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Scientific Articles   |    
Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
Marc J. Richard, MD1; J. Mack AldridgeIII, MD2; Ethan R. Wiesler, MD3; David S. Ruch, MD4
1 Division of Orthopaedic Surgery, Duke University Medical Center, 3609 Southwest Durham Drive, Durham, NC 27707. E-mail address: marc.richard@duke.edu
2 Division of Orthopaedic Surgery, Duke University Medical Center, 3116 N. Duke Street, Durham, NC 27704
3 Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
4 Division of Orthopaedic Surgery, Duke University Medical Center, Box 3466, Durham, NC 27710
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Duke University Medical Center, Durham, and Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Nov 01;90(11):2416-2422. doi: 10.2106/JBJS.G.01448
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Abstract

Background: The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair.

Methods: Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Results: Full active range of motion was achieved in ten patients; the remaining patient had a 20° flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6.

Conclusions: Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Marc J. Richard, MD
    Posted on November 24, 2008
    Drs. Richard and Ruch respond to Dr. Kini
    Duke University Medical Center

    We thank Dr. Kini for his interest in our recent article and we appreciate the opportunity to respond.

    While all of the patients included in our study were athletes, only 3 of the 11 patients were overhead athletes. However, all patients were evaluated for concomitant injuries and elbow pathology as reported in our study. None of the overhead athletes reported a history of pain through the deceleration phase of throwing prior to injury and none of the imaging studies revealed evidence of posteromedial impingement of the olecranon.

    Vitale et al have documented that newer muscle-splitting and docking techniques of ulnar collateral ligament reconstruction without obligatory transposition of the ulnar nerve has led to improved outcomes and lower rates of ulnar neuropathy(1). Closer examination of this review article shows that other authors have demonstrated much lower rates of ulnar neuropathy associated with subcutaneous or subfascial transpositions than with submuscular transposition as was routinely performed with earlier techniques(2,3). We performed subfascial ulnar nerve transposition in all of our patients. In our series, preoperative ulnar neuropathy was the reason for transposition in 3 patients. Seven patients had extensive mobilization of the ulnar nerve for ligament repair and underwent transposition for subluxation of the nerve. In the final patient, the ulnar nerve was transposed because of concern that it would be irritated by the suture material utilized for the ligament repair.

    Finally, in an in vitro study by Pichora et al, the authors demonstrated favorable results of a broad range of acceptable tensions for the ulnar collateral ligament of the elbow(4). We did not measure the tension of the ligament repair. Because these were ligament repairs and not reconstructions, the native anatomy was easily recreated. We placed the elbow in mid-flexion and slight varus at the time of repair to allow appropriate matching of the ligament origin to the footprint on the medial epicondyle.

    References

    1. Vitale MA and Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med. 2008 Jun;36(6):1193-205.

    2. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med. 1995;23:407-413.

    3. Azar FM, Andrews JR, Wilk KE, Groh D. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28:16-23.

    4. Pichora JE, Fraser GS, Ferreira LF, Brownhill JR, Johnson JA, King GJ. The effect of medial collateral ligament repair tension on elbow joint kinematics and stability. J Hand Surg. 2007 Oct;32(8):1210-7.

    Sunil Gurpur Kini, MBBS,M.S(Ortho),D.N.B(Ortho)
    Posted on November 09, 2008
    Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
    Guru Teg Bahadur Hospital , University College of Medical Sciences,Delhi,India

    To the Editor:

    I read with interest the article by Richard, et al.(1). Repair of avulsion injuries of the ulnar collateral ligament has yielded better results than repair of midsubstance tears but the superiority of outcomes of operative treatment over non operative treatment in isolated medial ligament injuries is questionable. I would like ask the authors to comment on the following:

    Posteromedial impingement of the elbow occurs in athletes who use overhead motions and manifests as terminal loss of extension and late onset pain in the deceleration phase of throwing. Was posteromedial impingement of the olecranon seen in any of their athletes?

    Was there any specific reason for ulnar nerve transfer in all patients? Articles have shown that abandoning obligatory transposition of ulnar nerve leads to better outcomes and decreased post operative ulnar nerve neuropathy (2).

    In what degree of flexion of the elbow were the sutures secured and were the sutures tensioned to any numerical value? In vitro studies have shown that overtensioning to over 60 N leads to varus overtightening in midflexion but its effect in vivo are yet to be proven(3).

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1.Marc J. Richard, J. Mack Aldridge, III, Ethan R. Wiesler, and David S. Ruch Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair J Bone Joint Surg Am 2008; 90: 2416-2422

    2. The Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes: A Systematic Review - M. A. Vitale and C. S. Ahmad Am. J. Sports Med., June 1, 2008; 36(6): 1193 - 1205.

    3. The Effect of Medial Collateral Ligament Repair Tension on Elbow Joint Kinematics and Stability . The Journal of Hand Surgery,2007 October, Volume 32,Issue 8,Pages 1210 – 1217 J.Pichora ,G.Fraser,L.Ferreira ,J.Brownhill ,J.Johnson,G . King.

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