Stabilizers of capitellocondylar total elbow arthroplasty

The contribution of the medial and lateral collateral ligaments (MCL, LCL) and muscle forces to the kinematics and stability of the capitellocondylar total elbow arthroplasty was investigated in six fresh cadaveric elbows. The three-dimensional orientation of the ulna relative to the humerus was monitored with the use of an electromagnetic tracking device in neutral, valgus, and varus stress positions with (1) the ligaments intact, (2) LCL insufficiency obtained by osteotomizing the lateral epicondyle, (3) partial MCL insufficiency obtained by sectioning either the anterior or posterior bundle of the MCL, and (4) complete MCL insufficiency. Simulated muscle forces were applied as follows: (1) no load, (2) 1 kg each to the biceps and the brachialis and 2 kg to the triceps, and (3) 2 kg to the biceps and the brachialis and 4 kg to the triceps. The laxity was defined as the difference in valgus/varus orientation of the ulna in the valgus and varus stress positions. The laxity at 40°, 75°, and 110° elbow flexion was analyzed. The greatest laxity occurred with LCL insufficiency (40.7° ± 11.6°, average at three flexion angles) followed by that with MCL insufficiency (15.7° ± 9.9°), both of which were significantly larger than laxity with the intact ligaments (5.6° ± 2.5°). The laxity with the anterior bundle sectioned (12.0° ± 8.1°) was significantly greater than with the posterior bundle sectioned (3.3° ± 3.6°); thus the contribution of anterior bundle to stability was four times that of posterior bundle. Stabilizing effect of muscle loading was small in elbows with intact ligaments, whereas it was large with LCL or MCL insufficiency. Based on these data, we can see that the integrity of both the MCL and LCL is essential to maintain stability of this total elbow, the anterior bundle is a more important stabilizer than the posterior bundle, and the collateral ligaments seem to be the primary stabilizer and the musculature seems to be the secondary stabilizer. Careful implantation technique to preserve the collateral ligaments is required to obtain postoperative stability of this arthroplasty. Otherwise, routine exposure of the MCL and repair or reinforcement of the MCL, if deficient, may need to be considered during surgery.