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Medial Collateral Ligament Reconstruction: Salvage of Instability From Osseous Deficiency
Introduction
The relationship of olecranon spur removal and medial ulnar collateral ligament injury was first recognized by Andrews. It is well known that valgus instability resulting from excessive removal of the medial corner of the olecranon is extremely difficult, if not impossible, to correct. To date, articular deficiency of the medial corner of the olecranon process has been thought not to be amenable to surgical correction. The procedure described in this chapter remains the only one in the literature that successfully addresses this difficult problem.
Rationale
The complementary stabilization effect of the olecranon process and the medial collateral ligament (MCL) has been studied experimentally. It has been shown that removal of as little as 3 mm of normal osseous structure results in increased laxity and increased strain in the MCL. Further, the instability that results from a deficient olecranon tip is manifest in higher degrees of flexion. Two recent investigations also revealed measurable instability with increasing amounts of resection and, of interest, demonstrated that instability was greatest at 60 to 90 degrees of flexion. Because the posterior bundle of the MCL is taut in flexion, it is logical that it could address an instability pattern that occurs in flexion. In our limited experience, a deficient tip of the olecranon manifests with instability in about 70 degrees of flexion ( Fig. 70.1 ). Hence, it is reasonable to reinforce or tighten the posterior bundle of the MCL in this clinical circumstance.
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