Adult Reconstruction, 1st Edition

Section IV - Elbow Reconstruction

Part B - Evaluation and Treatment of Elbow Disorders 

50

Chronic Posterolateral Rotatory Instability of the Elbow

Felix H. Savoie III

Melissa A. Yadao

Larry D. Field

  1. Randall Ramsey

In 1991, O'Driscoll introduced the term posterolateral rotatory instability (PLRI) to describe elbow instability caused by injury to the radial ulnohumeral ligament (RUHL) or lateral ulnar collateral ligament (LUCL). Since then the functional anatomy of the lateral collateral ligament complex has been closely examined, and the diagnosis and treatment of this condition have evolved with good results.

Pathogenesis

Etiology

The cause of PLRI may be traumatic or overuse. Traumatic injuries that produce subluxation events may result in PLRI. A fall onto a rotated forearm or a twisting event, such as a drill locking into an object and sending a supination force into the forearm or elbow, are typical mechanisms of injury. Unfortunately, surgical approaches to the lateral side of the elbow may also result in damage to the RUHL complex. Lateral epicondylitis surgery that involves the posterior/distal aspect of the epicondyle and radial head approaches for excision, replacement, or trauma may be associated with the development of PLRI.

Overuse conditions of the elbow have been reported by Cohen and Hastings to also result in PLRI. Repetitive use of the elbow when associated with a long-standing inflammatory response and weakness of the extensor musculature may result in stretching or disruption of the RUHL complex.

Epidemiology

O'Driscoll's original report described a group of patients who presented with symptoms of valgus instability after trauma but did not show typical clinical findings of a deficient medial collateral ligament complex. In this group, the radial head and lateral ulna rotated and subluxated posteriorly when the elbow was forced into valgus from a supinated and extended position. He attributed this instability to the incompetence of posterolateral structures, specifically the radial ulnohumeral ligament. Although these patients had responded poorly to the standard treatment for valgus instability, they did well after plication or reconstruction of this ligament. O'Driscoll named this condition posterolateral rotatory instability and developed the posterolateral rotatory instability test or pivot shift test to assist in diagnosis.

However, posterolateral rotatory instability is not really a new problem. In 1966 Osborne and Cotterill reported a group of patients with posterior subluxations of the radial head. Three of the 30 patients had normal exams. These authors felt that laxity in the posterolateral capsule caused this problem and successfully treated their patients with plication or repair of the lateral ligament complex.

In 1975, Symeonides et al. and Hassman et al. separately reported cases of recurrent elbow dislocations that were difficult to treat. One of the Hassman et al. patients clinically had a stable ulnohumeral joint despite a history of multiple dislocations. Other case reports described posttraumatic subluxations of the elbow that could be reproduced with maneuvers similar to the pivot shift test. The patients complained of locking and snapping of the elbow. Stress radiographs showed typical findings of PLRI: widening of the ulnohumeral joint space and posterior subluxation of the radial head.

These cases probably represent examples of what is now recognized as PLRI. The clinician should read the literature carefully as some reports of dislocations of the

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ulnohumeral joint or proximal radioulnar joint may indeed be misdiagnosed.

Pathophysiology

Anatomy

The elbow is one of the most inherently stable joints because of its bony articulations and soft tissue stabilizers. The three bony articulations include the radiocapitellar joint, the proximal radioulnar joint, and the ulnohumeral joint. With trochlea cradled by the olecranon posterior and the coronoid anterior, the ulnohumeral joint provides the primary static restraint to varus/valgus, anterior/posterior, and rotatory motion at the elbow. The radiocapitellar joint is an important secondary stabilizer, accepting up to 60% axial loads when the elbow is extended.

The medial and lateral ligament complexes are the major static soft tissue stabilizers of the elbow. Three major components make up the medial or ulnar ligament complex (MCL): the anterior medial bundle, the posterior medial bundle, and the transverse oblique bundle. Although the proximal fibers have been described as distinct structures, distally they resemble more the ligaments of the shoulder as capsular thickenings. The medial ligament complex protects the elbow against valgus stress with the forearm in pronation. Biomechanical studies have shown that only the anterior and posterior bundles play important roles in elbow stability.

The lateral or radial ligament complex is made up of four components: the radial ulnohumeral ligament (RUHL) or lateral ulnar collateral ligament (LUCL), the radial collateral ligament (RCL), the annular ligament, and the accessory lateral collateral ligament (Fig. 50-1). Unlike the medial structures, these individual ligaments are often difficult to differentiate proximally where they originate as a broad band from the lateral epicondyle deep to the extensor wad. Distally, the fibers either remain as a single broad band or split into two bands, with the RCL constituting the more anterior band and the RUHL the posterior band. The annular ligament sweeps over the radial head and is thought to be a stabilizer of the proximal radioulnar joint. The RCL primarily restrains varus stress.

 

Figure 50-1 Anatomy of the lateral ligamentous complex of the elbow. Lateral ulnar collateral ligament = radial ulnohumeral ligament.

O'Driscoll has shown the RUHL to play a key role in PLRI. This ligament originates from the posterior inferior aspect of the lateral epicondyle and inserts on the supinator crest of the ulna. The RUHL is often difficult to distinguish proximally and is more easily identified at its distal insertion. Positioning the arm in varus and supination may help differentiate this structure from the RCL.

Other soft tissue structures of the elbow such as the capsule and musculature act as important dynamic stabilizers of the elbow. The capsule augments the strength of both the medial and lateral ligaments. With the elbow extended, the anterior capsule acts as a powerful restraint against varus and valgus stresses. Surgical techniques to restore stability incorporate the capsule with ligament plication. The anconeus and extensor wad are important dynamic restraints laterally whereas the flexor-pronator mass strengthens stability medially.

Injury Patterns

Anatomic studies by O'Driscoll and associates have shown that deficiencies of the RUHL and laxity of the lateral capsule allow the proximal radioulnar joint to rotate and the radial head to sublux posteriorly when stressed, leading to PLRI. In patients with this instability, the radial head subluxates, and on rare occasions, can dislocate posteriorly depending on the position of the elbow. With the forearm supinated and slightly flexed, valgus stress applied to the elbow causes rotation of the ulnohumeral joint, compression of the radiocapitellar joint, and posterior subluxation of the radial head. Extreme supination of the forearm stresses the posterolateral structures whereas flexing the elbow releases the olecranon tip from the olecranon fossa, allowing rotation of the ulnohumeral joint.

The proximal radioulnar joint must remain intact for PLRI to occur. During posterolateral rotation, the proximal forearm rotates as a unit so that the coronoid passes under the trochlea as the radial head moves posterior. This explains why hyperflexion or extensor results in reduction of the instability. In O'Driscoll's anatomic studies, the annular ligament was intact in all specimens. The integrity of this joint distinguishes PLRI from other instabilities such as recurrent dislocations of the radial head and elbow where disruption of this joint was thought necessary for dislocation to occur.

Recent biomechanical studies have attempted to define the functional anatomy of the entire lateral collateral ligament complex and its relation to PLRI. Cohen has shown that injury to the RUHL alone was not sufficient to cause instability. The entire lateral ligament complex as well as the lateral musculature played significant roles. Similarly, Dunning et al. demonstrated that the RUHL and the RCL needed to be cut before PLRI occurred. On the other hand, Seki et al. and Olsen et al. found that transection of either the RUHL or the RCL created this instability.

Although there is still much disagreement over the exact roles of the lateral ligament complex, most consider PLRI to be the first phase of elbow instability that can develop into frank dislocation. As proposed by Morrey and O'Driscoll

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individually, the mechanism leading to an unstable elbow is a progressive disruption of the ring of soft tissue stabilizers beginning laterally and sweeping medially. The first injured structure is the RUHL, resulting in PLRI that can reduce spontaneously. Further injury tears anterior and posterior capsules, resulting in ulnohumeral subluxations. Complete dislocation occurs when the medial structures are disrupted, although the anterior band of the medial collateral ligament may be only minimally injured.

Classification

There is no specific classification system for PLRI.

Diagnosis

History and Physical Examination

Clinical Features

The patient with PLRI often presents with vague complaining of lateral elbow pain. The differential diagnosis of PLRI includes lateral epicondylitis, radial tunnel syndrome, valgus instability, and pure proximal radial head dislocation. Standard valgus/varus instability tests are often normal. Valgus instability should be tested with the forearm supinated and pronated. With valgus loads, pronation of the forearm tests the medial collateral ligamentous complex, whereas supination stresses posterolateral structures, in particular the RUHL.

Several provocative tests, including the posterolateral rotatory instability test or pivot shift test developed by O'Driscoll, can help make the diagnosis. The pivot shift test for the elbow resembles the pivot shift test for the anterior cruciate ligament (ACL)–deficient knee. With the patient supine, the arm is raised overhead, stabilizing the humerus to prevent external rotation. With the forearm fully supinated and the elbow extended, a valgus-supination force is applied to the elbow while slowing flexing it from an extended position. As a result, the ulnohumeral joint rotates and the radiohumeral joint subluxes posteriorly, sometimes even dislocating (Fig. 50-2A). Dimpling of the skin may be seen proximal to the subluxing radial head. As the elbow is flexed >40 degrees, the clinician may hear or feel the radiohumeral joint suddenly reduce.

This test is not easy to perform on the awake patient. Feelings of pain or apprehension are considered a positive result in such patients in the absence of instability. We prefer to perform the pivot shift test with the patient positioned prone. Resting the arm over the edge of the table stabilizes the humerus, allowing the examiner to more easily palpate the radiohumeral joint during the examination (Fig. 50-2B, C).

Two other provocative maneuvers designed by Regan simulate the pivot shift test. The first requires the patient to push up from a prone or wall position with the forearms maximally pronated so that the thumbs are turned toward each other. The test is repeated with forearms maximally supinated. The patient with PLRI will not want to allow the elbow to fully flex, describing a felling of pain and/or instability. Another test requires a patient to push up out of a chair using the armrests. With palms facing inward, essentially placing them in supination, pushing up will produce similar symptoms of pain.

Most patients will describe a history of trauma. Although elbow dislocation is the inciting event in 75% of patients younger than 20 years of age, varus extension stress without true dislocation is more likely the initiating event in older patients. PLRI can also occur secondary to repetitive stresses on the elbow. Some patients who present with lateral epicondylitis may also have PLRI. Repetitive motion may produce laxity in the lateral ligamentous complex, leading to secondary lateral epicondylitis. Previous surgery to the lateral side of the elbow can cause iatrogenic instability. PLRI has also been reported following radial head excision.

Most patients complain of pain, weakness to grip, and occasionally giving way of the elbow. As the instability may overstress the lateral musculature, lateral epicondylitis symptoms are common. The subluxation events may produce swelling in the posterolateral capsule and enlarged plica with resulting secondary plica syndrome. True dislocations tend to be rare. Rather, patients describe the elbow slipping in and out of the joint in certain positions but especially when the arm is supinated and slightly flexed.

Radiologic Features

Standard anteroposterior (AP) and lateral radiographs of the elbow should be obtained but are often normal. Bony avulsions following ligament injury can be identified. On lateral views, typical PLRI radiographic findings include widening of the ulnohumeral joint space with posterior subluxation of the radial head. These are best illustrated with radiographic or fluoroscopic stress views while performing the pivot shift test with the patient under anesthesia (Fig. 50-3A, B). Associated changes include degenerative changes on the capitellum and spur formation on the lateral aspect of the olecranon.

Currently MRI plays a limited role. Although the RUHL and any such injuries can be identified on MRI using special sequencing, this study requires experience in elbow MRI by both the radiologist and MRI technician. MR arthrograms may prove more useful, especially in posttraumatic cases.

Exam under Anesthesia and Arthroscopy

In difficult cases an exam under anesthesia with fluoroscopy may be valuable in making the diagnosis. Diagnostic arthroscopy can also demonstrate PLRI in a patient in whom instability is suspected. The pivot shift test should be performed while viewing from the anteromedial portal. The radial head will rotate and translate posterior if PLRI is present; with a competent ligament, the radial head will rotate but not translate (Fig. 50-4A, B). In addition, while viewing from the posterolateral portal, we have found the arthroscope can be easily driven through the lateral gutter and into the lateral aspect of the ulnohumeral joint if instability is present. We have described this as the “elbow drive through” sign, resembling the drive through sign in shoulder instability (Fig. 50-4C).

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Figure 50-2 The posterolateral rotatory instability (PLRI) test or pivot shift test. The test is performed by applying a valgus stress to the elbow with the humerus stabilized and the forearm maximally supinated. Symptoms occur as the arm is brought from full extension into slight flexion. A: Performing the test in the supine position maximally externally rotates the arm and allows the examiner to use both hands to manipulate the elbow. B: Performing the test with the patient prone stabilizes the humerus and frees one hand to more easily palpate the radiohumeral joint. C: Exam under anesthesia demonstrates the subluxation of severe PLRI.

 

Figure 50-3 Neutral (A) and stress (B) views of the elbow demonstrate widening of the ulnohumeral joint and posterior subluxation of the radial head.

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Figure 50-4 Arthroscopic findings of PLRI. A: The view from the anteromedial portal shows the normal position of the radial head with the forearm in pronation. B: During the PLRI or pivot shift test, the radial head can be seen to sublux posteriorly. In a stable elbow, the radial head would rotate but not translate posteriorly. C: Drive through sign.

Surgical Indications/Contraindications

The most difficult aspect of the management of posterolateral instability is often making the correct diagnosis. Once that is made, appropriate treatment measures may be taken.

Nonoperative Treatment

Nonoperative management of PLRI is focused on eliminating the secondary, pain-producing pathology; often a simple elbow sleeve will provide sensory feedback and stabilize the elbow enough to significantly reduce subluxation events. NSAIDs in pill and cream form may help with the swelling and inflammation of the extensors, muscles, and plica. Physiotherapy to include pain control modalities, tissue massage, extensor muscle strengthening, and biofeedback exercises to control subluxation may be helpful as well (Fig. 50-5).

Operative Treatment

The only indication for operative management is pain and functional impairment in the affected elbow not relieved by nonoperative management. Radiographic or MRI evidence alone is not a sufficient indication. Contraindications may include an uncooperative patient, psychiatric disorders, grade II or worse arthritis, or surgical inexperience with the reconstructive techniques and anatomic variations associated with this instability.

Posterolateral instability may be managed by open plication/repair, open graft reconstruction, or arthroscopic plication/repair. The specific technique used depends more on the surgeon's preference, experience, and the number of previous surgeries rather than any specific guidelines.

Open Technique

Open Repair.

O'Driscoll originally described an open technique to plicate, repair, and reconstruct the RUHL. With the patient supine, the elbow is entered through a modified Kocher approach, exposing the entire lateral ligament complex from the lateral epicondyle to the supinator crest. The pivot shift test is performed to identify laxity in the lateral capsule and insufficiencies of the RUHL. An attenuated or detached ligament can be repaired by reattaching the ligament through bone to the posterior inferior lateral epicondyle. The ligament can be advanced or imbricated as needed. The loose capsule is

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plicated with sutures tied following completion of the repair (Fig. 50-6A). One simple technique for doing this is to place double-sutured anchors at the origin of the RUHL on the condyle. One set of sutures can be used to plicate the ligament and repair it to the epicondyle while the second is used to repair any associated damage to the extensor muscle.

 

Figure 50-5 Diagnostic workup algorithm. PL, posterolateral; ECRB, extensor carpi radialis brevis; NSAIDs, nonsteroidal anti-inflammatory drugs; PT, physiotherapy; MRA, magnetic resonance arthrogram; MRI, magnetic resonance imaging; RUHL, radial ulnohumeral ligament.

Open Reconstruction.

Reconstruction with tendon autograft or allograft may be necessary should the ligament tissue be of poor quality owing to extensive trauma, multiple previous surgeries, or excessive injections. In this technique an open posterolateral extensile approach is used. The anconeus is retracted and any residual ligament or capsule split longitudinally. The anatomic origin and insertion sites are identified and then tested using a suture while ranging the elbow. We normally drill our tunnel into the insertion site or the supinated crest of the ulna first using a Beath pin. This pin is then overreamed with a 5.5- or 6-mm reamer unicortically. The midportion of the graft is then pulled into the tunnel until it contacts the ulnar cortex, and the graft is fixed into the ulnar tunnel using an interference screw. The isometric point on the humerus is then retested, and the proximal end of the graft is passed into the tunnel and fixed using either a docking technique, Endobutton, or interference screw. The elbow is positioned in 40-degree flexion and the forearm fully pronated (Fig. 50-6B).

The palmaris graft is the most commonly used autograft. The semitendinosus is the most common allograft. Single or double limbs of the graft can be passed through the isometric origin of the lateral epicondyle. However, a recent study by King et al. has shown no biomechanical differences between single- or double-strand grafts.

Arthroscopic Repair and Plication

Arthroscopic techniques have recently been developed to plicate or repair the RUHL. As mentioned earlier, PLRI can be diagnosed by a posterior subluxing radial head during a pivot shift test or by seeing a drive through sign. While

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viewing through the posterolateral portal, the surgeon passes an absorbable suture into the joint through a spinal needle placed into the joint directly adjacent to the lateral aspect of the proximal ulna at the level of the supinator crest (Fig. 50-7A). The first two sutures pierce the annular ligament. The suture is retrieved adjacent to the posterior inferior aspect of the lateral epicondyle, near the normal origin site of the RUHL. Four to seven sutures can be passed, starting distal to proximal. The two ends of each suture are brought out together through a lateral incision and are tied separately in the same order. By pulling the sutures prior to tying, one should see the lateral structures tighten and the lateral gutter space collapse (Fig. 50-7B–D).

 

Figure 50-6 Open lateral reconstruction for PLRI as described by O'Driscoll. A: Repair of the radial ulnohumeral ligament by imbricating the ligament and reattaching it to its insertion point on the lateral epicondyle. The redundant posterolateral capsule is also plicated. B:Reconstruction of the ligament with a free tendon graft. It is essential to place the ligament in its correct anatomic position on the humeral epicondyle and supinator crest of the ulna. The posterolateral capsule is also plicated. RCL, radial collateral ligament; LUCL, lateral ulnar collateral ligament.

If a humeral avulsion is found, the repair can be augmented with a suture anchor. Through an additional portal, the anchor is placed at the isometric point onto the posterior aspect of the lateral epicondyle. One limb is passed into the joint, lassoing all the plication sutures before being retrieved near the ulna. The plication sutures are then tied, closing the lateral gutter and plication the entire lateral ligament complex. The suture from the anchor is then passed subcutaneously back over the tied sutures to the anchor portal; tying this suture then pulls the entire plicated ligament complex back toward the humerus, essentially reattaching the entire ligament complex to the lateral epicondyle.

Postoperative Management

Postoperative rehabilitation is similar following either technique. Patients are immediately immobilized in a splint with the elbow flexed to 70 to 90 degrees with the arm in full pronation. After 1 to 2 weeks, limited flexion of 45 to 90 degrees is initiated with the elbow protected in a double-hinged elbow brace. Full range of motion in the brace is allowed at 3 weeks. Full painless range of motion should be achieved by 6 weeks, following which wrist and elbow strengthening exercises in the brace are started. At 10 to 12 weeks, the brace can be removed once the patient can perform all strengthening exercises in the brace painfree.

Results and Outcome

Few results following surgical management of PLRI are described in the literature. In O'Driscoll's first paper, four of five patients were followed for 15 to 30 months. None had any recurrence of instability, and all achieved full range of motion. In a follow-up study by Nestor et al. on 11 patients, 3 patients underwent repair whereas 7 underwent ligament reconstruction with palmaris graft. Stability was achieved in ten patients with seven having an excellent functional result.

On reviewing his series of patients, O'Driscoll has found 90% satisfaction with no subluxations if the radial head is intact and no degenerative articular changes are present. Patient satisfaction decreases to 67% to 75% in the face of radial head excision or arthritis. Mild flexion contracture (10 degrees) is accepted as it protects against instability. Recurrent laxity or redislocation has been reported but usually occurs after reinjury involving significant stress.

We have retrospectively reviewed 54 patients with an average follow-up of 41 months (range 12 to 103 months) who underwent operative management of PLRI at our institution. Diagnostic arthroscopy confirmed PLRI in all patients. Thirty-seven patients were treated with open techniques: 34 had ligament repair and 3 had reconstruction with tendon graft. Seventeen patients were treated with arthroscopy: 11 had ligament plication alone whereas 6 required an anchor to augment the repair.

Twenty-five percent of patients had a previous history of lateral epicondyle release. Indications for open rather than arthroscopic repair included having concurrent procedures such as lateral epicondyle release, open extensor mass avulsion repairs, and release of the posterior interosseous nerve.

Overall Andrew-Carson scores improved significantly for all repairs from 145 to 180 (p < 0.0001). Subjective scores improved from 57 to 85 (p < 0.0001) and objective scores

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from 88 to 95 (p = 0.008). Open repairs improved from 146 to 176 (p = 0.0001) and arthroscopic repairs from 144 to 182 (p < 0.001). Overall, open and arthroscopic techniques were shown to be equally effective (unpublished data).

 

Figure 50-7 Arthroscopic reconstruction of posterolateral instability is accomplished by passing plication sutures through the ulnar side of the ligament with a spinal needle (A), retrieving them through the humeral side (B). These sutures are then retrieved out the soft spot portal and tied, closing the lateral ligament complex (C). This complex may be repaired to the humerus by passing a stitch around the plicated sutures (D) and tying the entire complex to the humerus.

Conclusion

Posterolateral rotatory instability should be considered in a patient who complains of vague elbow pain and giving way with a history of an elbow dislocation or previous lateral elbow surgery. Although the topic is currently debated, the radial ulnohumeral ligament does play an important role in this instability. Future investigations will help determine the exact role of the lateral collateral ligament complex in the unstable elbow. Indeed, PLRI is part of a continuum of injury from instability to frank dislocation.

The diagnosis of PLRI can be difficult as the provocative tests are challenging to perform and radiographic studies are not helpful. Early recognition following acute trauma and attention to detail during open elbow procedures provide the best prevention of PLRI. Diagnostic arthroscopy is an excellent tool to demonstrate this instability. Although arthroscopic plication and repair have shown to be as effective as open techniques, the clinician should be prepared for open reconstruction if needed.

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