Lateral Collateral Ligament Complex Research Articles

Perfect Indications and How to Avoid Complications in Lateral Unicompartmental Knee Arthroplasty

Lateral unicompartmental knee arthroplasty (LUKA) is a favorable alternative to distal femoral osteotomy and total knee arthroplasty in patients with isolated lateral compartment knee osteoarthritis; however, it only accounts for less than 1% of the total number of knee replacements documented in national joint registries. The anatomy and biomechanics of the lateral knee compartment differ from the medial side, with a greater intrinsic laxity of the lateral collateral ligament complex compared to medial structures. Indications and surgical techniques must be tailored to each unicompartmental replacement to optimize outcomes and mitigate complications. This article will discuss the clinical indications, preoperative evaluation and workup, surgical technique, and outcomes for LUKA.

Lateral collateral ligament complex insufficiency in recalcitrant lateral epicondylitis: MRI evaluation with arthroscopic findings.

To evaluate the concomitant pathology in recalcitrant LE using MRI with arthroscopic finding correlation. A total of 49 patients were diagnosed with chronic recalcitrant LE and divided into two: LCL complex-intact and LCL complex-involved groups by evaluating MRI as confirmed by a radiologist. Patient information for the history of steroid injection and symptom duration was extracted from the medical records. Arthroscopic images taken during arthroscopic extensor carpi radialis brevis release were evaluated to assess the quality of lateral capsule and concomitant plica. A total of 24 and 25 patients were included in the LCL-intact and LCL-involved groups, respectively. Among them, seven had complete RCL tears recorded in the LCL-involved group. Symptom duration (15 ± 9 vs. 22 ± 13, p = 0.029) and the number of steroid injections (3 ± 2 vs. 5 ± 3, p = 0.040) were significantly higher in the LCL-involved group than that in the LCL-intact group. A capsular tear was detected for 5 (20%) patients in the LCL-intact and 14 (56%) in the LCL-involved group (p = 0.027). Concomitant plica was observed in 15 (62%) patients in LCL-intact and seven (28%) in the LCL-involved group (p = 0.015). RC joint widening was observed in four patients in the LCL-involved group. The recalcitrant LE is highly a concomitant pathology including LCL complex insufficiency and pathologic elbow plica lesion. The risk factors of LCL insufficiency associated with refractory LE may include multiple steroid injections. Arthroscopic finding such as capsular tears and elbow drive-through signs can be suspected signs for LCL complex insufficiency.

Lateral elbow magnetic resonance imaging findings in patients without pain complaints

Magnetic resonance imaging (MRI) can help evaluate lateral epicondylitis; however, abnormal findings on MRI are not always consistent with the symptoms. The occurrence of such abnormal MRI findings at the lateral side of the elbow in patients without pain remains unclear. Therefore, the purpose of this study was to investigate the MRI findings of the lateral elbow joint in patients with no complaints of pain in the elbow joint. We retrospectively identified 152 patients who had undergone MRI of the area including the elbow from July 2015 to January 2022. We excluded patients with pain in the elbow area and those with diagnosis of diseases that could affect MRI findings at the lateral elbow. The presence of lateral collateral ligament complex (LCLC) and common extensor tendon (CET) lesions on MRI was assessed by two reviewers. In total, 22 patients (12 men and 10 women) were included in the analysis. The mean age of the patients was 54 years. Five patients, all ≥65 years old, had abnormal findings related to the LCLC or CET on MRI. Abnormal LCLC and CET findings on MRI can be encountered in older patients even in the absence of elbow pain.

Fascia lata allograft: a suitable alternative in ligamentous reconstruction for chronic elbow instability?

BackgroundUp to now there is no gold standard concerning the optimal graft choice in the surgical therapy of chronic elbow instability. As donor site morbidity represents a rare (1-4%) but severe complication of graft harvest, using an allograft seems favorable. Fascia lata mimics the anatomy through its fan shaped configuration of the ligamentous complex of the elbow joint, making it questionable for use as a graft. The aims of the study are a) to evaluate the biomechanical suitability of fascia lata allograft and b) compare clinical and radiological outcome between ligament reconstruction of the lateral collateral ligament complex (LUCL) using either FibreTape augmented triceps autograft or FibreTape augmented fascia lata allograft. MethodsBiomechanical testing of fascia lata was performed using a 10 kN uniaxial test system with a 1 kN load cell. The retrospective cohort study evaluated all patients who received a ligament reconstruction of the elbow due to chronic instability with allogenic fascia lata or autologous triceps tendon. Exclusion criteria were any type of coexisting fracture or nerval injury. Demographic parameters, patient reported outcome parameters (PROMs) and radiological stability parameters (sonography, fluoroscopy) were evaluated. ResultsTensile testing of 39 fascia lata allografts revealed an ultimate load of 234.8±23.1 N and ultimate strength of 33.4±4.4 MPa. 21 patients were included in the clinical substudy (57.1% men, 42.9% women , age 41.0 ± 12.2 years, BMI 24.9 ± 4.1 kg/m2) with average follow-up of 21.6 ± 17.1 months. No significant differences were found concerning pain level, PROMs or Range of Motion (ROM), between fascia lata and triceps group. There was also no difference concerning sonographic stability of LUCL between the 2 groups (p=0.14). One revision occurred in fascia lata allograft group, 2 in triceps autograft group due to graft elongation. ConclusionCurrently, there is no clinical evidence demonstrating the superiority of either autograft or allograft tissue. Due to its demonstration of sufficient biomechanical properties fascia lata allograft seems an appropriate treatment option for ligamentous reconstruction of chronic elbow instability.

Posterior Translation of the Radial Head in Magnetic Resonance Imaging of Lateral Epicondylitis.

Posterolateral rotatory instability is produced by disruption of the lateral collateral ligament complex (LCLC); it is commonly induced by trauma, with few cases reported due to lateral epicondylitis. We examined the amount of posterior transition of the radial head with or without LCLC injury, common extensor tendon (CET) injury, and Baker classification in lateral epicondylitis. We retrospectively studied patients with lateral epicondylitis of the humerus who underwent surgery between April 2016 and July 2021. Fifteen elbows with coronal and sagittal images on preoperative magnetic resonance imaging (MRI) were included. We investigated the amount of posterior transition of the radial head in sagittal MRI images of the elbow, which were compared based on LCLC and CET lesion. The mean age of patients was 49 years. The lesions in four, nine, and two patients were classified as LCLC0, LCLC1, and LCLC2, respectively. The mean radio-humeral distance values among the LCLC lesions were 0.65, 2.46, and 2.22 mm in LCLC0, LCLC1, and LCLC2, respectively, with the RHD between LCLC0 and LCLC1 differing significantly. In five, six, and four patients, the lesions were classified as CET1, CET2, and CET3, respectively. The mean RHD values among the CET lesions were 1.33, 2.68, and 1.48 mm in CET1, CET2, and CET3, respectively. Our results showed that posterior transition of the radial head is greater in patients with lateral epicondylitis with LCLC lesions on MRI than those with normal findings of LCLC.

Internal Joint Stabilization for Recurrent Nontraumatic Elbow Dislocation in a Skeletally Immature Patient.

A 14-year-old adolescent boy with SCN1B mutation experienced frequent seizures and recurrent elbow dislocation, occurring up to 30 times per day. Following failed conservative treatment, the decision was made to surgically repair the lateral collateral ligament complex and stabilize the elbow with the internal joint stabilizer (IJS). At more than 3 years postoperatively, the patient has not had a dislocation event and will retain the device for the foreseeable future to maintain predictable elbow stability. Although there is scant evidence supporting the use of the IJS in pediatric cases, the current case supports its use in pediatric elbow instability.

Arthroscopic assessment for lateral collateral ligament complex deficiency of the elbow: a cadaveric study.

To evaluate whether elbow instability due to lateral collateral ligament complex injury can be assessed reliably through arthroscopy. Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. The radiocapitellar joint (RCJ) gap and ulnohumeral joint (UHJ) gap (mm) were measured with different sizes of probes from the posterolateral viewing portal. The elbow was 90 degrees flexed with neutral forearm rotation for RCJ gap measurement and 30 degrees flexed with full supination for UHJ gap measurement. Sequential testing was performed from Stage 0 to Stage 3 (Stage 0: intact; Stage 1: the release of the anterior 1/3 LCL complex; Stage 2: the release of the anterior two thirds of the LCL complex; and Stage 3: the release of the entire LCL complex) on each specimen. The mean gap of RCJ and lateral UHJ was used for the comparison between stages with the intact elbow. The mean RCJ gap distance in Stage 2 and Stage 3 was significantly increased compared to that in Stage 0 (Stage 0 vs. Stage 2: P = .008; Stage 0 vs. Stage 3: P = .010). The mean UHJ gap distance of Stage 1, Stage 2, and Stage 3 was significantly increased compared to that in Stage 0 (Stage 0 vs. Stage 1: P = 0.025; Stage 0 vs. Stage 2: P = .010; Stage 0 vs. Stage 3: P = .011). In contrast, the release of the anterior 1/3 of the LCL complex (Stage 1) was not significantly increased compared to the mean joint gap distance of RCJ (P = .157). Arthroscopic measurement of joint gap widening in RCJ and UHJ is a reliable assessment method to detect LCL complex deficiency that involves the anterior two thirds or more.

The Boyd approach: a valuable alternative to treating simple to complex elbow fractures and dislocations.

The Boyd approach is a single-incision posterior approach to the proximal radius and ulna based on a lateral anconeus muscle reflection and release of the lateral collateral ligamentous complex. This approach remains a lesser-used technique following early reports of proximal radioulnar synostosis and postoperative elbow instability. Although limited by small case series, recent literature does not support these early reported complications. This study presents a single surgeon's outcomes using the Boyd approach for the treatment of simple to complex elbow injuries. Following institutional review board approval, a retrospective review of all patients with simple to complex elbow injuries treated consecutively using a Boyd approach by a shoulder and elbow surgeon was conducted from 2016 to 2020. All patients with at least 1 postoperative clinic visit were included. Data collected included patient demographics, injury description, postoperative complications, elbow range of motion, and radiographic findings including heterotopic ossification and proximal radioulnar synostosis. Categorical and continuous variables were reported using descriptive statistics. A total of 44 patients were included with an average age of 49 years (range 13-82 years). The most commonly treated injuries were Monteggia fracture-dislocations (32%) and terrible triad injuries (18%). Average follow-up was 8 months (range 1-24 months). Final average elbow active arc of motion was from 20° (range 0°-70°) of extension to 124° (range 75°-150°) of flexion. Final supination and pronation were 53° (range 0°-80°) and 66° (range 0°-90°), respectively. There were no cases of proximal radioulnar synostosis. Heterotopic ossification contributing to less than functional elbow range of motion occurred in 2 (5%) patients who elected conservative management. There was 1 (2%) case of early postoperative posterolateral instability due to repair failure of injured ligaments that required revision using a ligament augmentation procedure. Five (11%) patients experienced postoperative neuropathy, including 4 (9%) with ulnar neuropathy. Of these, 1 underwent ulnar nerve transposition, 2 were improving, and 1 had persistent symptoms at final follow-up. This is the largest case series available demonstrating the safe utilization of the Boyd approach for the treatment of simple to complex elbow injuries. Postoperative complications including synostosis and elbow instability may not be as common as previously understood.

The Relationship between the Bevel of the Radial Head Epiphysis and the Posterior Synovial Fringe During Rotation of the Elbow: An Ultrasonography Study with Possible Implications Regarding the Pathophysiology of Nursemaid's Elbow.

Nursemaid's elbow is the most common upper extremity injury in children under 5 years of age. However, the exact pathomechanism underlying the nursemaid's elbow remains elusive, and approximate one-third of patients present with a nonclassical history. Using a high-frequency ultrasound probe, we attempted to determine the relationship between the anterior edge of the posterior synovial fringe and the peripheral rim of the radial head epiphysis during rotation. It is possible that the primary reason for the nursemaid's elbow is due to the pronator position. Twenty-one patients had a history of nursemaid's elbow and had a successful reduction before enrollment in this study. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small morphologic changes in the peripheral rim of the radial head epiphysis and the posterior synovial fringe during rotation of the capitellum-radial joint. In complete pronation, the anterior edge of the posterior synovial fringe contacts the beveled articular surface of the radial head peripheral rim in all 21 patients. In neutral and complete supination, the anterior edge of the posterior synovial fringe contacts the convexly nonarticular surface of the radial head peripheral rim and extends deep into the foveal radius. The posterior synovial fringe and the capsule-aponeurotic membrane were tightened in passive pronation in all 21 cases. The posterior synovial fringe and the capsule-aponeurosis membrane were all loose in the neutral and supination positions. The anterior edge of the posterior synovial fringe touches the beveled peripheral rim of the radial head epiphysis during complete pronation, and the tension of the lateral collateral ligament complex during pronation may further cause unstable conditions of the anterior edge of the posterior synovial fringe. We hypothesized that the beveled peripheral rim of the radial epiphysis and its relationship with the anterior edge of the posterior synovial fringe could be the reason why nursemaid's elbow only occurs while the elbow is in the pronator position.

Bracing with Tape and Extensor Refixation of Elbow with Posterolateral Instability Due to Cubitus Varus: A Case Report.

A 54-year-old patient had lateral ligament insufficiency due to cubitus varus from a childhood supracondylar fracture. Arthrolysis/synovectomy and at a later stage double-row extensor origin refixation and lateral ulnar collateral ligament bracing with nonabsorbent tape and anchors were performed. Follow-up at 3, 6, 12, and 24 months showed excellent Mayo Elbow Performance and Disabilities of Arm, Shoulder, and Hand Scores (24-month follow-up = 100 and 2.5, respectively). Suture tape augmentation and double-row extensor refixation in cases of lateral collateral ligament complex insufficiency due to cubitus varus may provide improved short-term functional outcomes, from the third postoperative month.

Mid-term results of the treatment of acute postero-lateral rotational instability of the elbow joint

Background: Dislocations of the forearm are rare injuries with the annual incidence of 6.1 cases per 100 000 population. Postero-lateral rotational instability is the most common complication after the conservative treatment of forearm dislocations. To restore the congruency and provide early movements in the elbow joint, the primary repair or reconstruction of the damaged ligaments of the elbow are required. Aim: to evaluate the clinical and functional results after the surgical repair of the elbow joint ligaments in acute postero-lateral rotational instability. Methods: The study was based on a retrospective analysis of a series of clinical cases, including 17 patients with acute postero-lateral rotational instability, among them 5 simple forearm dislocations, 9 fracture-dislocations of the forearm and 3 fractures of the radial head. Refixation of the lateral ulnar ligament was performed with anchor fixation or bone tunnels. The evaluation was performed using the clinical aspects (the lateral pivot shift test, the range of motion), according to the scale for the evaluation of the elbow joint functional condition (MEPS), Oxford scale of the elbow joint evaluation (OEC), the X-ray results were also estimated. Results: In all the cases the elbow joint stability had been achieved, according to the X-ray and clinical aspects. In 4 cases, additional plasty of the medial collateral ligament was needed and performed after the restoration of the lateral ligament complex. According to the MEPS scale, 58% of the achieved results were excellent, 35% were good and 5.8% were satisfactory. Conclusion: The restoration of the lateral ulnar collateral ligament complex is a safe and effective procedure, which restores the elbow joint stability and allows the patients to return to full physical activity and avoid the development of postero-lateral rotational joint instability.

Biomechanical evaluation of the anterior talo-fibular and calcaneo-fibular ligaments using shear wave elastography in young healthy adults

BackgroundThe objective of this study was to evaluate the stiffness of the anterior talo-fibular ligament (ATFL) and calcaneo-fibular ligament (CFL) using shear wave elastography (SWE) with the ankle in the neutral position and in varus, in young healthy adult volunteers. We also evaluated the reliability and reproducibility of the SWE measurements. HypothesisThe stiffness of both ligaments increases with increasing ankle varus. SWE may be a reliable tool for evaluating the lateral collateral ligament complex of the ankle. Material and methodsWe used SWE to evaluate both ankles of each of 20 healthy volunteers (10 females and 10 males). For each test, the foot was placed on a hinged plate and tested in the neutral position and in 15° and 30° of varus. Stiffness was evaluated based on shear wave velocity (SWV). ResultsStiffness of both the ATFL and CFL was minimal in the neutral position (2.06m/s and 3.43m/s, respectively). Stiffness increased significantly for both ligaments in 15° of varus (2.48m/s and 4.11m/s, respectively; p<0.0001) and was greatest in 30° of varus (3.15m/s and 4.57m/s, respectively; p<0.0001). ATFL stiffness was greater in males than in females in 15° (p=0.04) and 30° (p=0.02) of varus. For the CFL, in contrast, stiffness was not different between males and females. Stiffness of the ATFL and CFL was not associated with age, dominant side, height, or foot morphology. No correlations were found between stiffness of the two ligaments in any of the positions. Repeating each measurement three times produced excellent concordance for both ligaments in all three positions. ConclusionThe ATFL and CFL are the main lateral stabilisers of the ankle, and each exerts a specific function. Their stiffness increases with the degree of varus. This study describes a protocol for evaluating ATFL and CFL density by SWE, which is a reliable and reproducible technique that provides a normal range. Level of evidenceIV.

Efficacy of Ultrasonic Tenotomy and Debridement and Platelet-Rich Plasma Injections for Lateral Elbow Tendinopathy

To determine the efficacy of treatment of lateral elbow tendinopathy (LET) with platelet-rich plasma (PRP) injection and ultrasonic tenotomy and debridement (USTD) as well as risk factors for treatment failure. This was a retrospective study including patients treated for LET with PRP or USTD between January 2018 and December 2021. The efficacy of both procedures was assessed using pain-related patient-reported outcome measures at the 12-week follow-up. Baseline subject characteristics and diagnostic ultrasound findings were analyzed as risk factors for failure of treatment. Failure was classified as a surgical indication for LET within a year of the PRP or USTD. Ultrasonic tenotomy and debridement and PRP both led to significant improvement in patient pain within the 12-week follow-up period. There was no significant difference in efficacy between the two procedures. Common extensor tendon tearing on ultrasound and Worker's Compensation cases were found to be risk factors for failure of USTD. Lateral collateral ligament complex involvement and injection were found to be risk factors for failure of PRP. Platelet-rich plasma and USTD are both effective interventions for LET. They have separate risk factors for failure that should be taken in consideration while deciding the treatment approach. These procedures are minimally invasive alternatives to some of the more invasive surgical options to treat LET. Therapeutic III.

Posterolateral stabilization of the elbow by autologous ligament reconstruction to limit long-term development of osteoarthritis.

Posterolateral instability is the most frequent form of both acute and chronic elbow instability. Joint incongruity due to posterolateral unlocking leads to shear and compression stress of the internal aspect of the humeroulnar joint. We carried out long-term analysis of patients with posterolateral elbow instability in order to determine whether, in addition to improving their symptoms, reconstruction of the lateral collateral ligament complex may play a protective role against the development of post-traumatic osteoarthritis. We hypothesized that ligament reconstruction according to the technique of O'Driscoll stabilizes the elbow and also limits the development of osteoarthritis in the long term. Patients with symptomatic posterolateral instability of the elbow and who underwent ligament reconstruction according to the technique of O'Driscoll from January 1995 to December 2010 were identified and retrospectively included for 2 follow-up evaluations at a mean of 5 and 14years. Fourteen elbows in 14 patients were included. All had a negative lateral pivot shift test and none reported a new episode of instability. Two patients (14%) had osteoarthritis. The 2 radiographic evaluations showed no progression of osteoarthritis. Osteoarthritis developed in 33% of patients with intra-articular fracture. In simple dislocations, pre-existing osteoarthritic lesions were stabilized and there were no new cases of osteoarthritis. Elbow ligament reconstruction according to the technique of O'Driscoll gives effective posterolateral stabilization and appears to protect against progression to osteoarthritic degeneration in the long term. In the absence of associated lesions, it prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis.

Arthroscopic Modified Elbow Lateral Collateral Ligament Imbrication: An Operative Technique

When the lateral collateral ligament (LCL) complex fails to support the radiocapitellar and ulnohumeral joints in advanced stages of insufficiency, the patient experiences posterolateral rotatory instability (PLRI). Open lateral ulnar collateral ligament repair with a ligamentous graft has been the standard treatment for PLRI. Despite producing good clinical stability rates, this method is associated with significant lateral soft-tissue dissection and a lengthy recovery period. By fastening the LCL to its humeral insertion, arthroscopic imbrication of the LCL can increase stability. The senior author modified this technique. With the aid of a passer, the LCL complex, lateral capsule, and anconeus may be weaved with a single (doubled) suture, secured with a Nice knot. LCL complex imbrication may be used to restore stability and improve pain and function in patients with grade I and II PLRI.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

Trans-olecranon fracture posterior dislocation: a novel type of elbow injury

BackgroundBased on our experiences, we found that a kind of elbow injury is characterized by an olecranon fracture accompanied by elbow joint posterior dislocation with the proximal radioulnar joint intact. The aim of this study was to better define this kind of severe elbow instability, which has not been previously reported.MethodsWe retrospectively analyzed all patients with olecranon fractures who were treated at our institution from January 2013 to April 2021. Data on these patient demographics, injury characteristics, preoperative and postoperative imaging, surgical management, and outcomes were recorded and analyzed. We also made the inclusion criteria and exclusion criteria.ResultsA total of 309 patients were diagnosed olecranon fractures in our institution, and ten patients met the inclusion criteria, 9 males and 1 female, with an average age of 40.6 ± 12.7 years (26–68 years). Eight patients (80%) were comminuted, and two were oblique olecranon fracture. Nine patients (90%) suffered coronoid process fractures, eight fractures were type III, and one was type II. Eight patients (80%) suffered radial head fractures, seven fractures were type II, and one was type III. All patients suffered lateral collateral ligament complex injury. All patients underwent surgical management and were followed up on average for 15.8 ± 3.2 months (12–20 months). The motion of the elbow and functional outcome were evaluated with several methods. The mean arc of the elbow movement was 131.6° ± 6.0° (124°–140°), and the mean arc of the forearm rotation was 158.5° ± 17.8° (128°–180°). Nine patients’ functional results according to the Mayo Elbow Performance Score (MEPS) were excellent with a mean score of 96.5 ± 5.3 points (85–100 points), and another was good. The mean score according to the Broberg and Morrey functional rating index was 98.8 ± 2.5 points (92–100 points), nine patients were excellent, and another was good. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 0.75 ± 1.2 points (0–3.3 points).ConclusionsTrans-olecranon fracture posterior dislocation is a rare injury and has unique characteristics, and it is a kind of complex elbow instability involving the coronoid process and radial head fractures. After bony structure is restored, the repairment of lateral collateral ligament complex is also important to the stability of the elbow joint. Correct understanding of this kind of injury and reasonable treatment plan can achieve good function.

Closed Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV)1-4. The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction5. Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. This technique provided satisfactory clinical outcomes in our previous study6, with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. The steps need to be followed sequentially as described in order to achieve an anatomical reduction.After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex.This technique may not work in complex fractures with elbow dislocation because of the lack of ligamentous integrity.In the final step, the elbow is pronated and flexed simultaneously, with sustained pressure over the radial head in order to obtain further correction. This is the most critical step of the technique because anatomic reduction of the partially reduced fracture is achieved at this time. Percut. = percutaneousAP = anteroposteriorCR = closed reductionORIF = open reduction and internal fixation.

The Role of the Lateral Collateral Ligament-Capsule Complex (LCL-cc) of the Elbow Under Gravity Varus.

The lateral collateral ligament complex along with the capsule is likely to be at risk during arthroscopic ECRB release in lateral epicondylitis. We hypothesized that disruption of the lateral collateral ligament-capsule complex (LCL-cc) increases the mean contact pressure on the coronoid under the gravity varus. Eight cadaveric elbows were tested under the gravity varus and weighted varus stress tests (2Nm), using a custom-made machine designed to simulate muscle loads while allowing passive flexion of the elbow. Mean articular surface contact pressure data were collected and processed using intra-articular thin film sensors and software. Sequential testing was performed from Stage 0 to Stage 3 (Stage 0: Intact; Stage 1: release of anterior 1/3 LCL-cc; Stage 2; release of anterior 2/3 LCL-cc; and Stage 3; release of entire LCL-cc) on each specimen. The mean contact pressure of the coronoid and mean M/L ratio (ratio of contact pressure on medial coronoid to that on the lateral coronoid) were used for the comparison between stages with the intact elbow. The overall mean contact pressure significantly increased in Stage 2 (P =.0006 in gravity varus, P =.0002 in weighted varus) and Stage 3 (P <.0001 in gravity varus, P <.0001 in weighted varus) compared to that in Stage 0. In contrast, release of the anterior 1/3 of LCL-cc (Stage 1) did not significantly increase the mean contact pressure on the coronoid in any degree of flexion under gravity varus (P =.06) or weighted varus loading (P =.6). The M/L ratio difference between Stage 0 and Stage 1 was 1.1 ± 1.1 under gravity varus (P =.8) and 2.1 ± 0.9 under weighted varus. (P =.2) The overall M/L ratio in Stage 2 and Stage 3 were significantly higher compared to that seen in Stage 0 under gravity varus (P =.04 in Stage 2, P =.02 in Stage 3) or weighted varus (P =.006 in Stage 2, P <.0001 in Stage 3). Loss of the anterior 2/3 or more of the LCL-cc significantly increases the overall mean contact pressure of coronoid, especially in the medial coronoid under both gravity varus and weighted varus. The LCL-cc also plays a role in the distribution of coronoid contact pressure against gravity varus loads.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results.

Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n=20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P<.001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P<.001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.