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

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.

scholarly journals Ulnar Collateral Ligament Reconstruction Versus Repair With Internal Bracing: Comparison of Cyclic Fatigue Mechanics

2018 ◽  
Vol 6 (2) ◽  
pp. 232596711875599 ◽  
Author(s):  
Christopher M. Jones ◽  
David P. Beason ◽  
Jeffrey R. Dugas
Keyword(s):  
Ulnar Collateral Ligament ◽  
Fatigue Loading ◽  
Contralateral Side ◽  
Return To Play ◽  
Reconstruction Technique ◽  
Gap Formation ◽  
Collateral Ligament ◽  
Common Procedure ◽  
Flexion Extension ◽  
Internal Bracing

Background: Ulnar collateral ligament (UCL) injuries have increased significantly in recent years, and reconstruction has become the preferred treatment for UCL injury over ligament repair. In a recent study, UCL repair with internal bracing demonstrated significantly greater resistance to gap formation in biomechanical tests, even at low cycles of valgus loading. Purpose/Hypothesis: The purpose of this study was to compare the fatigue and failure mechanics of traditional UCL reconstruction with UCL repair and internal bracing. We hypothesized that repaired specimens would have less gap formation, closer return to native gap formation, and greater maximum torque to failure versus traditionally reconstructed specimens. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric elbows were positioned at 90° of flexion and the native UCL subjected to 500 cycles of subfailure valgus loading. A simulated tear was created, and the 10 cycles were repeated. Each pair of specimens was next given repair with internal bracing on 1 side and a modified Jobe reconstruction on the contralateral side, followed by 100 manual cycles of flexion-extension, 500 cycles of valgus rotation, and, finally, rotation to failure. Results: The specimens that received the repair unexpectedly experienced significantly less gapping in the torn state than did those in the reconstruction group. At the 10th cycle, repaired UCL injuries had significantly less gap formation than the reconstructed UCLs. At the 100th and 500th cycles, repaired UCL injuries continued to experience significantly less gap formation as compared with the reconstructed injuries. Conclusion: When compared with the gold standard reconstruction technique, UCL repair with internal bracing is more resistant to gap formation under fatigue loading. However, the unexpected early difference between the torn states may have confounded this finding. Time-zero failure properties of this repair technique are on par with those of traditional reconstruction, even after 500 cycles of valgus loading. Clinical Relevance: UCL reconstruction has become a common procedure among adolescent and elite-level throwers. Recent data suggest that UCL repair may be a viable option for younger athletes with acute proximal or distal UCL tears, allowing a faster return to play.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With a Modified Docking Technique With and Without Suture Augmentation

2019 ◽  
Vol 47 (4) ◽  
pp. 928-932 ◽  
Author(s):  
Jeremi Leasure ◽  
Kerisimasi Reynolds ◽  
Marc Thorne ◽  
Rafael Escamilla ◽  
Ken Akizuki
Keyword(s):  
Ulnar Collateral Ligament ◽  
Return To Play ◽  
Reconstruction Technique ◽  
Gap Formation ◽  
Collateral Ligament ◽  
Intact State ◽  
Time Zero ◽  
Load To Failure ◽  
Bone Tunnels ◽  
Reconstruction Group

Background: Throwing athletes with ulnar collateral ligament (UCL) injury and symptomatic valgus instability can expect to return to the same or higher level of play. Reconstruction with tendon graft is the dominant method of surgical treatment. Recent evidence suggests that spanning the joint with a suture anchored on both sides is biomechanically equivalent to reconstruction, with faster time to return to play. The authors developed a hybrid UCL reconstruction technique augmented with a suture brace to improve joint stability. Purpose/Hypothesis: The purpose of this study was to biomechanically evaluate a hybrid reconstruction technique and compare its performance to reconstruction without augmentation. The authors hypothesized that (1) both groups would lose stability after the simulated tear and regain stability with treatment, (2) the suture augmentation would improve stability, and (3) the addition of the suture anchors near the bone tunnels would not decrease the strength of the hybrid reconstruction. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric arms were dissected to expose the UCL. Each elbow was mounted on a test frame at 90° of flexion. A cyclic valgus rotational torque was applied to the humerus with the UCL in its intact state and repeated in its surgically torn state. Finally, each specimen received either a hybrid reconstruction with suture brace or a reconstruction and was again put through the cyclic protocol, followed by a valgus rotation load-to-fail protocol. Results: Gap formation in the torn state for the reconstruction and hybrid reconstruction groups (0.9 ± 0.1 mm and 0.8 ± 0.1 mm, respectively) was significantly higher ( P = .009 and P = .0002) than in the intact state (0.6 ± 0.2 mm and 0.6 ± 0.3 mm, respectively). After the procedures, the hybrid group showed greater resistance to gapping ( P = .017) as compared with the reconstruction group (0.4 ± 0.2 mm and 0.6 ± 0.1 mm). During load to failure, no hybrid reconstructions failed from bone fracture or screw pullout. No statistical differences were found for failure torque ( P = .058) and stiffness ( P = .101). Gap at 10 N·m was significantly lower ( P = .014) for the hybrid reconstruction group than for the reconstruction group. Conclusion: The current study showed that hybrid reconstruction with suture bracing replicated the time-zero strength of traditional UCL reconstruction and may be more resistant to joint gapping during low cyclic load and load to failure. The combination of the bone tunnels and fixation screw holes did not appear to weaken the construct. Clinical Relevance: This study demonstrated that reconstruction with suture bracing has important time-zero stability and strength as compared with the gold standard of UCL reconstruction. This technique may be useful for throwing athletes who need UCL reconstruction.

scholarly journals Treatment of Ulnar Collateral Ligament Tears of the Elbow

2017 ◽  
Vol 5 (1) ◽  
pp. 232596711668221 ◽  
Author(s):  
Brandon J. Erickson ◽  
Bernard R. Bach ◽  
Nikhil N. Verma ◽  
Charles A. Bush-Joseph ◽  
Anthony A. Romeo
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Return To Sport ◽  
Ulnar Collateral Ligament ◽  
Treatment Method ◽  
Gap Formation ◽  
Collateral Ligament ◽  
Level Of Evidence ◽  
Internal Bracing ◽  
Repair Techniques

Background: Ulnar collateral ligament (UCL) tears have become common, and UCL reconstruction (UCLR) is currently the preferred surgical treatment method for treating UCL tears. Purpose/Hypothesis: The purpose of this study was to review the literature surrounding UCL repair and determine the viability of new repair techniques for treatment of UCL tears. We hypothesized that UCL repair techniques will provide comparable results to UCLR for treatment of UCL tears. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic review was registered with PROSPERO and performed with PRISMA guidelines using 3 publicly available free databases. Biomechanical and clinical outcome investigations reporting on UCL repair with levels of evidence 1 through 4 were eligible for inclusion. Descriptive statistics were calculated for each study and parameter/variable analyzed. Results: Of the 46 studies eligible, 4 studies (3 clinical and 1 biomechanical) were included. There were 92 patients (n = 92 elbows; 61 males [62.3%]; mean age, 21.9 ± 4.7 years) included in the clinical studies, with a mean follow-up of 49 ± 14.4 months. Eighty-six percent of repairs performed were on the dominant elbow, and 38% were in college athletes. Most UCL repairs (66.3%) were performed via suture anchors. After UCL repair, 87.0% of patients were able to return to sport. Overall, 94.9% of patients scored excellent/good on the Andrews-Carson score. Patients who were able to return to sport after UCL repair did so within 6 months after surgery. Biomechanically, when UCL repair was compared with the modified Jobe technique, the repair group showed significantly less gap formation than the reconstruction group. Conclusion: In patients for whom repair is properly indicated, UCL repair provides similar return-to-sport rates and clinical outcomes with shorter return-to-sport timing after repair compared with UCL reconstruction. Future outcome studies evaluating UCL repair with internal bracing are necessary before recommending this technique.

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

2018 ◽  
Vol 46 (14) ◽  
pp. 3495-3501 ◽  
Author(s):  
Blake M. Bodendorfer ◽  
Austin M. Looney ◽  
Sloane L. Lipkin ◽  
Esther C. Nolton ◽  
Jihui Li ◽  
...  
Keyword(s):  
Primary Repair ◽  
Ulnar Collateral Ligament ◽  
Tendon Graft ◽  
Opening Angle ◽  
Matched Pairs ◽  
Collateral Ligament ◽  
Initial Fixation ◽  
Load To Failure ◽  
Internal Bracing ◽  
Fresh Frozen

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.

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

Hand ◽  
2016 ◽  
Vol 11 (3) ◽  
pp. 303-309 ◽  
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

Primary Repair of Ulnar Collateral Ligament Injuries of the Elbow

2021 ◽  
pp. 171-181
Author(s):  
Robert S. O’Connell ◽  
Felix H. Savoie ◽  
Michael J. O’Brien ◽  
Larry D. Field
Keyword(s):  
Primary Repair ◽  
Ulnar Collateral Ligament ◽  
Ligament Injuries ◽  
Collateral Ligament

scholarly journals Primary Repair of Proximal Ulnar Collateral Ligament Ruptures in Pediatric Overhead Athletes

2020 ◽  
Vol 9 (5) ◽  
pp. e639-e643
Author(s):  
Lafi S. Khalil ◽  
Austin G. Cross ◽  
Felix H. Savoie ◽  
Eric C. Makhni
Keyword(s):  
Primary Repair ◽  
Ulnar Collateral Ligament ◽  
Collateral Ligament ◽  
Overhead Athletes

Biomechanical Comparison of Anatomic Restoration of the Ulnar Footprint vs Traditional Ulnar Tunnels in Ulnar Collateral Ligament Reconstruction

2021 ◽  
pp. 036354652110544
Author(s):  
Edward S. Chang ◽  
Anthony H. Le ◽  
Austin M. Looney ◽  
MAJ Donald F. Colantonio ◽  
CPT William B. Roach ◽  
...  
Keyword(s):  
Ulnar Collateral Ligament ◽  
Anatomic Reconstruction ◽  
Reconstruction Technique ◽  
Collateral Ligament ◽  
Time Zero ◽  
Initial Fixation ◽  
Valgus Angle ◽  
Starting Point ◽  
Bone Tunnels

Background: Current techniques for ulnar collateral ligament (UCL) reconstruction do not reproduce the anatomic ulnar footprint of the UCL. The purpose of this study was to describe a novel UCL reconstruction technique that utilizes proximal-to-distal ulnar bone tunnels to better re-create the anatomy of the UCL and to compare the biomechanical profile at time zero among this technique, the native UCL, and the traditional docking technique. Hypothesis: The biomechanical profile of the anatomic technique is similar to the native UCL and traditional docking technique. Study Design: Controlled laboratory study. Methods: Ten matched cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and bones were sectioned 14 cm proximal and distal to the elbow joint. Specimen testing included (1) native UCL testing performed at 90° of flexion with 0.5 N·m of valgus moment preload, (2) cyclic loading from 0.5 to 5 N·m of valgus moment for 1000 cycles at 1 Hz, and (3) load to failure at 0.2 mm/s. Elbows then underwent UCL reconstruction with 1 elbow of each pair receiving the classic docking technique using either anatomic (proximal to distal) or traditional (anterior to posterior) tunnel locations. Specimen testing was then repeated as described. Results: There were no differences in maximum load at failure between the anatomic and traditional tunnel location techniques (mean ± SD, 34.90 ± 10.65 vs 37.28 ± 14.26 N·m; P = .644) or when including the native UCL (45.83 ± 17.03 N·m; P = .099). Additionally, there were no differences in valgus angle after 1000 cycles across the anatomic technique (4.58°± 1.47°), traditional technique (4.08°± 1.28°), and native UCL (4.07°± 1.99°). The anatomic group and the native UCL had similar valgus angles at failure (24.13°± 5.86° vs 20.13°± 5.70°; P = .083), while the traditional group had a higher valgus angle at failure when compared with the native UCL (24.88°± 6.18° vs 19.44°± 5.86°; P = .015). Conclusion: In this cadaveric model, UCL reconstruction with the docking technique utilizing proximal-to-distal ulnar tunnels better restored the ulnar footprint while providing valgus stability comparable with reconstruction with the docking technique using traditional anterior-to-posterior ulnar tunnel locations. These results suggest that utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties to the traditional method at the time of initial fixation (ie, not accounting for healing after reconstruction in vivo) while keeping the ulnar tunnels farther from the ulnar nerve. Further studies are warranted to determine if an anatomically based UCL reconstruction results in differing outcomes than traditional reconstruction techniques. Clinical Relevance: Current UCL reconstruction techniques do not accurately re-create the ulnar UCL footprint. The UCL is a dynamic constraint to valgus loads at the elbow, and a more anatomic reconstruction may afford more natural joint kinematics. This more anatomic technique performs similarly to the traditional docking technique at time zero, and the results of this study may offer a starting point for future in vivo studies.

Sign in / Sign up

Export Citation Format

Share Document