Technique Spotlight: Approach to Chronic Elbow Instability


The elbow is a complex joint comprising three distinct articulations and stabilized by multiple osseous and ligamentous structures. As a result, elbow instability can be a challenging problem to successfully treat. Elbow instability can present on a spectrum of severity, ranging from subtle ligamentous laxity to severe multidirectional instability with bony changes.

Indications

Patients with subtle instability often present with complaints of pain, mechanical symptoms, or a sense of instability with certain activities. In contrast, patients with more severe injuries present with a stiff, painful elbow with little functional use. Elbow instability is classified as either posteromedial or posterolateral instability. Posteromedial instability is due primarily to insufficiency of the medial structures including the anterior band of the ulnar collateral ligament (UCL), whereas posterolateral instability stems from insufficiency of the lateral ligamentous complex and the lateral ulnar collateral ligament (LUCL).

Patients with more severe injuries may present with chronic dislocation of the ulnohumeral and radiocapitellar joints and may have multiple associated bony injuries including distal humeral, radial head, and coronoid fractures. Associated fractures may be nonunited or malunited and there can be significant bone loss that needs to be addressed to restore stability. In the chronic setting, it is common to have extensive heterotopic ossification and scarring which may need to be resected before a congruent articulation is achieved. ,

In all cases of elbow instability, a careful clinical assessment with appropriate imaging and careful preoperative planning is essential for success. In cases of isolated posterolateral rotatory instability (PLRI) or posteromedial rotatory instability (PMRI) without bony injury, appropriate ligament reconstruction may be all that is necessary to restore stability. However, in cases of chronic instability with bony abnormalities, liberal resection of scar tissue, reconstruction of bony defects, and multiple ligament reconstruction may be necessary.

Coronoid fractures except small avulsions (O’Driscoll type I) should be repaired or reconstructed as this is a primary stabilizer of the ulnohumeral joint. In cases where the bony fragment is not amenable to fixation, it may be reconstructed from an excised radial head if available, the tip of the ipsilateral olecranon, the distal clavicle, or a costochondral autograft. The literature supporting different coronoid graft options does not support making strong conclusions regarding donor selection, and thus the choice is primarily a matter of surgical convenience and the surgeon’s preference.

Radial head deficiency should also be addressed. While radial head resection remains an option for comminuted radial head fractures, surgeons must assure that the collateral ligaments, forearm longitudinal ligaments, and the triangular fibrocartilage complex (TFCC) in the wrist are stable. Although the radial head is not considered a primary stabilizer of the elbow joint, its role in stabilizing the traumatized elbow has been well established. Small fractures of the radial head may be amenable to fixation, but chronic bone loss or comminuted fracture patterns are best addressed with radial head arthroplasty.

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