Clinical Outcome After Lateral Ulnar Collateral Ligament Reconstruction in an Adolescent Baseball Player: A Case Report.

Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical procedure to treat posterolateral rotatory instability (PLRI) of the elbow. We report a 17-year-old right-handed pitcher with symptomatic PLRI after an injury to his LUCL during a baseball game. Having failed 8 months of conservative treatment, a LUCL reconstruction using the modified O'Driscoll technique was performed with the contralateral gracilis autograft. At 5-year follow-up, an excellent patient-reported outcome was achieved and the patient continued to play baseball at the recreational level. This type of injury is rarely reported in adolescent baseball players, and improving our knowledge of the long-term outcomes is crucial to assist clinicians in counseling patients about expectations after surgery.

Quantifying the Center of Elbow Rotation: Implications for Medial Collateral Ligament Reconstruction.

BACKGROUND: Medial collateral ligament (MCL) reconstruction of the elbow mandates precise characterization of where the centerline of elbow rotation projects onto the medial epicondyle (ME). A muscle-splitting approach allows the flexor-pronator muscles to remain attached to the ME and facilitates visualization of the MCL remnant, the sublime tubercle, and the ulnohumeral joint line. Knowledge of where the centerline of rotation intersects the ME relative to the ulnohumeral joint line may assist the surgeon during placement of the proximal drill hole. METHODS: Models were created from the computed tomography scans of 29 normal elbows. The centerline of rotation, center of the trochlea, sublime tubercle, and ulnohumeral joint line were identified. Measurements were taken from the ulnohumeral joint line to the center of the trochlea and to the centerline of rotation in the sagittal view and along the course of the MCL. RESULTS: The centerline of rotation intersected the ME in a consistent location. With the elbow flexed 90°, the trochlea center and the centerline of rotation are essentially in line with each other. There are significant differences between the distances from the ulnohumeral joint line to the center of the trochlea and to the centerline of rotation in both the sagittal view and along the course of the MCL. CONCLUSIONS: The centerline of rotation is located 14.31 mm (1.70) from the ulnohumeral joint line in the sagittal view and 16.54 mm (2.09) from the ulnohumeral joint line along the course of the MCL.

Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model.

PURPOSE: The goal of this study was to determine the best angle at which to drill the femoral tunnels of the popliteus tendon (PT) and fibular collateral ligament (FCL) in combined reconstructive procedures so as to avoid either short tunnels or tunnel collisions with the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) femoral tunnels. METHODS: Eight cadaveric knees were studied. ACL/PCL femoral tunnels were arthroscopically drilled. PT and FCL tunnels were drilled at 0° and 30° axial and coronal angulations. They were scanned by computed tomography to document relations of the PT and FCL tunnels to the intercondylar notch and ACL/PCL tunnels. A minimum tunnel length of 25 mm was required. RESULTS: Drilling the PT tunnel at 0° axial angulation was associated with an increased risk of tunnel collision with the ACL (P < .001). Interference with the PCL tunnel can be avoided only if the K-wire guiding the PT tunnel is drilled with 30° coronal angulations (P < .001). The minimum tunnel length of the PT could be obtained only with both axial and coronal angulations of 30° (P = .003). Sufficient tunnel lengths of the FCL were obtained at all angulations evaluated (P = .036). However, only the tunnels drilled at 30° axial and 0° coronal angulations did not collapse with the ACL tunnels (P < .001). No intersections between FCL and PT tunnels were observed. CONCLUSIONS: When posterolateral reconstructions are performed in combination with concomitant anterior and posterior cruciate procedures, PT tunnels should be drilled at 30° axial and 30° coronal angulations. FCL tunnels should be drilled at 30° axial and 0° coronal angulations. These angulations should minimize such potential complications as short tunnels or collisions with the ACL/PCL tunnels. CLINICAL RELEVANCE: Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when FCL and PT femoral tunnels are performed in multiligament knee reconstructions.

Tissue-engineered collateral ligament composite allografts for scapholunate ligament reconstruction: an experimental study.

PURPOSE: In patients with chronic scapholunate (SL) dissociation or dynamic instability, ligament repair is often not possible, and surgical reconstruction is indicated. The ideal graft ligament would recreate both anatomical and biomechanical properties of the dorsal scapholunate ligament (dorsal SLIL). The finger proximal interphalangeal joint (PIP joint) collateral ligament could possibly be a substitute ligament. METHODS: We harvested human PIP joint collateral ligaments and SL ligaments from 15 cadaveric limbs. We recorded ligament length, width, and thickness, and measured the biomechanical properties (ultimate load, stiffness, and displacement to failure) of native dorsal SLIL, untreated collateral ligaments, decellularized collateral ligaments, and SL repairs with bone-collateral ligament-bone composite collateral ligament grafts. As proof of concept, we then reseeded decellularized bone-collateral ligament-bone composite grafts with green fluorescent protein-labeled adipo-derived mesenchymal stem cells and evaluated them histologically. RESULTS: There was no difference in ultimate load, stiffness, and displacement to failure among native dorsal SLIL, untreated and decellularized collateral ligaments, and SL repairs with tissue-engineered collateral ligament grafts. With pair-matched untreated and decellularized scaffolds, there was no difference in ultimate load or stiffness. However, decellularized ligaments revealed lower displacement to failure compared with untreated ligaments. There was no difference in displacement between decellularized ligaments and native dorsal SLIL. We successfully decellularized grafts with recently described techniques, and they could be similarly reseeded. CONCLUSIONS: Proximal interphalangeal joint collateral ligament-based bone-collateral ligament-bone composite allografts had biomechanical properties similar to those of native dorsal SLIL. Decellularization did not adversely affect material properties. CLINICAL RELEVANCE: These tissue-engineered grafts may offer surgeons another option for reconstruction of chronic SL instability.

Biomechanical analysis of medial collateral ligament reconstruction grafts of the elbow.

BACKGROUND: There are no biomechanical studies evaluating different tendon grafts for elbow medial collateral ligament reconstruction. HYPOTHESIS: Using a larger tendon for the graft will yield greater resistance to valgus load for medial collateral ligament docking technique reconstructions. The type of graft used for a medial collateral ligament docking technique reconstruction will have a significant effect on the resistance to valgus loads. STUDY DESIGN: Controlled laboratory study. METHODS: Cadaveric elbows from male donors were cyclically loaded to 3 and 5 mm elongation, both intact and after a docking technique medial collateral ligament reconstruction using palmaris longus, gracilis, semitendinosus, and patellar tendon grafts. RESULTS: There was no significant difference in load to 3 or 5 mm elongation, number of cycles to failure, or stiffness between any tendon graft studied. Every tendon graft reconstruction tested was significantly weaker and less stiff than was the native medial collateral ligament. CONCLUSION: There appears to be no biomechanical advantage to be gained by using a larger tendon graft instead of a palmaris longus graft. CLINICAL RELEVANCE: The most readily available graft source with the lowest morbidity (often the palmaris longus tendon) should be used for medial collateral ligament reconstruction.

Structural properties of lateral collateral ligament reconstruction at the fibular head.

BACKGROUND: Anatomical reconstruction of a ruptured lateral collateral ligament using allograft tissue secured within the fibular head with an interference screw has been described. HYPOTHESIS: Interference fixation at the fibular head does not reproduce the strength of the intact ligament. STUDY DESIGN: Controlled laboratory study. METHODS: Ten intact lateral collateral ligaments were tested to failure. The distal fixation of 11 ligaments reconstructed with a graft including a bone plug and 11 ligaments reconstructed with a graft without a bone plug were also tested. RESULTS: The reconstructed ligaments consistently failed at the fibular head. The intact specimens predominately failed through ligament rupture. The mean strength and stiffness values were 460 +/- 163 N and 82 +/- 25 N/mm, respectively, for the intact ligaments, 113 +/- 40 N and 36 +/- 10 N/mm, respectively, for reconstruction with a bone plug, and 135 +/- 81 N and 34 +/- 14 N/mm, respectively, for reconstruction without a bone plug. The strength and stiffness were significantly (P < .05) greater for the intact ligaments than for either reconstruction group. The variation in strength was significantly larger for reconstruction without a bone plug than for reconstruction with a bone plug. CONCLUSION: Tension applied to lateral collateral ligaments reconstructed using fibular interference fixation should be limited immediately after surgery. Soft tissue fixation should be employed with care because of the inconsistency in the failure strength. CLINICAL RELEVANCE: Although fibular interference fixation is increasingly being described in the literature, the properties of reconstructed lateral collateral ligaments have not previously been quantified.

An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique.

BACKGROUND: To date, no surgical technique to treat posterolateral knee instability anatomically reconstructs the 3 major static stabilizing structures of the posterolateral knee: the fibular collateral ligament, the popliteus tendon, and the popliteofibular ligament. HYPOTHESIS: Static varus and external rotatory stability would be restored to the reconstructed knee with a posterolateral knee injury. METHODS: The anatomical locations of the original fibular collateral ligament, popliteus tendon, and popliteofibular ligament were reconstructed using a 2-graft technique. Ten cadaveric specimens were tested in 3 states: intact knee, knee with the 3 structures cut to simulate a grade III injury, and the reconstructed knee. RESULTS: For the varus loading tests, joint stability was significantly improved by the posterolateral reconstruction compared to the cut state at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion. There were no significant differences between the intact and reconstructed knees at 0 degrees, 60 degrees, and 90 degrees for varus translation. For the external rotation torque tests, external rotation was significantly higher for the cut state than for the intact or reconstructed posterolateral knee. There was no significant difference in external rotation between the intact and reconstructed posterolateral knees at any flexion angle. CONCLUSIONS: This 2-graft technique to reconstruct the primary static stabilizers of the posterolateral knee restored static stability, as measured by joint translation in response to varus loading and external rotation torque, to knees with grade III posterolateral injuries.

The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction.

PURPOSE: To measure the biomechanical effect of the surgical capsulotomy made during a posterior cruciate ligament reconstruction using the tibial inlay technique. HYPOTHESIS: The posterior capsule contributes to posterior tibial stability. STUDY DESIGN: Controlled laboratory experiment. METHODS: Six knee specimens were tested on a robotic testing system from 0 degrees to 120 degrees of flexion with the posterior cruciate ligament intact and resected and with a posterior capsulotomy identical to that performed during tibial inlay reconstruction (sham surgery). A longitudinal incision with medial and lateral soft tissue stripping sufficient to mount an inlay bone block and pass an Achilles tendon graft into the knee was made in the oblique popliteal ligament, muscle belly of the popliteus, and posterior capsule. The posterior tibial translation was measured under a posterior tibial load of 130 N at multiple flexion angles. RESULTS: Capsulotomy increased the posterior laxity compared with the posterior cruciate ligament-resected knee at every flexion angle. An additional 0.97 +/- 0.48 mm, 0.65 +/- 0.47 mm, 0.56 +/- 0.33 mm, 0.48 +/- 0.38 mm, and 0.94 +/- 0.60 mm of posterior laxity was recorded at 0 degrees, 30 degrees, 60 degrees, 90 degrees, and 120 degrees of flexion, respectively. These values were all statistically significant (P < .001). CONCLUSIONS: A posterior capsulotomy alone, without associated posteromedial or posterolateral disruption, produces additional posterior tibial translation in vitro compared with posterior cruciate ligament-deficient knee with intact capsule. CLINICAL RELEVANCE: Damage to the posterior capsule may contribute to the residual posterior laxity noted clinically after posterior cruciate ligament reconstruction.

Bone-retinaculum-bone reconstruction for chronic posttraumatic instability of the metacarpophalangeal joint of the thumb.

PURPOSE: This study presents an autograft technique for the surgical management of chronic posttraumatic instability of the thumb metacarpophalangeal (MCP) joint by using a bone-retinaculum-bone graft from the second compartment of the extensor retinaculum. METHODS: The bone-retinaculum-bone graft was harvested from the second compartment. The graft ends were fixed into the host site with screws. Fourteen patients (12 ulnar, 2 radial collateral ligament tears) had the procedure. All patients were reviewed by an independent observer using objective and subjective criteria, the mean follow-up time was 20 months. RESULTS: Results were satisfactory overall (8 excellent, 4 good, 1 fair, 1 poor that subsequently was fused). All patients returned to their former jobs. All but one had a clinically stable first MCP joint; grasp was 87%, pinch was 80%, MCP joint range of motion (ROM) was 91%, and interphalangeal joint ROM was 98% of the unoperated side. CONCLUSIONS: Early results are encouraging. This procedure preserves ROM of the MCP and interphalangeal joints of the thumb, improves strength, and gives the stability required for proper thumb function.

Hemidigital resection with collateral ligament transplantation in the treatment of macrodactyly: a case report.

Macrodactyly is a rare congenital anomaly of the hand that is difficult to treat. We describe a new technique consisting of hemidigital, longitudinal, and transverse en bloc resection with collateral ligament transplantation to the proximal interphalangeal joint that we used in a case of macrodactyly. Four years after the procedure the digit's appearance was largely improved with preservation of complete motion at the proximal interphalangeal joint. Transplantation of the collateral ligament ensured a stable joint. Fingertip sensibility was maintained.

Functional anatomy of the lateral collateral ligament complex of the elbow.

Postero-lateral instability of the elbow joint is a rare clinical condition, commonly related to a disruption of the lateral collateral ligament complex of the elbow. Twenty elbow joint specimens were studied in order to describe the morphologic characteristics of this complex, and to determine the role of its different components in the stability of the elbow. After a morphologic and morphometric investigation, serial divisions of the medial bundle of the lateral collateral ligament were performed, with or without section of the annular ligament and the anterior bundle of the lateral collateral ligament. The anterior and medial bundles of the lateral collateral ligament had close relationships with the annular ligament and a common proximal course. Isolated section of the medial bundle of the lateral collateral ligament induced only minor laxity of the elbow joint. Combined divisions of the medial and the anterior bundles at their humeral insertion, or the medial bundle and the annular ligament at their ulnar insertion resulted in a reproducible subluxation of the ulno-humeral joint. Thus, postero-lateral rotatory stability of the elbow joint is largely maintained by the lateral collateral ligament complex, composed of three elements: the anterior and medial bundles of the lateral collateral ligament, and the annular ligament. In clinical practice, chronic postero-lateral instability is best treated by a ligamentous reconstruction, that must take into account all these anatomic considerations. We report here a new technique of ligamentoplasty using the fascia of the extensor carpi ulnaris muscle.