Percutaneous lateral ulnar collateral ligament reconstruction

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability of the Elbow: A Systematic Review

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.

Biomechanical assessment of lateral ulnar collateral ligament repair and reconstruction with or without internal brace augmentation

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 90^o 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.

LUCL internal bracing restores posterolateral rotatory stability of the elbow

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reconstruction of the lateral ulnar collateral ligament of the elbow: a comparative biomechanical study

PURPOSE

Posterolateral rotatory instability (PLRI) of the elbow is the result of an insufficient lateral collateral ligament complex (LCLC). Single-bundle reconstruction of the lateral ulnar collateral ligament (LUCL) represents the standard treatment method for chronic PLRI. However, cases of recurrent instability after LUCL reconstruction have been reported. The dual-reconstruction procedure has been described to anatomically restore the LUCL as well as the radial collateral ligament (RCL). It was hypothesized that anatomic reconstruction of the LCLC provides increased stability compared with the conventional technique.

METHODS

Posterolateral rotatory displacement was assessed in eight fresh-frozen human elbows with a maximum load of 20 N. Data were obtained in 0°, 30°, 60°, 90° and 120° of elbow flexion for native specimens, dissected LCLC and three reconstruction methods: (1) single-bundle LUCL reconstruction, (2) single-bundle LUCL reconstruction with RCL augmentation, (3) dual-reconstruction technique (LUCL + RCL).

RESULTS

All reconstruction methods were able to sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion. There were no significant differences between the intact specimens and either reconstruction method. Dissection of the LCLC significantly increased PLRI compared with the other groups (p < 0.001).

CONCLUSION

The less invasive dual-reconstruction technique is confirmed as a safe procedure for anatomic LCLC reconstruction. Primary stability is equal, yet not superior to conventional LUCL reconstruction. Hence, this biomechanical study does not confirm the hypothesis that more anatomic reconstruction techniques could reduce the risk of recurrent instability when compared to conventional LUCL reconstruction.

Functional anatomy of the lateral collateral ligament of the elbow

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

Ligament reconstruction with a circumferential graft represents an innovative technique for treatment of multidirectional elbow instability. This biomechanical study compared the stability of the intact elbow joint with the circumferential graft technique and the conventional technique.

METHODS

Seven fresh frozen cadaveric elbows were evaluated for stability against valgus and varus/posterolateral rotatory forces (3 Nm) over the full range of motion. Primary stability was determined for intact specimens, after sectioning of the collateral ligaments, after applying the circumferential graft technique (box-loop), and after conventional collateral ligament reconstruction. Cyclic loading (1000 cycles) was performed to assess joint stability and stiffness of the native ligaments and the tendon grafts.

RESULTS

Primary stability of both reconstruction techniques was equal to the native specimens (P = .17-.91). Sectioning of the collateral ligaments significantly increased joint instability (P < .001). The reconstruction techniques provided equal stability after 1000 cycles (P = .78). Both were inferior to the intact specimens (P = .02). Cyclic loading caused a significantly lower increase in stiffness of the native ligaments compared with the tendon grafts of either reconstruction technique (P = .001-.008). Significantly better graft stiffness was retained with the circumferential graft technique compared with conventional reconstruction (P = .04).

CONCLUSION

Neither reconstruction technique fully reproduces the biomechanical profile of the native collateral ligaments. The circumferential graft technique seems to resist cyclic loading slightly better than the conventional reconstruction technique, yet both reconstruction techniques provide comparable stability.

Anatomic relations between the lateral collateral ligament and the radial head: implications for arthroscopic resection of the synovial fold of the elbow

PURPOSE

The purpose of this study was to determine the anatomic relationship between the radial head and the lateral collateral ligament (LCL) and when the LCL would be at risk of iatrogenic injury during arthroscopic resection of the synovial fold.

METHODS

Thirty-four formalin-fixed upper extremities were dissected. A projection of the LCL onto the radial head was marked with a needle. The percentage of the posterior border of the radial head overlaid by the LCL was digitally measured. A portion of the projection of the LCL was statistically correlated with the overall diameter of the radial head.

RESULTS

The overall diameter of the radial head was 21.2 mm ± 2.3. The proportionate projection of the medial border of the LCL onto the radial head was 5.3 ± 1.6 mm on average. The lateral 25 % of the radial head was overlaid by the LCL with a maximum value of 40 % on average. The inter- and intraobserver reliability showed very good accordance with the digital measurements (r > 0.8).

CONCLUSION

Care must be taken when performing a resection in the lateral 40 % of the radial head, whereas resection in the medial 60 % of the radial head appears to be safe. The LCL is an important stabiliser of the elbow joint, a lesion of which by undeliberate arthroscopic dissection may lead to joint instability. Iatrogenic injury to the LCL presumably can be prevented when respecting the given data.

LEVEL OF EVIDENCE

Experimental study.

Elbow lateral collateral ligament injuries

The lateral collateral ligament (LCL) of the elbow is a complex capsuloligamentous structure critical in stabilizing the ulnohumeral and radiocapitellar articulations. LCL injury can result in elbow instability, allowing the proximal radius and ulna to externally rotate away from the humerus as a supination stress is applied to the forearm. Elbow dislocation is the most common cause of LCL injury, followed by iatrogenic injury. LCL pathology resulting in late recurrent instability is rare but disabling. The diagnosis requires a high index of suspicion, detailed history, and focused physical examination maneuvers. Stress radiographs are often the most useful imaging modality. Despite controversy over the anatomy of the LCL complex and the relative importance of its component structures, treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes.