Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction

Abstract

Background: A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined. Purpose: To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ). Study Design: Descriptive laboratory study. Methods: Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit. Results: The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; P < .001). Three upper limit outliers were discovered: 24.20°, 23.4°, and 21.1°. The mean posterior angle of entry was 40.44° (SD, ±6.18°; 95% CI, 39.22°-41.67°; P < .001). There were no outliers for the posterior angle of entry. Interobserver reliabilities were strong for the 4 measurements. Conclusion: To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry. Clinical Relevance: These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.

Anatomical and Biomechanical Stability of Single/Double Screw‐Cancellous Bone Fixations of Regan–Morry Type III Ulnar Coronoid Fractures in Adults: CT Measurement and Finite Element Analysis

“…The pull-out force of a cancellous bone screw is an important index for predicting screw loosening and fracture block displacement. 9,11,12,21 The study of Chatzistergos et al 26 has shown that the main parameters affecting the pull-out force are the outer diameter of the screw and the fixed length inside bone, and the pull-out force is linearly related to the fixed length of the bone. The experiments of Feng et al 27 indicated bone screws with a reverse buttress thread design will significantly increase the pull-out strength.…”

“…[5][6][7][8] Since the proximal ulna is covered with thin cortex and loose spongiosa, especially in patients with osteoporosis, problems such as screw loosening, displacement or rotation of the fracture block, and screws stripping may occur when the single or plural screws are improperly fixed. [9][10][11][12] To avoid problems with a single screw, double lag screws sometimes can be used to enhance fixation stability. However, experimental studies have shown that there is no significant difference in lateral bending stability between single-screw fixation and double-screw fixation, 13,14 and the single-screw fixation has the advantages of reducing time and costs of operation.…”

“…For larger fractures, surgeons can choose lag screw fixation methods directed anterior to posterior or vice versa 5–8 . Since the proximal ulna is covered with thin cortex and loose spongiosa, especially in patients with osteoporosis, problems such as screw loosening, displacement or rotation of the fracture block, and screws stripping may occur when the single or plural screws are improperly fixed 9–12 . To avoid problems with a single screw, double lag screws sometimes can be used to enhance fixation stability.…”