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Kotsapas M, Giotis D, Zampeli F, Giannatos V, Koutserimpas C, Kokkalis Z, Karadimos D, Koukos C. Anatomical considerations, diagnosis, and treatment of medial and posterolateral elbow rotatory instability in athletes: an arthroscopic perspective and literature review. INTERNATIONAL ORTHOPAEDICS 2025; 49:1439-1450. [PMID: 40047874 DOI: 10.1007/s00264-025-06485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2025] [Accepted: 02/28/2025] [Indexed: 05/14/2025]
Abstract
PURPOSE Elbow joint instability results from the disruption of one or more stabilizing anatomical structures. The two most common forms of instability are posterolateral rotatory instability (PLRI) and medial elbow instability (MEI), particularly in athletes. This review aims to explore the anatomical foundations, diagnostic methods, and therapeutic approaches for PLRI and MEI in athletes. METHODS A comprehensive literature review was performed to investigate the study objective. RESULTS Regarding the anatomical background, the primary stabilizing structures of the elbow joint include the humeroulnar joint (trochlea, olecranon, and coronoid process), the medial collateral ligament (MCL), and the lateral ulnar collateral ligament (LUCL). PLRI is primarily caused by LUCL insufficiency, while MEI results from MCL dysfunction. A thorough clinical evaluation, combined with advanced imaging-magnetic resonance imaging (MRI) or MR arthrography is essential for an accurate diagnosis. For high-level athletes, surgical intervention is often required, with the timing and type of surgery tailored to the athlete's specific needs, expectations, and the chronicity of the injury. CONCLUSION PLRI and MEI present diagnostic and therapeutic challenges, especially in athletes. Advanced imaging and clinical evaluation are crucial for the diagnosis. Surgical intervention, particularly arthroscopy, is often required for optimal outcomes.
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Affiliation(s)
- Michail Kotsapas
- Department of Orthopaedics and Traumatology, General Hospital of Naoussa, Naoussa, Greece
| | - Dimitrios Giotis
- Orthopaedic Department, General Hospital of Ioannina, Ioannina, Greece.
| | - Frantzeska Zampeli
- Hand-Upper Limb-Microsurgery Department, KAT Attica General Hospital, Kifissia, Greece
| | - Vasileios Giannatos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Orthopedics and Traumatology, University Hospital of Patras, Patras, Greece
| | - Christos Koutserimpas
- Orthopedic Surgery and Sports Medicine Department, Croix-Rousse University Hospital, Lyon, France
- Department of Surgical Anatomy, Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Zinon Kokkalis
- Department of Orthopedics and Traumatology, University Hospital of Patras, Patras, Greece
| | - Dimitrios Karadimos
- Department of Orthopaedics and Traumatology, General Hospital of Ptolemaida, Ptolemaida, Greece
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Geyer S, Hinz M, Kadantsev P, Lappen S, Winkler PW, Neumann J, Schwaiger BJ, Siebenlist S. Joint Position and General Hypermobility Affect Elbow Joint Congruence on Magnetic Resonance Imaging: A Prospective Cohort Study. Am J Sports Med 2025; 53:1469-1476. [PMID: 40230217 PMCID: PMC12044199 DOI: 10.1177/03635465251330152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 01/29/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND Patients with posterolateral rotational instability (PLRI) of the elbow exhibit a higher degree of joint incongruence on magnetic resonance imaging (MRI) than patients without PLRI. However, the influence of joint hypermobility and position of the elbow in healthy participants is yet unknown. PURPOSE To analyze the influence of general hypermobility and elbow joint position on joint congruence in healthy participants via MRI. STUDY DESIGN Case-control study; Level of evidence, 4. METHODS Twenty participants with Beighton score <5 (normal group) and 20 with Beighton score ≥5 (hypermobile group) who had healthy elbows underwent bilateral MRI in full extension and supination, full extension and pronation, and 30° of flexion in both supination and pronation. Sagittal radiocapitellar joint incongruence and ulnohumeral joint incongruence (in sagittal, coronal, and axial planes) were measured according to a standardized protocol. RESULTS Radiocapitellar congruence increased in pronation (P < .001) but did not change between flexion and extension (P > .05). Coronal ulnohumeral congruence increased significantly from extension and supination to pronation (P = .010) and to combined flexion and pronation (P = .011). Sagittal and axial ulnohumeral joint congruence did not change significantly between different elbow joint positions (P > .05). Significant differences between the normal and hypermobile groups were observed in 3 of the 4 evaluated joint positions. Overall, the hypermobile group showed an increased joint incongruence except in extension and pronation (P > .05). CONCLUSION In MRI examination of healthy elbows, joint congruence increased significantly from supination to pronation. In combined extension and pronation, the elbow joint was equally congruent in the normal and hypermobile groups. When MRI scans in supination or combined flexion and pronation are evaluated, increased joint incongruence in hypermobile individuals is physiological and should not be confused with PLRI.
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Affiliation(s)
- Stephanie Geyer
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Shoulder and Elbow Surgery, St Vinzenz Klinik, Pfronten, Germany
| | - Maximilian Hinz
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Center for Musculoskeletal Surgery, Charité, Berlin, Germany
| | - Pavel Kadantsev
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Sebastian Lappen
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Orthopaedic and Trauma Surgery, University Medical Centre, Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Philipp W. Winkler
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Jan Neumann
- Department of Radiology, Kantonsspital Graubünden, Chur, Switzerland
| | - Benedikt J. Schwaiger
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
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Schamberger CT, Grossner T, Rehnitz C, Findeisen S, Ferbert T, Suda AJ, Schmidmaier G, Stein S. The HuRaA Trial-The Radiocapitellar Line Shows Significant Posterior Translation in Healthy Elbows: A Prospective Analysis of 53 Healthy Individuals. Biomedicines 2024; 12:2660. [PMID: 39767567 PMCID: PMC11726721 DOI: 10.3390/biomedicines12122660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 11/15/2024] [Accepted: 11/19/2024] [Indexed: 01/16/2025] Open
Abstract
Background: The elbow joint is stabilized by complex interactions between bony structures and soft tissues, notably the lateral and medial collateral ligaments. Posterolateral rotatory instability (PLRI), a form of elbow instability, is challenging to diagnose due to overlapping symptoms with other conditions. The radiocapitellar line (RCL) is a radiographic tool for assessing humeroradial alignment and elbow stability, but its diagnostic accuracy remains debated. This study aims to provide normative data on RCL deviations in healthy individuals to improve diagnostic criteria for PLRI. Methods: A prospective study was conducted with 53 healthy individuals (27 males, 26 females) aged 18-45 years. MRI scans of the participants' elbows were performed in maximum extension and supination to assess radiocapitellar deviations (RCDs). Two orthopedic surgeons independently analyzed the images to evaluate RCDs and assess interobserver reliability. Statistical analyses, including independent t-tests and Pearson correlations, were used to explore the relationship between RCDs, demographic factors, and elbow stability. Results: The average RCD in the cohort was 1.77 mm (SD 1.06 mm). Notably, 62.9% of participants had deviations greater than 1.2 mm, while 12.9% exceeded 3.4 mm, thresholds traditionally used to diagnose PLRI. Gender and age did not significantly influence RCD values. The interobserver reliability was almost good (ICC = 0.87), supporting the consistency of the RCL measurements. Conclusions: Significant RCDs occur even in asymptomatic individuals, challenging the current diagnostic thresholds for PLRI based solely on RCL measurements. A comprehensive assessment that includes clinical, anatomical, and functional evaluations is essential for accurate diagnosis. These findings highlight the need for refined diagnostic criteria and further research into elbow stability.
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Affiliation(s)
- Christian T. Schamberger
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Tobias Grossner
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Christoph Rehnitz
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Sebastian Findeisen
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Thomas Ferbert
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Arnold J. Suda
- Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, 68167 Mannheim, Germany
| | - Gerhard Schmidmaier
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Stephan Stein
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
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Koukos C, Kotsapas M, Sidiropoulos K, Traverso A, Bilsel K, Montoya F, Arrigoni P. A Novel Surgical Treatment Management Algorithm for Elbow Posterolateral Rotatory Instability (PLRI) Based on the Common Extensor Origin Integrity. J Clin Med 2024; 13:2411. [PMID: 38673685 PMCID: PMC11051432 DOI: 10.3390/jcm13082411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
- Christos Koukos
- Medical Center Wuppertal, 42329 Wuppertal, Germany;
- Sports Trauma and Pain Ιnstitute, 54655 Thessaloniki, Greece
| | - Michail Kotsapas
- Orthopaedic Department, General Hospital of Naousa, 59200 Naousa, Greece
| | - Konstantinos Sidiropoulos
- Medical School of Patras, University of Patras, 26504 Patras, Greece
- Emergency Department, Papageorgiou General Hospital of Thessaloniki, 54635 Thessaloniki, Greece
| | - Aurélien Traverso
- Orthopaedic Department, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
- ASST Pini-CTO, 20122 Milan, Italy
| | - Kerem Bilsel
- Faculty of Medicine, Acibadem Mehmet Ali Aydınlar University, 34752 Instanbul, Turkey;
- Orthopaedics and Traumatology Department, FulyaAcibadem Hospital, 34349 Instanbul, Turkey
| | - Fredy Montoya
- Sanatorio Aleman Clinic, Universidad de Concepcion, Concepcion 4070386, Chile;
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Ricci V, Güvener O, Chang KV, Wu WT, Mezian K, Kara M, Leblebicioğlu G, Pirri C, Ata AM, Dughbaj M, Jain NB, Stecco C, Özçakar L. EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Elbow. Am J Phys Med Rehabil 2022; 101:e83-e92. [PMID: 34930863 DOI: 10.1097/phm.0000000000001915] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In this dynamic protocol, ultrasound examination of the elbow using different maneuvers is described for several/relevant elbow problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide-prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine])-will help musculoskeletal physicians perform a better and uniform/standard approach.
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Affiliation(s)
- Vincenzo Ricci
- From the Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy (VR); Department of Physical and Rehabilitation Medicine, Mersin University Medical School, Mersin, Turkey (OG); Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan (K-VC, W-TW); National Taiwan University College of Medicine, Taipei, Taiwan (K-VC); Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic (KM); Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey (MK, LÖ); The Hand Clinic, Ankara, Turkey (GL); Department of Neurosciences, Institute of Human Anatomy, University of Padova, Padova, Italy (CP, CS); Ankara City Hospital, Physical Medicine and Rehabilitation Hospital, Ankara, Turkey (AMA); Physical Medicine and Rehabilitation Hospital, Ministry of Health, Kuwait City, Kuwait (MD); and Departments of Physical Medicine and Rehabilitation, Orthopaedics, and Population and Data Sciences, University of Texas Southwestern, Dallas, Texas (NBJ)
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