Lateral Elbow Instability Repair and Augmentation Conflict of Interest is recorded on the Academy website. Elbow instability can be medial or lateral. Lateral instability is more common in a regular patient population as opposed to an athletic population. It often follows a relatively minor injury and is associated with tennis elbow. Most likely the instability pre-existed the damage to the extensor carpi radialis brevis and may well have caused the tendon failure. Posterolateral Rotatory Instability is a dysfunction of the radial ulno-humeral ligament complex. This includes the radial ulno-humeral ligament, the annular ligament, and the lateral collateral ligament. Examination for PLRI will show a shift and pop with supination in the most severe cases. Lateral instability does cause a significant impairment of activities of daily living as twisting the hand, opening a door, turning a key may cause shifting, popping, and pain in the elbow. The PLRI test supine as described by O'Driscoll can be done that way or prone. The chair lift as described by Reagan or the internal rotation push up are also good tests to do. My best test for subtle PLRI is to flex the elbow to about 100 degrees, supinate with a slight valve of stress, while keeping my thumb on the radial head. The initial management of PLRI may include non-operative treatment, including a brace or a sleeve, physical therapy, sometimes an injection of cortisone or other anti-inflammatory may be helpful, period. Most of the time, if it's significant enough, surgery should be contemplated. On radiographs, you may see a loose body in the joint on the lateral x-ray. An MRI scan will often show fluid dissecting into the lateral collateral and radial ulnar humeral ligament attachments to the lateral epicondyle. Radiographs again will show on the lateral image some sagging of the radial head on the capitellum. If a plain MRI is used, we really need a high Tesla scanner for fine detail. An MR arthogram is probably the best test for elbow ligament injuries and in these cases will show detachment of the radial collateral ligament as well as the radial ulnar humeral ligament. Sometimes that fluid will be captured beneath the extensor carpi radialis brevis or longest tendon and sometimes it will dissect posterior to both tendons and come up the back of the elbow as seen on this MRI scan. Conditions for surgery are primarily a failure of non-operative management, ongoing pain and functional impairment, and the surgeon's familiarity with the lateral elbow anatomy. In most cases, a repair will work much better than a reconstruction assuming you understand the anatomy and can delineate it on MRI scan and on surgery. When viewing the anterior aspect of the elbow from a proximal anterior medial portal, one can notice the sagging of the anterior ligament away from the radial head, sometimes chondromalation on the radial head, and the abnormal movement back and forth with pronation and supination of that radial head in relation to the capitellum. With the arthroscope in the posterior or posterolateral portal, one can move down the lateral gutter as seen in this left elbow. As we come down to that area with a relatively acute or subacute injury, you can certainly see the avulsion of the entire lateral capsule from its humeral attachment. This is usually pretty obvious even in chronic cases where the texture of the capsule and ligament change, and you can see where the normal capsule should be back attached to the humerus. One of the advantages of arthroscopy is this allows a precise anatomic placement of an anchor in order to repair that radial ulnar humeral ligament and lateral collateral ligament. In this view from a posterior central portal, one can see the ulna gapped away from the humerus and this large fragment of bone within the joint. This is not a free loose body, but actually has the capsule attached to it. As we move over to the lateral gutter, you can see the bed where this fragment of bone should be attached to the humerus. It is vitally important when doing an arthroscopy of a relatively acute injury that one looks for this fragment of bone and puts it back at its normal origin site in order to repair the ligament. One problem is that if it is excised and removed, you lose that normal capsular attachment and you cannot restore normal anatomy to the lateral side of the elbow. As you can see here, ligament islaxity or damaged lateral ligaments allows a hyperextension of the elbow. If we can see this damage, however, I think we can fix it. It does require a 3D concept of where the ligaments are and how they need to be repaired. Our Kramer equipment allows a very precise anatomical restoration of these ligaments in most situations. Here one can see a 16-year-old gymnast with a terrible triad. We have already arthroscopically repaired the radial head fracture. We have arthroscopically repaired the coronoid injury. And now we're looking at this complete avulsion of the entire lateral side of the elbow. Our arthroscope is in our posterior central portal, looking down the lateral gutter. And with this view, we can precisely localize the origin site of the radial ulnar humeral ligament, lateral capsule, and the lateral collateral ligament. Here we can see this lateral structure. Again, the origin site, red, angry, where bone has been pulled off this lateral side, allows us to place an anchor right into the anatomic origin site of that radial ulnar humeral ligament. We can then turn around and retrieve our sutures underneath the anterior ligament, coming from anterior to posterior, as seen in the inferior image, where you can see the sutures spaced out around the corner. The cannula to your right is in the anterolateral portal, and the sutures start just posterior to it and come all the way around to the ulna to allow a repair. Here in this view, we can see the radial head below, the capitellum above. Our retrograde retriever will come in and retrieve those sutures, as we saw in the last slide, in sequence, from anterior to posterior. As we then tension these sutures either over or under the ankyneas, depending on the surgeon's preference, the capsule will come back up to the capitellum, repairing that lateral collateral ligament, radial ulnar humeral ligament, tightening our anterior ligament, and restoring normal anatomy. In chronic PLRI, where there's enough tissue beneath the ankyneas muscle, one can take multiple PDS sutures, as seen here in this figure to the left, pass them in a plication fashion from the ulna back up to the humerus, and do four or five sutures in a row. I usually span the ankyneas with these. And then we'll place an anchor proximal, bring one limb of the suture under that whole mass of suture and back over the top of it, just beneath the skin, and shift the entire capsule which has been placated back up to the normal origin site on the lateral epicondyle. Graph reconstruction of PLRI is an excellent operation. It's described very well by O'Driscoll and involves moving a graph from tunnels in the ulna back up along the normal course of the ligaments to the epicondyle. It is vitally important one find the isometric site when doing this so that you can see where the problem occurs and how to fix it. I usually will pass one limb under the anterior ligament, but that has not been proven to be any more effective than channeling them up and sewing them into the lateral capsule. As you can see here in this left elbow, we actually will sometimes place an anchor distally, attach our graft, and bring it back under the skin, over the anconeus, and then isometrically place the graft using the arthroscopic techniques. This leaves the graft sitting on top of the anconeus rather than below. Postoperative rehabilitation includes splinting for the first week, followed by bracing for two to four weeks, limiting the arc of motion of the elbow, period. A brace on the elbow will not stabilize the elbow for lateral instability, but can limit the arc of motion so that the repair, or the graft, does not see aggressive tensioning. We usually do progressive therapy for six weeks once the bracing has been discontinued, and most patients can return to activity approximately four months postoperatively. We have previously published papers on PLRI. One of my favorite ones was Dr. Michael O'Brien's paper on Arthroscopic Management of Acute Dislocations in High-Level Athletes. This was published back in 2014 in the Journal of Arthroscopy, where we took 14 patients who were either collegiate or high-level high school athletes who dislocated their elbow, sustained a severe injury that would not remain located after a reduction. We operated on them acutely. We had a 100% return to play in these 14 athletes. The average time to return to play was 2.2 weeks in a brace and 6.6 weeks out of the brace. Our MEPS score at 6 months and 2 years was 99 out of 100, and motion was essentially normal. There was no recurrent instability. Other papers we have published on arthroscopic techniques include one by Zugen of 52 patients, where we noted that our acute repairs did much better than our subacute repairs, which did better than our chronic repairs. But overall, the success rate was quite high, with only four failures of these 52 patients. Gurley in the past has looked up this data, both open and arthroscopic, with an 88% overall satisfactory result in repairing the lateral side of the elbow. In summary, most lateral elbow instability can be managed arthroscopically. Elite athletes may do better with early reconstruction. Poor tissue quality, especially in revision cases, may require grafting, but that is becoming more and more rare for me. One new concept is the use of an internal joint stabilizer, as described by Dr. George Orbe, and it certainly has a place in managing lateral instability in traumatic injuries. Thank you for your attention. I remain available to answer any questions, should there be any.

elbow instability

posterolateral rotatory instability

surgical management

arthroscopy

internal joint stabilizer