Medial Collateral Instability of the ElbowSubluxation of nerve - 40% of cases. Imaging Studies...
Transcript of Medial Collateral Instability of the ElbowSubluxation of nerve - 40% of cases. Imaging Studies...
Medial Collateral Instability of the Elbow
CSES Residents CourseCalgary AB
February 1-3, 2017WD Regan MD
Disclosures
I have no disclosures to report
AnatomyMedial Collateral Ligament
Anterior ObliquePosterior ObliqueTransverse Ligament
AMCL Origin – Antero-inferior medial epicondyle
Insertion-sublime tubercle medial coronoid
AnatomyMedial Collateral Ligament
MCL undersurface is a sequential ligament insertion greater sigmoid fossa (anterior to posterior)
Regan et al. 1991 (CORR)
• CAM Effect• Based on degree of
elbow flexion• Anterior oblique
• tight in extension• Posterior oblique
• tight in flexion
Reciprocating relationship
MCL Anatomy and Biomechanics
Calloway et al JBJS 1997
MCL Biomechanics
Potted origin and insertion of AMCL & PMCL8 Specimens
AV
L
W
AMCL PMCL
21mm 16mm
7.6mm 8.8mm
Regan et al.1991 (CORR)
MCL Biomechanics
AMCL PMCL260 N 159 N
Stiffness1528 N 861N
Palmaris Longus10 fold greater stiffness
than AMCL.Regan et al. 1991(CORR)
MTS load to failure
MCL The injury
5 phases of throwing Late Cocking and acceleration phases
Flexion
Rapid
Extension
90-120o
30- 40 milisec.
25o of Flexion
Peak angular velocity 4500 degrees per secondWilson et all AJSM 1983
MCL Insufficiency Symptoms
Microscopic tears of Ligament = AttenuationGradual onset of medial elbow pain Progressive valgus laxity“Pop” with immediate onset of pain50% Jobe’s Series
Conway & Jobe JBJS 1992
Associated PathologyValgus extension Overload
Laxity AMCLValgus stress
Hypertrophic changes develop posteromedial olecranon against the olecranon fossaJobe 16% casesAltchek 45%
Pain on forced extension
Ulnar Neuritis
Secondary to:
1. Direct Trauma2. Traction Compression: Hypertrophy of
common flexors3. Subluxation of nerve - 40% of cases.
Imaging Studies
RadiographsCalcification of MCLTraction spursValgus gravity stress test-medial opening
CT ArthrogramThin cuts 3mm100% sensitive complete tearsCT arthrogram better than MRI for partial tears
71% CT arthro14% MR
Magnetic Resonance Imaging Based Classification for UCL Injuries
(Joyner et al. 2016)
• MRIs from 240 patients undergoing UCL reconstruction (Andrew’s)
• Classification type synonymous with valgus laxity • Type 1: 0.13mm• Type 2: 0.2mm• Type 3: 0.63mm• Type 4: 0.76mm
Magnetic Resonance Imaging Based Classification for UCL
Injuries con’t
Timmerman SignType 3 UCL from sublime
tubercle Partial UCL tear
Type 2 UCL
Arthroscopy
• 1 mm-open indicates AMCL attenuation
• 3 mm-complete tear
Altchek et al. 2009 (AJSM)
Valgus stress testElbow flex 30 deg.Humerus in abduction + external rotationValgus stress Pain over MCL + Opening
Distinguish medial epicondylitis by pain on forced resisted flexion-pronation
Moving Valgus Stress Test
Active Milking testShoulder abducted 90o
Elbow maximally flexedConstant valgus load applied to elbowElbow quickly extended to 30o
flexion.
O’Driscoll AJSM 2005
Moving Valgus Stress Test
Pain must reproduce MCL painMaximal pain 120-70o “Shear Range”Sensitivity 100%17 of 17 patientsSpecificity 75%3 of 4 ptsMRI 6-15 40% pts
Conservative Care
• Partial or complete UCL tear• 3 months rest and
rehabilitation
• Dismal Results • 42% return to play• Average time return to play
24.5 weeks• Duration of symptoms,
acuity of injury, nor age did not predict return to play
Rettig et al. 2001 (AJSM)
Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow with Platelet-Rich Plasma
• 34 patients with partial UCL injury (MRI diagnosis)
• 5mL PRP under ultrasound guidance in site of injury
• 12 weeks of rehabilitation
• Follow-up 70 weeks• 30/34 (88%) return
to play without complaints
• Significant improvement in DASH score
(21 +- 16 to 1 +-6)
Podesta et al.Am J Sp Med, 41:7, 2013
Indications for Surgery
• Complete/partial rupture in throwing athlete• Chronic pain without improvement after 3 months (conservative)• Rest, bracing, rehabilitation 40% return to throwing (Rettig)
• Reconstruction advised vs. repair
Modification to the Original Technique
Muscle splitting approach -Ulnar nerve protected but not transposed
Open tunnelsPalmaris Tendon autograft83 pts33 pts > 2 yr follow upNo operation for Ulnar Nerve
dysfunctionAll athletes return to their sport93% excellent result5% Ulnar Nerve Paresthesiae (transient)
Thompson and Jobe et al JSES 2001
Modifications – ALTCHEKDocking Technique
Arthroscopic treatment first of valgus extension overload osteophytes
Muscle Splitting aproachUlnar Nerve not transposedDocking of 2 ends of tendon graft tensioned in to a single
humeral tunnel closed(Avoid medial epicondyle fracture)
Technique
MCL Reconstruction Classic Open Tunnels
Systematic Review Of UCL ReconstructionTechniques
• 21 studies: Medline, Pubmed, Cochrane• 7 Biomechanical, 14 clinical• 1368 patients• 78.9 % Return to play.• 18.6 complication rate.
Watson et Al.Am J. Sp.Med: 2013
Return to Play
Overall 78.9% Return To Play
Complications Author/Technique Specific
Mainly Neurologic (Ulnar Nerve)
Overall Complication Rate
• Jobe Technique 29.2%• Modified Jobe Technique 19.1• Interference Screw Technique 10%• Docking Technique 6%
Summary• AMCL most important stabilizer to Valgus load
• Best History = “pop” but ALL pitchers lose velocity/control with chronic AMCL attenuation
• Associated injuries include valgus extension overload, medial epicondylitis, Ulnar Neuritis.
• Best physical test: Moving Valgus Stress Test
• Reconstruction with autograft yields best outcome Muscle splittingNo neural nerve transposition Open tunnels Vs Docking technique
• 1 yr Rehabilitation
• 79-80% return to competitive throwing/ 18% complication rate