JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Marc J. Richard, J. Mack Aldridge, III, Ethan R. Wiesler, and David S. Ruch
Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
J Bone Joint Surg Am 2008; 90: 2416-2422 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Drs. Richard and Ruch respond to Dr. Kini
Marc J. Richard, MD, David S. Ruch, MD   (25 November 2008)
[Read Letter to the Editor] Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
Sunil Gurpur Kini, MBBS,M.S(Ortho),D.N.B(Ortho)   (25 November 2008)

Drs. Richard and Ruch respond to Dr. Kini 25 November 2008
Previous Letter to the Editor Top
Marc J. Richard, MD,
Orthopaedic Surgery
Duke University Medical Center,
David S. Ruch, MD

Send letter to journal:
Re: Drs. Richard and Ruch respond to Dr. Kini

marc.richard{at}duke.edu Marc J. Richard, MD, et al.

We thank Dr. Kini for his interest in our recent article and we appreciate the opportunity to respond.

While all of the patients included in our study were athletes, only 3 of the 11 patients were overhead athletes. However, all patients were evaluated for concomitant injuries and elbow pathology as reported in our study. None of the overhead athletes reported a history of pain through the deceleration phase of throwing prior to injury and none of the imaging studies revealed evidence of posteromedial impingement of the olecranon.

Vitale et al have documented that newer muscle-splitting and docking techniques of ulnar collateral ligament reconstruction without obligatory transposition of the ulnar nerve has led to improved outcomes and lower rates of ulnar neuropathy(1). Closer examination of this review article shows that other authors have demonstrated much lower rates of ulnar neuropathy associated with subcutaneous or subfascial transpositions than with submuscular transposition as was routinely performed with earlier techniques(2,3). We performed subfascial ulnar nerve transposition in all of our patients. In our series, preoperative ulnar neuropathy was the reason for transposition in 3 patients. Seven patients had extensive mobilization of the ulnar nerve for ligament repair and underwent transposition for subluxation of the nerve. In the final patient, the ulnar nerve was transposed because of concern that it would be irritated by the suture material utilized for the ligament repair.

Finally, in an in vitro study by Pichora et al, the authors demonstrated favorable results of a broad range of acceptable tensions for the ulnar collateral ligament of the elbow(4). We did not measure the tension of the ligament repair. Because these were ligament repairs and not reconstructions, the native anatomy was easily recreated. We placed the elbow in mid-flexion and slight varus at the time of repair to allow appropriate matching of the ligament origin to the footprint on the medial epicondyle.

References

1. Vitale MA and Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med. 2008 Jun;36(6):1193-205.

2. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med. 1995;23:407-413.

3. Azar FM, Andrews JR, Wilk KE, Groh D. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28:16-23.

4. Pichora JE, Fraser GS, Ferreira LF, Brownhill JR, Johnson JA, King GJ. The effect of medial collateral ligament repair tension on elbow joint kinematics and stability. J Hand Surg. 2007 Oct;32(8):1210-7.
Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair 25 November 2008
Next Letter to the Editor Top
Sunil Gurpur Kini, MBBS,M.S(Ortho),D.N.B(Ortho),
Registrar Orthopaedics
Guru Teg Bahadur Hospital , University College of Medical Sciences,Delhi,India

Send letter to journal:
Re: Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair

drsunilkini{at}gmail.com Sunil Gurpur Kini, MBBS,M.S(Ortho),D.N.B(Ortho)

To the Editor:

I read with interest the article by Richard, et al.(1). Repair of avulsion injuries of the ulnar collateral ligament has yielded better results than repair of midsubstance tears but the superiority of outcomes of operative treatment over non operative treatment in isolated medial ligament injuries is questionable. I would like ask the authors to comment on the following:

Posteromedial impingement of the elbow occurs in athletes who use overhead motions and manifests as terminal loss of extension and late onset pain in the deceleration phase of throwing. Was posteromedial impingement of the olecranon seen in any of their athletes?

Was there any specific reason for ulnar nerve transfer in all patients? Articles have shown that abandoning obligatory transposition of ulnar nerve leads to better outcomes and decreased post operative ulnar nerve neuropathy (2).

In what degree of flexion of the elbow were the sutures secured and were the sutures tensioned to any numerical value? In vitro studies have shown that overtensioning to over 60 N leads to varus overtightening in midflexion but its effect in vivo are yet to be proven(3).

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References

1.Marc J. Richard, J. Mack Aldridge, III, Ethan R. Wiesler, and David S. Ruch Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair J Bone Joint Surg Am 2008; 90: 2416-2422

2. The Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes: A Systematic Review - M. A. Vitale and C. S. Ahmad Am. J. Sports Med., June 1, 2008; 36(6): 1193 - 1205.

3. The Effect of Medial Collateral Ligament Repair Tension on Elbow Joint Kinematics and Stability . The Journal of Hand Surgery,2007 October, Volume 32,Issue 8,Pages 1210 – 1217 J.Pichora ,G.Fraser,L.Ferreira ,J.Brownhill ,J.Johnson,G . King.