Elbow LUCL Reconstruction Using Local Extensor Fascia Septum Transposition: Surgical Technique

Angelo De Crescenzo , MD, ITALY Raffaele Garofalo, MD, ITALY Luigi A. Pederzini, MD, ITALY Andrea Celli, MD, ITALY

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Introduction

The lateral ulnar collateral ligament (LUCL) is a primary lateral stabilizer of the elbow that originates from the isometric centre of the capitulum and inserts into the supinator crest of the ulna. LUCL injury may be due to trauma, chronic strain, or iatrogenic causes. Acute severe injury of the LCL complex can lead to posterolateral rotatory instability (PLRI)4. The lesion is commonly the result of trauma, such as a fall on an outstretched arm with the forearm supinated and the elbow slightly flexed; the humeroulnar joint rotates posterolaterally to dislocate or subluxate the elbow posteriorly4,. In acute scenario, the injured LUCL is reattached to the lateral epicondyle with transosseous sutures and/or anchors at the isometric origin of the ligament. If the ligament quality is poor in the chronic setting, patients may require reconstruction with a tendon autograft or allograft (e.g., plantaris, semitendinosus, or gracilis tendon). Alternatively, the LUCL can be reconstructed by transposition of the local extensor fascia septum, a local flap that exploits the common extensor fascia connected to a thin strip of extensor digitorum quinti or the extensor digitorum communis intermuscular septum. In the present report, we describe a new LUCL reconstruction technique based on the transposition of the local extensor fascia septum

Surgical Technique

The patient lies in the supine position, and a sterile tourniquet is applied to the upper arm. The distal limited Kocher approach is performed. The interval between the ECU and the anconeus is developed, with care being taken to preserve the ECU fascial band with the remaining fibres of the LCL epicondyle insertion. The fascial band usually merges with the insertions of the extensor tendons and the ECU.

A triangular fragment of common extensor fascia (approximately 2 x 6 cm wide and 8 cm long), centred on the intermuscular septum, is marked (Fig. 1). The septum can be identified by palpation 3-4 mm medial to the humeral head of ECU. The EDQ and the fascial septum are easily identified anterior to the ECU insertion by passively moving the little finger with direct palpation.

The fascia can be elevated from the common extensor muscles, sparing the epicondylar insertion of the fascia and septum. The fascial flap should incorporate the superficial portion of the intermuscular septum (2-3 mm), preserving its continuity (Fig. 2) and keeping the deep portion intact.

The common extensor fascial band is folded around the split septum as a rotation flap and is mobilized, sparing the epicondylar insertion. Imbricated Krackow locking sutures are placed along the anterior and posterior aspects of the rotation flap, which provides a new ligament. (Fig. 3).

The interval between the EDC tendon insertion and the lateral insertions of the EDQ and the ECU is identified and split longitudinally to expose the underlying oblique fibres of the supinator muscle.

A plane under the ECU and EDQ tendons and above the supinator muscle fibres is carefully developed with use of blunt scissors so that the graft can be rotated posterior to the ulnar insertion and passed through it.

To ensure alignment with the native ligament, the new ligament is fixed with a suture anchor to the isometric point identified at the centre of the lateral epicondyle.

A groove for the rotation flap (1-1.5 x 0.5 cm) is excavated with a high-speed burr in the supinator crest, perpendicular to the intended direction of the LCL. Three holes are then drilled into the bottom (distally) of the groove, and the graft sutures are passed through them. The new ligament is laid in the groove, and the sutures are stretched to the correct length after repeated flexion-extension movements. Next, the sutures are tied with the forearm in full pronation and the elbow at 40° of flexion. The new ligament is sutured proximal to the remaining portion of of the native ligament, and the annular ligament incision is repaired (Fig. 4). The extensor fascia is closed, and the Kocher interval is reapproximated with absorbable sutures.

Postoperative Care

• 0-4 weeks: Elbow immobilization in a static posterior splint.

• 4-8 weeks: Hinged elbow brace enabling active and passive movement but limiting supination.

• 8 weeks: Active and passive movement without the brace, avoiding full supination and varus stress. Use of upper limb for normal daily activities.

Preliminary Clinical Experience

Ten consecutive patients (7 men and 3 women) with chronic PLRI of the elbow underwent LUCL reconstruction with transposition of the local extensor fascia septum at our institution. All procedures were performed by the same surgeon. The mean age at the time of surgery was 33 years (range, 25 to 50 years), and the mean interval from the injury to surgery was 15 months (range, 10 to 20 months). Anteroposterior dynamic examination under fluoroscopy documented varus instability in all cases. Before surgery, all patients had a positive lateral pivot shift test and a varus/valgus stability test under anaesthesia. The mean follow-up was 26 months (range, 24 to 30 months). All patients were assessed for pain, range of motion, and subjective and objective stability. The Mayo Elbow Performance Score (MEPS), the QuickDash questionnaire score, and the visual analogue scale (VAS) score for pain were calculated before surgery and at the latest follow-up. At the latest follow-up, 9 patients (90%) reported a completely stable elbow. The range of motion improved or was preserved in all patients All clinical measures improved significantly (p < 0.05). At the latest clinical evaluation, 9 patients (90%) were completely without pain and the lateral pivot shift test was negative for all elbows. All patients were satisfied with the outcome of the procedure, and 90% returned to sport at the preinjury level. In the cases of 2 patients, radiographs showed a small ectopic bone formation without clinical relevance on the lateral epicondyle. Early degenerative changes, detected in 1 patient, did not progress during the study period.

Discussion

LUCL insufficiency is the most common cause of recurrent elbow instability. The ulnar portion of the LCL complex is attenuated, and symptoms vary from recurrent posterolateral subluxation to subtle pain and discomfort.

Patients with recurrent subluxation describe the elbow as slipping in and out of the joint and often report popping, snapping, clicking, or locking when the forearm is supinated and the elbow is slightly flexed. Patients with chronic LUCL insufficiency experience lateral pain with a sensation of instability in certain positions when the elbow is loaded. This was the case in 80% of our patients and was the primary factor influencing the MEPS, QuickDash, and VAS scores. The PLRI was assessed with tests involving humeroradial joint subluxation or the typical apprehension response. Radial subluxation is easily demonstrated with the patient under anaesthesia.

Standard anteroposterior and lateral radiographs often show normal findings. After ligament injury, small fragments of avulsed bone may be detected under the lateral epicondyle on anteroposterior radiographs. Posterior subluxation of the radial head with widening of the humeroulnar joint space can be detected on lateral radiographs, whereas LUCL insufficiency is best demonstrated with use of radiographic or fluoroscopic stress views during the pivot-shift test with the patient under anaesthesia.

Whereas standard magnetic resonance imaging (MRI) plays a limited role, MR arthrography may show LCL complex injury. MRI may depict chondral damage to the capitulum or intra-articular loose bodies.

In patients with chronic ligament insufficiency, LUCL reconstruction with autologous graft tissue is recommended when reinsertion and plication do not appear to stabilize the humeroradial joint.

An autologous free tendon graft using the palmaris longus tendon (present in 85% of individuals), the plantaris tendon (found in 80% of lower limbs), a strip of triceps tendon, or the gracilis or semitendinosus tendon, is usually preferred. Different fixation techniques can be used. The traditional approaches include the figure-of-8 Yoke technique, the docking technique, and the circumferential graft or box loop technique. Our patients with chronic LUCL insufficiency were managed with local transposition of the extensor fascia septum. The approach restored adequate lateral elbow stability and enabled return to preinjury level of sport performance in 90% of patients. These outcomes are comparable with those reported by other researchers with different types of autografts and allografts. The chief advantage of this novel technique lies in its simplicity as it involves the use of donor tissue from the same surgical area and preserves the epicondylar insertion of the transposed local extensor fascia septum. For correct alignment with the native ligament, identification of the isometric point at the centre of the lateral epicondyle allows fixation of the new ligament with a suture anchor, sparing the insertion the transposed soft tissue. The new ligament is accommodated into a specially prepared ulnar groove, and, after repeated flexion-extension movements, the sutures are tied with the forearm in full pronation and the elbow at 40° of flexion. There was no donor-site morbidity, nor were there any complications related to soft-tissue transposition. No adverse functional effects on hand or wrist movement were seen at the latest follow-up. We attribute this outcome to the preservation of the muscle insertions and of the deep portion of the intermuscular septum. No contraindications can be identified for this technique thus far, but it would be interesting to prospectively compare this technique with other approaches involving the use of a tendon autograft or allograft.

Conclusion

The use of the extensor fascia septum as an autologous graft for LUCL reconstruction presents a promising alternative to traditional grafting techniques. This approach offers substantial advantages in terms of reduced donorsite morbidity, anatomical reconstruction, and ease of harvesting. However, as with any surgical technique, the comparison of larger patient groups managed with this and other autograft/allograft reconstruction techniques is clearly needed to establish the respective intermediate and long-term outcomes.

Figure 1. Development of the Kocher interval between the anconeus and the ECU allows visualization of the remainder of the ruptured LCL. The septum between the EDQ and the EDC is identified by palpation anterior to the ECU insertion, whereas the EDQ is identified by passive movement of the small finger with the wrist blocked. A triangular fragment of common extensor fascia (approximately 2 x 6 cm wide and 8 cm long) is marked and collected.

Figure 2. The superficial fascial flap is mobilized off the underlying muscles, preserving its continuity with the deep intermuscular septum. The muscle fibre insertions on the septa are raised and divided longitudinally, leaving 2-3 mm in continuity with the fascial flap. The fascial flap with the split septum is mobilized, preserving its epicondylar insertion.

Figure 3. The EDC is divided, with the EDQ and the ECU tendons being split as a unit from the underlying supinator muscle, capsule, and annular ligament with use of blunt scissors. The oblique fibres of the supinator muscle allow for the identification of the deep plane of dissection.

Figure 4. The graft is rotated posterior to the ulnar insertion under the ECU-EDQ tendon unit and above the supinator muscle. The supinator crest is excavated with a high-speed burr to receive the rotational flap. The graft sutures are passed through the ulnar holes, the new ligament is introduced into the groove, and the sutures are tied with correct tension with elbow in 40° of flexion and the forearm fully pronated. The remaining native ligament and the annular ligament are repaired in continuity with the LUCL.

References

1. Badhrinarayanan S, Desai A, Watson JJ, White CHR, Phadnis J. Indications, Outcomes, and Complications of Lateral Ulnar Collateral Ligament Reconstruction of the Elbow for Chronic Posterolateral Rotatory Instability: A Systematic Review. Am J Sports Med. 2021 Mar;49(3):830-837. doi: 10.1177/0363546520927412.
2. Baumfeld JA, van Riet RP, Zobitz ME, Eygendaal D, An KN, Steinmann SP. Triceps tendon properties and its potential as an autograft. J Shoulder Elbow Surg. 2010 Jul;19(5):697-9. doi: 10.1016/j.jse.2009.12.001.
3. Celli A, Paroni C, Bonucci P, Celli L. Elbow lateral ulnar collateral ligament reconstruction by transposition of the local extensor fascia septum: surgical technique and preliminary results. JSES Rev Rep Tech. 2022 Apr 26;2(3):360-368. doi: 10.1016/j.xrrt.2022.04.004.
4. Finkbone PR, O'Driscoll SW. Box-loop ligament reconstruction of the elbow for medial and lateral instability. J Shoulder Elbow Surg. 2015 Apr;24(4):647-54. doi: 10.1016/j.jse.2014.12.008.
5. Sanchez-Sotelo J, Morrey BF, O'Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br. 2005 Jan;87(1):54-61.

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