Radial Collateral Ligament Research Articles

Technical modifications to elbow interposition arthroplasty

Interposition arthroplasty of the elbow involves the interposition of afascia lata or dermis autograft or allograft between the distal humerus and the ulna or radius, while preserving the original form of articulation. Interposition arthroplasty is indicated for young patients with high functional demands who suffer from end-stage elbow arthritis and associated pain or joint stiffness. Contraindications include acute or subacute infection, skeletal immaturity, bone loss, deformity, or gross instability. Once the ulnar nerve has been secured, joint access is established via aposterior approach. The radial collateral ligament (RCL) and the common extensor tendon origin (CEO) are detached, while preserving the anconeus muscle and the lateral ulnar collateral ligament (LUCL). Subsequently, a capsular release is required to maintain adequate joint exposure and address the accompanying stiffness. Three to four transosseous drill holes are placed at the level of the distal humerus to secure the graft. After the graft has been positioned successfully within the joint space using two guide sutures, it can be secured to the distal humerus using ahorizontal mattress stitch. Finally, the detached tendon and ligament structures are reconstructed. After initial immobilization, early functional exercise of the elbow is performed in the motion orthosis, avoiding valgus or varus stress. The efficacy of elbow interposition arthroplasty has been demonstrated, particularly for young and active patients with severe inflammatory or post-traumatic osteoarthritis. Despite the results in terms of postoperative function and pain reduction are satisfactory, the current literature reports high complication, subsequent treatment, and revision rates. In the event of interposition arthroplasty failure, revision with another interposition procedure or conversion to endoprosthesis may be considered.

Proximal radioulnar joint, but not posterolateral, instability in patients with symptomatic minor instability of the lateral elbow

IntroductionThe elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament (LUCL) and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like SMILE (Symptomatic Minor Instability of the Lateral Elbow) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathological condition. Materials and MethodsTwenty-eight patients were included in this study: half of them were operated for suspected SMILE while the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, four parameters were analyzed: Annular Drive Through (ADT), Ulnar-humeral Stressed Distance (UHSD) at 45° and 30° of flexion, and Loose Collar Sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to do measurements. Results and DiscussionA statistically significative difference was found for LCS (p value 0,0003) and ADT (p value 0,000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly. Progressive stretching of the RLCL and annular ligament may lead to their elongation, allowing a pathological antero-posterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radio-ulnar instability. ConclusionsRLCL and annular ligament are elongated in SMILE patients compared to controls, causing instability of the proximal radio-ulnar joint (PRUJ) and confirming that ligament incompetency is involved in SMILE condition.

Novel figure-of-eight reconstruction with free tendon graft for unrepairable collateral ligament of the thumb metacarpophalangeal joint

ObjectivesThis study aimed to report surgical technique and clinical outcomes for a novel figure-of-eight collateral ligament reconstruction technique using palmaris longus autograft for chronic irreparable collateral ligament injury of the thumb metacarpophalangeal joint. Material and methodsThe Jobe elbow collateral ligament reconstruction method was adapted for thumb metacarpophalangeal joint collateral ligament reconstruction. Sixteen reconstructions (7 ulnar collateral ligament, 9 radial collateral ligament) using palmaris longus autograft were reviewed retrospectively. Surgery was performed at a mean 12 months post-injury. All 16 patients were followed up for more than 1 year. Metacarpophalangeal joint radial and ulnar deviation, metacarpophalangeal and interphalangeal joint range of motion, key pinch and grip strength, Glickel functional grade and QuickDASH score were evaluated. ResultsPreoperative radial or ulnar deviation improved from 19.3° to 5.3° postoperatively. Metacarpophalangeal range of motion improved from 31.5° to 46.6°, and interphalangeal range of motion from 48.4° to 65.6°. Preoperative key pinch and grip strength were respectively 49% and 81% of contralateral values and improved to 82% and 87%. On Glickel grade, 9 cases were excellent and 7 good. ConclusionThe novel Jobe-like figure-of-eight reconstruction technique using palmaris longus graft was useful for reconstructing irreparable thumb metacarpophalangeal joint instability without an incision on the opposite side or an additional implant. Level of evidenceTherapeutic study, level IV.

Dynamic Ultrasound Examination of the Thumb After a Volleyball Match: Metacarpal Head Fracture and Radial Collateral Ligament Injury.

Dynamic Ultrasound Examination of the Thumb After a Volleyball Match: Metacarpal Head Fracture and Radial Collateral Ligament Injury.

Radial Collateral Ligament Laxity of Thumb Metacarpophalangeal Joint Following Trapeziometacarpal Arthrodesis

Trapeziometacarpal (TM) arthrodesis may increase adduction motion of the thumb metacarpophalangeal (MCP) joint, causing radial collateral ligament laxity. Stability of the MCP joint is important to the long-term functional outcome after TM arthrodesis. This study assessed preoperative and postoperative radial collateral ligament laxity using dynamic radiographs to confirm whether laxity was exacerbated after surgery and examined whether there is a relationship between the fixation angle of arthrodesis and the degree of laxity. Forty-four thumbs in 33 patients who underwent TM arthrodesis and were followed for at least 5 years were studied. Dynamic radiographs in radial adduction-abduction and palmar adduction-abduction were obtained. We defined the midpoint of arc of motion as the fixation angle of arthrodesis in the radial and palmar planes. We measured the intersection angle between longitudinal axis of the first metacarpal (M1) and that of thumb proximal phalanx (P1). P1M1 angle in a palmar adduction view of dynamic radiographs reflected radial collateral ligament laxity in palmar adduction (adduction P1M1 angle). We subtracted a preoperative adduction P1M1 angle from a postoperative adduction P1M1 angle and defined its value as an exacerbated adduction P1M1 angle. Adduction P1M1 angle increased from 9° ± 5° to 18° ± 10°. The median exacerbated adduction P1M1 angle was 7°. Ten thumbs (23%) developed ulnar subluxation of MCP joint in the palmar adduction view of dynamic radiographs. Among them, two thumbs developed osteoarthritis of MCP joint (5%). Fixation angle of the arthrodesis was a mean of 35° ± 7° and 32° ± 9° in the radial arc and palmar arc planes, respectively. There was a positive correlation between increasing adduction P1M1 angle and TM arthrodesis in an increasingly palmarly abducted position. Radial collateral ligament laxity of thumb MCP joint was exacerbated after TM arthrodesis. Greater fixation angle in palmar abduction resulted in more laxity of the joint. Prognostic IV.

Return to Sport and Performance After Thumb Metacarpophalangeal Joint Collateral Ligament Surgery in the National Basketball Association.

Introduction Basketball players are at increased risk of thumb collateral ligament injury (ulnar collateral ligament (UCL) and radial collateral ligament (RCL)). Methods The National Basketball Association (NBA) players with thumb collateral ligament surgery were identified using publicly available data. Performance statistics, ligament injuries (UCL or RCL), return to sport (RTS) time, laterality, and injury dates were recorded. Cases were matched 1:1 with controls based on age (±1 year), body mass index (BMI), NBA experience (±1 year), and performance statistics prior to the index date. RTS was defined as playing in one NBA game postoperatively. Career longevity was evaluated. Summary statistics were calculated, and Student's t-tests (ɑ = 0.001) were performed. Results All 47 players identified with thumb collateral ligament surgeries returned to sport. Thirty-three players (age: 26.9 ± 3.0) had one year of postoperative NBA experience for performance analysis. Career length (case: 9.6 ± 4.1, control: 9.4 ± 4.3, p > 0.001) was not significantly different from controls (p > 0.001). The same season time to RTS (n = 20) was 7.1 ± 2.4 weeks. Off-season or season-ending surgery (n = 13) RTS time was 28.4 ± 18.7 weeks. Neither thumb collateral ligament (UCL, n = 7; RCL, n = 10; unknown, n = 16) had an identifiable difference between the groups when evaluating career length. Career length, games/season, and performance were not different for players who underwent surgery on their dominant thumb (63.6%, 21/33) compared to controls (p > 0.001). Conclusion RTS rate is high in NBA athletes undergoing thumb collateral ligament surgery. Players do not experience decreased performance or career length due to thumb collateral ligament surgery, regardless of a dominant or non-dominant thumb injury.

Satisfactory thumb metacarpophalangeal joint stability after ligament reconstruction with flexor digitorum superficialis in children with radial longitudinal deficiency.

We investigated thumb joint stability and patient-reported and functional outcomes a minimum of 1 year after flexor digitorum superficialis opponensplasty and ligament reconstruction in 23 thumbs of 20 consecutive children with radial longitudinal deficiency. In total, 15 thumbs had preoperative multidirectional instability in the metacarpophalangeal joint. We reconstructed 22 ulnar and 16 radial collateral ligaments. At follow-up, all the metacarpophalangeal joints were stable ulnarly. Seven metacarpophalangeal joints were unstable radially despite ligament reconstruction but had no related complaints. We recommend the flexor digitorum superficialis opponensplasty as a safe and reliable procedure in hypoplastic thumbs to create stability and augment thumb strength.Level of evidence: IV.

Stener-Like Lesions in the Hand: A Qualitative Review.

A Stener-like lesion is defined as the interposition of the sagittal band between the torn collateral ligament of the metacarpophalangeal (MCP) joint of a finger and its origin or insertion. Owing to the rarity of this injury, standardized protocols on the diagnosis and care of these injuries are not currently available. PubMed Central and Google Scholar were searched for published studies from 1962 to 2022. Inclusion criteria admitted any injury of the MCP joints of any nonthumb fingers involving a torn collateral ligament with sagittal band injury that trapped the collateral ligament. Eight studies were ultimately included in our analysis and contained 11 cases of Stener-like lesions. Eight of the 11 cases presented radial collateral ligament injury to the ring and little fingers. All 11 cases presented showed that detailed physical examination was a primary step in diagnosis of these lesions. Metacarpophalangeal joint laxity was present in all cases reported. Imaging-aided diagnosis was used in majority of the cases presented and included arthrography, ultrasound, or magnetic resonance imaging. All cases presented in this review were managed surgically. Following surgical repair, a majority of authors opted to use immobilization techniques immediately postoperatively. As awareness of this injury pattern increases, a standardized treatment algorithm may develop.

Histology of the volar plate of the thumb metacarpophalangeal joint

BackgroundThe aim of the study was to describe the histology of the thumb MCPJ volar plate. MethodsFive fresh-frozen thumbs were dissected. The volar plates were harvested from the thumb MCPJ. Histological analyses were performed using 0.04% Toluidine blue and counterstained with 0.005% Fast green. ResultsThe thumb MCPJ volar plate comprised two sesamoids, dense fibrous tissue and loose connective tissue. The two sesamoids were connected by dense fibrous tissue, with collagen fibers oriented transversely (perpendicular to the long axis of the thumb). In contrast, the collagen fibers within the dense fibrous tissue on the lateral sides of the sesamoid were oriented longitudinally in line with long axis of the thumb. These fibers blended with the fibers of the radial and ulnar collateral ligaments. The collagen fibers in the dense fibrous tissue distal to the sesamoids ran transversely, perpendicular to the long axis of the thumb. The proximal aspect of the volar plate showed only loose connective tissue. The volar plate of the thumb MCPJ was largely uniform with no division of layers from the dorsum to the palmar surface. There was no fibrocartilaginous component in the thumb MCPJ volar plate. ConclusionsThe histology of the volar plate of the thumb MCPJ differs significantly from the conventional understanding of the volar plate, based on the volar plate of finger proximal interphalangeal joints. The difference is likely due to the presence of the sesamoids, which confer additional stability, reducing the need for a specialized trilaminar fibrocartilaginous structure with the lateral check-rein ligaments found in the volar plate of finger proximal interphalangeal joints to confer additional stability.

Safe Arthroscopic Approaches for Epicodilitis: Topographic-Anatomical Study

Background. Arthroscopic methods of diagnosis and treatment of elbow diseases have not yet become widespread due to the small volume of the joint, the close location to neurovascular bundles and the manipulation difficulty.
 The aim of the study was to determine the safe zones for the minimally invasive approaches to the elbow in patients with lateral and medial epicondylitis.
 Methods. A complex anatomical and clinical study was performed. The anatomical part was carried out on 30 non-fixed anatomical preparations of the upper limb. The features of the tendon-muscular and neurovascular structures surrounding the elbow were studied, depending on the angle of elbow flexion at three different levels: level I 5 cm above the articular gap, level II the articular gap, level III the neck of the radius. In the clinical part of the study, the these structures were studied by MRI in 30 patients.
 Results. The brachial artery at the level I is located from the bone at a distance 28.6 (28.4-28.7) mm at the elbow flexion to 90. The radial nerve at level II is located at a distance of 15.8 (15.6-16.0) mm from the nominal medial epicondylar line (NMEL). From the NMEL the median nerve is located at a distance of 17.5 (16.6-18.1) mm, the brachial artery 22.4 (20.5-22.8) mm. The anterior bundle of the medial collateral ligament has the following average width throughout: the proximal part 6.21.4 mm; the middle part 6.51.5 mm; the distal part 9.31.4 mm. The average area of the medial collateral ligament attachment to the medial condyle of the humerus was 45.59.3 mm2 and has a rounded shape. The average length of the radial collateral ligament was 20.51.9 mm; width 5.20.8 mm, the average area of its attachment to the humerus was 13.61.4 mm2. The average area of the extensor carpi radialis brevis on the lateral condyle of the humerus was 53.13.7 mm2. The average distance from the entrance of the deep branch of the radial nerve into the supinator canal to the articular gap 28 (25.5-29.6) mm.
 Conclusion. The results of the study make it possible to choose the safe arthroscopic approaches to the elbow with minimal risk of damage to neurovascular structures in the treatment of patients with lateral and medial epicondylitis.

Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint.

Injuries to the radial collateral ligament (RCL) of the thumb are thought to be relatively uncommon, especially when compared to the ulnar collateral ligament. However, the radial collateral ligament is increasingly recognized as critical for the overall stability of the thumb metacarpophalangeal joint. This article sets out to provide a comprehensive review of RCL injuries of the thumb MCP joint, including epidemiology, biomechanics, diagnosis, and treatment. Although traditionally thought to respond well to conservative management, especially when compared to injuries to the ulnar collateral ligament, there is mounting evidence that chronic RCL injury leads to thumb metacarpophalangeal joint instability and can accelerate post-traumatic joint degeneration. Thus, much of the recent literature details surgical treatment options for radial collateral ligament injury, including repair and reconstruction. While incomplete tears of the thumb RCL respond well to immobilization, complete tears should generally be treated with operative management, either direct repair or anatomic reconstruction, depending on tissue quality. Even subacute and chronic injuries may be amenable to direct repair, with good to excellent outcomes, including in high-demand patient populations, such as professional athletes.

Mechanical Evaluation of Knee Ligament Allografts for Thumb Metacarpophalangeal and Finger Proximal Interphalangeal Reconstruction

Purpose This study evaluated knee collateral ligaments for use as allografts in small joint reconstruction in the hand, specifically the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) and the index finger proximal interphalangeal (PIP) joint radial collateral ligament (RCL), and compared them to the current gold standard, tendon autograft. Methods Uniaxial tensile testing was performed on native thumb MCP UCLs and index finger PIP RCLs and 2.5-mm–diameter grafts prepared from hemi-flexor carpi radialis (hemi-FCR) tendons and knee medial collateral ligaments (MCLs) cadaveric allografts. In situ angular testing was performed in thumb MCP and index finger PIP joints. Each MCP/PIP joint was secured to a mechanical testing system and cyclically loaded. The UCL/RCL was resected and reconstructed with either an MCL or hemi-FCR. Cyclic loading was repeated, followed by angular load to failure. Results Uniaxial testing of MCL allografts demonstrated greater ultimate stress, ultimate load, and elastic modulus than hemi-FCR grafts and native UCLs/RCLs. The maximum angular deviation of the reconstructed MCP and PIP joints was not significantly different compared with the intact joint with either an MCL or hemi-FCR graft. In situ load to failure demonstrated no differences in failure torque or angular stiffness between MCPs reconstructed with a hemi-FCR and MCL allograft, whereas reconstructed PIP joints demonstrated improved angular stiffness with an MCL allograft compared with a hemi-FCR. Conclusions Medial collateral ligament allografts demonstrated improved mechanical properties compared with hemi-FCR tendon grafts during uniaxial testing, and grafts performed equivalently in in situ testing of reconstructed thumb/finger joints. Clinical relevance Prepared knee ligament allografts may provide a viable graft material for use in reconstruction of small hand ligaments. This new allograft material avoids the need to harvest a tendon autograft and has a biologic structure similar to native hand ligaments. This study evaluated knee collateral ligaments for use as allografts in small joint reconstruction in the hand, specifically the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) and the index finger proximal interphalangeal (PIP) joint radial collateral ligament (RCL), and compared them to the current gold standard, tendon autograft. Uniaxial tensile testing was performed on native thumb MCP UCLs and index finger PIP RCLs and 2.5-mm–diameter grafts prepared from hemi-flexor carpi radialis (hemi-FCR) tendons and knee medial collateral ligaments (MCLs) cadaveric allografts. In situ angular testing was performed in thumb MCP and index finger PIP joints. Each MCP/PIP joint was secured to a mechanical testing system and cyclically loaded. The UCL/RCL was resected and reconstructed with either an MCL or hemi-FCR. Cyclic loading was repeated, followed by angular load to failure. Uniaxial testing of MCL allografts demonstrated greater ultimate stress, ultimate load, and elastic modulus than hemi-FCR grafts and native UCLs/RCLs. The maximum angular deviation of the reconstructed MCP and PIP joints was not significantly different compared with the intact joint with either an MCL or hemi-FCR graft. In situ load to failure demonstrated no differences in failure torque or angular stiffness between MCPs reconstructed with a hemi-FCR and MCL allograft, whereas reconstructed PIP joints demonstrated improved angular stiffness with an MCL allograft compared with a hemi-FCR. Medial collateral ligament allografts demonstrated improved mechanical properties compared with hemi-FCR tendon grafts during uniaxial testing, and grafts performed equivalently in in situ testing of reconstructed thumb/finger joints.

Immunofluorescence analysis of sensory nerve endings in the periarticular tissue of the human elbow joint.

To investigate the dynamic aspects of elbow stability, we aimed to analyze sensory nerve endings in the ligaments and the capsule of elbow joints. The capsule with its anterior (AJC) and posterior (PJC) parts, the radial collateral ligament (RCL), the annular ligament (AL), and the ulnar collateral ligament with its posterior (PUCL), transverse (TUCL) and anterior parts (AUCL) were dissected from eleven human cadaver elbow joints. Sensory nerve endings were analyzed in two levels per specimen as total cell amount/ cm2 after immunofluorescence staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, S-100 protein and 4',6-Diamidin-2-phenylindol, Carbonic anhydrase II and choline acetyltransferase on an Apotome microscope according to Freeman and Wyke's classification. Free nerve endings were the predominant mechanoreceptor in all seven structures followed by Ruffini, unclassifiable, Golgi-like, and Pacini corpuscles (p ≤ 0.00001, respectively). Free nerve endings were observed significant more often in the AJC than in the RCL (p < 0.00002). A higher density of Ruffini endings than Golgi-like endings was observed in the PJC (p = 0.004). The RCL contained significant more Ruffini endings than Pacini corpuscles (p = 0.004). Carbonic anhydrase II was significantly more frequently positively immunoreactive than choline acetyltransferase in all sensory nerve endings (p < 0.05). Sensory nerve endings were significant more often epifascicular distributed in all structures (p < 0.006, respectively) except for the AJC, which had a pronounced equal distribution (p < 0.00005). The high density of free nerve endings in the joint capsule indicates that it has pronounced nociceptive functions. Joint position sense is mainly detected by the RCL, AUCL, PUCL, and the PJC. Proprioceptive control of the elbow joint is mainly monitored by the joint capsule and the UCL, respectively. However, the extreme range of motion is primarily controlled by the RCL mediated by Golgi-like endings.

Neglected Radial Collateral Ligament Rupture: Rare Case Report

Introduction : Rupture of the Radial Collateral Ligament (RCL) of the index metacarpophalangeal (MCP) joint is mostly related to acute local mechanical causes, which severely affect the stability of the MCP joint. Radial collateral ligament (RCL) injuries account for 10-40% of collateral ligament injuries of the thumb metacarpophalangeal joint.ere, we present an extremely rare case of chronic RCL injury.&#x0D; Patient Concern : Pain in the thumb of the right hand accompanied by weakness when trying to grasp something. Complaints are not accompanied by swelling. Patient said 2 years ago had an accident. Thumb at right hand is said to be swollen and shifting.&#x0D; Diagnosis : Based on the combination of physical examination, X-ray, and ultrasonic and magnetic resonance imaging, the patient was diagnosed with Radial Collateral Ligament rupture. Eventually, intra-operative findings confirmed the diagnosis.&#x0D; Intervention : Patient was underwent ligament reconstruction using a Palmaris Longus tendon graft.&#x0D; Conclusion : Favorable results suggest that the free tendon graft using Palmaris Longus is a suitable, safe, and technically feasible procedure for the operative treatment of chronic instability of the thumb metacarpophalangeal joint after radial hyperadduction trauma and complete rupture or deinsertion of the radial collateral ligament.

Suture Tape Augmentation for the Repair of Index Finger Radial Collateral Ligament Injury: A Biomechanical Study

Despite their clinical importance in maintaining the stability of the pinch mechanism, injuries of the radial collateral ligament (RCL) of the index finger may be underrecognized and underreported. The purpose of this biomechanical study was to compare the repair of index finger RCL tears with either a standard suture anchor or suture tape augmentation. The index fingers from 24 fresh-frozen human cadavers underwent repair of torn RCLs using either a standard suture anchor or suture tape augmentation. Following the repairs, the initial displacement of the repair with a 3-N ulnar deviating load was evaluated. Next, the change in displacement (cyclic deformation) of the repair after 1,000 cycles of 3 N of ulnar deviating force was calculated (displacement of the 1000th cycle- displacement of the first cycle). Finally, the amount of force required to cause clinical failure (30° ulnar deviation) of the repair was determined. Suture tape augmentation repairs displayed significantly less cyclic deformation (0.8± 0.5 mm) after cyclic loading than suture anchor repairs (1.8 ± 0.7 mm). There was no significant difference in the force required to cause the clinical failure of the repairs between the suture tape (35.1 ± 18.1 N) and suture anchor (24.5 ± 9.2 N) repairs. Index finger RCL repair with suture tape augmentation results in decreased deformation with repetitive motion compared with RCL repair alone. Suture tape augmentation may allow for early mobilization following index finger RCL repair by acting as a brace that protects the repaired ligament from deforming forces.

Ultrasonography: an interesting imaging method for ligament assessment during the acute phase of closed elbow injuries.

To evaluate whether ultrasonography can be used to explore the medial and lateral ligament structures during the acute phase of a closed elbow injury. A single-center, prospective study performed between December 2019 and June 2020, including patients who suffered a radial head fracture or elbow dislocation. Two radiologists did a blinded analysis using ultrasonography of visibility, injury grade, and presence of bone avulsion for the radial collateral ligament (RCL), lateral ulnar collateral ligament (LUCL), annular ligament (AL), and anterior (MCLant) and posterior bundles (MCLpost) of the medial collateral ligament. The inter-rater agreement was calculated. The ultrasonography findings were compared with the intraoperative findings in the patients who subsequently underwent surgery. Forty patients were included (28 radial head fractures and 12 elbow dislocations). The inter-rater agreement was strong for all the study parameters (kappa between 0.65 and 1), except for the visibility of the LUCL (kappa 0.52) and the visibility and appearance of the MCLpost (kappa 0.54 and 0.47, respectively). The injured ligaments were thicker than their contralateral counterparts (p < 0.05). In the 10 patients who underwent surgery, the radiological-surgical correlation was 100% for the RCL and medial ligaments and 70% for the LUCL. Ultrasonography is a reproducible examination that can be used to assess the damage to elbow ligaments during the acute phase following an injury. This examination could be incorporated into the exploration protocol for elbow injuries during the preoperative assessment and to adapt the treatment.

Arthroscopic rod technique compared to stress ultrasound in the dynamic evaluation of lateral ligament instabilities of the elbow

IntroductionThe purpose was to compare the arthroscopic rod technique to stress ultrasound in the dynamic assessment of lateral elbow instabilities.Materials and methodsFifteen elbows of eight specimen with a mean age of 66.4 ± 13.3 years were assessed in a prone position following a defined dissection setup. After evaluation of the native status, an arthroscopic dissection of the radial collateral ligament (RCL) or lateral ulnar collateral ligament (LUCL), and finally of entire capsuloligamentous structures was performed. Three raters examined each state (native, RCL or LUCL lesion, complete lesion) with the arthroscopic rod technique in 90° flexion and with stress ultrasound in 30 and 90° flexion. The intra-class correlation coefficient (ICC) was calculated to assess the interrater reliability as well as test–retest reliability for each testing modality (arthroscopy and ultrasound).ResultsThe arthroscopic rod technique showed a superior interrater and test–retest reliability of 0.953 and 0.959 (P < 0.001), respectively, when compared to stress ultrasound with an ICC of 0.4 and 0.611 (P < 0.001). A joint space opening during arthroscopy of > 6 mm humero-ulnar or > 7 mm humero-radial was indicative for a lateral collateral ligament lesion. However, a differentiation between an isolated RCL or LUCL tear was not possible. A lateral joint opening of ≥ 9 mm was only observed in complete tears of the lateral capsuloligamentous complex.ConclusionsThe arthroscopic rod technique showed a superior interrater and test–retest reliability when compared to stress ultrasound. Arthroscopic assessment for radial elbow instability was found to be reliable and reproducible. A joint gapping ≥ 9 mm in the arthroscopic evaluation is a sign for a complete insufficiency of the radial capsuloligamentous complex. However, it is not possible to precisely distinguish between a lesion of the RCL or LUCL by arthroscopy.On the basis of our results, dynamic ultrasound testing may be inappropriate to objectify lateral elbow instability.

Modified Wassel-Flatt Type III Radial Polydactyly: Subtypes and Their Outcomes

We aimed to subdivide modified type III radial polydactyly and evaluate the applied surgical procedures and outcomes according to the subtypes. This study included 32 thumbs of 32 patients treated for modified Wassel-Flatt type III radial polydactyly from March 2008 to December 2018. Each patient was subclassified into parallel, divergent, and convergent types according to the alignment of the duplicated digit. The parallel type was further divided according to the treatment method applied. The parallel A group comprised patients treated with reconstructing the radial collateral ligament of the interphalangeal (IP) joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit, and the parallel B group comprised patients treated with excision of the extra digit at the bifurcation site of the proximal phalanx. We evaluated the Japanese Society for Surgery of the Hand scores and radiographic angulation of the IP and metacarpophalangeal joints at a mean follow-up of 38 months. Fourteen cases were parallel type (6 and 8 in the parallel A and B groups, respectively), 14 were divergent type, and 4 were convergent type. Patients in the parallel A group had significantly better IP and metacarpophalangeal joint angulation and Japanese Society for Surgery of the Hand scores than those in the parallel B group. Patients in the parallel A group had significantly better Japanese Society for Surgery of the Hand scores than those in the divergent and convergent groups. Reconstructing the radial collateral ligament of the IP joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit was associated with better outcomes than the excision of the extra digit at the bifurcation site in the parallel type cases. The parallel type treated with proximal phalanx preservation and ligament reconstruction had better clinical outcomes than other types of modified Wassel-Flatt type III radial polydactyly. Prognostic IV.

Anatomical and radiological description of ligament insertions on the radial aspect of the scaphoid bone

Anatomical studies on the radial side of the scaphoid mention inter-ligamentous connections, but without detailed description of their relations to one another. The purpose of this study was to provide an anatomical and radiological description of the ligamentous structure on the radial side of the scaphoid. High-field 3-Tesla 3D MRI scans of 7 cadaveric formaldehyde-fixed wrists were performed to assess the presence and location of each ligament. Dissection was performed in 10 wrists under microscopy on the radial side to assess the dimensions, anatomical variations and angles between ligaments in various wrist positions during in intracarpal pronation/supination, flexion/extension and ulnar/radial deviation. This study confirmed that the same ligament configuration was found on MRI and on dissection. The scaphotrapezial ligament, dorsal intercarpal ligament and radial collateral ligament fibers merge along the dorsal ridge of the scaphoid. The fibers of the radial collateral and radioscaphocapitate ligaments could be distinguished in only 4/10 specimens. Wrist position changes from intracarpal pronation to supination produced major changes in angle between the scaphotrapezial and dorsal intercarpal ligaments, while other position changes affected this angle only slightly. 3D MRI sequences allow these structures to be systematically analyzed in case of scapholunate instability. Further studies should be conducted to assess the biomechanical properties of these ligaments and the clinical consequences of isolated injury in this region.

Comparative histomorphological analysis of elbow ligaments and capsule

This study aimed to compare the histomorphology of the elbow capsule and its ligaments to gain a better understanding of the clinically relevant biomechanical stabilization. Eleven human elbows were dissected including the joint capsule with its anterior (AJC) and posterior (PJC) parts, the annular ligament (AL), the radial collateral ligament (RCL) and the ulnar collateral ligament with its anterior (AUCL), posterior (PUCL) and transverse (TUCL) parts. Hematoxylin-Eosin and Elastica van Gieson as conventional histology stainings were applied to determine collagenous and elastic fiber arrangements in transmission and polarization light microscopy. The radial collateral ligament and the anterior part of the ulnar collateral ligament showed significantly more densely packed parallel fiber arrangement than the anterior joint capsule, the posterior joint capsule, and the posterior part of the ulnar collateral ligament (p < 0.02, respectively). The PUCL had significantly more mixed tight and loose parallel arrangements than the PJC, the annular ligament, the RCL, the AUCL and the transverse part of the ulnar collateral ligamentp < 0.02, respectively), while the PJC showed significantly more interlaced mixed tight and loose fiber arrangement than the AL, the RCL and the AUCL (p < 0.003, respectively). The AJC had a significantly higher amount of elastic fibers as compared to the AL, the RCL, the AUCL and the TUCL in fascicular regions (p < 0.04, respectively), while the AUCL had significantly lesser elastic fibers than the AJC and the PJC (p < 0.004, respectively). The densely packed parallel fiber arrangement and few elastic fibers of the AUCL, RCL, and AL indicate a strong biomechanically stabilizing function. The fiber arrangement of the PUCL and the TUCL with few elastic fibers support the medial elbow stabilization. Crimping and elastic fibers provide the viscoelasticity of the joint capsule.