Posterolateral rotatory instability (PLRI) of the elbow is characterized by a three-dimensional displacement pattern of abnormal external rotatory subluxation of the ulna coupled with valgus displacement on the humeral trochlea.1 In this chapter, the history and physical examination fi ndings of PLRI are reviewed, along with the rel-ative indications and surgical technique for lateral ulnar collateral ligament re-pair versus reconstruction.
HistoryPatients with PLRI may relate a his-tory of an elbow dislocation or surgery on the lateral aspect of the elbow (for example, radial head replacement or tennis elbow release). After reduction and immobilization of the initial dis-location, recurrent instability, pain, or both may persist. Frank, recurrent dislocation is rare.2-4 Because patients often learn maneuvers to reduce the joint, formal reduction may not be
required. Recurrent painful clicking, snapping, clunking, or locking of the elbow are the most common symptoms and often occur in the extension half of the arc of motion, with the forearm in supination. Patients may report that the elbow feels “loose” or slides out of joint when they perform activities with the elbow extended. Patients often are apprehensive about performing activi-ties that precipitate the instability, such as pushing against the armrests while rising from a chair.
Physical ExaminationOn initial examination, the elbow may appear normal, with full, painless range of motion and possibly some hyperex-tension, particularly in atraumatic-type instability.1 The clinical examination is unremarkable, except for specifi c testing for PLRI.4 The posterolateral pivot-shift test is best performed with the patient supine and the affected extremity over the patient’s head and the shoulder in full external rotation. In this position, a combination of axial compression, valgus, and supination is
Repair and Reconstruction of the Lateral Ulnar Collateral Ligament
Nicolas S. Bonnaig, MDThomas (Quin) Throckmorton, MD
SYMPOSIUM
Dr. Throckmorton or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet; serves as a paid consultant to or is an employee of Biomet and Zimmer; has received research or institutional support from Biomet; and serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons and the Mid-American Orthopaedic Association. Neither Dr. Bonnaig nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
AbstractLateral ulnar collateral ligament repair and reconstruction are techniques used to treat posterolateral rotatory instability of the elbow. The choice to perform repair versus recon-struction is typically dependent on the chronicity of the injury and the quality of tissue available at the time of surgery.
placed on the forearm.4 The externally rotated shoulder stabilizes the humerus and allows the elbow to be examined independent of shoulder motion. The examiner then grasps the patient’s fore-arm, which is placed in full supination. In this position, the elbow looks like a knee, and the maneuver is analogous to the pivot-shift test used to assess anterior cruciate ligament instability.1 Starting with the forearm supinated and the elbow extended, the elbow is slowly fl exed while the examiner applies a slight valgus force and axial load and maintains the supination (Figure 1). This maneuver produces a rotatory supination torque on the forearm that can produce rotatory subluxation of the ulnohumeral joint. The ulna tilts externally on the trochlea, and this ro-tation dislocates the radial head poste-riorly because it is coupled to the ulna by the annular ligament. As the elbow is fl exed to approximately 40°, the ro-tatory displacement is at a maximum. At this point, the subluxated radial head produces a posterior and lateral prominence associated with an obvious dimple in the skin proximal to the radial head. The rotatory subluxation pivots on the anterior band of the medial col-lateral ligament of the elbow.5 With fl ex-ion past 40°, the triceps becomes taut and forces reduction of radiocapitellar joint.5 The posterolateral pivot shift can be painful and often can be elicited only under anesthesia; therefore, the test has been modifi ed to associate patient ap-prehension with a positive result.6,7
Other tests include the prone push-up and chair push-up tests described by Regan and Morrey.7 The patient at-tempts to rise from a prone position or from a chair (by pushing against the armrests). The maneuver is attempt-ed fi rst with the forearms maximally
pronated, then repeated with the fore-arms maximally supinated. If the symp-toms occur with forearm supination but not with pronation, the tests are positive for PLRI.7
ImagingIn patients with PLRI, plain radio-graphs usually are negative; however, stress radiographs can be taken while provocative maneuvers are being per-formed.8 Subtle subluxation sometimes can be seen on nonstress radiographs in which the ulna is abnormally supinated on the trochlea, which is typically seen as ulnohumeral joint space widening. Fractures of the coronoid process and radial head should be identifi ed if pres-ent. Performing the provocation tests under fl uoroscopy with local anes thetic infi ltrated into the joint may allow a radiographic assessment of instability.
The use of MRI to diagnose PLRI has been controversial. Initially, it was believed to be an inconsistent modal-ity;8 however, Potter et al9 showed that with proper sequencing, the lateral ul-nar collateral ligament can be reliably identifi ed. Conversely, a more recent study reported that the lateral ulnar col-lateral ligament could be identifi ed with MRI in only 10 of 20 asymptomatic elbows.10 In addition, there have even been reports of chronic PLRI with a normal elbow MRI.11
ManagementA patient may learn to avoid PLRI by performing activities with his or her el-bow fl exed to prevent subluxation.1 El-bow braces can be used, although they are burdensome and unlikely to be tol-erated for an extended period. Surgery is indicated in patients with persistent
Illustration of the posterolateral pivot-shift test, which produces an ulnohumeral subluxation as the elbow is extended. With the radius tethered to the ulna, the subluxation manifests as a characteristic dimple over the lateral elbow. (Reproduced with permission from Phillips BB: Recurrent dislocations, in Canale ST, Beaty JH, eds: Campbell’s Operative Orthopaedics, ed 12. Phil-adelphia, PA, Elsevier, 2013, pp 2255-2310.)
Figure 1
Repair and Reconstruction of the Lateral Ulnar Collateral Ligament Chapter 21
Relative contraindications to surgery include open physes in children, con-comitant arthritis of the elbow, gener-alized ligamentous laxity, and volitional recurrent dislocations.1
The surgical approach uses the Kocher interval between the ancone-us and the extensor carpi ulnaris mus-cles, identifi ed by a thin fat stripe that can be seen through the deep fascia13
(Figure 2). The interval is developed to expose the elbow capsule, the lat-eral epicondyle, and the proximal ulna. When determining whether repair or reconstruction is more appropriate, it is critical to assess the lateral soft tissues and the ligament complex. Repair is a good option if adequate tissue is avail-able; however, if tissue quality is poor, it is best to proceed with lateral ligament reconstruction.8,12 The technique for surgical repair involves a Krackow or a Bunnell stitch in the lateral ligamen-tous complex, which then is advanced and repaired through drill holes in the lateral epicondyle.1,2,8,12
Reconstruction is appealing be-cause it is consistent with accepted
principles of other ligament recon-structions.1 It is an isometric, extra-capsular, ana tomic reconstruction using an autogenous graft.2 The re-quired graft length is approximately 20 cm, and if the palmaris longus tendon is used, a strip of the attached palmar aponeurosis may be required. The palmaris longus tendon is present in 85% of individuals.14 Other graft options include toe extensor, split semitendinosus, and allograft.
A 3.5-mm hole is drilled into the supinator crest, which can be identi-fi ed at the distal attachment of the lat-eral capsule. A second hole is drilled 1.25 cm proximal at the base of the attachment of the annular ligament to the ulna. Both holes are extra-artic-ular and just external to the capsular attachment (Figure 3). A bony tunnel is created between these two holes, and suture is placed through holes and ad-vanced with a hemostat to the lateral epicondyle. The isometric point of the lateral epicondyle is confi rmed by the point at which the suture remains taut throughout elbow range of motion. Having identifi ed the isometric point
on the humerus, a Y-shaped tunnel is made in the lateral epicondyle. The fi rst hole is drilled in the lateral cortex us-ing a 4.5-mm drill bit slightly posterior and proximal to the isometric point, so that the graft passes over the isometric point. The drill is advanced through to the posterior aspect of the lateral humeral condyle (distal exit hole). The drill is withdrawn and again advanced through the isometric point, but it is directed proximally and posteri orly (proximal exit hole), taking care to ensure that there is an adequate bone bridge between the two posterior holes. The graft is then threaded through the lateral epicondylar drill holes, and the tendon is sewn to itself at the isometric point2,12 (Figure 4).
The Kocher interval is marked by a thin fat stripe (arrow) in the fascia between the anconeus and the fl exor carpi ulnaris. Figure 2
Holes are drilled in the ulna near the anatomic insertion of the lateral ulnar collateral ligament (arrows). Graft passage can be facilitated with a suture passer.
SummaryPLRI is a common posttraumatic in-stability of the elbow after injury to the lateral ulnar collateral ligament/lateral soft-tissue complex. A high index of suspicion should be maintained for PLRI in patients with elbow symptoms such as clicking, locking, or catching (primarily in extension and supination). Positive PLRI testing is diagnostic.
Lateral ulnar collateral ligament repair usually is effective in providing joint stability if adequate soft tissue exists. An isometric ligament reconstruction is recommended if inadequate tissue is available.
References 1. Mehta JA, Bain GI: Posterolateral
rotatory instability of the elbow. J Am Acad Orthop Surg 2004;12(6):405-415.
2. Nestor BJ, O’Driscoll SW, Morrey BF: Ligamentous reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1992;74(8):1235-1241.
3. O’Driscoll SW: Elbow instability. Hand Clin 1994;10(3):405-415.
4. O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73(3):440-446.
5. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.
6. O’Driscoll SW, Morrey BF, Korinek S, An KN: Elbow subluxation and dislocation: A spectrum of instability. Clin Orthop Relat Res 1992;280:186-197.
7. Regan WD, Morrey BF: The physical examination of the elbow, in Morrey BF, ed: The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 73-85.
8. Smith JP III, Savoie FH III, Field LD: Posterolateral rotatory insta-bility of the elbow. Clin Sports Med 2001;20(1):47-58.
9. Potter HG, Weiland AJ, Schatz JA, Paletta GA, Hotchkiss RN: Posterolateral rotatory instability of the elbow: Usefulness of MR imaging in diagnosis. Radiolog y 1997;204(1):185-189.
10. Terada N, Yamada H, Toyama Y: The appearance of the lateral ulnar collateral ligament on magnetic res-onance imaging. J Shoulder Elbow Surg 2004;13(2):214-216.
11. Grafe MW, McAdams TR, Beaulieu CF, Ladd AL: Magnetic resonance imaging in diagnosis of chronic posterolateral rotatory instability of the elbow. Am J Orthop (Belle Mead NJ) 2003;32(10):501-504.
12. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW: Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2005;87(1):54-61.
13. Bain G, Mehta JA: Anatomy of the elbow joint and surgical approaches, in Baker CL Jr, Plancher KD, eds: Op-erative Treatment of Elbow Injuries. New York, NY, Springer-Verlag, 2002, pp 1-27.
14. Reimann AF, Daseler EH, Anson BJ, Beaton LE: The palmaris longus mus-cle and tendon: A study of 1600 ex-tremities. Anat Rec 1944;89(4):495-505.
Video Reference Vanhees M, Verstreken F, van Riet RP: Arthroscopic Lateral Collateral Ligament Imbrica-tion of the Elbow [video]. Staborek, Belgium, 2014. http://orthoportal.aaos.org/emedia/singleVideoPlayer.aspx?resource=EMEDIA_OSVL_14_38. Accessed October 20, 2014.
The graft is passed through the isometric point (arrow) and then tied to itself to complete the reconstruction.
