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PubMed2004

Medial collateral ligament tears in the throwing athlete.

Medial collateral ligament (MCL) injuries of the elbow in throwing athletes are part of a spectrum of valgus extension overload injuries. Clinicians should consider reconstruction of the injured MCL in those patients who are unable to return to sports activities or work after an interval of rest and rehabilitation. Surgical treatment of this disorder has continued to evolve from the original technique developed by Jobe and associates. The authors' surgical technique involves reconstruction of the MCL using a single ulnar tunnel and single humeral tunnel that is performed through a muscle-splitting approach that usually obviates the need for ulnar nerve transposition. Knowledge of the biology and biomechanics of MCL function is important in the diagnosis and treatment of MCL injuries of the elbow in the throwing athlete.

Arthroplasty↗
PubMed1994

[The collateral ligaments of the elbow joint: their functional anatomy with special reference to the pathology and treatment of post-traumatic stiff elbow].

Factors which cause stiff elbow were investigated both experimentally and clinically. Since a thickened and shortened medial collateral ligament is often seen in stiff elbow, then changes in the length of the medial collateral ligament (MCL) and in the length of the lateral collateral ligament (LCL) were investigated in cadaver elbow specimens, and correlated with the observed range of motion. The MCL was divided into five bundles, and the LCL into three bundles. The length changes during flexion and extension of the elbow joint were measured, and the length change pattern was found to be different from bundle to bundle. The lengths of the LCL and the anterior oblique ligament (AOL) of the MCL changed little during elbow flexion. On the other hand, the length of the posterior oblique ligament (POL) of the MCL considerably increased when the elbow joint was flexed. The more posterior the bundle was, the larger the change in length that was observed. Because the origin of the POL is far distant from the axis of motion, it was suspected that a shortening in the POL was one of the most important pathologic changes in stiff elbow. The results of the biomechanic study were applied to a subsequent clinical study. Scar formation or ectopic ossification on the medial and/or posterior parts of the elbow joint was observed in 38 of 43 cases at surgery. These pathologic regions were resected, including the scarred POL. The intra-operative findings revealed that the major restraints in stiff elbow were the medial and/or posterior parts of the elbow. The importance of the shortened POL in the clinical pathology of stiff elbow was clearly demonstrated.

Adolescent↗
PubMed1997

Injury size affects long-term strength of the rabbit medial collateral ligament.

Long-term effects (104 weeks) of 2 extremes of gap size on the mechanical behavior of the rabbit medial collateral ligament were examined. In the midsubstance of each right medial collateral ligament, either an 8 mm gap injury was created or a 4 mm Z plasty injury was created and repaired. Each group was subdivided into a healing interval of 40, 78, or 104 weeks. Femur-medial collateral ligament-tibia complexes were tested mechanically or examined with light microscopy. Both injuries healed with histologically similar tissue and showed improved mechanical behavior 78 weeks after injury. No further improvement was measurable 104 weeks after injury. Scar material properties remained markedly inferior to normal regardless of injury. Low load and viscoelastic behavior recovered relatively well regardless of gap size. However, gap injuries showed significantly inferior structural properties at all intervals. These results suggest that a large initial gap between ligament ends in the extraarticular space predisposes scars to long term structural weakness. If this principle is true clinically, then patients with large gaps between torn ligament ends (caused by displacement, folding, or retraction) may function well at lower loads, but they may be chronically at greater risk of reinjury at high loads.

Animals↗
PubMed2002

The lateral collateral ligament complex and related muscles act as a dynamic stabilizer as well as a static supporting structure at the elbow joint: an anatomical and experimental study.

Among 71 osteoligamentous elbow joint specimens from Japanese subjects, 66% of the lateral ulnar collateral ligaments (LUCLs) were in an incomplete form, such as a fibrous intermuscular septum lying between the anconeus, supinator and extensors, and terminated on the annular ligament. The 'typical' complete ligament, extending from the lateral epicondyle and over the radial collateral ligament (RCL) to the crista spinatoris, appeared in only 20% of the elbows examined. This observation suggests that, in Japanese subjects, the LUCL is not usually a simple ligamentous static stabilizer, but acts as a dynamic stabilizer, together with its related muscles. In addition, when the elbow was flexed by more than 90 degrees, the distance between the lateral epicondyle and the radial head became almost 1.5 mm larger than the distance from the epicondyle to the annular ligament. We therefore consider that, in the overflexed position, the radial head moves slightly distal while the length of the RCL remains almost constant. This morphometrical observation suggests that the annular ligament needs to be supported by the LUCL-muscle complex from the distal side, as well as by the RCL from the proximal side. This extended definition of the lateral collateral ligament complex and its associated muscular function is discussed.

Aged↗
PubMed2004

Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow.

BACKGROUND: Comminuted radial head fractures associated with an injury of the medial collateral ligament can be treated with a radial head implant. We hypothesized that lengthening and shortening of the radial neck would alter the kinematics and the pressure through the radiocapitellar joint in the medial collateral ligament-deficient elbow. METHODS: The effects of lengthening (2.5 and 5 mm) and shortening (2.5 and 5 mm) of the radial neck were assessed in six human cadaveric upper extremities in which the medial collateral ligament had been surgically released. The three-dimensional spatial orientation of the ulna was recorded during simulated active motion from extension to flexion. Total varus-valgus laxity and ulnar rotation were measured. Radiocapitellar joint pressure was assessed with use of pressure-sensitive film. RESULTS: Radial neck lengthening or shortening of >/=2.5 mm significantly changed the kinematics in the medial collateral ligament-deficient elbow. Lengthening caused a significant decrease (p < 0.05) in varus-valgus laxity and ulnar rotation (p < 0.05), with the ulna tracking in varus and external rotation. Shortening caused a significant increase in varus-valgus laxity (p < 0.05) and ulnar rotation (p < 0.05), with the ulna tracking in valgus and internal rotation. The pressure on the radiocapitellar joint was significantly increased after 2.5 mm of lengthening. CONCLUSIONS: This study suggests that accurate restoration of radial length is important and that axial understuffing or overstuffing of the radiohumeral joint by >/=2.5 mm alters both elbow kinematics and radiocapitellar pressure. CLINICAL RELEVANCE: This in vitro cadaver study indicates that a radial head replacement should be performed with the same level of concern for accuracy and reproducibility of component position and orientation as is appropriate with any other prosthesis.

Aged↗
PubMed2001

[Repair of medial collateral ligament defect of knee joint with transposition of great adductor muscular tendon pedicled vessels].

OBJECTIVE: To study the effect of transposition of great adductor muscular tendon pedicled vessels in repairing the medial collateral ligament defect of knee joint. METHODS: From September 1991 to September 1999, on the basis study of applied anatomy, 30 patients with the medial collateral ligament defect were repaired with great adductor muscular tendon transposition pedicled vessels. Among them, there were 28 males and 2 females, aged 26 years in average. RESULTS: Followed up for 17 to 60 months, 93.3% patients reached excellent or good grades. No case fell into the poor grade. CONCLUSION: Because the great adductor muscular tendon is adjacent to the knee joint and similar to the knee ligament, it is appropriate to repair knee ligament. Transposition of the great adductor muscular tendon pedicled vessels is effective in the reconstruction of the medial collateral ligament defect of knee joint.

Adolescent↗
PubMed2006

Radial head fracture in the medial collateral ligament deficient elbow; biomechanical comparison of fixation, replacement and excision in human cadavers.

A widely used clinical recommendation is that in the presence of medial collateral ligament injuries, two-part radial head fractures should be fixed rather than excising or replacing the radial head. Direct biomechanical data comparing fracture fixation, radial head replacement and excision in a human cadaveric elbow model, have not been previously described. Such comparison is clinically important as with the increasing availability of radial head implants and promising follow up results, the role of radial head replacement in fracture management may have to be redefined. In this study, five fresh cadaveric elbows had radial head fracture creation and medial collateral ligament division, fracture fixation, radial head replacement and excision. Valgus and varus laxity were determined using an electromagnetic tracking system. Radial head replacement leads to a similar valgus (P=0.80) [corrected] laxity as compared to radial head fixation. Radial head excision resulted in a significantly greater valgus laxity as compared to radial head fixation (P=0.02) or replacement (P=0.03). Both radial head excision and replacement led to a greater varus laxity as compared to fixation. Our results suggest that in the elbow with medial collateral ligament injury and two-part radial head fracture, fixation is overall biomechanically superior as compared to replacement and excision.

Aged↗
PubMed2005

Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases.

BACKGROUND: Although various surgical procedures that attempt to restore the function of the medial collateral ligament have been reported, none have achieved consistently satisfactory results. HYPOTHESIS: Our reconstructive procedure using autogenous semitendinosus and gracilis tendons yields improved results compared with conventional procedures. STUDY DESIGN: Case series. Level of evidence, 4. METHOD: In our surgical procedure, autogenous semitendinosus and gracilis tendons were used to anatomically reconstruct the anterior longitudinal component of the superficial medial collateral ligament. From April 1995 through December 2000, 27 patients with symptomatic medial instability underwent this surgical procedure. The majority of the subjects were diagnosed with combined cruciate ligament injuries, necessitating concomitant cruciate ligament reconstructions. Of these 27 patients, 24 were evaluated after a minimum period of 2 years, with a mean follow-up period of 27 months (range, 24-48 months). RESULTS: At follow-up, medial stability, as well as postoperative range of motion in all patients, was graded as normal or nearly normal according to the International Knee Documentation Committee evaluation system. No significant postoperative complications were encountered. CONCLUSION: Although this is a short-term follow-up study involving a small number of cases, we considered our procedure to be an effective method of surgically restoring the function of the medial collateral ligament.

Adolescent↗
PubMedDate not supplied

Allograft ligament transplantation. A morphological and biochemical evaluation of a medial collateral ligament complex in a rabbit model.

Our purpose in this investigation was to describe and compare several morphological, histological, vascular, and biochemical healing processes of allograft and autograft bone-medial collateral ligament-bone complexes in a rabbit model. Forty-nine animals had their right medial collateral ligament complex replaced with a frozen allograft while 30 separate control animals each received a fresh autograft. Animals were sacrificed at 3, 6, 12, 24, or 48 weeks after transplantation for comparison of grafted with unoperated contralateral control complexes. Results demonstrate some recovery of both allografts and autografts over time. Allografts generally showed slower recovery than autografts with more persistent abnormalities in gross appearances, increased cellularity (corresponding to increased DNA content), and decreased collagen content. Allografts also showed aggressive remodeling of bone at insertions and they remained hypervascular throughout their substance as compared with contralateral controls. Autografts went through similar but less chronic increases in cellularity and DNA concentration with no changes in collagen content. While both types of grafts showed some signs of "healing" and some recovery of control ligament biology, results are also consistent with allograft encasement, infiltration, and at least partial replacement by host tissue. This was particularly true of insertions. Collectively, these results also demonstrate some differences between allografts and autografts in this extraarticular model. The causes, mechanisms, and longer-term consequences of these changes, including defining the qualities of these graft and host tissues, clearly requires further investigation.

Animals↗
PubMed1997

[The medial collateral ligament of the knee].

Injuries of the medial collateral ligament (MCL) of the knee are easily diagnosed on clinical grounds. These lesions are generally treated conservatively. Radiological examinations are generally unhelpful. However, injuries of the MCL may be associated with those of many other ligaments of the knee in the case of complex strain of the knee so that the clinical diagnosis may be challenging; in some cases, surgical repair of associated lesions is indicated. In these cases of multiple ligamentous injuries, a radiological study of ligamentous abnormalities may be of interest. The anatomical background and the different radiological findings including those of X-rays, US, arthrography and MRI, obtained in patients with injuries of the MCL, are described; radiological differentiation of ruptures of the MCL with or without knee instability is emphasized.

Arthrography↗
PubMed1993

Tears of the medial collateral ligament: magnetic resonance imaging findings and associated injuries.

For 23 patients with a surgically proven tear of the medial collateral ligament the findings from magnetic resonance imaging (MRI) of the knee were evaluated retrospectively. MRI revealed the tear in all cases, although when the injury was severe, distinguishing high-grade partial tears from complete tears was difficult. Physical examination had indicated a tear in 22 (96%) of the cases. A high prevalence of associated cruciate and meniscal injuries was seen (in 23 [100%] and 12 [52%] of the cases respectively). Tears of the fibular collateral ligament occurred in 13 (57%) of the patients and at least one bony infraction in 22 (96%); most of the infractions were in the lateral compartment. Infractions of the lateral femoral condyle were frequently geographic (in 14 [70%] of the 20 cases) or impacted (in 5 [25%]). The spectrum of injuries associated with tears of the medial collateral ligament was consistent with the findings of previous studies focusing on cruciate and meniscal abnormalities; the minor variations were likely due to the severity of valgus stress in this sample.

Adolescent↗
PubMed1997

[Late results of surgical treatment of acute and chronic instability of the ulnar collateral ligaments].

A total of 113 patients with acute and chronic instability of the ulnar collateral ligament metacarpal phalangeal (MP) joint of the thumb were treated surgically between 1980 and 1985; 82 patients were followed up after a mean period of 10 years. Of 59 patients with acute injuries, 52 were painfree with full stability of the MP joint; 23 patients with chronic instability and tendon grafting also showed restoration of stability. Nevertheless, the range of motion was reduced severely and opposition of the thumb was impaired. The results of follow-up reveal that acute reattachment of the injured ulnar collateral ligament is more effective.

Adult↗
PubMed1996

Trabecular trauma of the talus and medial malleolus concurrent with lateral collateral ligamentous injuries of the ankle: evaluation with MR imaging.

OBJECTIVE: The objective of this study was to elucidate the relationship between lateral collateral ligamentous injuries of the ankle (ankle sprain) and bone bruise (trabecular trauma) of the talus and/or malleoli in the patients with twisting injuries of the ankle. DESIGN: Magnetic resonance studies of the ankle were retrospectively reviewed, focusing on the presence or absence of lateral collateral ligamentous injuries and the location of bone bruise in the talus and/or malleoli. PATIENTS: Thirty-five patients with acute twisting injuries of the ankle were studied. RESULTS AND CONCLUSION: Four patterns of bone bruise were found in 14 patients: (1) bone bruise in the talar dome equivalent to osteochondral fracture in two patients, (2) bone bruise in the posteromedial aspect of the talus and the medial malleolus singly or in combination in four, (3) bone bruise in the anteromedial aspect of the talus in six, and (4) bone bruise with a combination of the second and third patterns in two. The second pattern was associated with tear of the anterior talofibular (ATAF) ligament in all patients and injury of the calcaneofibular (CF) ligament in one out of four. The third and fourth patterns were associated with tears of both ATAF and CF ligaments in all patients. The identification of bone bruise was of value in indicating lateral collateral ligamentous injuries.

Adolescent↗
PubMed1990

Replacing the medial collateral ligament with an allogenic tendon graft. An experimental canine study.

In order to determine whether an allogeneic tendon could be used to replace an extra-articular ligament, the right medial collateral ligament from 11 adult dogs was replaced with a fresh-frozen allogeneic patellar tendon. At each of 3, 6, 15, 30 and 52 weeks postoperatively, one dog was killed for micro-angiographical and histological studies; at 52 weeks the remaining six dogs were killed for tensile testing. Micro-angiograms showed that the allogeneic tendon was revascularised with infiltration of the mesenchymal cells from the surrounding tissues and both ends of the graft. Histologically, the alignment of the fibroblasts and collagen bundles became more regular over time, without any immunological rejection. A biomechanical study performed at 52 weeks found no significant difference in stiffness or ultimate load between normal and reconstructed ligaments. Fresh-frozen allogeneic tendons are therefore considered useful for extra-articular ligament reconstruction.

Angiography↗
PubMed2000

Compressive compared with tensile loading of medial collateral ligament scar in vitro uniquely influences mRNA levels for aggrecan, collagen type II, and collagenase.

To test the hypothesis that loading conditions can be used to engineer early ligament scar behaviors, we used an in vitro system to examine the effect that cyclic hydrostatic compression and cyclic tension applied to 6-week rabbit medial collateral ligament scars had on mRNA levels for matrix molecules, collagenase, and the proto-oncogenes c-fos and c-jun. Our specific hypothesis was that tensile stress would promote more normal mRNA expression in ligament whereas compression would lead to higher levels of mRNA for cartilage-like molecules. Femur (injured medial collateral ligament)-tibia complexes were subjected to a hydrostatic pressure of 1 MPa or a tensile stress of 1 MPa of 0.5 Hz for 1 minute followed by 14 minutes of rest. On the basis of a preliminary optimization experiment, this 15-minute testing cycle was repeated for 4 hours. Semiquantitative reverse transcription-polymerase chain reaction analysis was performed for mechanically treated medial collateral ligament scars with use of rabbit specific primer sets for types I, II, and III collagen, decorin, biglycan, fibromodulin, versican, aggrecan, collagenase, c-fos, c-jun, and a housekeeping gene, glyceraldehyde-3-phosphate dehydrogenase. Cyclic hydrostatic compression resulted in a statistically significant increase in mRNA levels of type-II collagen (171% of nonloaded values) and aggrecan (313% of nonloaded values) but statistically significant decreases in collagenase mRNA levels (35% of nonloaded values). Cyclic tension also resulted in a statistically significant decrease in collagenase mRNA levels (66% of nonloaded values) and an increase in aggrecan mRNA levels (458% of nonloaded values) but no significant change in the mRNA levels for the other molecules. The results show that it is possible to alter mRNA levels for a subset of genes in scar tissue by supplying unique mechanical stimuli in vitro and thus that further investigation of scar engineering for potential reimplantation appears feasible.

Aggrecans↗
PubMed2002

Thumb metacarpophalangeal joint ulnar collateral ligament reconstruction using a tendon graft.

Chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb can cause significant functional disability due to pain and weakness of pinch and grasp. In the absence of adequate ligament to repair, stability of the joint can be restored by reconstruction using a free tendon graft. The technique described here routes the tendon graft through two holes in the proximal phalangeal base and one hole in the metacarpal neck in a triangular configuration, which recapitulates the normal anatomy of the ulnar collateral ligament. The results of reconstruction are good. Stability and strength are restored without sacrificing significant range of motion and with minimal donor site morbidity.

Journal Article↗
PubMed1995

Arthroscopic treatment of acute complete thumb metacarpophalangeal ulnar collateral ligament tears.

An arthroscopic technique was used to reduce Stener lesions associated with acute ulnar collateral ligament ruptures of the thumb. We operated on eight thumbs, seven dominant and one nondominant. The average follow-up period was 39 months (range, 30-48). At follow-up examination, no patient reported pain or functional limitation or had joint contracture. In most cases, key pinch, tip pinch, grip strength, and range of motion were equal to or greater than in the thumb on the unaffected side. The only complication, a pin track infection, resolved after wire removal and treatment with oral antibiotics. Results indicate that arthroscopic reduction of a Stener lesion allows healing of the ulnar collateral ligament without the need for open repair.

Adolescent↗
PubMed2003

Combined anterior and posterior cruciate and medial collateral ligament injury: nonsurgical and delayed surgical treatment.

A detailed history, thorough examination, and a high index of suspicion for associated injuries together are the cornerstone for diagnosing and treating a knee with multiple ligament injuries. Acute surgery in patients with combined ligament injuries of the knee can lead to stiffness, primarily with medial-side injuries. Knee dislocations with lateral-side injuries require acute repair to achieve a good long-term result. All knee dislocations should not be grouped together because of the difference in healing potential between medial- and lateral-side injuries. Patients likely prefer a knee that is mildly lax but functional with full range of motion as opposed to a stiff, painful, stable knee. Treatment is based on the individual healing potential of the injured structures and the natural history of these injuries, along with the following principles: (1) medial-side injuries can heal with proper nonsurgical treatment; (2) posterior cruciate ligament (PCL) tears with grade II laxity or less can heal with similar long-term results as PCL tears with grade I laxity; therefore, surgery may not be indicated. As surgical techniques are developed and improved upon, a more aggressive approach to PCL reconstruction may be warranted; (3) PCL laxity greater than grade II and a soft end point should be considered for semiacute reconstruction; and (4) anterior cruciate ligament injuries in combination with medial collateral ligament and/or PCL injury can initially be treated nonsurgically and reconstructed later as dictated by patient symptoms and activity level.

Anterior Cruciate Ligament Injuries↗