Posterolateral Rotatory Research Articles

A Novel Surgical Treatment Management Algorithm for Elbow Posterolateral Rotatory Instability (PLRI) Based on the Common Extensor Origin Integrity.

Background: Here, we introduce a comprehensive treatment algorithm for posterolateral rotatory instability (PLRI) of the elbow, a condition affecting elbow mobility. We outline a diagnostic approach and a novel surgical management plan through the arthroscopic surgeon's point of view. Methods: The central focus of this management approach is the integrity of common extensor origin (CEO). High clinical suspicion must be evident to diagnose PLRI. Special clinical and imaging tests can confirm PLRI but sometimes the final confirmation is established during the arthroscopic treatment. The most appropriate treatment is determined by the degree of CEO integrity. Results: The treatment strategy varies with the CEO's condition: intact or minor tears require arthroscopic lateral collateral ligament imbrication, while extensive tears may need plication reinforced with imbrication or, in cases of retraction, a triceps tendon autograft reconstruction of the lateral ulnar collateral ligament alongside CEO repair. These approaches aim to manage residual instability and are complemented using a tailored rehabilitation protocol to optimize functional outcomes. Conclusion: PLRI is a unique clinical condition and should be treated likewise. This algorithm offers valuable insights for diagnosing and treating PLRI, enhancing therapeutic decision-making.

A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note.

The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.

Clinical and Functional Results of Lateral Ulnar Collateral Ligament Repair for Posterolateral Rotatory Instability of the Elbow.

Background Posterolateral rotatory instability of the elbow arises from damage to the lateral ulnar collateral ligament (LUCL). While various methods exist for reconstructing or repairing the LUCL's attachment to the humerus, the most effective approach remains debatable. This study aims to assess the outcomes of directly repairing the LUCL when the injury occurs at the humeral attachment. Methodology This retrospective study, conducted at the Royal Berkshire Foundation Trust NHS hospital in Reading, UK, assessed outcomes through a review of 15 patients who underwent direct repair of the lateral ulnar collateral ligament between 2017 and 2022, evaluating a range of motion, the Mayo Elbow Performance Score, and the Nestor grading system. Results This study included nine males and six females, with an average age of 38.8 years. Most LUCL injuries arose from elbow dislocation (46.7%). The average follow-up period for patients was 26 months. At the final assessment, the mean Mayo Elbow Performance Score reached 99. According to the Nestor grading system, 12 patients achieved excellent results, and three had good outcomes. On average, there was an 11.3° loss of final extension and 5° of final flexion, yet achieving a comparable pronation-supination arch to the contralateral side. Conclusion Direct repair of the LUCL for elbow posterolateral rotary instability yielded excellent outcomes, obviating ligament reconstruction. Recognized as minimally invasive, it accelerates recovery, minimizes trauma, and offers a cost-effective procedure for managing instability.

Case of a misleading ECG

An elderly man with severe chronic obstructive pulmonary disease and a history of complete heart block with pacemaker placement was found to have pacemaker lead infection and required device extraction. He had a standard dual chamber pacemaker in place, however the ECG obtained showed paced QRS complexes with presence of R wave in lead V1 and QS in lead I suggestive of left ventricular pacing. Additional imaging with CT scan obtained for confirmation revealed that the heart was displaced to the left posterior hemithorax secondary to pulmonary disease. Due to significant posterolateral rotation of the heart, a right ventricular paced rhythm can demonstrate Q/S waves in the lateral leads (I, aVL, V5–6) and R waves in the right precordial leads (V1–3). This can be misdiagnosed as a left ventricular paced rhythm.

Posterolateral Rotatory Instability Develops Following the Modified Kocher Approach and Does Not Resolve Following Interval Repair.

The modified Kocher and extensor digitorum communis (EDC)-splitting intervals are commonly utilized to approach the lateral elbow. Iatrogenic injury to the lateral ulnar collateral ligament may result in posterolateral rotatory instability (PLRI). in the present cadaveric study, we (1) evaluated lateral elbow stability following the use of these approaches and (2) assessed the accuracy of static lateral elbow radiographs as a diagnostic tool for PLRI. Ten matched-pair cadaveric upper-extremity specimens (n = 20) were randomly assigned to Kocher or EDC-splitting approaches. Specimens underwent evaluation pre-dissection, post-dissection, and following repair of the surgical interval. Clinical evaluation of lateral elbow stability was performed with the lateral pivot-shift maneuver. Radiographic radiocapitellar displacement was evaluated with the fully extended hanging arm test and on lateral elbow 30° flexion radiographs. Paired Wilcoxon signed-rank tests with Bonferroni correction were utilized to compare groups. All Kocher group specimens (10 of 10) developed PLRI on the pivot-shift maneuver following dissection. No EDC-splitting group specimens (0 of 10) developed instability with pivot-shift testing. The fully extended hanging arm test showed no difference in radiocapitellar displacement between groups (p > 0.008). Lateral elbow 30° flexion radiographs in the Kocher group showed an increased radiocapitellar displacement difference (mean, 8.46 mm) following dissection compared with the pre-dissection baseline (p < 0.008). Following repair of the Kocher interval, the radiocapitellar displacement (mean, 6.43 mm) remained greater than pre-dissection (mean, 2.26 mm; p < 0.008). In the EDC-splitting group, no differences were detected in radiocapitellar displacement on lateral elbow radiographs with either the fully extended hanging arm or lateral elbow 30° flexion positions. The Kocher approach produced PLRI that did not return to baseline conditions following repair of the surgical interval. The EDC-splitting approach did not cause elbow instability clinically or radiographically. The hanging arm test was not reliable for the detection of PLRI. The Kocher interval for lateral elbow exposure results in iatrogenic PLRI that is not detectable on the hanging arm test and that does not return to baseline stability following repair of the surgical interval.

A Simple and Versatile Test for Elbow Posterolateral Rotatory Instability.

Posterolateral rotatory instability (PLRI) results from lateral ulnar collateral ligament (LCL) deficiency. The lateral pivot shift test is used to diagnose PLRI but can be difficult to perform and is poorly tolerated. We present a new maneuver, the Posterior Radiocapitellar Subluxation Test (PRST), that we believe is easier to perform. The purpose of this study was to compare the efficacy and reproducibility of the PRST with the lateral pivot shift test. We obtained 10 cadaveric upper extremity specimens, performed a Kocher approach on each, released the LCL origin in 5, then closed. The specimens were randomized, and 3 attending orthopedic surgeons and 1 resident blindly performed the PRST then the lateral pivot shift test after re-randomization and assessed presence or absence of PLRI. This process was repeated the following day. The data for each test were analyzed for sensitivity, specificity, and accuracy. For the blinded testing when comparing PRST with the pivot shift test, overall accuracy was 77.5%, compared with 67.5% (P = .03), sensitivity was 75.0%, compared with 50.0% (P = .003), and specificity was 80.0%, compared with 85.0% (P = .55). Conclusions: The PRST appears to be at least as accurate as the lateral pivot shift test, with comparable intraobserver and interobserver reliability.

Lateral ulnar collateral ligament (LUCL) Reconstruction using an Autologous Triceps Tendon Graft for Subclinical Posterolateral Rotatory Instability in Recalcitrant Lateral Epicondylitis.

To evaluate mid-term outcome of LUCL repair with triceps autograft in patients with PLRI under recalcitrant lateral epicondylitis. In total 25 elbows (23 patients) with recalcitrant epicondylitis longer than 12 months were included into this retrospective study. All patients underwent arthroscopic instability examination. In 18 elbows (16 patients, mean age 47.4 years, range 25-60) PLRI was verified, and a LUCL repair using an autologous triceps tendon graft was performed. Clinical outcome was evaluated before and at least three years after surgery using the American Shoulder and Elbow Surgeons Score (ASES), Liverpool Elbow Score (LES), Mayo Elbow Performance Index (MEPI), Patient-Rated Elbow Evaluation score (PREE), Subjective Elbow Value (SEV), quick Disabilities of the Arm, Shoulder and Hand score (qDASH), and the visual analog scale (VAS) for pain. Postoperative satisfaction with the procedure and complications were recorded. Seventeen patients were available at a mean follow-up of 66.4 months (range 48-81). Patient satisfaction postoperatively was reported in 15 elbows as excellent (90-100%) and 2 as moderate with 93.1% overall. All scores of the three female and 12 male patients significantly increased from pre- to the postoperative follow-up (ASES: 28.3±10.7 to 54.6±12.1, p<0.001; MEPI: 49.2±8.3 to 90.5±15.4, p<0.001; PREE: 66.1±14.9 to 11.3±23.5, p<0.001; qDASH: 63.2±21.1 to 11.5±22.6, p<0.001; VAS: 8.75±1.0 to 1.5±2.0, p<0.001) All patients suffered from high extension pain preoperatively, which was reported to be relived after surgery. No reinstability nor major complication occurred. The repair and augmentation of the LUCL with a triceps tendon autograft reached significant improvements; hence, it seems to be a good treatment option for posterolateral elbow rotatory instability with promising mid-term results under a low rate of reinstability.

Winter sports injuries to the elbow joint

Elbow injuries occur quite often when practicing winter sports. Due to the high sports dynamics and risk of fall the elbow joint is prone to injuries. Hereby, the most common injury is the dislocation of the elbow. Isolated ligamentous instabilities can usually be treated non-operatively when the joint is centered on post-reduction imaging. In the case of persistent symptomatic instability, secondary ligament reconstruction surgery is associated with reliable and good results. Most fractures of the elbow involve the radial head in terms of postero-lateral rotation instability, whereas distal humerus and olecranon fractures are more likely to occur in high-energy or direct trauma. Indication for surgical treatment is given according to common guidelines, including involvement of the joint line, fragment dislocation and instability with risk of secondary fracture dislocation. Minimally invasive techniques for the radial head as well as anatomic preformed locking plate systems seem to have reached a wide acceptance.

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability After Failed Common Extensor Origin Release: Outcomes at Minimum 2-Year Follow-up.

Background:In patients with chronic lateral epicondylitis who have failed nonoperative treatment, open or percutaneous release of the common extensor origin (CEO) without subsequent reconstruction tends to result in good clinical outcomes. However, surgery can lead to iatrogenic injuries of the lateral collateral ligamentous complex, causing posterolateral rotatory instability (PLRI).Purpose:To determine the clinical outcomes of lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon graft after failed open CEO surgery.Study Design:Case series; Level of evidence, 4.Methods:A total of 103, patients underwent revision surgery at a single institution because of PLRI after failed open release of the CEO (Hohmann procedure) between January 2007 and October 2016. The primary surgery had been performed at other institutions in all cases. Of these patients, 72 were available for follow-up (49 by clinical examination, 23 by telephone interview). Standardized clinical examination; Mayo Elbow Performance Score (MEPS); 11-item version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH); subjective elbow value (SEV); and patient satisfaction were assessed at least 2 years after LUCL reconstruction.Results:The mean age of patients in the study was 46.9 years (range, 21-74 years), and the mean follow-up was 2.8 years after revision surgery. The mean MEPS was 78.9, and the mean QuickDASH score reached 20.4. The mean SEV was 78.6%, and 75% of the patients rated the surgery as good to excellent. Complications were detected in 14% of the patients, and 9 needed revision surgery, primarily owing to graft failure with recurrent instability (n = 5).Conclusion:LUCL reconstruction in patients with PLRI after release of the CEO can restore elbow stability and achieve high patient satisfaction. However, outcome scores and revision rates in this cohort were inferior to published outcomes of primary LUCL reconstruction for treatment of noniatrogenic or traumatic PLRI.

Arthroscopic Lateral Collateral Ligament Complex Reconstruction for Posterolateral Rotatory Instability of the Elbow, the Operative Technique

Posterolateral rotatory instability is concerning pathology in patients with recalcitrant lateral elbow pain. An arthroscopic technique can be used to perform reconstruction of lateral collateral ligament for eradicating the instability and also to manage concomitant lesions in a simultaneous operation. Similar to the modified Brostrӧm procedure using an inferior extensor retinaculum to augment the lateral collateral ligament for lateral ankle instability, in our Technical Note, we use anconeus muscles and annular ligament to augment the lateral collateral ligament for elbow instability during the reconstruction, allowing all tissue to heal with the bone by using a knotless technique.

Reconstruction Surgeries for Management of Posterolateral Rotatory Instability of The Elbow: A Systematic Review

We aimed to investigate the indications, techniques, and results of lateral ulnar collateral ligament reconstruction (LUCLR) for posterolateral rotatory instability of the elbow (PLRI) by collecting currently available data. Several databases (PUBMED &amp; EMBASE) were explored for articles published between 2010 and 2020. A search strategy was applied. Altogether, 2,583 studies were recovered for possible inclusion. After adjusting for duplicates, revision of methodology, exclusion of non-full text studies, and those in languages other than English, only four studies remained, which included 51 patients, with more males than females (56.9% and 43.1%, respectively). The patients’ mean age was 35.1 years. Eight patients (15.7%) were managed by the Docking technique in one retrospective study, while 43 patients (84.3%) were managed by the trans-osseous technique. Both trans-osseous and Docking techniques are safe and efficient in the management of PLRI cases. The trans-osseous technique has better functional and postoperative results and lesser complications. Mesh Words: posterolateral rotatory instability of the elbow; lateral ulnar collateral ligament reconstruction surgery; systematic review; meta-analysis

Ultrasound assessment of the posterolateral elbow ulnohumeral gap in normal subjects with and without posterolateral drawer testing

Posterolateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability, and current imaging to aid PLRI diagnosis is limited. Thus, we sought to define use of ultrasound (US) to determine normal lateral ulnohumeral joint measurements, with and without posterolateral drawer testing to provide an insight into how US may aid diagnosis. Sixty elbows were evaluated in thirty healthy volunteers. The lateral ulnohumeral gap (LUHG) was measured with US in the resting position while the posterolateral drawer stress test maneuver was applied. Joint laxity was calculated as the difference between maximum stress and average rest measurements. Two independent readers assessed each elbow with comparison performed between stress and rest positions. Differences in the LUHG were evident between stress and rest conditions (reader 1: P<.0001 and reader 2: P=.0002). At rest, median LUHG values were 2.31 mm and 2.05 mm for readers 1 and 2 respectively, while at stress 2.88 mm and 2.9 mm for readers 1 and 2. Median joint laxity was 0.8 mm for reader 1 and 1.1 mm for reader 2. Pearson correlation was r=0.457 (absolute intraclass correlation coefficient [ICC]=0.608) while under stress and r=0.308 (absolute intraclass correlation coefficient [ICC]=0.417) at rest. Median joint laxity demonstrated a Pearson correlation of r=0.161 and absolute intraclass correlation coefficient [ICC]=0.252. This study demonstrates a dynamic US assessment for PLRI, which aimed to assess the usefulness and feasibility of a laxity measurement after the application of a posterolateral drawer stress maneuver in a healthy population. Although establishing concordance between readers in measuring an LUHG under stress, the utility of a laxity measurement alone is not clear as correlation of measurements is not excellent; hence, an upper limit of normal for the ulnohumeral gap under stress may be more useful. Further evaluation of this technique is required in patients with PLRI.

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.

Arthroscopic Diagnosis of Posterolateral Rotatory Instability of the Elbow

Posterolateral rotatory instability (PLRI) is the most common form of symptomatic acute and chronic elbow instability. Diagnosis is usually made using a combination of clinical tests and imaging modalities; however, in more subtle forms of instability, these measures may be equivocal. Arthroscopy is a valuable adjunct for diagnosis and treatment of PLRI. It allows direct appreciation of the instability process, quantification of the degree of instability, and identification of concurrent associated pathology. The aim of this technique article is to report a series of reproducible arthroscopic tests used for diagnosis of PLRI with examples of normal and pathologic arthroscopic findings.

Percutaneous Lateral Collateral Ligament Reconstruction

The lateral collateral ligament (LCL) is 1 of the 3 major static stabilizers of the lateral knee. It acts as a restraint to varus stress as well as posterolateral rotation of the knee. Injury to the LCL rarely occurs in isolation. It is usually associated with injuries to other structures such as the anterior and/or posterior cruciate ligament, as well as other ligaments of the posterolateral corner. Grade I and II tears are usually treated conservatively, whereas complete tears are treated by either primary repair or reconstruction. This article describes a surgical technique in which the LCL is reconstructed percutaneously using an autograft.

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.

Open Anatomic Reconstruction of the Posterolateral Corner: The Arciero Technique

The posterolateral corner (PLC) is an important stabilizer of the knee. This complex of ligaments and tendons functions as the primary restraint to varus and posterolateral rotation of the knee. Injury to the PLC can result in chronic instability, a varus-thrust gait, and early arthrosis of the medial compartment of the knee if left untreated. Several techniques have been designed to address injuries of the PLC. Over the last 30 years, our understanding of the posterolateral corner as well as its operative reconstruction evolved. This evolution has attempted to refine what is an “anatomic” reconstruction. With more improved techniques and new, innovative fixation devices, we hope to make a more favorable repair for recreating the native stability of the posterolateral corner.

Closed Reduction of Irreducible Posterolateral Rotatory Knee Dislocation

Closed Reduction of Irreducible Posterolateral Rotatory Knee Dislocation

Posterolateral Rotatory Instability of the Elbow Following Humerus Lateral Epicondyle Nonunion in a Child

Posterolateral Rotatory Instability of the Elbow Following Humerus Lateral Epicondyle Nonunion in a Child

LUCL internal bracing restores posterolateral rotatory stability of the elbow.

Posterolateral rotatory instability (PLRI) of the elbow occurs from an insufficient lateral collateral ligament complex (LCLC). For subacute LCLC injuries, lateral ulnar collateral ligament (LUCL) internal bracing rather than reconstruction may be a viable option. The purpose of the study was to compare the stabilizing effects of LUCL internal bracing to triceps tendon graft reconstruction in simulated PLRI. Sixteen cadaveric elbows were assigned for either LUCL internal bracing (n = 8) or reconstruction with triceps tendon graft (n = 8). Specimen were mounted and a valgus rotational torque was applied to the ulna to test posterolateral rotatory stability. Posterolateral rotation was measured at 0°, 30°, 60°, 90° and 120° of elbow flexion. Cyclic loading was performed for 1000 cycles at 90° of elbow flexion. Three conditions were compared in each specimen: intact elbow, LUCL and radial collateral ligament (RCL) transected, and then either LUCL internal bracing or reconstruction with triceps tendon graft. Transection of the LUCL and RCL significantly increased posterolateral rotation in all degrees of elbow flexion compared to the intact condition (P < 0.05). Both LUCL internal bracing and reconstruction restored posterolateral rotatory stability to the native state between 0° and 120° of elbow flexion, with no significant difference in improvement between groups. Similarly, LUCL internal bracing and reconstruction groups showed no significant difference in posterolateral rotation compared to the intact condition during cyclic loading. At time zero, both LUCL internal bracing and reconstruction with triceps tendon graft restored posterolateral rotatory stability. As such, this study supports the use of internal bracing as an adjunct to primary ligament repair in subacute PLRI.