Ulnar Collateral Ligament (UCL) Reconstruction With Proximal Single-Tunnel Suspensory Fixation.

Ulnar collateral ligament (UCL) reconstruction of the medial elbow is considered to be the gold standard for treating valgus instability seen in overhead throwing athletes. The first UCL construction was performed by Frank Jobe in 1974, and this procedure has evolved over time to include multiple techniques that improved the biomechanical strength of the graft fixation and maximize the rate of return to athletic competition for these patients. The most common UCL-reconstruction technique used today is the docking technique. The purpose of this Technical Note is to describe our technique, including pearls and pitfalls, which combines the many advantages of the docking technique with a proximal single-tunnel suspensory fixation technique. This method allows for optimal tensioning of the graft, allowing for secure fixation that relies on metal implants as opposed to tying sutures over a proximal bone bridge.

Biomechanical comparison of ulnar collateral ligament reconstruction with single-tunnel proximal suspensory fixation versus modified docking technique.

Background: Despite technical advancement, elbow ulnar collateral ligament (UCL) reconstruction is a challenging procedure due to the limitations regarding the challenging tunnel placement and potential injury to the ulnar nerve. Furthermore, current techniques for reconstruction and repair are inferior functionally and biomechanically when compared to native UCL tissue. A modified docking technique using a single-tunnel proximal suspensory fixation may reduce complications and potentially provide a technique for UCL reconstruction that is biomechanically superior. Decreasing the number of bone tunnels decreases the number of places that bone tear through could occur. The purpose was to evaluate and compare the biomechanical performances for 2 elbow UCL reconstruction techniques: (1) standard docking technique (SD) and (2) a proximal single tunnel (PST) technique using a suspensory fixation. We hypothesized that the PST technique would be biomechanically superior to the SD technique. Methods: Twelve matched pairs of cadaveric elbows were dissected and fixed at 70 degrees for biomechanical testing. Gracilis grafts were used for a docking reconstruction and the modified reconstruction with a PST suspensory fixation. A cyclic valgus torque protocol was used to precondition specimens for either reconstruction technique and the ulnohumeral gapping was then assessed. Following gapping measurements, postsurgical specimens underwent a valgus rotation applied at a rate of 5°/s until the anterior band of the UCL failed or fracture occurred. Ultimate load to failure, stiffness, and mode of failure were recorded. Results: There were no statistical differences between the two groups. Mean rotational stiffness of the SD (2.3 ± 0.6 Nm/deg) compared to the PST (1.9 ± 0.7 Nm/deg) (P = .41) and mean ultimate failure torque of the SD (30.5 ± 9.2 Nm) compared to the PST (30.9 ± 8.6 Nm) (P = .86) were similar. There was also no statistically significant difference (P = .83) when comparing the native UCL ulnohumeral gapping (6.0 ± 2.0 mm) to the mean ulnohumeral gapping of the SD reconstruction (6.0 ± 1.8 mm). Conclusions: This study compares the biomechanical strength of elbow UCL reconstructions performed using the SP technique to that of a PST technique. Among all tested parameters, including ultimate failure torque, stiffness, and ulnohumeral gapping, there were no statistically significant differences between the 2 techniques.

Quantitative and Qualitative Analyses of the Lateral Ligamentous Complex and Extensor Tendon Origins of the Elbow: An Anatomic Study.

BACKGROUND: The lateral collateral ligament complex of the elbow is important in preventing posterolateral rotary instability of the elbow. Understanding the quantitative anatomy of this ligamentous complex and the overlying extensor musculature can aid in the surgical treatment of problems affecting the lateral side of the elbow. PURPOSE: To perform qualitative and quantitative anatomic evaluations of the lateral elbow ligamentous complex and common extensor muscle origins with specific attention to pertinent osseous landmarks. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 10 nonpaired, fresh-frozen human cadaveric elbows (mean age, 42.2 years; all male) were utilized. Quantitative analysis was performed using a 3-dimensional coordinate measuring device to quantify the location of pertinent bony landmarks, tendons, and ligament footprints of the lateral side of the elbow. RESULTS: The extensor carpi radialis brevis was the only humeral footprint found to cross the radiocapitellar joint line, extending a mean 5.9 mm (95% CI, 4.7-7.0) distal to the joint line. With the elbow in full extension, the lateral ulnar collateral ligament (LUCL) humeral footprint was found 7.1 mm (95% CI, 4.7-9.4) anterior and 9.8 mm (95% CI, 8.4-11.2) distal to the lateral epicondyle and 8.6 mm (95% CI, 7.5-9.7) proximal to the radiocapitellar joint line, while the radial collateral ligament humeral footprint was found 6.6 mm (95% CI, 5.5-7.8) anterior and 5.6 mm (95% CI, 4.0-7.2) distal to the lateral epicondyle and 12.7 mm (95% CI, 11.4-14.0) proximal to the radiocapitellar joint line. The center of the ulnar attachment of the LUCL was found 1.4 mm (95% CI, 0.7-2.1) anterior and 2.4 mm (95% CI, 1.2-6.0) proximal to the supinator tubercle and 24.4 mm (95% CI, 22.7-26.1) distal to the radiocapitellar joint line. The center of the ulnar attachment of the annular ligament was found to be 17.3 mm proximal to the supinator tubercle. CONCLUSION: The current study provides measured distances of LUCL and radial collateral ligament attachments in reference to clinically relevant landmarks, which can potentially aid surgeons in performing more anatomic reconstruction or repair of the lateral ligamentous complex of the elbow.

Elbow Fractures.

The elbow joint consists of the humeroulnar, humeroradial, and proximal radioulnar joints. Elbow stability is maintained by a combination of static and dynamic constraints. Elbow fractures are challenging to treat because the articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized and appropriately managed. Most elbow fractures are best treated operatively with restoration of normal bony anatomy and rigid internal fixation and repair and/or reconstruction of the collateral ligaments. Advanced imaging, improved understanding of the complex anatomy of the elbow joint, and improved fixation techniques have contributed to improved elbow fracture outcomes.

Can the impingement test predict outcome after arthroscopic subacromial decompression?

The impingement test, placement of local anesthetic in the subacromial space, is considered a useful tool in diagnosing impingement syndrome. The purpose of this study was to examine the predictive value of the impingement test with respect to outcome after arthroscopic subacromial decompression. Fifty-five patients who had a preoperative impingement test were evaluated at 3 and 12 months postoperatively. We noted 88% satisfactory results in patients in whom the impingement test was positive, with only 63% satisfactory results at 3 months and 60% satisfactory results at 12 months in patients in whom the impingement test was negative. Although workers' compensation patients tended to have lower scores than others, the impingement test result was more predictive of outcome than was compensation status. Impingement test results and preoperative American Shoulder and Elbow Surgeons scores were independent predictors of postoperative American Shoulder and Elbow Surgeons scores. Our evidence indicates that the impingement test can be used as a predictor of outcome for patients with impingement syndrome treated by arthroscopic subacromial decompression.