Abstract
Background: Posterolateral rotatory instability (PLRI) is a common form of recurrent elbow instability. The aim of this systematic review is to present the outcomes and complications of lateral ulnar collateral ligament (LUCL) reconstruction surgery for PLRI. Methods: A literature search of LUCL reconstructions was performed, identifying 99 potential papers; 11 of which met inclusion/exclusion criteria, accounting for 148 patients. Papers were included if they reviewed cases of PLRI from 1976 to 2016 with reported outcome measures. Data were pooled and analyzed focusing on patient demographics as well as subjective and objective patient outcomes and complications. Results: The average age of patients was 34 years with a mean follow-up time of 49.8 months. The most common mechanism of injury was a traumatic elbow dislocation (66%), followed by cubitus varus deformity (7%), and unknown mechanisms (7%). Overall, 90% of patients achieved elbow stability and 2.7% experienced a failed reconstruction that necessitated an additional surgery. Furthermore, 93% were satisfied with the outcome of the reconstruction, and 83% reported good to excellent outcomes with 11% reporting moderate to severe persistent pain. Nearly half (45%) of reconstructions were done using a palmaris longus tendon graft, 24% with a triceps tendon graft, and 7% with a synthetic graft. Conclusions: Outcomes following LUCL reconstruction for PLRI are excellent and revision rates are low. LUCL reconstruction is a safe and reliable procedure.
Level of Evidence: IV Therapeutic
Keywords: posterolateral rotatory instability, elbow instability, lateral ulnar collateral ligament, reconstruction
Introduction
Posterolateral rotatory instability (PLRI) is a common form of recurrent elbow instability. Descriptions of this injury were first reported by Osborne and Cotteril 1 in 1966, and this was further described by O’Driscoll et al 2 implicating the lateral ulnar collateral ligament (LUCL) as the primary stabilizer of the elbow against PLRI. Despite this, the functional anatomy of the remaining lateral elbow stabilizing structures demonstrates that PLRI represents a more complex problem than originally described.3-5 Although most cases of PLRI follow from elbow dislocations, additional causes of PLRI include iatrogenic, chronic overuse, or generalized ligamentous laxity. 6 Biomechanically, disruption in the lateral collateral ligament (LCL) complex leads to instability as this complex resists forced supination and external rotation of the forearm. 7 Therefore, when injured the ulna and radius rotate as a unit posterolaterally, losing its congruency with the distal humerus. 8 However, making the diagnosis may be difficult and is often delayed due to its variable presentation. 9
Bone block procedures and tendon transfers were traditionally used to treat PLRI; however, those were soon replaced by reparative and reconstructive techniques of the LUCL.10-12 Reconstruction of the LUCL is the most frequently used method for treating PLRI supported by multiple biomechanical studies, which show that isolated reconstruction of the LUCL appropriately restores varus and posterolateral rotatory stability of the elbow, particularly in sub-acute and chronic cases.13-15 Multiple reconstructive techniques have been described, and have demonstrated comparable clinical outcomes.16-18 However, only case series with relatively small cohorts have reported on clinical outcomes of LUCL reconstruction. The purpose of this systematic review is to present the overall outcomes and complications of LUCL reconstruction surgery.
Materials and Methods
Literature Search
A systematic review of the literature was performed to analyze the outcomes of LUCL reconstruction for PLRI of the elbow. PubMed, Google Scholar, and EBSCO were queried from 1975 to 2016 with combinations of search terms: lateral ulnar collateral ligament, posterolateral rotatory elbow instability, and LUCL reconstruction. Independent reviewers assessed methodology and quality of each study. Disagreement concerning study quality was moderated by the senior author. All identified articles had their reference section queried for additional relevant studies. We extracted homogenous data from studies that met the inclusion/exclusion criteria and generated frequency-weighted means. A systematic review was performed when data collected was sufficiently homogenous. The search resulted in 2179 potentially eligible studies, while 11 met inclusion and exclusion criteria (Figure 1).
Figure 1.
Systematic review formulation.
Note: LUCL = lateral ulnar collateral ligament.
Inclusion/Exclusion Criteria
The inclusion criteria for the studies were as follows: (1) published in English; (2) involved posterolateral rotary elbow instability secondary to trauma, iatrogenic damage, general laxity, and all other means; (3) functional outcome measures were analyzed; (4) reconstructive surgical intervention for each patient in the analysis; and (5) patient demographics presented including age and follow up time. The exclusion criteria were as follows: (1) published in any language other than English; (2) studies in which the patients did not get reconstructive specific surgical intervention; and (3) those lacking functional outcome measures.
The authors independently performed electronic searches. Abstracts with clearly or potentially relevant titles were browsed for relevance to LUCL disruption and PLRI elbow instability and were included as appropriate. If an abstract met inclusion/exclusion criteria, the authors reviewed the entire text to verify qualification. There was no discrepancy between the findings of the authors.
Data Extraction
We extracted and analyzed study design, demographic variables, type of graft, and all relevant surgical and functional outcomes, including subjective and objective stability, as well as complications. The authors independently extracted the data, then conferred and compiled the data.
Statistical Analysis
The weighted averages were calculated for the demographic and outcome data. Categorical data such as outcomes were pooled from the studies and used to determine the overall elbow stability, patient satisfaction, persistent pain, and Mayo Elbow Performance Score (MEPS) on postoperative follow-up. For each variable, the calculations were performed out of the total number of patients or elbows, which reported that variable. The authors assessed each aforementioned data set for homogeneity. Heterogeneous data were excluded from meta-analysis.
Surgical Technique
The various surgical techniques for reconstruction were also identified and commented on. These techniques primarily include Morrey’s original tunnel technique 16 and the contemporary docking technique. 17
Elbow Stability
Elbow stability was assessed both objectively and subjectively. Objective stability was determined by a member of the operative team during the postoperative physical exam in 144/147 of the patients available for follow-up. This was assessed via the lateral pivot-shift at the latest follow-up. Subjective stability in activities of daily living was evaluated at latest follow-up in 107/147 patients.
Results
There were 11 case series included, accounting for 148 patients. Analyses of the included case series are depicted (Table 1).
Table 1.
Included Studies, Study Characteristics, Outcomes and Complications.
| Included Studies | Recon | Mean age (years) | Recon technique | MOI | Mean follow up (Mo) | Mean Mayo Elbow Performance Score (MEPS) | Type of graft | Outcomes |
|---|---|---|---|---|---|---|---|---|
| Jones et al 17 | 8 | 40 (17-57) |
Docking technique
17
(8) |
1. Dislocation (4) 2. Iatrogenic degeneration (3) 3. Surgical complication (1) |
85.2 (62-114) |
87.5 (75-100) |
Palmaris longus tendon | 8/8 (100%) patients had objective elbow stability 6/8 (75%) patients had subjective stability 2/8 (25%) reported occasional instability with activities of daily living 8/8 (100%) were subjectively satisfied with outcome 4/8 (50%) no pain with activities of daily living 3/8 (38%) experienced mild pain with activity only 1/8 (13%) reported persistent mild pain with activity and at rest |
| Olsen and Sojbjerg 7 | 18 | 27 (14-50) |
Bone anchor fixation (18) |
Dislocation (18) | 44 (14-88) |
92 (60-100) |
Triceps tendon | 14/18 (78%) patients had objective elbow stability 17/18 (94%) patients had subjective elbow stability 3/18 (17%) had minor limitation to movement 15/18 (83%) returned to preaccident level of activity 17/18 (94%) were satisfied with outcome 13/18 (72%) had no or only occasional slight pain 1/18 (6%) Failure |
| Lee and Teo 19 | 6 | 34 (21-48) |
Morrey’s technique
16
(6) |
1. Varus Stress (2) 2. Unknown (2) 3. Dislocation (1) 4. Hyperextension (1) |
27.8 (9-52) |
NR | Palmaris longus tendon | 6/6 (100%) patients had objective elbow stability 6/6 (100%) patients had subjective elbow stability 3/6 (50%) Excellent; 2/6 (33%) Good; 1/6 (17%) Fair 3/6 (50%) no persistent pain 3/6 (50%) mild persistent pain |
| Lin et al 9 | 14 | 32 (18-60) |
Morrey’s technique
16
(14) |
Dislocation (14) | 49 (24-72) |
93.2 (65-100) |
Palmaris longus tendon (8), gracillis tendon (6) |
13/14 (93%) patients had objective and subjective elbow
stability 10/14 (71%) excellent; 3/14 (21%) good; 1/14 (7%) fair 9/14 (64%) had no residual pain 5/14 (36%) had mild persistent pain 1 re-operation of MCL for persistent instability |
| Sanchez-Sotelo et al 8 | 33 | 33 (12-68) |
Morrey’s technique
16
(33) |
1. Dislocation ± fracture (19) 2. Strain (6) 3. Unknown (4) 4. Previous surgery (3) |
69.6 (24-182) |
87.3 (60-100) |
Palmaris longus (20), triceps tendon (4), Achilles tendon (3), plantaris tendon (3), tendon of semitendinosus (2), NR (1) | 30/32 (94%) patients had objective elbow stability 27/32 (84%) were satisfied with outcome *1 patient lost to follow-up 14/32 (44%) had no residual pain 13/32 (41%) had mild persistent pain 15/32 (47%) Excellent; 10/32 (31%) Good; 5/32 (16%) Fair; 2/32 (6%) Poor |
| Vernet et al 20 | 18 | 38 (20-63) |
Morrey’s technique
16
(18) |
1. Dislocation ± fracture (11) 2. Elbow Trauma (7) |
61 (12-145) |
90 (60-100) |
Palmaris longus tendon | 15/15 (100%) patients had objective elbow stability 18/18 (100%) patients had subjective elbow stability 18/18 (100%) were satisfied or very satisfied with their result 18/18 (100%) patients returned to their previous activity 10/17 (59%) patients were free of pain, 5/17 (29%) reported only climate-related pain and 2/17 (12%) were taking occasional step-1 analgesics (1 lost to follow-up) - Mean Quick-DASH score was 21 |
| Nestor et al 16 | 8 | 29 (9-46) |
Morrey’s technique
16
(8) |
1. Dislocation ± fracture (4) 2. Varus stress (2) 3. Hyperextension (2) |
38 (4-144) |
NR | Palmaris longus (7), triceps tendon (1) |
5/8 (63%) patients had objective elbow stability 4/8 (50%) excellent; 3/8 (38%) fair; 1/8 poor (13%)-failure at 3 months |
| O’Driscoll et al 21 | 10 | 37 (13-60) |
NR | Cubitus varus deformity (10) | 48 (24-96) |
92.5 (75-100) |
NR | 10/10 (100%) patients had subjective and objective elbow
stability 7/10 (70%) excellent, 3/10 (30%) good, 0/10 (0%) poor 10/10 (100%) returned to preaccident level of activity |
| Eygendaal 18 | 12 | 35 (19-65) |
Modified docking technique, interference screws (12) |
Dislocation (12) | 23 (17-28) |
NR | Triceps tendon | 11/12 (92%) patients had objective elbow stability 11/12 (92%) reported subjective stability 1/12 (8.3%) occasional instability with ADLs 9/12 (75%) Excellent; 2/12 Good (17%); 1/12 (8%) Moderate |
| Johnston et al 22 | 11 | 47 (18-68) |
Docking technique 17 (11) | NR | 27.6 (14-43) |
89.5 (80-100) |
NR | 11/11 (100%) patients objective elbow stability 9/11 (82%) patients had subjective elbow stability 11/11 (100%) were satisfied with outcome 3/11 (27%) patients had full ROM 2/11 (18%) had subjective instability with a single activity (pushups or forceful gripping) - Mean Quick-DASH score was 19.4 |
| Tawari et al. 23 | 10 | 30 (16-50) |
Morrey’s technique
16
(10) |
1. Dislocation (7) 2. Unknown (3) |
27 (12-71) |
87.5 (45-100) |
Synthetic polyester ligament | 7/10 (70%) patients had objectively stable elbows with no feelings of recurrent instability |
| Overall | n = 148 | 34 (n = 148) |
1. Morrey’s technique (89/138) 2. Docking technique (19/138) 3. Bone anchor (18/138) 4. Interference screw (12/138) |
1. Dislocation ± fracture (90) 2. Cubitus varus deformity(10) 3. Unknown (9) 4. Iatrogenic (7) 5. Elbow trauma (7) 6. Strain (6) 7. Varus stress (4) 8. Hyperextension (3) |
49.8 (n = 147) |
89.7 (n = 122) |
*See Table 2 | 130/144 (90%) had objective elbow stability 97/107 (91%) had subjective elbow stability 100/107 (93%) were subjectively satisfied with outcome 85/95 (89%) had no to mild persistent pain 68/82 (83%) good to excellent outcomes 4/147 (2.7%) failed primary reconstruction, additional surgery required |
Note. Recon = reconstruction; MOI = mechanism of injury; Mo = months; NR = not reported; ROM = range of motion; MCL = medial collateral ligament; DASH = Disabilities of the Arm, Shoulder, and Hand; ADLs = activities of daily living.
The average age was 34 years and after an average follow-up of 49.8 months, the mean MEPS was 89.7. The most common mechanism of injury was a traumatic elbow dislocation at 66%. Overall, 90% (130/144) of patients had objective elbow stability and 91% (97/107) of patients had subjective elbow stability in the postoperative period. Furthermore, 93% were subjectively satisfied with the outcome of the reconstruction, and 83% reported good to excellent outcomes with 11% reporting moderate to severe persistent pain (Table 1).
Recurrent elbow instability was the only indication to return to the operating room. There were a total of 4 re-operations (2.7%). One episode of recurrent instability requiring repeat surgery was reported by Sanchez-Sotelo et al. 8 This patient had recurrent instability due to failure of the reinforced palmaris longus graft without a history of further trauma. Graft failure in Olsen and Sojbjerg 7 was secondary to a deficiency of the graft on the humeral side. Likewise, Nestor et al 16 described a single case of a reconstruction requiring a revision surgery. This was a patient who underwent an ulnar band of the radial collateral ligament reconstruction with the palmaris longus tendon, augmented with a prosthetic ligament, who had a positive lateral pivot shift at 3 months. Of note, this patient had already failed both a lateral repair and triceps autograft reconstruction in the past. Finally, Lin et al 9 reported 1 patient having persistent instability after surgery due to an undiagnosed medial collateral ligament (MCL) injury, which was subsequently treated with a semitendinosus tendon graft revision reconstruction. Postoperatively no recurrent instability was noted.
Overall, 10 of 11 articles present in this analysis provided enough information to comment on their surgical technique. Morrey’s technique 16 was used in the majority of the studies (6/10) accounting for 64% (89/135) of the LUCL reconstructions. Two studies involved a the docking technique. 17 One study described suture anchor fixation for LUCL reconstruction where the autograft was affixed using a single lateral epicondyle bone anchor and 2 supinator crest anchors. 7 Lastly, 1 study utilized a modified docking technique with both ulnar and humeral bioabsorbable interference screw fixation. 18
Nearly half (45%) of all reconstructions were performed using a palmaris longus tendon graft, 24% used a triceps tendon graft, and 7% used a synthetic graft. Less common grafts account for 9% of the total including the gracillis tendon, Achilles tendon, plantaris tendon, and semitendinosus tendon (Table 2).
Table 2.
Graft Selection for Lateral Ulnar Collateral Ligament Reconstruction.
| Type of reconstructive graft | Percent of total reconstructions (n = 148) |
|---|---|
| Palmaris longus tendon (n = 67) |
45 |
| Triceps tendon (n = 35) |
24 |
| Synthetic tendon (n = 10) |
7 |
| Gracillis tendon (n = 6) |
4 |
| Achilles tendon (n = 3) |
2 |
| Plantaris tendon (n = 3) |
2 |
| Semitendinosus tendon (n = 2) |
1 |
| Not reported (n = 22) |
15 |
Discussion
Our systematic review highlights positive clinical outcomes in patients with PLRI treated with LUCL reconstruction. Despite differences in surgical technique and graft selection, the reported outcomes of the included studies consistently demonstrate that LUCL reconstruction is successful in achieving lateral elbow stability while limiting pain in the setting of PLRI.
Most causes of PLRI are due to traumatic events, such as elbow dislocation, that are sustained in younger, more active populations, with an average age at time of reconstruction of 34 years. Concrete diagnosis of PLRI is often delayed and difficult to elicit requiring a careful history of elbow trauma in combination with a focused physical exam and imaging studies. For instance, Lin et al 9 report the mean time between injury and index surgery to be 45 months. A reason for the difficulty in diagnosis is that the instability exam in a patient with a painful elbow is very difficult to adequately perform. 24 Therefore, advanced imaging is often necessary to confirm the diagnosis. 15 In the acute traumatic setting, LUCL repair is an option if the soft tissues are amenable, however, given the frequent difficulty in diagnosis, repair is often not feasible as the soft tissues are irreparable. 8 Therefore, reconstruction of the lateral collateral ligament complex is the recommended choice to restore stability of the elbow in patients presenting with sub-acute to chronic PLRI.2,25,26
Despite the delay in diagnosis the surgical outcomes following LUCL reconstruction are generally excellent with 90% achieving postoperative elbow stability on physical exam with a MEPS of 89.7 at long-term follow-up. While recurrent instability is unlikely in the general population, an overhead athletic population, for example, may not have similar outcomes. Patient selection may also play a part in these excellent outcomes as most of the patients were of a younger population (34 years) possibly indicating better healing potential with less comorbid complicating conditions. In addition, a majority of patients in this review had full strength and range of motion of the elbow following surgical reconstruction. 18 ,19-22
While 10% of patients remained objectively unstable, only 2.7% underwent reoperation. Olsen and Sojbjerg 7 reported that despite having 4 patients with objective instability evidenced by persistent apprehension to the pivot-shift stress test at follow-up, 3 of the 4 were still subjectively satisfied with the results. The fourth, grossly unstable graft failed on the humeral side and underwent revision reconstruction. Although unknown, it is possible that the 3 lax, but satisfied patients underwent graft loosening, but retained enough subjective stability to provide a comfortable arc of motion. Lin et al 9 had 1 case of residual postoperative instability due to a concomitant MCL injury that went undiagnosed prior to LUCL reconstruction. MCL injuries are not uncommon in traumatic, complete elbow dislocations with some studies reporting up to 100% of patients (n = 15) having disruption.27,28 Therefore, a careful preoperative evaluation is warranted to assess for these concomitant injuries.
The most common complication following reconstruction was persistent moderate to severe pain with activity (11%, 10/95). Three of 10 patients described their pain with activity as severe, and all were within a single cohort. 8 One of the patients had severe pain secondary to recurrent instability, 1 patient had concurrent degenerative joint disease, and 1 had severe pain for unknown reasons. Mild activity-related pain was seen in many of the patients postoperatively (42%, 32/77 patients). For example, Vernet et al 20 reported that 29% of the cohort reported climate-related pain and 12% were taking occasional analgesics for pain. Despite pain in nearly a third of patients, all patients had stable elbows and every patient was either satisfied or very satisfied with their postoperative outcome. 21
There are 3 primary limitations to this study. First, the findings of this review are subject to the bias and error inherent to retrospective data collection. Most of the included articles are made up of single surgeon, non-blinded, small cohorts where reporting bias is likely to exist and negative outcomes may not be reported. Second, it is not infrequent for misdiagnosis where patients with imaging finding indicating LUCL disruption are mistakenly diagnosed with PLRI without having true instability. Lastly, the interpretation of outcomes are limited by their heterogeneity from report to report with variable outcome measures, non-standardized time points of follow-up and rehabilitation protocols, and varying patient activity demands limiting the eternal validity of our results.
Despite these limitations, we present the largest systematic review of LUCL reconstruction for PLRI of the elbow. With a careful history and physical exam supplemented by imaging studies, patients with PLRI can reliably attain a stable elbow with symptom relief following LUCL reconstruction. However, patients must be counseled about the potential for mild activity-related pain.
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: This article does not contain any studies with human or animal subjects.
Statement of Informed Consent: Informed consent was obtained when necessary.
Disclaimers: Some authors are employees of the U.S. Federal Government and the U.S. Army. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of William Beaumont Army Medical Center, the Department of Defense, or U.S. Government. Data presented in this investigation are derived from the Armed Forces Medical Examiner System (AFMES). The AFMES is not responsible for any claims arising from works based on the original data.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
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