Posterolateral Instability Reconstruction

Introduction

Posterolateral rotator instability (PLRI) of the elbow describes the subluxation of the proximal ulna and radial head in a posterolateral direction relative to the distal humerus. Insufficiency of the lateral collateral ligament (LCL) complex has been implicated in the pathogenesis, eventually leading to instability of the elbow. Studies have shown that in addition to the entire complex, which includes the lateral ulnar collateral ligament (LUCL), radial collateral ligament, accessory LCL, and annular ligament, secondary stabilization is provided by both the bony anatomy and the common extensor group. ^, In the lateral ligament–deficient elbow with symptomatic pain and instability, ligamentous reconstruction of the LUCL restores varus and posterolateral stability. In acute injuries, LCL repair is a reasonable treatment option. In the more common setting of chronic insufficiency, reconstruction of the LUCL is the mainstay of treatment and has demonstrated superior results compared with repair. ^,

LUCL reconstruction has been shown to be effective in restoring stability, with subjective patient satisfaction reported in 86% of patients. However, the procedure may lead to several complications and sequelae such as stiffness, which may require contracture release or excision of heterotopic bone, cubital tunnel symptoms requiring nerve decompression, or infection and hematoma requiring irrigation and debridement. ^, The most common reported complication is recurrent instability, which may be prevented by avoiding pitfalls during the preoperative, intraoperative, and postoperative phases of treatment.

In a 2014 systematic review of seven studies that included 76 elbows, the overall rate of complications was 11%, with six cases of recurrent instability, one case of superficial infection, and one postoperative hematoma. However, only two patients in this study required reoperation. A more recent study of LUCL reconstruction in U.S. military service members that was not included in the prior systematic review, 17% of patients experienced a complication, with 13% requiring a reoperation. The complications were related to cubital tunnel symptoms, postoperative flexion contractures, and deep infection.

Overall, a few cases have been reported in the literature of lateral ulnar collateral ligament reconstruction with relatively low complication and reoperation rates; however, an understanding of the potential problems during the preoperative, intraoperative, and postoperative phases is pivotal in preventing complications from arising. This chapter will outline the key considerations when planning, performing, and guiding patients through recovery following LUCL reconstruction, and how to approach complications if and when they should arise.