Chronic Posterolateral Rotatory Instability Research Articles

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow

Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). Fifty-two patients were available at final follow-up. The mean age of patients was 51±12 years with a mean follow-up of 53±14 months (range 20-76). Clinical examination after surgery (n=41) showed no clinical signs of instability in 98% of the patients (P<.001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40±10 of 48 points, 92±12 of 100 points, and 1±2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results.

Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n=20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P<.001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P<.001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.

Posterolateral rotatory instability of the elbow

Posterolateral rotatory instability (PLRI) of the elbow is the most common chronic instability pattern identified. It is the resultant ulno-humeral instability secondary to compromised lateral ligament complex. The characteristic injury is the avulsion of the lateral ulnar collateral ligament (LUCL) from its humeral attachment. Acute PLRI can present following simple or complex elbow dislocations. Chronic PLRI mostly follows trauma but also can be the result of iatrogenic injury.

Indications, Outcomes, and Complications of Lateral Ulnar Collateral Ligament Reconstruction of the Elbow for Chronic Posterolateral Rotatory Instability: A Systematic Review

Background: Posterolateral rotatory instability (PLRI) of the elbow can lead to pain, recurrent dislocations, and, in the worst-case scenario, disability. Purpose: To report the indications, outcomes, and complication rates of lateral ulnar collateral ligament (LUCL) reconstruction for chronic PLRI of the elbow. Study Design: Systematic review. Methods: This systematic review was registered with PROSPERO and performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The review entailed 17 studies that included 168 patients with isolated LUCL reconstruction for chronic PLRI. Patients with concurrent medial collateral ligament reconstruction were excluded. The primary outcome measures were patient characteristics, indication for surgery, surgical technique, functional outcomes, and complications. Results: Chronic PLRI commonly occurred after a previous traumatic injury (n = 168). Of these, there were 119 simple instabilities (no fracture) and 33 complex instabilities (associated fracture). In 11 patients, PLRI was iatrogenic. The cause was unknown in 5 patients. Grafts used were autograft (n = 102; 61%), allograft (n = 18; 11%), synthetic graft (n = 15; 9%), and unknown (n = 33; 20%). The most common surgical technique was a docking procedure or a modification of this (n = 145; 86%). Other techniques included suture anchors (n = 18; 11%), nonanatomic (n = 1; 0.6%), and unknown (n = 4; 2%). There were 45 complications reported in 37 patients (22%). The most frequent complication was recurrent instability (21/138; 15%). No other major complications were reported. The rate of recurrent instability was significantly higher in revision reconstructions (6/15 elbows; 40%) compared with primary reconstructions (15/123 elbows; 12.2%) (P = .005). The mean Mayo Elbow Performance Score and abbreviated Disabilities of the Arm, Shoulder and Hand score were 87.5 (range, 40-100) and 18.8 (range, 0-77), respectively. Of the patients in whom range of motion was measured, 134 of 144 patients (93%) regained a functional range (30L–130L). Conclusion: LUCL reconstruction for chronic PLRI proved a reliable method of reconstruction, save for the moderate rate of recurrent instability, which was highest in revision reconstructions.

Suture tape augmentation of the lateral ulnar collateral ligament increases load to failure in simulated posterolateral rotatory instability.

Simple elbow dislocations are accompanied with lateral ulnar collateral ligament ruptures. For persisting instability, surgery is indicated to prevent chronic posterolateral rotatory instability. After lateral collateral ligament (LCL) complex repair the repair is protected by temporary immobilization, limited range of motion and hinged bracing. Internal bracing is an operative alternative augmenting the LCL repair using non-absorbable suture tapes. However, the stability of LCL repair with and without additional augmentation remains unclear. The hypothesis was that LCL repair with additional suture tape augmentation would improve load to failure. Secondary goal of this study was to evaluate different humeral fixation techniques. A humeral fixation using separate anchors for the LCL repair and the augmentation was not expected to provide superior stability compared to using only one single anchor. Twenty-one elbows were tested. A cyclic varus rotational torque of 0.5-3.5Nm was applied in 90°, 60°, 30°, and 120° elbow flexion to the intact, torn, and repaired LCLs. The specimens were randomized into three groups: repair alone (group I), repair with additional internal bracing using two anchors (group II), repair using one humeral anchor (group III). A load-to-failure protocol was conducted. Load to failure was significantly higher in groups II (26.6Nm; P = 0.017) and III (23.18Nm; P = 0.038) than in group I (12.13Nm). No significant difference was observed between group II and III. All specimens lost reduction after LCL dissection by a mean of 4.48° ± 4.99° (range 0.66-15.82). The mean reduction gain after repair was 7.21° ± 4.97° (2.70-21.23; mean over reduction, 2.73°). The laxity was comparable between the intact and repaired LCLs (n.s.), except for varus movements at 30° in group II (P = 0.035) and 30° (P = 0.001) and 120° in group III (P = 0.008) with significantly less laxity. Inserting the ulnar suture anchor showed failure in the thread in 10 cases. LCL repair with additional internal bracing yielded higher load to failure than repair alone. Repair with additional internal bracing for the humeral side using one anchor was sufficient. A higher primary stability would facilitate postoperative management and allow immediate functional treatment. Reducing the number of humeral anchors would save costs.

Arthroscopic Repair of the Lateral Ulnar Collateral Ligament of the Elbow Using a Knotless Suture Anchor

The lateral collateral ligament (LCL) complex of the elbow plays a crucial role in the stability of the elbow joint, especially to varus loads. Deficiency of particularly the lateral ulnar collateral component of the LCL can lead to chronic posterolateral rotatory instability, which can be functionally debilitating and can lead to a rapid onset of early degenerative arthritis. Commonly, in the setting of acute rupture of the LCL, the ligament is repaired using an open technique with suture anchor fixation to the lateral epicondyle insertion point. However, with advancing arthroscopic techniques, it has become possible to repair the LCL arthroscopically. We present a relatively simple method for an all-arthroscopic repair of the LCL to the humerus using a knotless suture anchor technique.

Lateral collateral ligament injuries of the elbow - chronic posterolateral rotatory instability (PLRI).

Chronic posterolateral rotatory instability (PLRI) is the most common form of chronic elbow instability.PLRI usually occurs from a fall on the outstretched hand. On impact, the radial head and ulna rotate externally coupled with valgus displacement of the forearm. This leads to posterior displacement of the radial head relative to the capitellum, thus causing disruption of some or all of the lateral-sided stabilisers.PLRI is mainly a clinical diagnosis with a history of instability, clicking and lateral-sided pain, with a positive clinical examination including the pivot-shift test, push-up, chair and tabletop test.MRI can often help guide diagnosis but more commonly assists in surgical planning.Surgery is indicated in patients with persistent, symptomatic instability of the elbow causing pain or functional deficit. There are several surgical techniques to treat PLRI, often leading to good to excellent results.An open or arthroscopic technique has been successfully used in patients with symptomatic PLRI following one or more episodes of dislocation or subluxation. At the pre-operative examination under general anaesthesia, all of our patients had a positive pivot-shift test but not a frank dislocation. We prefer to perform a lateral collateral ligament (LCL) reconstruction with an allograft tendon.The outcomes after repair are good to excellent in the majority of patients. Results of acute repair are generally better compared with reconstruction. This is due to the fact that predictive factors for a poor outcome include the number of previous surgeries and the prevalence of degenerative changes at the elbow.Recurrent instability is not uncommon following repair or reconstruction and has been reported in up to 25% of patients after medium- to longer-term follow-up.Cite this article: EFORT Open Rev 2016;1:461-468. DOI: 10.1302/2058-5241.160033

Revision allograft reconstruction of the lateral collateral ligament complex in elbows with previous failed reconstruction and persistent posterolateral rotatory instability.

Primary reconstruction of the lateral collateral ligament complex (LCLC) using graft tissue restores elbow stability in many, but not all, elbows with acute or chronic posterolateral rotatory instability (PLRI). Revision reconstruction using a tendon allograft is occasionally considered for persistent PLRI, but the outcome of revision ligament reconstruction in this setting is largely unknown. We determined whether revision allograft ligament reconstruction can (1) restore the stability and (2) result in improved elbow scores for patients with persistent PLRI of the elbow after a previous failed primary reconstructive attempt and in the context of the diverse pathology being addressed. Between 2001 and 2011, 160 surgical elbow procedures were performed at our institution for the LCLC reconstruction using allograft tissue. Only patients undergoing revision allograft reconstruction of the LCLC for persistent PLRI with a previous failed primary reconstructive attempt using graft tissue and at least I year of followup were included in the study. Eleven patients (11 elbows) fulfilled our inclusion criteria and formed our study cohort. The cohort consisted of six female patients and five male patients. The mean age at the time of revision surgery was 36years (range, 14-59years). The revision allograft reconstruction was carried out after a mean of 3years (range, 2.5months to 9years) from a failed attempted reconstruction of the LCLC. Osseous deficiency to some extent was identified in the preoperative radiographs of eight elbows. Mean followup was 5years (range, 1-12years). Revision allograft reconstruction of the LCLC restored elbow stability in eight of the 11 elbows; two of the three elbows with persistent instability were operated on a third time (at 6 and 7months after allograft revision reconstruction). For elbows with no persistent instability, the mean Mayo Elbow Performance Score at most recent followup was 83 points (range, 60-100 points), and six elbows were rated with a good or excellent result. All patients with persistent instability had some degree of preoperative bone loss. Revision allograft reconstruction of the LCLC is an option for treating recurrent PLRI, although this is a complex and resistant problem, and nearly ½ of the patients in this cohort either had persistent instability and/or had a fair or poor elbow score. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment and Clinical Implication for Posterolateral Rotatory Instability of the Elbow: Osborne-Cotterill Lesion of the Elbow

An osteochondral fracture in the posterolateral margin of the capitellum is recognized as being a cause of posterolateral rotatory instability (PLRI). Five patients who presented with chronic PLRI of the elbow were associated with an osteochondral fracture in the posterolateral margin of the capitellum (Osborne-Cotterill lesion). All presented instability and deficient radiocapitellar articulation at extension. Ligament reconstruction was performed in the first three cases, and combined ligament and osseous reconstruction was performed in the other two cases. Simple excision and ligament reconstruction resulted in one failure out of three, and combined ligament and osseous reconstruction resulted in no failure out of two. Osteochondral defect in the posterolateral aspect of the capitellum is an important indicator of PLRI; however, the result of this study suggests ligament reconstruction for those with a large bone defect may not be always successful.

Reconstruction Techniques for Chronic Posterolateral Rotatory Instability of the Knee

Reconstruction Techniques for Chronic Posterolateral Rotatory Instability of the Knee

Osborne-Cotterill Lesion: An Osseous Defect of the Capitellum Associated with Instability of the Elbow

Posterolateral rotatory instability of the elbow is a diagnosis largely made by clinical examination; no relevant radiographic signs have been reported. We have seen four patients with an osseous defect and detachment of a fragment of bone in the posterolateral margin of the capitellum. These patients had chronic posterolateral rotatory instability of the elbow. An osseous defect of the posterolateral corner of the capitellum is an uncommon finding that in each instance was associated with chronic posterolateral rotatory instability of the elbow. We termed this lesion the "Osborne-Cotterill lesion." We report our findings in these patients; when this lesion is diagnosed, clinicians should consider posterolateral rotatory instability.

Posterolateral corner reconstruction for posterolateral rotatory instability combined with posterior cruciate ligament injuries: comparison between fibular tunnel and tibial tunnel techniques

The aim of this study was to compare the results of two different methods of posterolateral corner reconstruction (fibular head tunnel versus tibial tunnel), performed at the same time as a posterior cruciate ligament reconstruction. Between January 1999 and October 2003, 47 patients underwent tensioning of a remnant posterior cruciate ligament and anterolateral bundle reconstruction along with a posterolateral corner reconstruction using a fibular head bone or tibial bone tunnel. Thirty-nine patients determined to be eligible were enrolled in this retrospective study after a minimum follow-up duration of 2 years. The average duration of follow-up was 35.3 months (range 24-70 months). Satisfactory results were achieved in 32 patients (82%) according to the International Knee Documentation Committee(IKDC) scores, and 29 patients (74%) had restored external rotational stability. The fibular head tunnel was superior to the tibial tunnel method in terms of operation time (43.0 +/- 15.7 vs. 66.6 +/- 9.4 min, respectively, P < 0.001) and improved rotational stability (85 vs. 65%, respectively, P = 0.007). However, there were no significant differences seen in anteroposterior stability and clinical assessments [Orthopädische Arbeitsgruppe Knie (OAK) P = 0.277 and IKDC scores P = 0.564]. In grade 2 chronic posterolateral rotatory instability with little or no varus instability associated with injury to the posterior cruciate ligament, a posterolateral reconstructive procedure with a single sling through the fibular tunnel offers advantages of less surgical morbidity and operation time, as well as better rotational stability, over reconstruction through the tibial tunnel.

Surgical Treatment of Chronic Posterolateral Rotatory Instability of the Knee Using Capsular Procedures

Chronic posterolateral rotatory instability of the knee was introduced as a diagnostic classification by Hughston and associates in the early 1970s and occurs as a result of dysfunctional healing of a strained arcuate complex, causing a patulous posterolateral capsuloligamentous complex to exist. This capsular redundancy allows varying degrees of recurvatum and adduction instability during single-limb stance. Eradication of the redundant pouch with a capsular shift-type reconstruction has been shown to eliminate the instability and hold up under long-term follow-up studies. Understanding the complex normal and injured anatomy of the posterolateral corner of the knee is essential for effective reconstruction of this instability.

A Comparison of Fibular Head Tunnel and Tibial Tunnel in the Reconstruction of a Posterolateral Instability of the Knee

Purpose : This study compared the surgical results of various posterolateral corner sling methods performed through either the fibula head tunnel or tibia tunnel in patients with chronic PLRI (PosteroLateral Rotatory Instability). Materials and Methods : Between January 1999 and October 2003, 20 and 19 patients who had undergone surgery for PCL (posterior cruciate ligament) tensioning and an ALB (anterolateral bundle) reconstruction through the fibula head tunnel or tibia tunnel, respectively and were followed up more than 1 year were enrolled in this study. Results : The fibular head tunnel was found to be superior compared with the tibia tunnel method in terms of the operation time (36.5±7.5 versus 68.4±12.8) (p＜0.0001), rotational stability (p=0.0018) and IKDC objective score (p＜0.0001). In the fibula head tunnel group, 85% of patients had an equal to normal or tighter than normal rotational stability in the tibial tunnel group with 63% having an equal to normal or tighter than normal side at the last evaluation. In the IKDC objective score, 85% of patients in the fibula head tunnel group had a rating B or higher at the last evaluation compared with 79% in the tibial tunnel group (p＜0.0001). However there were no significant differences in anteroposterior stability and OAK score. Conclusion : The modified posterolateral corner sling through the fibula head tunnel produces better results in terms of a posterolateral rotational stability of grade II chronic PLRL in a combined PCL injury than that using the tibia tunnel method.

Trivalent Reconstruction for Posterolateral and Lateral Knee Instability

Chronic posterolateral rotatory and lateral instability of the knee is approached from multiple anatomic and functional points of view. Traditional surgical techniques provide one-directional stabilization using autologous tendon transplantation and the split-tendon biceps procedure. Both of these resolve the lateral opening of the joint but do not secure the rest of the anatomic structures that are very important, such as the arcuate ligament and the capsule. This new approach to solving an old problem acts by tightening the fibular collateral ligament, arcuate ligament, the capsule (partially), and biceps tendon in 1 step by performing an oblique fibular-head osteotomy and pulling down these structures with good results. We report 2 cases in which this technique was used. The first was a 26-year-old man who hit the dashboard in an automobile accident and presented 1 week later with posterolateral instability associated with a tear of the posterior cruciate ligament. The second was a case of pure chronic lateral instability of the knee in a 32-year-old man who sustained a fall that caused a rupture of his lateral collateral ligament. This was repaired using a trivalent reconstruction at 3 months. Both patients successfully achieved good stability after reconstruction.

Acute and chronic posterolateral rotatory instability of the knee.

Isolated posterolateral rotatory instability of the knee is an uncommon injury pattern that may result in significant degrees of functional disability. This injury complex can be a challenging diagnostic and therapeutic problem for the orthopaedic surgeon. The presence of associated ligamentous and soft-tissue injuries, resulting in combined instability patterns, further complicates management. The results of recent research have enhanced our understanding of the complex anatomy and biomechanics of the posterolateral aspect of the knee. Numerous surgical techniques have been described for both repair and reconstruction of the injured posterolateral structures; however, long-term functional results have been only moderately successful.

Injuries to the posterolateral structures of the knee

In recent years, injuries of the posterolateral structures of the knee are being increasingly recongnized because of improved clinical awareness and diagnostic skills, as well as technological advances in magnetic resonance imaging. The functional anatomy and biomechanical concepts of the posterolateral structures of the knee are briefly discussed to improve our understanding of the posterolateral corner injury in the clinical setting. A good history and a systematic, detailed physical examination are required to make an early, accurate diagnosis. In turn, early diagnosis is necessary so that an appropriate treatment plan can be followed to achieve optimum knee stability and function. In athletically active patients who are involved in strenuous recreational and competitive sports, surgical repair of the torn posterolateral structures should be performed when the acute inflammatory phase has subsided (usually within 7–10 days). If knee swelling is present, a judgement must be made as to the risk of stiffness versus mobility of the knee after surgery. Generally, for posterolateral corner injuries, early surgery with a greater local healing response is of value and therefore we recommend early repair even in the face of swelling and limited knee motion. If the torn posterolateral structures of the knee are not repaired acutely, a state of chronic posterolateral rotatory instability may result. Patients with such an instability may present with persistent symptoms of pain, recurrent swelling and giving-way, that interfere with a sporting lifestyle and/or activities of daily living. Therefore in patients involved with high sporting demands, our goald is to acutely repair (and augment when necessary), the torn posterolateral structures to restore knee stability and function. Prospective studies with a long-term follow-up are needed to clarify the role of various surgical procedures that are used for the management of patients with acute injuries of the posterolateral corner or chronic posterolateral rotatory instability of the knee.

Chronic posterolateral rotatory instability of the knee.

Posterolateral rotatory instability of the knee, usually accompanied by other instabilities, is easily missed, misdiagnosed, and mistreated. The correct diagnosis requires a complete examination of the knee, including both the external rotation-recurvatum and posterolateral drawer tests. The most effective operative approach when the lesion is interstitial or at the site of the femoral attachment consists of advancing the arcuate ligament complex and its osseous attachment anteriorly and distally on the femur to support the arcuate ligament repair. When the lesion is distal and the arcuate ligament attachment to the tibia and fibula is loose, this area must be stabilized. In a consecutive series of 140 patients, 141 knees were reconstructed with this procedure. Ninety-five patients (ninety-six knees), with a follow-up of two to thirteen years, form the basis for this report. Seventy-one of the patients had undergone a combined total of 112 prior operations on the knee without functional recovery. After surgery directed at the arcuate ligament complex, eighty-two knees (85 per cent) were objectively rated as good; thirteen (14 per cent), as fair; and one, as poor. Subjectively, seventy-five (78 per cent) of the patients considered the result to be good; twenty-one (22 per cent), fair; and none, poor. Functionally, seventy-seven (80 per cent) of the knees were rated by the patient as good; sixteen (16 per cent), as fair; and three (4 per cent), as poor. This is the first report on the long-term results of reconstruction of the arcuate ligament complex for the correction of chronic posterolateral rotatory instability. The results demonstrate the effectiveness of the procedure.