Systematic Review
Surgical Treatment of Posterolateral Rotatory Instability of the Elbow Oke A. Anakwenze, M.D., Dennis Kwon, B.S., Evan O’Donnell, B.A., William N. Levine, M.D., and Christopher S. Ahmad, M.D.
Purpose: The purpose of this systematic review was to critically examine the outcomes of lateral ulnar collateral ligament reconstruction for posterolateral rotatory instability (PLRI) of the elbow. Methods: A systematic review of the literature was performed. Two reviewers assessed and confirmed the methodologic and patient data from the included studies. Frequency-weighted means were calculated for outcomes that were present in multiple studies. Results: Eight studies fulfilled our criteria, and they included 130 patients. The mean age was 38.1 years, and the mean follow-up period was 44.5 months. Traumatic dislocation was the most common cause of PLRI. Of the studies that reported the Mayo Elbow Performance Score, 91% of patients had good or excellent results, with a frequency-weighted mean of 91. Improvement in elbow range of motion was noted (133 to 138 of flexion [P < .0001] and 6.6 to 3.9 of extension [P ¼ .005]). A complication rate of 11% was noted, with recurrent instability noted to occur in 8% of patients. Conclusions: PLRI of the elbow remains to be fully understood. Treatment strategies vary and should be performed based on surgeon experience and evidence available. Most patients will have good or excellent results after surgery; however, up to 11% of patients may have complications. Level of Evidence: Level IV, systematic review of Level II through IV studies.
P
osterolateral rotatory instability (PLRI) of the elbow, described by O’Driscoll et al.1 in 1991, has become a formal and recognizable clinical entity. Initially thought to be a result of damage to the lateral ulnar collateral ligament (LUCL),1 more recent biomechanical and cadaveric studies have suggested that damage to the lateral collateral ligamentous complex as a whole is responsible for PLRI.2,3 In addition to ligamentous injury, damage to other structures such as the radial head4 or coronoid process5 can predispose to PLRI. Proper diagnosis and treatment of patients with PLRI can be challenging to the inexperienced clinician. Patients typically have an insidious course and may present in myriad ways. Treatment of this condition is
From the Department of Orthopaedic Surgery, Kaiser Permanente (O.A.A.), San Diego, California; and Department of Orthopaedic Surgery, Center for Shoulder, Elbow, and Sports Medicine, Columbia University (D.K., E.O., W.N.L., C.S.A.), New York, New York, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 1, 2014; accepted February 19, 2014. Address correspondence to Okechukwu A. Anakwenze, M.D., Department of Orthopaedic Surgery, Kaiser Permanente, 5893 Copley Dr, San Diego, CA 92111, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/1482/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.029
variable and has continued to evolve. Recalcitrant cases are frequently treated surgically. The treatment depends on the etiology and individual surgeon preference. Reconstruction of the ligamentous complex is commonly performed. PLRI of the elbow, while becoming more recognized as a source of elbow symptoms, has limited reports in the literature. There remains a lack of consensus as to the most efficacious treatment approaches. Furthermore, we are aware of no systematic review that analyzes the published outcomes for PLRI. Therefore the purposes of this systematic review were to (1) identify the demographic characteristics of patients who undergo surgery for ligamentous PLRI, (2) identify reported techniques used for managing these patients, and (3) report the outcomes and complications of patients treated surgically for ligamentous PLRI of the elbow.
Methods Search Strategy We performed a systematic literature review to determine the outcomes of treatment for PLRI. The PubMed, Scopus, and Embase computerized literature databases were queried with keyword terms and their respective combinations (Table 1). Two of the authors (O.A.A. and D.K.) reviewed the article titles and
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Table 1. Search Terms Entered Into Scopus, PubMed, and Embase Search Engines to Identify Studies From January 1940 to March 2013
these 8 articles. Our systematic review process is shown in Fig 1.
1. 2. 3. 4. 5.
Data Extraction We extracted relevant data from each included study and recorded them on separate worksheets. The specific data that were extracted included the number of eligible patients, the demographic characteristics of the patients, patient-oriented outcomes, rating systems for evaluation of the elbow, range-of-motion deficits, results of pivot-shift testing, imaging findings, surgical technique used, recurrence rates, complications, and duration of follow-up. The worksheets were compared, and any discrepancies were resolved by means of review of the original article and discussion to achieve consensus.
Posterolateral instability elbow Posterolateral instability PLRI Lateral collateral ligament Lateral ulnar collateral ligament
NOTE. The term “OR” was used as a Boolean operator.
abstracts for relevance. When there was doubt, the full article was retrieved for further analysis. At each stage, the article in question was evaluated according to our criteria. Inclusion and Exclusion Criteria Articles were included if (1) they were written in the English language, (2) they were published in a peerreviewed journal, and (3) they had Level IV Evidence or higher. In addition, to be included, articles must have (1) described a surgical repair or reconstruction of the lateral collateral ligament complex to treat PLRI; (2) provided data for patients aged at least 17 years; (3) had a minimum of 12 months’ follow-up; and (4) included at least 1 relevant functional outcome score, such as range of motion, recurrence rate, pain, patient satisfaction, or complications. Studies were excluded (1) if they did not meet the inclusion criteria; (2) if they included patients who had concomitant bony injury, such as fracture-dislocations, or altered bony anatomy, such as cubitus varus; (3) if they included patients who underwent lateral collateral ligament complex repair or reconstruction in association with more extensive surgical procedures, including open reductioneinternal fixation of the radial head, coronoid, lateral epicondyle, or distal humerus; or (4) if they included patients who had undergone prior lateral elbow surgery. Of note, many of the studies had differing inclusion and exclusion criteria, presenting a heterogeneous population within and among studies. However, before the exclusion of any article in the final stage, all studies that presented clear, individualized patient data were carefully analyzed to determine whether there were patients who fit the inclusion criteria. These studies were included if agreed on by both reviewers, but the data pooling and final analysis were limited to patients who fit the inclusion criteria. The final group represented a near-homogeneous patient population. Study Selection Our search returned 2,355 unique articles, and 91 potentially relevant studies were identified based on their titles, of which 45 articles contained relevant abstracts. The full text of the remaining articles was further scrutinized, and 8 articles met the stringent inclusion and exclusion criteria. No additional articles were found despite reviewing the bibliographies of
Results Study Characteristics Eight studies fulfilled the inclusion and exclusion criteria and were the focus of our study.1,6-12 The studies were published between 1991 and 2012. Assessment of the methodologic quality of these studies showed no randomized controlled trials (Level I), 1 prospective cohort study (Level II),6 1 retrospective cohort study (Level III),11 and 6 case series (Level IV).1,7-10,12 Indications to perform a surgical intervention for all studies were persistent instability or pain in the lateral aspect of the elbow with a functional impairment despite nonoperative treatment. The population in which PLRI surgical intervention was performed was heterogeneous. All studies included patients in whom PLRI developed because of a ligamentous injury. However, 1 study also included patients in whom PLRI developed because of fracturedislocations,11 and 2 studies also included patients in whom tardy PLRI developed because of a childhood supracondylar fracture.6,8 Two studies included children,1,11 and 1 study included patients in whom iatrogenic PLRI developed because of a bony procedure.11 These studies were not excluded from our final analysis because individualized data for patients who satisfied our criteria were presented in a clear table. After application of our inclusion and exclusion criteria, 130 patients were included in our analysis. This homogeneous group consisted of patients in whom PLRI developed due to a purely ligamentous lateral collateral ligament (LCL) cause and who were surgically treated for PLRI. Demographic Data The preoperative data are presented in Table 2. The mean age was 38.1 years (range, 17 to 70 years). Seven studies included demographic data on sex, with 41 male (53.9%) and 35 female patients (46.1%) represented.1,6-11
POSTEROLATERAL ROTATORY INSTABILITY OF ELBOW
3
Fig 1. Flow diagram showing systematic review process of identification, inclusion, and exclusion of studies, as well as reasons for exclusion.
Etiology In the articles that detailed etiology,1,6-11 damage to the LCL complex and the development of PLRI were consequences of trauma in most patients (67 of 71,
94%), and iatrogenic attritional degeneration of the LCL complex occurred in 4 patients (6%) (3 after steroid injections and 1 after arthroscopic lateral epicondylitis debridement).7 The etiology was unknown in 8 patients.
Table 2. Included Studies and Study Characteristics No. of Patients Author (Year) Eygendaal6 (2004) Jones et al.7 (2012) Lee and Teo8 (2003) Lin et al.9 (2012) O’Driscoll et al.1 (1991) Olsen and Søjbjerg10 (2003) Sanchez-Sotelo et al.11 (2005) Savoie et al.12 (2010) NR, not reported.
Type of Study Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
Baseline 12 8 10 14 5 18 44 54
Final 11 8 8 14 3 18 14 54
Mean Age (yr) 32.6 39.8 30.62 31.57 34 27.27 38.21 NR
Male/ Female (n) 7/4 4/4 5/3 10/4 2/1 5/13 8/6 NR
Dominant/ Nondominant (n) 11/0 NR 5/3 NR 0/3 11/7 NR NR
Mean Duration of Follow-Up (mo) 23 85.2 21.37 48.57 21 43.44 72.84 41
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Physical Examination Five articles described the results of the preoperative pivot-shift test.1,7-10 A positive pivot-shift test was found in 49 patients (96%). Sanchez-Sotelo et al.11 reported an 87% rate of positive pivot-shift tests. However, these data were not included in our analysis because this heterogeneous cohort of patients did not have individual physical examination documentation.11 Surgical Technique The weighted average length of time between the onset of symptoms and surgical intervention was 55.7 weeks (range, 10.3 to 162.0 weeks).1,7-10 All studies reported the surgical technique that was used. The specific technique was listed for each patient in 7 of 8 studies (72 patients),1,6-11 whereas 1 study did not individualize these data.12 The incidence and types of graft used for reconstruction were specified in 6 studies (58 patients).1,6-10 A triceps aponeurosis graft was used in 30 of these 58 patients (51.7%), a palmaris longus tendon graft was used in 19 (32.7%), a gracilis graft was used in 6 (10.3%), and a semitendinosus graft was used in 1 (1.7%).1,6,10 Sanchez-Sotelo et al.11 used the palmaris longus tendon as the autograft of choice, but when it was absent, they used the tendons of the semitendinosus or plantaris or, rarely, the triceps aponeurosis or Achilles tendon. Savoie et al.12 reported using palmaris longus and gracilis grafts. SanchezSotelo et al. and Savoie et al. did not specify the number of patients in whom each graft was used. Therefore, though not included in our analysis, it is likely that the palmaris tendon was the most commonly used graft. All reconstructions adhered to the principles of fixation at the humeral isometric point and at the native LUCL insertion at the supinator tubercle on the supinator crest. A “yoke” technique with humeral and ulnar tunnels was performed in 2 studies.1,11 One study described suture anchor fixation at the ulnar and humeral bone tunnels.10 Interference screw fixation was used in the humerus and ulna in 1 study.6 One article reported a series of patients who all underwent reconstruction by a “docking” technique with humeral and ulnar tunnels.7 Two studies used bony tunnels but did not specify the specific number of tunnels or type of graft configuration.8,9 Outcomes Compilation of the data from all 8 studies showed that a total of 130 patients (with a range of 3 to 54 patients per study) were included in the postoperative analyses. The mean follow-up period was 44.5 months; among studies in which the follow-up range was reported, the minimum and maximum were 21 months and 85 months, respectively.
Outcome Scores. The authors of 3 studies reported only the postoperative Mayo Elbow Performance Score (MEPS),7,10,11 and the weighted average of the 4 reported postoperative MEPSs was 91.0 (range, 87.5 to 93.6). The MEPS is a 4-part test in which clinical information is rated based on a 100-point scale. A score of 60 or less is classified as poor; 60 to 74, fair; 75 to 89, good; and 90 to 100, excellent. Of the 47 patients in total with a postoperative MEPS, 29 (61.7%) had a rating of excellent, 14 (29.8%) had a rating of good, and 4 (8.5%) had a rating of fair. No patients had a rating of poor. Postoperative Examination. The authors of 6 studies reported postoperative pivot-shift test findings, which were negative in 72 of 78 patients (92%).1,6-11 The authors of 5 studies reported postoperative patient satisfaction: 50 of 51 patients (98.0%) were satisfied with the outcome and believed that their elbow was functionally better after the surgical procedure.1,7-10 Range of Motion. With regard to functional assessment on physical examination, the authors of 5 studies reported postoperative ranges of motion for flexion and extension of the elbow.6,8-11 The frequency-weighted mean postoperative flexion and extension were 138.39 and 3.34 , respectively. Four studies reported specific preoperative and postoperative elbow range of motion.6,8,9,11 In this cohort of patients, the frequencyweighted mean preoperative and postoperative flexion was 133.57 (SD, 13.10 ) and 138.40 (SD, 8.85 ), respectively (P < .0001). In terms of extension, patients had a frequency-weighted mean of 6.66 (SD, 10.54 ) and 3.94 (SD, 9.61 ) (P ¼ .005) preoperatively and postoperatively, respectively. The authors of 2 studies described patients’ postoperative ranges of motion without specifying the degrees of motion.1,7 O’Driscoll et al.1 described all their patients as having full range of motion postoperatively. Jones et al.7 noted that 6 of 8 patients had full range of motion postoperatively and 2 patients had lost 5 and 10 of extension due to deliberate over-tightening of the graft because of the degree of instability noted during intraoperative examination. Complications, Reoperations, and Recurrences. The authors of 7 studies reported on surgical complications, which included 6 cases of recurrent elbow laxity or instability, 1 postoperative hematoma, and 1 superficial infection.1,6-11 The overall complication rate was 11% (8 of 76 patients). Two patients with recurrent instability had subsequent surgery. Therefore the overall reoperation rate was 2.6% (2 of 76 patients).
Discussion Although our understanding of PLRI of the elbow has seen a momentous expansion over the past 2 decades, many questions loom about the clinical and anatomic
POSTEROLATERAL ROTATORY INSTABILITY OF ELBOW
etiology of this kinematic abnormality. As a result, treatment strategies and respective efficacy remain to be fully elucidated. In addition, successful diagnosis depends on proper understanding of the risk factors, history, and appropriate physical examination maneuvers. Much of our understanding of PLRI can be credited to O’Driscoll et al.,1 who recognized and described this clinical entity. Although more recent cadaveric studies have suggested differently,2,13,14 O’Driscoll et al. identified damage to the LUCL to be the critical lesion precipitating this unique instability. Subsequently, repair and reconstructive strategies have focused on the LUCL. Given the relative rarity of reports of this clinical entity and the technical challenges required to diagnose and treat it, there is a paucity of literature documenting the unique patient features and efficacy of treatment strategies. Therefore we conducted a systematic review to improve our understanding of the most current principles and outcomes of operative treatment of patients with PLRI. In terms of demographic characteristics, we noted that most patients who underwent surgical treatment were young and had had some type of elbow trauma. Patients with a history of elbow surgery were excluded from this systematic review because their operative course may be very different from that in those without previous surgery. However, though not included in our analysis, prior surgery can be an iatrogenic cause of PLRI.11 We found that most of these patients will complain of a sensation of recurrent instability and will have radial-sided pain. The pivot-shift examination was found to be sensitive among the studies and caused a sense of apprehension in most patients. However, in the presence of equivocal examination findings, a preoperative stress radiograph is recommended15 because we have found this to be sensitive. In terms of outcomes, the most commonly reported functional assessment tool was the Mayo elbow score. The mean score was 91, indicating that a significant portion of patients reported excellent results after surgery. No patient reported a poor outcome; this may imply a lack of sensitivity with commonly used functional assessment tools in this patient population. Eleven percent of the patient population had objective complications. Of the 8 complications, 6 involved recurrent elbow laxity or dislocation. Patients with PLRI do not typically present with significant loss of motion. Correspondingly, an insignificant change in range of motion was noted. Limitations There are a number of limitations in this study. The quality of a systematic review is determined by the quality of the studies included. Only 2 studies were prospectively carried out, and these represented a limited number of patients without power analysis.6,11 Therefore there was insignificant control for bias, chance, or
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random findings. The population and treatment strategies are heterogeneous in nature. In addition, the reported outcomes are disparate among the studies. For these reasons, our study is observational in nature but does provide insight into the nature and expectations associated with surgery for PLRI of the elbow. As a result of very strict exclusion criteria to strengthen our conclusions, a number of surgical patients were excluded. It is possible that such limitations regarding patients may have biased the results. Our search terms and results were systematically approached, but there is a chance that different search terms may have provided more studies that would have met our inclusion criteria.
Conclusions PLRI of the elbow remains to be fully understood. Treatment strategies vary and should be performed based on surgeon experience and evidence available. Most patients will have good or excellent results after surgery; however, up to 11% of patients may have complications.
References 1. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73: 440-446. 2. Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 2001;83:1823-1828. 3. Imatani J, Ogura T, Morito Y, Hashizume H, Inoue H. Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. J Shoulder Elbow Surg 1999;8:625-627. 4. Hall JA, McKee MD. Posterolateral rotatory instability of the elbow following radial head resection. J Bone Joint Surg Am 2005;87:1571-1579. 5. Okazaki M, Takayama S, Seki A, Ikegami H, Nakamura T. Posterolateral rotatory instability of the elbow with insufficient coronoid process of the ulna: A report of 3 patients. J Hand Surg Am 2007;32:236-239. 6. Eygendaal D. Ligamentous reconstruction around the elbow using triceps tendon. Acta Orthop Scand 2004;75: 516-523. 7. Jones KJ, Dodson CC, Osbahr DC, et al. The docking technique for lateral ulnar collateral ligament reconstruction: Surgical technique and clinical outcomes. J Shoulder Elbow Surg 2012;21:389-395. 8. Lee BP, Teo LH. Surgical reconstruction for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg 2003;12:476-479. 9. Lin KY, Shen PH, Lee CH, Pan RY, Lin LC, Shen HC. Functional outcomes of surgical reconstruction for posterolateral rotatory instability of the elbow. Injury 2012;43:1657-1661. 10. Olsen BS, Søjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg Br 2003;85:342-346.
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11. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2005;87:54-61. 12. Savoie FH III, O’Brien MJ, Field LD, Gurley DJ. Arthroscopic and open radial ulnohumeral ligament reconstruction for posterolateral rotatory instability of the elbow. Clin Sports Med 2010;29:611-618. 13. McAdams TR, Masters GW, Srivastava S. The effect of arthroscopic sectioning of the lateral ligament complex of
the elbow on posterolateral rotatory stability. J Shoulder Elbow Surg 2005;14:298-301. 14. Seki A, Olsen BS, Jensen SL, Eygendaal D, Søjbjerg JO. Functional anatomy of the lateral collateral ligament complex of the elbow: Configuration of Y and its role. J Shoulder Elbow Surg 2002;11:53-59. 15. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect 2001;50: 89-102.
Surgical Treatment of Posterolateral Rotatory Instability of the Elbow Oke A. Anakwenze, M.D., Dennis Kwon, B.S., Evan O’Donnell, B.A., William N. Levine, M.D., and Christopher S. Ahmad, M.D.
Purpose: The purpose of this systematic review was to critically examine the outcomes of lateral ulnar collateral ligament reconstruction for posterolateral rotatory instability (PLRI) of the elbow. Methods: A systematic review of the literature was performed. Two reviewers assessed and confirmed the methodologic and patient data from the included studies. Frequency-weighted means were calculated for outcomes that were present in multiple studies. Results: Eight studies fulfilled our criteria, and they included 130 patients. The mean age was 38.1 years, and the mean follow-up period was 44.5 months. Traumatic dislocation was the most common cause of PLRI. Of the studies that reported the Mayo Elbow Performance Score, 91% of patients had good or excellent results, with a frequency-weighted mean of 91. Improvement in elbow range of motion was noted (133 to 138 of flexion [P < .0001] and 6.6 to 3.9 of extension [P ¼ .005]). A complication rate of 11% was noted, with recurrent instability noted to occur in 8% of patients. Conclusions: PLRI of the elbow remains to be fully understood. Treatment strategies vary and should be performed based on surgeon experience and evidence available. Most patients will have good or excellent results after surgery; however, up to 11% of patients may have complications. Level of Evidence: Level IV, systematic review of Level II through IV studies.
P
osterolateral rotatory instability (PLRI) of the elbow, described by O’Driscoll et al.1 in 1991, has become a formal and recognizable clinical entity. Initially thought to be a result of damage to the lateral ulnar collateral ligament (LUCL),1 more recent biomechanical and cadaveric studies have suggested that damage to the lateral collateral ligamentous complex as a whole is responsible for PLRI.2,3 In addition to ligamentous injury, damage to other structures such as the radial head4 or coronoid process5 can predispose to PLRI. Proper diagnosis and treatment of patients with PLRI can be challenging to the inexperienced clinician. Patients typically have an insidious course and may present in myriad ways. Treatment of this condition is
From the Department of Orthopaedic Surgery, Kaiser Permanente (O.A.A.), San Diego, California; and Department of Orthopaedic Surgery, Center for Shoulder, Elbow, and Sports Medicine, Columbia University (D.K., E.O., W.N.L., C.S.A.), New York, New York, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 1, 2014; accepted February 19, 2014. Address correspondence to Okechukwu A. Anakwenze, M.D., Department of Orthopaedic Surgery, Kaiser Permanente, 5893 Copley Dr, San Diego, CA 92111, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/1482/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.029
variable and has continued to evolve. Recalcitrant cases are frequently treated surgically. The treatment depends on the etiology and individual surgeon preference. Reconstruction of the ligamentous complex is commonly performed. PLRI of the elbow, while becoming more recognized as a source of elbow symptoms, has limited reports in the literature. There remains a lack of consensus as to the most efficacious treatment approaches. Furthermore, we are aware of no systematic review that analyzes the published outcomes for PLRI. Therefore the purposes of this systematic review were to (1) identify the demographic characteristics of patients who undergo surgery for ligamentous PLRI, (2) identify reported techniques used for managing these patients, and (3) report the outcomes and complications of patients treated surgically for ligamentous PLRI of the elbow.
Methods Search Strategy We performed a systematic literature review to determine the outcomes of treatment for PLRI. The PubMed, Scopus, and Embase computerized literature databases were queried with keyword terms and their respective combinations (Table 1). Two of the authors (O.A.A. and D.K.) reviewed the article titles and
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2014: pp 1-6
1
2
O. A. ANAKWENZE ET AL.
Table 1. Search Terms Entered Into Scopus, PubMed, and Embase Search Engines to Identify Studies From January 1940 to March 2013
these 8 articles. Our systematic review process is shown in Fig 1.
1. 2. 3. 4. 5.
Data Extraction We extracted relevant data from each included study and recorded them on separate worksheets. The specific data that were extracted included the number of eligible patients, the demographic characteristics of the patients, patient-oriented outcomes, rating systems for evaluation of the elbow, range-of-motion deficits, results of pivot-shift testing, imaging findings, surgical technique used, recurrence rates, complications, and duration of follow-up. The worksheets were compared, and any discrepancies were resolved by means of review of the original article and discussion to achieve consensus.
Posterolateral instability elbow Posterolateral instability PLRI Lateral collateral ligament Lateral ulnar collateral ligament
NOTE. The term “OR” was used as a Boolean operator.
abstracts for relevance. When there was doubt, the full article was retrieved for further analysis. At each stage, the article in question was evaluated according to our criteria. Inclusion and Exclusion Criteria Articles were included if (1) they were written in the English language, (2) they were published in a peerreviewed journal, and (3) they had Level IV Evidence or higher. In addition, to be included, articles must have (1) described a surgical repair or reconstruction of the lateral collateral ligament complex to treat PLRI; (2) provided data for patients aged at least 17 years; (3) had a minimum of 12 months’ follow-up; and (4) included at least 1 relevant functional outcome score, such as range of motion, recurrence rate, pain, patient satisfaction, or complications. Studies were excluded (1) if they did not meet the inclusion criteria; (2) if they included patients who had concomitant bony injury, such as fracture-dislocations, or altered bony anatomy, such as cubitus varus; (3) if they included patients who underwent lateral collateral ligament complex repair or reconstruction in association with more extensive surgical procedures, including open reductioneinternal fixation of the radial head, coronoid, lateral epicondyle, or distal humerus; or (4) if they included patients who had undergone prior lateral elbow surgery. Of note, many of the studies had differing inclusion and exclusion criteria, presenting a heterogeneous population within and among studies. However, before the exclusion of any article in the final stage, all studies that presented clear, individualized patient data were carefully analyzed to determine whether there were patients who fit the inclusion criteria. These studies were included if agreed on by both reviewers, but the data pooling and final analysis were limited to patients who fit the inclusion criteria. The final group represented a near-homogeneous patient population. Study Selection Our search returned 2,355 unique articles, and 91 potentially relevant studies were identified based on their titles, of which 45 articles contained relevant abstracts. The full text of the remaining articles was further scrutinized, and 8 articles met the stringent inclusion and exclusion criteria. No additional articles were found despite reviewing the bibliographies of
Results Study Characteristics Eight studies fulfilled the inclusion and exclusion criteria and were the focus of our study.1,6-12 The studies were published between 1991 and 2012. Assessment of the methodologic quality of these studies showed no randomized controlled trials (Level I), 1 prospective cohort study (Level II),6 1 retrospective cohort study (Level III),11 and 6 case series (Level IV).1,7-10,12 Indications to perform a surgical intervention for all studies were persistent instability or pain in the lateral aspect of the elbow with a functional impairment despite nonoperative treatment. The population in which PLRI surgical intervention was performed was heterogeneous. All studies included patients in whom PLRI developed because of a ligamentous injury. However, 1 study also included patients in whom PLRI developed because of fracturedislocations,11 and 2 studies also included patients in whom tardy PLRI developed because of a childhood supracondylar fracture.6,8 Two studies included children,1,11 and 1 study included patients in whom iatrogenic PLRI developed because of a bony procedure.11 These studies were not excluded from our final analysis because individualized data for patients who satisfied our criteria were presented in a clear table. After application of our inclusion and exclusion criteria, 130 patients were included in our analysis. This homogeneous group consisted of patients in whom PLRI developed due to a purely ligamentous lateral collateral ligament (LCL) cause and who were surgically treated for PLRI. Demographic Data The preoperative data are presented in Table 2. The mean age was 38.1 years (range, 17 to 70 years). Seven studies included demographic data on sex, with 41 male (53.9%) and 35 female patients (46.1%) represented.1,6-11
POSTEROLATERAL ROTATORY INSTABILITY OF ELBOW
3
Fig 1. Flow diagram showing systematic review process of identification, inclusion, and exclusion of studies, as well as reasons for exclusion.
Etiology In the articles that detailed etiology,1,6-11 damage to the LCL complex and the development of PLRI were consequences of trauma in most patients (67 of 71,
94%), and iatrogenic attritional degeneration of the LCL complex occurred in 4 patients (6%) (3 after steroid injections and 1 after arthroscopic lateral epicondylitis debridement).7 The etiology was unknown in 8 patients.
Table 2. Included Studies and Study Characteristics No. of Patients Author (Year) Eygendaal6 (2004) Jones et al.7 (2012) Lee and Teo8 (2003) Lin et al.9 (2012) O’Driscoll et al.1 (1991) Olsen and Søjbjerg10 (2003) Sanchez-Sotelo et al.11 (2005) Savoie et al.12 (2010) NR, not reported.
Type of Study Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
Baseline 12 8 10 14 5 18 44 54
Final 11 8 8 14 3 18 14 54
Mean Age (yr) 32.6 39.8 30.62 31.57 34 27.27 38.21 NR
Male/ Female (n) 7/4 4/4 5/3 10/4 2/1 5/13 8/6 NR
Dominant/ Nondominant (n) 11/0 NR 5/3 NR 0/3 11/7 NR NR
Mean Duration of Follow-Up (mo) 23 85.2 21.37 48.57 21 43.44 72.84 41
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Physical Examination Five articles described the results of the preoperative pivot-shift test.1,7-10 A positive pivot-shift test was found in 49 patients (96%). Sanchez-Sotelo et al.11 reported an 87% rate of positive pivot-shift tests. However, these data were not included in our analysis because this heterogeneous cohort of patients did not have individual physical examination documentation.11 Surgical Technique The weighted average length of time between the onset of symptoms and surgical intervention was 55.7 weeks (range, 10.3 to 162.0 weeks).1,7-10 All studies reported the surgical technique that was used. The specific technique was listed for each patient in 7 of 8 studies (72 patients),1,6-11 whereas 1 study did not individualize these data.12 The incidence and types of graft used for reconstruction were specified in 6 studies (58 patients).1,6-10 A triceps aponeurosis graft was used in 30 of these 58 patients (51.7%), a palmaris longus tendon graft was used in 19 (32.7%), a gracilis graft was used in 6 (10.3%), and a semitendinosus graft was used in 1 (1.7%).1,6,10 Sanchez-Sotelo et al.11 used the palmaris longus tendon as the autograft of choice, but when it was absent, they used the tendons of the semitendinosus or plantaris or, rarely, the triceps aponeurosis or Achilles tendon. Savoie et al.12 reported using palmaris longus and gracilis grafts. SanchezSotelo et al. and Savoie et al. did not specify the number of patients in whom each graft was used. Therefore, though not included in our analysis, it is likely that the palmaris tendon was the most commonly used graft. All reconstructions adhered to the principles of fixation at the humeral isometric point and at the native LUCL insertion at the supinator tubercle on the supinator crest. A “yoke” technique with humeral and ulnar tunnels was performed in 2 studies.1,11 One study described suture anchor fixation at the ulnar and humeral bone tunnels.10 Interference screw fixation was used in the humerus and ulna in 1 study.6 One article reported a series of patients who all underwent reconstruction by a “docking” technique with humeral and ulnar tunnels.7 Two studies used bony tunnels but did not specify the specific number of tunnels or type of graft configuration.8,9 Outcomes Compilation of the data from all 8 studies showed that a total of 130 patients (with a range of 3 to 54 patients per study) were included in the postoperative analyses. The mean follow-up period was 44.5 months; among studies in which the follow-up range was reported, the minimum and maximum were 21 months and 85 months, respectively.
Outcome Scores. The authors of 3 studies reported only the postoperative Mayo Elbow Performance Score (MEPS),7,10,11 and the weighted average of the 4 reported postoperative MEPSs was 91.0 (range, 87.5 to 93.6). The MEPS is a 4-part test in which clinical information is rated based on a 100-point scale. A score of 60 or less is classified as poor; 60 to 74, fair; 75 to 89, good; and 90 to 100, excellent. Of the 47 patients in total with a postoperative MEPS, 29 (61.7%) had a rating of excellent, 14 (29.8%) had a rating of good, and 4 (8.5%) had a rating of fair. No patients had a rating of poor. Postoperative Examination. The authors of 6 studies reported postoperative pivot-shift test findings, which were negative in 72 of 78 patients (92%).1,6-11 The authors of 5 studies reported postoperative patient satisfaction: 50 of 51 patients (98.0%) were satisfied with the outcome and believed that their elbow was functionally better after the surgical procedure.1,7-10 Range of Motion. With regard to functional assessment on physical examination, the authors of 5 studies reported postoperative ranges of motion for flexion and extension of the elbow.6,8-11 The frequency-weighted mean postoperative flexion and extension were 138.39 and 3.34 , respectively. Four studies reported specific preoperative and postoperative elbow range of motion.6,8,9,11 In this cohort of patients, the frequencyweighted mean preoperative and postoperative flexion was 133.57 (SD, 13.10 ) and 138.40 (SD, 8.85 ), respectively (P < .0001). In terms of extension, patients had a frequency-weighted mean of 6.66 (SD, 10.54 ) and 3.94 (SD, 9.61 ) (P ¼ .005) preoperatively and postoperatively, respectively. The authors of 2 studies described patients’ postoperative ranges of motion without specifying the degrees of motion.1,7 O’Driscoll et al.1 described all their patients as having full range of motion postoperatively. Jones et al.7 noted that 6 of 8 patients had full range of motion postoperatively and 2 patients had lost 5 and 10 of extension due to deliberate over-tightening of the graft because of the degree of instability noted during intraoperative examination. Complications, Reoperations, and Recurrences. The authors of 7 studies reported on surgical complications, which included 6 cases of recurrent elbow laxity or instability, 1 postoperative hematoma, and 1 superficial infection.1,6-11 The overall complication rate was 11% (8 of 76 patients). Two patients with recurrent instability had subsequent surgery. Therefore the overall reoperation rate was 2.6% (2 of 76 patients).
Discussion Although our understanding of PLRI of the elbow has seen a momentous expansion over the past 2 decades, many questions loom about the clinical and anatomic
POSTEROLATERAL ROTATORY INSTABILITY OF ELBOW
etiology of this kinematic abnormality. As a result, treatment strategies and respective efficacy remain to be fully elucidated. In addition, successful diagnosis depends on proper understanding of the risk factors, history, and appropriate physical examination maneuvers. Much of our understanding of PLRI can be credited to O’Driscoll et al.,1 who recognized and described this clinical entity. Although more recent cadaveric studies have suggested differently,2,13,14 O’Driscoll et al. identified damage to the LUCL to be the critical lesion precipitating this unique instability. Subsequently, repair and reconstructive strategies have focused on the LUCL. Given the relative rarity of reports of this clinical entity and the technical challenges required to diagnose and treat it, there is a paucity of literature documenting the unique patient features and efficacy of treatment strategies. Therefore we conducted a systematic review to improve our understanding of the most current principles and outcomes of operative treatment of patients with PLRI. In terms of demographic characteristics, we noted that most patients who underwent surgical treatment were young and had had some type of elbow trauma. Patients with a history of elbow surgery were excluded from this systematic review because their operative course may be very different from that in those without previous surgery. However, though not included in our analysis, prior surgery can be an iatrogenic cause of PLRI.11 We found that most of these patients will complain of a sensation of recurrent instability and will have radial-sided pain. The pivot-shift examination was found to be sensitive among the studies and caused a sense of apprehension in most patients. However, in the presence of equivocal examination findings, a preoperative stress radiograph is recommended15 because we have found this to be sensitive. In terms of outcomes, the most commonly reported functional assessment tool was the Mayo elbow score. The mean score was 91, indicating that a significant portion of patients reported excellent results after surgery. No patient reported a poor outcome; this may imply a lack of sensitivity with commonly used functional assessment tools in this patient population. Eleven percent of the patient population had objective complications. Of the 8 complications, 6 involved recurrent elbow laxity or dislocation. Patients with PLRI do not typically present with significant loss of motion. Correspondingly, an insignificant change in range of motion was noted. Limitations There are a number of limitations in this study. The quality of a systematic review is determined by the quality of the studies included. Only 2 studies were prospectively carried out, and these represented a limited number of patients without power analysis.6,11 Therefore there was insignificant control for bias, chance, or
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random findings. The population and treatment strategies are heterogeneous in nature. In addition, the reported outcomes are disparate among the studies. For these reasons, our study is observational in nature but does provide insight into the nature and expectations associated with surgery for PLRI of the elbow. As a result of very strict exclusion criteria to strengthen our conclusions, a number of surgical patients were excluded. It is possible that such limitations regarding patients may have biased the results. Our search terms and results were systematically approached, but there is a chance that different search terms may have provided more studies that would have met our inclusion criteria.
Conclusions PLRI of the elbow remains to be fully understood. Treatment strategies vary and should be performed based on surgeon experience and evidence available. Most patients will have good or excellent results after surgery; however, up to 11% of patients may have complications.
References 1. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73: 440-446. 2. Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 2001;83:1823-1828. 3. Imatani J, Ogura T, Morito Y, Hashizume H, Inoue H. Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. J Shoulder Elbow Surg 1999;8:625-627. 4. Hall JA, McKee MD. Posterolateral rotatory instability of the elbow following radial head resection. J Bone Joint Surg Am 2005;87:1571-1579. 5. Okazaki M, Takayama S, Seki A, Ikegami H, Nakamura T. Posterolateral rotatory instability of the elbow with insufficient coronoid process of the ulna: A report of 3 patients. J Hand Surg Am 2007;32:236-239. 6. Eygendaal D. Ligamentous reconstruction around the elbow using triceps tendon. Acta Orthop Scand 2004;75: 516-523. 7. Jones KJ, Dodson CC, Osbahr DC, et al. The docking technique for lateral ulnar collateral ligament reconstruction: Surgical technique and clinical outcomes. J Shoulder Elbow Surg 2012;21:389-395. 8. Lee BP, Teo LH. Surgical reconstruction for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg 2003;12:476-479. 9. Lin KY, Shen PH, Lee CH, Pan RY, Lin LC, Shen HC. Functional outcomes of surgical reconstruction for posterolateral rotatory instability of the elbow. Injury 2012;43:1657-1661. 10. Olsen BS, Søjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg Br 2003;85:342-346.
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11. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2005;87:54-61. 12. Savoie FH III, O’Brien MJ, Field LD, Gurley DJ. Arthroscopic and open radial ulnohumeral ligament reconstruction for posterolateral rotatory instability of the elbow. Clin Sports Med 2010;29:611-618. 13. McAdams TR, Masters GW, Srivastava S. The effect of arthroscopic sectioning of the lateral ligament complex of
the elbow on posterolateral rotatory stability. J Shoulder Elbow Surg 2005;14:298-301. 14. Seki A, Olsen BS, Jensen SL, Eygendaal D, Søjbjerg JO. Functional anatomy of the lateral collateral ligament complex of the elbow: Configuration of Y and its role. J Shoulder Elbow Surg 2002;11:53-59. 15. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect 2001;50: 89-102.
