Step 1: Perform a Medial and Lateral Approach Approach the elbow joint through either a single posterior skin incision or separate lateral and medial incisions.
Step 2: Drill the Bone Tunnels Create humeral and ulnar bone tunnels for circumferential graft placement.
Step 3: Place the Graft Use a plantaris allograft, which we recommend; however, a semitendinosus autograft may also be used.
Step 4: Close the Wound Ensure that meticulous wound closure is achieved as it is key to preventing postoperative complications such as superficial or deep infection and persistent seroma.
While early functional treatment can be considered the gold standard for the management of ligamentous or “simple” elbow dislocation, with good clinical results in most patients3, some who have more extensive soft-tissue trauma and/or subsequent dislocations may have gross instability of the elbow. In patients who have persistent disability with insufficiency of both the lateral and the medial collateral ligament complex, ligament reconstruction is warranted in order to restore the joint stability and improve the functionality of the affected arm.
The circumferential graft technique was initially reported in 2006 by van Riet et al.2 and separately in a series of 14 patients described by Finkbone and O’Driscoll1. This technique aims to restore elbow stability by simultaneous reconstruction of the lateral and medial collateral ligaments with a single tendon graft.
Indications & Contraindications
Combined medial and lateral elbow instability
Intact osseous congruity of the elbow joint
No or low-grade osteoarthritis
Acute ligamentous instability
Acute or chronic infection
Step 1: Perform a Medial and Lateral Approach
Approach the elbow joint through either a single posterior skin incision or separate lateral and medial incisions.
Place the patient in the supine position with the arm either across the chest (posterior incision) or placed on an arm rest (bilateral incisions).
A tourniquet may or may not be used, depending on the surgeon’s preference.
When performing a single posterior incision, mobilize full-thickness flaps medially and laterally.
Release and protect the ulnar nerve.
Enter the joint medially through the bed of the ulnar nerve (flexor carpi ulnaris split) or through the common flexor-pronator tendon origin.
Enter the joint laterally through the Kocher interval between the anconeus and the extensor carpi ulnaris muscle.
For better visualization, detach the common flexors and extensors from their humeral origin and mobilize them anteriorly. If they are intact, make every effort to preserve them.
Step 2: Drill the Bone Tunnels
Create humeral and ulnar bone tunnels for circumferential graft placement.
Identify the motion axis of the elbow. When in doubt, a true lateral radiograph can be helpful to identify the motion axis (Fig. 1).
Identify the sublime tubercle at the medial side of the ulna and the supinator crest at the lateral side posterior to the radial head.
Create a 2.0-mm drill-hole or place a 2.0-mm Kirschner wire in the distal end of the humerus along the motion axis of the elbow using a target device.
Create a 2.0-mm drill-hole or place a 2.0-mm Kirschner wire from the sublime tubercle to the supinator crest using a target device (Fig. 2).
Remove the drills or Kirschner wires.
Take great care to protect the ulnar nerve at all times.
Step 3: Place the Graft
Use a plantaris allograft, which we recommend; however, a semitendinosus autograft may also be used.
Perform a Krakow stitch over a length of 2 cm at both ends of the graft with a number 2-0 FiberWire (Arthrex).
If possible, loop the graft through the bone tunnels once more.
Before fixation of the graft, close the underlying capsule to avoid leakage of joint fluid.
Reduce the elbow at 90° of flexion by placing the humerus flat on the operating table and the forearm in a vertical position.
While one assistant maintains this position, have the other assistant tighten the graft ends by pulling on the FiberWires.
Suture the overlapping tendon grafts onto each other with a number 2-0 FiberWire using a Krakow stitch at the medial and/or lateral side for secure fixation of the graft (Fig. 6-A).
Step 4: Close the Wound
Ensure that meticulous wound closure is achieved as it is key to preventing postoperative complications such as superficial or deep infection and persistent seroma.
For patients with preoperative ulnar neuropathy, consider anterior transposition of the ulnar nerve.
If the common flexor and extensor tendons have been dissected at the beginning of the surgery or were traumatically torn off their humeral origin, carefully reattach them to the ulnar and radial epicondyles with transosseous sutures or suture anchors (Figs. 6-B and 7).
Consider placing a wound drain to prevent hematoma formation.
Carefully close the forearm fascia at the medial and lateral sides.
Close the subcutaneous tissue and the skin.
Apply sterile dressings and a pressure bandage to limit postoperative swelling.
As multidirectional instability represents a rather rare complication following ligamentous elbow dislocation, clinical data regarding the circumferential graft technique are scarce1,2. From a biomechanical standpoint, we were able to show that this technique may be preferred over conventional reconstruction of the medial collateral ligament and the lateral ulnar collateral ligament4. While both reconstruction techniques were found to be inferior to the native collateral ligament complex, the circumferential graft technique withstood cyclic loading better than the conventional technique4.
In 2006, van Riet et al. were the first, as far as we know, to describe the circumferential graft technique2. They applied this technique in a 13-year-old boy with recurrent elbow dislocation and were able to successfully restore joint stability at a 2-year follow-up2. In 2015, Finkbone and O’Driscoll reported what we believe is the largest case series to date regarding treatment of multidirectional elbow instability using the circumferential graft technique, which they termed the box-loop ligament reconstruction1. In their series of 14 patients, they reported a mean American Shoulder and Elbow Surgeons (ASES) score of 81 points and a mean Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score of 13 points1. None of the patients had recurrent instability at a mean follow-up of 5.3 years1. One revision surgery for delayed-onset ulnar neuropathy had been performed at the time of the latest follow-up1.
Pitfalls & Challenges
Consider the contraindications of this procedure and do not use this technique in patients with osseous instability.
Be aware of the location of the ulnar nerve and check previous surgical reports for possible anterior transposition of the nerve.
Consider anterior transposition of the nerve in patients with preoperative ulnar neuropathy.
Perform careful dissection as posttraumatic scarring, especially in revision surgery, may make it more difficult to identify anatomic landmarks.
Use a target device for precise creation of the bone tunnels and to avoid multiple drilling with subsequent weakening of the cortical bone.
Remember that the bone tunnels are not parallel to each other as the ulnar bone tunnel is directed from proximal-medial (sublime tubercle) to distal-lateral (supinator crest).
Check for adequate tensioning of the graft over the full range of motion before performing fixation.
Make sure that the elbow is securely reduced when performing graft fixation.
Carefully reattach the extensor and flexor tendons. They cover the graft to reduce the risk of infection, and they provide active joint stability.
Meticulously close the forearm fascia to avoid herniation of the forearm muscles, to reduce the risk of infection, and to enhance elbow stability.
Consider applying an additional hinged external fixator in patients who are noncompliant and overweight (especially in those with a long forearm, which causes a large lever on the joint).
Published outcomes of this article can be found at: J Shoulder Elbow Surg. 2015;24(4):647-54.
Disclosure: On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author received payment or services from a third party (government, commercial, private foundation, etc.) for an aspect of the submitted work.
- Copyright © 2017 by The Journal of Bone and Joint Surgery, Incorporated