Simultaneous Reconstruction of Medial and Lateral Elbow Ligaments for Instability Using a Circumferential Graft

Abstract

Reconstructing elbow instability remains a challenging problem. Techniques described have included techniques for the lateral ligamentous complex, including the lateral ulnar collateral ligament, and techniques to reconstruct the medial collateral ligament. We describe a new circumferential technique to reconstruct both the lateral and medial ligament complexes, using 1 circular graft. A hole is drilled through the center of rotation of the distal humerus and through the insertion sites of the medial and lateral ligament complexes. A hamstring tendon graft is passed through the humerus twice to reconstruct the anterior and posterior bands of the medial collateral ligament and sutured onto itself. Endobutton fixation is used to fix the graft on either side of the ulna. The graft is tightened on the lateral and medial sides and fixed into the humerus using interference fit screws. Advantages of the technique described include stabilization of both the medial and lateral ligament complexes with 1 graft. The strength of fixation allows for individual tensioning in all limbs of the reconstruction and the multiple passes of the graft through a single humeral tunnel increasing the strength of the reconstruction. Potential complications could include ulnar nerve damage, recurrent instability, elbow stiffness, and wound breakdown. Complications related to the potential use of a hinged external fixator are not specific to this procedure but can be associated. Early active mobilization can be initiated because of the strong stability provided by the circumferential graft and good fixation.

Box-loop ligament reconstruction of the elbow for medial and lateral instability

“…[1][2][3]10,12,14,16,18 The midterm results were generally excellent with few complications. This has become our preferred technique in the situation of the grossly unstable elbow.…”

“…A similar circumferential grafting technique has been described by van Riet et al 18,19 Their technique involves drilling 2 ulnar tunnels, using gracilis autograft, and using a posterior midline approach. They have described singleloop and double-loop techniques.…”

Arthroscopic Treatment of Annular Drive Through and Radial Lateral Collateral Ligament Articular-Side Tear of the Elbow

“…LCL repair has previously been described in traumatic settings, [5][6][7][8] but the novelty of the described treatment is the focus on plication of the R-LCL and retensioning of the annular ligament. The annular ligament is not an independent structure, being part of the complex of the LCL, but no signs of major instability are present during the preoperative or intraoperative evaluation.…”

Elbow dislocations

“…38 In the acute setting, a direct repair of the ligament is preferred. If the construct is deemed to be too fragile, a dynamic external fixator can be used to protect the repair, 39 instead of augmenting the repair with a graft.…”