Chronic medial instability of the elbow

Diagnostic accuracy of fat pad sign, X-ray, and computed tomography in elbow trauma: implications for treatment choices-a retrospective study

Introduction

Identifying skeletal injuries significantly impacts patient outcomes in trauma cases. This study aims to compare the diagnostic accuracy of X-ray (XR) and computed tomography (CT) in detecting elbow fractures among patients presenting at the emergency department (ED). Additionally, the study assesses the potential contribution of the fat pad sign to enhancing the diagnostic accuracy of XR images in identifying elbow fractures. The secondary aim focused on evaluating the precision of XR imaging in determining the necessity for surgical intervention among patients presenting with elbow trauma.

Methods

Conducted retrospectively at an ED within a secondary hospital, this study included patients with elbow trauma between January 1, 2017, and January 1, 2020, who underwent both XR and CT imaging of the elbow joint. Following the application of exclusion criteria, the analysis comprised 183 patients based on remaining image data.

Results

When comparing XR to CT for fracture detection, XR exhibited a sensitivity of 46.9%, specificity of 85.9%, positive predictive value (PPV) of 79.3%, negative predictive value (NPV) of 58.4%, area under the curve (AUC) of 0.664. Considering the fat pad sign in XR as a fracture indicator, the sensitivity is 60.2%, specificity is 81.2%, PPV is 78.7%, NPV is 63.9% and AUC is 0.707. A significant difference was found when comparing the AUCs obtained with and without considering the fat pad sign (p = 0.039). Regarding surgical treatment decision-making, XR showed a sensitivity of 50%, specificity of 100%, PPV of 95%, NPV of 100%, and an AUC of 0.750 when compared to CT.

Conclusion

The findings indicate that XR alone is insufficient for detecting elbow fractures and determining the need for surgical treatment. Incorporating the fat pad sign improves the diagnostic accuracy of XR. In cases where suspicion of fracture is high, considering CT imaging is crucial to avoid missed diagnoses, prevent complications, and guide treatment decisions effectively.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

The level of evidence of this study is level IV.

Fascia lata allograft: a suitable alternative in ligamentous reconstruction for chronic elbow instability?

Background

Up to now, there is no gold standard concerning the optimal graft choice in the surgical therapy of chronic elbow instability. As donor site morbidity represents a rare (1%-4%) but severe complication of graft harvest, using an allograft seems favorable. Fascia lata mimics the anatomy through its fan-shaped configuration of the ligamentous complex of the elbow joint, making it questionable for use as a graft. The aims of the study are (1) to evaluate the biomechanical suitability of fascia lata allograft and (2) to compare clinical and radiological outcome between ligament reconstruction of the lateral collateral ligament complex using either FiberTape augmented triceps autograft or FibreTape augmented fascia lata allograft.

Methods

Biomechanical testing of fascia lata was performed using a 10 kN uniaxial test system with a 1 kN load cell. The retrospective cohort study evaluated all patients who received a ligament reconstruction of the elbow due to chronic instability with allogenic fascia lata or autologous triceps tendon. Exclusion criteria were any type of coexisting fracture or nerval injury. Demographic parameters, patient-reported outcome parameters and radiological stability parameters (sonography and fluoroscopy) were evaluated.

Results

Tensile testing of 39 fascia lata allografts revealed an ultimate load of 234.8 ± 23.1 N and ultimate strength of 33.4 ± 4.4 MPa. Twenty one patients were included in the clinical substudy (57.1% men, 42.9% women, age 41.0 ± 12.2 years, body mass index 24.9 ± 4.1 kg/m2) with average follow-up of 21.6 ± 17.1 months. No significant differences were found concerning pain level, patient-reported outcome measures, or range of motion, between fascia lata and triceps group. There was also no difference concerning sonographic stability of lateral ulnar collateral ligament between the 2 groups (P = .14). One revision occurred in fascia lata allograft group and 2 in triceps autograft group due to graft elongation.

Conclusion

Currently, there is no clinical evidence demonstrating the superiority of either autograft or allograft tissue. Due to its demonstration of sufficient biomechanical properties, fascia lata allograft seems an appropriate treatment option for ligamentous reconstruction of chronic elbow instability.

Chronic elbow instability in adults: The why, when and how of ligament reconstruction

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.

Anatomic Study of the Medial Collateral Ligament in Thai Population: A Cadaveric Study of 56 Elbows

PURPOSE

This study aims to elucidate basic anatomic and geometric features of MCL, providing more accurate and detailed information, as guidance for surgeons, to improve patient's outcome of the treatment.

METHODS

The anterior bundle (AB), posterior bundle (PB) and transverse bundle (TB) ligament of 56 fresh frozen Thai cadaveric elbows, were measured and recorded, comprise key ligament's geometric features, footprints and dimensions, and its relation to bony landmarks. Sagittal and coronal planes were used in respect of the anatomical position.

RESULTS

The mean distance between the center of AB origin and the apex of medial epicondyle is as follows: 2.97 ± 2.21 mm anteriorly, 4.73 ± 1.60 mm inferiorly in the sagittal plane, and 4.23 ± 1.13 mm deep from the epicondyle in the coronal plane. Its dimension is 6.23 ± 1.02 mm in width and 45.97 ± 6.75 mm in length. The ligament's insertion triangular shape has its base located 28.44 ± 3.51 mm anterior from the posterior olecranon border, and 22.52 ± 2.49 mm superior from the inferior ulnar border. The tip located 50.79 ± 4.86 mm anterior from the posterior olecranon border and 17.64 ± 2.80 mm superior from the inferior ulnar border.

CONCLUSION

Apprehension of the precise geometries and distances of the ligament's footprint relative to key anatomical point is crucial. This stereographically comprehended data are useful for surgeon as reference points to obtain stability, motion, kinetic, and kinematic properties of the elbow.

LEVEL OF EVIDENCE

Level V evidence.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00648-x.

TREATMENT OF SIMPLE CHRONIC INSTABILITY OF THE ELBOW JOINT

Simple chronic instability of the elbow joint is one of the urgent problems in modern traumatology due to the fact that the standard tactics of managing patients with traumatic injuries of the elbow joint due to dislocation, which amounts to its elimination, immobilization of the upper limb and subsequent development of movements in the joint, most often does not take into account damage to specific soft tissue structures. With untimely treatment for qualified help, with late or unsuccessful attempts to eliminate dislocation of the bones of the forearm, less often with chronic traumatization of the ligamentous apparatus of the elbow joint during some types of occupation, one of the most unpleasant complications may form, namely, chronic instability. This article discusses the main types of chronic instability of the elbow joint, analyzes approaches to the management of patients with simple chronic instability. Despite the not very high occurrence of this pathology, the effectiveness of modern surgical treatment options aimed at reconstruction of the ligamentous apparatus of the elbow joint, the percentage of unsatisfactory results of treatment of simple chronic recurrent and persistent instability of the elbow joint remains high.

Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review

Objective

Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non‐professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non‐professional athletes and in non‐sport‐related trauma patients with MUCL lesions.

Methods

A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were “ulnar collateral ligament injury,” “elbow,” “surgery,” and “conservative treatment”. Patients were divided into three groups: patients who underwent conservative treatment (C‐group), surgical treatment (S‐group), and surgery after a failed conservative treatment (C&S‐group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan–Jobe Orthopaedic Clinic score (KJOC).

Results

A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C‐group had better results. Excellent results were found in 98.8% of the C‐group, in 88.1% of the S‐group, and in 87.7% of the C&S‐group. The complication rate in the C‐group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction.

Conclusions

There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.

Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up

The ulnar collateral ligament (UCL) is the primary restraint to valgus angulation at the elbow. Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing. Conventional treatment is reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation. Modern surgical techniques have led to renewed interest in repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. Here we present the first patient treated with this technique who achieved excellent recovery with return to college level American Football after 4 months. Five years later he has good elbow function and plays at the same level.

[Research progress of posteromedial rotatory instability of the elbow]

Objective

To summarize the research progress in posteromedial rotatory instability (PMRI) of the elbow joint.

Methods

The recent researches about the management of PMRI of the elbow joint from the aspects of pathological anatomy, biomechanics, diagnosis, and therapy were analyzed and summarized.

Results

The most important factors related to PMRI of the elbow joint are lateral collateral ligament complex (LCLC) lesion, posterior bundle of the medial collateral ligament complex (MCLC) lesion, and anteromedial coronoid fracture. Clinical physical examination include varus and valgus stress test of the elbow joint. X-ray examination, computed tomography, particularly three-dimensional reconstruction, are particularly useful to diagnose the fracture. Also MRI, arthroscopy, and dynamic ultrasound can assistantly evaluate the affiliated injury of the parenchyma. It is important to repair and reconstruct LCLC and MCLC and fix coronoid process fracture for recovering stability of the elbow joint. There are such ways to repair ligament injury as in situ repairation and functional reconstruction, which include direct suturation, borehole repairation, wire anchor repairation, and transplantation repairation etc. The methods for fixation of coronal fracture include screw fixation, plate fixation, unabsorbable suture fixation, and arthroscopy technology.

Conclusion

It is crucial that recovering the stability of the elbow joint and early functional exercise for the treatment of PMRI. Individual treatment is favorable to protect soft tissue, reduce surgical complications, and improve the functional recovery and the quality of life.