Posterolateral Rotatory Reconstruction

Brian J. Kelly

Larry D. Field

Sterile Instruments/Equipment

• Sterile tourniquet

• Tendon stripper (if using autograft)

• 4-mm round burr

• Used to create bone tunnels for graft passage

• 1.5-mm round burr or drill bit

• Used to create bone tunnels for suture passage

• Curved awl

• Used to connect ulnar bone tunnels to facilitate graft passage

• Hewson suture passer

• No. 2 braided, nonabsorbable suture (surgeon preference)

• Implants

• Tendon allograft (if not using autograft)

• Suture anchors (if performing an open or arthroscopic ligament repair)

• Arthroscopic instruments

• 4-mm 30-degree arthroscope

• Interchangeable cannulas

• Retrograde suture retriever

• Suture grasper

• Arthroscopic knot pusher

• Suture for skin closure (surgeon preference)

• Dressing and splint material

Positioning

• The patient is positioned supine on a regular operating room table.

• The arm is placed on an arm board.

• Alternatively, the arm can be positioned across the patient’s chest.

• The extremity is prepared and draped according to surgeon preference such that the entire upper extremity is exposed.

• A sterile tourniquet is placed on the upper arm.

Surgical Approach

• The surgical approach is the same for all of the open reconstruction and repair techniques. There may be slight variation in the amount of dissection necessary depending on the location of bone tunnels.

• The incision begins 2-3 cm proximal to the lateral epicondyle and extends 8-10 cm distally toward the subcutaneous border of the ulna (Fig. 24-1).

Figure 24-1 | An 8-cm skin incision is marked over the Kocher interval using the supracondylar ridge (SR), lateral epicondyle (L), radial head (RH), and ulnar crest (UC) as palpable landmarks.

• The Kocher approach is used.

• The interval between the anconeus and extensor carpi ulnaris (ECU) muscles is identified, and the fascia is opened with a scalpel. The interval often can be defined by a thin fat stripe that is seen through the deep fascia (Fig. 24-2).

• The anconeus is elevated from distal to proximal to facilitate the clearest distinction from the underlying lateral ulnar collateral ligament (LUCL).

• The anconeus muscle is retracted posteriorly to expose the supinator crest, which is the ulnar attachment site of the LUCL (Fig. 24-3).

• The ECU muscle fibers are sharply dissected from the LUCL, and the muscle is elevated anteriorly along with some of the common extensor origin (Fig. 24-3).

• The lateral epicondyle and supracondylar ridge are cleared of soft tissue to obtain the exposure necessary for drilling the humeral bone tunnels. This often requires elevation of some of the common extensor origin and triceps muscle.

Figure 24-2 | Illustration (A) and intraoperative photo (B) show the incision made in the deep fascia between the ECU and the anconeus muscles. This interval often can be identified by a fat stripe deep to the fascia (red arrow). The dissection is continued proximally between the ECRL and the triceps to expose the supracondylar ridge.

Figure 24-3 | Illustration (A) and intraoperative photo (B) show the anconeus (AC) reflected posteriorly and the ECU reflected anteriorly to reveal the LUCL (yellow arrow) and supinator crest (black arrow). L Epi, lateral epicondyle.

Graft Options

• Palmaris longus autograft

• Gracilis autograft

• Semitendinosus autograft

• Plantaris autograft

• Multiple allograft options

Docking Technique^1-5

• Ulnar tunnel preparation

• The first hole is created with a 4-mm burr near the tubercle on the supinator crest; this should be distal to the radial head-neck junction to ensure the most stable construct (Fig. 24-4).

• The second hole is created with a 4-mm burr at the proximal aspect of the supinator crest near the insertion of the annular ligament. A sufficient bone bridge of 15-20 mm is maintained between the two tunnels (Fig. 24-4).

Figure 24-4 | Illustration (A) and intraoperative photo (B) show the proximal and distal ulnar holes, which are created along the supinator crest with a 4-mm burr, leaving at least a 15- to 20-mm bone bridge. It is important that the distal hole (yellow arrow) is distal to the radial head-neck junction to ensure the most stable construct. The proximal hole (black arrow) is located near the insertion of the annular ligament. RH, radial head.

• While the supinator tubercle may be palpable only ˜50% of the time, the distal tunnel should be placed ˜15 mm distal to the proximal margin of the radial head.⁶,⁷

• These holes do not need to be drilled deeper than the cortex. A curved awl is used to create an osseous tunnel connecting the two holes while taking care not to violate the bone bridge.

• Humeral tunnel preparation

• Identification of the isometric point is facilitated by passing a suture through the two ulnar tunnels and tying it to itself. The proximal end of the suture is held over the lateral epicondyle while the elbow is flexed and extended. The location where the suture does not move during the range of motion is the isometric point (Fig. 24-5). It is typically located anterior and inferior to the center of the lateral epicondyle.¹

• A 4-mm burr drilled to a depth of 15 mm is used to create the humeral docking site at the isometric point (Fig. 24-6).

Figure 24-5 | Identification of the isometric point. A suture is passed through the two ulnar tunnels and tied to itself. The proximal end of the suture is held over the lateral epicondyle with a hemostat while the elbow is flexed and extended. The location where the suture does not move during the range of motion is the isometric point.

Figure 24-6 | Illustration (A) and intraoperative photo (B) show the humeral bone tunnels. A 4-mm burr is used to make the larger tunnel at the previously identified isometric point (marked on lateral epicondyle with skin marker). A 1.5-mm burr is used to make the proximal holes for suture passage; these are angled toward the isometric point to facilitate suture passage. A bone bridge of at least 10 mm is left between all three holes. In the illustration, the Krackow sutures through the anterior and posterior capsule can also be seen. RH, radial head.

• A 1.5-mm burr or drill bit is used to drill two additional holes to a depth of 15 mm angled toward the isometric point tunnel and with bone bridges of at least 10 mm between each of the three holes (Fig. 24-6).

▪ A Hewson suture passer is used to pass a looped suture from each of these holes, exiting from the humeral docking tunnel; these will be used to facilitate graft passage and the optional capsular repair/plication.

• Capsular repair/plication

• The capsule is often patulous, and it can be repaired and tightened in conjunction with graft passage.

• The capsule, with any residual LUCL, is incised linearly along its fibers.

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