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Paper 102: Outcome of Ulnar Collateral Ligament Reconstruction of the Elbow Using Hamstring Allografts
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ABSTRACTS
Results: The pain and feeling of instability before the operation disappeared at final follow-up and there was no recurrence. However, strange feeling at the movement of toes remained in 3 cases. No restriction on the joint mobility was noted in any of the cases. As to the activity level, recovery to the previous level was noted for once in all the cases at the least. According to the findings of second look after 6 months to 2 years from the operation, the lesion was covered with a ligament-like tissue in all the cases even though the tissue was not very elastic. No rupture occurred in any of the cases. Discussion: Reinforcement of cervical ligament was done as a surgical treatment for subtalar instability in the past. However, as this method caused ROM restriction, we opted for reconstruction of interosseous talocalcaneal ligament. There was no problem in the durability of artificial ligament and the ligament was favorably covered in all the cases in which arthroscopic re-examination was possible. The X-ray findings did not indicate any arthrosis-like changes. Nor was there any deterioration case in comparison with the status observed 6 months after operation. These middle term results indicated the usefulness of this treatment method in the patients with unstable subtalar joint. Paper 101: Osteochondral Fragment Fixation Using Osteochondral Autograft (Berlet Technique) for Osteochondritis Dissecans of the Humeral Capitellum HAREHIKO TSUKADA, MD, JAPAN, PRESENTING AUTHOR YASUYUKI ISHIBASHI, MD, JAPAN EIICHI TSUDA, MD, JAPAN AKIRA FUKUDA, MD, JAPAN SATOSHI TOH, MD, JAPAN ABSTRACT Objective: The treatment for osteochondritis dissecans (OCD) of the humeral capitellum varies depending on fragment stability and cartilage quality of the OCD lesion. When the cartilage of the unstable osteochondral fragment is preserved from advanced degeneration, arthoroscopic fixation is one of the effective surgical options. Recently, Berlet et al. reported good short-term results of knee OCD lesions treated with a new fixation technique using cylindrical autogenous osteochondral graft, however, the prognosis after this surgery remains unclear. Therefore, the objective of this study was to evaluate the clinical results of osteochondral fragment fixation using osteochondral autograft (Berlet technique) for OCD of the humeral capitellum. Methods: Since 1999, we have treated 48 patients with OCD of the humeral capitellum. Of those 8 patients were treated with Berlet technique and followed up for a
minimum of 1 year. First, arthroscopic evaluation was performed, followed by direct visualization of the OCD lesion by the posterolateral approach. The osteochondral fragment was fixed with osteochondral grafts obtained from the ipsilateral knee joint, and the elbow joint was immobilized in a long arm cast for 2 weeks after surgery. All patients were evaluated with range of motion (ROM) of elbow joint, Timmerman’s scoring system, magnetic resonance imaging (MRI), and the return to activity level. Results: No significant difference between pre and post operative ROM was detected. The postoperative average of 189⫹/⫺9 points was statistically significantly higher than preoperative average of 142⫹/⫺13 points in the scoring system. In the postoperative MRI evaluation, the high signal intensity in the subchondral bone area that was detected in the preoperative T2-weighted MRI not detected in 6 cases. 7 patients returned to full activity level. In 1 patient who had poor preoperative ROM, a second surgery was performed because of elbow contracture, however, the osteochondral fragment was stabilized macroscopically. Discussion: Recently, we have showed that Berlet technique had no major disadvantage in the initial fixation strength compared to the convntional fixation techniques such as PLLA pin fixation or Herbert screw fixation, and that the donor site morbidities were not detected for osteochondral autograft transplantation techniques. The current study showed that the good results were obtained after Berlet technique. Therefore, this technique is a useful treatment for OCD of the humeral capitellum. On the other hand, it is necessary take care with patients with poor preoperative ROM, because this technique requires casting. Paper 102: Outcome of Ulnar Collateral Ligament Reconstruction of the Elbow Using Hamstring Allografts STEPHEN J. NICHOLAS, MD, USA, PRESENTING AUTHOR TIMOTHY F. TYLER, USA MICHAEL J. MULLANEY, USA STEVEN J. LEE, USA MATTHEW GREENBERG, USA MALACHY P. MCHUGH, USA ABSTRACT Objective: Injury to the ulnar collateral ligament (UCL) of the elbow in athletes often leads to symptomatic valgus instability. Reconstruction using palmaris longus tendon grafts yields excellent results. However, in some patients the palmaris longus tendon graft is not available or is insufficient. Additionally, there may be donor site
ABSTRACTS morbidity and increased surgical time. The purpose of this study was to evaluate the results of UCL reconstruction using hamstring allografts performed by a single surgeon in a group of athletes. Methods: Eighteen patients (17 males, 1 female; age 16-63 yr) underwent UCL reconstruction using a hamstring allograft. Fifteen patients had traumatic disruptions and 3 had insidious onset of symptoms. The average duration of symptoms until surgery was 7.8 months, range (1-32 months). There were 13 competitive athletes (9 baseball, 1 football, lacrosse, wrestling, volleyball) and 5 recreational athletes (2 softball, 2 handball, 1 swimming). One handball player had bilateral UCL reconstructions. The flexor carpi ulnaris was split and subcutaneous ulnar nerve transposition was performed in all cases. Tendon grafts were fixed by tying the tendon into a knot posterior to the medial epicondyle. Successful return to sport and medial elbow pain (0-10 scale) were assessed at an average of 38 months after surgery (12-76 months). Results: Patients had a significant improvement in pain (pre-op 6.7/10, follow-up 1.4/10, P⬍0.001) with 12 patients reporting no pain at follow-up and only 2 with residual symptoms (pain greater than 3/10). Sixteen of 18 patients successfully returned to their sport at pre-injury competitive level. These players commenced practice at an average of 11 months post-op with full return to play at 14 months. The two patients who did not return to play were recreational athletes. Conclusions: These successful outcomes for UCL reconstructions using a hamstring tendon allograft indicate that this procedure is a viable alternative to reconstruction using palmaris longus tendon autografts. Greater available length with hamstring grafts allows for better fixation. All competitive athletes had successful return to sport at their pre-injury level of competition. Paper 103: Arthroscopic Treatment of Combined TFCC Tears; A New Clinical Entity MICHAEL R. REDLER, MD, USA, PRESENTING AUTHOR STEVEN P. FRIES, PA-C, USA BETH A. ROROS, CHT, USA LAUREN E. REDLER, USA ABSTRACT In recent years, appreciation for the role of triangular fibrocartilage complex tears in ulnar sided wrist pain has significantly increased ( TFCC - triangular fibrocartilage complex).1 The TFCC functions as the major stabilizer of the distal radioulnar joint. It is the focal point that allows the carpus to rotate with the radius around the ulna.1,2 As a stabilizer of the ulnar carpus, the TFCC
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transmits 20% of an axially applied load from the ulnar carpus to the distal ulna.1,2 Severe twisting and loading injuries of the wrist are commonly responsible for tears of the TFCC. These patients will not only present with ulnar sided wrist pain, but pain with the extremes of supination and pronation as well as repetitive activity. Injuries to the TFCC have presented a challenge in regards to treatment. We have previously reported on a successful technique for arthroscopic repair of peripheral TFCC tears. The technique involves the use of spinal needles placed percutaneously through the safe zone and the use of a Shuttle relay (Linvatec) and Panacryl suture to create a mattress type repair. Follow up for a minimum of 24 months has produced excellent results when evaluated using the Mayo Modified wrist score. As our series of patients has grown, we have noted an interesting subset of patients that have had not only peripheral TFCC tears, but central tears as well. To the best of our knowledge, lesions of the TFCC involving both central and peripheral tears have not previously been described. Past studies have demonstrated successful outcomes with debridement of central lesions and repair of peripheral lesions. Both arthroscopic as well as open techniques have been described. However, when we first encountered a TFCC tear with both a central and a peripheral component; what we have termed a Combined TFCC lesion, we were perplexed as to how to approach the problem. We ultimately did a thorough debridement of the central component and a secure arthroscopic repair of the peripheral component and then treated the patient post-operatively as we would any other peripheral repair. This first patient post operatively had and excellent outcome with a Modified Mayo wrist score of 100. Since that first patient, review of our series of TFCC repairs has yielded nineteen additional patients with combined lesions of the TFCC for a total of twenty patients. This report is an evaluation of these twenty patients with combined TFCC lesions. There were sixteen males and four female patients. Their average age was thirty-three years old. There were seven right wrist injuries and two left wrist injuries. The dominant wrist was injured 16/20 times. Mechanism of injuries included seventeen sports related injuries (baseball, hockey and tennis), two MVA’s and one assault. Associated pathology involved one scapholunate ligament rupture and one ECU sling rupture. Follow up ranged from 24 to 48 months and averaged 30 months. Average Mayo Modified wrist score was 90. This compared favorable with our previous series of peripheral TFCC repairs where the average score was 92.5. We believe that debridement of the central portion of a Combined TFCC lesion in conjunction with repair of the peripheral portion can lead to good and excellent
ABSTRACTS
Results: The pain and feeling of instability before the operation disappeared at final follow-up and there was no recurrence. However, strange feeling at the movement of toes remained in 3 cases. No restriction on the joint mobility was noted in any of the cases. As to the activity level, recovery to the previous level was noted for once in all the cases at the least. According to the findings of second look after 6 months to 2 years from the operation, the lesion was covered with a ligament-like tissue in all the cases even though the tissue was not very elastic. No rupture occurred in any of the cases. Discussion: Reinforcement of cervical ligament was done as a surgical treatment for subtalar instability in the past. However, as this method caused ROM restriction, we opted for reconstruction of interosseous talocalcaneal ligament. There was no problem in the durability of artificial ligament and the ligament was favorably covered in all the cases in which arthroscopic re-examination was possible. The X-ray findings did not indicate any arthrosis-like changes. Nor was there any deterioration case in comparison with the status observed 6 months after operation. These middle term results indicated the usefulness of this treatment method in the patients with unstable subtalar joint. Paper 101: Osteochondral Fragment Fixation Using Osteochondral Autograft (Berlet Technique) for Osteochondritis Dissecans of the Humeral Capitellum HAREHIKO TSUKADA, MD, JAPAN, PRESENTING AUTHOR YASUYUKI ISHIBASHI, MD, JAPAN EIICHI TSUDA, MD, JAPAN AKIRA FUKUDA, MD, JAPAN SATOSHI TOH, MD, JAPAN ABSTRACT Objective: The treatment for osteochondritis dissecans (OCD) of the humeral capitellum varies depending on fragment stability and cartilage quality of the OCD lesion. When the cartilage of the unstable osteochondral fragment is preserved from advanced degeneration, arthoroscopic fixation is one of the effective surgical options. Recently, Berlet et al. reported good short-term results of knee OCD lesions treated with a new fixation technique using cylindrical autogenous osteochondral graft, however, the prognosis after this surgery remains unclear. Therefore, the objective of this study was to evaluate the clinical results of osteochondral fragment fixation using osteochondral autograft (Berlet technique) for OCD of the humeral capitellum. Methods: Since 1999, we have treated 48 patients with OCD of the humeral capitellum. Of those 8 patients were treated with Berlet technique and followed up for a
minimum of 1 year. First, arthroscopic evaluation was performed, followed by direct visualization of the OCD lesion by the posterolateral approach. The osteochondral fragment was fixed with osteochondral grafts obtained from the ipsilateral knee joint, and the elbow joint was immobilized in a long arm cast for 2 weeks after surgery. All patients were evaluated with range of motion (ROM) of elbow joint, Timmerman’s scoring system, magnetic resonance imaging (MRI), and the return to activity level. Results: No significant difference between pre and post operative ROM was detected. The postoperative average of 189⫹/⫺9 points was statistically significantly higher than preoperative average of 142⫹/⫺13 points in the scoring system. In the postoperative MRI evaluation, the high signal intensity in the subchondral bone area that was detected in the preoperative T2-weighted MRI not detected in 6 cases. 7 patients returned to full activity level. In 1 patient who had poor preoperative ROM, a second surgery was performed because of elbow contracture, however, the osteochondral fragment was stabilized macroscopically. Discussion: Recently, we have showed that Berlet technique had no major disadvantage in the initial fixation strength compared to the convntional fixation techniques such as PLLA pin fixation or Herbert screw fixation, and that the donor site morbidities were not detected for osteochondral autograft transplantation techniques. The current study showed that the good results were obtained after Berlet technique. Therefore, this technique is a useful treatment for OCD of the humeral capitellum. On the other hand, it is necessary take care with patients with poor preoperative ROM, because this technique requires casting. Paper 102: Outcome of Ulnar Collateral Ligament Reconstruction of the Elbow Using Hamstring Allografts STEPHEN J. NICHOLAS, MD, USA, PRESENTING AUTHOR TIMOTHY F. TYLER, USA MICHAEL J. MULLANEY, USA STEVEN J. LEE, USA MATTHEW GREENBERG, USA MALACHY P. MCHUGH, USA ABSTRACT Objective: Injury to the ulnar collateral ligament (UCL) of the elbow in athletes often leads to symptomatic valgus instability. Reconstruction using palmaris longus tendon grafts yields excellent results. However, in some patients the palmaris longus tendon graft is not available or is insufficient. Additionally, there may be donor site
ABSTRACTS morbidity and increased surgical time. The purpose of this study was to evaluate the results of UCL reconstruction using hamstring allografts performed by a single surgeon in a group of athletes. Methods: Eighteen patients (17 males, 1 female; age 16-63 yr) underwent UCL reconstruction using a hamstring allograft. Fifteen patients had traumatic disruptions and 3 had insidious onset of symptoms. The average duration of symptoms until surgery was 7.8 months, range (1-32 months). There were 13 competitive athletes (9 baseball, 1 football, lacrosse, wrestling, volleyball) and 5 recreational athletes (2 softball, 2 handball, 1 swimming). One handball player had bilateral UCL reconstructions. The flexor carpi ulnaris was split and subcutaneous ulnar nerve transposition was performed in all cases. Tendon grafts were fixed by tying the tendon into a knot posterior to the medial epicondyle. Successful return to sport and medial elbow pain (0-10 scale) were assessed at an average of 38 months after surgery (12-76 months). Results: Patients had a significant improvement in pain (pre-op 6.7/10, follow-up 1.4/10, P⬍0.001) with 12 patients reporting no pain at follow-up and only 2 with residual symptoms (pain greater than 3/10). Sixteen of 18 patients successfully returned to their sport at pre-injury competitive level. These players commenced practice at an average of 11 months post-op with full return to play at 14 months. The two patients who did not return to play were recreational athletes. Conclusions: These successful outcomes for UCL reconstructions using a hamstring tendon allograft indicate that this procedure is a viable alternative to reconstruction using palmaris longus tendon autografts. Greater available length with hamstring grafts allows for better fixation. All competitive athletes had successful return to sport at their pre-injury level of competition. Paper 103: Arthroscopic Treatment of Combined TFCC Tears; A New Clinical Entity MICHAEL R. REDLER, MD, USA, PRESENTING AUTHOR STEVEN P. FRIES, PA-C, USA BETH A. ROROS, CHT, USA LAUREN E. REDLER, USA ABSTRACT In recent years, appreciation for the role of triangular fibrocartilage complex tears in ulnar sided wrist pain has significantly increased ( TFCC - triangular fibrocartilage complex).1 The TFCC functions as the major stabilizer of the distal radioulnar joint. It is the focal point that allows the carpus to rotate with the radius around the ulna.1,2 As a stabilizer of the ulnar carpus, the TFCC
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transmits 20% of an axially applied load from the ulnar carpus to the distal ulna.1,2 Severe twisting and loading injuries of the wrist are commonly responsible for tears of the TFCC. These patients will not only present with ulnar sided wrist pain, but pain with the extremes of supination and pronation as well as repetitive activity. Injuries to the TFCC have presented a challenge in regards to treatment. We have previously reported on a successful technique for arthroscopic repair of peripheral TFCC tears. The technique involves the use of spinal needles placed percutaneously through the safe zone and the use of a Shuttle relay (Linvatec) and Panacryl suture to create a mattress type repair. Follow up for a minimum of 24 months has produced excellent results when evaluated using the Mayo Modified wrist score. As our series of patients has grown, we have noted an interesting subset of patients that have had not only peripheral TFCC tears, but central tears as well. To the best of our knowledge, lesions of the TFCC involving both central and peripheral tears have not previously been described. Past studies have demonstrated successful outcomes with debridement of central lesions and repair of peripheral lesions. Both arthroscopic as well as open techniques have been described. However, when we first encountered a TFCC tear with both a central and a peripheral component; what we have termed a Combined TFCC lesion, we were perplexed as to how to approach the problem. We ultimately did a thorough debridement of the central component and a secure arthroscopic repair of the peripheral component and then treated the patient post-operatively as we would any other peripheral repair. This first patient post operatively had and excellent outcome with a Modified Mayo wrist score of 100. Since that first patient, review of our series of TFCC repairs has yielded nineteen additional patients with combined lesions of the TFCC for a total of twenty patients. This report is an evaluation of these twenty patients with combined TFCC lesions. There were sixteen males and four female patients. Their average age was thirty-three years old. There were seven right wrist injuries and two left wrist injuries. The dominant wrist was injured 16/20 times. Mechanism of injuries included seventeen sports related injuries (baseball, hockey and tennis), two MVA’s and one assault. Associated pathology involved one scapholunate ligament rupture and one ECU sling rupture. Follow up ranged from 24 to 48 months and averaged 30 months. Average Mayo Modified wrist score was 90. This compared favorable with our previous series of peripheral TFCC repairs where the average score was 92.5. We believe that debridement of the central portion of a Combined TFCC lesion in conjunction with repair of the peripheral portion can lead to good and excellent