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Breulmann FL, Lappen S, Ehmann Y, Bischofreiter M, Lacheta L, Siebenlist S. Treatment strategies for simple elbow dislocation - a systematic review. BMC Musculoskelet Disord 2024; 25:148. [PMID: 38365699 PMCID: PMC10874000 DOI: 10.1186/s12891-024-07260-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/04/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Current treatment concepts for simple elbow dislocation involve conservative and surgical approaches. The aim of this systematic review was to identify the superiority of one treatment strategy over the other by a qualitative analysis in adult patients who suffered simple elbow luxation. STUDY DESIGN A systematic review in accordance with the PRISMA guidelines and following the suggestions for reporting on qualitative summaries was performed. A literature search was conducted using PubMed and Scopus, including variations and combinations of the following keywords: elbow, radiohumeral, ulnohumeral, radioulnar, luxation, and therapy. Seventeen studies that performed a randomized controlled trial to compare treatment strategies as conservative or surgical procedures were included. Reviews are not selected for further qualitative analysis. The following outcome parameters were compared: range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand outcome measure (Quick-DASH), recurrent instability, pain measured by visual analog scale (VAS) and time to return to work (RW). RESULTS Early mobilization after conservative treatment strategies showed improved ROM compared to immobilization for up to 3 weeks after surgery with less extension deficit in the early mobilization group (16° ± 13°. vs. 19.5° ± 3°, p < 0.05), as well as excellent clinical outcome scores. Surgical approaches showed similar results compared to conservative treatment, leading to improved ROM (115 vs. 118 ± 2.8) and MEPS: 95 ± 7 vs. 92 ± 4. CONCLUSION Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. The surgical procedure provides similar outcomes compared to conservative treatment regarding MEPS and ROM for patients with slight initial instability in physical examination and radiographs. People with red flags for persistent instability, such as severe bilateral ligament injuries and moderate to severe instability during initial physical examination, should be considered for a primary surgical approach to prevent recurrent posterolateral and valgus instability. Postoperative early mobilization and early mobilization for conservatively treated patients is beneficial to improve patient outcome and ROM.
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Affiliation(s)
- Franziska Lioba Breulmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Lappen
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Yannick Ehmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Martin Bischofreiter
- Department of Orthopedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Linz, 4010, Austria
- Department of Orthopedics and Traumatology, Klinik Diakonissen Schladming, Schladming, 8970, Austria
| | - Lucca Lacheta
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany.
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Hinz M, Geyer S, Winden F, Braunsperger A, Kreuzpointner F, Irger M, Imhoff AB, Mehl J. Clinical and biomechanical outcomes following patellar tendon repair with suture tape augmentation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3569-3576. [PMID: 37233797 PMCID: PMC10651537 DOI: 10.1007/s00590-023-03572-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Patellar tendon ruptures (PTR) occur predominantly in middle-aged patients following indirect trauma. The aim of this study was to quantify the short-term results using a suture tape augmentation technique for the repair of PTR. METHODS All consecutive patients with acute (< 6 weeks) PTR who underwent suture tape augmentation between 03/2014 and 11/2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Visual Analog Scale (VAS) for pain, Tegner Activity Scale (TAS) and return to sport rates, Lysholm score, International Knee Documentation Committee subjective knee form (IKDC) as well as Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, a standardized clinical examination and an isometric strength evaluation of knee extension and flexion were performed. It was hypothesized that high return to sport rates and good functional outcome would be observed and that the majority of patients would not present with a severe (> 20%) knee extension strength deficit when compared to the contralateral side. RESULTS A total of 7 patients (mean age 37.0 ± SD 13.5 years; 6 male/1 female) were available for final assessment at a median follow-up of 17.0 (25-75% IQR 16.0-77.0) months. Three injuries occurred during ball sports, two injuries occurred during winter sports, and one injury each occurred during a motorcycling and skateboarding accident. The average time between trauma and surgery was 4.7 ± 2.6 days. At follow-up, patients reported little pain (VAS: 0 [0-0.4]). Return to sport was possible for all patients 8.9 ± 4.0 months postoperatively at a high level (TAS: 7.0 [6.0-7.0]). Five patients (71.4%) returned to the preinjury level of play, and 2 (28.6%) did not return to the preinjury level of play. Patient-reported outcome measures were moderate to good (Lysholm score: 80.4 ± 14.5; IKDC: 84.2 ± 10.6; KOOS subscales: pain 95.6 ± 6.0, symptoms 81.1 [64.9-89.1], activities of daily living 98.5 [94.1-100], sport and recreation function 82.9 ± 14.1 and knee-related quality of life 75.9 ± 16.3). All patients were very satisfied (57.1%) or satisfied (42.9%) with the postoperative result. No postoperative complications were reported. Strength measurements revealed a severe knee extension deficit in 3 patients (42.9%), but no significant deficit of isometric knee extension or flexion strength in comparison with the contralateral side was observed overall (p > 0.05). CONCLUSION Suture tape augmentation in acute PTR repair leads to good functional outcome without major complications. Although a severe knee extension strength deficit may occur in some patients postoperatively, an excellent return to sports rate and high patient satisfaction can be expected nonetheless. LEVEL OF EVIDENCE Retrospective cohort study; III.
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Affiliation(s)
- Maximilian Hinz
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Stephanie Geyer
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Felix Winden
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Alexander Braunsperger
- Department of Sport and Health Sciences, Prevention Center, Technical University of Munich, Munich, Germany
| | - Florian Kreuzpointner
- Department of Sport and Health Sciences, Prevention Center, Technical University of Munich, Munich, Germany
| | - Markus Irger
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Julian Mehl
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
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Barco R, Gonzalez-Escobar S, Acerboni-Flores F, Vaquero-Picado A. Acute elbow dislocation: a critical appraisal of the literature. JSES Int 2023; 7:2560-2564. [PMID: 37969505 PMCID: PMC10638560 DOI: 10.1016/j.jseint.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background The purpose of this study was to perform a narrative review of acute elbow dislocation (AED). There are certain aspects of the management of AED that are controversial, including type and length of immobilization, indications for surgery, type of surgery, and new evidence available. Material and methods A literature search was performed using MEDLINE and Embase databases for studies regarding AED. Preference was given to studies according to their level of evidence. Studies regarding the outcome of conservative and surgical treatment, including patient-reported outcomes, complications, and conversion to stabilization or revision surgery were included. Results We found only 1 level I study and 3 level II randomized clinical trials. The rest consisted of level III-V evidence. Conservative care continues to be the standard of care for stable AEDs. Shorter immobilization periods are favored when possible. A consensus definition of an unstable elbow still needs to be improved. Unstable simple elbow dislocation may benefit from surgical intervention with different techniques showing similar outcomes. Advances in surgical procedures and suture designs, including tapes, and ligament augmentation, need to prove their role in managing acute elbow instability. Conclusion There is a need for higher quality studies after the reduction of an AED, including discerning the outcome of specific patterns of injury and particular groups of patients like high-level athletes or people with preoperative laxity. Comparison between different surgical techniques is warranted, including arthroscopic techniques and types of ligament augmentation to promote early motion and reduce postoperative stiffness.
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Affiliation(s)
- Raul Barco
- Upper Limb Unit, Hospital Universitario La Paz, Fundación Instituto de Investigación IDIPaz, Madrid, Spain
| | | | - Francesc Acerboni-Flores
- Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Atónoma de Barcelona, Sabadell, Spain
| | - Alfonso Vaquero-Picado
- Upper Limb Unit, Hospital Universitario La Paz, Fundación Instituto de Investigación IDIPaz, Madrid, Spain
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Heifner JJ, Mercer DM. Improved Understanding of Traumatic Complex Elbow Instability. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00014. [PMID: 37747701 PMCID: PMC10519515 DOI: 10.5435/jaaosglobal-d-23-00041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 09/26/2023]
Abstract
Recent advancements in surgical treatment have improved clinical results in complex traumatic elbow injury. There is increasing recognition that conservative treatment and inadequate surgical fixation carry high risk of substantial morbidity in many of these cases. Recent literature displays improved outcomes in complex elbow instability, in part, because of a more complete comprehension of the injury patterns and fixation methods. Prompt surgical management with stable internal fixation, which permits immediate postoperative mobilization, has been a consistent variable across the reports leading to more satisfactory outcomes. This applies to both acute and chronic cases.
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Affiliation(s)
- John J. Heifner
- From the Miami Orthopaedic Research Foundation, Miami, FL (Dr. Heifner), and the University of New Mexico Department of Orthopaedics and Rehabilitation, Albuquerque, NM (Dr. Mercer)
| | - Deana M. Mercer
- From the Miami Orthopaedic Research Foundation, Miami, FL (Dr. Heifner), and the University of New Mexico Department of Orthopaedics and Rehabilitation, Albuquerque, NM (Dr. Mercer)
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Hunt KJ, Hewitt MA, Buckley SE, Bartolomei J, Myerson MS, Hogan MV, Laf Committee ISAKOS. Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons. J ISAKOS 2023; 8:239-245. [PMID: 37100118 DOI: 10.1016/j.jisako.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/30/2022] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p = 0.005). CONCLUSION LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Kenneth J Hunt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA.
| | - Michael A Hewitt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Sara E Buckley
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Jonathan Bartolomei
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Mark S Myerson
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - MaCalus V Hogan
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - I S A K O S Laf Committee
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
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Klute L, Henssler L, Alt V, Kerschbaum M. [Elbow joint dislocation : Frequent concomitant injuries and current treatment concepts]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:405-418. [PMID: 37081090 PMCID: PMC10160183 DOI: 10.1007/s00113-023-01318-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/22/2023]
Abstract
Dislocations of the elbow joint are among the most prevalent dislocation injuries in the human body after shoulder joint dislocations and represent a challenge in the clinical routine because of the concomitant injuries and complications. They predominantly affect young adults who become injured during athletic or daily activities. A distinction is generally made between a simple elbow dislocation and a dislocation fracture of the elbow; however, a uniform classification or treatment algorithm has not yet been established, especially for simple elbow dislocations with associated ligamentous, muscular and capsular concomitant injuries. Due to this and the complexity of this injury, a standardized approach is needed to initiate the optimal treatment at an early stage and to correctly select the narrow treatment pathway between impending chronic instability and elbow stiffness.
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Affiliation(s)
- Lisa Klute
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
| | - Leopold Henssler
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Maximilian Kerschbaum
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
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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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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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[Augmented primary sutures "internal bracing" following ligamentous elbow dislocation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:43-55. [PMID: 36469104 PMCID: PMC9895014 DOI: 10.1007/s00064-022-00788-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/23/2021] [Accepted: 09/25/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Aim of surgical treatment is the primary stabilization of the unstable elbow following a ligamentous elbow dislocation. INDICATIONS Ligamentous elbow dislocations are typically accompanied by injuries to the surrounding musculature and collateral ligaments of the elbow joint. Surgical treatment is indicated in case of failure of nonoperative therapy, i.e., when a dislocation can only be prevented in immobilization > 90° and pronation of the elbow or an active muscular centering of the elbow fails after 5-7 days. CONTRAINDICATIONS Contraindications for a solely "internal bracing" augmented primary suture are generally in the case of accompanying bony injuries in elbow dislocations, extensive soft-tissue injuries, and septic arthritis of the elbow. SURGICAL TECHNIQUE The augmented primary suture of the elbow is performed using both a lateral (Kocher or Kaplan) and medial (FCU split) approach to the elbow. After reduction of the elbow, the collateral ligaments are first augmented with high-strength polyethylene suture and fixed in the distal humerus together with another high-strength polyethylene augmentation suture. The extensors and flexors are then fixed to the medial and lateral epicondyle, respectively, using suture anchors. POSTOPERATIVE MANAGEMENT The aim of the postoperative management is early functional exercise of the elbow. The elbow is placed in an elbow brace to avoid varus and valgus load. RESULTS Between August 2018 and January 2020, a total of 12 patients were treated with an augmented primary suture following unstable ligamentous elbow dislocation. After a mean follow-up of 14 ± 12.7 months, the mean Mayo Elbow Performance Score was 98.5 points with a mean functional arc of 115°. None of the patients reported a recurrent dislocation or persistent instability of the elbow.
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Ott N, Harland A, Lanzerath F, Leschinger T, Hackl M, Wegmann K, Müller LP. Locking suture repair versus ligament augmentation-a biomechanical study regarding the treatment of acute lateral collateral ligament injuries of the elbow. Arch Orthop Trauma Surg 2023; 143:857-863. [PMID: 35064826 PMCID: PMC9925465 DOI: 10.1007/s00402-022-04337-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 01/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lateral collateral ligament (LCL) tears are frequently observed in fractures and dislocations of the elbow. Recent biomechanical evidence suggests that additional ligament augmentation may improve repair stability. The aim of this biomechanical in-vitro study was to compare the resistance of a locking suture repair of the LCL with a ligament augmentation technique. MATERIAL AND METHODS Eight fresh frozen cadaveric elbows were evaluated for stability against varus/posterolateral rotatory forces (3 Nm). A strain gauge (µm/m; negative values) was placed at the origin and insertion of the lateral ulnar collateral ligament (LUCL) and cyclic loading was performed for 1000 cycles. We analyzed three distinct scenarios: (A) native LCL, (B) locking transosseou suture repair of the LCL, (C) simple LCL repair with additional ligament augmentation of the LUCL. RESULTS The mean measured strain was - 416.1 µm/m (A), - 618 µm/m (B) and - 288.5 µm/m (C) with the elbow flexion at 90°; the strain was significantly higher in scenario B compared to C (p = .01). During the cyclic load (1000) the mean measured strain was - 523.1 µm/m (B) and - 226.3 µm/m (C) with the elbow flexion at 60°; the strain was significantly higher in scenario B compared to C (p = .01). No significant difference between the first and the last cycles was observed (p = .09; p = .07). One failure of the LCL repair was observed after 1000 cycles; none of the ligament augmentations failed. CONCLUSION Ligament augmentation (C) provides higher resistance compared to the native LCL (A) and to the locking suture repair technique (B). Both techniques, however, hold up during 1000 cycles. While ligament augmentation might enhance the primary stability of the repair, future clinical studies have to show whether this increase in resistance leads to negative effects like higher rates of posttraumatic elbow stiffness. LEVEL OF EVIDENCE Basic science study, biomechanics.
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Affiliation(s)
- Nadine Ott
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
| | - Arne Harland
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937 Cologne, Germany
| | - Fabian Lanzerath
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937 Cologne, Germany
| | - Tim Leschinger
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937 Cologne, Germany
| | - Michael Hackl
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937 Cologne, Germany
| | - Kilian Wegmann
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937 Cologne, Germany
| | - Lars Peter Müller
- Department of Trauma and Orthopedic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937 Cologne, Germany
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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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12
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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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13
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Sachinis NP, Vasiadis I, Yiannakopoulos CK, Givissis P. Modified Graft Loop Technique Augmented With Nonabsorbable Suture Tape for Chronic Elbow Dislocation. Tech Hand Up Extrem Surg 2022; 26:202-207. [PMID: 35696618 DOI: 10.1097/bth.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The task of achieving a good clinical outcome on patients with chronic elbow dislocation is arduous. Any stabilization method used should be robust enough in order to allow for early elbow motion. Immobilization of the elbow for a prolonged time period may lead to stiffness and heterotopic ossification. Several methods of ligament reconstruction have tried to address the global instability that is present in such scenarios. We describe a technique of reconstructing both bands of the medial ligament, and the lateral ulnar collateral ligament of the elbow, by using a looped tendon graft and reinforcing the lateral side with nonabsorbable tape and anchors. The graft is passed as a loop once through the humerus and ulna, recreating the anterior portion of the medial collateral ligament and the lateral ulnar collateral ligament. Then the lateral side is augmented with the tape and anchors and the loop is fixed. Lastly, the medial tail of the graft is used in order to recreate the posterior part of the medial ligament. This technique uses a single graft along with nonabsorbable tape and anchors to make a robust construct that will withstand early range of motion, without jeopardizing elbow stability. Potential complications include damage to the ulnar nerve, infection, elbow stiffness, or persistent instability in complex cases with bone involvement.
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Affiliation(s)
- Nikolaos P Sachinis
- Department of First Orthopaedic, Georgios Papanikolaou Hospital, Aristotle University, Thessaloniki
| | - Ioannis Vasiadis
- Department of First Orthopaedic, Georgios Papanikolaou Hospital, Aristotle University, Thessaloniki
| | | | - Panagiotis Givissis
- Department of First Orthopaedic, Georgios Papanikolaou Hospital, Aristotle University, Thessaloniki
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14
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Ozdag Y, Luciani AM, Delma S, Baylor JL, Foster BK, Grandizio LC. Learning Curve Associated With Operative Treatment of Terrible Triad Elbow Fracture Dislocations. Cureus 2022; 14:e27156. [PMID: 36039230 PMCID: PMC9394747 DOI: 10.7759/cureus.27156] [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] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose: To assess the outcomes of operatively treated terrible triad (TT) elbow injuries for a single surgeon at the start of clinical practice. We aimed to define postoperative patient reported outcome measures (PROMs), range of motion (ROM), and complications during the period immediately following fellowship training, in order to describe the learning process for surgical treatment of TT. Methods: All operatively treated TTs from 2017 to 2020 were included. All cases were performed by a single, fellowship-trained upper-extremity surgeon and represented a consecutive series at the start of clinical practice. Baseline demographics, injury characteristics, and surgical details were recorded for each case. PROMs [QuickDisability of arm, shoulder, and hand (DASH) and (visual analog scale) pain scale], ROM, and complications were recorded at the time of final follow-up. A perioperative glucocorticoid protocol was used in all cases without diabetes. Results: There was a total of 21 included TT cases with a mean follow-up of 20 months. The operative time averaged 89 min for the first 10 cases and 83 min for the subsequent 11 cases. The mean QuickDASH and VAS pain score at final follow-up were 19 and 2.3, respectively. The mean flexion-extension arc was 122° and two cases (9%) had < 100° arc of motion. The mean pronation-supination arc was 145°. Three cases (14%) had a postoperative complication, all of which underwent reoperation. Of the 21 included cases, these reoperations represented cases #1, #14, and #17 respectively. Conclusions: Upper-extremity surgeons at the start of clinical practice may be able to achieve outcomes similar to more experienced surgeons for operatively treated TT elbow fracture dislocations. There does not appear to be a substantial “learning curve” after fellowship training with respect to PROMs, complication rates, or operative time associated with surgical treatment of TT elbow injuries.
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15
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Catapano M, Pupic N, Multani I, Wasserstein D, Henry P. Early functional mobilization for non-operative treatment of simple elbow dislocations: a systematic review. Shoulder Elbow 2022; 14:211-221. [PMID: 35265188 PMCID: PMC8899322 DOI: 10.1177/1758573220957631] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE This systematic review aims to elucidate a non-operative rehabilitation program that optimizes recovery based on published approaches and outcomes. METHODS Searches of four databases from inception to 1 January 2020 were performed to identify clinical studies addressing the non-operative management of simple elbow dislocations. RESULTS Of 2435 studies that were eligible for title screen, 15 studies satisfied inclusion criteria. Three randomized control studies demonstrated that early mobilization expedited the return of range of motion, function and return to work or activities, however, resulted in increased pain within the six-week rehabilitation period compared to Plaster of Paris casting for 21 days. Patients returned to work sooner after early mobilization (10 vs. 18 days; p = 0.02) compared to Plaster of Paris casting. In all studies, early mobilization resulted in similar re-dislocation rates of 1.3% (3/237) versus 2.2% (12/549) in those with Plaster of Paris casting as well as lower incidence of heterotopic ossification (36% vs. 54%). No significant differences between rehabilitation protocols were determined; however, the large majority of recent papers utilized rehabilitation protocols. CONCLUSION Early mobilization of simple elbow dislocations results in early return of Range-of-Motion, function and return to work with no increase in complication rates; however, increased pain during the rehabilitation period.
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Affiliation(s)
- Michael Catapano
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada,Michael Catapano, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON, Canada M5G 2A2.
| | - Nikola Pupic
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Institute of Bio-Materials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada,Toronto Rehabilitation Institute, Toronto, ON, Canada
| | | | - David Wasserstein
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Orthopaedic Rehabilitation Institute, Toronto, ON, Canada
| | - Patrick Henry
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Orthopaedic Rehabilitation Institute, Toronto, ON, Canada
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16
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Otto A, McCarthy MBR, Baldino JB, Mehl J, Muench LN, Tamburini LM, Uyeki CL, Arciero RA, Mazzocca AD. Biologically Augmented Suture for Ligament Bracing Procedures Positively Affects Human Ligamentocytes and Osteoblasts In Vitro. Arthroscopy 2022; 38:498-505. [PMID: 34785293 DOI: 10.1016/j.arthro.2021.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose was to evaluate the response of human ligamentocytes and osteoblasts after biological augmentation with thrombin, concentrated bone marrow aspirate (cBMA), or platelet-rich plasma (PRP) on two different types of nonresorbable flat braided suture used for ligament bracing. METHODS Uncoated (U) and collagen-coated (C) flat braided suture material was augmented with either thrombin (T), cBMA (B), PRP (P), or a combination of these three (A), while platelet-poor plasma was used as a source for fibrin (F) in each assay. Previously cultured ligamentocytes and osteoblasts were added with a defined density and assayed after the required time period for adhesion, proliferation, and alkaline phosphatase activity. RESULTS Biological augmentation of uncoated [(UFT, UFBT, UFA; P < .001), (UFPT; P = .017)] and collagen-coated suture (CFT, CFPT, CFBT, CFA; P < .001) led to a significantly higher ligamentocyte adhesion. Significantly higher adhesion was also observed for osteoblasts (UFT, UFPT, UFBT, UFA; P < .001; CFT, CFPT, CFBT, CFA; P < .001). Similarly, ligamentocyte proliferation was significantly higher [(UFT, UFPT, UFA; P = .009), (UFBT; P = .001), (CFT; P = .009), (CFBT; P = .001), and (CFA; P = .01)]. Osteoblasts showed significantly higher proliferation as well [(UFT, UFPT, UFA; P = .002), (UFBT; P = .001); (CFT: P = .003), and (CFPT, CFBT, CFA; P = .001)]. Augmentation with thrombin, PRP, and BMA for uncoated (UFT; P = .006, UFPT; P = .035, UFBT; P = .001) and BMA for coated suture (CFBT; P = .027) led to significantly higher alkaline phosphatase activity. CONCLUSION Biological enhancement of suture used for ligament bracing significantly increased ligamentocyte and osteoblast adhesion and proliferation, as well as alkaline phosphatase activity of osteoblasts in an in vitro model. After biological augmentation, cellular adhesion, proliferation, and alkaline phosphatase activity changed up to 1,077%, 190%, and 78%, respectively. Furthermore, no overall superiority between uncoated or collagen-coated suture material was observed for cellular adhesion, proliferation, or alkaline phosphatase activity. CLINICAL RELEVANCE This study provides in vitro data on a new treatment concept of biologic augmentation for acute ligamentous lesions treated with ligament bracing that has not been widely described. This concept may improve the healing of injured ligaments, in addition to providing immediate biomechanical stabilization.
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Affiliation(s)
- Alexander Otto
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany.
| | - Mary Beth R McCarthy
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Joshua B Baldino
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Julian Mehl
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lukas N Muench
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lisa M Tamburini
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Colin L Uyeki
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Robert A Arciero
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
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17
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Lee SJ, Bedford BB, Kim AH, Rahman OF, Zbeda RM. Elbow Osteochondral Allograft Transplantation and Lateral Ulnar Collateral Ligament Repair with Internal Brace: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00024. [PMID: 35050925 DOI: 10.2106/jbjs.cc.21.00615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 23-year-old woman with an Osborne-Cotterill lesion and posterolateral rotatory instability (PLRI) of the elbow was treated with osteochondral allograft transplantation (OCA) and lateral ulnar collateral ligament (LUCL) repair with internal brace. Two years after surgery, she reported resolution of pain and returned to all recreational activities. She reported no mechanical symptoms and no episodes of postoperative instability. CONCLUSION PLRI can present with an Osborne-Cotterill lesion in addition to LUCL injury. The purpose of this case report was to describe the use of OCA to manage bony defects in the capitellum in addition to LUCL repair for patients with PLRI.
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Affiliation(s)
- Steven J Lee
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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18
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Repair of Acute Patellar Tendon Rupture Using an Internal Brace Technique. Case Rep Orthop 2021; 2021:1086625. [PMID: 34840838 PMCID: PMC8616684 DOI: 10.1155/2021/1086625] [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: 08/03/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
Acute patellar tendon rupture is a serious injury, resulting in the disruption of the knee extensor mechanism. Many authors recommend augmented repairs of patellar tendon ruptures to allow early active rehabilitation. An internal brace technique, which is a ligament augmentation using high-strength suture tape and knotless anchors, has been used as augmentation for the primary tendon or ligament injury. A case of acute patellar tendon rupture in a Judo player, who was successfully treated with primary repair and augmentation using an internal brace technique, is presented. In this case, the patient regained full function of the knee and returned to full sports activities postoperatively. An internal brace technique provides biomechanical stability of the repaired tendon without donor site morbidity and could be an effective procedure for the treatment of acute patellar tendon rupture.
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19
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Anvari A, Fathi A, Bolia IK, Piatt E, Hasan LK, Haratian A, Weber AE, Petrigliano FA. Utilization of Internal Bracing in Elbow Medial UCL Stabilization: From Biomechanics to Clinical Application and Patient Outcomes. Orthop Res Rev 2021; 13:201-208. [PMID: 34703328 PMCID: PMC8541765 DOI: 10.2147/orr.s321890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.
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Affiliation(s)
- Andre Anvari
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Amir Fathi
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric Piatt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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20
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Lan R, Piatt ET, Bolia IK, Haratian A, Hasan L, Peterson AB, Howard M, Korber S, Weber AE, Petrigliano FA, Tan EW. Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211045978. [PMID: 35097476 PMCID: PMC8532228 DOI: 10.1177/24730114211045978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.
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Affiliation(s)
- Rae Lan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric T. Piatt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander B. Peterson
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Mark Howard
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Shane Korber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric W. Tan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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21
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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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22
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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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Early Rehabilitation after Surgical Repair of Medial and Lateral Collateral Elbow Ligaments: A Report of Three Cases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176133. [PMID: 32846892 PMCID: PMC7503836 DOI: 10.3390/ijerph17176133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 12/03/2022]
Abstract
Elbow ligament injuries are commonly caused by overuse; degeneration; and trauma; such as from a fall or collision. The purpose of this study was to present the results of three cases involving patients undergoing early rehabilitation after surgical treatment for complex injury of the elbow medial collateral ligament (MCL) and lateral collateral ligament (LCL). Two patients were non-athlete middle-aged women and one was a recreational judo player. Surgery was performed through open incision or arthroscopically. Rehabilitation consisted of range of motion (ROM) exercise; muscle strength restoration; and neuromuscular training. Passive ROM exercise and isometric strength exercise began at 7 days; isotonic strength training at 6 weeks; and neuromuscular training at 3 months after operation. Center- and home-based methods of exercise participation were combined. Center-based exercises were performed 1–2 times per week for the first 6 months and 1–2 times per month for the next 6 months. Patients also performed home-based and self-monitoring exercise. Examinations included ROM using a goniometer; muscle strength test using isokinetic equipment; and Oxford elbow score. In the six months after surgery; flexion ROM was 130° for Case A (health side 145°), 110° for Case B (health side 145°), and 135° for Case C (health side 135°); grip strength was restored to 13 kg (health side 28 kg), 16 kg (health side 25 kg), and 38 kg (health side 52 kg); and isokinetic flexion strength was improved to 30 Nm (health side 58 Nm), 21 Nm (health side 50 Nm), and 72 Nm (health side 80 Nm), respectively. In conclusion; patients who underwent early rehabilitation recovered ROM and muscle strength and returned to daily activity without any side effects. This study showed that patients with elbow MCL and LCL injuries took approximately 3 months to recover meaningful ROM; approximately 6 months to recover muscle strength; and 4–8 months to play light recreational sports. In addition; it took patients 6 weeks to return to their daily activities and 6 months to improve questionnaire scores in their function and pain during daily activity. In follow-up two years after surgery; all three patients had full ROM and muscle strength within 10% of the healthy side
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Bachmaier S, Wijdicks CA, Verma NN, Higgins LD, Greiner S. Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair Stabilization. Am J Sports Med 2020; 48:1884-1892. [PMID: 32453667 DOI: 10.1177/0363546520921174] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques. HYPOTHESIS Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament. STUDY DESIGN Controlled laboratory study. METHODS We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min). RESULTS Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness (P < .001) and residual torque (P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair (P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair (P = .766). CONCLUSION Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow. CLINICAL RELEVANCE We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.
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Hogg-Cornejo V, Hunt KJ, Bartolomei J, Rullkoetter PJ, Myers C, Shelburne KB. Normal Kinematics of the Syndesmosis and Ankle Mortise During Dynamic Movements. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420933007. [PMID: 35097392 PMCID: PMC8697205 DOI: 10.1177/2473011420933007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Documenting the healthy articulation of the syndesmosis and talocrural joints, and measurement of 3D medial and lateral clear spaces may improve diagnostic and treatment guidelines for patients suffering from severe syndesmotic injury or chronic instability. This study aimed to define the range of motion (ROM) and displacement of the fibula and talus during static and dynamic activities, and measure the 3D movement in the tibiofibular (syndesmosis) and medial clear space. Methods: Six healthy volunteers performed dynamic weightbearing motions on a single-leg: heel-rise, squat, torso twist, and box jump. Participants posed in a nonweightbearing neutral stance as well as weightbearing neutral standing, plantarflexion, and dorsiflexion. High-speed stereoradiography measured 3D rotation and translation of the fibula and talus throughout each task. Medial clear space and tibiofibular gap distances were measured under each condition. Results: Total ROM for the fibula was greatest in internal-external rotation (9.3 ± 3.5 degrees), and anteroposterior (3.3 ± 2.2 mm) and superior-inferior (2.5 ± 0.9 mm) translation, rather than lateral widening (1.7 ± 1.0 mm). The total rotational ROM of the talus was greatest in dorsiflexion-plantarflexion (34.7 ± 12.9 degrees) and internal-external rotation (15.0 ± 3.4 degrees). Single-leg squatting increased the lateral clear space (P = .045) and widened the medial tibiofibular joint, whereas single-leg heel-rises decreased the lateral clear space (P = .001) and widened the tibiotalar space. Gap spaces in the tibiofibular and medial clear spaces did not exceed 2.3 ± 0.9 mm and 2.7 ± 1.2 mm, respectively. Conclusion: These data support a potential shift in the clinical understanding of fibula displacements during dynamic activities and how implant device constructs might be developed to restore physiologic mechanics. Clinical Relevance: Syndesmosis stabilization and rehabilitation should consider restoration of normal physiologic rotation and translation of the fibula and ankle mortise rather than focusing solely on the restriction of lateral translation.
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Affiliation(s)
- Veronica Hogg-Cornejo
- Center for Orthopaedic Biomechanics, Department of Mechanical and Materials Engineering, The University of Denver, Denver, CO, USA
| | - Kenneth J. Hunt
- Department of Orthopedic Surgery, The University of Colorado, Denver, CO, USA
| | - Jonathan Bartolomei
- Department of Orthopedic Surgery, The University of Colorado, Denver, CO, USA
| | - Paul J. Rullkoetter
- Center for Orthopaedic Biomechanics, Department of Mechanical and Materials Engineering, The University of Denver, Denver, CO, USA
| | - Casey Myers
- Center for Orthopaedic Biomechanics, Department of Mechanical and Materials Engineering, The University of Denver, Denver, CO, USA
| | - Kevin B. Shelburne
- Center for Orthopaedic Biomechanics, Department of Mechanical and Materials Engineering, The University of Denver, Denver, CO, USA
- Kevin B. Shelburne, PhD, Center for Orthopaedic Biomechanics Department of Mechanical and Materials Engineering, The University of Denver, 2155 East Wesley Ave, Denver, CO, 80208, USA.
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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: 10] [Impact Index Per Article: 2.5] [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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Komplikationsmanagement bei traumatischer Ellenbogeninstabilität. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00340-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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