Posterolateral Rotatory Instability Of Elbow Research Articles

Ligamentous Reconstruction with Semitendinosus Tendon Autograft for Posterolateral Rotatory Instability of Elbow—a Case Report with an Update of Literature Review

The elbow joint is a comparatively very stable joint owing to the adjacent osseo-ligamentous complex structural integrity around the joint. Posterolateral rotatory instability (PLRI) primarily refers to an injury of the lateral ulnar collateral ligament (LUCL) and the lateral ligamentous complex collectively referred to as the lateral collateral ligament (LCL). PLRI is often a neglected or missed injury, hence remains a relatively rare clinical entity, and reconstruction of the injured ligament is the mainstay of management. A 25-year-old male presented to the orthopedic outpatient department with complaints of post-traumatic instability with dull aching pain over the left elbow for the last 1 year. Varus stress test along with a positive pivot shift test established the clinical diagnosis of posterolateral elbow instability. The LUCL reconstruction was considered using the ipsilateral semitendinosus autograft tendon. At the final follow-up of 1.5 years, the VAS score improved from 8/10 to 1/10 during moderate activities, the Mayo elbow performance score improved from 40/100 to 85/100, and the DASH score was 10.7/100 from preoperative 52.5/100 without any clinical evidence of residual elbow instabilities. The hamstring tendon autograft is a reliable and an easily available option for reconstruction of LUCL owing to its superior inherent graft tensile strength, which helps in improving the elbow instability with minimum effect on donor site morbidities.

Lateral collateral ulnar ligament reconstruction techniques in posterolateral rotatory instability of the elbow: A systematic review

BackgroundElbow chronic instability is a disable complication, presenting as recurrent joint subluxations or dislocations. This systematic review aims to assess (1) the clinical outcome and (2) the complication rates of the surgical techniques currently used in the management of posterolateral rotatory elbow instability. MethodsOVID-MEDLINE®, SCOPUS, and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The search terms used were "LUCL", "Posterolateral dislocation", "Elbow Docking technique", "Elbow Jobe technique" and "Elbow single strand technique". The methodological qualities of the studies were evaluated, relevant data were extracted. ResultsThree studies, published between 2012 and 2015, were included in this review. No studies concerning the single strand technique met the inclusion criteria. The included studies had a level of evidence IV and recruited 33 patients undergoing a Jobe technique reconstruction and 8 patients undergoing a Docking technique. Jobe procedure registered better clinical and functional outcome, assessed using the Mayo Clinic Elbow Performance Scale (MEPS), compared with patients managed with Docking technique. Nonetheless, this difference is not significant. There was not a significantly different complication rate (p = 0.57) between patients treated with these two different techniques. ConclusionThis systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. However, future studies with larger sample size and a longer follow-up interval are needed to draw stronger conclusions on the efficacy of the different LUCL surgical reconstruction techniques.

The effect of torsional moments on the posterolateral rotatory stability of a lateral ligament deficient elbow: An in vitro biomechanical investigation

BackgroundClinical tests for posterolateral rotatory instability of the elbow apply external torsional moments to the forearm; however, biomechanical studies of lateral collateral ligament injuries and their surgical repair, reconstruction and rehabilitation have primarily relied on varus gravity loading to quantify instability.The aim of this investigation was to determine the effect of torsional moments on the posterolateral rotatory instability of the lateral ligament deficient elbow. MethodsSix cadaveric arms were tested in an elbow motion simulator with the arm in the varus position. A threaded outrigger was inserted on the dorsal aspect of the proximal ulna to suspend 400 g, 600 g, and 800 g of weight to allow torsional moments of 0.12, 0.18, and 0.23 Nm respectively on the ulna. An injured model was created by sectioning of the common extensor origin, and the lateral collateral ligament. FindingsDuring simulated active flexion with the arm in varus, the injured model resulted in a significant increase in external rotation of the ulnohumeral articulation with the forearm both pronated and supinated (pronation: P = .021; supination: P = .015). The application of torsional moments to the lateral ligament deficient elbow resulted in a significant increase in the posterolateral rotatory instability of the elbow. InterpretationThis investigation demonstrates that the application of even small amounts of external torsional moments on the forearm with the arm in the varus position increases the rotational instability of the lateral ligament deficient elbow. During clinical examination for posterolateral rotatory instability and biomechanical studies of lateral ligament injury, the application of external torsion to the forearm should be considered to detect subtle instability. Level of evidenceBasic Science Study.

Crista Supinatoris Fractures of the Proximal Part of the Ulna

The crista supinatoris is the insertion site of the lateral collateral ligament complex on the proximal part of the ulna. The purpose of this study was to report the presentation, management, and outcomes of patients with crista supinatoris fractures. Twelve patients with fractures of the crista supinatoris were assessed clinically and radiographically and with validated outcomes at a mean of thirty-nine months after injury. Outcome measures included the Patient-Rated Elbow Evaluation (PREE), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons elbow (ASES-e) score, and strength measured with a dynamometer. No crista supinatoris fracture occurred in isolation. Other associated injuries included radial head fracture in ten patients (83%), a radial neck fracture in one patient, and a capitellar fracture in one. At the time of presentation, all crista factures were difficult to identify on standard radiographs, but oblique radiographs and/or computed tomography (CT) allowed definitive fracture identification. Four patients were managed nonoperatively, and eight patients were managed surgically, with the indication for surgery being the associated injuries, not specifically the presence of a crista fracture. At the time of surgery, posterolateral rotatory elbow instability, if present, was due to the crista fracture. At the time of follow-up, all elbows were clinically stable and had radiographic concentric reductions. Elbow flexion and extension were a mean (and standard deviation) of 136° ± 6° and 5° ± 8°, respectively. The mean PREE score was 15 ± 20, and the mean DASH was 13.5 ± 18. Crista supinatoris fractures are difficult to identify on standard elbow radiographs. Fracture management is based on an assessment of elbow stability and on appropriate treatment of the associated injuries.

Surgical Reconstructions for Posterolateral Rotatory Instability of Elbow using a Synthetic Ligament

BackgroundChronic posterolateral rotatory instability occurs as a result of disruption of the lateral ulnar collateral ligament of the elbow. It is usually treated by ligament reconstruction using an autogenous graft. We present our experience of reconstruction with the use of a synthetic polyester (LARS®; Ligament Advanced Reinforcement System; Surgical Implants and Devices, Arc-sur-Tille, France) ligament and discuss the advantages of this technique.MethodsTen consecutive cases of lateral ligament reconstruction using a LARS® ligament were reviewed. The mean age at the time of surgery was 30.2 years. The mean duration of instability symptoms preoperatively was 32.4 months. Three patients had generalized hyperlaxity. Three patients had previously undergone an unsuccessful autogenous graft reconstruction.ResultsThe mean postoperative follow-up was 27 months. At review, seven of the 10 patients had stable elbows with no feelings of recurrent instability. This included two of the patients with generalized hyperlaxity. The mean postoperative arc of flexion/extension was 13° to 137°. The mean Mayo Elbow Performance Score was 87.5.ConclusionsThe use of a synthetic ligament for reconstruction of posterolateral rotatory instability of the elbow provides satisfactory stability. It avoids the associated morbidity of using an autograft, appears to be well tolerated and is particularly valuable in the treatment of complex generalized hyperlaxity problems.

Children’s orthopaedics

The October 2013 Children’s orthopaedics Roundup360looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.

Functional outcomes of surgical reconstruction for posterolateral rotatory instability of the elbow

BackgroundThe disruption or insufficiency of lateral ligament complex including lateral ulnar collateral ligament (LUCL) leads to posterolateral rotatory instability (PLRI). An accurate clinical staging is quite useful in predicting the prognosis. The purpose of our study is to review our experience with surgical reconstruction for PLRI of the elbow and to investigate the relationship between the clinical stage of elbow instability and the functional outcomes of PLRI. Materials and methodsPatients with PLRI of the elbow determined by fluoroscopic stress view under anaesthesia underwent surgical reconstruction of the LUCL with autogenous tendon graft. ResultsThirteen of the fourteen patients (93%) were subjectively satisfied with the outcome of the surgery. The mean follow-up was 49 months (range: 24–72). The results were better in patients with stage 1 or 2 instability (group I) compared to those with stage 3 instability (group II). ConclusionsReconstruction of the LUCL using an autogenous tendon graft is an effective method for patients with PLRI of elbow. Since better results were obtained in patients with stage 1 or 2 instability rather than stage 3, accurate clinical staging determined by fluoroscopic stress view under anaesthesia is important before surgery for appropriate treatment and prediction of functional outcomes.

Preliminary report on lateral ulnar collateral ligament reconstruction or repair for treatment of posterolateral rotatory instability of elbow

To explore the preliminary results of lateral ulnar collateral ligament (LUCL) reconstruction or repair for posterolateral rotatory instability (PLRI) of elbow. Between December 2006 and September 2010, 9 consecutive patients (9 elbows) undergoing surgical reconstruction or repair of LUCL for the treatment of elbow PLRI were studied. Surgical reconstruction of LUCL was performed with a tendon graft in 6 elbows and reattachment of LUCL to humerus in 3. The mean patient age was 28 years (range: 17 - 48). All patients had a previous history of elbow injury. Among them, 6 had a history of elbow dislocation. The average duration of symptoms was 10.7 months (range: 5 days - 30 months). The outcomes were graded with respects to objective and subjective stability, pain and range of motion as defined by Nestor. All patients were followed up. The mean follow-up period was 20 months (range: 4 - 49). Postoperatively, no patient had residual instability or a positive pivot shift test in elbow. Their outcomes were graded as excellent (n = 6), good (n = 2) and fair (n = 1). Subjective assessment revealed that all were satisfied with their surgical outcomes. An accurate recognition of PLRI of elbow is important for its appropriate management. Tendon graft is recommended for the reconstruction of LUCL. Surgical ligament reconstruction or repair is the preferred treatment option for restoring normal functions and elbow stability. Further studies are warranted because of a limited number of patients in the present study.

Posterolateral Instability of the Elbow in an Adolescent Boy with a Lateral Epicondyle Fracture: A Case Report

Posterolateral rotatory instability of elbow is considered to be due to the disruption of the ulnar part of the lateral collateral ligament (LUCL). This instability pattern may also be induced by a fracture of components of the lateral column. We present the case of a 16-year-old boy who fell on his left outstretched arm as he attempted to jump over a tennis net. On initial physical examination, the elbow had instability found on varus stress and the radial head could be felt posteriorly. With attempted valgus and supination force combined with axial loading, the elbow gapped open and the patient had a sense of increased instability. X-rays showed a fracture of the lateral humeral epicondyle and posterolateral subluxation of the elbow. In the operating room, the patient was found to have reproducible posterolateral instability of the elbow. The lateral epicondyle was found to be fractured off the humerus with the LUCL still attached to the fragment. The elbow was reduced, and the injury was stabilized with small screws and suture anchors. At 6-month follow-up, the patient was pain-free, and physical examination revealed 170° of flexion, full extension, 90° of pronation, and 65° of supination. X-rays showed healing of the fracture with concentric reduction of the elbow joint. In lateral epicondyle fractures, the affected elbow should be assessed for any signs of associated instability. If signs of clear instability are seen that would prohibit proper postinjury rehabilitation, then surgical reduction and fixation of the epicondyle with reinforcement of the LUCL is an effective method of treatment.

Posterolateral rotatory instability of elbow: an uncommon entity.

Posterolateral rotatory instability of elbow is an exceedingly uncommon entity, which results from injury to the lateral ligamentous complex. Failure of adequate healing of lateral collateral ligaments may necessitate its surgical repair or reconstruction. We describe here a boy 12 years of age who was initially treated as soft tissue injury and later presented with instability of the same elbow. He later required repair of lateral ulnar collateral ligament.

Snapping plicae associated with radiocapitellar chondromalacia

Purpose: Painful snapping of the elbow joint is usually attributed to intra-articular loose bodies, instability, or medial dislocation of the triceps muscle over the medial epicondyle. We report our experience with 14 patients who were treated arthroscopically for snapping elbow that was found to be caused by hypertrophic synovial folds associated with radiocapitellar chondromalacia. Type of Study: Case series. Methods: The records of 14 patients who were treated arthroscopically for painful snapping elbows caused by intra-articular plicae were reviewed. There were 6 women and 8 men with an average age of 36 years (range, 27 to 48 years). Nine patients had had some type of trauma to the joint. Four patients had been previously diagnosed with lateral epicondylitis and 5 with intra-articular loose bodies. The average time from initial onset of symptoms to treatment was 13 months (range, 8 to 36 months). Average follow-up was 24 months (range, 6 to 66 months). Results: All patients complained of painful snapping in the posterolateral or anterolateral aspect of the elbow. The snapping occurred between 90° and 110° of flexion with the forearm in pronation. In 7 patients, the snapping was reproducible by passively flexing the pronated elbow, which we refer to as the flexion-pronation test. At the time of arthroscopic surgery, all patients had a thickened synovial plica that would snap back and forward over the radial head, usually associated with a chondromalacic area on the radial head. Twelve patients had complete relief of their snapping after surgery. One patient in whom there was associated posterolateral rotatory elbow instability did not improve. One patient became asymptomatic for 4 years but then had recurrence of her symptoms, which persisted despite 2 subsequent arthroscopies. Conclusions: The presence of synovial plicae in the radiocapitellar joint must be considered in the differential diagnosis of painful snapping elbow. Arthroscopy confirms the diagnosis and allows excision of the plica.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 491–495