Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow

BACKGROUND

Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes.

METHODS

Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs).

RESULTS

Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes.

CONCLUSIONS

The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

A Novel Surgical Treatment Management Algorithm for Elbow Posterolateral Rotatory Instability (PLRI) Based on the Common Extensor Origin Integrity

Background: Here, we introduce a comprehensive treatment algorithm for posterolateral rotatory instability (PLRI) of the elbow, a condition affecting elbow mobility. We outline a diagnostic approach and a novel surgical management plan through the arthroscopic surgeon's point of view. Methods: The central focus of this management approach is the integrity of common extensor origin (CEO). High clinical suspicion must be evident to diagnose PLRI. Special clinical and imaging tests can confirm PLRI but sometimes the final confirmation is established during the arthroscopic treatment. The most appropriate treatment is determined by the degree of CEO integrity. Results: The treatment strategy varies with the CEO's condition: intact or minor tears require arthroscopic lateral collateral ligament imbrication, while extensive tears may need plication reinforced with imbrication or, in cases of retraction, a triceps tendon autograft reconstruction of the lateral ulnar collateral ligament alongside CEO repair. These approaches aim to manage residual instability and are complemented using a tailored rehabilitation protocol to optimize functional outcomes. Conclusion: PLRI is a unique clinical condition and should be treated likewise. This algorithm offers valuable insights for diagnosing and treating PLRI, enhancing therapeutic decision-making.

No difference in torque load to failure between split anconeus fascia transfer and autograft palmaris longus tendon for reconstruction of the lateral ulnar collateral ligament

Background

The split anconeus fascia transfer (SAFT) is an option for reconstruction of the lateral ulnar collateral ligament (LUCL) in chronic posterolateral rotatory instability (PLRI) of the elbow with potential advantages of using only local tissue within the surgical exposure and not requiring ulnar fixation. This study aimed to assess SAFT strength compared to a traditional free graft reconstruction in a PLRI biomechanical model.

Methods

To measure biomechanical strength, eight cadaveric upper extremity pairs were utilized. Within each pair, one specimen was randomly assigned to LUCL reconstruction with autograft palmaris longus and the other to SAFT reconstruction. Torque load to failure was assessed on a load frame with the elbow in 30 degrees of flexion, 5 degrees of valgus, and 25 N axial load as the elbow was brought into external rotation. Torque load to failure was compared between the two reconstruction techniques.

Results

No difference was found in the torque load to failure between SAFT specimens compared to palmaris longus autograft specimens (mean 14.6 ± 4.4 Nm vs. mean 11.3 ± 3.9 Nm; P = .16).

Discussion

In this biomechanical study, the SAFT LUCL reconstruction provided torque load to failure similar to that of the traditional technique. These findings suggest that the SAFT technique warrants continued study as a biomechanically sound option for LUCL reconstruction in the setting of elbow PLRI.

Lateral ulnar collateral ligament reconstruction enhancing secondary stabilizers in chronic PLRI of the elbow provides good to excellent clinical results with no recurrent instability

PURPOSE

The adopted treatment for chronic elbow PLRI is lateral ulnar collateral ligament reconstruction. However, the most frequently reported complication after primary reconstruction is recurrent instability - up to 25 %. It was thus hypothesized that enhancing the secondary stabilizers will provide successful results with a lower rate of recurrent instability in comparison to techniques with primary reconstruction only. This study aimed to demonstrate a novel surgical technique involving secondary stabilizers.

METHODS

In this retrospective study of 29 cases with chronic PLRI the mean duration of symptoms was 39.6 ± 4.9 months. The mean age was 47.9 years with mainly male patients. The surgeries were performed by one senior surgeon at a single institution. The Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) were recorded.

RESULTS

The mean follow-up was 36.8 ± 7.7 months. The MEPS score improved significantly from 59.8 ± 13.1 to 84.7 ± 7.6 (p < 0.001). 23/29 patients (79.2 %) had converted to good and excellent results (MEPS >75 points). The DASH score improved from 40.8 ± 4.6 to 20.9 ± 7.2 (p < 0.001). The total complication rate was 10.3 % (N = 3). No recurrent instability was recorded in comparison to 12.2 % for primary reconstruction only, as reported in the literature (p < 0.05).

CONCLUSION

Enhancing the secondary stabilizers by utilizing an adjacently located autograft provided good and excellent results with no recurrent instability. This novel surgical procedure is easy to reproduce and provides a safe and reliable alternative in cases of chronic PLRI when compared to techniques with primary reconstruction only.

Preoperative and operative risk factors for failed lateral collateral ligament reconstruction

Repair or reconstruction of the lateral collateral ligament (LCL) using autograft or allograft is a well-accepted treatment of posterolateral rotatory instability. The prevalence and causes for failure of LCL reconstruction are not well documented in the literature. Any approach to the assessment and management of failed LCL reconstruction must begin with understanding the risk factors for failure in the first place. Such understanding would likely make many failures preventable as well. In our experience, there are a number of identifiable preoperative risk factors concerning bony and/or soft tissue constraints for failure of LCL reconstruction. There are also operative factors such as tunnel and graft placement as well as excessive lateral condyle stripping that play a role in risk of failure. This report is an attempt to provide a systematic approach to identifying and managing the preoperative and operative risk factors. Further studies are warranted to determine the indications for, and success rates of surgical intervention in managing these risk factors.

Use of Triceps Tendon and Paratenon Composite Graft for Extensor Tendon Reconstruction in the Hand: A Case Report

An extensor tendon defect in the hand requires reconstruction to restore extension. We report a 44-year-old woman with a 24-mm extensor tendon defect of the middle finger over the dorsum of the hand that was reconstructed using a composite graft consisting of the triceps tendon and paratenon. This composite graft from the posterior aspect of the distal arm is simple, safe and may be considered in extensor tendon reconstruction. Level of Evidence: Level V (Therapeutic).