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Bilateral Elbow Ligament Reconstruction: Surgical Technique
Maria A Munsch, MD1, Devon Moody, AST2 and Robert Kaufmann, MD1, (1)University of Pittsburgh, Pittsburgh, PA, (2)Bolttech Mannings Inc, North Versailles, PA

Bidirectional ligamentous elbow instability is an uncommon problem. It may be caused by trauma or, intraoperatively, during interposition arthroplasty. After resurfacing the distal humerus, the elbow is invariably destabilized and may require external fixation or an epicondyle osteotomy followed by fixation to ensure postoperative stability. A need exists to treat grossly unstable elbows via simultaneous tensioning of medial and lateral ligament reconstruction graft limbs and employs hardware that does not require removal. Bidirectional ligament reconstruction with a Cylindrical Ligament Retention Device (CLRD) is proposed for this purpose.
The distal humerus and proximal ulna are exposed, the centerline of ulnohumeral rotation is identified. A transhumeral tunnel is drilled, connecting the medial and lateral epicondyles about the ulnohumeral axis (Figure 1). This tunnel allows for passage of the appropriately sized CLRD.
Tendon grafts pass freely through the CLRD eyelets. The CLRD is centrally located in the transhumeral tunnel and secures the graft limbs (Figure 2).
Aggressively teethed plates are secured to the proximal olecranon with two transulnar bolts and splined nuts (Figure 3).
Medial and lateral sides are simultaneously and equally tensioned. This force is maintained by compression of the ulnar plates. The ulnohumeral joint is seated with pressure exerted between the ulna and the distal humerus while the tendons are tensioned and the bolts are tightened. The grafts then sit in an isometric location and heal to bone.
This procedure is indicated for treatment of acute or chronic bidirectional elbow instability. Isometric graft placement allows for elbow motion without stretching of either graft limb and, thus, minimizes potential graft impingement, stiffness, stretching, and subsequent failure. Simultaneous graft tensioning aims to impart symmetrical stability and restore native elbow kinematics. Graft tension is maintained with aggressively teethed plates that exert compression between the graft and the proximal ulna.
Bidirectional ligamentous reconstruction offers a novel technique for treatment of grossly unstable elbows either in the acute or chronic setting.

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