Dual reconstruction of lateral collateral ligament is safe and effective in treating posterolateral rotatory instability of the elbow

Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases

BACKGROUND

The treatment of simple elbow dislocations (SEDs) has become more functional last decade with a tendency to shorter immobilization of the elbow, whereas simultaneously, surgical stabilization has been promoted by some authors. The primary aim of this study was to systematically review the literature and analyze the outcomes and complications of different treatment options for acute and persistent SEDs, including operative and nonoperative treatments with varying immobilization periods.

METHODS

A literature search was performed based on the online medical databases MEDLINE, Embase, and the Cochrane databases. Articles presenting patients with a SED were eligible for inclusion. When an SED persists for >3 weeks, it is categorized as persistent. Various outcome measures were assessed, including the range of motion (ROM), patient-reported outcome measures, and complication rates. To get insight into the severity of complications, all complications were categorized as minor or major. The Methodological Index for Nonrandomized Studies was used to assess the methodological quality of nonrandomized studies. The risk of bias in the randomized studies was assessed with the Cochrane risk-of-bias tool.

RESULTS

A total of 37 articles were included with 1,081 dislocated elbows (1,078 patients). A fair quality of evidence was seen for the nonrandomized studies and a low risk of bias for the randomized study. Nonoperative treatment was administered to 710 elbows, with 244 elbows treated with early mobilization, 239 with 1- to 3-week immobilization, and 163 with ≥3-week immobilization. These groups showed a ROM flexion-extension arc (ROM F/E) of 137, 129, and 131°, respectively. Surgical treatment as open reduction and ligament repair or reconstruction was performed in 228 elbows and showed a ROM F/E of 128°. All persistent SEDs were treated surgically and showed a ROM F/E of 90°.

CONCLUSION

The early mobilization treatment showed the most consistent satisfactory outcomes in the literature compared with the other treatment options. Nevertheless, there remains ambiguity regarding which patients would benefit more from surgery than nonoperative treatment.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

No difference in torque load to failure between split anconeus fascia transfer and autograft palmaris longus tendon for reconstruction of the lateral ulnar collateral ligament

Background

The split anconeus fascia transfer (SAFT) is an option for reconstruction of the lateral ulnar collateral ligament (LUCL) in chronic posterolateral rotatory instability (PLRI) of the elbow with potential advantages of using only local tissue within the surgical exposure and not requiring ulnar fixation. This study aimed to assess SAFT strength compared to a traditional free graft reconstruction in a PLRI biomechanical model.

Methods

To measure biomechanical strength, eight cadaveric upper extremity pairs were utilized. Within each pair, one specimen was randomly assigned to LUCL reconstruction with autograft palmaris longus and the other to SAFT reconstruction. Torque load to failure was assessed on a load frame with the elbow in 30 degrees of flexion, 5 degrees of valgus, and 25 N axial load as the elbow was brought into external rotation. Torque load to failure was compared between the two reconstruction techniques.

Results

No difference was found in the torque load to failure between SAFT specimens compared to palmaris longus autograft specimens (mean 14.6 ± 4.4 Nm vs. mean 11.3 ± 3.9 Nm; P = .16).

Discussion

In this biomechanical study, the SAFT LUCL reconstruction provided torque load to failure similar to that of the traditional technique. These findings suggest that the SAFT technique warrants continued study as a biomechanically sound option for LUCL reconstruction in the setting of elbow PLRI.

The lateral ulnar collateral ligament: Anatomical and structural study for clinical application in the diagnosis and treatment of elbow lateral ligament injuries

The lateral ulnar collateral ligament (LUCL) is considered one of the main stabilizers of the elbow. However, its anatomical description is not well established. Imaging techniques do not always have agreed upon parameters for the study of this ligament. Therefore, herein, we studied the macro and microanatomy of the LUCL to establish its morphological and morphometric characteristics more precisely. Fifty-five fresh-frozen human elbows underwent dissection of the lateral collateral ligament. Morphological characteristics were studied in detail. Ultrasound (US) and magnetic resonance (MR) were done before dissection. Two specimens were selected for PGP 9.5 S immunohistochemistry. Ten additional elbows were analyzed by E12 sheet plastination. LUCL was identified in all specimens and clearly defined by E12 semi-thin sections. It fused with the common extensor tendon and the radial ligament. The total length of the LUCL was 48.50 mm at 90°, 46.76 mm at maximum flexion and 44.10 mm at complete extension. Three morphological insertion variants were identified. Both US and MR identified the LUCL in all cases. It was hypoechoic in the middle and distal third in 85%. The LUCL was hypointense on MR in 95%. Free nerve endings were present on histology. The LUCL is closely related to the anular ligament. It is stretched during flexion and supination. US and MR can reliably identify its fibers. Anatomical data are relevant to the surgeon who repairs the ligaments of the elbow. Also, to the radiologist and pain physician who interpret imaging and treat patients with pain syndromes of the elbow.

Arthroscopic Modified Elbow Lateral Collateral Ligament Imbrication: An Operative Technique

When the lateral collateral ligament (LCL) complex fails to support the radiocapitellar and ulnohumeral joints in advanced stages of insufficiency, the patient experiences posterolateral rotatory instability (PLRI). Open lateral ulnar collateral ligament repair with a ligamentous graft has been the standard treatment for PLRI. Despite producing good clinical stability rates, this method is associated with significant lateral soft-tissue dissection and a lengthy recovery period. By fastening the LCL to its humeral insertion, arthroscopic imbrication of the LCL can increase stability. The senior author modified this technique. With the aid of a passer, the LCL complex, lateral capsule, and anconeus may be weaved with a single (doubled) suture, secured with a Nice knot. LCL complex imbrication may be used to restore stability and improve pain and function in patients with grade I and II PLRI.

Lateral elbow ligament reconstruction for posterolateral rotatory instability: 10 years follow-up in 32 patients

Background

Posterolateral rotatory instability (PLRI) is the most frequent form of both acute and chronic elbow instability. It is due to mechanical incompetence of the lateral collateral ligament. O'Driscoll et al described treatment of this instability by autologous reconstruction of the lateral ulnar collateral ligament. The aim of our study was to evaluate the medium and long-term clinical, functional and radiological results of patients who were surgically treated for PLRI by this technique. We hypothesized that such ligament reconstruction restores a functional joint complex and durably stabilizes the elbow and limits the long-term risk of osteoarthritis.

Methods

All patients treated for symptomatic PLRI by ligament reconstruction since January 1995 and who had a minimum follow-up of 36 months were retrospectively included.

Results

Thirty-two patients (32 elbows) underwent clinical and radiological evaluation with a mean follow-up of 112 months (range, 36-265 months). The success rate of the procedure was 97% with one patient requiring revision reconstruction. Twenty-four patients (75%) were free from pain. Pain was significantly greater in patients with associated lesions (P = .03) and those with morbid obesity (body mass index ≥40) (P = .03). Twenty-nine (91%) patients had resumed their previous activities. Twenty-eight patients (87%) were satisfied or very satisfied. The mean Mayo Clinic score was 96/100 and the QuickDash 14.7/100. Two patients (6%) with accompanying lesions developed severe osteoarthritis.

Conclusion

Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. The only failure in our series was due to several technical errors. Patients who had dislocation with associated lesions or morbid obesity are at risk of poorer functional results.

Prospective clinical results of an additive ligament bracing for stabilizing simple and complex elbow instabilities

INTRODUCTION

Ligament bracing augments ligament repair using a non-absorbable suture tape. Although biomechanically an increase in primary stability has been proven, there is a lack of clinical evidence. Purpose of this study was to evaluate clinical results of patients treated with ligament bracing due to primary elbow instability, including an analysis of complications. Furthermore, clinical results for patients treated with and without early functional mobilization were compared.

MATERIALS AND METHODS

This prospective case-series evaluated clinical and functional results from patients treated with ligament bracing due to primary elbow instability. Clinical outcome measures were range of motion (ROM) as well as objective and subjective elbow scores [Mayo Elbow Performance Score (MEPS); Disabilities of Arm, Shoulder and Hand Score (DASH score)]. Stability was evaluated sonographically by humero-radial gapping under varus stress.

RESULTS

This study involved 34 patients treated with ligament bracing. After a mean follow-up of 12.9 months ROM was 112° ± 29, MEPS 88 ± 13 points, DASH 91 ± 11 points, and 84% were satisfied with their result. Lateral joint gapping was 2.4 mm. No significant difference was observed regarding a postoperative mobilization with and without limitations. Most common complication after ligament bracing was elbow stiffness including heterotopic ossifications in four patients (12%).

CONCLUSION

Operatively treated elbow instability with additional ligament bracing results in good clinical outcomes with high patient satisfaction and recovery of elbow stability. The high primary stability of the ligament bracing allows early functional mobilization without bracing, which facilitates postoperative rehabilitation. Elbow stiffness with heterotopic ossification seems to be a potential complication. Furthermore, the optimal tensioning of the ligament bracing remains challenging, including the risk of an over tensioning.

LEVEL OF EVIDENCE

III.

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

INTRODUCTION

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.

METHODS

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.

RESULT

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.

CONCLUSION

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.

Repair Versus Non-Repair of Lateral Ulnar Collateral Ligament in Elbow Varus Posteromedial Rotatory Instability Treatment: A Comparative Study

OBJECTIVE

To compare the effects of repairing and not repairing the lateral ulnar collateral ligament (LUCL) when surgically treating elbow varus posteromedial rotatory instability (PMRI).

METHODS

In this retrospective study spanning June 2014 to February 2019, 24 patients with elbow PMRI who were treated surgically were assigned to group RL (Repair LUCL) or group NL (Non-repair LUCL) depending on whether the LUCL was repaired. Hospitalization time, operation time, intraoperative blood loss, and related complications were reviewed. The elbow range of motion (ROM), the visual analog scale (VAS), the Mayo elbow performance score (MEPS), and the disabilities of the arm, shoulder, and hand (DASH) score were used for functional assessment.

RESULTS

Among the 24 patients with PMRI, 15 were assigned to group RL and nine were assigned to group NL. The mean blood loss (184.66 ± 20.3 vs 207.33 ± 19.447, P < 0.001), the operation time (98.88 ± 12.693 min vs 184.66 ± 20.3 min, P < 0.001) were significantly lower in group RL compared to group NL. There were no significant differences between the two groups in time until surgery and follow-up time (6.66 ± 1.838 vs 6.11 ± 1.900 days, 25.53 ± 2.099 vs 26.11 ± 2.891 months, P = 0.577, P = 0.486). All of the patients achieved bone union. The elbow flexion-extension ROM (122.00° ± 3.162°vs 121.11° ± 3.333° at 12 months, P = 0.520) and pronation-supination ROM (154.53° ± 3.335° vs 155.55° ± 4.639° at 12 months, P = 0.537). Both groups achieved similar results in MEPS score (90.53 ± 2.695 vs 89.77 ± 3.865, P = 0.578) and DASH (9.77 ± 1.897 vs 9.99 ± 1.550, P = 0.772) score at the final follow-up. And the MEPS score revealed excellent results (87% in group RL, 89% in group NL).The VAS scores decreased significantly in group RL (from 6.13 ± 0.990 to 1.93 ± 0.593) and group NL (from 5.77 ± 1.481 to 1.88 ± 0.781), and no significant differences in preoperative or final follow-up were observed between the two groups (P = 0.487, P = 0.876). Complications observed in group NL with one patient occurred cubital tunnel syndrome 3 months after the operation, the patient underwent ulnar nerve simple neurolysis and the symptoms were relieved after 3 weeks.

CONCLUSION

For patients with elbow PMRI, satisfactory functional outcomes can be yielded with non-repair of the LUCL as long as the stable elbow joint is performed during operation.

Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years

PURPOSE

The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft.

METHODS

A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor.

RESULTS

A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients.

CONCLUSIONS

LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Biomechanical comparison of lateral collateral ligament reconstruction with and without additional internal bracing using a three-dimensional elbow simulator

BACKGROUND

Although an additional internal bracing significantly increases stability in a repair of the lateral ulnar collateral ligament, it remains unclear whether it also does in reconstruction. Aim of this study was to implement a three-dimensional elbow simulator for testing posterolateral rotatory instability. We hypothesized that (1) reconstruction with and without internal bracing is comparable in biomechanical properties, and (2) there would be higher load-to-failure with internal bracing.

METHODS

Posterolateral rotatory instability was tested by imitating the lateral pivot shift test in 16 elbows. Valgus and supination torques were simultaneously increased stepwise up to 1.2 Nm. Specimens were tested at 30°, 60°, 90°, and 120° elbow flexion with an intact lateral collateral ligament complex, dissected complex, and after reconstruction with or without internal bracing. Outcome measures included joint gapping, laxity, and load to failure.

FINDINGS

With the implemented elbow simulator no significant difference was observed for gapping or laxity between both treatment groups. Comparing treatment and native ligament, gapping was reduced, especially with increased elbow flexion. Laxity was also reduced at some flexion angles. The mean load-to-failure was 8.1 ± 2.7 Nm without and 9.6 ± 3.6 Nm with internal bracing (P = 0.645).

INTERPRETATION

Both treatments were comparable in biomechanical properties but did not fully restore the native state. Although the additional augmentation of the LUCL reconstruction tends to increase the maximum load to failure, this difference was not statistically significant. Still, reconstruction with internal bracing seems to be a reasonable option in selected primary reconstructions. It could also be useful in revision reconstruction.