Elbow Rehabilitation After Lateral Collateral Ligament Reconstruction



Elbow Rehabilitation After Lateral Collateral Ligament Reconstruction


Shannon R. Carpenter, MD

Vikram M. Sathyendra, MD

Anand M. Murthi, MD


Dr. Murthi or an immediate family member has received royalties from Integra Orthopaedics; serves as a paid consultant to Arthrex, Integra Orthopaedics, and Zimmer; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Current Opinion in Orthopaedics and the Journal of Bone and Joint Surgery–American; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Shoulder and Elbow Surgeons, Current Orthopaedic Practice, the Journal of Bone and Joint Surgery–American, and the Journal of Shoulder and Elbow Surgery. Neither Dr. Sathyendra nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.



Introduction

The lateral ligament complex plays a critical role in stability of the elbow. All elbow dislocations and many elbow fracture dislocations include injury of the lateral ligament complex.

An incompetent lateral collateral ligament (LCL) complex may cause recurrent dislocations or posterior lateral rotatory instability (PLRI), the latter more commonly than the former. In addition, iatrogenic lateral ligament insufficiency is an uncommon complication of surgical treatment of lateral epicondylitis. Repair of the lateral capsule and ligamentous complex is recommended for adolescents and adults with symptomatic recurrent dislocation of the elbow to restore elbow stability and function.


Relevant Anatomy

The LCL complex includes four components (Figure 16.1). The LCL originates from the lateral epicondyle of the humerus and attaches to the annular ligament. The lateral ulnar collateral ligament (LUCL) originates from the isometric point on the lateral epicondyle and attaches to the supinator crest on the ulna. The annular ligament originates from and inserts onto the anterior and posterior aspects of a sigmoid notch, respectively, and encircles the radial neck. The accessory LCL originates from the annular ligament and attaches onto the supinator crest of the ulna. The function of the LCL complex is to resist rotatory instability of the elbow. PLRI can occur after a simple elbow dislocation when the posterolateral capsular and ligamentous structures fail to reattach or from chronic attenuation of the LCL complex after multiple injuries. Incompetence of the lateral complex allows the forearm to rotate and translate in supination and posteriorly away from the distal humerus.


Patient Evaluation

Patients with PLRI often have a history consistent with an ulnohumeral dislocation. In the acute injury setting, a thorough physical exam should be conducted, including neurovascular exam and range of motion (ROM) of the affected extremity. To perform a reduction of the elbow joint, an axial compressive and valgus force are applied to the elbow with the forearm in full supination. As the elbow is slowly brought from an extended position into a flexed position, the ulnohumeral joint would reduce from a subluxed or dislocated position. In the chronic setting, patients with PLRI present either later after a traumatic injury or after surgery with symptoms that range from mild mechanical clicking or vague elbow pain to frank subluxation or dislocation. Diagnosis of subtle PLRI can be very challenging, and because of guarding, it can be difficult to perform an adequate physical examination in the clinic on an awake patient. Examination under anesthesia with fluoroscopic imaging may be required to make a definitive diagnosis.

Two tests, in particular, are most helpful: the supine rotatory instability test (or pivot shift test) and the drawer test. In order to perform the supine lateral pivot shift test, the patient is placed supine on the examination table with the elbow in approximately 30° of flexion and full supination. This position causes the elbow to subluxate. The examiner then applies a valgus load to the elbow while continuing to flex the elbow fully. As this occurs, the subluxed radial head can be palpated as it relocates. A clunk may be elicited. This test may also be performed with the patient in the prone position. Patient
guarding can make it difficult to elicit the diagnosis from this examination. The drawer sign can also be used to make the diagnosis of PLRI. With the patient supine on the table, the affected arm is brought over the patient’s head, with the forearm fully supinated. The examiner then places the index finger posterior to the radial head and the thumb anterior. The examiner attempts to translate the radius posteriorly. The sign is considered positive if the radial head is felt to subluxate, in which case PLRI is likely present.






Figure 16.1 A, Illustration demonstrating the bony and ligamentous anatomy of the lateral elbow. B, Illustration of the bony anatomy of the lateral ulna and radius with the lateral collateral ligament complex stripped off. (A reproduced with permission from Mehta JA, Bain GI: Posterolateral rotatory instability of the elbow. J Am Acad Orthop Surg 2004;12:405–415. B adapted with permission from Bain GI, Mehta JA: Anatomy of the elbow joint and surgical approaches, in Baker CL Jr, Plancher KD [eds]: Operative Treatment of Elbow Injuries. New York, NY, Springer-Verlag, 2001, pp 1–27.)

In addition, patients with PLRI can report pain and difficulty while rising from a chair using their arms or trying to perform push-ups. A chair push-up test may be performed in which patients are asked to push themselves up from a chair with the forearm in supination. The test is positive if there is pain with resisted elbow extension, which may be indicative of PLRI.


Surgical Procedure


Indications

The indications for surgery include elbow pain, functional limitation, and instability. In the setting of chronic instability of the elbow in adolescents and adults, nonoperative treatment is attempted. Typically, in either acute or chronic dislocations, the lateral ligamentous complex is repaired first, then the MCL is examined for instability. In the absence of gross medial instability, the MCL is not repaired, even in complex elbow fractures such as a terrible triad.



Procedure: Open Repair

The patient is given general anesthesia and a tourniquet is applied to the upper extremity. A lateral pivot shift test is performed to confirm posterolateral rotatory instability of the elbow joint. Next, a modified Kocher approach is made between the extensor carpi ulnaris and the anconeus muscles (Figure 16.2, A and B). In acute injuries, there is often a disruption of the extensor muscle and overlying fascia. This rent in the fascia and muscle can be extended proximally and distally. We extend it proximally to the lateral epicondyle. Once the lateral epicondyle is identified, the common extensor origin is elevated and the proximal stump of the LUCL is identified (Figure 16.2, C). The LCL complex typically avulses off of the humeral insertion, but can also avulse off of the ulna. The hematoma is removed and the forearm is pronated to reduce the ulnohumeral joint and, concomitantly, the radiocapitellar joint. Next, the isometric point of the elbow at the lateral epicondyle is identified and a suture anchor or transosseous drill holes are placed at the isometric point. A locking stitch is placed into the LUCL stump and reattached to the lateral epicondyle. The common extensor origin is also repaired to the lateral epicondyle. In the acute setting, associated bony injury that may contribute to instability must also be addressed and appropriately fixed and repaired.


Procedure: Open Reconstruction

The LUCL is reconstructed using tissue grafts fixed to the ulna and the isometric point of the lateral elbow (Figure 16.3). The
set-up and approach for open reconstruction of the LUCL is very similar to that described earlier for the open-repair technique. A modified Kocher approach is used. The common extensors are reflected anteriorly and the anconeus is reflected posteriorly, revealing the disrupted and/or deficient ligaments. Both the lateral epicondyle and the supinator crest are exposed. A pivot shift test will reveal laxity of the capsule over the radiocapitellar joint. The joint is examined for any loose bodies or articular cartilage damage. If the ligament is lax but the tissue is of good quality, then both the radial and the ulnar portions of the LCL are imbricated. The anterior and posterior capsule surrounding the radiocapitellar joint is also imbricated. In cases of deficient or poor-quality tissue, a graft is used to reconstruct the ligament. A variety of grafts can be used. Most commonly, a palmaris longus autograft from the involved forearm is used. However, if the patient does not have a palmaris longus, a gracilis tendon autograft of allograft can be used.






Figure 16.2 Standard Kocher approach to the elbow. A, Clinical photograph showing landmarks and incision. B, Clinical photograph showing interval between the anconeus (A) and extensor carpi ulnaris (E); supracondylar ridge (SR), lateral epicondyle (L), radial head (RH), ulnar crest (UC). C, This clinical photograph shows that after opening the interval, the torn LCL (L) and the annular ligament (AL) can be visualized.

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Oct 13, 2018 | Posted by in ORTHOPEDIC | Comments Off on Elbow Rehabilitation After Lateral Collateral Ligament Reconstruction
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