Medial Collateral Instability of the Elbow. CSES Residents Course Calgary AB February 1-3, 2017 WD Regan MD

Transcription

1 Medial Collateral Instability of the Elbow CSES Residents Course Calgary AB February 1-3, 2017 WD Regan MD

2 Disclosures I have no disclosures to report

3 Anatomy Medial Collateral Ligament Anterior Oblique Posterior Oblique Transverse Ligament AMCL Origin Antero-inferior medial epicondyle Insertion-sublime tubercle medial coronoid

4 Anatomy Medial Collateral Ligament MCL undersurface is a sequential ligament insertion greater sigmoid fossa (anterior to posterior) Regan et al (CORR)

5 MCL Anatomy and Biomechanics CAM Effect Based on degree of elbow flexion Anterior oblique tight in extension Posterior oblique tight in flexion Reciprocating relationship Calloway et al JBJS 1997

6 MCL Biomechanics Potted origin and insertion of AMCL & PMCL 8 Specimens AV AMCL PMCL L 21mm 16mm W 7.6mm 8.8mm Regan et al.1991 (CORR)

7 MCL Biomechanics MTS load to failure AMCL PMCL 260 N 159 N Stiffness 1528 N 861N Palmaris Longus 10 fold greater stiffness than AMCL. Regan et al (CORR)

8 MCL The injury 5 phases of throwing Late Cocking and acceleration phases Flexion o milisec. Rapid 25 o of Flexion Extension Peak angular velocity 4500 degrees per second Wilson et all AJSM 1983

9 MCL Insufficiency Symptoms Microscopic tears of Ligament = Attenuation Gradual onset of medial elbow pain Progressive valgus laxity Pop with immediate onset of pain 50% Jobe s Series Conway & Jobe JBJS 1992

10 Associated Pathology Valgus extension Overload Laxity AMCL Valgus stress Hypertrophic changes develop posteromedial olecranon against the olecranon fossa Jobe 16% cases Altchek 45% Pain on forced extension

11 Ulnar Neuritis Secondary to: 1. Direct Trauma 2. Traction Compression: Hypertrophy of common flexors 3. Subluxation of nerve - 40% of cases.

12 Imaging Studies Radiographs Calcification of MCL Traction spurs Valgus gravity stress test-medial opening

13 CT Arthrogram Thin cuts 3mm 100% sensitive complete tears CT arthrogram better than MRI for partial tears 71% CT arthro 14% MR

14 Magnetic Resonance Imaging Based Classification for UCL Injuries 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 (Joyner et al. 2016)

15 Magnetic Resonance Imaging Based Classification for UCL Injuries con t Partial UCL tear Type 2 UCL Timmerman Sign Type 3 UCL from sublime tubercle

16 Arthroscopy 1 mm-open indicates AMCL attenuation 3 mm-complete tear Altchek et al (AJSM)

17 Valgus stress test Elbow flex 30 deg. Humerus in abduction + external rotation Valgus stress Pain over MCL + Opening Distinguish medial epicondylitis by pain on forced resisted flexion-pronation

18 Moving Valgus Stress Test Active Milking test Shoulder abducted 90 o Elbow maximally flexed Constant valgus load applied to elbow Elbow quickly extended to 30 o flexion. O Driscoll AJSM 2005

19 Moving Valgus Stress Test Pain must reproduce MCL pain Maximal pain o Shear Range Sensitivity 100% 17 of 17 patients Specificity 75% 3 of 4 pts MRI % pts

20 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 (AJSM)

21 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 ( to 1 +-6) Podesta et al. Am J Sp Med, 41:7, 2013

22 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

23 Modification to the Original Technique Muscle splitting approach -Ulnar nerve protected but not transposed Open tunnels Palmaris Tendon autograft 83 pts 33 pts > 2 yr follow up No operation for Ulnar Nerve dysfunction All athletes return to their sport 93% excellent result 5% Ulnar Nerve Paresthesiae (transient) Thompson and Jobe et al JSES 2001

24 Modifications ALTCHEK Docking Technique Arthroscopic treatment first of valgus extension overload osteophytes Muscle Splitting aproach Ulnar Nerve not transposed Docking of 2 ends of tendon graft tensioned in to a single humeral tunnel closed (Avoid medial epicondyle fracture)

25 Technique

26 MCL Reconstruction Classic Open Tunnels

27 Systematic Review Of UCL ReconstructionTechniques 21 studies: Medline, Pubmed, Cochrane 7 Biomechanical, 14 clinical 1368 patients 78.9 % Return to play complication rate. Watson et Al. Am J. Sp.Med: 2013

28 Return to Play Overall 78.9% Return To Play

29 Complications Author/Technique Specific Mainly Neurologic (Ulnar Nerve)

30 Overall Complication Rate Jobe Technique 29.2% Modified Jobe Technique 19.1 Interference Screw Technique 10% Docking Technique 6%

31 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 splitting No neural nerve transposition Open tunnels Vs Docking technique 1 yr Rehabilitation 79-80% return to competitive throwing/ 18% complication rate