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Soler A, Voss A, Schramm S, Greiner S. Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow. J Shoulder Elbow Surg 2024; 33:1116-1124. [PMID: 38182022 DOI: 10.1016/j.jse.2023.11.017] [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] [Received: 07/17/2023] [Revised: 10/27/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. METHODS Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). RESULTS Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. CONCLUSIONS The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.
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Affiliation(s)
- Anna Soler
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | - Andreas Voss
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany; Sporthopaedicum Regensburg, Regensburg, Germany
| | - Sophia Schramm
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | - Stefan Greiner
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany; Sporthopaedicum Regensburg, Regensburg, Germany.
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Valencia M, Foruria AM. The role of arthroscopy in the management of adult elbow trauma. J Exp Orthop 2023; 10:144. [PMID: 38133719 PMCID: PMC10746683 DOI: 10.1186/s40634-023-00710-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Fractures around the elbow are often challenging to treat and in most cases require an extensive approach. Since the development of elbow arthroscopy, most authors have pointed out the potential advantages of a less invasive technique that can be useful for visualization and reduction of the articular fragments with an eventual percutaneous fixation. Arthroscopic techniques provide a limited exposure that may lead to a faster wound healing, lower rate of complications and thus, better recovery of range of motion. However, elbow arthroscopy is also a demanding technique, especially in a swollen and fractured joint, and it is not exempt of risks. The overall rate of complications has been rated from 1.5% to 11% and nerve injury rates from 1.26-7.5%.The objective of this review is to present the arthroscopic setup and general surgical technique for the management of elbow trauma and to define some clear indications. Patient positioning and operating room display is key in order to obtain success. In addition to the arthroscopic equipment, fluoroscopy is almost always necessary for percutaneous fixation and precise preparation is mandatory. In the last decade, literature regarding new portals or surgical tips for arthroscopic treatment of elbow fractures have been published.The main indications for fracture arthroscopic-assisted fixation are those articular fractures involving the coronoid, distal humerus shear fractures in the coronal plane (trochlear and capitellum fractures) and, more controversially, those affecting the radial head. The treatment of these type of fractures all arthroscopically is exponentially demanding as it might also require ligament repair. For coronoid fractures, it can be useful in Morrey type II and III, and O´Driscoll anteromedial facet fractures associated to a posteromedial instability pattern that also require a repair of the LCL. Although excellent results have been published, comparative series are scarce. Radial head fractures can also be approached arthroscopically in simple non-comminute fractures that can be fixed percutaneously.In conclusion, arthroscopy of the elbow is an excellent tool to better understand and visualize articular fractures of the elbow. However, despite the advances in surgical technique, whether it improves clinical and radiological results is still to be proven.
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Affiliation(s)
- Maria Valencia
- Division of Shoulder and Elbow Surgery, Hospital Universitario Fundación Jiménez Díaz, Avenida Reyes Católicos Nº2, Madrid, 28040, Spain
| | - A M Foruria
- Head of Division of Shoulder and Elbow Surgery Unit, Hospital Universitario Fundación Jiménez Díaz, Avenida Reyes Católicos Nº2, Madrid, 28040, Spain.
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Dimitrov N, Tsenkov T. Lateral ulnar collateral ligament reconstruction enhancing secondary stabilizers in chronic PLRI of the elbow provides good to excellent clinical results with no recurrent instability. J Orthop Sci 2023:S0949-2658(23)00327-5. [PMID: 38044214 DOI: 10.1016/j.jos.2023.11.013] [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: 04/17/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE The adopted treatment for chronic elbow PLRI is lateral ulnar collateral ligament reconstruction. However, the most frequently reported complication after primary reconstruction is recurrent instability - up to 25 %. It was thus hypothesized that enhancing the secondary stabilizers will provide successful results with a lower rate of recurrent instability in comparison to techniques with primary reconstruction only. This study aimed to demonstrate a novel surgical technique involving secondary stabilizers. METHODS In this retrospective study of 29 cases with chronic PLRI the mean duration of symptoms was 39.6 ± 4.9 months. The mean age was 47.9 years with mainly male patients. The surgeries were performed by one senior surgeon at a single institution. The Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) were recorded. RESULTS The mean follow-up was 36.8 ± 7.7 months. The MEPS score improved significantly from 59.8 ± 13.1 to 84.7 ± 7.6 (p < 0.001). 23/29 patients (79.2 %) had converted to good and excellent results (MEPS >75 points). The DASH score improved from 40.8 ± 4.6 to 20.9 ± 7.2 (p < 0.001). The total complication rate was 10.3 % (N = 3). No recurrent instability was recorded in comparison to 12.2 % for primary reconstruction only, as reported in the literature (p < 0.05). CONCLUSION Enhancing the secondary stabilizers by utilizing an adjacently located autograft provided good and excellent results with no recurrent instability. This novel surgical procedure is easy to reproduce and provides a safe and reliable alternative in cases of chronic PLRI when compared to techniques with primary reconstruction only.
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Affiliation(s)
- Nikolay Dimitrov
- University Hospital of Orthopaedics "Prof. B. Boichev", Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetan Tsenkov
- University Hospital of Orthopaedics "Prof. B. Boichev", Medical University of Sofia, Sofia, Bulgaria.
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O’Driscoll SW, Chaney GK. Preoperative and operative risk factors for failed lateral collateral ligament reconstruction. JSES Int 2023; 7:2578-2586. [PMID: 37969521 PMCID: PMC10638557 DOI: 10.1016/j.jseint.2023.03.017] [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] [Indexed: 11/17/2023] Open
Abstract
Repair or reconstruction of the lateral collateral ligament (LCL) using autograft or allograft is a well-accepted treatment of posterolateral rotatory instability. The prevalence and causes for failure of LCL reconstruction are not well documented in the literature. Any approach to the assessment and management of failed LCL reconstruction must begin with understanding the risk factors for failure in the first place. Such understanding would likely make many failures preventable as well. In our experience, there are a number of identifiable preoperative risk factors concerning bony and/or soft tissue constraints for failure of LCL reconstruction. There are also operative factors such as tunnel and graft placement as well as excessive lateral condyle stripping that play a role in risk of failure. This report is an attempt to provide a systematic approach to identifying and managing the preoperative and operative risk factors. Further studies are warranted to determine the indications for, and success rates of surgical intervention in managing these risk factors.
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Affiliation(s)
| | - Grace K. Chaney
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Daniels SD, France TJ, Peek KJ, Tucker NJ, Baldini T, Catalano LW, Lauder A. Posterolateral Rotatory Instability Develops Following the Modified Kocher Approach and Does Not Resolve Following Interval Repair. J Bone Joint Surg Am 2023; 105:1601-1610. [PMID: 37616381 DOI: 10.2106/jbjs.23.00199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND The modified Kocher and extensor digitorum communis (EDC)-splitting intervals are commonly utilized to approach the lateral elbow. Iatrogenic injury to the lateral ulnar collateral ligament may result in posterolateral rotatory instability (PLRI). in the present cadaveric study, we (1) evaluated lateral elbow stability following the use of these approaches and (2) assessed the accuracy of static lateral elbow radiographs as a diagnostic tool for PLRI. METHODS Ten matched-pair cadaveric upper-extremity specimens (n = 20) were randomly assigned to Kocher or EDC-splitting approaches. Specimens underwent evaluation pre-dissection, post-dissection, and following repair of the surgical interval. Clinical evaluation of lateral elbow stability was performed with the lateral pivot-shift maneuver. Radiographic radiocapitellar displacement was evaluated with the fully extended hanging arm test and on lateral elbow 30° flexion radiographs. Paired Wilcoxon signed-rank tests with Bonferroni correction were utilized to compare groups. RESULTS All Kocher group specimens (10 of 10) developed PLRI on the pivot-shift maneuver following dissection. No EDC-splitting group specimens (0 of 10) developed instability with pivot-shift testing. The fully extended hanging arm test showed no difference in radiocapitellar displacement between groups (p > 0.008). Lateral elbow 30° flexion radiographs in the Kocher group showed an increased radiocapitellar displacement difference (mean, 8.46 mm) following dissection compared with the pre-dissection baseline (p < 0.008). Following repair of the Kocher interval, the radiocapitellar displacement (mean, 6.43 mm) remained greater than pre-dissection (mean, 2.26 mm; p < 0.008). In the EDC-splitting group, no differences were detected in radiocapitellar displacement on lateral elbow radiographs with either the fully extended hanging arm or lateral elbow 30° flexion positions. CONCLUSIONS The Kocher approach produced PLRI that did not return to baseline conditions following repair of the surgical interval. The EDC-splitting approach did not cause elbow instability clinically or radiographically. The hanging arm test was not reliable for the detection of PLRI. CLINICAL RELEVANCE The Kocher interval for lateral elbow exposure results in iatrogenic PLRI that is not detectable on the hanging arm test and that does not return to baseline stability following repair of the surgical interval.
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Affiliation(s)
- Stephen D Daniels
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Thomas J France
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Kacy J Peek
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nicholas J Tucker
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Todd Baldini
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Louis W Catalano
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Alexander Lauder
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Orthopedic Surgery, Denver Health Medical Center, Denver, Colorado
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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.
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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
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Sachinis NP, Yiannakopoulos CK, Beitzel K, Koukos C. Arthroscopic Modified Elbow Lateral Collateral Ligament Imbrication: An Operative Technique. Arthrosc Tech 2023; 12:e709-e714. [PMID: 37323785 PMCID: PMC10265613 DOI: 10.1016/j.eats.2023.01.009] [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: 09/15/2022] [Accepted: 01/19/2023] [Indexed: 06/17/2023] Open
Abstract
When the lateral collateral ligament (LCL) complex fails to support the radiocapitellar and ulnohumeral joints in advanced stages of insufficiency, the patient experiences posterolateral rotatory instability (PLRI). Open lateral ulnar collateral ligament repair with a ligamentous graft has been the standard treatment for PLRI. Despite producing good clinical stability rates, this method is associated with significant lateral soft-tissue dissection and a lengthy recovery period. By fastening the LCL to its humeral insertion, arthroscopic imbrication of the LCL can increase stability. The senior author modified this technique. With the aid of a passer, the LCL complex, lateral capsule, and anconeus may be weaved with a single (doubled) suture, secured with a Nice knot. LCL complex imbrication may be used to restore stability and improve pain and function in patients with grade I and II PLRI.
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Affiliation(s)
- Nikolaos Platon Sachinis
- First Orthopaedic Department of Aristotle University of Thessaloniki, “Georgios Papanikolaou” Hospital, Thessaloniki, Greece
| | - Christos K. Yiannakopoulos
- Iaso Hospital, Athens, Greece
- School of Physical Education and Sports Science, National & Kapodistrian University of Athens, Athens, Greece
| | - Knut Beitzel
- Shoulder Institute, ATOS Orthoparc Klinik, Cologne, Germany
| | - Christos Koukos
- Special Sports Surgery Department, St. Josef Krankenhaus, Wuppertal, Germany
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Corbet C, Boudissa M, Dao Lena S, Ruatti S, Corcella D, Tonetti J. Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up. Orthop Traumatol Surg Res 2023; 109:103057. [PMID: 34536597 DOI: 10.1016/j.otsr.2021.103057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 10/02/2020] [Accepted: 12/31/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair. MATERIAL AND METHODS A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair. RESULTS Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications. DISCUSSION TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Clémentine Corbet
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France.
| | - Mehdi Boudissa
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | | | - Sébastien Ruatti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Denis Corcella
- Service de Chirurgie de la Main et des Brûlés, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Jérôme Tonetti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
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Bachmaier S, Wijdicks CA, Verma NN, Higgins LD, Greiner S. Biomechanical Stability of Lateral Ulnar Collateral Ligament Reconstruction and Repair of the Elbow: The Role of Ligament Bracing on Gap Formation and Stabilization. Am J Sports Med 2023; 51:1303-1311. [PMID: 36876745 DOI: 10.1177/03635465231157735] [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] [Indexed: 03/07/2023]
Abstract
BACKGROUND Augmented (internal braced) lateral ulnar collateral ligament (LUCL) repair has been biomechanically compared with reconstruction techniques in the elbow. However, LUCL repair alone has not yet been compared with augmented repair and reconstruction techniques. HYPOTHESIS Internal bracing of LUCL repair would improve time-zero stabilization regarding gap formation, stiffness, and residual torque as compared with repair alone and reconstruction techniques to restore native elbow stability. STUDY DESIGN Controlled laboratory study. METHODS Overall, 24 cadaveric elbows were used for either internal braced LUCL repair (Repair-IB) or single- and double-strand ligament reconstruction with triceps (Recon-TR) and palmaris longus tendon graft (Recon-PL), respectively. Laxity testing in external rotation was consecutively performed at 90° of elbow flexion on the intact, dissected, and repaired conditions and with the previously assigned techniques. First, intact elbows were loaded to 7.0-N·m external torque to evaluate time-zero ligament rotations at 2.5, 4.0, 5.5, and 7.0 N·m. Rotation-controlled cycling was performed (total of 1000 cycles) for each surgical condition. Gapping, stiffness, and residual torque were analyzed. Finally, these and 8 additional intact elbows underwent torque-to-failure testing (30 deg/min). RESULTS The dissected state showed the highest gap formation and lowest peak torques (P < .001). While gap formation of Repair-IB (P < .021) was significantly lower than that of repair without internal bracing at all rotation levels, gaps of Recon-PL were similar to and Recon-TR were significantly higher than those of Repair-IB except for the highest torsion level. Residual peak torques at specific rotation angles between native state and Recon-TR (α2.5), Recon-PL (α4.0), and Repair-IB (α5.5) were similar; all other comparisons were significantly different (P < .027). Torsional stiffness of Repair-IB was significantly higher at all rotation angles measured. Analysis of covariance showed significantly less gap formation over residual peak torques for Repair-IB (P < .001) as compared with all other groups. The native state failure load was significantly higher than Recon-PL and Recon-TR failure loads, with similar stiffness to all other groups. CONCLUSION Repair-IB and Recon-PL of the LUCL showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability to the native state in a cadaveric model. Recon-TR demonstrated lower residual peak torques but provided near-native rotational stiffness. CLINICAL RELEVANCE Internal bracing of LUCL repair may reduce suture-tearing effects through tissue and provide sufficient stabilization for healing throughout accelerated and reliable recovery without the need for a tendon graft.
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Affiliation(s)
| | - Coen A Wijdicks
- Arthrex Department of Research and Development, Munich, Germany
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10
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Tranier M, Bacle G, Marteau E, Sos C, Laulan J, Roulet S. Lateral elbow ligament reconstruction for posterolateral rotatory instability: 10 years follow-up in 32 patients. JSES Int 2023; 7:357-363. [PMID: 36911761 PMCID: PMC9998886 DOI: 10.1016/j.jseint.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Posterolateral rotatory instability (PLRI) is the most frequent form of both acute and chronic elbow instability. It is due to mechanical incompetence of the lateral collateral ligament. O'Driscoll et al described treatment of this instability by autologous reconstruction of the lateral ulnar collateral ligament. The aim of our study was to evaluate the medium and long-term clinical, functional and radiological results of patients who were surgically treated for PLRI by this technique. We hypothesized that such ligament reconstruction restores a functional joint complex and durably stabilizes the elbow and limits the long-term risk of osteoarthritis. Methods All patients treated for symptomatic PLRI by ligament reconstruction since January 1995 and who had a minimum follow-up of 36 months were retrospectively included. Results Thirty-two patients (32 elbows) underwent clinical and radiological evaluation with a mean follow-up of 112 months (range, 36-265 months). The success rate of the procedure was 97% with one patient requiring revision reconstruction. Twenty-four patients (75%) were free from pain. Pain was significantly greater in patients with associated lesions (P = .03) and those with morbid obesity (body mass index ≥40) (P = .03). Twenty-nine (91%) patients had resumed their previous activities. Twenty-eight patients (87%) were satisfied or very satisfied. The mean Mayo Clinic score was 96/100 and the QuickDash 14.7/100. Two patients (6%) with accompanying lesions developed severe osteoarthritis. Conclusion Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. The only failure in our series was due to several technical errors. Patients who had dislocation with associated lesions or morbid obesity are at risk of poorer functional results.
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Affiliation(s)
- Manon Tranier
- Department of Orthopedic Surgery, Hand and Peripheral Nerve Surgery Unit, Trousseau University Hospital of Tours, Medical University François Rabelais of Tours, Tours, France
| | - Guillaume Bacle
- Department of Orthopedic Surgery, Hand and Peripheral Nerve Surgery Unit, Trousseau University Hospital of Tours, Medical University François Rabelais of Tours, Tours, France
| | - Emilie Marteau
- Department of Orthopedic Surgery, Hand and Peripheral Nerve Surgery Unit, Trousseau University Hospital of Tours, Medical University François Rabelais of Tours, Tours, France
| | - Clara Sos
- Department of Orthopedic Surgery, Hand and Peripheral Nerve Surgery Unit, Trousseau University Hospital of Tours, Medical University François Rabelais of Tours, Tours, France
| | - Jacky Laulan
- Department of Orthopedic Surgery, Hand and Peripheral Nerve Surgery Unit, Trousseau University Hospital of Tours, Medical University François Rabelais of Tours, Tours, France
| | - Steven Roulet
- ELSAN, Clinique Belledonne, France.,Centre de l'Épaule et de la Main du Dauphiné - Groupe Chirurgical Verdun, Grenoble, France
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11
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Ozdag Y, Baylor JL, Nester JR, Foster BK, Daly CA, Grandizio LC. Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability. J Hand Surg Am 2023; 48:117-125. [PMID: 36539319 DOI: 10.1016/j.jhsa.2022.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/04/2022] [Accepted: 10/26/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Ligament repair with suture-tape augmentation has been used in the operative treatment of joint instability and may have advantages with respect to early motion and stability. The purpose of this investigation was to describe the clinical results of traumatic elbow instability treated with lateral ulnar collateral ligament repair with suture-tape augmentation. METHODS All cases of acute and chronic elbow instability treated surgically between 2018 and 2020 were included if they underwent ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament as part of the procedure. Cases with <6 months of follow-up were excluded. A manual chart review was performed to record patient demographics as well as injury and surgery characteristics. Radiographic outcomes, range of motion, and patient-reported outcome measures, including the visual analog pain scale and Disabilities of the Arm, Shoulder, and Hand, were recorded. Range of motion measurements were recorded at the end of the clinical follow-up, as were surgical complications. RESULTS Eighteen cases were included with a mean follow-up of 20 months. Five (28%) cases involved a high-energy mechanism, and 11 (62%) cases involved terrible triad fracture dislocations. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire and visual analog pain scale scores were 17 and 2, respectively. The mean flexion-extension arc was 124°, and 2 (11%) cases had <100° flexion-extension arc. There were 2 (11%) postoperative complications, and both cases had postoperative instability requiring reoperation. We observed no cases of capitellar erosion from the suture-tape material. CONCLUSIONS For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jessica L Baylor
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jordan R Nester
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Brian K Foster
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Charles A Daly
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
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12
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Carlier Y, Soubeyrand M. Chronic elbow instability in adults: The why, when and how of ligament reconstruction. Orthop Traumatol Surg Res 2023; 109:103449. [PMID: 36273505 DOI: 10.1016/j.otsr.2022.103449] [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: 02/04/2022] [Accepted: 05/31/2022] [Indexed: 12/24/2022]
Abstract
Chronic elbow instability in adults mainly consists of valgus instability and posterolateral instability. They most often occur because of ligament damage following elbow dislocation but can also occur due to repeated microtrauma. The aim of ligament stabilization surgery is always the same: recreate the anatomy and function of the original ligament. Extensive knowledge of the elbow's anatomical structures and biomechanics is crucial to understanding why the elbow is unstable and how to treat it. In this review, we will explain how elbow instability develops, what types of grafts are available and which reconstruction techniques can be used for posterolateral or valgus instability. LEVEL OF EVIDENCE: 3.
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Affiliation(s)
- Yacine Carlier
- Centre de l'arthrose de Mérignac, 6, rue Georges-Négrevergne, 33700 Mérignac, France.
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13
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Ellwein A, Janning L, DeyHazra RO, Smith T, Lill H, Jensen G. Prospective clinical results of an additive ligament bracing for stabilizing simple and complex elbow instabilities. Arch Orthop Trauma Surg 2022; 142:3837-3844. [PMID: 34988672 DOI: 10.1007/s00402-021-04276-2] [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: 04/19/2021] [Accepted: 11/21/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Ligament bracing augments ligament repair using a non-absorbable suture tape. Although biomechanically an increase in primary stability has been proven, there is a lack of clinical evidence. Purpose of this study was to evaluate clinical results of patients treated with ligament bracing due to primary elbow instability, including an analysis of complications. Furthermore, clinical results for patients treated with and without early functional mobilization were compared. MATERIALS AND METHODS This prospective case-series evaluated clinical and functional results from patients treated with ligament bracing due to primary elbow instability. Clinical outcome measures were range of motion (ROM) as well as objective and subjective elbow scores [Mayo Elbow Performance Score (MEPS); Disabilities of Arm, Shoulder and Hand Score (DASH score)]. Stability was evaluated sonographically by humero-radial gapping under varus stress. RESULTS This study involved 34 patients treated with ligament bracing. After a mean follow-up of 12.9 months ROM was 112° ± 29, MEPS 88 ± 13 points, DASH 91 ± 11 points, and 84% were satisfied with their result. Lateral joint gapping was 2.4 mm. No significant difference was observed regarding a postoperative mobilization with and without limitations. Most common complication after ligament bracing was elbow stiffness including heterotopic ossifications in four patients (12%). CONCLUSION Operatively treated elbow instability with additional ligament bracing results in good clinical outcomes with high patient satisfaction and recovery of elbow stability. The high primary stability of the ligament bracing allows early functional mobilization without bracing, which facilitates postoperative rehabilitation. Elbow stiffness with heterotopic ossification seems to be a potential complication. Furthermore, the optimal tensioning of the ligament bracing remains challenging, including the risk of an over tensioning. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexander Ellwein
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany. .,Department for Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany.
| | - Larissa Janning
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany
| | - Rony-Orijit DeyHazra
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany
| | - Tomas Smith
- Department for Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Helmut Lill
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany
| | - Gunnar Jensen
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany
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Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results. J Shoulder Elbow Surg 2022; 31:2316-2321. [PMID: 35872170 DOI: 10.1016/j.jse.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/21/2022] [Accepted: 06/05/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. METHODS We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n = 20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. RESULT Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P < .001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P < .001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. CONCLUSION As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.
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Ellwein A, Stryga M, Ferle M, Pastor MF, Lill H, Smith T. Biomechanical Comparison of Two Fixation Techniques for Lateral Ulnar Collateral Ligament Repair With Ligament Bracing. J Hand Surg Am 2022; 47:1016.e1-1016.e8. [PMID: 34565637 DOI: 10.1016/j.jhsa.2021.08.004] [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: 07/15/2020] [Revised: 06/07/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Ligament bracing is a technique of suture reinforcement that can be used to augment lateral ulnar collateral ligament repair in the treatment of posterolateral rotatory instability of the elbow, thereby improving early stability of the repair. However, multiple failures of the ulnar anchor during implantation have been documented. We hypothesized that the use of a cortical button for ulnar fixation of the ligament brace would be biomechanically comparable to a suture anchor construct. METHODS Sixteen elbows were tested with a materials testing machine. The intact, dissected, and repaired lateral collateral ligament complex was tested with a cyclic varus rotational torque of 0.5-3.5 Nm in 120°, 90°, 60°, and 30° elbow flexion. For the repair, the specimens were randomized into 2 groups: ulnar fixation of the ligament bracing using a suture anchor and ulnar fixation of the ligament bracing using a cortical button. The number of implant failures was documented. A load-to-failure protocol was conducted in 90° elbow flexion. RESULTS Load to failure was comparable and was found to be 20.7 Nm in the suture anchor group and 21.8 Nm in the cortical button group. Laxity after ligament bracing did not differ significantly between suture anchor and cortical button fixation. Compared with the native ligament, the laxity was significantly reduced after ligament bracing. The failure mode was slippage of the suture tape through the humeral anchor in all cases. Additionally, the capitellum was damaged in 9 of 16 cases. CONCLUSIONS A cortical button for ulnar fixation of the ligament bracing was comparable with a suture anchor fixation with regard to biomechanical properties such as laxity and load to failure. CLINICAL RELEVANCE A cortical button fixation is less prone to failure of insertion. This would improve the implantation technique, while clinical results are expected to be comparable.
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Affiliation(s)
- Alexander Ellwein
- Department of Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Hannover, Germany; Department of Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Hannover, Germany.
| | - Marvin Stryga
- Department of Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Hannover, Germany
| | - Manuel Ferle
- Laboratory of Biomechanics and Biomaterials, Medical School Hannover, Hannover, Germany
| | - Marc-Frederic Pastor
- Department of Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Hannover, Germany
| | - Helmut Lill
- Department of Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Hannover, Germany
| | - Tomas Smith
- Department of Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Hannover, Germany
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16
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Postoperative MR Imaging of the Elbow. Magn Reson Imaging Clin N Am 2022; 30:629-643. [DOI: 10.1016/j.mric.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Celli A, Paroni C, Bonucci P, Celli L. Elbow lateral ulnar collateral ligament reconstruction by transposition of the local extensor fascia septum: surgical technique and preliminary results. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:360-368. [PMID: 37588856 PMCID: PMC10426691 DOI: 10.1016/j.xrrt.2022.04.004] [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
The lateral ulnar collateral ligament (LUCL) is a primary lateral stabilizer of the elbow that originates from the isometric center of the capitulum and inserts into the supinator crest of the ulna. LUCL injury may be due to trauma, chronic strain, or iatrogenic lesion. In patients with symptomatic LUCL insufficiency and recurrent posterolateral rotatory instability, surgical reconstruction can restore elbow stability. In primary acute treatment, the injured LUCL is reattached to the lateral epicondyle with transosseous sutures and anchors placed at the isometric origin of the ligament. If the ligament quality is poor, patients with chronic elbow instability may require reconstruction with a tendon autograft or allograft. Alternatively, the LUCL can be reconstructed by transposition of the local extensor fascia septum, a local flap that exploits the common extensor fascia connected to a thin strip of extensor digitorum quinti or the extensor digitorum communis intermuscular septum. We describe a new LUCL reconstruction technique based on the transposition of the local extensor fascia septum and report the preliminary result in a series of patients aged 50 years or less.
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Affiliation(s)
- Andrea Celli
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hesperia Hospital, Modena, Italy
| | - Chiara Paroni
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hesperia Hospital, Modena, Italy
| | - Pierluigi Bonucci
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hesperia Hospital, Modena, Italy
| | - Luigi Celli
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hesperia Hospital, Modena, Italy
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Fares A, Kusnezov N, Dunn JC. Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability of the Elbow: A Systematic Review. Hand (N Y) 2022; 17:373-379. [PMID: 32686513 PMCID: PMC8984710 DOI: 10.1177/1558944720917763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Posterolateral rotatory instability (PLRI) is a common form of recurrent elbow instability. The aim of this systematic review is to present the outcomes and complications of lateral ulnar collateral ligament (LUCL) reconstruction surgery for PLRI. Methods: A literature search of LUCL reconstructions was performed, identifying 99 potential papers; 11 of which met inclusion/exclusion criteria, accounting for 148 patients. Papers were included if they reviewed cases of PLRI from 1976 to 2016 with reported outcome measures. Data were pooled and analyzed focusing on patient demographics as well as subjective and objective patient outcomes and complications. Results: The average age of patients was 34 years with a mean follow-up time of 49.8 months. The most common mechanism of injury was a traumatic elbow dislocation (66%), followed by cubitus varus deformity (7%), and unknown mechanisms (7%). Overall, 90% of patients achieved elbow stability and 2.7% experienced a failed reconstruction that necessitated an additional surgery. Furthermore, 93% were satisfied with the outcome of the reconstruction, and 83% reported good to excellent outcomes with 11% reporting moderate to severe persistent pain. Nearly half (45%) of reconstructions were done using a palmaris longus tendon graft, 24% with a triceps tendon graft, and 7% with a synthetic graft. Conclusions: Outcomes following LUCL reconstruction for PLRI are excellent and revision rates are low. LUCL reconstruction is a safe and reliable procedure.Level of Evidence: IV Therapeutic.
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Affiliation(s)
- Austin Fares
- William Beaumont Army Medical Center, El
Paso, TX, USA,Austin Fares, Department of Orthopaedic
Surgery, William Beaumont Army Medical Center, 5005 N. Piedras Street, El Paso,
TX 79920, USA.
| | | | - John C. Dunn
- William Beaumont Army Medical Center, El
Paso, TX, USA
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De Giorgi S, Vicenti G, Bizzoca D, Carrozzo M, Baglioni M, Virgilio A, Moretti L, Moretti B. Lateral collateral ulnar ligament reconstruction techniques in posterolateral rotatory instability of the elbow: A systematic review. Injury 2022; 53 Suppl 1:S8-S12. [PMID: 33187675 DOI: 10.1016/j.injury.2020.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Elbow chronic instability is a disable complication, presenting as recurrent joint subluxations or dislocations. This systematic review aims to assess (1) the clinical outcome and (2) the complication rates of the surgical techniques currently used in the management of posterolateral rotatory elbow instability. METHODS OVID-MEDLINE®, SCOPUS, and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The search terms used were "LUCL", "Posterolateral dislocation", "Elbow Docking technique", "Elbow Jobe technique" and "Elbow single strand technique". The methodological qualities of the studies were evaluated, relevant data were extracted. RESULTS Three studies, published between 2012 and 2015, were included in this review. No studies concerning the single strand technique met the inclusion criteria. The included studies had a level of evidence IV and recruited 33 patients undergoing a Jobe technique reconstruction and 8 patients undergoing a Docking technique. Jobe procedure registered better clinical and functional outcome, assessed using the Mayo Clinic Elbow Performance Scale (MEPS), compared with patients managed with Docking technique. Nonetheless, this difference is not significant. There was not a significantly different complication rate (p = 0.57) between patients treated with these two different techniques. CONCLUSION This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. However, future studies with larger sample size and a longer follow-up interval are needed to draw stronger conclusions on the efficacy of the different LUCL surgical reconstruction techniques.
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Affiliation(s)
- Silvana De Giorgi
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Giovanni Vicenti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy.
| | - Davide Bizzoca
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Massimiliano Carrozzo
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Marco Baglioni
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Antonio Virgilio
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Lorenzo Moretti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Biagio Moretti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
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Schneider MM, Müller K, Hollinger B, Nietschke R, Zimmerer A, Ries C, Burkhart KJ. Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability After Failed Common Extensor Origin Release: Outcomes at Minimum 2-Year Follow-up. Orthop J Sports Med 2022; 10:23259671211069340. [PMID: 35155705 PMCID: PMC8832605 DOI: 10.1177/23259671211069340] [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: 09/25/2021] [Accepted: 10/03/2021] [Indexed: 11/17/2022] Open
Abstract
Background: In patients with chronic lateral epicondylitis who have failed nonoperative treatment, open or percutaneous release of the common extensor origin (CEO) without subsequent reconstruction tends to result in good clinical outcomes. However, surgery can lead to iatrogenic injuries of the lateral collateral ligamentous complex, causing posterolateral rotatory instability (PLRI). Purpose: To determine the clinical outcomes of lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon graft after failed open CEO surgery. Study Design: Case series; Level of evidence, 4. Methods: A total of 103, patients underwent revision surgery at a single institution because of PLRI after failed open release of the CEO (Hohmann procedure) between January 2007 and October 2016. The primary surgery had been performed at other institutions in all cases. Of these patients, 72 were available for follow-up (49 by clinical examination, 23 by telephone interview). Standardized clinical examination; Mayo Elbow Performance Score (MEPS); 11-item version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH); subjective elbow value (SEV); and patient satisfaction were assessed at least 2 years after LUCL reconstruction. Results: The mean age of patients in the study was 46.9 years (range, 21-74 years), and the mean follow-up was 2.8 years after revision surgery. The mean MEPS was 78.9, and the mean QuickDASH score reached 20.4. The mean SEV was 78.6%, and 75% of the patients rated the surgery as good to excellent. Complications were detected in 14% of the patients, and 9 needed revision surgery, primarily owing to graft failure with recurrent instability (n = 5). Conclusion: LUCL reconstruction in patients with PLRI after release of the CEO can restore elbow stability and achieve high patient satisfaction. However, outcome scores and revision rates in this cohort were inferior to published outcomes of primary LUCL reconstruction for treatment of noniatrogenic or traumatic PLRI.
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Affiliation(s)
- Marco M. Schneider
- Arcus Sportklinik, Pforzheim, Germany
- University Witten/Herdecke, Witten, Germany
| | | | - Boris Hollinger
- Orthopädische Klinik Markgröningen, Abteilung Sportorthopädie, Markgröningen, Germany
| | | | | | - Christian Ries
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus J. Burkhart
- Arcus Sportklinik, Pforzheim, Germany
- University of Cologne, Cologne, Germany
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LUCL reconstruction of the elbow: clinical midterm results based on the underlying pathogenesis. Arch Orthop Trauma Surg 2022; 142:1809-1816. [PMID: 33606084 PMCID: PMC9296399 DOI: 10.1007/s00402-021-03759-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/01/2021] [Indexed: 11/14/2022]
Abstract
PURPOSE Traumatic and atraumatic insufficiency of the lateral ulnar collateral ligament (LUCL) can cause posterolateral rotatory instability (PLRI) of the elbow. The influence of the underlying pathogenesis on functional outcomes remains unknown so far. The objective of this study was to determine the impact of the initial pathogenesis of PLRI on clinical outcomes after LUCL reconstruction using an ipsilateral triceps tendon autograft. METHODS Thirty-six patients were reviewed in this retrospective study. Depending on the pathogenesis patients were assigned to either group EPI (atraumatic, secondary LUCL insufficiency due to chronic epicondylopathia) or group TRAUMA (traumatic LUCL lesion). Range-of-motion (ROM) and posterolateral joint stability were evaluated preoperatively and at follow-up survey. For clinical assessment, the Mayo elbow performance (MEPS) score was used. Patient-reported outcomes (PROs) consisting of visual analogue scale (VAS) for pain, disability of arm, shoulder and hand (DASH) score, patient-rated elbow evaluation (PREE) score and subjective elbow evaluation (SEV) as well as complications were analyzed. RESULTS Thirty-one patients (group EPI, n = 17; group TRAUMA, n = 14), 13 men and 18 women with a mean age of 42.9 ± 11.0 were available for follow-up evaluation (57.7 ± 17.5 months). In 93.5%, posterolateral elbow stability was restored (n = 2 with re-instability, both group TRAUMA). No differences were seen between groups in relation to ROM. Even though group EPI (98.9 ± 3.7 points) showed better results than group TRAUMA (91.1 ± 12.6 points) (p = 0.034) according to MEPS, no differences were found for evaluated PROs (group A: VAS 1 ± 1.8, PREE 9.3 ± 15.7, DASH 7.7 ± 11.9, SEV 92.9 ± 8.3 vs. group B: VAS 1.9 ± 3.2, PREE 22.4 ± 26.1, DASH 16.0 ± 19.4, SEV 87.9 ± 15.4. 12.9% of patients required revision surgery. CONCLUSION LUCL reconstruction using a triceps tendon autograft for the treatment of PLRI provides good to excellent clinical outcomes regardless of the underlying pathogenesis (traumatic vs. atraumatic). However, in the present case series, posterolateral re-instability tends to be higher for traumatic PLRI and patient-reported outcomes showed inferior results. LEVEL OF EVIDENCE Therapeutic study, LEVEL III.
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Kwak JM, Rotman D, Lievano JR, Fitzsimmons JS, O'Driscoll SW. Ultrasonographic Measurement of Elbow Varus Laxity With a Sequential Injury Model of the Lateral Collateral Ligament-Capsular Complex. Orthop J Sports Med 2021; 9:23259671211048941. [PMID: 34778473 PMCID: PMC8586189 DOI: 10.1177/23259671211048941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is no consensus how to determine the varus laxity due to the LCL injury using the ultrasonography. There is a risk of lateral collateral ligament injury during or after arthroscopic extensor carpi radialis brevis release for tennis elbow. The equator of the radial head has been suggested as a landmark for the safe zone to not increase this risk; however, the safe zone from the intra-articular space has not been established. Hypothesis Increased elbow varus laxity due to lateral collateral ligament-capsular complex (LCL-cc) injury could be assessed reliably via ultrasound. Study Design Descriptive laboratory study. Methods Eight cadaveric elbows were evaluated using a custom-made machine allowing passive elbow flexion under gravity varus stress. The radiocapitellar joint (RCJ) space was measured via ultrasound at 30° and 90° of flexion during 4 stages: intact elbow (stage 0), release of the anterior one-third of the LCL-cc (stage 1), release of the anterior two-thirds (stage 2), and release of the entire LCL-cc (stage 3). Two observers conducted the measurements separately, and the mean RCJ space in the 3 LCL-cc injury models (stages 1-3) at both flexion angles was compared with that of the intact elbow (stage 0). We also compared the measurements at 30° versus 90° of flexion. Results At 30° of elbow flexion, the RCJ space increased 2 mm between stages 0 and 2 (95% confidence interval [CI], 1-3 mm; P < .01) and 4 mm between stages 0 and 3 (95% CI, 2-5 mm; P < .01). At 90° of elbow flexion, the RCJ space increased 1 mm between stages 0 and 2 (95% CI, 1-2 mm; P < .01) and 2 mm between stages 0 and 3 (95% CI, 2-3 mm; P < .01). Conclusion Elbow varus laxity under gravity stress can be reliably assessed via ultrasound by measuring the RCJ space. Clinical Relevance Because ultrasonographic measurement of the RCJ space can distinguish the increasing varus laxity seen with release of two-thirds or more of the LCL-cc, the anterior one-third of the LCL-cc, based on the diameter of the radial head, can be considered the safe zone in arthroscopic extensor carpi radialis brevis release for tennis elbow.
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Affiliation(s)
- Jae-Man Kwak
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, College of Medicine, Eulji University, Uijeongbu, Republic of Korea
| | - Dani Rotman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Shawn W O'Driscoll
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Yano K, Kaneshiro Y, Sakanaka H. Acute elbow trauma similar to Osborne-Cotterill lesion, capitellar impaction fracture associated with posterolateral rotatory instability: A case report and literature review. J Orthop Sci 2021; 26:1152-1155. [PMID: 30686689 DOI: 10.1016/j.jos.2018.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 12/05/2018] [Accepted: 12/31/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Koichi Yano
- Department of Orthopaedic Surgery, Seikeikai Hospital, 1-1-1 Minamiyasuicho, Sakai-ku, Sakai City, Osaka, 590-0064, Japan.
| | - Yasunori Kaneshiro
- Department of Orthopaedic Surgery, Seikeikai Hospital, 1-1-1 Minamiyasuicho, Sakai-ku, Sakai City, Osaka, 590-0064, Japan
| | - Hideki Sakanaka
- Department of Orthopaedic Surgery, Seikeikai Hospital, 1-1-1 Minamiyasuicho, Sakai-ku, Sakai City, Osaka, 590-0064, Japan
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Midtgaard KS, Nolte PC, Miles JW, Tanghe KK, Douglass BW, Peebles LA, Provencher MT. Pullout Strength of All-Suture and Metallic Anchors in Repair of Lateral Collateral Ligament Injuries of the Elbow. Arthroscopy 2021; 37:2800-2806. [PMID: 34126221 DOI: 10.1016/j.arthro.2021.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/17/2021] [Accepted: 05/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of metallic anchor (MA) and all-suture anchor (ASA) constructs in the anatomic reattachment of the lateral ulnar collateral ligament complex to its humeral insertion. METHODS Twenty paired male human cadaveric elbows with a mean age of 46.3 years (range: 33-58 years) were used in this study. Each pair was randomly allocated across 2 groups of either MA or ASA. A single 3.5-mm MA or 2.6-mm ASA was then inserted flush into the lateral epicondyle. A dynamic tensile testing machine was used to perform cyclic loading followed by a load to failure test. During the cyclic loading phase, the anchors were sinusoidally tensioned from 10 N to 100 N for 1,000 cycles at a frequency of 0.5 Hz. In the load to failure test, the anchors were pulled at a rate of 3 mm/s. Load at 1-mm and 2-mm displacement, as well as load to ultimate failure were assessed. Clinical failure was defined as displacement of more than 2 mm. Normality of data was assessed with the Shapiro-Wilk test. Continuous data are presented as medians and compared with the Mann-Whitney U test and categorical data was compared with the χ2 test or Fisher exact test. RESULTS Displacement was significantly greater for the ASA group during cyclic loading starting from the tenth cycle (P < .05). Displacement of more than 5 mm within the first 100 cycles was observed in 2 anchors in the ASA group. No difference was observed in loads required to displace 1 mm (MA: 146 N [6-169] vs ASA: 144 N [2-153]; P = .53) and 2 mm (MA: 171 N [13-202] vs ASA: 161 N [9-191]; P = .97), but there was a statistically significant difference between ultimate loads in favor of ASA in the load to failure test (MA: 297 N [84-343] vs 463 N [176-620]; P < .01). CONCLUSIONS In the cyclic test, no difference in clinical failure defined as pull-out of more than 2 mm was observed between 3.5 mm MAs and 2.6 mm ASAs. In the ultimate load to failure analysis, no difference was observed between groups in force causing 1 and 2 mm of displacement, but there was a significant difference in favor of ASA in the pull to ultimate failure test. CLINICAL RELEVANCE Potential benefits of all-suture anchors include preservation of bone stock, reduced radiographic artifacts, and easier revisions. Although their use has been investigated thoroughly in the shoulder, there remains a paucity of literature regarding displacement and pull-out strength in the elbow.
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Affiliation(s)
- Kaare S Midtgaard
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Norwegian Armed Forces Joint Medical Services, Forsvarsvegen, Norway
| | - Philip-C Nolte
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen, Germany
| | - Jon W Miles
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Kira K Tanghe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Liam A Peebles
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic, Vail, Colorado, U.S.A..
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Schoch C, Dittrich M, Seilern Und Aspang J, Geyer M, Geyer S. Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1111-1118. [PMID: 34363106 DOI: 10.1007/s00590-021-03081-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. METHODS A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. RESULTS A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. CONCLUSIONS LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.
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Affiliation(s)
- Christian Schoch
- St. Vinzenz Klinik Pfronten GmbH, Kirchweg 15, 87459, Pfronten, Germany.
| | - Michael Dittrich
- St. Vinzenz Klinik Pfronten GmbH, Kirchweg 15, 87459, Pfronten, Germany
| | | | - Michael Geyer
- St. Vinzenz Klinik Pfronten GmbH, Kirchweg 15, 87459, Pfronten, Germany
| | - Stephanie Geyer
- Department for Orthopaedic Sports Medicine, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
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Kholinne E, Kwak JM, Kim H, Sun Y, Koh KH, Jeon IH. Osteochondral reconstruction for post-traumatic coronoid deficiency. J Orthop Surg (Hong Kong) 2021; 28:2309499020968606. [PMID: 33150847 DOI: 10.1177/2309499020968606] [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: 11/16/2022] Open
Abstract
PURPOSE This study aimed to evaluate the clinical outcome and graft survival following coronoid reconstruction with osteochondral bone grafts for post-traumatic coronoid deficiency treatment. We hypothesized that coronoid reconstruction using an osteochondral bone graft will provide favorable results in treating post-traumatic coronoid deficiency. METHODS A retrospective review was performed on eight patients (mean age = 45.8 years) who underwent osteochondral bone graft reconstruction indicated for post-traumatic coronoid deficiency. The osteochondral bone grafts were obtained from the radial head remnant (four patients), olecranon tip (two patients), and iliac crest (two patients). All the injuries were terrible triad. The mean duration from injury to surgery was 79.3 weeks. The visual analog scale (VAS) for pain, motion arc, and Mayo elbow performance score (MEPS) were used to evaluate the clinical outcome. Radiologic evaluation of graft healing and integrity was performed using computed tomography at 19 months and plain elbow radiography at 24.1 months after reconstruction. The immediate graft height was measured. RESULTS VAS and MEPS values improved from 4.1 ± 1.2 to 1.1 ± 0.3 and 34.2 ± 16.9 to 85.0 ± 7.1, respectively (p = 0.018, p = 0.018) after reconstruction. The motion arc significantly improved from 84.2° ± 16.1° to 102.1° ± 18.2° at the final follow-up of 39.1 ± 18.8 months (p = 0.048). All the osteochondral grafts survived, with nonunion in two patients (25%). The mean immediate graft height was 15.4 ± 2.6 mm. Among the eight patients, three (37.5%) developed secondary osteoarthritis of the ulnohumeral joint. CONCLUSIONS Coronoid reconstruction with osteochondral bone graft may serve as an option to salvage post-traumatic coronoid deficiency. Sufficient graft height was required for graft survival. Secondary osteoarthritis of the ulnohumeral joint should not be underestimated during follow-up.
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Affiliation(s)
- Erica Kholinne
- Department of Orthopedic Surgery, St. Carolus Hospital, Faculty of Medicine, 482858Trisakti University, Jakarta, Indonesia.,Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Jae-Man Kwak
- Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Hyojune Kim
- Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Yucheng Sun
- Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu, China
| | - Kyoung-Hwan Koh
- Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea
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Gilotra MN, Fridman J, Enobun B, Kuntz AF, Glaser DL, Huffman GR. Risk factors associated with atraumatic posterolateral rotatory instability. JSES Int 2021; 5:827-833. [PMID: 34223438 PMCID: PMC8245999 DOI: 10.1016/j.jseint.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Traumatic posterolateral rotatory instability after elbow dislocation or fracture dislocation has been well described. However, few reports cover atraumatic posterolateral rotatory instability as a cause of lateral-sided elbow pain. We assessed the risk factors and epidemiology of atraumatic posterolateral rotatory instability in a case-control study. Methods A retrospective review of all patients treated operatively for atraumatic posterolateral rotatory instability during a 6-year period was compared with a group of patients with extensor carpi radialis brevis tendinopathy without instability treated during the same time period. Bivariate and multiple logistic regression statistical analyses were used to investigate the following risk factors: gender, age, hand dominance, diabetes, smoking, body mass index, corticosteroid injection history, and duration of symptoms. Disabilities of the Arm, Shoulder, and Hand and pain scores were obtained preoperatively and postoperatively. Results Thirteen patients with atraumatic posterolateral rotatory instability were compared with 12 patients with extensor carpi radialis brevis tendinopathy. Multivariate analysis revealed patients with atraumatic posterolateral rotatory instability were more likely to have multiple corticosteroid injections (P = .05) and present with a longer duration of symptoms (P = .03). Postoperative pain scores improved in both groups. Conclusions Atraumatic posterolateral rotatory instability should be considered in the differential diagnosis of lateral elbow when patients present with a protracted clinical course. Statistically, posterolateral rotatory instability patients more often present with a history of multiple corticosteroid injections.
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Affiliation(s)
- Mohit N Gilotra
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jake Fridman
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Blessing Enobun
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew F Kuntz
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - David L Glaser
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - G Russell Huffman
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Bellato E, Castoldi F, Marmotti A, Greco V, Pautasso A, Blonna D. Relationship Between the Lateral Collateral Ligament of the Elbow and the Kocher Approach: A Cadaver Study. J Hand Surg Am 2021; 46:245.e1-245.e7. [PMID: 33308903 DOI: 10.1016/j.jhsa.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/16/2020] [Accepted: 09/28/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The lateral ulnar collateral ligament (LUCL) is considered to be the portion of the lateral collateral ligament playing the most important stabilizing role. Iatrogenic forms of posterolateral rotatory instability have been described. The Kocher approach is a popular approach to the lateral side of the elbow. The aim of this study was to describe the relationship between the LUCL and the Kocher interval. METHODS The Kocher interval was identified and marked in 20 cadavers. The LUCL was identified and the distance between the LUCL insertion on the tubercle of the cresta supinatoris and the Kocher interval was calculated (TK distance). This distance was considered 0 if the Kocher interval was directly above the tubercle, as a positive value if it was anterior to the tubercle, and as a negative value if it was posterior. Finally, the Kocher interval was sharply opened, and elbow stability was tested using the posterolateral rotatory drawer test. RESULTS A discrete LUCL was identified in 16 specimens. The mean TK distance was -2.3 ± 4.4 mm (range, -11 to +10). The median TK distance was -3 mm. The posterolateral rotatory drawer test was positive for subluxation after the sharp incision of the Kocher interval in 15 specimens. The median TK distance was significantly higher in the stable group (+2 mm) than in the unstable group (-3 mm). CONCLUSIONS The LUCL often lies beneath the Kocher interval and is at risk during the Kocher approach. CLINICAL RELEVANCE Iatrogenic forms of posterolateral rotatory instability could result from this approach.
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Affiliation(s)
| | | | - Antonio Marmotti
- San Luigi Gonzaga Hospital, Orthopedics and Traumatology Department, University of Turin - Medical School, Turin, Italy
| | | | | | - Davide Blonna
- Mauriziano-Umberto I Hospital, Orthopedics and Traumatology Department, University of Turin - Medical School, Turin, Italy
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Badhrinarayanan S, Desai A, Watson JJ, White CHR, Phadnis J. Indications, Outcomes, and Complications of Lateral Ulnar Collateral Ligament Reconstruction of the Elbow for Chronic Posterolateral Rotatory Instability: A Systematic Review. Am J Sports Med 2021; 49:830-837. [PMID: 32877230 DOI: 10.1177/0363546520927412] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterolateral rotatory instability (PLRI) of the elbow can lead to pain, recurrent dislocations, and, in the worst-case scenario, disability. PURPOSE To report the indications, outcomes, and complication rates of lateral ulnar collateral ligament (LUCL) reconstruction for chronic PLRI of the elbow. STUDY DESIGN Systematic review. METHODS This systematic review was registered with PROSPERO and performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The review entailed 17 studies that included 168 patients with isolated LUCL reconstruction for chronic PLRI. Patients with concurrent medial collateral ligament reconstruction were excluded. The primary outcome measures were patient characteristics, indication for surgery, surgical technique, functional outcomes, and complications. RESULTS Chronic PLRI commonly occurred after a previous traumatic injury (n = 168). Of these, there were 119 simple instabilities (no fracture) and 33 complex instabilities (associated fracture). In 11 patients, PLRI was iatrogenic. The cause was unknown in 5 patients. Grafts used were autograft (n = 102; 61%), allograft (n = 18; 11%), synthetic graft (n = 15; 9%), and unknown (n = 33; 20%). The most common surgical technique was a docking procedure or a modification of this (n = 145; 86%). Other techniques included suture anchors (n = 18; 11%), nonanatomic (n = 1; 0.6%), and unknown (n = 4; 2%). There were 45 complications reported in 37 patients (22%). The most frequent complication was recurrent instability (21/138; 15%). No other major complications were reported. The rate of recurrent instability was significantly higher in revision reconstructions (6/15 elbows; 40%) compared with primary reconstructions (15/123 elbows; 12.2%) (P = .005). The mean Mayo Elbow Performance Score and abbreviated Disabilities of the Arm, Shoulder and Hand score were 87.5 (range, 40-100) and 18.8 (range, 0-77), respectively. Of the patients in whom range of motion was measured, 134 of 144 patients (93%) regained a functional range (30L-130L). CONCLUSION LUCL reconstruction for chronic PLRI proved a reliable method of reconstruction, save for the moderate rate of recurrent instability, which was highest in revision reconstructions.
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Affiliation(s)
| | - Ankit Desai
- Brighton and Sussex University Hospitals, Brighton, UK
| | | | | | - Joideep Phadnis
- Brighton and Sussex University Hospitals, Brighton, UK.,Brighton & Sussex Medical School, Brighton, UK
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Lateral ulnar collateral ligament (LUCL) reconstruction for the treatment of recalcitrant lateral epicondylitis of the elbow: a comparison with open débridement of the extensor origin. JSES Int 2021; 5:578-587. [PMID: 34136874 PMCID: PMC8178594 DOI: 10.1016/j.jseint.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Based on the controversy over whether the extensor tendon is the only lesion of lateral epicondylitis of the elbow and numerous reports of concomitant lateral collateral ligament involvement, potential damage to the lateral collateral ligament complex should be considered for the treatment. Methods About 25 elbows in 23 patients (débridement group) and 22 elbows in 20 patients (reconstruction group) who were diagnosed with lateral epicondylitis and had an average of 22 months of symptoms revealing anatomical lesion on MRI were included. The capitellum-sublime tubercle-radial head (CSR) angle was measured on both sides preoperatively, and the visual analog scale (VAS) and Mayo elbow performance score (MEPS) were measured over 12 months, postoperatively. Results The initial preoperative mean VAS was statistically significant with 4.6 in the débridement group and 6.5 in the reconstruction group (P < .05). Postoperative VAS was continuously decreased in both groups with no significant difference at each assessment period (P < .05) but showed more rapid improvement in the reconstruction group compared with the débridement group. For MEPS, the reconstruction group showed significant improvement during the follow-up periods, and at the final follow-up MEPS, 3 cases in the débridement group and 0 cases in the reconstruction group showed a poor result, which was considered as surgery failure. The CSR angle of the affected side (7.2 ± 1.9) was significantly larger than that of the normal side (3.6 ± 1.5) (P < .05) in the reconstruction group. Increased CSR by more than 5 degrees was identified as a significant predictive indicator for potential concomitant ligament insufficiency (area under curve = 0.875, P < .001) showing 80.9% of the sensitivity, 82.1% of the specificity. Conclusions In the surgical treatment of recalcitrant lateral epicondylitis, lateral ulnar collateral ligament reconstruction added to the débridement of extensor origin may provide better results for the patients with suspicious lateral ligament insufficiency or failed previous surgery.
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Ellwein A, Becker S, Nebel D, Horstmann H, Smith T, Lill H, Pastor MF. Biomechanical comparison of lateral collateral ligament reconstruction with and without additional internal bracing using a three-dimensional elbow simulator. Clin Biomech (Bristol, Avon) 2021; 81:105236. [PMID: 33234324 DOI: 10.1016/j.clinbiomech.2020.105236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although an additional internal bracing significantly increases stability in a repair of the lateral ulnar collateral ligament, it remains unclear whether it also does in reconstruction. Aim of this study was to implement a three-dimensional elbow simulator for testing posterolateral rotatory instability. We hypothesized that (1) reconstruction with and without internal bracing is comparable in biomechanical properties, and (2) there would be higher load-to-failure with internal bracing. METHODS Posterolateral rotatory instability was tested by imitating the lateral pivot shift test in 16 elbows. Valgus and supination torques were simultaneously increased stepwise up to 1.2 Nm. Specimens were tested at 30°, 60°, 90°, and 120° elbow flexion with an intact lateral collateral ligament complex, dissected complex, and after reconstruction with or without internal bracing. Outcome measures included joint gapping, laxity, and load to failure. FINDINGS With the implemented elbow simulator no significant difference was observed for gapping or laxity between both treatment groups. Comparing treatment and native ligament, gapping was reduced, especially with increased elbow flexion. Laxity was also reduced at some flexion angles. The mean load-to-failure was 8.1 ± 2.7 Nm without and 9.6 ± 3.6 Nm with internal bracing (P = 0.645). INTERPRETATION Both treatments were comparable in biomechanical properties but did not fully restore the native state. Although the additional augmentation of the LUCL reconstruction tends to increase the maximum load to failure, this difference was not statistically significant. Still, reconstruction with internal bracing seems to be a reasonable option in selected primary reconstructions. It could also be useful in revision reconstruction.
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Affiliation(s)
- Alexander Ellwein
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany; Department of Orthopedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169 Hannover, Germany.
| | - Sören Becker
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany
| | - Dennis Nebel
- Laboratory of Biomechanics and Biomaterials, Medical School Hannover, 30625 Hannover, Germany
| | - Hauke Horstmann
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany
| | - Tomas Smith
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany
| | - Helmut Lill
- Department of Orthopedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169 Hannover, Germany
| | - Marc-Frederic Pastor
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany
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Ellwein A, Füßler L, Ferle M, Smith T, Lill H, Pastor MF. Suture tape augmentation of the lateral ulnar collateral ligament increases load to failure in simulated posterolateral rotatory instability. Knee Surg Sports Traumatol Arthrosc 2021; 29:284-291. [PMID: 32162045 DOI: 10.1007/s00167-020-05918-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 02/24/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Simple elbow dislocations are accompanied with lateral ulnar collateral ligament ruptures. For persisting instability, surgery is indicated to prevent chronic posterolateral rotatory instability. After lateral collateral ligament (LCL) complex repair the repair is protected by temporary immobilization, limited range of motion and hinged bracing. Internal bracing is an operative alternative augmenting the LCL repair using non-absorbable suture tapes. However, the stability of LCL repair with and without additional augmentation remains unclear. The hypothesis was that LCL repair with additional suture tape augmentation would improve load to failure. Secondary goal of this study was to evaluate different humeral fixation techniques. A humeral fixation using separate anchors for the LCL repair and the augmentation was not expected to provide superior stability compared to using only one single anchor. METHODS Twenty-one elbows were tested. A cyclic varus rotational torque of 0.5-3.5 Nm was applied in 90°, 60°, 30°, and 120° elbow flexion to the intact, torn, and repaired LCLs. The specimens were randomized into three groups: repair alone (group I), repair with additional internal bracing using two anchors (group II), repair using one humeral anchor (group III). A load-to-failure protocol was conducted. RESULTS Load to failure was significantly higher in groups II (26.6 Nm; P = 0.017) and III (23.18 Nm; P = 0.038) than in group I (12.13 Nm). No significant difference was observed between group II and III. All specimens lost reduction after LCL dissection by a mean of 4.48° ± 4.99° (range 0.66-15.82). The mean reduction gain after repair was 7.21° ± 4.97° (2.70-21.23; mean over reduction, 2.73°). The laxity was comparable between the intact and repaired LCLs (n.s.), except for varus movements at 30° in group II (P = 0.035) and 30° (P = 0.001) and 120° in group III (P = 0.008) with significantly less laxity. Inserting the ulnar suture anchor showed failure in the thread in 10 cases. CONCLUSION LCL repair with additional internal bracing yielded higher load to failure than repair alone. Repair with additional internal bracing for the humeral side using one anchor was sufficient. A higher primary stability would facilitate postoperative management and allow immediate functional treatment. Reducing the number of humeral anchors would save costs.
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Affiliation(s)
- Alexander Ellwein
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany. .,Department of Orthopedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany.
| | - Luca Füßler
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Manuel Ferle
- Laboratory of Biomechanics and Biomaterials, Medical School Hannover, 30625, Hannover, Germany
| | - Tomas Smith
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Helmut Lill
- Department of Orthopedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany
| | - Marc-Frederic Pastor
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
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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.
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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
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Abstract
Acute elbow dislocations are commonly seen in clinical practice, and attention to management principles and strategies can help facilitate improved outcomes. Patients may present with simple elbow dislocation, in which nonoperative treatment is highly successful. Alternatively, fracture dislocations can be sometimes easily managed but frequently are associated with the need for surgical intervention and operative and postoperative challenges.
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Krishna SV, Ballal M, BR V, HS C. Instabilidade multidirecional em uma luxação negligenciada do cotovelo gerenciada com reconstrução do ligamento circunferencial. Um relato de caso. Rev Bras Ortop 2020; 58:168-172. [PMID: 36969788 PMCID: PMC10038705 DOI: 10.1055/s-0040-1714232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022] Open
Abstract
ResumoA luxação negligenciada do cotovelo é uma condição incomum e seu tratamento permanece desafiador. Apresentamos o caso de uma mulher de meia-idade que apresentou luxação negligenciada do cotovelo e instabilidade multidirecional, na qual foi realizada redução aberta da articulação do cotovelo e reconstrução ligamentar circunferencial com enxerto de tendão gracilis. O resultado funcional avaliado com o índice de desempenho do cotovelo de Mayo foi excelente. Essa técnica circunferencial é, sem dúvida, uma técnica viável e as indicações podem ser estendidas para gerenciar até mesmo um deslocamento negligenciado. Este procedimento reduz a necessidade ou diminui a duração da exigência de fixação externa e, assim, incentiva a mobilização precoce.
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Affiliation(s)
- Sathya Vamsi Krishna
- Departamento de Cirurgia da Mão, Instituto de Ortopedia e Trauma Sanjay Gandhi, Bangalore, Karnataka, Índia
| | - Madan Ballal
- Departamento de Ortopedia e Lesões Esportivas, Instituto de Ortopedia e Trauma Sanjay Gandhi, Karnataka, Índia
| | - Vivekanandea BR
- Departamento de Ortopedia e Lesões Esportivas, Instituto de Ortopedia e Trauma Sanjay Gandhi, Karnataka, Índia
| | - Chandrahsekar HS
- Departamento de Ortopedia e Lesões Esportivas, Instituto de Ortopedia e Trauma Sanjay Gandhi, Karnataka, Índia
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Biomechanical assessment of lateral ulnar collateral ligament repair and reconstruction with or without internal brace augmentation. JSES Int 2020; 4:224-230. [PMID: 32490406 PMCID: PMC7256890 DOI: 10.1016/j.jseint.2020.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Surgical treatment of posterolateral rotatory instability (PLRI) using primary repair or reconstruction of the lateral collateral ligament complex have proven inconsistent. This study aimed to test the hypothesis that augmentation of LUCL repair or palmaris longus tendon reconstruction using a suture tape augmentation would be associated with less rotational displacement and greater torque load to failure (LTF) compared with nonaugmented constructs. Methods Cadaveric elbows (n = 12 matched pairs) were used. Baseline stiffness and displacement values were obtained. The LUCL was transected followed by repair alone, repair with augmentation, reconstruction with palmaris longus graft, or reconstruction with augmentation. Specimens were retested including torque LTF. Paired t tests were performed to assess the biomechanical effects of augmentation. Results Augmentation was associated with higher LTF than repair and reconstruction alone (P = .008 and .047, respectively). Displacement was less with augmentation in reconstruction groups (P = .048) but not in repair groups. Suture tape augmentation maintained rotational stiffness better than repair alone (P = .01). Although reconstruction with augmentation maintained rotational stiffness better than nonaugmented reconstruction, the differences were not statistically significant (P = .057). Mode of failure for repair alone was predominantly suture pulling through repaired ligament. Augmented repairs primarily failed at the anchor-bone interface. Modes of failure for both reconstruction groups were similar, including graft tearing and/or slipping at the anchor. Conclusion When positioned in neutral forearm rotation and 90o of flexion to simulate postoperative conditions, augmentation of LUCL repair or tendon reconstruction using suture tape is associated with better resistance to rotational loads compared with nonaugmented repair or reconstruction, while maintaining near-native rotational stiffness.
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LUCL internal bracing restores posterolateral rotatory stability of the elbow. Knee Surg Sports Traumatol Arthrosc 2020; 28:1195-1201. [PMID: 31352495 DOI: 10.1007/s00167-019-05632-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Posterolateral rotatory instability (PLRI) of the elbow occurs from an insufficient lateral collateral ligament complex (LCLC). For subacute LCLC injuries, lateral ulnar collateral ligament (LUCL) internal bracing rather than reconstruction may be a viable option. The purpose of the study was to compare the stabilizing effects of LUCL internal bracing to triceps tendon graft reconstruction in simulated PLRI. METHODS Sixteen cadaveric elbows were assigned for either LUCL internal bracing (n = 8) or reconstruction with triceps tendon graft (n = 8). Specimen were mounted and a valgus rotational torque was applied to the ulna to test posterolateral rotatory stability. Posterolateral rotation was measured at 0°, 30°, 60°, 90° and 120° of elbow flexion. Cyclic loading was performed for 1000 cycles at 90° of elbow flexion. Three conditions were compared in each specimen: intact elbow, LUCL and radial collateral ligament (RCL) transected, and then either LUCL internal bracing or reconstruction with triceps tendon graft. RESULTS Transection of the LUCL and RCL significantly increased posterolateral rotation in all degrees of elbow flexion compared to the intact condition (P < 0.05). Both LUCL internal bracing and reconstruction restored posterolateral rotatory stability to the native state between 0° and 120° of elbow flexion, with no significant difference in improvement between groups. Similarly, LUCL internal bracing and reconstruction groups showed no significant difference in posterolateral rotation compared to the intact condition during cyclic loading. CONCLUSIONS At time zero, both LUCL internal bracing and reconstruction with triceps tendon graft restored posterolateral rotatory stability. As such, this study supports the use of internal bracing as an adjunct to primary ligament repair in subacute PLRI.
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Engaging Posterior Capitellum Fracture and Elbow Posterolateral Rotatory Instability: Is It Always Necessary to Treat the Bone Defect? Case Rep Orthop 2020; 2020:3260106. [PMID: 32206364 PMCID: PMC7079214 DOI: 10.1155/2020/3260106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 12/02/2022] Open
Abstract
Case We present a 23-year-old male with 7 episodes of left elbow dislocation during a two-year period. He had a positive pivot shift test with engaging. The original treatment plan included lateral ulnar collateral ligament reconstruction and eventually bone defect grafting and osteosynthesis. However, a bone graft was not performed. After 2 years of follow-up, the DASH score was 3.3. The Mayo Score was 90. Conclusion Posterolateral instability associated with an engaging bone defect, in every elbow extension and pivot shift test, was not found in the literature. The capitellum defects are associated with PLRI and make it worse. Bone reconstruction may not be indicated.
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Greiner S, Koch M, Kerschbaum M, Bhide PP. Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation. Knee Surg Sports Traumatol Arthrosc 2019; 27:3269-3275. [PMID: 30762088 DOI: 10.1007/s00167-019-05402-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 02/06/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability. METHODS Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3 days. RESULTS At 10 month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity. CONCLUSION Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Stefan Greiner
- Sporthopaedicum, Straubing and Regensburg, Bahnhofplatz, 27, 94315, Straubing, Germany.
| | - Matthias Koch
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | | | - Pushkar P Bhide
- Sporthopaedicum, Straubing and Regensburg, Bahnhofplatz, 27, 94315, Straubing, Germany
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Biomechanical Role and Motion Contribution of Ligaments and Bony Constraints in the Elbow Stability: A Preliminary Study. Bioengineering (Basel) 2019; 6:bioengineering6030068. [PMID: 31394803 PMCID: PMC6784216 DOI: 10.3390/bioengineering6030068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 11/16/2022] Open
Abstract
In flexion–extension motion, the interaction of several ligaments and bones characterizes the elbow joint stability. The aim of this preliminary study was to quantify the relative motion of the ulna with respect to the humerus in two human upper limbs specimens and to investigate the constraints role for maintaining the elbow joint stability in different section conditions. Two clusters of four markers were fixed respectively to the ulna and humerus, and their trajectory was recorded by a motion capture system during functional orthopedic maneuver. Considering the posterior bundle of medial collateral complex (pMUCL) and the coronoid, two section sequences were executed. The orthopedic maneuver of compression, pronation and varus force was repeated at 30°, 60° and 90° flexion for the functional investigation of constraints. Ulna deflection was compared to a baseline elbow flexion condition. With respect to the intact elbow, the coronoid osteotomy influences the elbow stability at 90° (deflection = 11.49 ± 17.39 mm), while small differences occur at 30° and 60°, due to ligaments constraint. The contemporary pMUCL section and coronoid osteotomy causes elbow instability, with large deflection at 30° (deflection = 34.40 ± 9.10 mm), 60° (deflection = 45.41 ± 18.47 mm) and 90° (deflection = 52.16 ± 21.92 mm). Surgeons may consider the pMUCL reconstruction in case of unfixable coronoid fracture.
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Clinical Outcome After Lateral Ulnar Collateral Ligament Reconstruction in an Adolescent Baseball Player: A Case Report. Clin J Sport Med 2019; 29:e70-e72. [PMID: 31241540 DOI: 10.1097/jsm.0000000000000529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical procedure to treat posterolateral rotatory instability (PLRI) of the elbow. We report a 17-year-old right-handed pitcher with symptomatic PLRI after an injury to his LUCL during a baseball game. Having failed 8 months of conservative treatment, a LUCL reconstruction using the modified O'Driscoll technique was performed with the contralateral gracilis autograft. At 5-year follow-up, an excellent patient-reported outcome was achieved and the patient continued to play baseball at the recreational level. This type of injury is rarely reported in adolescent baseball players, and improving our knowledge of the long-term outcomes is crucial to assist clinicians in counseling patients about expectations after surgery.
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Kholinne E, Ha TH, Tan J, Jeon IH. Three-dimensional computed tomography modeling for kinematic analysis of double-strand lateral ulnar collateral ligament reconstruction. J Shoulder Elbow Surg 2019; 28:1378-1386. [PMID: 31104892 DOI: 10.1016/j.jse.2018.11.070] [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: 06/11/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND When treating posterolateral rotatory instability, the lateral ulnar collateral ligament (LUCL) is more commonly reconstructed than the other dynamic stabilizer structures. Although numerous surgical techniques have been described for LUCL reconstruction, studies have been limited to static analyses of single-strand reconstructions. The aim of this study was to dynamically analyze the kinematics of double-strand LUCL reconstructions with 3 different configurations of graft placement: horizontal, vertical, and triangular. METHODS Five healthy elbow joints with no signs of pre-existing pathology were scanned by computed tomography, and the images were converted into 3-dimensional models. The humeral origin and ulnar insertions of the 2 ligament strands were registered in 3-matic software for the 3 graft placement configurations. A dynamic elbow joint was simulated at 1° increments throughout the motion arc. The ligament strand lengths and the difference between them were measured. RESULTS The ligament lengths for each strand for the 3 graft configurations were as follows: horizontal, 31.0 ± 4.6 mm and 34.3 ± 5.0 mm; vertical, 32.5 ± 3.6 mm and 35.4 ± 4.2 mm; and triangular, 32.0 ± 4.0 mm and 33.7 ± 3.1 mm. The minimum length differences for the graft strands through the motion arc for the horizontal, vertical, and triangular graft configurations were 1.1, 0.0, and 1.0 mm, respectively. CONCLUSIONS Dynamic analyses using a 3-dimensional elbow model showed that none of the configurations for double-strand LUCL reconstruction were isometric. However, the vertical double-strand configuration was nearly isometric and may therefore serve as a coequal option.
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Affiliation(s)
- Erica Kholinne
- Department of Orthopedic Surgery, St Carolus Hospital, Jakarta, Indonesia; Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Tae-Hyun Ha
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Jun Tan
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Nantong University, Jiangsu, China
| | - In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea.
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Brownhill JR, Pollock JW, Ferreira LM, Johnson JA, King GJW. The effect of implant linking and ligament integrity on humeral loading of a convertible total elbow arthroplasty. Shoulder Elbow 2019; 11:45-52. [PMID: 30719097 PMCID: PMC6348587 DOI: 10.1177/1758573217728292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 05/22/2017] [Accepted: 07/19/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Both unlinked and linked total elbow arthroplasty (TEA) implants have been employed with no consensus as to the optimal design. The present study aimed to evaluate the effect of collateral ligament integrity and implant linkage on wear-inducing loads in a convertible TEA. METHODS Eight fresh frozen upper extremities were tested in an elbow motion simulator. A convertible TEA with an instrumented humeral stem was inserted using computer navigation. Elbow kinematics and humeral loading were recorded with the TEA both linked and unlinked. The collateral ligaments were then sectioned and testing was repeated. RESULTS In the dependent position, there was no effect of implant linkage or ligament sectioning on humeral loading. Humeral loading was significantly greater following sectioning of the collateral ligaments but not after linking the TEA with the arm in the valgus position. Humeral loading was significantly greater after linking the TEA but not after sectioning of the collateral ligaments and with the arm in the varus position. CONCLUSIONS Collateral ligament integrity reduces wear-inducing loads for both an unlinked and linked TEA. Linkage of a convertible TEA increases humeral loading, which may have detrimental effects on implant longevity.
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Affiliation(s)
- James R Brownhill
- Department of Mechanical Engineering, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - J Whitcomb Pollock
- Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - Louis M Ferreira
- Department of Mechanical Engineering, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada,Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - James A Johnson
- Department of Mechanical Engineering, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada,Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - Graham JW King
- Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada,Graham J. W. King, 268 Grosvenor Street, The Hand and Upper Limb Centre, London, Ontario N6A 4L6, Canada.
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Abstract
Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex). In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity. Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first). The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation. For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint. Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability. Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function. The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.
Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.
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Affiliation(s)
- Sebastian Siebenlist
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Arne Buchholz
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Karl F Braun
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany
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Shim JW, Yoo SH, Park MJ. Surgical management of lateral epicondylitis combined with ligament insufficiency. J Shoulder Elbow Surg 2018; 27:1907-1912. [PMID: 30170794 DOI: 10.1016/j.jse.2018.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/03/2018] [Accepted: 06/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency. METHODS We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone débridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery. RESULTS The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency. CONCLUSIONS Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.
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Affiliation(s)
- Jae Woo Shim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Si Hoon Yoo
- Department of Orthopedic Surgery, Inseong Hallym Hospital, Incheon, Republic of Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Kwak SH, Lee SJ, Jeong HS, Do MU, Suh KT. Subtle elbow instability associated with lateral epicondylitis. BMC Musculoskelet Disord 2018; 19:136. [PMID: 29734945 PMCID: PMC5938800 DOI: 10.1186/s12891-018-2069-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background In lateral epicondylitis, even in the absence of apparent instability, subtle instability can be found under anesthesia. We wanted to ascertain the following: (1) how many elbows surgically treated with lateral epicondylitis showed subtle instability during examination under anesthesia (EUA), (2) how effective magnetic resonance imaging (MRI) was in predicting subtle instability, and (3) if any difference existed in preoperative clinical data between elbows with and without subtle instability during EUA. Methods One hundred and twenty-two elbows (117 patients) diagnosed with intractable lateral epicondylitis underwent surgical treatment. No elbow showed apparent instability with conventional physical examination. Under general anesthesia, the elbows were examined for subtle instability via fluoroscopy and divided into unstable and stable groups. Potential prognostic factors and functional scores were assessed retrospectively. The MRIs were reviewed again by two radiologists. Results Seventeen elbows (unstable group, 13.9%) had subtle instability in EUA, while 105 elbows (stable group, 86.1%) did not. Lateral collateral ligament (LCL) complex injury was noted in the MRIs of 28 elbows. Fifteen elbows showed subtle instability among 28 elbows with abnormal MRI (positive predictive value, 53.6%), while 81 elbows did not show subtle instability among 82 elbows with normal MRI (negative predictive value, 98.7%). The preoperative visual analog scale score was higher in the unstable group than in the stable group (p < 0.001), and a history of multiple corticosteroid injections (≥3) was related to subtle instability in EUA (p = 0.042). Other factors showed no significant differences between both groups. Conclusions Subtle instability resulting from LCL complex injury was noted in elbows with lateral epicondylitis. This could be visualized with fluoroscopic EUA, and preoperative MRI could be used to exclude subtle instability. Surgeons should consider checking for subtle instability, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain and MRI indicates instability.
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Affiliation(s)
- Sang Ho Kwak
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Seung-Jun Lee
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Republic of Korea.
| | - Hee Seok Jeong
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Min Uk Do
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Kuen Tak Suh
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Republic of Korea
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Chanlalit C, Dilokhuttakarn T. Lateral collateral ligament reconstruction in atraumatic posterolateral rotatory instability. JSES OPEN ACCESS 2018; 2:121-125. [PMID: 30675579 PMCID: PMC6334856 DOI: 10.1016/j.jses.2018.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Chronic elbow pain has several causes. Instability pain is one of the differential diagnosis. Posterolateral rotatory instability (PLRI) of the elbow results from lateral collateral ligament (LCL) insufficiency. This instability has been recognized in association with trauma of the elbow. The standard treatment of LCL insufficiency is ligament reconstruction with a tendon graft. Treatment outcome of LCL reconstruction in atraumatic PLRI cases has been rarely reported. This study reports the results of LCL reconstruction in patients with chronic lateral elbow pain from atraumatic PLRI. Materials and methods Data were collected from 36 patients referred to our institution for surgery because of chronic lateral elbow pain between November 2011 and June 2015. Six patients with atraumatic PLRI underwent LCL reconstruction with tendon graft. Demographic data, number of steroid injections, postoperative clinical examination, Mayo Elbow Performance Index, 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and complications were recorded with a mean follow-up of 24 months. Results Reconstruction resulted in significant improvement of pain. The mean postoperative Mayo Elbow Performance Index score was 97.5 (range, 95-100), and the score of the 11-item version of the Disabilities of the Arm, Shoulder, and Hand was 9 (range, 3.3-33). Postoperative instability test results were negative in all patients. Mean postoperative range of motion was 136° in flexion and 1° in extension. No complications were detected at the follow-up assessment. Conclusions We consider LCL reconstruction is one of the reference treatments for atraumatic PLRI because it provides effective and reliable results.
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Affiliation(s)
- Cholawish Chanlalit
- Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Thitinut Dilokhuttakarn
- Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
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Schnetzke M, Bergmann M, Wegmann K, Müller LP, Grechenig S, Grützner PA, Guehring T. Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model: A Cadaveric Study. J Bone Joint Surg Am 2018; 100:564-571. [PMID: 29613925 DOI: 10.2106/jbjs.17.00836] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of our study was to analyze, under fluoroscopy, joint angulation of uninjured elbows and elbows with distinct induced collateral ligament injury. METHODS Twelve elbow specimens were tested for varus and valgus joint angulation using 4 different examination methods (application of both varus and valgus stress by each of 2 examiners [Examiner 1 and Examiner 2] and application of 1 and 2 Nm of torque using a calibrated electric force scale) in 4 elbow positions (in full extension with 90° of supination and 90° of pronation, and in 30° of flexion with 90° of supination and 90° of pronation). Six elbow specimens were examined under varus stress at each of 5 sequential stages: (1) intact, (2) transection of the lateral ulnar collateral ligament (LUCL), (3) complete transection of the lateral collateral ligament complex (LCLC), (4) transection of the anterior aspect of the capsule (AC), and (5) transection of the medial collateral ligament (MCL). An additional 6 elbow specimens were examined under valgus stress at 5 sequential stages: (1) intact, (2) transection of the anteromedial collateral ligament (AML), (3) complete transection of the MCL, (4) transection of the AC, and (5) transection of the LCLC. Examinations under fluoroscopy were made to measure the joint angulation. Intraclass correlation coefficients (ICCs) were calculated. RESULTS Testing of the intact elbow specimen by both examiners showed a joint angulation of <5°. Transection of the LUCL led to a varus joint angulation of 4.3° to 7.0°, and transection of the AML resulted in a valgus joint angulation of 4.9° to 8.8°. Complete dissection of the respective collateral ligament complex resulted in a joint angulation of 7.9° to 13.4° (LCLC) and 9.1° to 12.3° (MCL), and additional transection of the AC led to a joint angulation of >20° in some positions in both the medial and the lateral series. Under varus stress, elbow dislocations occurred only after dissection of the LCLC+AC (26% of the examinations) and additional dissection of the MCL (59%). Under valgus stress, elbow dislocations occurred only after dissection of the MCL+AC (30%) and additional dissection of the LCLC (47%). Very good to excellent ICCs were found among Examiners 1 and 2 and the tests done with the standardized torques at stages 1 through 4. CONCLUSIONS Dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow and therefore might be helpful for guiding treatment of simple elbow dislocations. CLINICAL RELEVANCE Assessment of collateral ligament injury with varus and valgus stress testing under fluoroscopy is an easily available method and is often used as the imaging modality of choice to determine the degree of elbow laxity. The technique and results described in this study should form the basis for additional clinical studies.
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Affiliation(s)
- Marc Schnetzke
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Moritz Bergmann
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Kilian Wegmann
- Center for Orthopedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Lars-Peter Müller
- Center for Orthopedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Stephan Grechenig
- Department of Traumatology, University Hospital Regensburg, Regensburg, Germany
| | - Paul-Alfred Grützner
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Thorsten Guehring
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
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Schwarzkopf E, Südkamp N, Maier D. Engaging Osborne-Cotterill lesion with Mason 4 radial head elbow dislocation fracture: a case report of biomechanical importance and operative treatment. J Shoulder Elbow Surg 2018; 27:e75-e78. [PMID: 29433648 DOI: 10.1016/j.jse.2017.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/08/2017] [Accepted: 11/14/2017] [Indexed: 02/01/2023]
Affiliation(s)
- Eugenia Schwarzkopf
- Department of Orthopedics and Trauma Surgery, Medical Center-Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg im Breisgau, Germany.
| | - Norbert Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center-Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg im Breisgau, Germany
| | - Dirk Maier
- Department of Orthopedics and Trauma Surgery, Medical Center-Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg im Breisgau, Germany
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