Posterolateral Rotatory Research Articles

Osborne-Cotterill Lesionを伴う陳旧性後外側回旋不安定性の治療経験

Osborne-Cotterill Lesionを伴う陳旧性後外側回旋不安定性の治療経験

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.

Early Surgical Treatment of High-grade Multiligamentous Knee Injuries

Objectives: The aim of this study was to describe the clinical outcomes of patients with high-grade multiligamentous knee injuries treated with early surgery and range of motion. Design: This study was a case series. Setting: This study was conducted in the setting of an academic level-1 trauma center. Patients: Forty-seven patients (83% male individuals; average age 35 y; range, 18 to 70) with high-grade multiligamentous knee injuries were included in this study. Patients who had suffered knee dislocations III to V (KD III-KD V) (28 KD III, 16 KD IV, and 3 KD V injuries) between July 2006 and May 2014 were treated using a standard protocol of surgical treatment within 3 weeks of injury followed by early postoperative range of motion. Treatment: The treatment consisted of open primary repair [21/42 (50%), anterior cruciate ligament; 36/43 (83%), posterior cruciate ligament; 26/27 (92%), lateral cruciate ligament; 17/18 (96%), posterolateral corner] or allograft reconstruction with early range of motion. Main Outcome Measurements: The main outcome measurements were infection, range of motion, International Knee Documentation Committee, and Tegner and Lysholm scores at 12 months after surgery. Results: No patient had a postoperative deep wound infection requiring surgery. Two patients had a superficial infection that required oral antibiotics only. The average extension was 0 degrees. All but 1 patient achieved full extension; the patient developed a 5-degree flexion contracture. Mean active range of motion at 6 and 12 months was a mean arc of 119 and 123 degrees, respectively. Anterior tibiofemoral translation of >5 mm measured with KT-1000 was present in 6 (13%) patients. Six of the 47 patients (13%) had circumferential avulsions, and 1 patient with a poor subjective outcome had a concomitant complete patellar tendon avulsion in the setting of an open dislocation. One patient (2%) had laxity and instability requiring revision arthroscopic reconstruction of the posterior cruciate ligament and manipulation under anesthesia, and 3 patients required manipulation under anesthesia or open lysis because of stiffness. Fifteen (32%) patients reported knee function between 7 and 10 (competitive or higher) on the Tegner activity level scale. The mean International Knee Documentation Committee ±SD scores were 53.3±26.7 (range, 8 to 97.7) with 16/47 (34%) knees found to be normal, 13/47 (27.6%) near normal, 13 (27.6%) abnormal, and 5 (10.6%) severely abnormal. The mean Lysholm knee score was 75.4±22.1 (range, 25 to 98). No patient in the study had rotational instability at final follow-up with clinical assessment of posteromedial or posterolateral rotation (Dial test). Conclusions: Open operative treatment within the first 3 weeks of injury with primary repair or reconstruction of all injured structures can yield outcomes similar to those reported in patients treated with delayed or staged reconstruction of ligaments. Early treatment allows definitive management of injuries that are difficult to address on a delayed basis. Complications of infection, revision because of laxity, and stiffness are uncommon with this approach.

Posterolateral Corner Repair With Suture Tape Augmentation

The posterolateral corner (PLC) of the knee is the main restraint to varus forces of the knee as well as posterolateral rotation of the tibia relative to the femur. Primary PLC repairs have been associated with a high failure rate in past literature. However, with modern improved arthroscopic instrumentation and devices, there has been a renewed interest in repair of the ligaments around the knee. Internal bracing with suture tape augmentation encourages healing and allows early mobilization. This article describes, with video illustration, PLC repair with suture tape augmentation.

Posterolateral Rotatory Knee Instability-MRI Evaluation of Anatomic Landmarks for Tibial Drill Tunnel Placement in Open and Arthroscopic Popliteus Tendon Reconstruction.

Anatomic reconstruction of the popliteus tendon and arcuate complex results in superior functional and a biomechanically more stable outcome compared with extra-anatomic techniques in posterolateral rotatory knee instability. Although specific characteristics of the femoral and fibular footprint of the anatomic posterolateral reconstruction have been described, data for tibial tunnel placement while popliteus tendon reconstruction do not exist. The purpose of this study was to quantify reasonable parameters, which could be used in arthroscopy, fluoroscopy, or open surgery to determine the anatomic tibial drill tunnel position in popliteus tendon reconstruction. Thirty magnetic resonance images of 30 patients with an intact posterolateral corner (PLC) were analyzed to specify the ideal point for tibial fixation of a popliteus tendon graft with respect to 17 bony, cartilaginous, and ligamentous anatomic landmarks. The ideal point for tibial fixation was defined as the musculotendinous junction of the popliteus tendon near to the insertion of the popliteofibular ligament. In the coronal plane, the ideal tibial fixation was located at the crossing of a tangent to the fibular head, parallel to the joint line with a tangent to the medial border of the fibular head, and vertical to the joint line with a deviation of less than 1 mm. It was located 0.26 (±1.91) mm superior to the distal edge and 11.75 (±2.66) mm lateral to the lateral edge of the tibial posterior cruciate ligament footprint and only 8.68 (±2.81) mm lateral to the lateral edge of the neurovascular bundle. Interrater reliability to detect the correct position of the popliteus tendon graft footprint was almost perfect. The position for tibial drill tunnel placement in anatomic popliteus tendon reconstruction showed low interindividual differences. The present findings of the quantified anatomic landmarks might improve open, fluoroscopy, or arthroscopy guided PLC reconstruction.

Posterolateral Rotatory Instability of the Elbow Joint

Posterolateral Rotatory Instability of the Elbow Joint

Arthroscopic Assisted Surgery for Posterolateral Rotatory Instability with Ulnar Coronoid Process Nonunion; A Case Report

Arthroscopic Assisted Surgery for Posterolateral Rotatory Instability with Ulnar Coronoid Process Nonunion; A Case Report

Diagnosis and Treatment of Posterolateral Rotatory Instability

Posterolateral rotatory instability is caused by insufficiency of the lateral stabilizers of the elbow. Acute instability occurs as a consequence of trauma and is best treated by primary repair. Chronic instability may be a consequence of trauma, but has also been described in the setting of corticosteroid injections for lateral epicondylitis and repetitive varus load. In this setting, ligament reconstruction is typically required.

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability of the Elbow

Reconstruction of the lateral ulnar collateral ligament of the elbow is the primary treatment for recurrent symptomatic posterolateral rotatory instability. Although a number of lateral ulnar collateral ligament reconstruction techniques have been described, the docking technique has received general acceptance. In this technique, the graft is passed through a tunnel on the ulnar side and the 2 free limbs are docked into the humerus at the isometric point on the lateral condyle. Advantages of this method of reconstruction include reduced bone removal, decreased soft tissue damage, and precise control of graft tensioning. When precise surgical steps are followed, this technique can be performed in a reliable, efficient, and reproducible manner for patients with posterolateral rotatory instability of the elbow.

An Unusual Case of Posterolateral Rotatory Instability of the Elbow.

An Unusual Case of Posterolateral Rotatory Instability of the Elbow.

Functional Outcomes following Lateral Ulnar Collateral Ligament Reconstruction for Symptomatic Posterolateral Rotatory Instability in an Athletic Population

This purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability (PLRI) in an active military cohort with intense upper extremity demands. All U.S. military service members who underwent LUCL reconstruction between 2008-2013 were identified. A retrospective chart review and prospective Mayo Elbow Performance Score (MEPS) and QuickDASH Score were obtained for all patients. The primary outcomes were return to pre-injury levels of activity and the resolution of instability and pain. Secondary outcome measures were complications, reoperation, and revision surgery. A total of 23 patients were identified with a mean age of 31.6±7.2 years (range, 19-46). Majority of patients (87%) were male. A history of instability and/or dislocation was reported by 11 patients (47.8%), and 8 patients (34.8%) had undergone prior elbow surgery. At final follow-up of 4.6±1.8 years (range, 2.2-7.6), all patients demonstrated significant decreases in pain (average pain score preoperatively = 4; postoperatively = 1.34) and achieved a functional arc of motion (>100 degrees). No patients experienced recurrent instability, and 82.6% were able to return to full duty and activity without restriction after surgical reconstruction. Four patients underwent medical separation (21.7%), including 3 with elbow disability precluding continued service (13.0%). Overall 82.6% of patients reported good to excellent outcomes by the MEPS score (mean 85.9, range 45-100) and 95.7% of patients reported no significant disability by the QuickDash disability evaluation (mean 11.2, range 0-72.7). Post-operatively, 17.4% of patients experienced complications, with 3 (13.0%) requiring re-operation. Although the diagnosis and surgical management of isolated LUCL injury is relatively infrequent, primary LUCL reconstruction for PLRI offers a reliable return to pre-injury level of function among active individuals with intense upper extremity demands. However, while function reliably improves, there is a >15% rate of perioperative complications.

Posterolateral Rotatory Instability of the Elbow: Part I. Mechanism of Injury and the Posterolateral Rotatory Drawer Test

Posterolateral rotatory instability (PLRI) is the most commonly encountered pattern of elbow instability. It is the result of disruption of the lateral collateral ligament complex leading to a posterolateral rotatory subluxation of the ulna and radial head. A number of examination maneuvers have been described to assist in clinical identification of PLRI. Despite this, some inconsistency in the description of these techniques remains in the orthopaedic literature. This Technical Note details the mechanism of injury and patient presentation, and emphasizes the primacy of the posterolateral rotatory drawer test in the assessment of PLRI while providing video instruction on how it should be performed.

Posterolateral Rotatory Instability of the Elbow: Part II. Supplementary Examination and Dynamic Imaging Techniques

Currently, a number of examination and imaging techniques exist for diagnosing posterolateral rotatory instability of the elbow. Although the posterolateral rotatory drawer is the primary examination maneuver, other special tests include the lateral pivot-shift test, prone push-up test, chair push-up test, and tabletop push-up test. In addition, posterolateral rotatory instability can be evaluated using radiography, magnetic resonance imaging, dynamic fluoroscopy, or dynamic ultrasound. In this Technical Note, each of these tests is described in detail. Video instruction is also provided to further explain the techniques and provide examples of positive tests.

Arthroscopic Technique for Isolated Posterolateral Rotational Instability of the Knee

Isolated posterolateral corner injury is an uncommon injury that could be a source of unexplained knee pain and dysfunction. Most of these patients present instability caused by concomitant ligament injuries. Numerous studies have shown open approach posterolateral repair or reconstruction surgeries to restore posterolateral rotational stability. Still, there is a certain population of patients who present posterolateral rotation instability without significant injury to the fibular collateral ligament, popliteal fibular ligament, and popliteus tendon. The posterolateral capsular ligament is critical to provide posterolateral rotation stability. In this Technical Note, with video, we show a completely arthroscopic approach to stabilize the posterolateral corner, by stabilizing the posterior lateral joint capsule with the lateral meniscus attached to the rim of the lateral tibial plateau.

Two Cases of Posterolateral Rotatory Instability with Non-Union of Coronoid Process

Two Cases of Posterolateral Rotatory Instability with Non-Union of Coronoid Process

Lattisimus Dorsi Transfer assisted by arthroscopy for the treatment of irreparable posterolateral Rotator Cuff Tears

Objective:To evaluate subjective and functional mid term results of patients treated by a lattisimus dorsi tendón transfer arthroscopically assisted for massive irreparable posterolateral injuries of the Rotator Cuff.Methods:Between 2009 and 2012, 17 Lattisimus Dorsi transfers (Paribelli technique) for irreparable posterolateral rotator cuff tears were performed. Distribution by sex: 12 men and 5 women with a mean age of 53 years old (range, 40-63). Thirteen right shoulders and 4 left shoulders. Average duration of symptoms prior to surgery was 8 months (range, 6-13 months). Mean follow-up was 28 months (range, 18-44). Patients were evaluated by the VAS, satisfaction rate, the Constant Modified Scale, postoperative range of motion and strength. Postoperative radiological studies included simple AP radiographs and MRI in order to measure AC distance and asses the integrity of the plasty.Results:Postoperative Constant Modified score averaged 63.54 points. (average increase of 13 points compared to preoperative score. (P ..05)). Active Mobility: a) Mean elevation: 142° postop vs. 119° preop (p <.001). b) Mean abduction: 138.24º postop vs. 112.35º preop (p <.001). c) Mean external rotation 40° postop vs. 20.29º preop (p <.004). Insert text.Conclusion:Lattisimus Dorsi transfer in patients with posterolateral massive irreparable injuries of the RC, is a highly demanding and palliative procedure for those cases with loss of active mobility, especially lifting and shoulder abduction.

Functional anatomy of the lateral collateral ligament of the elbow.

The aim of this study was to analyze the functional anatomy of the lateral collateral ligament complex (LCLC) and the surrounding forearm extensors. Using 81 human cadaveric upper extremities, the anatomy of the forearm extensors-especially the anconeus, supinator and extensor carpi ulnaris (ECU)-was analyzed. After removal of aforementioned extensors the functional anatomy of the LCLC was analyzed. The origin of the LCLC was evaluated for isometry. The insertion types of the lateral ulnar collateral ligament (LUCL) were analyzed and classified. The ECU runs parallel to the RCL to dynamically preserve varus stability. The supinator and anconeus muscle fibers coalesce with the LCLC and lengthen during pronation. The anconeus fibers run parallel to the LUCL in full flexion. The LCLC consists of the annular ligament (AL) and the isometric radial collateral ligament (RCL). During elbow flexion, its posterior branches (LUCL) tighten while the anterior branches loosen. When performing a pivot shift test, the loosened LUCL fibers do not fully tighten in full extension. The LUCL inserts along with the AL at the supinator crest. Three different insertion types could be observed. The LUCL represents the posterior branch of the RCL rather than a distinct ligament. It is non-isometric and lengthens during elbow flexion. The RCL was found to be of vital importance for neutralization of posterolateral rotatory forces. Pronation of the forearm actively stabilizes the elbow joint as the supinator, anconeus and biceps muscle work in unison to increase posterolateral rotatory stability.

Arthroscopic Reinsertion of Lateral Collateral Ligament, Anterior Capsular Plication, and Coronoid Tunneling Technique for Chronic Elbow Posterolateral Rotatory Instability

Posterolateral rotatory instability (PLRI) of the elbow is a chronic condition that results from lateral collateral ligament complex injury and presents with pain, clicking, and subluxation within the flexion and extension arcs of elbow motion. The primary cause involves a lesion of the lateral collateral ligament complex and its avulsion from the lateral epicondyle. In most cases, it is the result of trauma such as a fall on an outstretched hand or any other mechanism that imparts axial compression, valgus force, and supination. Several surgical techniques have been described for the treatment of PLRI, but there is no consensus regarding the ideal surgical treatment. The advantages of an arthroscopic approach for the treatment of PLRI are first diagnostic. Arthroscopy allows for visualization and diagnosis of every compartment of the elbow. The main steps of the surgical procedure consist of reinsertion of the lateral collateral ligament, anterior capsular plication, and coronoid tunneling. By use of this technique, it is possible to perform an anatomic repair and provide stability of the elbow.

Rehabilitation, clinical outcome and return to sporting activities after posterolateral elbow instability: a systematic review.

The aim of this study was to systematically review the literature for rehabilitation concepts, clinical outcome and sporting performance after surgical or non-surgical treatment of Posterolateral Rotatory Instability of the elbow (PLRI). In order to identify any published clinical study reporting on rehabilitation concepts and sporting performance following surgical or non-surgical treatment of PLRI a systematic search in literature was conducted. Rehabilitation protocols were reviewed according to main rehabilitation protocol categories (bracing, range of motion [ROM], strengthening and return to sport [RTS]). Seven articles, including 148 patients met the inclusion criteria. Lateral ulnar collateral ligament (LUCL) repair with sutures or suture anchors was reported in two studies. In four studies, treatment was an isolated graft reconstruction and in one study a repair or graft reconstruction was performed. No study reporting on conservative treatment was found. Bracing with initially limiting ROM was declared in all studies. Duration of immobilization varied from one day to six weeks postoperative. Limitation of ROM to 30° of elbow extension was reported in the majority of studies. Strengthening was allowed from six to eight weeks postoperative. Postoperative improvement in elbow range of motion was noted in all studies. Although there is agreement concerning bracing and limiting ROM following PLRI surgery there is currently no consensus in the rehabilitative- and conservative treatment modalities for patients with symptomatic PLRI. The majority of surgically treated patients with PLRI regain high acceptable results but further research is needed to determine the postoperative level of performance of these athletes.

Surgical Treatment for Posterolateral Rotatory Instability due to Pseudarthrosis of the Posterolateral Margin of the Lateral Epicondyle; A Case Report

Surgical Treatment for Posterolateral Rotatory Instability due to Pseudarthrosis of the Posterolateral Margin of the Lateral Epicondyle; A Case Report