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Chronische Bandinstabilitäten des Ellenbogengelenks

Chronic ligamentous instability of the elbow

  • Leitthema
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Zusammenfassung

Hintergrund

Die chronische ligamentäre Ellenbogeninstabilität ist eine bedeutende Pathologie, da sie mit einer ausgeprägten Dysfunktion einhergeht und einen Risikofaktor für die Arthroseentwicklung darstellt. Die häufigste Form ist die posterolaterale Rotationsinstabilität (PLRI) durch Insuffizienz des lateralen Kollateralbandes (LCL), die meist Folge einer traumatischen Ellenbogenluxation ist. Insbesondere bei Wurfsportlern kann es im Rahmen von chronischer Überbelastung zu einer Insuffizienz des ulnaren Seitenbandes (UCL) mit Valgusinstabilität kommen.

Diagnostik

Klinisch äußert sich eine chronische Ellenbogeninstabilität nicht immer durch Instabilitätsgefühle und rezidivierende Luxationen, sondern ist häufig durch Schmerzen und sekundäre Gelenksteifen geprägt. Es existieren verschiedene klinische Tests, die in Abhängigkeit der Beschwerdesymptomatik jedoch nur eingeschränkte Aussagekraft haben. Ein „drop sign“ im Röntgen sowie der Nachweis von Bandverletzungen und Gelenkinkongruenzen im MRT können die klinische Verdachtsdiagnose stützen. Manchmal lässt sich die Vermutung erst mittels diagnostischer Arthroskopie verifizieren.

Therapie

Die Bandplastik des lateralen ulnaren Kollateralbands (LUCL) bei PLRI weist in der Regel gute klinische Ergebnisse auf, Rezidivinstabilitäten werden jedoch in etwa 8 % der Fälle berichtet. Bei medialer Instabilität führt die UCL-Plastik bei Wurfsportlern zu einer Rekonvaleszenz in etwa 86 % der Fälle. Die Ulnarisneuropathie ist die häufigste Komplikation und tritt bei etwa 6 % auf. Im seltenen Fall einer multidirektionalen Instabilität können das LUCL und UCL simultan mit einem singulären Sehnengraft in Form einer zirkumferenziellen Box-loop-Rekonstruktion ersetzt werden. Bisher wurden hierzu 15 Fälle mit vielversprechenden Ergebnissen publiziert.

Abstract

Background

Chronic ligamentous instability of the elbow is an important pathology as it is accompanied with pronounced dysfunction. Moreover, it represents an established risk factor for the development of osteoarthritis. Posterolateral rotatory instability (PLRI) caused by insufficiency of the lateral collateral ligament (LCL) is the most common type of chronic elbow instability and is usually a sequel of traumatic elbow dislocation. Chronic overload can lead to insufficiency of the ulnar collateral ligament (UCL) with subsequent valgus instability, especially in overhead athletes.

Diagnostics

Subjective instability and recurrent elbow dislocations are not always the main symptoms but elbow instability is instead often characterized by pain and secondary joint stiffness. Many clinical tests are available yet eliciting them can be difficult and inconclusive. A “drop sign” on lateral radiographs as well as the detection of collateral ligament injuries and joint incongruity on MRI scans can support the suspected diagnosis. In some cases, instability can only be verified by diagnostic arthroscopy.

Treatment

Reconstruction of the lateral ulnar collateral ligament (LUCL) for treatment of PLRI generally leads to good clinical results, yet recurrent instability remains an issue and has been reported in 8 % of cases. UCL reconstruction for chronic valgus instability leads to a return-to-sports rate of about 86 % in the overhead athlete. Ulnar neuropathy, which is seen in approximately 6 % of patients, represents the most common complication. On the rare occasion of multidirectional instability, the box-loop technique can be used for simultaneous reconstruction of the LUCL and UCL with a circumferential graft. 15 cases with promising results have been reported in literature thus far.

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  1. Schwerpunkt für Unfall-, Hand- und Ellenbogenchirurgie, Universitätsklinik zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland

    M. Hackl, T. Leschinger, L. P. Müller & K. Wegmann

  2. Cologne Center for Musculoskeletal Biomechanics (CCMB), Universität zu Köln, Köln, Deutschland

    M. Hackl, T. Leschinger, L. P. Müller & K. Wegmann

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M. Hackl, T. Leschinger, L. P. Müller und K. Wegmann weisen auf folgende Beziehung hin: Unterstützung durch die Arthrex GmbH (München, Deutschland) für Forschungsprojekte.

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Hackl, M., Leschinger, T., Müller, L.P. et al. Chronische Bandinstabilitäten des Ellenbogengelenks. Orthopäde 45, 809–821 (2016). https://doi.org/10.1007/s00132-016-3324-z

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