan A, Bernholt D, Lake SP. Mechanical Properties and Microstructural Collagen Alignment of the Ulnar Collateral Ligament During Dynamic Loading. Am J Sports Med 2019; 47:151-157. [PMID: 30495972 DOI: 10.1177/0363546518812416] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The ulnar collateral ligament (UCL) microstructural organization and collagen fiber realignment in response to load are unknown. PURPOSE/HYPOTHESIS The purpose was to describe the real-time microstructural collagen changes in the anterior bundle (AB) and posterior bundle (PB) of the UCL with tensile load. It was hypothesized that the UCL AB is stronger and stiffer with more highly aligned collagen during loading when compared with the UCL PB. STUDY DESIGN Descriptive laboratory study. METHODS The AB and PB from 34 fresh cadaveric specimens were longitudinally sectioned to allow uniform light passage for quantitative polarized light imaging. Specimens were secured to a tensile test machine and underwent cyclic preconditioning, a ramp-and-hold stress-relaxation test, and a quasi-static ramp to failure. A division-of-focal-plane polarization camera captured real-time pixelwise microstructural data of each sample during stress-relaxation and at the zero, transition, and linear points of the stress-strain curve. The SD of the angle of polarization determined the deviation of the average direction of collagen fibers in the tissue, while the average degree of linear polarization evaluated the strength of collagen alignment in those directions. Since the data were nonnormally distributed, the median ± interquartile range are presented. RESULTS The AB has larger elastic moduli than the PB ( P < .0001) in the toe region (median, 2.73 MPa [interquartile range, 1.1-5.6 MPa] vs 0.65 MPa [0.44-1.5 MPa]) and the linear region (13.77 MPa [4.8-40.7 MPa] vs 1.96 MPa [0.58-9.3 MPa]). The AB demonstrated larger stress values, stronger collagen alignment, and more uniform collagen organization during stress-relaxation. PB collagen fibers were more disorganized than the AB during the zero ( P = .046), transitional ( P = .011), and linear ( P = .007) regions of the stress-strain curve. Both UCL bundles exhibited very small changes in collagen alignment (SD of the angle of polarization) with load. CONCLUSION The AB of the UCL is stiffer and stronger, with more strongly aligned and more uniformly oriented collagen fibers, than the PB. The small changes in collagen alignment indicate that the UCL response to load is due more to its static collagen organization than to dynamic changes in collagen alignment. CLINICAL RELEVANCE The UCL collagen organization may explain its susceptibility to injury with repetitive valgus loads.
Collapse
Affiliation(s)
- Matthew V Smith
- Department of Orthopaedic Surgery, Washington University, St Louis, Missouri, USA
| | - Ryan M Castile
- Department of Mechanical Engineering and Materials Science, Washington University, St Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University, St Louis, Missouri, USA
| | - Ashvin Dewan
- Methodist Orthopedic Specialists of Texas, Sugar Land, Texas, USA
| | - David Bernholt
- Department of Orthopaedic Surgery, Washington University, St Louis, Missouri, USA
| | - Spencer P Lake
- Department of Orthopaedic Surgery, Washington University, St Louis, Missouri, USA.,Department of Mechanical Engineering and Materials Science, Washington University, St Louis, Missouri, USA
| |
Collapse
|
44
|
Qian Y, Liu WJ, Wang W, Fan CY. Structural Restoration of the Medial Collateral Ligament Using Cubital Tunnel Retinaculum in Stiff Elbow Instability. Chin Med J (Engl) 2018; 131:2608-2610. [PMID: 30381596 PMCID: PMC6213836 DOI: 10.4103/0366-6999.244115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Yun Qian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Wen-Jun Liu
- Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai 201306; Graduate School, Taishan Medical University, Taian, Shandong 271016, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai 201306, China
| | - Cun-Yi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233; Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai 201306, China
| |
Collapse
|
45
|
Frangiamore SJ, Bigart K, Nagle T, Colbrunn R, Millis A, Schickendantz MS. Biomechanical analysis of elbow medial ulnar collateral ligament tear location and its effect on rotational stability. J Shoulder Elbow Surg 2018; 27:2068-2076. [PMID: 30076036 DOI: 10.1016/j.jse.2018.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/09/2018] [Accepted: 05/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent anatomic and clinical studies have shown that the location of the injury to the elbow ulnar collateral ligament (UCL) is an important variable in deciding on surgical intervention; however, no studies have evaluated these findings biomechanically. METHODS This study tested 16 intact elbow specimens. Valgus torques of 2.5 and 5 Nm were applied to the elbow at various flexion angles, and the resulting valgus angles were measured. The valgus angles were applied to the elbows in their intact states and again after partial and complete cuts were made on the proximal and distal insertions of the UCL. Resulting valgus torques were measured, and stiffness was calculated for each elbow flexion angle. Unpaired t tests were used to evaluate the effects of cut location and flexion angle on joint rotational stability and stiffness. RESULTS The posterior-distal insertion contributed the most to stability. At valgus angles generated from 2.5 Nm intact torques, the posterior-distal insertions contributed to 51% ± 26% (P < .03) intact rotational stability, and at valgus angles generated from 5 Nm intact torques, the posterior-distal insertions contributed to 41% ± 17% (P < .02) intact rotational stability. For overall stiffness, the posterior-distal insertions contributed to 31% ± 12% (P < .045) intact stiffness. CONCLUSION Overall, the posterior distal insertion of the UCL contributed most to rotational stability and stiffness of the medial elbow when subjected to valgus stress at 90° and 120° of elbow flexion. At higher elbow flexion angles, the posterior insertions contributed more to stability, whereas the anterior insertions had a greater effect at lower flexion angles.
Collapse
Affiliation(s)
- Salvatore J Frangiamore
- Department of Orthopedic Surgery and Sports Medicine, Summa Health Medical Group, Akron, OH, USA
| | - Kevin Bigart
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tara Nagle
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robb Colbrunn
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Andrew Millis
- Orthopedics and Sports Medicine, Winona Health, Winona, MN, USA
| | | |
Collapse
|
46
|
Arrigoni P, Luceri F, Cucchi D, Tamini J, Randelli PS. Reliability of anterior medial collateral ligament plication of the elbow. Musculoskelet Surg 2018; 102:85-91. [PMID: 30343479 DOI: 10.1007/s12306-018-0554-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/02/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. METHODS Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner. RESULTS In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35-74.5] points; postoperative median OES was 17 [15.5-31.5] points; postoperative median MEPI was 65 [57.5-72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities. CONCLUSIONS The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension. CLINICAL RELEVANCE The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.
Collapse
Affiliation(s)
- P Arrigoni
- U.O. Clinica Ortopedica e Traumatologica Universitaria CTO, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy.,Laboratorio di Biomeccanica Applicata, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - F Luceri
- U.O. Clinica Ortopedica e Traumatologica Universitaria CTO, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy. .,Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy.
| | - D Cucchi
- Laboratorio di Biomeccanica Applicata, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy.,Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - J Tamini
- U.O. Clinica Ortopedica e Traumatologica Universitaria CTO, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy.,Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - P S Randelli
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.,U.O.C. 1a Divisione, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| |
Collapse
|
47
|
Bartoli M, Pederzini LA, Severini G, Serafini F, Prandini M. Elbow Medial Ulnar Collateral Ligament chronic isolated insufficiency: anatomical M-UCL reconstruction technique and clinical experience in a mid-term follow-up. Musculoskelet Surg 2018; 102:75-83. [PMID: 30343469 DOI: 10.1007/s12306-018-0559-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/24/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE This study aims to clinically evaluate, at mid-term follow-up, a group of patients treated by the senior author in the last 6 years with our anatomical double-bundle reconstruction surgical technique for the medial ulnar collateral ligament (M-UCL) insufficiency. METHODS In this study, we included only patients affected by chronic valgus elbow instability, diagnosed with an accurate clinical evaluation combined with an MRI, without associated fractures that had been surgically treated in the past and without additional instability detected during the first checkup and in the preoperative evaluation under anesthesia. The nine patients enrolled were operated by the senior author between 2011 and 2014 (from 16 to 49 years old at surgery, all amateur sportsmen). The average follow-up is 4 years (47.6 months). The values of the range of movement were recorded and compared. Pain assessment was performed using the VAS scoring system. The recovery of daily activities was evaluated through the validated MEPS and Quick-DASH score scales. All patients underwent an X-ray in two standard projections and a preoperative and follow-up MRI. RESULTS The recovery of the range of motion was complete in six cases. The remaining three patients had minor loss of extension. None of the patients reported flexion deficits nor pronation-supination at follow-up. All patients achieved subjectively perceived stability and clinically objectified stability at follow-up. Five patients referred a total lack of pain at follow-up. Seven patients achieved full marks in the Mayo Elbow Performance Score and an excellent improvement in the Quick-DASH score. CONCLUSIONS Excellent functional results indicate that M-UCL isolated reconstruction with autologous hamstrings described in this study is a reliable and replicable technique with a reduced incidence of complications. Resuming sports is consistently successful in our patients.
Collapse
Affiliation(s)
- M Bartoli
- Orthopaedics and Traumatology Department, Università Cattolica del Sacro Cuore - Fondazione Policlinico Gemelli, Largo Agostino Gemelli 8, 00168, Rome, RM, Italy.
| | - L A Pederzini
- Orthopaedics and Traumatology Unit, Nuovo Ospedale Civile di Sassuolo, Via Francesco Ruini 2, 41049, Sassuolo, MO, Italy
| | - G Severini
- Orthopaedics and Traumatology Department, Università Cattolica del Sacro Cuore - Fondazione Policlinico Gemelli, Largo Agostino Gemelli 8, 00168, Rome, RM, Italy
| | - F Serafini
- Orthopaedics and Traumatology Unit, Nuovo Ospedale Civile di Sassuolo, Via Francesco Ruini 2, 41049, Sassuolo, MO, Italy
| | - M Prandini
- Orthopaedics and Traumatology Unit, Nuovo Ospedale Civile di Sassuolo, Via Francesco Ruini 2, 41049, Sassuolo, MO, Italy
| |
Collapse
|
48
|
Williams PN, McGarry MH, Ihn H, Schulz BM, Limpisvasti O, ElAttrache NS, Lee TQ. The biomechanical evaluation of a novel 3-strand docking technique for ulnar collateral ligament reconstruction in the elbow. J Shoulder Elbow Surg 2018; 27:1672-1678. [PMID: 29748121 DOI: 10.1016/j.jse.2018.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/28/2018] [Accepted: 03/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND HYPOTHESIS The original 2-strand docking technique for elbow ulnar collateral ligament reconstruction has recently been modified to use a 3-strand graft. To date, no biomechanical study has compared the 2 techniques. We hypothesized that the 3-strand docking technique would restore valgus laxity to its native state, with comparable load-to-failure characteristics to the 2-strand docking technique. MATERIALS AND METHODS Sixteen fresh cadaveric elbows were matched to the corresponding contralateral side from the same individual to create 8 matched pairs and were then randomized to undergo ulnar collateral ligament reconstruction using either the 2- or 3-strand technique. Valgus laxity and rotation measurements were quantified using a MicroScribe 3DLX digitizer at various flexion angles for the native state, transected state, and 1 of the 2 tested reconstructed ligaments. Each reconstruction was then tested to failure. RESULTS Valgus laxity for the intact state at elbow flexion angles of 30°, 60°, 90°, and 120° was 7° ± 2°, 7° ± 2°, 6° ± 1°, and 5° ± 2°, respectively. These values were similar to those of both reconstruction techniques. On load-to-failure testing, there was no significant difference in any parameter recorded. Yield torques for the 3- and 2-strand reconstructions were 13.4 ± 4.80 N/m and 11.8 ± 4.76 N/m, respectively (P = .486). The ultimate torques were 15.7 ± 6.10 N/m and 14.4 ± 5.58 N/m for the 3- and 2-strand techniques, respectively (P = .582). CONCLUSION The 3-strand docking technique was able to restore valgus laxity to the native state, with similar load-to-failure characteristics to the 2-strand docking technique.
Collapse
Affiliation(s)
- Phillip N Williams
- Department of Orthopedics, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Michelle H McGarry
- Orthopedics Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Hansel Ihn
- Orthopedics Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | | | | | | | - Thay Q Lee
- Orthopedics Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| |
Collapse
|
49
|
Nishida K, Hashizume K, Nasu Y, Ozawa M, Fujiwara K, Inoue H, Ozaki T. Mid-term results of alumina ceramic unlinked total elbow arthroplasty with cement fixation for patients with rheumatoid arthritis. Bone Joint J 2018; 100-B:1066-1073. [PMID: 30062938 PMCID: PMC6413761 DOI: 10.1302/0301-620x.100b8.bjj-2017-1451.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Aims The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina
ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA). Patients and Methods We retrospectively reviewed 87 elbows, in 75 patients with RA, which was replaced using a
cemented JACE total elbow arthroplasty (TEA) between August 2003 and December 2012, with a follow-up
of 96%. There were 72 women and three men, with a mean age of 62 years (35 to 79). The mean
follow-up was nine years (2 to 14). The clinical condition of each elbow before and after surgery
was assessed using the Mayo Elbow Performance Index (MEPI, 0 to 100 points). Radiographic loosening
was defined as a progressive radiolucent line of >1 mm that was completely circumferential
around the prosthesis. Results The mean MEPI scores significantly improved from 40 (10 to 75) points preoperatively to 95 (30 to
100) points at final follow-up (p < 0.0001). Complications were noted in ten elbows
(ten patients; 11%). Two had an intraoperative humeral fracture which was treated by fixation and
united. One had a postoperative fracture of the olecranon which united with conservative treatment
and one had a radial neuropathy which resolved. Further surgery was required for one with a
dislocation, three with an ulnar neuropathy and one with a postoperative humeral fracture. Revision
with removal of the components was performed in one elbow due to deep infection. There was no
radiographic evidence of loosening around the components.With any revision surgery or revision with
implant removal as the endpoint, the rates of survival up to 14 years were 93% (95% confidence
interval (CI), 83.9 to 96.6) and 99% (95% CI 91.9 to 99.8), respectively, as determined by
Kaplan-Meier analysis. Conclusion With the appropriate indications, the mid-term clinical performance of the cemented JACE TEA is
reliable and comparable to other established TEAs in the management of the elbow in patients with
RA. Cite this article: Bone Joint J 2018;100-B:1066–73.
Collapse
Affiliation(s)
- K Nishida
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - K Hashizume
- Department of Rehabilitation, Japan Labour Health and Welfare Organization, Okayama Rosai Hospital, Okayama, Japan
| | - Y Nasu
- Department of Medical Materials for Musculoskeletal Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - M Ozawa
- Department of Orthopaedic Surgery, Okayama City Hospital, Okayama, Japan
| | - K Fujiwara
- Department of Intelligent Orthopaedic System Development, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - H Inoue
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - T Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| |
Collapse
|
50
|
Gluck MJ, Beck CM, Golan EJ, Nasser P, Shukla DR, Hausman MR. Varus posteromedial rotatory instability: a biomechanical analysis of posterior bundle of the medial ulnar collateral ligament reconstruction. J Shoulder Elbow Surg 2018; 27:1317-1325. [PMID: 29678397 DOI: 10.1016/j.jse.2018.02.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/08/2018] [Accepted: 02/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recently, there has been growing interest in the involvement of the posterior bundle of the medial ulnar collateral ligament (pMUCL) in varus posteromedial rotatory instability (PMRI). Varus PMRI has been observed clinically, but the degree of involvement of the pMUCL remains unclear. This study assessed the degree to which the pMUCL is involved in stabilizing the elbow and the feasibility of a pMUCL reconstruction to restore stability. METHODS Movements simulating PMRI were performed in 8 cadaveric elbows. Joint gapping values were obtained by 3-dimensional motion capture for the proximal and distal aspects of the ulnohumeral joint. Specimens were assessed at "intact," "cut coronoid + pMUCL," "reconstruction," and "cut anterior aspect MUCL + reconstruction" conditions with mechanical testing at 30°, 60°, and 90° of elbow flexion. RESULTS Proximal joint gapping significantly increased from intact to cut coronoid + pMUCL at 60° and 90°, and distal joint gapping significantly increased at 90°. In the reconstruction condition, joint gapping across the proximal joint at 60° and 90° significantly recovered, as did distal joint gapping at 90°. In the cut anterior aspect MUCL + reconstruction condition, no significant increase occurred in proximal or distal joint gapping. CONCLUSIONS Transection of the pMUCL with a coronoid fracture leads to increased joint gapping, suggesting the presence of PMRI. PMRI can still occur with an intact lateral ligamentous complex. A pMUCL tendon graft reconstruction confers some elbow stability in this injury mechanism.
Collapse
Affiliation(s)
- Matthew J Gluck
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Christina M Beck
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Elan J Golan
- Maimonides Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Philip Nasser
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Dave R Shukla
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Michael R Hausman
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA
| |
Collapse
|