Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

397. Lateral Collateral Ligament Reconstruction of the Elbow

Jason A. Stein and Anand M. Murthi

DEFINITION

images Lateral collateral ligament (LCL) injuries most often occur after significant elbow trauma, most commonly dislocation.

images Attenuation of the LCL can also occur after multiple surgeries to the lateral side of the elbow and after multiple corticosteroid injections4 and has recently been reported to occur in patients who have residual cubitus varus after malunion of supracondylar humerus fractures.7

images Significant injury to the LCL complex can result in posterolateral rotatory instability (PLRI).

ANATOMY

images The LCL is made up of four major components: the lateral ulnar collateral ligament (LUCL), also called the radial ulnohumeral ligament (RUHL); the radial collateral ligament proper (RCL); the annular ligament; and the accessory collateral ligament (FIG 1).

images The ligaments originate from a broad band over the lateral epicondyle, deep to the extensor muscle mass, and separate distally into more discrete structures.

images The RUHL is the most important stabilizer against PLRI, and it attaches distally on the supinator crest of the ulna.6

images The RCL is more anterior and primarily resists varus stress.

images The annular ligament sweeps around the radial head and stabilizes the proximal radioulnar joint.

images The capsule acts as a static stabilizer, especially at the anterior portion, while the arm is extended.

images The anconeus and extensor muscle groups act as dynamic stabilizers.

PATHOGENESIS

images Multiple studies have shown that injury to the LCL can lead to PLRI, which is the first stage in elbow instability that can lead to frank elbow dislocation.

images It is controversial whether injury to the RUHL alone can lead to PLRI or whether further injury to the LCL complex is necessary.5

images When the forearm is supinated and slightly flexed, a valgus stress with an attenuated LCL causes the ulnohumeral joint to rotate, compresses the radiocapitellar joint, and ultimately causes the radial head to subluxate or dislocate posteriorly.

NATURAL HISTORY

images PLRI is not a new condition, but it has only recently been described and studied.

images The prevalence and natural history of this condition are currently not known.

PATIENT HISTORY AND PHYSICAL FINDINGS

images Patients typically report trauma but may have had recurrent lateral epicondylitis or previous surgery.

images Elderly patients may not have frank dislocation of the elbow, but 75% of patients younger than 20 years report elbow dislocation.5

images Patients report mechanical-type symptoms (clicking, popping, and slipping) during elbow supination and extension and rarely report recurrent dislocations.

images Physical examination can be difficult; provocative tests are described below. It is often necessary to conduct these tests with the patient under anesthesia or with the aid of fluoroscopy.

images Inspection for effusion: With acute injuries, effusion is likely to be present, but in more chronic situations, it may be absent.

images Range of motion (ROM): Locking of the elbow could represent loose bodies; stiffness may indicate intrinsic capsular contracture.

images

FIG 1  A. The lateral collateral ligament complex is made up of four major components: the lateral ulnar collateral ligament, also called the radial ulnohumeral ligament; the radial collateral ligament proper; the annular ligament; and the accessory collateral ligament. B. Osseous anatomy of the lateral collateral ligament insertion.

images Supine lateral pivot-shift test: When the elbow is slightly flexed, the radial head can be palpated to subluxate or frankly dislocate, and as the elbow flexes past 40 degrees, it relocates, often with a palpable clunk.6 This test is difficult to perform on an awake patient because often apprehension is felt and the patient does not allow the test to continue.

images Prone pivot-shift test: Radial head or ulnohumeral subluxation constitutes a positive test, same as the supine lateral pivot-shift test. Examination under anesthesia may be required.

images Push-up test: Reproduction of the patient’s symptoms of apprehension during supination and not pronation constitutes a positive test. Inability to complete the push-up also constitutes a positive test.

images Chair push-up: Elicited pain constitutes a positive test.

images Table-top relocation test: Elicited pain or apprehension as the elbow reaches 40 degrees constitutes a positive test.

images Elbow drawer test: Ulnohumeral subluxation constitutes a positive test.

images A thorough examination of the elbow should also be completed to rule out other injuries.

images Valgus instability with the forearm in pronation and 30 degrees of flexion suggests medial collateral ligament (MCL) injury.

images Lateral epicondylitis or radial tunnel syndrome can present with tenderness over the proximal extensor mass and with resisted extension of the wrist (Thompson test) and long finger.

images Loose bodies may present with crepitus or locking of the elbow during ROM.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Standard anteroposterior (AP) and lateral view radiographs often indicate normal findings but may reveal small lateral epicondyle avulsion fractures and radiocapitellar wear.

images Stress AP and lateral view radiographs may reveal widening of the ulnohumeral joint and posterior subluxation of the radial head (FIG 2A).

images Magnetic resonance imaging (MRI), especially with intraarticular contrast enhancement, may reveal injuries to the LCL complex. The proximal extensor mass requires attention (FIG 2B).

images Diagnostic arthroscopy of the elbow can be performed, although we do not recommend routine diagnostic arthroscopy for this injury.

images The drive-through sign occurs when the scope can easily be “driven through” the lateral gutter into the ulnohumeral joint from the posterolateral portal.

images The pivot-shift test also can be performed during arthroscopy, and the radial head will subluxate posteriorly.

DIFFERENTIAL DIAGNOSIS

images Lateral epicondylitis

images Loose bodies

images Elbow fracture-dislocation

images MCL injury

images Radial head dislocation

NONOPERATIVE MANAGEMENT

images If the injury is diagnosed early, immobilization in a hinged elbow brace in pronation for 4 to 6 weeks may prevent chronic instability.3

images Removable neoprene sleeves may offer support.

images A trial of elbow extensor strengthening can be performed.

SURGICAL MANAGEMENT

Indications

images Recurrent symptomatic PLRI despite nonoperative treatment

Preoperative Planning

images All imaging studies should be reviewed and informed consent obtained.

images An examination of the elbow should be performed with the patient under anesthesia, especially the pivot-shift test.

images If there is any doubt regarding the diagnosis, a pivot-shift test should be performed under fluoroscopy.

Positioning

images The patient is placed supine on the operating room table.

images The arm can be placed on an arm board or across the patient’s chest with a sterile tourniquet applied to the upper arm and the entire arm draped free (FIG 3).

images During the approach, the forearm should be pronated to protect the posterior interosseous nerve.

images

FIG 2  A. Lateral view stress radiograph reveals complete ulnohumeral and radial head (RH) rotatory instability. O, olecranon. B. Coronal oblique view magnetic resonance image of elbow (with contrast enhancement). Lateral collateral ligament disruption can be seen (arrow).

images

FIG 3  The patient is placed supine on the operating room table. The arm is placed on an arm board with a sterile tourniquet applied to the upper arm and the entire arm draped free. During the approach, the forearm should be pronated to protect the posterior interosseous nerve.

Approach

images The main approach is the Köcher interval between the anconeus and extensor carpi ulnaris muscles.

images This can be accomplished through a lateral skin incision or through a utilitarian posterior incision.

images A posterior incision should be considered if a medial approach will also be needed to repair concomitant ligamentous or bony injury.

TECHNIQUES

FIGURE 8 YOKE TECHNIQUE

Surgical Approach

images  A 10-cm incision is made over the Köcher interval.

images The interval between the anconeus and the extensor carpi ulnaris is developed, and the remainder of the LCL complex is identified along with the supinator crest and the lateral epicondyle.

images  The lateral epicondyle and 2 cm of the supracondylar ridge are exposed.

Tunnel Placement

images  Two drill holes for the graft insertion site are made in the ulna.

images One is drilled near the tubercle of the supinator crest (palpate in supination and varus stress), the other 1.25 cm proximal to that, near the insertion of the annular ligament (TECH FIG 1A).

images  A suture is passed through the two holes and tied to itself. The suture is then held up against the lateral epicondyle as the elbow is ranged in flexion and extension to determine its isometric point.

images The isometric ligament insertion occurs at the point where the suture does NOT move.

images The isometric point is usually more anteroinferior than expected (TECH FIG 1B,C).

images  A Y-shaped tunnel is made with the base exiting at the isometric point.

images The hole is widened to accept a three-ply graft. (Palmaris longus is usually harvested; if not present, gracilis or allograft is used.) A 16-cm graft is usually sufficient.

Graft Passage and Tensioning and Wound Closure

images  The graft is passed through the ulnar tunnel with enough length to just reach the isometric point.

images The end is then sutured to the long end of the graft

(the Yoke stitch).

images The long end is then passed through the isometric point and exits the superior humeral tunnel (TECH FIG 2A).

images



images

TECH FIG 1  A. Two drill holes for the graft insertion site are made in the ulna. One is drilled near the tubercle of the supinator crest (palpate while varus and supination applied); the other is drilled 1.25 cm proximal, near the insertion of the annular ligament. 1, proximal hole near insertion of annular ligament; 2, tubercle of supinator crest. B. The ulnar holes should lie perpendicular to the intended direction of the lateral ulnar collateral ligament. C. A suture is passed through the two holes and tied to itself. The suture is then held up with a hemostat against the lateral epicondyle as the elbow is ranged in flexion and extension to determine its isometric point. No movement occurs if the suture is at the isometric point.

images  The long end is wrapped around the supracondylar ridge and passed through the distal tunnel, exiting back through the isometric point and into the ulnar tunnel.

images The graft is then tensioned in 40 degrees of flexion, full pronation, and axial tension.

images If the graft is not long enough to reach the ulnar tunnel, it can be sutured back to itself (TECH FIG 2B).

images  The reconstruction can be reinforced by weaving a no. 2 Fiberwire suture (Arthrex, Inc., Naples, FL) from distal to proximal through the course of the figure 8, thus sewing the graft to itself.

images  Plicate the anterior and posterior capsule as needed.

images  The extensor origin is repaired to the lateral epicondyle, and the extensor carpi ulnaris fascia is reapproximated to the anconeus muscle with absorbable sutures.

images

TECH FIG 2  A. A Y-shaped tunnel is made with the base exiting at the isometric point (3). The hole is widened to accept a three-ply graft. The tendon graft is passed through the ulnar tunnel (1 → 2) with enough length to just reach the isometric point. The end is then sutured to the long end of the graft (the Yoke stitch). The long end is then passed through the isometric point and exits the superior humeral tunnel (3 → 4). B. The long end is then passed through the distal tunnel, exiting back through the isometric point (5 → 3) and into the ulnar tunnel (3 → 1 → 2). The graft is then tensioned in 40 degrees of flexion, full pronation, and axial tension. If the graft is not long enough to reach the ulnar tunnel, it can be sutured back to itself.

SPLIT ANCONEUS FASCIA TRANSFER

images  We have developed a reproducible technique for LCL reconstruction that has proved biomechanical strength and reproducibility.

images  Advantages include using only local autograft tissue and the minimal creation of bone tunnels.1,2

Surgical Approach

images  A 6- to 8-cm skin incision is made over the Köcher interval, exposing the underlying Köcher interval between the extensor carpi ulnaris and anconeus (TECH FIG 3A,B).

images  The interval between the anconeus and extensor carpi ulnaris muscles is developed, taking care to preserve the remainder of the underlying LCL complex.

images The annular ligament, lateral epicondyle, and 2 cm of supracondylar ridge are isolated (TECH FIG 3C).

Graft Preparation

images  The anconeus and distal triceps fascia are isolated in continuity. A 1.0-cm-wide by 8.0-cm-long band of fascia is mobilized off the underlying muscle, leaving the ulnar insertion intact (TECH FIG 4A,B).

images

TECH FIG 3  A. A 6to 8-cm skin incision is made over the Kocher interval. SR, supracondylar ridge; L, lateral epicondyle; RH, radial head; UC, ulnar crest. B. The underlying Kocher interval between the extensor carpi ulnaris (E) and anconeus (A) is exposed. C. The interval between the anconeus (A) and the extensor carpi ulnaris (E) is developed, taking care to preserve the remainder of the underlying lateral collateral ligament complex (held in forceps). The annular ligament (AL), lateral epicondyle (L), and 2 cm of the supracondylar ridge are isolated.

images  The band is then divided longitudinally into two bands of equal width (TECH FIG 4C).

images  The anterior band is passed through an incision just distal to the annular ligament while the posterior band is passed under the anconeus muscle (TECH FIG 4D).

images  The isometric point of the lateral epicondyle is then located by holding the two bands against the epicondyle while ranging the elbow (TECH FIG 4E).

images  The final lengths of the fascial bands are estimated by holding the bands along their respective paths. The bands are then trimmed appropriately to prevent them from “bottoming out” prematurely in the humeral docking tunnel.

images  Separate Krackow sutures are placed in each band with no. 0 FiberWire suture.

Tunnel Preparation

images  A 5-mm round burr is used to create a 1.5-cm-long(depth) docking tunnel into the humerus at the isometric point. A 1-mm side-cutting burr is then used to make anterior and posterior bone bridge holes. The holes are separated by 1.5 cm. Individual suture lassos are placed from proximal to distal into the docking tunnel from the separate humeral tunnels (TECH FIG 5).

images



images

TECH FIG 4  A. The anconeus and distal triceps fascia are isolated in continuity. B. A 1.0-cm-wide by 8.0-cm-long band of fascia is mobilized off the underlying muscle, leaving the ulnar insertion. C. The split anconeus fascia band is then divided longitudinally into two bands of equal width. A, anterior band; P, posterior band; U, ulnar insertion point. D. The anterior band (thin arrow) is passed through an incision just distal to the annular ligament (AL) while the posterior band (thick arrow) is passed under the anconeus muscle (A). E. The isometric point of the lateral epicondyle (L) is then located by holding the two bands against the epicondyle while ranging the elbow. The point of minimal tension loss in either band while ranging the elbow is the optimal isometric point. Arrows, anterior and posterior split anconeus fascia bands.

Graft Passage and Tensioning and Wound Closure

images  The anterior band sutures are brought out the anterior humeral exit hole by using suture passers. The posterior band passes superficial to the annular ligament, and its sutures are brought out the posterior humeral exit tunnel.

images  The ends of the fascial bands are docked into the humeral tunnel, and the grafts are tensioned with the elbow in 40 degrees of flexion, in full pronation, and with a valgus stress.

images  The sutures are then tied over the bony bridge on the supracondylar ridge (TECH FIG 6A).

images  The extensor origin is then repaired to the lateral epicondyle and the extensor carpi ulnaris fascia is reapproximated to the anconeus muscle with absorbable sutures.

images  The skin is closed with a running subcuticular suture (TECH FIG 6B).

images

TECH FIG 5  A. Suture lassos passed through exit holes out distal docking tunnel. SCR, supracondylar ridge. B. Suture lasso wires exiting docking tunnel.

images

TECH FIG 6  A. The ends of the fascial bands are docked into the humeral tunnel, and the grafts are tensioned with the elbow in 40 degrees of flexion, full pronation, and valgus stress. Sutures are then tied over the bony bridge on the supracondylar ridge (clamp on posterior band). B. The incision is closed with subcuticular suture.

DOCKING TECHNIQUE

images  As previously discussed, the Köcher approach is used for the docking technique.

images  Preparation of the ulnar drill holes is described in the section on the figure 8 yoke technique elsewhere in this chapter.

images  A 5-mm round burr is used to create a 1.5-cm-long (depth) docking tunnel into the humerus at the isometric point. A 1-mm side-cutting burr is then used to make anterior and posterior bone bridge holes. The holes are separated by 1.5 cm. Individual suture lassos are placed from proximal to distal into the docking tunnel from the separate humeral tunnels (see Tech Fig 5).

images  After passage of the graft through the ulnar tunnels, the final lengths of the two graft strands are estimated by holding the strands against the docking tunnel with the arm in the “reduced” position of 40 degrees of flexion, full pronation, and axial tension.

images  The strands are then trimmed appropriately to prevent the strands from “bottoming out” prematurely in the humeral docking tunnel.

images Separate Krackow sutures are placed in each graft strand with no. 0 FiberWire suture for 1 cm.

images  The anterior graft strand sutures are brought out the anterior humeral exit hole by using suture passers. The posterior graft strand sutures are brought out the posterior humeral exit tunnel.

images  The ends of the humeral graft portion are docked into the humeral tunnel, and the grafts are tensioned with the elbow in 40 degrees of flexion, in full pronation, and with a valgus stress.

images  The sutures are then tied over the bony bridge on the supracondylar ridge.

images  Standard incision closure is performed.

DIRECT REPAIR

images  As previously discussed, the Köcher approach is used for direct repair.

images  If the LCL complex is intact but avulsed from its ulnar or humeral attachments (or both), it can be directly repaired to its correct anatomic location with suture anchors or bone tunnels.

images  A running locked no. 2 FiberWire suture is placed into the detached LCL complex and repaired back to its origin on the lateral epicondyle through the anterior and posterior drill holes (TECH FIG 7).

images  A careful repair of the extensor origin and the interval between the anconeus and the extensor carpi ulnaris is performed.

images

TECH FIG 7  Primary lateral ulnar collateral ligament repair. Running locked suture placed through detached lateral ulnar collateral ligament. A relaxing incision can be made at its attachment to the base of the annular ligament. Repair through drill holes in the lateral epicondyle.

PEARLS AND PITFALLS

images

POSTOPERATIVE CARE

images Stage I (0 to 3 weeks.

images Elbow immobilization in posterior splint or brace at 40 degrees of flexion

images Wrist and hand isometrics as tolerated

images Shoulder active and passive ROM

images Stage II (3 to 6 weeks.

images Hinged elbow brace or orthoplast splint, with limits set by surgeon

images Begin flexor–pronator isometrics

images Continue with wrist and hand strengthening

images Continue shoulder as above

images Active-assisted ROM: 20 to 120 degrees of flexion; keep forearm pronated at all times

images Stage III (6 to 12 weeks.

images Discontinue immobilization

images Passive ROM and active-assisted ROM to full motion, including supination

images Begin unrestricted strengthening of flexor–pronators and extensors

images Stage IV (3 to 6 months.

images Avoid varus stress to elbow and ballistic movement in terminal elbow ranges

images Begin shoulder strengthening with light resistance (emphasis on cuff)

images Start total body conditioning

images Terminal elbow stretching in flexion and extension

images Resistive elbow exercises as tolerated

OUTCOMES

images Nestor et al5 have shown successful functional outcomes in patients using the figure 8 reconstruction technique with reproducible results.

images Our early experience with the split anconeus fascia reconstruction technique has shown excellent results, with no failures to date in 22 patients at an average follow-up of 2 years. All elbows have achieved stability without loss of motion.

COMPLICATIONS

images Recurrent elbow instability

images Elbow stiffness

images Infection

images Graft harvest site morbidity (if remote autograft is used for reconstruction)

images Humerus stress fracture through bone tunnels

images Ulnar stress fracture through bone tunnels

images Bone bridge compromise

REFERENCES

1. Chebli CA, Murthi AM. Lateral collateral ligament complex: anatomic and biomechanical testing. 73rd Annual Meeting and Scientific Program of the American Academy of Orthopaedic Surgeons, Chicago, March 2006.

2. Chebli CM, Murthi AM. Split anconeus fascia transfer for reconstruction of the elbow lateral collateral ligament complex: anatomic and biomechanical testing. 22nd Open Meeting of the American Shoulder and Elbow Surgeons. Chicago, IL, March 2006.

3. Cohen MS, Hastings H II. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg 1998;6:15–23.

4. Kalainov DM, Cohen MS. Posterolateral rotatory instability of the elbow in association with lateral epicondylitis: a report of three cases. J Bone Joint Surg Am 2005;87A:1120–1125.

5. Nestor BJ, O’Driscoll SW, Morrey BF. Ligamentous reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1992;74A:1235–1241.

6. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73A:440–446.

7. O’Driscoll SW, Spinner RJ, McKee MD, et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001;83A:1358–1369.



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