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Background Although most radiologic findings of medial epicondylitis (ME) are normal, up to 25% show calcification, and little is known about the clinical relevance of soft tissue calcification in ME. The purpose of this study was to reveal the characteristics of calcification in ME, and to identify their clinical relevance. Methods This study included 187 patients (222 elbows) who were diagnosed with ME. We classified calcification according to its anatomic location, and further evaluated its distribution. Logistic regression analysis was performed to calculate the odds ratios and 95% confidence intervals for possible factors that may affect calcification in ME: age, sex, laterality, hand dominance, visual analog scale (VAS) pain score, Mayo elbow performance score, symptom duration, history of steroid injection, number of steroid injections, concomitant ulnar neuropathy, and treatment method in terms of conservative treatment or surgery. Results In a total of 222 elbows, 53% (118 of 222 elbows) showed calcification in radiologic findings. The VAS pain score, number of steroid injections, and concomitant ulnar neuropathy were significantly associated with calcification in ME. Calcification was most commonly identified at the anatomical insertion site of the common flexor tendon (33%), followed by the pronator teres (18%), and the medial collateral ligament (10%). Of the total cases of calcification, 45% were distributed at multiple sites, and age was strongly associated with multiple distribution. Conclusions Calcification in ME was more commonly identified than previously reported and was distributed over a relatively broad area. Calcification was associated with a higher VAS pain score, history of steroid injection, and combined ulnar neuropathy. The anatomical insertion site of the common flexor tendon most commonly showed calcification, and age was a strong indicator of a broad distribution of calcification.

Background It is widely accepted that transolecranon fracture-dislocations are not associated with collateral ligament disruption. The aim of the present study was to investigate the significance of the collateral ligaments in transolecranon fractures. Methods Twenty cadaveric elbows with a mean age of 46.3 years were used. All soft tissue was dissected to the level of the capsule, leaving the anterior band of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) intact. A standardized, oblique osteotomy starting from the distal margin of the cartilage bare area of the ulna was made. The elbows were loaded with an inferiorly directed force of 5 and 10 N in the intact, MCL cut, LCL cut, and both ligaments cut states. All measurements were recorded on lateral calibrated radiographs. Results The mean inferior translation with intact ligaments (n = 20) when the humerus was loaded with 5 and 10 N was 1.52 mm (95% confidence interval [CI], 1.02-2.02) and 2.23 mm (95% CI, 1.61-2.85), respectively. When the LCL was cut first (n = 10), the inferior translation with 5 and 10 N load was 4.11 mm (95% CI, 0.95-7.26) and 4.82 mm (95% CI, 1.91-7.72), respectively. When the MCL was cut first (n = 10), the inferior translation when loaded with 5 and 10 N was 3.94 mm (95% CI, 0.796-7.08) and 5.68 mm (95% CI, 3.03-8.33), respectively. The inferior translation when loaded with 5 and 10 N and both ligaments cut was 15.65 mm (95% CI, 12.59-18.79) and 17.50 mm (95% CI, 14.86-20.13), respectively. There was a statistical difference between the intact and MCL cut first at 10 N and when both ligaments were cut at 5 and 10 N. Conclusions The findings suggest that collateral ligament disruption is a prerequisite for a transolecranon fracture-dislocation. An inferior translation of more than 3 mm suggests that at least one of the collateral ligaments is disrupted, and more than 7.5 mm indicates that both collateral ligaments are disrupted.

Purpose Several surgical approaches to the medial elbow are described; however, it remains unclear which exposure provides the optimal view of relevant medial elbow structures. The purpose of this anatomic study was to determine the visible surface area of the coronoid process, distal humerus, and radial head through 5 approaches to the medial elbow. Methods Eight fresh-frozen cadaveric upper extremity specimens were dissected. Five surgical approaches were performed on each specimen. The Smith muscle-splitting approach to the ulnar collateral ligament was performed first (Smith), followed by the Hotchkiss medial “Over the top” approach (Hotchkiss), the extended medial elbow approach (EMEA), the flexor carpi ulnaris splitting approach (FCU-Split), and the Taylor and Scham approach (TS Artec 3D). The scans were segmented using commercially available digital software (Geomagic Wrap; 3D Systems Corporation), and the surface area visualized was determined. A descriptive analysis of the joint areas visible using the medial collateral ligament (MCL) as a clinical landmark was performed. Results The EMEA visualized the highest proportion of the total elbow joint from the medial side showing 13.9 ± 6.0 cm2, or 15% ± 4% of the joint. It also provided the best visualization of the coronoid (3.2 ± 1.7 cm2 of surface area, or 26% ± 9%) and distal humerus (9.9 ± 4.3 cm2, or 15% ± 4%). The Hotchkiss approach was best at visualizing the radial head (0.8 ± 0.3 cm2, or 7% ± 3%). The EMEA, Hotchkiss, and Smith approaches showed primarily the anterior bundle of the MCL, its insertion, and the regions anterior to it, whereas the FCU-Split showed the anterior bundle of the MCL and regions both anterior and posterior to it. The TS the anterior regions were not visible. The FCU-Split and the T&S allowed visualization of the posterior bundle of the MCL. The intraclass correlation coefficients (ICCs) for intraobserver reliability were 0.997, 0.992, and 0.974 for the test distal humerus, test coronoid, and test radial head, respectively. The ICCs for interobserver reliability were 0.915 for the test distal humerus, 0.66 for the coronoid, and 0.583 for the radial head. Conclusion The EMEA provides the most visualization of the coronoid and distal humerus, whereas the Hotchkiss showed the most radial head. However, these approaches mainly visualize structures anterior to the MCL. If exposure of structures posterior to the MCL is required, the FCU-Split and T&S approaches are more appropriate.

Background The medial collateral ligament of the elbow joint consists of the anterior oblique ligament (AOL), posterior oblique ligament (POL), and transverse ligament (TL). This study aimed to clarify the structure of the TL, with a focus on the continuity between the TL and AOL. Methods A total of 42 cadavers (18 males, 24 females) were dissected at Aichi Medical University between 2016 and 2018. Cases of elbow deformity or atrophy were excluded, and 60 elbows (15 males, 15 females) were dissected to assess the fibers of both the TL and AOL using a stereomicroscope. Results The TL could be detected in all elbows and always continued to the AOL. The TL was classified into 2 types. The TLs continuing to the distal half of the AOL (type I) were observed in 44 elbows (73.3%), whereas the TLs continuing to the entire AOL (type II) were found in 16 elbows (26.7%). Type II TLs were significantly more frequently observed in the elbows of females than in those of males (P = .041). Stereomicroscopic observation revealed that the TL fibers entered perpendicularly to the distal half of the AOL in both types. Conclusions The TL frequently continues to the distal half of the AOL, but rarely continues to the entire AOL. The TLs continuing to the entire AOL were more frequently detected in the elbows of females than in those of males. The TL possibly contributes to medial elbow stability via its continuity to the AOL.

Background Recently, the Internal Joint Stabilizer of the Elbow (IJS-E) was developed as an internal dynamic fixator for use in the setting of traumatic elbow instability. This study reviews the patients who had an IJS-E placed at our institution. Specifically, postoperative complications, postoperative functional outcomes, and need for subsequent procedures were reviewed. Methods A retrospective chart review was conducted of patients in whom the IJS-E was implanted from June 2016 to July 2018. Indications for use, range of motion at final follow-up, and the need for subsequent procedures were reviewed. Disabilities of the Arm, Shoulder, and Hand (DASH) and Broberg-Morrey scores were also obtained. Results Ten IJS-E devices were implanted into 10 patients. Average length of follow-up was 13.4 months. Average flexion-extension and pronation-supination motion arcs at final follow-up were 106° and 141°, respectively. Seventy-eight percent of patients achieved >100° arcs of both flexion-extension and pronation-supination. Average DASH and Broberg-Morrey scores were 28.7 and 68.2, respectively. Four subsequent procedures were required in 4 patients: 2 contracture releases, 1 medial collateral ligament reconstruction, and 1 total elbow arthroplasty. There were no postoperative infections or nerve injuries. Discussion The IJS-E has replaced the use of external hinged fixation at our institution. Final range of motion was consistent with that reported for terrible triad and complex elbow dislocation injuries. The IJS-E is a good option for use in patients with traumatic elbow instability, as it restores motion and function without immediate postoperative complication. However, it does not eliminate the potential for future operative intervention in these complex injuries.

Background Because medial elbow stability is essential for stiff elbow release, surgical techniques have been reported for reconstructing medial elbow stability. However, medial collateral ligament (MCL) defects, caused by inevitable detachment and resection performed for complete release, make the reconstruction more challenging. To our knowledge, no study has evaluated the outcomes after using a flexor-pronator fascia patch in medial elbow reconstruction for open release of stiff elbows. We hypothesized that this technique is effective for repairing MCL defects. Methods We retrospectively reviewed the records of 10 patients. The MCL defects were all reconstructed with a flexor-pronator fascia patch. An external fixator was used in all patients. One patient could not be contacted and was thus excluded from the study. Outcome measures included stability, range of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, power grip, and radiographic findings. Results The mean follow-up period was 19.6 months; all elbows were stable by the last follow-up. One patient presented with moderate elbow instability and then regained stability 3 months after the external fixator was removed. The Mayo Elbow Performance Score improved from 58 points to 94 points, and the mean flexion arc improved from 40° to 133°. No radiographic manifestations of elbow dislocation or suture anchor looseness were observed. Conclusion A flexor-pronator fascia patch provides sufficient stability for repairing MCL defects without restricting the range of motion gained during arthrolysis.

Background There has been a renewed interest in the pathomechanics of elbow dislocation, with recent literature having suggested that the medial ulnar collateral ligament is more often disrupted in dislocations than the lateral ligamentous complex. The purpose of this serial sectioning study was to determine the influence of the posterior bundle of the medial ulnar collateral ligament (pMUCL) as a stabilizer against elbow dislocation. Methods An elbow dislocation was simulated in 5 cadaveric elbows by mechanically applying an external rotation moment and valgus force. Medial ulnohumeral joint gapping was measured at 30°, 60°, and 90° of flexion in an intact elbow after sectioning of the medial collateral ligament's anterior bundle (aMUCL) and then after sectioning of the pMUCL as well. Results After sectioning of the aMUCL, the pMUCL was able to stabilize the joint against dislocation. After aMUCL sectioning, the proximal joint space significantly increased by 4.2 ± 0.6 mm at 30° of flexion and 2.6 ± 0.3 mm at 60° of flexion, although it did not dislocate. The gapping increase of 0.9 ± 0.6 at 90° of flexion did not reach significance. After sectioning of the pMUCL (after having already sectioned the aMUCL), all of the specimens frankly dislocated at all flexion angles. Conclusions An intact pMUCL can prevent elbow dislocation and limited joint subluxation to within 6.6 mm. Our findings indicate that repair or reconstruction may be warranted in certain circumstances (ie, residual instability after operative management of a terrible triad injury or after aMUCL reconstruction).

This study aimed to determine the extent to which the medial collateral ligament (MCL) can be visualized during a standard posterior arthroscopic view of the elbow.Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. Standard elbow arthroscopy was performed on each specimen using a standard posterior portal for visualization with a 30° arthroscope. The most distal borders of the visible part of the MCL were marked using a spinal needle and tagged using nylon sutures. Subsequently, the elbow was dissected. The overall surface area of the entire MCL and that defined by the suture tags were calculated for each specimen.The mean area of the visible part of the MCL represented 48% of the mean overall area. The arthroscopically tagged part of the posterior band of the MCL represented50% of the entire MCL. Arthroscopic visualization was not available for most of the posterior bands of the MCL.Less than half of the MCL is visible with a 30° arthroscope from standard posterior portal. Thus, sole reliance on arthroscopic visualization with this manner is not enough to release of the MCL. The variable effort is required to improve the limited visualization during the procedure. Moreover, the individual attention is essential to protect the ulnar nerve because the ulnar nerve is very close to the MCL especially to the anterior band.

Background Acute injuries to the anterior medial collateral ligament (AMCL) can occur due to valgus trauma or during other dislocating events to the elbow. AMCL lesions are often associated with bony lesions, such as radial head fractures or fractures of the coronoid process. We analyzed the insertion of the AMCL on the sublime tubercle in relation to surrounding osseous structures. We aimed to increase the understanding of the involvement of the AMCL in bony lesions to the sublime tubercle. Methods We investigated 86 elbows from 43 embalmed human specimens. We measured the most ventral extensions of the AMCL at the sublime tubercle in relation to a clearly defined and reproducible landmark. We used as our landmark a horizontal line (baseline) originating on the lesser sigmoid notch in a right angle to the ulnar ridge. Results The mean distance of the coronoid process tip to the baseline was 4.0 mm (standard deviation [SD], 1.3 mm; range, 1.4-6.7 mm). The mean distance of the ventral extension of the AMCL to the horizontal line was 3.7 mm (SD, 2.6 mm; range: 9.4-2.2 mm). The mean horizontal distance between the ventral aspect of the AMCL and the coronoid tip was 13.7 mm (SD, 2.5 mm; range, 7.7-20.5 mm). Conclusions We present a detailed description of the insertional anatomy of the AMCL at the sublime tubercle. These values could be helpful for classifications of coronoid fractures and to estimate the involvement of the AMCL in fractures of the sublime tubercle.

Tendinous and ligamentous injuries commonly occur in the elbow. This study characterized the location, surface areas, and origin and insertional footprints of major elbow capsuloligamentous and tendinous structures in relation to bony landmarks with the use of a precision 3-dimensional modeling system.Nine unpaired cadaveric elbow specimens were dissected and mounted on a custom jig. Mapping of the medial collateral ligament (MCL), lateral ulnar collateral ligament (LUCL), triceps, biceps, brachialis, and capsular reflections was then performed with 3-dimensional digitizing technology. The location, surface areas, and footprints of the soft tissues were calculated.The MCL had a mean origin (humeral) footprint of 216 mm(2), insertional footprint of 154 mm(2), and surface area of 421 mm(2). The LUCL had a mean origin footprint of 136 mm(2), an insertional footprint of 142 mm(2), and a surface area of 532 mm(2). Of the tendons, the triceps maintained the largest insertional footprint, followed by the brachialis and the biceps (P.001-.03). The MCL, LUCL, and biceps footprint locations were consistent, with little variability. The surface areas of the anterior (1251 mm(2)) and posterior (1147 mm(2)) capsular reflections were similar (P = .82), and the anterior capsule extended farther proximally.Restoring the normal anatomy of key elbow capsuloligamentous and tendinous structures is crucial for effective reconstruction after bony or soft tissue trauma. This study provides the upper extremity surgeon with information that may aid in restoring elbow biomechanics and preserving range of motion in these patients.

It is now well recognized that excessive resection of the osteophyte at the medial corner of the olecranon for extension overload impingement will cause an increased strain of the medial collateral ligament and, ultimately, medial collateral ligament deficiency. 3 Studies have shown that removal of as little as 3 mm of normal bone will result in measurable increased strain in the anterior bundle of the medial collateral ligament. 2 It is also accepted that instability during throwing, which occurs from excessive removal of the medial corner of the olecranon, is extremely difficult if not impossible to correct surgically. Surprisingly, to date, there has been no information in the orthopedic literature that describes successful treatment of symptomatic instability from deficiency of the medial corner of the olecranon process, even after the anterior bundle of the medial collateral ligament has been

Background Although the anterior bundle of the medial collateral ligament (AMCL) is a critical stabilizer of the elbow joint, little information exists on in vivo and 3-dimensional functional anatomy of the AMCL. The purposes of this study were to investigate in vivo changes in the length of the AMCL during elbow flexion and to clarify the 3-dimensional functional anatomy of the AMCL. Methods We created 3-dimensional models of the AMCL and bones from computed tomography data of 4 healthy elbows in 5 different elbow positions. The AMCL was subdivided into 9 ligaments. We calculated changes in lengths of ligaments during flexion and related ligament origins to the axis of rotation of the elbow joint. Results There were 4 uniquely configured isometric ligaments, where their origins aligned broadly along the course of the axis of rotation in the coronal plane. The medially originating ligaments inserted on the posterior portion of the tubercle of the coronoid process, whereas the laterally originating ligaments inserted on its anterior portion. There were 5 non-isometric ligaments, 3 of which had origins proximal to the axis and became taut only in extension and the other 2 having origins distal to the axis and becoming taut only in flexion. Conclusions Isometric ligaments within the AMCL do not originate from a narrow area; rather, they originate from a broader area that extends more medially in the coronal plane than previously thought, which explains how the AMCL reconciles isometricity and robustness. The proximal and distal ligaments act as checkreins that work only at the limits of elbow motion.

Background Our objective was to analyze the effect of different anteromedial coronoid fracture patterns with different combinations of ligamentous repairs. We hypothesized that smaller fractures would be sufficiently treated with ligamentous repair alone but that larger fragments would require a combination of ligament and bony repair versus reconstruction. Methods Two multibody models were created from cadaveric specimens in the ADAMS program. Four different conditions were simulated: (1) no fracture, (2) O'Driscoll anteromedial subtype I (2.5-mm) fracture, (3) subtype II 2.5-mm fracture, and (4) subtype II 5-mm fracture. In each of these conditions, 3 ligament repairs were studied: lateral ulnar collateral ligament (LUCL), posterior bundle of the medial collateral ligament (pMCL), and both LUCL and pMCL. For each condition, kinematics and articular contact areas were calculated. Results LUCL repair alone increases whereas pMCL repair decreases internal rotation of the ulna relative to all tested posteromedial rotatory instability conditions; their rotational effects are summative when both ligaments are repaired. With a subtype I fracture and both pMCL and LUCL injuries, repairing the LUCL alone corrects angulation whereas rotational stability is satisfactory through the arc from 0° to 90°. In a subtype II 2.5-mm fracture, isolated repair of the LUCL or pMCL is not capable of restoring rotation or angulation. For a subtype II 5-mm fracture, no combination of ligamentous repairs could restore rotation or angulation. Conclusions This study suggests that LUCL repair alone is sufficient to restore kinematics for small subtype I fractures for an arc avoiding deep flexion; whereas nearly normal kinematics throughout the arc of motion can be achieved if the pMCL is also repaired. Larger anteromedial coronoid fractures should ideally have fragments fixed in addition to ligament repairs.

Single-strand elbow medial collateral ligament reconstruction strength was evaluated by use of double-docking and interference screw methods with either a palmaris longus tendon or GraftJacket as the reconstruction material. Thirteen upper extremities were mounted in 90 degrees of valgus orientation and subjected to cyclic valgus loading that increased progressively until failure occurred. The double-docking reconstructions outperformed the interference screw reconstructions (P.05), whereas the palmaris longus and GraftJacket performed comparably (P.05). The favorable initial strength of the GraftJacket make it a potentially viable alternative to the use of autogenous palmaris longus tendons; however, further studies are required to evaluate graft strength during healing. The clinical use of the double-docking technique of single-strand medial collateral ligament reconstruction should be considered because of its simplicity and initial strength.

The objective of this study was to determine the effect of suture repair of type 1 coronoid fractures on elbow kinematics in ligamentously intact and medial collateral ligament (MCL)-deficient elbows. Cadaveric testing was performed in stable and MCL-deficient elbows with radial head arthroplasty and with the coronoid intact, with the coronoid fractured, and after suture repair. Ulna versus humerus angulation was measured during active motion. Varus and valgus motion pathways were measured during passive gravity-loaded flexion. With intact ligaments, there was a small increase in valgus angulation after a type 1 fracture that was not corrected with suture fixation. With MCL deficiency, there was no change in kinematics regardless of coronoid status. Type 1 coronoid fractures cause only small changes in elbow kinematics that are not corrected with suture repair. MCL repair, rather than type 1 coronoid fixation, should be considered if the elbow remains unstable after radial head repair or replacement and lateral ligament repair.

Capsular plication or thermal shrinkage can be used to enhance surgical joint stabilization. We compared mechanical or morphologic properties of the medial collateral ligament of the rabbit knee treated by either bipolar radiofrequency electrothermal shrinkage or surgical plication. After 12 weeks, the medial collateral ligaments were procured from treated and contralateral knees to undergo viscoelastic (creep) testing, quantitative transmission electron microscopy, and immunohistochemistry. Creep strain in thermal (1.85% +/- 0.32%) and plicated (1.92% +/- 0.36%) ligaments was almost twice that of the control group (1.04% +/- 0.15%), although there was no difference between treatment modalities. The morphologic parameters of all 3 groups were significantly different (P.001). The thermal ligaments demonstrated predominantly small fibrils, whereas the plicated group displayed an intermediate distribution of heterogeneous fibrils, suggesting a different pattern of remodeling. Viscoelastic properties are similar after thermal shrinkage or plication, though inferior to those of intact ligaments.

The purpose of this study was to evaluate the incidence of combined osteochondral and ligamentous injuries by magnetic resonance imaging (MRI) in 24 patients with an acute radial head fracture (Mason type II and III) without documented dislocation or tenderness at the distal radioulnar joint. Elbow radiographs (anteroposterior and lateral views) were obtained on all patients as well as magnetic resonance images in the sagittal, coronal, axial, axial oblique, and coronal oblique planes with the injured elbow in a splint. The incidence of associated injuries revealed by MRI was medial collateral ligament not intact in 13 of 24 (54.16%), lateral ulnar collateral ligament not intact in 18 of 24 (80.1%), both collateral ligaments not intact in 12 of 24 (50%), capitellar osteochondral defects in 7 of 24 (29.1%), capitellar bone bruises in 23 of 24 (95.83%), and loose bodies in 22 of 24 (91.67%). A high level of suspicion should be used when one is treating displaced or comminuted radial head fractures, because concurrent osteochondral injuries and/or ligamentous injuries may be present.

Background The purpose of this study was to investigate the pathoanatomy of acute valgus instability without elbow dislocation and to evaluate clinical outcomes after operative treatment. Methods Seven patients presented with acute severe valgus instability without elbow dislocation or fracture after a single traumatic episode. Five patients had primary repair of the medial collateral ligament (MCL) and flexor-pronator tendon (FPT) with suture anchor. Two patients with highly unstable elbow had primary repair of both the medial and lateral structures. On the basis of magnetic resonance imaging and intraoperative findings, the injury patterns of the ligament, capsule, tendon, and bone structures were evaluated. Clinical outcomes were assessed with the Mayo Elbow Performance Score and the shortened Disabilities of the Arm, Shoulder, and Hand score. Results A complete tear of the MCL from its humeral origin and FPT was found in all patients. The anterior capsule was also damaged. A stripping-type complete tear of the lateral collateral ligament complex with significant instability was observed in 2 patients. Bone contusion at the capitellum or radial head was found in 6 patients. The mean Mayo Elbow Performance Score and shortened Disabilities of the Arm, Shoulder, and Hand score at final follow-up were 95.7 and 12.0. All patients returned to previous work levels within 4 months after operation. Conclusion These results indicate that complete tears of both the MCL and FPT occur with severe valgus instability. Primary repair of medial structures with suture anchor in acute severe valgus instability can restore stability.

The purpose of this study was to determine the contribution of the central portion of the anterior bundle of the medial collateral ligament (MCL) to elbow stability and to evaluate the effectiveness of a single-strand MCL reconstruction in restoring elbow stability. Testing of 11 fresh-frozen upper extremities was first performed on the intact elbow and then with the capsule, flexor-pronator muscle group, posterior bundle, anterior or posterior band, and central band cut sequentially. Next, a single-strand reconstruction of the MCL was performed. The elbow was moved passively through a full arc of flexion in both varus and valgus gravity-loaded positions. Ulnar movement with respect to the humerus was analyzed by means of an electromagnetic tracking system. Maximum varus-valgus laxity throughout the arc of supinated flexion and pronated flexion was 6.6 degree plus minus 2.4 degree and 7.4 degree plus minus 2.0 degree, respectively, for the intact specimen, 34.2 degree plus minus 5.6 degree and 37.7 degree plus minus 11.8 degree for the specimen with all of the medial valgus elbow stabilizers cut, and 9.0 degree plus minus 2.5 degree and 10.5 degree plus minus 2.7 degree for the reconstructed specimen. Maximum varus-valgus laxity was not significantly different among any of the sectioning sequences until the central band was cut (P.0001). There was no significant difference in maximum varus-valgus laxity between the intact and reconstructed elbows (P.05). Our results demonstrate that the central band is an important valgus stabilizer of the elbow and that a simplified single-strand reconstruction is able to restore stability to the MCL-deficient elbow.

Background Total elbow arthroplasty is successful in older, lower demand patients but not in the younger, more active individual with severe elbow arthritis. Interposition arthroplasty is an alternative for younger patients who hope to minimize the degree to which arm use is restricted. Interposition arthroplasty traditionally involves release of all ligaments and capsule. As a result, the postoperative care included the use of a hinged external fixator of the elbow to apply distraction and to permit motion during the early phases of healing. We describe a novel surgical technique without a hinged external fixator that allows secure fixation of the interposition graft through arthroscopic assistance and maintains the integrity of the medial collateral ligament with only a takedown and repair of the lateral collateral ligament complex. Methods A retrospective chart review was performed to analyze 4 patients with an average age of 57 years who underwent surgery between 2007 and 2011. The patients were also contacted to assess elbow-specific American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder, and Hand scores. Results The average follow-up was 3.6 years (range, 2.5-6 years), and 1 patient was converted to a total elbow arthroplasty after 2.5 years because of persistent pain. The remaining 3 patients have done well with regard to pain control, stability, and functional use of the operative extremity. There were no postoperative complications. Discussion On the basis of our small series of patients, an arthroscopically assisted elbow interposition arthroplasty without hinged external fixation can provide satisfactory medium-term outcomes as a salvage procedure for a difficult condition with limited options.

Background Elbow instability remains a challenging surgical problem. Most commonly, isolated reconstructions of the medial collateral ligament or lateral collateral ligament are performed; however, on occasion, there can be deficiency that requires reconstruction of both ligaments. The senior author has developed a method to reconstruct both the medial and lateral collateral ligaments using 1 graft. This technique uses a “box-loop” design, whereby the donor tendon is passed through the humerus and ulna and tied back to itself, creating a loop. Materials and methods Fourteen cases with mean follow-up of 64 months were reviewed. Nine patients returned to the clinic and were evaluated both clinically and radiographically. An additional 5 patients participated by phone questionnaire. Results Average follow-up time was 64 months (range, 19-109 months). According to the Summary Outcome Determination given by the patients, 7 elbows were normal or nearly normal, 4 were greatly improved, 2 were improved, and 1 was worse compared with before surgery. The Summary Outcome Determination score average was 7 (range, −2 to 10). American Shoulder and Elbow Surgeons scores (including both clinic patients and phone questionnaire patients) ranged from 36 to 100, with an average of 81; of 14 patients, 8 had an American Shoulder and Elbow Surgeons self-satisfaction score of 10. The average Quick Disabilities of the Arm, Shoulder, and Hand score was 13 (range, 0-64). The average Mayo Elbow Performance Index score was 88 (range, 60-100), with 4 excellent (90-100), 3 good (75-89), and 3 fair (60-74) results and no poor results. Discussion This technique was found to have excellent midterm results. Compared with separate medial- and lateral-sided reconstruction, there is simplification of bone tunnel formation as well as graft fixation.

Background Despite an improved understanding of coronoid anteromedial facet (AMF) fractures, the optimal treatment protocol and technique have not yet been established. The goals of the study were to describe the characteristics of AMF fractures, to suggest a surgical strategy, and to report the outcomes after treatment according to this protocol. Methods This was a retrospective study of 19 patients with AMF fractures between 2010 and 2012. Eight patients were excluded because of secondary olecranon fracture, radial head fracture, and elbow dislocation, leaving 11 patients with isolated AMF fracture in the study cohort. There were 7 men and 4 women, with an average age of 42 years (range, 29-62 years). Fracture classification, injury pattern, and accompanying collateral ligament injury were analyzed. O'Driscoll subtype 1 fractures were treated with lateral collateral ligament (LCL) repair; O'Driscoll subtype 2 and subtype 3 fractures were treated with buttress plating and LCL repair. Plain radiographs were used to evaluate union, arthritic change, and joint articulation. Functional outcomes were evaluated with range of motion and the Mayo Elbow Performance Score. Results Two patients had O'Driscoll anteromedial subtype 1 fracture, 4 patients had subtype 2, and 5 patients had subtype 3. Two patients with subtype 1 fracture had associated posterior dislocation; 9 patients with subtype 2 or subtype 3 had associated varus posteromedial injury. All 11 patients had associated LCL injury, and 6 patients had associated medial collateral ligament injury. The mean range of motion was 128°, and the average Mayo Elbow Performance Score was 89 points. Qualitatively, patient outcomes were scored excellent in 4 patients, good in 6 patients, and fair in 1 patient. Conclusion AMF fractures are almost always accompanied by collateral ligament injuries. Thus, our surgical strategies, which include collateral ligament repair, are able to stabilize and result in favorable clinical outcomes. On the basis of our results, we recommend LCL repair alone for subtype 1 fractures and buttress plating and LCL repair for subtype 2 and subtype 3 fractures.

Thermal denaturation of collagen in ligament tissue has the potential to enhance arthroscopic shoulder stabilization. Previous studies have shown that laser energy produces significant capsular shortening without alteration of viscoelastic properties, but little information is available on the effects of radio frequency electrothermal energy. We assessed the acute effects of radio frequency shrinkage with use of the lapine medial collateral ligament model, in which the tibial insertion was shifted proximally to produce abnormal laxity. Thermal treatment resulted in restoration of laxity from 3.33 +/- 0.25 mm to 0.66 +/- 0.31 mm, which was not significantly different from medial collateral ligaments replaced anatomically (0.50 +/- 0.34 mm). When tested at 4.1 megapascals, cyclic and static creep strains were increased twofold to threefold in thermally-treated ligaments (P.01), and partial failure occurred in 2 of 8 cases. We conclude that radio frequency electrothermal shrinkage is effective at reducing laxity but significantly alters viscoelastic properties, posing a risk of recurrent stretching-out at "physiological" loads.

The purposes of this study were to evaluate the usefulness of thin-section 3-dimensional Fourier Transform (3DFT) gradient echo imaging of the medial collateral ligament and to evaluate the usefulness of intraarticular gadolinium for the detection of tears of the ligament. Magnetic resonance imaging was performed on 5 fresh-frozen cadaveric elbows through use of T1-weighted and 3DFT gradient echo T2-weighted sequences. The elbows were then arthroscoped, and lesions were created in the medial collateral ligaments. Magnetic resonance imaging was then repeated with the T1 and 3DFT sequences. In addition, dilute gadolinium was then injected intraarticularly, and fat-suppressed T1-weighted images and 3DFT images were obtained. Magnetic resonance imaging findings were correlated with the appearance of the dissected ligament. We found that in the prearthroscopy specimens, the ligament was best seen on the 3DFT images reformatted into a slightly posteriorly obliqued coronal plane. In the postarthroscopy elbows, 4 full-thickness perforations were detected with the 3DFT sequence; fat-suppressed T1-weighted images with intraarticular gadolinium detected these 4 as well as 1 partial inner surface tear. In conclusion, fat-suppressed T1-weighted magnetic resonance arthrography with gadolinium can provide information regarding inner surface partial tears and small full-thickness perforations. (J Shoulder Elbow Surg 2000;9:418-22.)

We performed a retrospective review to evaluate acute medial collateral ligament injuries of the elbow in professional football players from 1991 to 1996 (5 seasons). There were 5 acute medial collateral ligament injuries in 4 players (1 player with bilateral involvement). All injuries occurred with the hand planted on the playing surface while a valgus or hyperextension force was applied to the elbow. There were 2 centers, both involved with long-snapping situations, 1 running back, and 1 quarterback. All elbows had valgus instability on physical examination. Despite this instability, all players were able to function without operative reconstruction of the medial collateral ligament. No evidence of valgus instability was seen at the time of follow-up (average, 3.4 years). Next, we reviewed all acute elbow injuries in the National Football League from the same 5-season period. Ninety-one acute elbow injuries were reviewed. Overall, there were 70 (76.9%) elbow sprains, 16 (17.6%) dislocation/subluxation patterns, 4 (4.4%) fractures, and 1 (1.1%) miscellaneous injury. Review of the acute elbow sprains revealed 39 (55.7%) hyperextension injuries, 14 (20%) medial collateral ligament injuries, 2 (2.9%) lateral collateral ligament sprains, and 15 (21.4%) nonspecific sprains. The epidemiology of the 14 medial collateral ligament injuries was studied in more detail. The 2 most common mechanisms of injury were blocking at the line of scrimmage (50%) and the application of a valgus force with the hand planted on the playing surface (29%). There were 8 linemen, 4 receivers, 1 running back, and 1 quarterback. All injuries were managed with nonoperative treatment. The average time lost was 0.64 games (range, 0 to 4). We report 19 acute medial collateral ligament injuries of the elbow in elite football players, 2 of whom are considered overhead throwing athletes, who were able to function at a competitive level without surgical repair or reconstruction, in contrast to baseball players, in whom the mechanics and demands may differ.

According to an epidemiologic study (Scand J Med Sci 1996/ 6: 297-302) the mechanism of "handball goalie's elbow" may be forced hyperextension. The pathomechanics of hyperextension were studied in nine macroscopically normal male cadaver elbow joints. The mean age of the donors was 43.2 years (range 25 to 61 years). Kinematic tests were performed with an experimental three-dimensional kinematic loading apparatus. Hyperextension loads induced joint laxity during flexion of less than 50 degrees. The kinematic changes were significant in joint flexion during forced valgus and external and internal axial rotation, but were not significant in flexion during forced varus. No instability was found with flexion beyond 90 degrees. The hyperextension loads produced four lesions: (1) anterior capsule rupture; (2) L-shaped rupture of the pronator/flexor origin with elongation of the anterior part of the medial collateral ligament; (3) occasional incomplete rupture of the lateral collateral ligament; and (4) small fragments of cartilage near the posterior edge of the ulna in one of the specimens. One or more of these lesions may be responsible for the symptoms in "handball goalie's elbow."

Radial head fractures can lead to significant upper extremity disability. A comminuted radial head fracture with a medial collateral ligament tear presents a clinical conundrum. The radiocapitellar (RC) joint should be maintained, yet the head frequently cannot be reduced and stabilized. The silicone rubber implant currently available is not biomechanically or clinically satisfactory, and thus there is a need for a more suitable prosthetic replacement for the radial head. We have attempted to design such a prosthesis and have examined prosthetic design with various materials that would best transmit force of the RC joint. Design configurations based on our cadaveric and radiographic measurements were tested with structural finite element method computer analyses. Materials examined included titanium alloy, cobalt-chrome alloy, alumina ceramic, and ultrahigh molecular weight polyethylene (UHMWPE). Metals and ceramic transmitted force at the distal bone and implant interface and strain shielded the proximal radial cortex while UHMWPE distributed load uniformly through the cortex and along the entire bone and implant interface. In addition, load transmission comparisons were made with the intact radial head, with a silicone prosthesis, and with 6 and 10 mm thick UHMWPE prostheses in cadaveric specimens. UHMWPE prostheses transmit more force to the RC joint than the silicone prosthesis and with leads closer to physiologic levels at all flexion angles. UHMWPE prostheses not only transmit much more force than silicone, but because of substantially less deformation under load, also provide more stability to the joint.

Background An established nonunion of the lateral humeral condyle often reveals elbow instability and accompanying pain. The purpose of this study was to obtain 3-dimensional and quantitative information about the pathologic kinematics of the ulnohumeral joint with nonunion of the lateral humeral condyle by an in vivo and 3-dimensional motion analysis. Methods Magnetic resonance or computed tomography images of the elbows of 14 patients were acquired in 3 positions between full extension and full flexion. We evaluated ulnohumeral motion and calculated the change in the length of the medial collateral ligament during elbow flexion. Results Ulnohumeral motion was associated with an excessive lateral shift of ulnar movement. In addition, the distal part of the ulna was rotated in the varus direction, leading to a decrease in the carrying angle. The ulna tended to exhibit internal rotation from full extension to 90° of flexion of the elbow. With further flexion, the ulna rotated externally and returned to its neutral position. Furthermore, the length of the medial collateral ligament increased with an increase in the elbow flexion angle. Conclusion Patients with lateral humeral condyle nonunion showed excessive lateral shift of the ulna and ulnar axial rotation. Also, the lateral shift caused an osseous protrusion of the medial trochlea, leading to elongation of the medial collateral ligament.

The medical collateral ligament is a common site of injury in baseball pitchers, causing substantial morbidity and loss of pitching time. Twenty-six skilled baseball pitchers with medial collateral ligament insufficiency were studied before surgery with high-speed cinematography and fine-wire electromyography of eight muscles around the elbow. Data from the pitchers with injured elbows were compared with data obtained from uninjured pitchers. The flexor carpi radialis muscle in the pitchers with medial collateral ligament deficiencies revealed significantly decreased firing during the acceleration and deceleration phase of the fastball when compared with that of the pitchers with normal elbows, and the flexor carpi radialis muscle was significantly depressed during the early cocking and deceleration phases. The extensor muscles revealed slightly increased activity in the injured elbows; however, this was not statistically significant. Although the muscles of the flexor pronator group (especially the flexor carpi ulnaris muscle and the flexor digitorum superficialis muscles) are anatomically positioned to provide dynamic stability of the elbow, they did not demonstrate increased electrical activity in pitchers with medial collateral ligament deficiencies. This finding suggests that the muscles on the medial side of the elbow do not supplant the role of the medial collateral ligament during the fastball pitch.

In the last decade, there has been increasing interest in medial ulnar collateral ligament (MUCL) reconstruction techniques for MUCL insufficiency of the elbow. All case series are based on American and Asian Athletes and use primarily a palmaris longus tendon or gracilis tendon as an autograft in reconstructions. A new technique is the interference screw fixation. Evidence that supports the use of this technique is mainly from controlled laboratory studies. The purpose was to evaluate the interference screw technique for MUCL reconstructions in a European, clinical setting, with a triceps tendon fascia autograft.Twenty consecutive athletes with diagnosed MUCL insufficiency who underwent a MUCL reconstruction using the interference screw technique were reviewed retrospectively. Indications for reconstruction were medial elbow pain and/or instability caused by insufficiency of the MUCL that prevented the athlete from sport activity after a minimum of 3 months of conservative treatment.At a mean follow-up of 55 months (range, 36-94), the mean Mayo Elbow Performance Index (MEPI) score improved from 82 to 91 points (range, 80-100); P.001. In the end, 6 patients (30%) quit the sport activities they were preoperatively participating in, all because of reasons unrelated to the MUCL reconstruction. There were excellent results on the Conway scale in 18 patients.Good results are reported based on the postoperative MEPI and Conway scores with clinically stable MUCL reconstructions without signs of break-out or fractures on radiographic follow-up. However, the dropout, even after successful reconstruction in European athletes, is high.

Injuries to the medial collateral ligament (MCL) of the elbow and the common flexor origin are common in contact and throwing sports. As athletes have previously been considered to be unable to return to the same standard of play following elbow surgery, the gold standard treatment may be considered to be reconstruction or augmentation of a primary repair of the MCL using tendon autograft. The recovery, rehabilitation, and return to play following these procedures may take up to a year; and even then, approximately a third of patients may not return to the same standard of play. We report the case of an Olympic Judoka medallist who, within a year of the forthcoming Olympics, sustained a complete rupture of his right elbow medial collateral ligament and a tear of the common flexor tendon origin (CFT) and pronator teres (PT). We considered that there would be insufficient time available for adequate rehabilitation following reconstruction. He was managed nonoperatively with injections of a preparation rich in growth factors (PRGF) into the MCL and CFT. The PRGF is one of the techniques to obtain platelet rich plasma (PRP).

Purpose This study determined whether elbow stability could be restored with open reduction and internal fixation (ORIF) of type II coronoid fractures and evaluated the role of collateral ligament repair. Methods Passive varus and valgus and simulated active vertical motion were performed using an in vitro elbow motion simulator. Varus/valgus angle and internal/external rotation were measured with the coronoid intact, with 50% removed, and after ORIF. Testing was performed with the collateral ligaments detached and repaired. Results Vertical: stability was normal when both the lateral collateral ligament (LCL) and medial collateral ligament (MCL) were repaired, irrespective of the coronoid state. Kinematics were altered with a repaired LCL, incompetent MCL, and type II coronoid fracture ( P P Conclusions These findings suggest that repair of type II coronoid fractures and injured collateral ligaments should be performed where possible. Over-tensioning the LCL, in the setting of MCL and coronoid deficiency, may contribute to instability. Level of evidence Basic science study.

We studied the kinematics of 8 ligamentous unstable elbow joint preparations after application of the Orthofix elbow external fixation device. Valgus, varus, external rotatory, and internal rotatory load tests were performed in lateral collateral ligament (LCL)-deficient and LCL/medial collateral ligament (MCL)-deficient joints. After placement of the fixator, the mean extension decreased significantly to 19.5 degrees +/- 7.2 degrees in the LCL-deficient joint and to 19.1 degrees +/- 6.6 degrees in the LCL/MCL-deficient joint compared with the mean extension of the intact joint, which was 10.5 degrees +/- 4.2 degrees. After application of the fixator, valgus displacement was significantly decreased by 4.0 degrees +/- 3.4 degrees in the LCL-deficient joint and by 3.6 degrees +/- 3.3 degrees in the LCL/MCL-deficient joint compared with the intact joint. External rotatory displacement was significantly decreased in the LCL-deficient joint by 4.9 degrees +/- 3.7 degrees and in the LCL/MCL-deficient joint by 5.0 degrees +/- 4.7 degrees. Internal rotatory displacement was significantly decreased by 3.3 degrees +/- 2.7 degrees in the LCL-deficient joint, but it was not significantly changed in the LCL/MCL-deficient joint. The Orthofix elbow external fixator guided elbow motion to a more varus position compared with the intact elbow and decreased the range of motion of the joint, constraining mainly extension. We conclude that the fixator stabilized the ligamentous unstable elbow joint efficiently but at the expense of changes in the normal motion pattern.

The initial strength of the intact medial collateral ligament (MCL) of the elbow and the strength of 4 reconstruction techniques were compared. Twenty cadaveric upper extremities were mounted in a custom jig with the elbow at 90 degrees , and a pneumatic cyclic valgus loading protocol was used. The mean peak load to failure was 142.5+/-39.4 N for the intact ligaments and 53.0+/-9.5 N for the docking reconstructions, 52.5+/-10.4 N for the EndoButton reconstructions, 41.0+/-16.0 N for the interference screw reconstructions, and 33.3+/-7.1 N for the figure-eight reconstructions. The peak load to failure of the MCL reconstructions was inferior compared with the intact ligament (P.001). No difference in strength was found between the docking and single-strand medial collateral reconstruction with the use of an EndoButton for ulnar fixation (P.05, beta=.14). Both of these reconstruction methods were stronger than the interference screw or figure-eight technique (P.004). The optimal fixation method for a single-strand MCL reconstruction may require improved interference screws or a modified EndoButton procedure.

We identified 5 patients with valgus instability of the elbow due to nonunion of a previous fracture of the medial epicondyle. There were 4 male patients and 1 female patient with a mean age of 35 years (range, 15-54 years). The original avulsion fracture of the medial epicondyle had occurred a mean of 10.1 years previously (range, 4 months to 25 years), and all patients had had their initial fracture treated nonoperatively. After the development of medial epicondyle nonunion, 3 patients had been treated nonoperatively and 2 had undergone unsuccessful attempts at osteosynthesis. All patients were treated with excision of the medial epicondyle, advancement of the medial collateral ligament, and fixation to the distal humerus with suture anchors. The mean Mayo Elbow Performance Score improved from 66 preoperatively to 91 postoperatively (P

To prevent the occurrence of secondary contracture during maturation of heterotopic ossification of the elbow, early, wide excision of heterotopic ossification was performed on 9 consecutive patients with a stiff elbow caused by the mass. The average duration between initial injury and operation was 7.7 months. The thick, elastic mass on the posterior oblique ligament of the medial collateral ligament, which included mature and immature heterotopic ossification, was resected widely with the posterior oblique ligament, the posteromedial joint capsule, and the surrounding scar tissue. After an average follow-up of 52.0 months, the total arc of motion improved from a preoperative mean of 37.3° to a postoperative mean of 112.8°. No patient complained of instability or pain on movement. Despite recurrence of spotty heterotopic ossification at the medial elbow in 5 cases, at final follow-up, a sufficient range of motion was obtained in all patients. (J Shoulder Elbow Surg 2001;10:164-8.)

We studied the gross and histologic anatomic characteristics of the lateral collateral ligament complex of the elbow joint from 15 cadavers to demonstrate its cross-sectional anatomy. The lateral ulnar collateral ligament adheres closely to the supinator, the extensor muscles, its intermuscular fascia, and the anconeus muscle and lies posterior to the radial collateral ligament. The lateral ulnar collateral ligament itself was identified with microscopy as a slender, poor structure consisting of the thick area of the posterolateral capsuloligamentous layer and a poorer structure than the anterior bundle of the medial collateral ligament as the primary stabilizer of the elbow joint. We believe that the lateral ulnar collateral ligament contributes to rather than is a major constraint to the posterolateral rotatory instability as part of the lateral collateral ligament complex with the surrounding tissues.

In this study the kinematics of partial and total ruptures of the medial collateral ligament of the elbow are investigated. After selective transection of the medial collateral ligament of 8 osteoligamentous intact elbow preparations was performed, 3-dimensional measurements of angular displacement, increase in medial joint opening, and translation of the radial head were examined during application of relevant stress. Increase in joint opening was significant only after complete transection of the anterior part of the medial collateral ligament was performed. The joint opening was detected during valgus and internal rotatory stress only. After partial transection of the anterior bundle of the medial collateral ligament was performed, there was an elbow laxity to valgus and internal rotatory force, which became significant after transection of 100% of the anterior bundle of the medial collateral ligament and was maximum between 70 degrees to 90 degrees of flexion. No radial head movement was seen after partial or total transection of the anterior bundle of the medial collateral ligament was performed. In conclusion, this study indicates that valgus or internal rotatory elbow instability should be evaluated at 70 degrees to 90 degrees of flexion. Detection of partial ruptures in the anterior bundle of the medial collateral ligament based on medial joint opening and increased valgus movement is impossible.

The anatomic relation between the proximal attachment of the medial collateral ligament of the elbow joint and the humero-ulnar joint axis has not been clearly shown in a published study. We examined cadaveric specimens to find the exact relation between them. The medial collateral ligament was microscopically dissected to isolate specific fiber bundles. The length of each bundle was measured with a charge-coupled device camera system that faced the medial side of the elbow joint. The measurements indicated that the projected length of the deep middle bundle of the anterior oblique ligament, which is the strong cord-like part of the medial collateral ligament, is isometric during elbow flexion. The proximal end of the deep middle bundle was thus considered to be located almost on the humero-ulnar joint axis.

The action of throwing places significant demands on the shoulder and elbow. These motions create a compression force on the lateral compartment, a distraction force on the medial side, and both shear and distraction forces on the posterior compartment of the elbow, s The throwing injuries of the elbow include osteochondritis dissecans of the capitellum, medial epicondylitis, 12 medial collateral ligament (MCL) injury, 1 and posteromedial osteophytes. 1 ~s Stress fractures are common injuries in the athletic population. Although stress fractures occur more frequently in the lower extremities, several cases of olecranon stress fractures have been reported. 4+,9nl The stress fractures through the physis or the persistence of the olecranon physis are seen in adolescent athletes, 5'6, ;1 and the stress fractures of the olecranon with an oblique fracture line have been reported in throwing athletes with a closed physis. 4, 9, lo In this article we report two olecranon stress fractures with oblique fracture lines and discuss the pathomechanics of this type of olecranon stress fracture.