Musculoskelet Surg (2014) 98 (Suppl 1):S87–S93 DOI 10.1007/s12306-014-0325-0
ORIGINAL ARTICLE
Elbow ulnar collateral ligament reconstruction: clinical, radiographic, and ultrasound outcomes at a mean 3-year follow-up G. Merolla • S. Del Sordo • P. Paladini G. Porcellini
•
Received: 28 November 2013 / Accepted: 24 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background Ulnar collateral ligament (UCL) has the main function to be stress-resistant to elbow valgus overload. Multilayer tears require a reconstruction with a tendon graft. In this study, we report the clinical, radiographic, and ultrasound outcomes after tendon graft reconstruction for symptomatic UCL insufficiency. Materials and methods Among twenty-six subjects underwent elbow UCL reconstruction from 2006 to 2012, fifteen were available to be evaluated at a mean follow-up of 36 months. Preoperative assessment included clinical examination and MRI. The outcome measures were the Mayo Elbow Performance Score (MEPS); the Oxford Elbow Score (OES); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Conway–Jobe Scale. Overall population was postoperatively investigated with X-ray and ultrasound (US). Reconstruction was performed with autograft (palmaris longus) in five cases and allograft (semitendinosus) in ten cases using the figure-of-eight configuration (five cases), the docking technique (eight cases), or a fixation with screws (two cases). Results We found a significant improvement in postoperative MEPS, OES, and DASH scores (p \ 0.01). One G. Merolla (&) P. Paladini G. Porcellini Unit of Shoulder and Elbow Surgery, D. Cervesi Hospital, Cattolica, Rimini, Italy e-mail: [email protected]; [email protected] G. Merolla Laboratory of Biomechanics ‘‘Marco Simoncelli’’, D. Cervesi Hospital, Cattolica, Italy S. Del Sordo Orthopedic and Trauma Unit, ‘‘Santa Chiara’’ Hospital, Trento, Italy
case was unsatisfied and required an additional procedure of ulnar nerve transposition 12 months after the reconstruction. X-ray showed calcifications along the graft in ten cases. At US examination, all the grafts assessed appeared anatomically intact without structural changes, and the dynamic examination showed a slight medial laxity with the valgus stress maneuver without pain or other sign of medial instability. Conclusions This study confirms the efficacy of the graft reconstruction for chronic UCL insufficiency and introduces fresh insight on the role of musculoskeletal ultrasound to evaluate the reconstructed UCL. Keywords Elbow Ulnar collateral ligament Reconstruction Ultrasound
Introduction Ulnar collateral ligament (UCL) has a complex structure having the main function to be stress-resistant to elbow valgus overload [1, 2]. It is anatomically divided into three components: the anterior, posterior, and transverse bundles [3]. The anterior band of the anterior bundle primarily stabilizes the elbow from 30° to 120° of flexion, while the posterior band has the same function at the terminal phase of the elbow flexion [4]. The UCL can be frequently injured after repeated functional valgus force applied to the elbow as it happens in overhead sports or work activities or as a result of indirect trauma caused by shoulder external rotation and valgus stress like fall on the hyperextended elbow [4]. Such trauma may be associated with bone injuries including fractures of the radial head, olecranon, and medial epicondyle [5].
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When torn, this ligament usually does not heal or it may heal in a loosened, lengthened position. Sprains are classified into three grades: in a first-degree sprain, the ligament is not lengthened, but it is painful; with a seconddegree sprain, the ligament is stretched but still functions; with a third-degree sprain, the ligament is torn and does not function [6]. In case of acute avulsion of the UCL at its ulnar insertion, the palpation along the ligament may be the cause of pain. The load on the forearm with the elbow flexed at 30° marks the gap of the ulno-humeral joint, due to the UCL insufficiency; moreover, the symptoms of ulnar nerve neuritis might be associated with the UCL complex inflammation. Ultrasonography (US) [6] and above all MRI [7] represent the best imaging modalities to address the diagnosis when the clinical presentation is suspect for ligament injuries. US is also a reliable diagnostic tool for a static and dynamic evaluation of the ligaments tears [8]. Operative repair is indicated in symptomatic young patients, especially in active overhead sportsmen, when the conservative treatment has failed and the elbow is painful. An isolated acute proximal or distal lesion may require a direct repair [9], while a multilayer tear, following repetitive microtraumatic sport or work activity, needs a reconstruction with a tendon graft [10–12]. In the current study, we report the clinical and ultrasonographic outcomes in a case series of patients treated with tendon graft for ulnar collateral ligament reconstruction.
Patients and methods Study population From January 2006 to December 2012, twenty-six subjects those who underwent UCL reconstruction for chronic UCL insufficiency were retrospectively enrolled. Fifteen of them were available to be assessed at a mean follow-up of 36 months (min 12, max 72). All patients enrolled gave their informed consent to be included in the study, which was approved by the Local Ethics committee (prot. no. 0.1131/2013/I.5/206) and performed in accordance with the Ethical Standards of the 1964 Declaration of Helsinki as revised in 2000. We used an autologous palmaris longus graft in five cases (33 %) and a semitendinosus allograft in 10 cases (77 %) (Bone bank allograft, Rizzoli Orthopedic Institute, Bologna, Italy). Six patients were overhead athletes, four were overhead heavy workers, and five had a previous trauma including dislocation or subluxation of the elbow. Demographic and anthropometric features of the study population are reported in the Table 1.
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Musculoskelet Surg (2014) 98 (Suppl 1):S87–S93 Table 1 Demographic and anthropometric data of the study population Variable
Data
Patients (no.)
15
Mean age (years ± SD)
38 ± 2.35
Gender (M/F) (%)
12/3 (80/20)
Mean height (cm ± SD)
174 ± 2.42
Mean weight (kg ± SD)
73 ± 2.11
Side Right/left (%) Dominant
10/5 (66/34) 9/6 (60/40)
Follow-up (months) (range)
36 (12–72)
SD standard deviation
Clinical assessment and outcome measures Overall, patients complained for elbow pain during sport and work activities and had positive signs for medial ligament injuries, including the valgus stress test [13] and the milking maneuver [14]. Magnetic resonance imaging (MRI) was performed in all cases to confirm the UCL injuries. We used the ultrasound (US) to document the presence or absence of a palmaris longus to the wrist, and we also searched for tendon features (length and width) to evaluate its suitability for a surgical reconstruction. The outcome measures were the Mayo Elbow Performance Score (MEPS) [15]; Oxford Elbow Score (OES) [16]; the Disabilities of the Arm, Shoulder, and Hand (DASH) [17]; and the Conway–Jobe Scale [18]. Measurements were taken independently by two examiners who had not been involved in the surgical procedures. The OES is a 12-item multiple choice questionnaire with a final score ranging from 0 to 48 and classified as poor (0–19), fair (20–29), good (30–39), and excellent (40–48). The DASH is a self-reported questionnaire scored in two components: the disability/symptom questions (30 items, scored 1–5) and the optional high-performance sport/music or work section (4 items, scored 1–5). The assigned values for all completed responses are simply summed and averaged and finally transformed to a score out of 100 by subtracting one and multiplying by 25. A higher score indicates greater disability. The Conway–Jobe Scale was applied to assess the level of competition in professional athletes and was scored as Excellent: return to pre-injury level of competition for more than one season. Good: return to play at a lower level of competition for more than one season. Fair: able to play regularly at a recreational level. Poor: unable to play at any level.
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X-ray and ultrasound assessment Overall, population underwent a radiographic evaluation of the operated elbow, including anteroposterior (AP) and true lateral elbow view [19]. The AP was performed with the elbow fully extended and the forearm supinated, allowing optimal visualization of the medial and lateral epicondyles, radiocapitellar joint, and estimation of the carrying angle [20]. The lateral view was obtained with the elbow in 90° of flexion and the forearm in neutral (thumb up) position [20]. A true lateral radiograph allowed a good visualization of the ulnotrochlear joint, coronoid process, and olecranon process and highlighted the ‘‘teardrop’’ appearance formed by the boundaries of the coronoid and olecranon fossae [21]. Ultrasonography was performed using a GE Logiq seven machine with a high-frequency linear transducer of 7.5–14 MHz; the transducer was placed in the coronal plane (long axis) with its cranial aspect over the medial epicondyle so that the hyperechoic bony contours of the medial epicondyle and ulnotrochlear articulation will be seen [6]. Compared to the original anterior fibrillar band of the UCL, the graft appeared as a more hyperechoic compact ‘‘cordlike’’ band that lay just deep to the common flexor tendon. The US allows to follow the course of the graft from the isometric origin on the anteroinferior aspect of the medial epicondyle to the ulnar insertion closeness to the sublime tubercle. Dynamic US was also performed to evaluate the tensile properties and the resistance of the neoligament with the application of valgus stress on the elbow.
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Postoperative
p value
MEPS
56.3 (3.9)
93.8 (6.1)
0.0006
OES
23.9 (1.9)
45.8 (2.8)
0.0006
DASH
31.8 (5.2)
1.81 (0.98)
0.0006
Data refer to mean values The values in bracket report the standard deviation (SD) MEPS Mayo Elbow Performance Score [15]; OES Oxford Elbow Score [16]; and DASH Disability of Arm, Shoulder, and Hand [17]
closed in layers, and the arm was placed in a hinged orthosis. Early passive mobilization was carefully begun on the 15th postoperative day protected with an hinged orthosis \90° of flexion–extension. The elbow was removed by the orthosis within 30th postoperative day [22]. Elastic resistance exercises were allowed at 60 days and heavy work or sports activity after 90 days. Statistical analysis Statistical analysis was performed using the Wilcoxon signed-rank test for paired data to assess the difference between pre- and postoperative clinical scores. Correlations between patient’s features (age, gender, height, weight) and clinical scores were sought using nonparametric Spearman’s test. Bravais–Pearson correlation coefficient was used to search the difference between the two independent observations.
Surgical technique All surgical procedures were performed by same two surgeons (GP and GM). A medial approach was used for MCL reconstruction, with the incision extending from the medial epicondyle to the proximal ulnar metaphysis. The ulnar nerve was isolated; the isometric origin of the anterior band of the MCL on the anteroinferior aspect of the medial epicondyle was identified, preserving the origin of flexor– pronator tendons. After exposure of the sublime tubercle on the medial aspect of the proximal ulna, humeral and ulnar tunnels were bored with a 5.0-mm cutter and rounded with a suture passer to foster the passage of the graft, which was then fixed using a figure-of-eight configuration (five cases) or a docking technique (eight cases); in two cases, we used an interference screws of 5 mm 9 23 mm (Arthrex Inc, Naples, Fl, USA) to fix the graft on the humeral side. After the fixation, the end of the graft was holded on themselves, stitched up with non-absorbable sutures (Terofil 0.4 mm), and reinforced with capsular stitches; the ulnar nerve was transposed in the subcutaneous tissues. The wound was
Results Clinical outcomes All but one patient was satisfied after the surgical procedures and described their level of satisfaction as excellent in ten cases, good in four cases, and poor in one case. The unsatisfied patient complained for pain and discomfort during work activity and required an additional procedure of anterior ulnar nerve transposition after 12 months from the UCL reconstruction. The analysis of clinical scores showed a significant improvement in postoperative MEPS, OES, and DASH scores (p \ 0.01) (Table 2). The cases who were reconstructed using palmaris longus autograft had similar outcomes compared with those who received a semitendinosus allograft (p [ 0.05). The valgus stress test and the milking maneuver were negative in 14 subjects. No significant correlation was found between patient’s features (age, gender, height, weight) and clinical scores (p [ 0.05).
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The Conway–Jobe Scale in the five athletes was reported as excellent in four and good in one. Interobserver agreement yielded k values ranging from 0.81 to 0.85 for MEPS, from 0.80 to 0.83 for OES, from 0.83 to 0.85 for DASH, and from 0.80 to 0.83 for Conway–Jobe Score. Intra-observer agreement was good (k = 0.83–0.88). Radiographic outcomes X-ray showed calcification along the tendon graft in ten cases (67 %) that were located along the humeral insertion in ten cases and near the ulnar insertion in five cases (Fig. 1). At US examination, all the grafts assessed appeared anatomically intact, with slight signs of fraying and were surrounded by scar tissues that did not prevent the free flow of the graft (Fig. 2). We also performed a dynamic ultrasonography assessment that demonstrates slight medial laxity with valgus stress maneuver without pain or other sign of medial instability.
Discussion Ulnar collateral ligament insufficiency is a cause of pain and elbow dysfunction that may result in end of sport career or inability to return to work [23, 24]. Whereas there is unanimous consensus on the effect of valgus overload in the late cooking and acceleration phase of throwing [25, 26], the mechanism of UCL injuries after elbow dislocation remains still debated. In the posterolateral rotatory instability (PLI) proposed by O’Driscoll et al. [27], the medial collateral ligament might be injured after elbow dislocation preceded by a complete rupture of the lateral ligament complex and anterior capsule; thus, in all dislocations, the lateral ulnar collateral ligament (LUCL) has been known to be torn, whereas the rupture of the UCL and overlying flexor–pronator muscle group depends on the degree of the progression. Conversely, in the less common posteromedial direction of elbow instability (PMI), the torn UCL was found to be habitually associated with fractures of the coronoid process since it provides an anterior buttress to resist posterior dislocation [28], giving attachment to the anterior bundle of the UCL and the middle third of the anterior capsule; therefore, an anteromedial facet fracture of the coronoid is associated with posteromedial varus rotatory instability [29]. Nevertheless, a new mechanism of posterior dislocation recently proposed showed more severe damage of the soft tissue on the medial side, including a torn UCL, in cases with PLI compared with the more severe damages of the soft tissues on the lateral side that are found in the rare cases of PMI [30]. The authors concluded that the posterolateral dislocation was thought to start from the medial side in contrary to posteromedial
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Fig. 1 X-ray in AP view of the left elbow. Calcifications are present along the course of the reconstructed ulnar collateral ligament (UCL)
Fig. 2 Ultrasound assessment of the right reconstructed UCL. The course of the graft appears iperechoic (black arrows), surrounded by scar tissues without significant structural changes. ME medial epicondyle, F common flexor tendon
dislocation that began at the lateral side [30]. The aforementioned research findings are partially consistent with our data that showed five cases of UCL injuries in patients who had experienced a complete elbow dislocation or had history of elbow trauma with suspect of instability. Despite these different pathomechanic theories, the tendon graft reconstruction represents the procedure of choice to treat
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the ultimate failure of the UCL. Although MRI [7] and ultrasound [6] are useful and reliable to detect the site and the extension of the ligament tears, the clinical assessment remains a crucial point to select the patients who are good candidates for UCL reconstruction. Specifically, the valgus stress test and the milking maneuver are positive in all cases, but for overhead athletes, such as baseball and javelin throwers, it is mandatory to assess their sports performance and evaluate which is the phase where the athlete complains for pain and weakness that in the thrower coincide with the late cooking and acceleration phases. Several technically demanding procedures using different types of tendon grafts have been described to treat UCL insufficiency, reporting from good to satisfactory results [12, 31]. In our study, we had no different clinical outcomes with autograft compared with allograft, and this is consistent with the current literature [10, 31]. The most difficult step of the surgical procedure was the passage of the graft in the bone tunnels because we found that the thickness of the graft made difficult its free flow in the bone tunnels and at the same time, the diameters of the tunnels could not be excessively widened to avoid the risk of weakening the bone walls. On this regard, Byram et al. [32] found that the maximal humeral tunnel length is achieved by starting central or lateral to the midpoint of the epicondyle, angulated 30 to the humeral axis in the sagittal plane and 15 in the coronal plane. A reasonable goal tunnel depth should range from 15 to 20 mm; ulnar tunnels should be placed on the anterior and posterior aspects of the sublime tubercle, and a bone bridge of 6–8 mm between these tunnels can be reasonably achieved. While the fixation technique and the type of graft did not affect the outcomes, we do believe that the critical point of the surgical procedure was the respect of the course and the isometric origin of the anterior band of the medial collateral ligament complex to reproduce the biomechanical effect of the native ligament. An additional issue arised from this research is the role of postoperative imaging used to evaluate the results. X-ray was a simple and standardized method that offered the advantage to detect any bony abnormalities, including ossifications along the graft or close to the bone tunnels. Ultrasonography (US) is accurate, easy to perform in experienced hands with an excellent cost–benefit ratio; we used US as an additional postoperative tool in our outpatient office during follow-up examination after UCL reconstruction to detect early complication, such as edema and hematoma, and to assess the topographic anatomy of the ‘‘neoligament,’’ its width, length, and any structural changes of the graft. We found a fair amount of scar tissues all around the graft, especially in the vicinity of the inlet holes of the bone tunnels and in the areas where the ligament was overturned and sutured. Nonetheless, the dynamic ultrasound evaluation under
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valgus stress showed a stable and painless elbow with an intact graft for all its length. Overall, the analysis of the results of this study showed excellent patient satisfaction; nevertheless, we had one subject who complained for pain and was unable to return to his previous work activity; in this patient, we found an ulnar nerve neuropathy that did not resolved after an additional procedure of ulnar nerve transposition 1 year after the UCL reconstruction. Although we considered this case a surgical failure, we do believe that he was a worker compensation patient. The six athletes were able to return to the previous sport activity within 6 months but the two baseball players required a mean period of 10 months to gain the pre-injury sport level. One of these two patients had a painful period of 6 months during the late cooking. None of the subjects who had a traumatic ligament injury had pain and they considered their postoperative quality of life very satisfactory. Our results are consistent with the available literature [10, 11, 31, 33, 34]. Savoie et al. [10] reviewed 123 overhead throwing athletes with UCL reconstruction with hamstring allograft at 24 months and reported that 97 of them returned to play above or at the same level that prior to injury. Excellent results were also reported by Hechtman et al. [11] in 34 athletes where the UCL was reconstructed using an hybrid technique with ulnar osseous tunnel and suture anchor fixation on the humerus. Similar excellent to good results were described by Jones et al. [33] and Kodde et al. [34]. Vitale and Ahmad [31] in a systematic review of published studies evaluating reconstruction of the UCL in overhead athletes from 1950 to November 2007 found eight Level III (retrospective cohort) studies with a minimum of 1-year follow-up; 83 % of patients in all studies had an excellent result, and there was an overall 10 % complication rate, with the most common complication being postoperative ulnar neuropathy, which occurred in 6 % of patients; the authors also emphasized how transition to the muscle-splitting approach was associated with better outcomes than detachment of the flexor–pronator mass. Watson et al. [12] in a systematic review of the clinical outcomes and biomechanics results of UCL reconstruction techniques concluded that the docking technique results in a significantly higher rate of return to play and a lower complication rate when compared with the Jobe and modified Jobe techniques. There is also literature evidence about collateral ligament injuries after elbow dislocation without concomitant fractures [35, 36]. Josefsson et al. [35] examined 30 elbow after dislocation who were randomly assigned to non-surgical or surgical treatment; all of the surgically treated elbow showed complete rupture of both the medial and lateral collateral ligaments, and there was no evidence that the results of the surgical repair were better than those of the non-surgical treatment. An additional study of the same authors [36] reported that
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ligaments suture was performed medially in all 31 cases examined and laterally in 18 cases. From our data arised that a torn UCl induces pain and weakness after valgus loading even in cases of stable joint. These patients also complained for pain during their work activity, especially when the load was applied in valgus and supination on the elbow flexed at 30° and the shoulder abducted at 90° and externally rotated. This happens because the UCL cannot prevent the opening of the medial ulno-humeral joint and is worsened when the UCL injury is associated with capsular ruptures and/or injury of the flexor–pronator mass. Some limitations are noteworthy in this study, they are as follows: (1) the sample size is relatively small, (2) the population enrolled is heterogeneous including valgus overload and post-instability UCL injuries, (3) the study is retrospective without a control group for comparison, (4) the type of graft and the technique of fixation were not the same for all the patients enrolled. Although this limitation, this study confirms the efficacy of the graft reconstruction techniques in subjects with chronic UCL insufficiency, shows similar clinical and radiographic results of allograft versus autograft, and introduces fresh insight into the role of musculoskeletal ultrasound to evaluate the reconstructed UCL. Acknowledgments We are grateful to Dr. Hemant Parekh (SKM Medical College, Pune, India) for the contribution in the language revision. We are also grateful to Dr. Elisabetta Fabbri (U.O Ricerca ed Innovazione, AUSL Rimini, Italy) for the precious professional support in the statistical analysis. Conflict of interest G. Merolla, S. Del Sordo, P. Paladini, G. Porcellini declare that they have no conflict of interest. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification. Human and Animal Rights The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.
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ORIGINAL ARTICLE
Elbow ulnar collateral ligament reconstruction: clinical, radiographic, and ultrasound outcomes at a mean 3-year follow-up G. Merolla • S. Del Sordo • P. Paladini G. Porcellini
•
Received: 28 November 2013 / Accepted: 24 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background Ulnar collateral ligament (UCL) has the main function to be stress-resistant to elbow valgus overload. Multilayer tears require a reconstruction with a tendon graft. In this study, we report the clinical, radiographic, and ultrasound outcomes after tendon graft reconstruction for symptomatic UCL insufficiency. Materials and methods Among twenty-six subjects underwent elbow UCL reconstruction from 2006 to 2012, fifteen were available to be evaluated at a mean follow-up of 36 months. Preoperative assessment included clinical examination and MRI. The outcome measures were the Mayo Elbow Performance Score (MEPS); the Oxford Elbow Score (OES); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Conway–Jobe Scale. Overall population was postoperatively investigated with X-ray and ultrasound (US). Reconstruction was performed with autograft (palmaris longus) in five cases and allograft (semitendinosus) in ten cases using the figure-of-eight configuration (five cases), the docking technique (eight cases), or a fixation with screws (two cases). Results We found a significant improvement in postoperative MEPS, OES, and DASH scores (p \ 0.01). One G. Merolla (&) P. Paladini G. Porcellini Unit of Shoulder and Elbow Surgery, D. Cervesi Hospital, Cattolica, Rimini, Italy e-mail: [email protected]; [email protected] G. Merolla Laboratory of Biomechanics ‘‘Marco Simoncelli’’, D. Cervesi Hospital, Cattolica, Italy S. Del Sordo Orthopedic and Trauma Unit, ‘‘Santa Chiara’’ Hospital, Trento, Italy
case was unsatisfied and required an additional procedure of ulnar nerve transposition 12 months after the reconstruction. X-ray showed calcifications along the graft in ten cases. At US examination, all the grafts assessed appeared anatomically intact without structural changes, and the dynamic examination showed a slight medial laxity with the valgus stress maneuver without pain or other sign of medial instability. Conclusions This study confirms the efficacy of the graft reconstruction for chronic UCL insufficiency and introduces fresh insight on the role of musculoskeletal ultrasound to evaluate the reconstructed UCL. Keywords Elbow Ulnar collateral ligament Reconstruction Ultrasound
Introduction Ulnar collateral ligament (UCL) has a complex structure having the main function to be stress-resistant to elbow valgus overload [1, 2]. It is anatomically divided into three components: the anterior, posterior, and transverse bundles [3]. The anterior band of the anterior bundle primarily stabilizes the elbow from 30° to 120° of flexion, while the posterior band has the same function at the terminal phase of the elbow flexion [4]. The UCL can be frequently injured after repeated functional valgus force applied to the elbow as it happens in overhead sports or work activities or as a result of indirect trauma caused by shoulder external rotation and valgus stress like fall on the hyperextended elbow [4]. Such trauma may be associated with bone injuries including fractures of the radial head, olecranon, and medial epicondyle [5].
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When torn, this ligament usually does not heal or it may heal in a loosened, lengthened position. Sprains are classified into three grades: in a first-degree sprain, the ligament is not lengthened, but it is painful; with a seconddegree sprain, the ligament is stretched but still functions; with a third-degree sprain, the ligament is torn and does not function [6]. In case of acute avulsion of the UCL at its ulnar insertion, the palpation along the ligament may be the cause of pain. The load on the forearm with the elbow flexed at 30° marks the gap of the ulno-humeral joint, due to the UCL insufficiency; moreover, the symptoms of ulnar nerve neuritis might be associated with the UCL complex inflammation. Ultrasonography (US) [6] and above all MRI [7] represent the best imaging modalities to address the diagnosis when the clinical presentation is suspect for ligament injuries. US is also a reliable diagnostic tool for a static and dynamic evaluation of the ligaments tears [8]. Operative repair is indicated in symptomatic young patients, especially in active overhead sportsmen, when the conservative treatment has failed and the elbow is painful. An isolated acute proximal or distal lesion may require a direct repair [9], while a multilayer tear, following repetitive microtraumatic sport or work activity, needs a reconstruction with a tendon graft [10–12]. In the current study, we report the clinical and ultrasonographic outcomes in a case series of patients treated with tendon graft for ulnar collateral ligament reconstruction.
Patients and methods Study population From January 2006 to December 2012, twenty-six subjects those who underwent UCL reconstruction for chronic UCL insufficiency were retrospectively enrolled. Fifteen of them were available to be assessed at a mean follow-up of 36 months (min 12, max 72). All patients enrolled gave their informed consent to be included in the study, which was approved by the Local Ethics committee (prot. no. 0.1131/2013/I.5/206) and performed in accordance with the Ethical Standards of the 1964 Declaration of Helsinki as revised in 2000. We used an autologous palmaris longus graft in five cases (33 %) and a semitendinosus allograft in 10 cases (77 %) (Bone bank allograft, Rizzoli Orthopedic Institute, Bologna, Italy). Six patients were overhead athletes, four were overhead heavy workers, and five had a previous trauma including dislocation or subluxation of the elbow. Demographic and anthropometric features of the study population are reported in the Table 1.
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Musculoskelet Surg (2014) 98 (Suppl 1):S87–S93 Table 1 Demographic and anthropometric data of the study population Variable
Data
Patients (no.)
15
Mean age (years ± SD)
38 ± 2.35
Gender (M/F) (%)
12/3 (80/20)
Mean height (cm ± SD)
174 ± 2.42
Mean weight (kg ± SD)
73 ± 2.11
Side Right/left (%) Dominant
10/5 (66/34) 9/6 (60/40)
Follow-up (months) (range)
36 (12–72)
SD standard deviation
Clinical assessment and outcome measures Overall, patients complained for elbow pain during sport and work activities and had positive signs for medial ligament injuries, including the valgus stress test [13] and the milking maneuver [14]. Magnetic resonance imaging (MRI) was performed in all cases to confirm the UCL injuries. We used the ultrasound (US) to document the presence or absence of a palmaris longus to the wrist, and we also searched for tendon features (length and width) to evaluate its suitability for a surgical reconstruction. The outcome measures were the Mayo Elbow Performance Score (MEPS) [15]; Oxford Elbow Score (OES) [16]; the Disabilities of the Arm, Shoulder, and Hand (DASH) [17]; and the Conway–Jobe Scale [18]. Measurements were taken independently by two examiners who had not been involved in the surgical procedures. The OES is a 12-item multiple choice questionnaire with a final score ranging from 0 to 48 and classified as poor (0–19), fair (20–29), good (30–39), and excellent (40–48). The DASH is a self-reported questionnaire scored in two components: the disability/symptom questions (30 items, scored 1–5) and the optional high-performance sport/music or work section (4 items, scored 1–5). The assigned values for all completed responses are simply summed and averaged and finally transformed to a score out of 100 by subtracting one and multiplying by 25. A higher score indicates greater disability. The Conway–Jobe Scale was applied to assess the level of competition in professional athletes and was scored as Excellent: return to pre-injury level of competition for more than one season. Good: return to play at a lower level of competition for more than one season. Fair: able to play regularly at a recreational level. Poor: unable to play at any level.
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X-ray and ultrasound assessment Overall, population underwent a radiographic evaluation of the operated elbow, including anteroposterior (AP) and true lateral elbow view [19]. The AP was performed with the elbow fully extended and the forearm supinated, allowing optimal visualization of the medial and lateral epicondyles, radiocapitellar joint, and estimation of the carrying angle [20]. The lateral view was obtained with the elbow in 90° of flexion and the forearm in neutral (thumb up) position [20]. A true lateral radiograph allowed a good visualization of the ulnotrochlear joint, coronoid process, and olecranon process and highlighted the ‘‘teardrop’’ appearance formed by the boundaries of the coronoid and olecranon fossae [21]. Ultrasonography was performed using a GE Logiq seven machine with a high-frequency linear transducer of 7.5–14 MHz; the transducer was placed in the coronal plane (long axis) with its cranial aspect over the medial epicondyle so that the hyperechoic bony contours of the medial epicondyle and ulnotrochlear articulation will be seen [6]. Compared to the original anterior fibrillar band of the UCL, the graft appeared as a more hyperechoic compact ‘‘cordlike’’ band that lay just deep to the common flexor tendon. The US allows to follow the course of the graft from the isometric origin on the anteroinferior aspect of the medial epicondyle to the ulnar insertion closeness to the sublime tubercle. Dynamic US was also performed to evaluate the tensile properties and the resistance of the neoligament with the application of valgus stress on the elbow.
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Postoperative
p value
MEPS
56.3 (3.9)
93.8 (6.1)
0.0006
OES
23.9 (1.9)
45.8 (2.8)
0.0006
DASH
31.8 (5.2)
1.81 (0.98)
0.0006
Data refer to mean values The values in bracket report the standard deviation (SD) MEPS Mayo Elbow Performance Score [15]; OES Oxford Elbow Score [16]; and DASH Disability of Arm, Shoulder, and Hand [17]
closed in layers, and the arm was placed in a hinged orthosis. Early passive mobilization was carefully begun on the 15th postoperative day protected with an hinged orthosis \90° of flexion–extension. The elbow was removed by the orthosis within 30th postoperative day [22]. Elastic resistance exercises were allowed at 60 days and heavy work or sports activity after 90 days. Statistical analysis Statistical analysis was performed using the Wilcoxon signed-rank test for paired data to assess the difference between pre- and postoperative clinical scores. Correlations between patient’s features (age, gender, height, weight) and clinical scores were sought using nonparametric Spearman’s test. Bravais–Pearson correlation coefficient was used to search the difference between the two independent observations.
Surgical technique All surgical procedures were performed by same two surgeons (GP and GM). A medial approach was used for MCL reconstruction, with the incision extending from the medial epicondyle to the proximal ulnar metaphysis. The ulnar nerve was isolated; the isometric origin of the anterior band of the MCL on the anteroinferior aspect of the medial epicondyle was identified, preserving the origin of flexor– pronator tendons. After exposure of the sublime tubercle on the medial aspect of the proximal ulna, humeral and ulnar tunnels were bored with a 5.0-mm cutter and rounded with a suture passer to foster the passage of the graft, which was then fixed using a figure-of-eight configuration (five cases) or a docking technique (eight cases); in two cases, we used an interference screws of 5 mm 9 23 mm (Arthrex Inc, Naples, Fl, USA) to fix the graft on the humeral side. After the fixation, the end of the graft was holded on themselves, stitched up with non-absorbable sutures (Terofil 0.4 mm), and reinforced with capsular stitches; the ulnar nerve was transposed in the subcutaneous tissues. The wound was
Results Clinical outcomes All but one patient was satisfied after the surgical procedures and described their level of satisfaction as excellent in ten cases, good in four cases, and poor in one case. The unsatisfied patient complained for pain and discomfort during work activity and required an additional procedure of anterior ulnar nerve transposition after 12 months from the UCL reconstruction. The analysis of clinical scores showed a significant improvement in postoperative MEPS, OES, and DASH scores (p \ 0.01) (Table 2). The cases who were reconstructed using palmaris longus autograft had similar outcomes compared with those who received a semitendinosus allograft (p [ 0.05). The valgus stress test and the milking maneuver were negative in 14 subjects. No significant correlation was found between patient’s features (age, gender, height, weight) and clinical scores (p [ 0.05).
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The Conway–Jobe Scale in the five athletes was reported as excellent in four and good in one. Interobserver agreement yielded k values ranging from 0.81 to 0.85 for MEPS, from 0.80 to 0.83 for OES, from 0.83 to 0.85 for DASH, and from 0.80 to 0.83 for Conway–Jobe Score. Intra-observer agreement was good (k = 0.83–0.88). Radiographic outcomes X-ray showed calcification along the tendon graft in ten cases (67 %) that were located along the humeral insertion in ten cases and near the ulnar insertion in five cases (Fig. 1). At US examination, all the grafts assessed appeared anatomically intact, with slight signs of fraying and were surrounded by scar tissues that did not prevent the free flow of the graft (Fig. 2). We also performed a dynamic ultrasonography assessment that demonstrates slight medial laxity with valgus stress maneuver without pain or other sign of medial instability.
Discussion Ulnar collateral ligament insufficiency is a cause of pain and elbow dysfunction that may result in end of sport career or inability to return to work [23, 24]. Whereas there is unanimous consensus on the effect of valgus overload in the late cooking and acceleration phase of throwing [25, 26], the mechanism of UCL injuries after elbow dislocation remains still debated. In the posterolateral rotatory instability (PLI) proposed by O’Driscoll et al. [27], the medial collateral ligament might be injured after elbow dislocation preceded by a complete rupture of the lateral ligament complex and anterior capsule; thus, in all dislocations, the lateral ulnar collateral ligament (LUCL) has been known to be torn, whereas the rupture of the UCL and overlying flexor–pronator muscle group depends on the degree of the progression. Conversely, in the less common posteromedial direction of elbow instability (PMI), the torn UCL was found to be habitually associated with fractures of the coronoid process since it provides an anterior buttress to resist posterior dislocation [28], giving attachment to the anterior bundle of the UCL and the middle third of the anterior capsule; therefore, an anteromedial facet fracture of the coronoid is associated with posteromedial varus rotatory instability [29]. Nevertheless, a new mechanism of posterior dislocation recently proposed showed more severe damage of the soft tissue on the medial side, including a torn UCL, in cases with PLI compared with the more severe damages of the soft tissues on the lateral side that are found in the rare cases of PMI [30]. The authors concluded that the posterolateral dislocation was thought to start from the medial side in contrary to posteromedial
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Fig. 1 X-ray in AP view of the left elbow. Calcifications are present along the course of the reconstructed ulnar collateral ligament (UCL)
Fig. 2 Ultrasound assessment of the right reconstructed UCL. The course of the graft appears iperechoic (black arrows), surrounded by scar tissues without significant structural changes. ME medial epicondyle, F common flexor tendon
dislocation that began at the lateral side [30]. The aforementioned research findings are partially consistent with our data that showed five cases of UCL injuries in patients who had experienced a complete elbow dislocation or had history of elbow trauma with suspect of instability. Despite these different pathomechanic theories, the tendon graft reconstruction represents the procedure of choice to treat
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the ultimate failure of the UCL. Although MRI [7] and ultrasound [6] are useful and reliable to detect the site and the extension of the ligament tears, the clinical assessment remains a crucial point to select the patients who are good candidates for UCL reconstruction. Specifically, the valgus stress test and the milking maneuver are positive in all cases, but for overhead athletes, such as baseball and javelin throwers, it is mandatory to assess their sports performance and evaluate which is the phase where the athlete complains for pain and weakness that in the thrower coincide with the late cooking and acceleration phases. Several technically demanding procedures using different types of tendon grafts have been described to treat UCL insufficiency, reporting from good to satisfactory results [12, 31]. In our study, we had no different clinical outcomes with autograft compared with allograft, and this is consistent with the current literature [10, 31]. The most difficult step of the surgical procedure was the passage of the graft in the bone tunnels because we found that the thickness of the graft made difficult its free flow in the bone tunnels and at the same time, the diameters of the tunnels could not be excessively widened to avoid the risk of weakening the bone walls. On this regard, Byram et al. [32] found that the maximal humeral tunnel length is achieved by starting central or lateral to the midpoint of the epicondyle, angulated 30 to the humeral axis in the sagittal plane and 15 in the coronal plane. A reasonable goal tunnel depth should range from 15 to 20 mm; ulnar tunnels should be placed on the anterior and posterior aspects of the sublime tubercle, and a bone bridge of 6–8 mm between these tunnels can be reasonably achieved. While the fixation technique and the type of graft did not affect the outcomes, we do believe that the critical point of the surgical procedure was the respect of the course and the isometric origin of the anterior band of the medial collateral ligament complex to reproduce the biomechanical effect of the native ligament. An additional issue arised from this research is the role of postoperative imaging used to evaluate the results. X-ray was a simple and standardized method that offered the advantage to detect any bony abnormalities, including ossifications along the graft or close to the bone tunnels. Ultrasonography (US) is accurate, easy to perform in experienced hands with an excellent cost–benefit ratio; we used US as an additional postoperative tool in our outpatient office during follow-up examination after UCL reconstruction to detect early complication, such as edema and hematoma, and to assess the topographic anatomy of the ‘‘neoligament,’’ its width, length, and any structural changes of the graft. We found a fair amount of scar tissues all around the graft, especially in the vicinity of the inlet holes of the bone tunnels and in the areas where the ligament was overturned and sutured. Nonetheless, the dynamic ultrasound evaluation under
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valgus stress showed a stable and painless elbow with an intact graft for all its length. Overall, the analysis of the results of this study showed excellent patient satisfaction; nevertheless, we had one subject who complained for pain and was unable to return to his previous work activity; in this patient, we found an ulnar nerve neuropathy that did not resolved after an additional procedure of ulnar nerve transposition 1 year after the UCL reconstruction. Although we considered this case a surgical failure, we do believe that he was a worker compensation patient. The six athletes were able to return to the previous sport activity within 6 months but the two baseball players required a mean period of 10 months to gain the pre-injury sport level. One of these two patients had a painful period of 6 months during the late cooking. None of the subjects who had a traumatic ligament injury had pain and they considered their postoperative quality of life very satisfactory. Our results are consistent with the available literature [10, 11, 31, 33, 34]. Savoie et al. [10] reviewed 123 overhead throwing athletes with UCL reconstruction with hamstring allograft at 24 months and reported that 97 of them returned to play above or at the same level that prior to injury. Excellent results were also reported by Hechtman et al. [11] in 34 athletes where the UCL was reconstructed using an hybrid technique with ulnar osseous tunnel and suture anchor fixation on the humerus. Similar excellent to good results were described by Jones et al. [33] and Kodde et al. [34]. Vitale and Ahmad [31] in a systematic review of published studies evaluating reconstruction of the UCL in overhead athletes from 1950 to November 2007 found eight Level III (retrospective cohort) studies with a minimum of 1-year follow-up; 83 % of patients in all studies had an excellent result, and there was an overall 10 % complication rate, with the most common complication being postoperative ulnar neuropathy, which occurred in 6 % of patients; the authors also emphasized how transition to the muscle-splitting approach was associated with better outcomes than detachment of the flexor–pronator mass. Watson et al. [12] in a systematic review of the clinical outcomes and biomechanics results of UCL reconstruction techniques concluded that the docking technique results in a significantly higher rate of return to play and a lower complication rate when compared with the Jobe and modified Jobe techniques. There is also literature evidence about collateral ligament injuries after elbow dislocation without concomitant fractures [35, 36]. Josefsson et al. [35] examined 30 elbow after dislocation who were randomly assigned to non-surgical or surgical treatment; all of the surgically treated elbow showed complete rupture of both the medial and lateral collateral ligaments, and there was no evidence that the results of the surgical repair were better than those of the non-surgical treatment. An additional study of the same authors [36] reported that
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ligaments suture was performed medially in all 31 cases examined and laterally in 18 cases. From our data arised that a torn UCl induces pain and weakness after valgus loading even in cases of stable joint. These patients also complained for pain during their work activity, especially when the load was applied in valgus and supination on the elbow flexed at 30° and the shoulder abducted at 90° and externally rotated. This happens because the UCL cannot prevent the opening of the medial ulno-humeral joint and is worsened when the UCL injury is associated with capsular ruptures and/or injury of the flexor–pronator mass. Some limitations are noteworthy in this study, they are as follows: (1) the sample size is relatively small, (2) the population enrolled is heterogeneous including valgus overload and post-instability UCL injuries, (3) the study is retrospective without a control group for comparison, (4) the type of graft and the technique of fixation were not the same for all the patients enrolled. Although this limitation, this study confirms the efficacy of the graft reconstruction techniques in subjects with chronic UCL insufficiency, shows similar clinical and radiographic results of allograft versus autograft, and introduces fresh insight into the role of musculoskeletal ultrasound to evaluate the reconstructed UCL. Acknowledgments We are grateful to Dr. Hemant Parekh (SKM Medical College, Pune, India) for the contribution in the language revision. We are also grateful to Dr. Elisabetta Fabbri (U.O Ricerca ed Innovazione, AUSL Rimini, Italy) for the precious professional support in the statistical analysis. Conflict of interest G. Merolla, S. Del Sordo, P. Paladini, G. Porcellini declare that they have no conflict of interest. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification. Human and Animal Rights The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.
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