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