Mr Lee Van Rensburg October 2015. J Shoulder Elbow Surg (2012) 21, 1006-1012 Flexion extension axis...

Mr Lee Van Rensburg

October 2015

J Shoulder Elbow Surg (2012) 21, 1006-1012

Flexion extension axis Centre capitellum to anteroinferior medial

epicondyle

JSES 1996;5:103-12

Kinematic study Did not separate LCL from LUCL Found

LCL important ulnohumeral stabilizer LCL stabilizes radial head

Varus External rotation

Ulno humeral stability independent of forearm rotation

J Shoulder Elbow Surg 2002;11:53-9.)

Concept ‘Y’ to LCL complex

Previous studies Instability release superior band No instability if release posterior band

VarusExternal rotation

J Shoulder Elbow Surg 2002;11:53-9.)

Release of anterior band increased laxity Varus External rotation

VarusExternal rotation

J Shoulder Elbow Surg 2002;11:53-9.)

Released anterior band Laxity

Then release posterior band Instability

If release anterior capsule and anterior band effectively leave a LUCL, still tethers

ulna

VarusExternal rotation

Important where LCL complex injured 1. Humeral epicondylar bony avulsion – 8%

Paediatric 2. LCL Sleeve avulsion, bare epicondyle – 52% 3. Mid substance tear – 29% 4. Soft tissue ulnar avulsion – 5% 5. Bony ulnar avulsion – 1% 6. Combined – 6%

J Shoulder Elbow Surg 2003;12:391-6

Common extensor origin Completely avulsed 66%

Bare epicondyle

Dislocations worse than fracture dislocations Look at degree of displacement

J Shoulder Elbow Surg 2003;12:391-6

Approach dictated by injury

Beware superficial fascia may be intact

Incise superficial fascia ‘Bomb’ gone off Avulsion of CEO and LCL

Mass repair suture anchors 5.5 twin fix, 2 fibrewire

Axis of rotation middle of capitellum

Early movementEnsure sound repair

If LCL Shredded midsubstance Internal brace

Anchor into middle capitellum Anchor supinator crest

tie one set of sutures of fibrewire to each other

Internal brace medial side

?

J Bone Joint Surg Am, 2000 May 01;82(5):724-724

Kocher interval Split -- Anconeus - ECU

Elevate anconeus on ulna to expose supinator crest and lateral

face of proximal ulna Palpate tubercle of supinator ridge Expose supracondylar ridge

2 cm anterior and posterior

J Bone Joint Surg Am, 2000 May 01;82(5):724-724

2 drill holes in ulna 1st near tubercle on the supinator

crest 2nd - 1.25 cm at base of annular

ligament Pass suture through two points

and offer up to lateral epicondyle – isometric point Usually more anterior than think Remember needs to be tight in

extension (PLRI in ext)

J Bone Joint Surg Am, 2000 May 01;82(5):724-724

Drill entry hole in lateral epicondyle, widen for graft

Connect 2 exit holes ant and post supracondylar ridge

Auto/ allo graft Palmaris Plantaris Hamstring 15-16 cm gives 3 ply graft

J Bone Joint Surg Am, 2000 May 01;82(5):724-724

Humeral fixation Several options One or both limbs of graft into isometric point Stich two limbs together and pull with ‘Yoke’

stitch through tunnel anterior to supracondylar ridge

Free end of the graft just reaches the tunnel – 2 ply to, pass free end back through tunnels into ulna again or suture back onto itself for 3 ply

Tension 40 degrees flexion and full pronation

J Bone Joint Surg [Br] 2005;87-B:54-61.20002000

J Shoulder Elbow Surg 2002;11:60-4

No significant difference

2 strand1 strandProximal

1 strand Distal