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

Postoperative Elbow Instability: Options for Revision Stabilization

Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.

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.

Preoperative and operative risk factors for failed lateral collateral ligament reconstruction

Repair or reconstruction of the lateral collateral ligament (LCL) using autograft or allograft is a well-accepted treatment of posterolateral rotatory instability. The prevalence and causes for failure of LCL reconstruction are not well documented in the literature. Any approach to the assessment and management of failed LCL reconstruction must begin with understanding the risk factors for failure in the first place. Such understanding would likely make many failures preventable as well. In our experience, there are a number of identifiable preoperative risk factors concerning bony and/or soft tissue constraints for failure of LCL reconstruction. There are also operative factors such as tunnel and graft placement as well as excessive lateral condyle stripping that play a role in risk of failure. This report is an attempt to provide a systematic approach to identifying and managing the preoperative and operative risk factors. Further studies are warranted to determine the indications for, and success rates of surgical intervention in managing these risk factors.

Prosthetic resurfacing of engaging posterior capitellar defects in recurrent posterolateral rotatory instability of the elbow

BACKGROUND

Posterolateral rotatory instability (PLRI) is a common mechanism of recurrent elbow instability. While the essential lesion is a deficiency in the lateral ulnar collateral ligament (LUCL), there are often associated concomitant bony lesions, such as an Osborne-Cotterill lesions (posterior capitellar fractures) and marginal radial head fractures, that compromise stability. Currently, there is no standard treatment for posterior capitellar deficiency associated with recurrent PLRI.

METHODS

We conducted a retrospective review of five patients with recurrent PLRI of the elbow associated with a posterior capitellar impaction fracture engaging with the radial head during normal range of motion. The patients were treated surgically with LUCL reconstruction or repair and off-label reconstruction of the capitellar joint surface using a small metal prosthesis designed for metatarsal head resurfacing (HemiCAP toe classic).

RESULTS

Five patients (three adolescent males, two adult females) were treated between 2007 and 2018. At a median follow-up of 5 years, all patients had complete relief of their symptomatic instability. No patients had pain at rest, but two patients had mild pain (visual analog scale 1-3) during physical activity. Three patients rated their elbow as normal, one as almost normal, and one as greatly improved. On short-term radiographic follow-up there were no signs of implant loosening. None of the patients needed reoperation.

CONCLUSIONS

Recurrent PLRI of the elbow associated with an engaging posterior capitellar lesion can be treated successfully by LUCL reconstruction and repair and filling of the capitellar defect with a metal prosthesis. This treatment option has excellent clinical results in the short-medium term. Level of evidence: IV.

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.

TREATMENT OF SIMPLE CHRONIC INSTABILITY OF THE ELBOW JOINT

Simple chronic instability of the elbow joint is one of the urgent problems in modern traumatology due to the fact that the standard tactics of managing patients with traumatic injuries of the elbow joint due to dislocation, which amounts to its elimination, immobilization of the upper limb and subsequent development of movements in the joint, most often does not take into account damage to specific soft tissue structures. With untimely treatment for qualified help, with late or unsuccessful attempts to eliminate dislocation of the bones of the forearm, less often with chronic traumatization of the ligamentous apparatus of the elbow joint during some types of occupation, one of the most unpleasant complications may form, namely, chronic instability. This article discusses the main types of chronic instability of the elbow joint, analyzes approaches to the management of patients with simple chronic instability. Despite the not very high occurrence of this pathology, the effectiveness of modern surgical treatment options aimed at reconstruction of the ligamentous apparatus of the elbow joint, the percentage of unsatisfactory results of treatment of simple chronic recurrent and persistent instability of the elbow joint remains high.

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.

Lateral ulnar collateral ligament (LUCL) reconstruction for the treatment of recalcitrant lateral epicondylitis of the elbow: a comparison with open débridement of the extensor origin

Background

Based on the controversy over whether the extensor tendon is the only lesion of lateral epicondylitis of the elbow and numerous reports of concomitant lateral collateral ligament involvement, potential damage to the lateral collateral ligament complex should be considered for the treatment.

Methods

About 25 elbows in 23 patients (débridement group) and 22 elbows in 20 patients (reconstruction group) who were diagnosed with lateral epicondylitis and had an average of 22 months of symptoms revealing anatomical lesion on MRI were included. The capitellum-sublime tubercle-radial head (CSR) angle was measured on both sides preoperatively, and the visual analog scale (VAS) and Mayo elbow performance score (MEPS) were measured over 12 months, postoperatively.

Results

The initial preoperative mean VAS was statistically significant with 4.6 in the débridement group and 6.5 in the reconstruction group (P < .05). Postoperative VAS was continuously decreased in both groups with no significant difference at each assessment period (P < .05) but showed more rapid improvement in the reconstruction group compared with the débridement group. For MEPS, the reconstruction group showed significant improvement during the follow-up periods, and at the final follow-up MEPS, 3 cases in the débridement group and 0 cases in the reconstruction group showed a poor result, which was considered as surgery failure. The CSR angle of the affected side (7.2 ± 1.9) was significantly larger than that of the normal side (3.6 ± 1.5) (P < .05) in the reconstruction group. Increased CSR by more than 5 degrees was identified as a significant predictive indicator for potential concomitant ligament insufficiency (area under curve = 0.875, P < .001) showing 80.9% of the sensitivity, 82.1% of the specificity.

Conclusions

In the surgical treatment of recalcitrant lateral epicondylitis, lateral ulnar collateral ligament reconstruction added to the débridement of extensor origin may provide better results for the patients with suspicious lateral ligament insufficiency or failed previous surgery.

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.

Reconstructing the Epicondyle and Collateral Ligament in Missing Condylar Region Associated with Severe Elbow Trauma: A Report of 2 Cases

CASES

We report 2 cases of missing condylar region associated with severe elbow trauma treated with our new surgical technique and present the outcomes at the 9- and 10-year follow-ups. Our method focused on anatomical isometric point reconstruction, which consisted of the reconstruction of the missing condylar region with the iliac bone and the collateral ligament with the palmaris longus tendon.

CONCLUSIONS

This injury is rare, and treatment is challenging because of the difficulty in identifying the isometric point. Both patients achieved good elbow function. The bone defect region was almost remodeled with minimal bone tunnel enlargement. Overall, our technique can provide positive results.

LUCL internal bracing restores posterolateral rotatory stability of the elbow

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

There is a role for allografts in reconstructive surgery of the elbow and forearm

PURPOSE

Allografts play an important role in tendon, ligament, and bone reconstruction surgery, particularly when suitable available autologous tissue is limited. Enthusiasm for the use of allografts in reconstructive orthopedic surgery has increased over the past decade, with an increase in allograft use in a variety of procedures. The purpose of this review is to provide an overview of the various applications and indications for the use of allografts in reconstructive surgical procedures of the elbow and forearm.

METHODS

MEDLINE/PubMed was searched from 1990 through October 2018 for studies on tendon and bony allografts in elbow and forearm reconstructive surgery.

RESULTS

The Achilles tendon allograft is the most frequently used tendinous allograft, predominantly used in distal biceps and triceps reconstruction. Although reconstruction of the ulnar collateral ligament of the elbow is generally performed using autografts, it has been shown that semitendinosus and gracilis allografts may be equally effective. Extensor hallucis longus allografts are recommended for reconstruction of the lateral collateral ligaments in patients with posterolateral rotatory instability, and there may be a role for osteochondral allograft transplantation in capitellar osteochondral defects. In addition, the use of allografts in reconstruction of the interosseous membrane and various bone pathologies (fractures, bone tumors, forearm nonunions) has been described in current literature.

CONCLUSION

There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm.

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

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

INTRODUCTION

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).

EVIDENCE ACQUISITION

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]).

EVIDENCE SYNTHESIS

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.

CONCLUSIONS

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.

Management of Adult Elbow Fracture Dislocations

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.