Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With the Docking Technique Versus Repair With Internal Bracing

Background: The modified Jobe technique of ulnar collateral ligament (UCL) reconstruction has previously been biomechanically compared with primary repair augmented with internal bracing. However, the docking technique has not been compared with repair with internal bracing. Hypothesis: Load to failure, gapping, and valgus opening angle are similar under valgus loading at 90° of flexion between repair with internal bracing and the docking technique for the UCL. Study Design: Controlled laboratory study. Methods: Nine matched pairs of fresh-frozen cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and the bone was sectioned 14 cm proximal and distal to the elbow joint. First, native UCL testing was performed at 90° of flexion with 0.5 N·m preload, followed by a 5 N·m valgus moment to the elbow in cycles of 1, 10, 100, and 1000 at 1 Hz. The specimens were then loaded to failure at a rate of 0.2 mm/s. Next, the elbows were randomly divided into matched pairs to undergo either UCL reconstruction with docking technique or UCL repair augmented with internal bracing. Last, these specimens underwent testing as aforementioned. Results: Load to failure, gapping, and valgus opening angle did not differ significantly between native ligaments that underwent reconstruction or repair with internal bracing, paired native ligaments and reconstructions, paired native ligaments and repairs augmented with internal bracing, or reconstructions and repairs augmented with internal bracing. Conclusion: UCL reconstruction with docking technique and repair augmented with internal bracing provides valgus stability to the medial elbow comparable to the native ligament at 90°. No significant differences were noted between docking reconstruction and repair techniques for load to failure, gapping, or valgus opening angle during cyclic loading at time zero. Clinical Relevance: Our results suggest that UCL repair with internal bracing has a similar biomechanical profile at the time of initial fixation compared with the docking technique of UCL reconstruction.

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Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair Stabilization

The American Journal of Sports Medicine ◽

10.1177/0363546520921174 ◽

2020 ◽

Vol 48 (8) ◽

pp. 1884-1892

Author(s):

Samuel Bachmaier ◽

Coen A. Wijdicks ◽

Nikhil N. Verma ◽

Laurence D. Higgins ◽

Stefan Greiner

Keyword(s):

Primary Repair ◽

Ulnar Collateral Ligament ◽

Analysis Of Covariance ◽

Torsional Stiffness ◽

Gap Formation ◽

Initial Stiffness ◽

Collateral Ligament ◽

Time Zero ◽

Torsional Resistance ◽

Internal Bracing

Background: Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques. Hypothesis: Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament. Study Design: Controlled laboratory study. Methods: We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min). Results: Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness ( P < .001) and residual torque ( P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair ( P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair ( P = .766). Conclusion: Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow. Clinical Relevance: We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.

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Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: Biomechanical Comparison of a Novel Anatomic Technique to the Docking Technique

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119857592 ◽

2019 ◽

Vol 7 (7) ◽

pp. 232596711985759 ◽

Cited By ~ 2

Author(s):

Christopher L. Camp ◽

Christopher Bernard ◽

Bill Benavitz ◽

John Konicek ◽

David W. Altchek ◽

...

Keyword(s):

Ultimate Load ◽

Biomechanical Testing ◽

Ulnar Collateral Ligament ◽

Return To Play ◽

Reconstruction Technique ◽

The Novel ◽

Collateral Ligament ◽

Initial Strength ◽

Load To Failure ◽

Fresh Frozen

Background: In recent years, understanding of the anatomy of the ulnar collateral ligament (UCL) has evolved, demonstrating that the insertional footprint of the UCL on the ulna is more elongated and distally tapered than previously described. Current UCL reconstruction configurations do not typically re-create this native anatomy, which may represent a potential area for improvement. Purpose/Hypothesis: The purposes of this study were (1) to describe a novel anatomic UCL reconstruction technique designed to better replicate the native UCL anatomy and (2) to biomechanically compare this with the docking technique. The hypothesis was that the ultimate load to failure for the anatomic technique would not be inferior to the docking technique. Study Design: Controlled laboratory study. Methods: A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were utilized. One elbow in each pair was randomized to receive UCL reconstruction via the docking technique or the novel anatomic UCL reconstruction technique with palmaris tendon autograft. Following reconstruction, biomechanical testing was performed by applying valgus rotational torque at a constant rate of 5 deg/s until ultimate mechanical failure of the construct occurred. Maximal torque (N·m), rotation stiffness (N·m/deg), and mode/location of failure were recorded for each specimen. Results: The mean ultimate load to failure for elbows in the docking technique group was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic technique group ( P = .045). Mean rotational stiffness was 1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups, respectively ( P = .338). The most common mode of failure was suture pullout from the graft, which occurred in all 8 (100%) docking technique specimens and 7 of 8 (88%) specimens that underwent the anatomic UCL reconstruction technique. Conclusion: Ultimately, the anatomic UCL reconstruction technique demonstrated superior strength and resistance to valgus torque when compared with the docking technique, and this was comparable with that of the native UCL from prior studies. Increased initial strength may allow for earlier initiation of throwing postoperatively and potentially shorten return-to-play times. Clinical Relevance: Current UCL reconstruction techniques do not accurately reproduce the UCL insertional anatomy on the ulna. The novel anatomic technique described may result in more natural joint kinematics. This study demonstrated load-to-failure rates that are significantly higher than with the docking technique and consistent with the native ligament, as reported from previous studies. These findings may serve as a foundation for future clinical study and optimization of this technique.

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Anatomic and Biomechanical Evaluation of Ulnar Tunnel Position in Medial Ulnar Collateral Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546519880182 ◽

2019 ◽

Vol 47 (14) ◽

pp. 3491-3497 ◽

Cited By ~ 1

Author(s):

Pascual H. Dutton ◽

Michael B. Banffy ◽

Trevor J. Nelson ◽

Melodie F. Metzger

Keyword(s):

Motion Tracking ◽

Full Range ◽

Ulnar Collateral Ligament ◽

Elbow Flexion ◽

Joint Line ◽

Collateral Ligament ◽

Proximal Ulna ◽

Tunnel Position ◽

Fresh Frozen ◽

Ulnar Tunnel

Background: Although numerous techniques of reconstruction of the medial ulnar collateral ligament (mUCL) have been described, limited evidence exists on the biomechanical implication of changing the ulnar tunnel position despite the fact that more recent literature has clarified that the ulnar footprint extends more distally than was appreciated in the past. Purpose: To evaluate the size and location of the native ulnar footprint and assess valgus stability of the medial elbow after UCL reconstruction at 3 ulnar tunnel locations. Study Design: Controlled laboratory study. Methods: Eighteen fresh-frozen cadaveric elbows were dissected to expose the mUCL. The anatomic footprint of the ulnar attachment of the mUCL was measured with a digitizing probe. The area of the ulnar footprint and midpoint relative to the joint line were determined. Medial elbow stability was tested with the mUCL in an intact, deficient, and reconstructed state after the docking technique, with ulnar tunnels placed at 5, 10, or 15 mm from the ulnotrochlear joint line. A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion-tracking cameras as the elbow was cycled through a full range of motion. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion. Results: The mean ± SD length of the mUCL ulnar footprint was 27.4 ± 3.3 mm. The midpoint of the anatomic footprint was located between the 10- and 15-mm tunnels across all specimens at a mean 13.6 mm from the joint line. Sectioning of the mUCL increased elbow valgus rotation throughout all flexion angles and was statistically significant from 30° to 100° of flexion as compared with the intact elbow ( P < .05). mUCL reconstruction at all 3 tunnel locations restored stability to near intact levels with no significant differences among the 3 ulnar tunnel locations at any flexion angle. Conclusion: Positioning the ulnar graft fixation site up to 15 mm from the ulnotrochlear joint line does not significantly increase valgus rotation in the elbow. Clinical Relevance: A more distal ulnar tunnel may be a viable option to accommodate individual variation in morphology of the proximal ulna or in a revision setting.

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Biomechanical Evaluation of a Modified Internal Brace Construct for the Treatment of Ulnar Collateral Ligament Injuries

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119874135 ◽

2019 ◽

Vol 7 (10) ◽

pp. 232596711987413 ◽

Cited By ~ 2

Author(s):

Ekaterina Urch ◽

Orr Limpisvasti ◽

Neal S. ElAttrache ◽

Yasuo Itami ◽

Michelle H. McGarry ◽

...

Keyword(s):

Ulnar Collateral Ligament ◽

Reconstruction Technique ◽

Full Extension ◽

Failure Characteristics ◽

Intact State ◽

The Sublime ◽

Load To Failure ◽

Internal Bracing ◽

Internal Brace ◽

Reconstruction Group

Background: Ulnar collateral ligament (UCL) repair augmented with the “internal brace” construct for the management of acute UCL injuries has recently garnered increasing interest from the sports medicine community. One concern with this technique is excessive bone loss at the sublime tubercle, should revision UCL reconstruction be required. In an effort to preserve the bony architecture of the sublime tubercle, an alternative internal brace construct is proposed and biomechanically compared with the gold standard UCL reconstruction. Hypothesis: The internal brace repair construct will restore valgus laxity and rotation to its native state and demonstrate comparable load-to-failure characteristics with the 3-strand reconstruction technique. Study Design: Controlled laboratory study. Methods: For this study, 8 matched pairs of fresh-frozen cadaveric elbows were randomized to undergo either UCL reconstruction with the 3-ply docking technique or UCL repair with a novel internal brace construct focused on augmenting the posterior band of the anterior bundle of the ligament (modified repair-IB technique). Valgus laxity and rotation measurements were quantified through use of a MicroScribe 3DLX digitizer at various flexion angles of the native ligament, transected ligament, and repaired or reconstructed ligament. Laxity testing was performed from maximum extension to 120° of flexion. Each specimen was then loaded to failure, and the method of failure was recorded. Results: Valgus laxity was restored to the intact state at all degrees of elbow flexion with the modified repair-IB technique, and rotation was restored to the intact state at both full extension and 30°. In the reconstruction group, valgus laxity was not restored to the intact state at either full extension or 30° of flexion ( P < .001 and P = .004, respectively). Laxity was restored at 60° of flexion, but the elbow was overconstrained at 90° and 120° of flexion ( P = .027 and P = .003, respectively). In load-to-failure testing, the reconstruction group demonstrated significantly greater yield torque (19.1 vs 9.0 N·m; P < .005), yield angle (10.2° vs 5.4°; P = .007), and ultimate torque (23.9 vs 17.6 N·m; P = .039). Conclusion: UCL repair with posterior band internal bracing was able to restore valgus laxity and rotation to the native state. The construct exhibited lower load-to-failure characteristics when compared with the reconstruction technique. Clinical Relevance: In selected patients with acute, avulsion-type UCL injuries, ligament repair with posterior band internal bracing is a viable alternative surgical option that, by preserving bone at the sublime tubercle, may decrease the complexity of future revision procedures.

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Quantitative Anatomic Analysis of the Medial Ulnar Collateral Ligament Complex of the Elbow

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118762751 ◽

2018 ◽

Vol 6 (3) ◽

pp. 232596711876275 ◽

Cited By ~ 13

Author(s):

Christopher L. Camp ◽

Hamidreza Jahandar ◽

Alec M. Sinatro ◽

Carl W. Imhauser ◽

David W. Altchek ◽

...

Keyword(s):

Surface Area ◽

Ulnar Collateral Ligament ◽

Surgical Reconstruction ◽

Collateral Ligament ◽

3 Dimensional ◽

Visual Center ◽

Bony Landmarks ◽

Fresh Frozen ◽

Detailed Assessment ◽

The Mean

Background: A more detailed assessment of the anatomy of the entire medial ulnar collateral ligament complex (MUCLC) is desired as the rate of medial elbow reconstruction surgery continues to rise. Purpose: To quantify the anatomy of the MUCLC, including the anterior bundle (AB), posterior bundle (PB), and transverse ligament (TL). Study Design: Descriptive laboratory study. Methods: Ten unpaired, fresh-frozen cadaveric elbows underwent 3-dimensional (3D) digitization and computed tomography with 3D reconstruction. Ligament footprint areas and geometries, distances to key bony landmarks, and isometry were determined. A surgeon digitized the visual center of each footprint, and this location was compared with the geometric centroid calculated from the outline of the digitized footprint. Results: The mean surface area of the AB was 324.2 mm2, with an origin footprint of 32.3 mm2 and an elongated insertional footprint of 187.6 mm2 (length, 29.7 mm). The mean area of the PB was 116.6 mm2 (origin, 25.9 mm2; insertion, 15.8 mm2), and the mean surface area of the TL was 134.5 mm2 (origin, 21.2 mm2; insertion, 16.7 mm2). The geometric centroids of all footprints could be predicted within 0.8 to 1.3 mm, with the exception of the AB insertion centroid, which was 7.6 mm distal to the perceived center at the apex of the sublime tubercle. While the PB remained relatively isometric from 0° to 90° of flexion ( P = .606), the AB lengthened by 2.2 mm ( P < .001). Conclusion: Contrary to several historical reports, the insertional footprint of the AB was larger, elongated, and tapered. The TL demonstrated a previously unrecognized expansive soft tissue insertion directly onto the AB, and additional analysis of the biomechanical contribution of this structure is needed. Clinical Relevance: These findings may serve as a foundation for future study of the MUCLC and help refine current surgical reconstruction techniques.

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Long-Term Outcomes of Primary Repair of Chronic Thumb Ulnar Collateral Ligament Injuries

Hand ◽

10.1177/1558944716628482 ◽

2016 ◽

Vol 11 (3) ◽

pp. 303-309 ◽

Cited By ~ 4

Author(s):

Thomas Christensen ◽

Shumaila Sarfani ◽

Alexander Y. Shin ◽

Sanjeev Kakar

Keyword(s):

Primary Repair ◽

Ulnar Collateral Ligament ◽

Long Term Outcomes ◽

Ligament Injuries ◽

Collateral Ligament

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Treatment of Chronic Injuries of the Ulnar Collateral Ligament of the Thumb Using a Free Tendon Graft and Bone Suture Anchors

Journal of Hand Surgery (European Volume) ◽

10.1054/jhsb.1999.0353 ◽

2000 ◽

Vol 25 (2) ◽

pp. 208-211 ◽

Cited By ~ 38

Author(s):

G. I. MITSIONIS ◽

S. E. VARITIMIDIS ◽

G. G. SOTEREANOS

Keyword(s):

Ulnar Collateral Ligament ◽

Metacarpophalangeal Joint ◽

Tendon Graft ◽

Pinch Strength ◽

Suture Anchors ◽

Collateral Ligament ◽

The Mean ◽

Chronic Injuries ◽

Weather Changes ◽

Loss Of Motion

We report the results of a simple technique, using bone suture anchors and free tendon graft, for the reconstruction of chronic injuries of the ulnar collateral ligament complex at the thumb metacarpophalangeal (MP) joint. Our series includes 20 patients, with a mean age of 29 years. The mean follow-up period was 42 months. Using the Glickel grading system, 14 patients had excellent results and six had good results. Seventeen patients had no pain and three complained of mild pain with weather changes. Fourteen patients regained full stability of the MP joint and six had mild laxity. The mean loss of pinch strength was 18% compared with the contralateral thumb. The mean loss of motion at the metacarpophalangeal joint was 21%.

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