J Shoulder Elbow Surg (2015) 24, 647-654

www.elsevier.com/locate/ymse

Box-loop ligament reconstruction of the elbow

for medial and lateral instability
Patrick R. Finkbone, MD, Shawn W. O’Driscoll, MD, PhD*

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA

Background: Elbow instability remains a challenging surgical problem. Most commonly, isolated recon-
structions of the medial collateral ligament or lateral collateral ligament are performed; however, on occa-
sion, there can be deficiency that requires reconstruction of both ligaments. The senior author has
developed a method to reconstruct both the medial and lateral collateral ligaments using 1 graft. This tech-
nique uses a ‘‘box-loop’’ design, whereby the donor tendon is passed through the humerus and ulna and
tied back to itself, creating a loop.
Materials and methods: Fourteen cases with mean follow-up of 64 months were reviewed. Nine patients
returned to the clinic and were evaluated both clinically and radiographically. An additional 5 patients
participated by phone questionnaire.
Results: Average follow-up time was 64 months (range, 19-109 months). According to the Summary
Outcome Determination given by the patients, 7 elbows were normal or nearly normal, 4 were greatly
improved, 2 were improved, and 1 was worse compared with before surgery. The Summary Outcome
Determination score average was 7 (range, 2 to 10). American Shoulder and Elbow Surgeons scores
(including both clinic patients and phone questionnaire patients) ranged from 36 to 100, with an average
of 81; of 14 patients, 8 had an American Shoulder and Elbow Surgeons self-satisfaction score of 10. The
average Quick Disabilities of the Arm, Shoulder, and Hand score was 13 (range, 0-64). The average Mayo
Elbow Performance Index score was 88 (range, 60-100), with 4 excellent (90-100), 3 good (75-89), and 3
fair (60-74) results and no poor results.
Discussion: This technique was found to have excellent midterm results. Compared with separate medial-
and lateral-sided reconstruction, there is simplification of bone tunnel formation as well as graft fixation.
Level of evidence: Level IV, Case Series, Treatment Study.
Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Elbow instability; box-loop reconstruction; medial collateral ligament; lateral collateral
ligament

Reconstructive techniques have been described to

The Mayo Clinic Institutional Review Board that convened on October 22,
2009, approved this project: Protocol No. 09-001432. Consent forms were
signed by all participating patients.
*Reprint requests: Shawn W. O’Driscoll, PhD, MD, Department of
Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA.
E-mail address: odriscoll.shawn@mayo.edu (S.W. O’Driscoll).
address each of the forms of instability, including the
medial collateral ligament (MCL) or the lateral collateral
ligament (LCL) complex.7-11,14,17 Gross instability of the
elbow requires reconstruction of both ligaments.15,18,19 A
technique has been described by van Riet et al18,19 to

1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2014.12.008
 648
Table I Patient demographics
Case Age at Side Job Comorbidities Preoperative Prior surgeries Concomitant surgery at time
surgery diagnosis of box-loop reconstruction
1 28 Left Merchant None Contracture, HO after closed 1dAnterior capsulectomy and HO and capsular excision, ulnar nerve
Marine officer head injury HO excision transposition
2 25 Right) Flight student None Chronic instability with deficient 4dORIF with radial head Revision radial head arthroplasty,
(U.S. Navy) coronoid and radial head replacement, radial head implant coronoid osteotomy and ORIF,
removal and capsular release, ulnar ulnar nerve neurolysis
nerve transposition and MUA, MCL
reconstruction
3 48 Right) Nurse None Chronic instability with medial 1dORIF of medial epicondyle Excision of medial epicondyle
epicondyle nonunion, ulnar nonunion nonunion, ulnar nerve
neuropathy decompression
4 68 Left Homemaker Smoker, Chronic instability, failed radial 1dRadial head replacement Revision radial head arthroplasty
fibromyalgia, head replacement
history of
lung cancer
5 56 Left Livestock None Chronic instability with coronoid 0 None
producer/ nonunion
loan officer
6 38 Left Registered Diabetes Chronic instability, overstuffed 2dRadial head replacement, LCL Removal of radial head prosthesis,
nurse mellitus radial head prosthesis with repair and capsular imbrication ulnar nerve decompression
erosion of capitellum
7 50 Left Engineer None Chronic instability after terrible 1dORIF of radial head and LCL ORIF coronoid nonunion, HO and
triad injury, ulnar neuropathy repair, external fixator placement capsular excision, ulnar nerve
(in place  6 weeks) transposition
8 18 Left Material None Chronic instability, capitellar 0 Hemicap reconstruction of capitellum
handler nonunion
9 49 Right) Accountant None Contracture, radioulnar synostosis 2dORIF ulna, delayed skin grafting HO and capsular excision, radial head
after proximal radius and ulna arthroplasty, ulnar nerve
fracture, ulnar neuropathy transposition
10 26 Right) Manual None Chronic instability with medial 0 Ulnar nerve decompression
laborer epicondylar avulsion, ulnar
neuropathy
Right) Farmer

P.R. Finkbone, S.W. O’Driscoll

11 51 None Chronic varus and valgus instability, 2dUlnar nerve transposition, Distal radius osteotomy/correction
prior ulnar neuropathy, distal joint debridement and MCL repair
radius malunion
12 20 Left Sales None Chronic instability after multiple 0 None
instability episodes
13 18 Left Student None Chronic instability with coronoid 0 ORIF coronoid nonunion, ulnar nerve
(athlete) nonunion transposition
14 32 Left Teacher None Chronic instability with medial 0 Excision of medial epicondyle
epicondylar nonunion nonunion, ulnar nerve decompression
HO, heterotopic ossification; ORIF, open reduction and internal fixation; MUA, manipulation under anesthesia; MCL, medial collateral ligament; LCL, lateral collateral ligament.
) Dominant side.
Box-loop ligament reconstruction 649

Figure 1 Box-loop technique. After a 3.2-mm drill hole at the origin of the ligaments (isometric point at the axis of rotation) was created,
this process was repeated on the ulna, making the insertions in the middle of the sublime tubercle and the tubercle on the supinator crest. An
allograft (most commonly plantaris) is passed through the humerus, looped through the ulna, and again through the humerus and ulna once
again (A). After all passes have been completed, the capsule and residual ligamentous tissue are then closed, followed by tensioning and
tying of the graft (B). Lateral (C) and medial (D) views demonstrate the placement of the drill holes and the graft. (By permission of Mayo
Foundation for Medical Education and Research. All rights reserved.)

reconstruct both the MCL and LCL using 1 graft. The se-
nior author has also independently developed a similar
technique. This technique uses a ‘‘box-loop’’ design,
whereby the donor tendon is passed through the humerus
and ulna and tied back on itself, creating 1 continuous loop.
The purpose of the present study is to describe the box-loop
technique and to report early to midterm results with the
technique.
Materials and methods
This study is a retrospective case series of 18 box-loop re-
constructions performed by the senior author (S.O.D.) between
December 2003 and May 2009. Patients were contacted by phone
and asked to participate in the study either by returning to the
clinic or completing questionnaires by phone or mail-in. In all, 14
patients agreed to participate (2 were lost to follow-up and 2
declined). Nine patients agreed to come to the clinic, whereas 5
were willing to participate only by phone and correspondence.
Patients were included in the study regardless of additional
simultaneous surgery performed (i.e., radial head replacement,
fracture fixation) or prior diagnoses, surgeries, or injuries. Twelve
of the patients had persistent instability after trauma. The other 2
patients had severe contractures with heterotopic ossification
(HO), and the planned operation to regain motion would cause
gross instability of the elbow. Several of the patients had prior
surgery on the elbow (Table I).
Surgical technique
The box-loop technique is performed through separate medial and
lateral incisions, with care taken to avoid injury to any cutaneous
nerve branches. Starting on the medial side, identify the origins
650
Figure 2 Preoperative (A and C) and postoperative (B and D) radiographs of case 3.
and insertions of the MCL as follows. The origin is on the anterior
inferior margin of the epicondyle. With the elbow flexed 90 , the
anterior bundle of the MCL travels in a 45 direction from the
anterior inferior margin of the epicondyle to the sublime tubercle
of the ulna. The origin is the point at which that line intersects the
anterior inferior epicondyle. The insertion is on the sublime tu-
bercle of the ulna, which is a bump that can usually be readily
palpated immediately anterior to the ulnar nerve. The anterior
bundle of the MCL is exposed by splitting the common flexor-
pronator tendon origin in that line from the anterior inferior
margin of the epicondyle to the sublime tubercle. A 3.2-mm drill
hole is made, just a few millimeters deep, into the anterior inferior
margin of the epicondyle and also into the ulna immediately distal
to the sublime tubercle. Do not drill deeper than a few millimeters
at this point as the line of drilling must be determined after
identifying the corresponding points on the lateral side.
The deep dissection on the lateral side is in the anconeus in-
terval, between the extensor carpi ulnaris and anconeus muscle-
tendon units. The tubercle on the supinator crest is exposed by
subperiosteal elevation of the anconeus muscle. The interosseous
recurrent vessels are cauterized. The LCL complex and capsule
are then split longitudinally in a line from the epicondyle toward
the tubercle on the supinator crest. The isometric point on the
lateral condyle is determined by visually estimating the center of
P.R. Finkbone, S.W. O’Driscoll
the circle that is partially defined by the circular shape of the
capitellum when it is viewed directly from the lateral side. This is
facilitated by placing small Hohmann retractors on the proximal
and distal margins of the capitellum, taking the midpoint between
the 2. That midpoint should be equidistant from the anterior
margin of the capitellum as from the proximal and distal margins.
A 3.2-mm drill hole is made, just a few millimeters deep, into the
isometric point on the lateral condyle and also into the ulna
adjacent and immediately posterior to the tubercle on the supi-
nator crest. Place the targeting end of a targeted drill guide into the
previously drilled hole on the medial epicondyle, then sit the drill
bit into the hole at the isometric point on the lateral condyle and
drill about 60% of the distance from lateral to medial through the
humerus. Do the same thing with the ulnar holes, noting that the
angle of this tunnel is unexpectedly sharp because of the offset
between the ulnar insertions on the medial and lateral sides.
Once having drilled 60% of the way across the humerus and
the ulna from the lateral side, do the same from the medial side
with each hole respectively. It should be possible to advance the
drill through the partial tunnel and come out on the lateral side,
confirming completion of the tunnels.
An allograft is then prepared using a No. 2-0 FiberWire
(Arthrex, Naples, FL, USA) stitch in a Krackow fashion on each
end. If a small-diameter graft (such as our preferred graft, a
Box-loop ligament reconstruction
Figure 3 Subjective Outcome Determination (SOD) score. Clinical outcomes were assessed according to patient-reported SOD score.
(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)
plantaris allograft) is used, it is passed through the humerus loo-
ped through the ulna twice. If a larger diameter graft is used, such
as a split semitendinosus or gracilis, it is passed through the hu-
merus and ulna only once. After all passes have been completed,
the capsule and residual ligamentous tissue are imbricated, fol-
lowed by tensioning and tying of the graft. Finally, the graft is
sutured to the underlying ligamentous tissues (Figs. 1 and 2).
Postoperatively, the patients are placed in a cast for 3 weeks. This
is followed by 3 weeks in a removable posterior splint, removing it 2
to 5 times per day for gentle overhead active and active-assistive
range of motion exercises. The splint is continued for 6 weeks more
for protection at night and when the elbow is at risk.
Follow-up evaluation for the patients returning to the clinic
included taking a history for subjective instability or complica-
tions of surgery, physical examination, radiographs, and evalua-
tion by several different performance scores (see later).
Examination parameters included range of motion, lateral pivot
shift test, posterolateral rotatory drawer test, and varus and valgus
stresses in full extension and 30 of flexion.16 These physical
examination findings were compared with preoperative physical
examination findings.
Patient outcomes were assessed by the Mayo Elbow Perfor-
mance Index (MEPI),13 American Shoulder and Elbow Surgeons
(ASES) score,12 Quick Disabilities of the Arm, Shoulder, and Hand
(QuickDASH) questionnaire,1 and Summary Outcome Determina-
tion (SOD) score2,3,5 (Fig. 3).
651
The patients who were willing to participate only by phone or
mail-in were assessed by the MEPI, ASES, QuickDASH, and
SOD scores. The questionnaires were sent to the patients and then
either completed over the phone or completed independently by
the patients and mailed back in. The MEPI score was reported
only if the patients also supplied a picture of their elbow in full
extension and full flexion (from a perfect side view) for confir-
mation of their range of motion.6
Results
Average follow-up time was 64 months (range, 19-
109 months). No patients who returned to the clinic had
symptoms or physical examination signs of instability or any
radiographic evidence of instability. Curiously, 3 of these
patients responded on the MEPI stating that their elbow was
‘‘moderately unstable’’ but denied instability when ques-
tioned specifically about it by the examiner, and their elbows
were stable on examination. Two of the patients who had
completed phone questionnaires claimed to have ‘‘moderate
instability’’ of their elbow but denied any frank instability
episodes. One patient had slight laxity to both varus and
valgus stress at the 3-month follow-up appointment. The
 652
Table II Physical examination and radiographic results
Case Follow-up Preoperative Preoperative Postoperative Postoperative Increase Varus Stability Posterolateral Radiographs
(months) flexion/ pronation/ flexion/ pronation/ in F/E arc (preoperative/ rotatory
extension supination extension supination postoperative)
F/E P/S F/E P/S Valgus
1 66 85/65 0/0 135/15 90/90 100 0/0 0/0 0/0 Moderate DJD
2 19 145/10 70/75 150/0 90/90 15 3/0 3/0 3/0 Moderate DJD
3 71 130/15 85/85 145/5 90/90 25 Pos/0 ND/0 3/0 Negative (residual lateral
ossicle)
4 44 150/0 90/90 150/0 80/90 0 1/0 2/0 3/0 Mild DJD
5 46 135/10 90/90 147/3 80/90 19 2 (EUA)/0 2 (EUA)/0 3/0 Moderate DJD
6 20 105/35 90/90 135/15 80/80 40 2 (EUA)/0 2 (EUA)/0 Pos/0 Moderate DJD, HO
7 56 90/60 30/30 120/33 45/30 57 Sublux/0 Sublux/0 Sublux/0 Moderate DJD
8 29 155/-5 90/90 155/ 5 90/90 0 3/0 3/0 3/0 Negative
9 87 85/70 0/0 105/35 80/30 55 0/0 0/0 0/0 Advanced DJD, residual HO
10 62 140/0 90/90 150/0 10 1 3 1
11 109 130/25 25/10 2 2 1
12 96 130/20 70/70 1 (EUA) 1 (EUA) 3
13 94 135/10 80/85 2 3 3
14 95 150/0 85/85 ND ‘‘Unstable’’ ‘‘Unstable’’
Pos, examination finding documented as positive but not graded; ND, not documented in the medical record; EUA, examination under anesthesia; Sublux, joint was chronically subluxed; DJD, degenerative
joint disease; HO, heterotopic ossification.
Cases 10 to 14 were not evaluated in the clinic; examination listed is only preoperative examination. Case 10 submitted photographs, which allowed calculation of flexion and extension.
Instability grading: 0, none; 1, mild laxity with end point; 2, moderate laxity with end point; 3, gross instability.

P.R. Finkbone, S.W. O’Driscoll

Box-loop ligament reconstruction 653

elbow was immobilized in a long arm cast for 6 weeks, and

Table III Scoring system results
the examination at 6-month follow-up showed the elbow to
be stable. Range of motion for this patient at that time was Case ASES ASES self- QuickDASH MEPI SOD
reported as full flexion but lacking 15 of full extension. satisfaction
(1-10)
Range of motion improved or was the same (as preop-
erative) in all patients. The average improvement in range 1 100 10 0 100 10
of motion (flexion-extension arc) from preoperative to 2 86 10 7 85 9
postoperative was 32 (see Table II for detailed results of 3 79 6 23 65 5
4 87 10 3 85 9
range of motion, stability, and postoperative radiographs for
5 100 10 0 100 10
each patient). Strength was normal (5 of 5) in all patients 6 36 4 64 65 3
for elbow flexion and extension; 1 patient had slight 7 85 10 7 95 9
weakness (4 of 5) in pronation and supination. 8 83 10 0 85 10
Functional outcomes (as determined by performance 9 61 10 43 60 6
scores and questionnaires) were obtained for all 14 patients. 10 99 Not answered 0 100 10
This was done by phone questionnaire for the 5 of the 14 11 74 8 20 8
patients who were not evaluated in the clinic (Table II). The 12 90 8 2 7
functional outcomes for the box-loop procedure were 13 89 10 2 6
exceptional for the majority of patients (Table III). Ac- 14 66 0 7 2
cording to the SOD given by the patients, 7 elbows were MEPI, Mayo Elbow Performance Index; ASES, American Shoulder and
normal or nearly normal, 4 were greatly improved, 2 were Elbow Surgeons elbow assessment; QuickDASH, Quick Disabilities of the
Arm, Shoulder, and Hand questionnaire; SOD, Subjective Outcome
improved, and 1 was worse compared with before surgery. Determination.
The SOD score average was 7 (range, 2 to 10). ASES
scores (including both clinic patients and phone question-
naire patients) ranged from 36 to 100, with an average of
81; of 14 patients, 8 had an ASES self-satisfaction score of
10. The average QuickDASH score was 13 (range, 0-64). Table IV Correlation of Outcome Scores
The average MEPI score was 88 (range, 60-100), with 4 Spearman rho P value
excellent (90-100), 3 good (75-89), and 3 fair (60-74) re- SOD vs. QuickDASH 0.98 <.001
sults and no poor results (Tables III and IV). ASES vs. MEPI 0.87 <.01
Pain had improved in most patients, with 4 patients SOD vs. MEPI 0.82 <.025
reporting no pain, 6 patients with mild pain, 4 patients with MEPI vs. QuickDASH 0.78 <.025
moderate pain, and no patients with severe pain. One pa- ASES vs. QuickDASH 0.75 <.025
tient with an ASES score of 36 had painful arthritis but SOD vs. ASES 0.73 <.05
thought she had gained significant improvement in function
after the surgery. She had been having the arthritic pain
before surgery. Another patient thought that her elbow was
the same or slightly worse after the surgery; this patient was Discussion
only able to complete a phone questionnaire and unable to
come into the clinic. The present study describes the box-loop technique and
Radiographs showed that all ulnohumeral joints were reports the early to midterm patient outcomes. This pro-
congruent in appearance without any signs of instability. cedure is effective in restoring the stability to the elbow,
There were mild to moderate degenerative changes in obviating the need for separate MCL and LCL re-
7 of 9 elbows. Mild to moderate HO was seen in 6 of constructions in grossly unstable elbows. This is our
9 elbows, 2 of which were residual HO in patients un- preferred method in treating combined medial and lateral
dergoing excision of HO. None of the patients required instability of the elbow. The advantages of the box-loop
additional operations for instability, range of motion, or technique include less exposure on each side of the elbow,
arthritis. quicker surgery, and the need for only 1 graft. To our
knowledge, this is the largest collection of cases reported
Complications with this technique.
A similar circumferential grafting technique has been
One patient developed a delayed-onset ulnar neuropathy described by van Riet et al.18,19 Their technique involves
necessitating ulnar nerve transposition on postoperative day drilling 2 ulnar tunnels, using gracilis autograft, and using a
12.2,4,5 After transposition, her symptoms resolved during posterior midline approach. They have described single-
the following 3 to 4 months. This same patient also loop and double-loop techniques. By drilling 2 ulnar tun-
developed incisional erythema that resolved after admin- nels and using the double-loop technique, they are able to
istration of oral antibiotics. anatomically reconstruct both the anterior and posterior
654
MCL. There have not been any results published with use
of this technique other than a case report of a 13-year-old
patient who presented with recurrent elbow dislocations
and a coronoid fracture. In this case, they used a variation
of their double-loop technique, tying the end of the graft to
the LCL complex. At 2 years of follow-up, this patient was
doing very well with a stable elbow.19
The box-loop technique is also useful in cases involving
ossification of the collateral ligaments. Two of the patients
in this study required ligament reconstruction for this
reason at the time of surgical excision of HO. These pa-
tients had significant improvement in range of motion,
which was sustained over time. Their follow-up radio-
graphs showed no new formation of HO.
Conclusions
The box-loop technique is a quicker, simpler, and
preferable way to reconstruct both the MCL and LCL
of the elbow in comparison to a combination of
various techniques described for reconstructing them
individually.1-3,10,12,14,16,18 The midterm results were
generally excellent with few complications. This has
become our preferred technique in the situation of the
grossly unstable elbow.
Disclaimer
The authors, their immediate families, and any research
foundation with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
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