DEFINITION

Lateral collateral ligament (LCL) injuries most often occur after significant elbow trauma, most commonly after dislocation.

Attenuation of the LCL can also occur after multiple surgeries to the lateral side of the elbow and after corticosteroid injections.9 It has recently been reported that even one corticosteroid injection may result in lower complete recovery rates and in recurrence rates after 1 year.6

LCL attenuation has been reported to occur in patients who have residual cubitus varus after malunion of supracondylar humerus fractures.12

Significant injury to the LCL complex can result in posterolateral rotatory instability (PLRI).

 

 

ANATOMY

 

The LCL is made up of four major components: the lateral ulnar collateral ligament (LUCL), also called the radial ulnohumeral ligament (RUHL); the radial collateral ligament (RCL) proper; the annular ligament; and the accessory collateral ligament (FIG 1).

 

The ligaments originate from a broad band over the lateral epicondyle, deep to the extensor muscle mass, and separate distally into more discrete structures.

 

The RUHL is the most important stabilizer against PLRI, and it attaches distally on the supinator crest of the ulna.11

 

The supinator tubercle resides approximately 15 mm distal to the proximal border of the proximal radioulnar joint (PRUJ).1

 

The RCL is more anterior and primarily resists varus stress.

 

The annular ligament sweeps around the radial head/neck and stabilizes the PRUJ.

 

 

 

FIG 1 • A. The LCL complex is made up of four major components: the LUCL, also called the radial ulnohumeral ligament; the RCL proper; the annular ligament; and the accessory collateral ligament. B. Osseous anatomy of the LCL insertion.

 

 

 

The capsule acts as a static stabilizer, especially at the anterior portion, while the arm is extended. The anconeus and extensor muscle groups act as dynamic stabilizers.

 

On average, the posterior interosseous nerve crosses the midpoint of the radius 33.4 ± 5.7 mm with the forearm in supination. This distance increases to 52.0 ± 7.8 mm with the forearm in full pronation, thereby

increasing the safe zone for exposure of the lateral elbow.7

 

PATHOGENESIS

 

Multiple studies have shown that injury to the LCL can lead to PLRI, which is the first stage in elbow instability that can lead to frank elbow dislocation.

 

It is controversial whether injury to the RUHL alone can lead to PLRI or whether further injury to the LCL complex is necessary.10

 

When the forearm is supinated and slightly flexed, a valgus stress with an attenuated LCL causes the ulnohumeral joint to rotate, compresses the radiocapitellar joint, and ultimately causes the radial head to subluxate or dislocate posteriorly from the ulnohumeral joint.

 

NATURAL HISTORY

 

 

PLRI is not a new condition, but it has only recently been described and studied. The prevalence and natural history of this condition are currently not known.

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients typically report trauma but may have had recurrent lateral epicondylitis or previous surgery.

 

 

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Elderly patients may not have frank dislocation of the elbow, but 75% of patients younger than 20 years report an elbow dislocation.10

 

Patients typically report mechanical-type symptoms (clicking, popping, and slipping) during elbow supination and extension and rarely report recurrent dislocations. These symptoms may impact activities such as pushing up from a chair with the arms or doing pushups.

 

Physical examination can be difficult; provocative tests are described in the following text. It is often necessary to conduct these tests with the patient under anesthesia or with the aid of fluoroscopy.

 

 

Inspection for effusion: With acute injuries, lateral gutter soft spot effusion is likely to be present, but in more chronic situations, it may be absent.

 

Range of motion (ROM): Locking of the elbow can represent loose bodies; stiffness may indicate intrinsic capsular contracture.

 

Supine lateral pivot shift test: When the elbow is slightly flexed, the radial head can be palpated to subluxate or frankly dislocate, and as the elbow flexes past 40 degrees, it relocates, often with a palpable

clunk.11 This test is often difficult to perform on an awake patient because apprehension is felt and the patient does not allow the test to continue.

 

Prone pivot shift test: Radial head or ulnohumeral subluxation constitutes a positive test, same as the supine lateral pivot shift test. Examination under anesthesia may be required.

 

Push-up test: Reproduction of the patient's symptoms of apprehension during supination and not pronation constitutes a positive test. Inability to complete the push-up also constitutes a positive test.

 

 

 

FIG 2 • A. Lateral view stress radiograph reveals complete ulnohumeral and radial head (RH) rotatory instability. O, olecranon. B. Coronal oblique view MRI of elbow (with contrast enhancement). LCL disruption can be seen (arrow). C. Sagittal MRI showing Osborne-Cotterill lesion (asterisk and white arrows). D. Coronal MRI showing Osborne-Cotterill lesion (white arrow).

 

 

Chair push-up: Elicited pain constitutes a positive test.

 

Table top relocation test: Elicited pain or apprehension as the elbow reaches 40 degrees constitutes a positive test.

 

Elbow drawer test: Ulnohumeral subluxation constitutes a positive test.

 

A thorough examination of the elbow should also be completed to rule out other injuries.

 

 

Valgus instability with the forearm in pronation and 30 degrees of flexion suggests medial collateral ligament (MCL) injury.

 

Lateral epicondylitis or radial tunnel syndrome can present with tenderness over the proximal extensor mass and with resisted extension of the wrist (Thompson test) and long finger.

 

Loose bodies may present with crepitus or locking of the elbow during ROM.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Standard anteroposterior (AP) and lateral view radiographs often indicate normal findings but may reveal small lateral epicondyle avulsion fractures and radiocapitellar wear.

 

Stress AP and lateral view radiographs may reveal widening of the ulnohumeral joint and posterior subluxation of the radial head (FIG 2A).

 

Magnetic resonance imaging (MRI), especially with intraarticular contrast enhancement, may reveal injuries to

the LCL complex. The proximal extensor mass requires attention (FIG 2B). Chronic PLRI may lead to evidence of a posterolateral osteochondral defect coined the Osborne-Cotterill lesion (FIG 2C,D).8

 

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Diagnostic arthroscopy of the elbow can be performed, although we do not recommend routine diagnostic arthroscopy for this injury.

 

 

The drive-through sign occurs when the scope can easily be “driven through” the lateral gutter into the ulnohumeral joint from the posterolateral portal.

 

The pivot shift test also can be performed during arthroscopy, and the radial head will subluxate posteriorly.

DIFFERENTIAL DIAGNOSIS

Lateral epicondylitis Extensor tendon tear Loose bodies

Elbow fracture-dislocation MCL injury

Radial head dislocation

 

 

NONOPERATIVE MANAGEMENT

 

If the injury is diagnosed early, immobilization in a hinged elbow brace in pronation for 4 to 6 weeks may prevent chronic instability.5

 

Removable neoprene sleeves may offer support.

 

A trial of elbow extensor strengthening with progressive ROM can be performed.

 

SURGICAL MANAGEMENT

Indications

Recurrent symptomatic PLRI despite nonoperative treatment

 

 

Preoperative Planning

 

All imaging studies should be reviewed, and informed consent obtained.

 

An examination of the elbow should be performed with the patient under anesthesia, especially the pivot shift test.

 

If there is any doubt regarding the diagnosis, a pivot shift test should be performed under fluoroscopy.

 

Positioning

 

The patient is placed supine on the operating room table.

 

The arm can be placed on an arm board or across the patient's chest with a sterile tourniquet applied to the upper arm and the entire arm draped free (FIG 3).

 

During the approach, the forearm should be pronated to protect the posterior interosseous nerve.

 

Approach

 

The main approach is the Kocher interval between the anconeus and extensor carpi ulnaris muscles. Care must be taken to gently elevate the anconeus off the underlying LCL complex.

 

This can be accomplished through a lateral skin incision or through a utilitarian posterior incision.

 

 

A posterior incision should be considered if a medial approach will also be needed to repair concomitant ligamentous or bony injury.

 

 

 

 

FIG 3 • The patient is placed supine on the operating room table. The arm is placed on an arm board with a sterile tourniquet applied to the upper arm and the entire arm draped free. During the approach, the forearm should be pronated to protect the posterior interosseous nerve.

 

TECHNIQUES

• Figure-8 Yoke Technique

Surgical Approach

A 10-cm incision is made over the Kocher interval.

The interval between the anconeus and the extensor carpi ulnaris is developed, and the remainder of

 

the LCL complex is identified along with the supinator crest and the lateral epicondyle.

 

The lateral epicondyle and 2 cm of the supracondylar ridge are exposed.

Tunnel Placement

 

Two drill holes for the graft insertion site are made in the ulna.

 

One is drilled near the tubercle of the supinator crest (palpate in supination and varus stress), the other is 1.25 cm proximal to that, near the insertion of the annular ligament (TECH FIG 1A).

 

A suture is passed through the two holes and tied to itself. The suture is then held up against the lateral epicondyle as the elbow is ranged in flexion and extension to determine its isometric point.

 

 

The isometric ligament insertion occurs at the point where the suture does not move. The isometric point is usually more anteroinferior than expected (TECH FIG 1B,C).

 

A Y-shaped tunnel is made with the base exiting at the isometric point.

 

The hole is widened to accept a three-ply graft. (Ipsilateral palmaris longus is usually harvested; if not present, gracilis or allograft is used.) A 16-cm graft is usually sufficient.

 

 

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TECH FIG 1 • A. Two drill holes for the graft insertion site are made in the ulna. One is drilled near the tubercle of the supinator crest (palpate while varus and supination applied); the other is drilled 1.25 cm proximal, near the insertion of the annular ligament. 1, proximal hole near insertion of annular ligament; 2, tubercle of supinator crest. B. The ulnar holes should lie perpendicular to the intended direction of the LUCL. C. A suture is passed through the two holes and tied to itself. The suture is then held up with a hemostat against the lateral epicondyle as the elbow is ranged in flexion and extension to determine its isometric point. No movement occurs if the suture is at the isometric point.

Graft Passage and Tensioning and Wound Closure

 

The graft is passed through the ulnar tunnel with enough length to just reach the isometric point.

 

The end is then sutured to the long end of the graft (the Yoke stitch).

 

The long end is then passed through the isometric point and exits the superior humeral tunnel (TECH FIG 2A).

 

 

 

TECH FIG 2 • A. A Y-shaped tunnel is made with the base exiting at the isometric point (3). The hole is widened to accept a three-ply graft. The tendon graft is passed through the ulnar tunnel (1→2) with enough length to just reach the isometric point. The end is then sutured to the long end of the graft (the Yoke stitch). The long end is then passed through the isometric point and exits the superior humeral tunnel (3→4). (continued)

 

 

The long end is wrapped around the supracondylar ridge and passed through the distal tunnel, exiting back through the isometric point and into the ulnar tunnel.

 

The graft is then tensioned in 40 degrees of flexion, full pronation, and axial tension.

 

If the graft is not long enough to reach the ulnar tunnel, it can be sutured back to itself (TECH FIG 2B).

 

The reconstruction can be reinforced by weaving a no. 2 Fiber-Wire suture (Arthrex, Inc., Naples, FL) from distal to proximal through the course of the figure 8, thus sewing the graft to itself.

 

Plicate the anterior and posterior capsule as needed.

 

The extensor origin is repaired to the lateral epicondyle, and the extensor carpi ulnaris fascia is reapproximated to the anconeus muscle with absorbable sutures.

 

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TECH FIG 2 • (continued) B. The long end is then passed through the distal tunnel, exiting back through the isometric point (5→3) and into the ulnar tunnel (3→1→2). The graft is then tensioned in 40 degrees of flexion, full pronation, and axial tension. If the graft is not long enough to reach the ulnar tunnel, it can be sutured back to itself.

• Split Anconeus Fascia Transfer

 

We have developed a reproducible technique for LCL reconstruction that has proven biomechanical strength and reproducibility.

 

Advantages include using only local autograft tissue and the minimal creation of bone tunnels.3,4

Surgical Approach

 

A 6- to 8-cm skin incision is made over the Kocher interval, exposing the underlying Kocher interval between the extensor carpi ulnaris and anconeus (TECH FIG 3A,B).

 

 

 

TECH FIG 3 • A. A 6- to 8-cm skin incision is made over the Kocher interval. SR, supracondylar ridge; L, lateral epicondyle; RH, radial head; UC, ulnar crest. B. The underlying Kocher interval between the extensor carpi ulnaris (E) and anconeus (A) is exposed. C. The interval between the anconeus (A) and the extensor carpi ulnaris (E) is developed, taking care to preserve the remainder of the underlying LCL complex (held in forceps). The annular ligament (AL), lateral epicondyle (L), and 2 cm of the supracondylar ridge are isolated.

 

 

The interval between the anconeus and extensor carpi ulnaris muscles is developed, taking care to preserve the remainder of the underlying LCL complex.

 

The annular ligament, lateral epicondyle, and 2 cm of supracondylar ridge are isolated (TECH FIG 3C).

Graft Preparation

 

The anconeus and distal triceps fascia are isolated in continuity. A 1.0-cm wide × 8.0-cm long band of fascia is mobilized off the underlying muscle, leaving the ulnar insertion intact (TECH FIG 4A,B).

 

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The band is then divided longitudinally into two bands of equal width (TECH FIG 4C).

 

The anterior band is passed through an incision just distal to the annular ligament, whereas the posterior band is passed under the anconeus muscle (TECH FIG 4D).

 

The isometric point of the lateral epicondyle is then located by holding the two bands against the epicondyle while ranging the elbow (TECH FIG 4E).

 

The final lengths of the fascial bands are estimated by holding the bands along their respective paths. The bands are then trimmed appropriately to prevent them from “bottoming out” prematurely in the humeral docking tunnel.

 

Separate Krackow sutures are placed in each band with no. 0 FiberWire suture.

 

 

 

TECH FIG 4 • A. The anconeus and distal triceps fascia are isolated in continuity. B. A 1.0-cm wide × 8.0-cm long band of fascia is mobilized off the underlying muscle, leaving the ulnar insertion. C. The split anconeus fascia band is then divided longitudinally into two bands of equal width. A, anterior band; P, posterior band; U, ulnar insertion point. D. The anterior band (thin arrow) is passed through an incision just distal to the annular ligament (AL), whereas the posterior band (thick arrow) is passed under the anconeus muscle (A). E. The isometric point of the lateral epicondyle (L) is then located by holding the two bands against the epicondyle while ranging the elbow. The point of minimal tension loss in either band while ranging the elbow is the optimal isometric point. Arrows, anterior and posterior split anconeus fascia bands.

Tunnel Preparation

 

A 5-mm round burr is used to create a 1.5-cm long (depth) docking tunnel into the humerus at the

isometric point. A 1-mm side-cutting burr is then used to make anterior and posterior bone bridge holes. The holes are separated by 1.5 cm. Individual suture lassos are placed from proximal to distal into the docking tunnel from the separate humeral tunnels (TECH FIG 5).

Graft Passage and Tensioning and Wound Closure

 

The anterior band sutures are brought out the anterior humeral exit hole by using suture passers. The posterior band passes superficial to the annular ligament and its sutures are brought out the posterior humeral exit tunnel.

 

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TECH FIG 5 • A. Suture lassos passed through exit holes out to the distal docking tunnel. B. Suture lasso wires exiting docking tunnel.

 

 

The ends of the fascial bands are docked into the humeral tunnel, and the grafts are tensioned with the elbow in 40 degrees of flexion, in full pronation, and with a valgus stress.

 

 

The sutures are then tied over the bony bridge on the supracondylar ridge (TECH FIG 6A). The grafts can be augmented with any remaining LCL complex.

 

 

 

TECH FIG 6 • A. The ends of the fascial bands are docked into the humeral tunnel, and the grafts are tensioned with the elbow in 40 degrees of flexion, full pronation, and valgus stress. Sutures are then tied over the bony bridge on the supracondylar ridge (clamp on posterior band). B. The incision is closed with subcuticular suture.

 

 

The extensor origin is then repaired to the lateral epicondyle, and the extensor carpi ulnaris fascia is

 

reapproximated to the anconeus muscle with absorbable sutures. The skin is closed with a running subcuticular suture (TECH FIG 6B).

• Docking Technique

   

  As previously discussed, the Kocher approach is used for the docking technique.

   

  Preparation of the ulnar drill holes is described in the section on the figure-8 Yoke Technique elsewhere in this chapter.

   

  A 5-mm round burr is used to create a 1.5-cm long (depth) docking tunnel into the humerus at the isometric point. A 1-mm side-cutting burr is then used to make anterior and posterior bone bridge holes. The holes are separated by 1.5 cm. Individual suture lassos are placed from proximal to distal into the docking tunnel from the separate humeral tunnels (see TECH FIG 5).

   

  After passage of the graft through the ulnar tunnels, the final lengths of the two graft strands are estimated by holding the strands against the docking tunnel with the arm in the “reduced” position of 40 degrees of flexion, full pronation, and axial tension.

   

  The strands are then trimmed appropriately to prevent the strands from bottoming out prematurely in the humeral docking tunnel.

   

  Separate Krackow sutures are placed in each graft strand with no. 0 FiberWire suture for 1 cm.

   

  The anterior graft strand sutures are brought out to the anterior humeral exit hole by using suture passers. The posterior graft strand sutures are brought out to the posterior humeral exit tunnel.

   

  The ends of the humeral graft portion are docked into the humeral tunnel, and the grafts are tensioned with the elbow in 40 degrees of flexion, in full pronation, and with a valgus stress.

   

   

  The sutures are then tied over the bony bridge on the supracondylar ridge. Standard incision closure is performed.

   

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• Direct Repair

 

As previously discussed, the Kocher approach is used for direct repair.

 

If the LCL complex is intact but traumatically avulsed from its ulnar or humeral attachments (or both), it can be directly repaired to its correct anatomic location with suture anchors or bone tunnels. This most commonly occurs in the setting of acute, traumatic injuries.

 

A running locked no. 2 FiberWire suture is placed into the detached LCL complex and repaired back to its origin on the lateral epicondyle through the anterior and posterior drill holes (TECH FIG 7).

 

A careful repair of the extensor origin and the interval between the anconeus and the extensor carpi ulnaris is performed.

 

 

 

TECH FIG 7 • Primary LUCL repair. Running locked suture placed through detached LUCL. A relaxing incision can be made at its attachment to the base of the annular ligament. Repair through drill holes in the lateral epicondyle.

 

 

PEARLS AND PITFALLS
	Indications ▪ Iatrogenic causes (eg, “tennis elbow” surgery) very common. Careful history and physical examination to exclude other pathologic conditions History of numerous lateral elbow corticosteroid injections     Split anconeus fascia ▪ Isolate Kocher interval; fatty stripe within interval. technique: exposure ▪ Anconeus fibers oblique to extensor carpi ulnaris Identify LCL disruption.

 

	Isolate annular ligament; protect posterior interosseous nerve.     Splint anconeus fascia ▪ Be careful to harvest long enough fascial band (proximal to humeral preparation bone tunnels). Be careful not to detach from ulnar insertion. Isolate LCL complex isometric point of origin. Harvest fascial band in line with old LUCL.     Figure-8 yoke technique ▪ Carefully isolate isometric point on lateral epicondyle, usually more anterior and inferior; err on inferior placement. Make ulnar tunnel perpendicular to direction of LUCL. Chamfer bone tunnels to prevent graft impingement and breakage.     Bone tunnel preparation ▪ Maintain sufficient bony bridge between tunnels. Smooth edges to prevent graft irritation.     Arm position for final ▪ Forty degrees of elbow flexion graft tensioning ▪ Full pronation Axial load, valgus stress

 

 

POSTOPERATIVE CARE

 

Stage I (0 to 3 weeks)

 

 

 

Elbow immobilization in posterior splint or brace at 40 degrees of flexion Wrist and hand isometrics as tolerated

 

 

Shoulder active and passive ROM Stage II (3 to 6 weeks)

 

 

Hinged elbow brace or orthoplast splint, with limits set by surgeon Begin flexor-pronator isometrics

 

 

Continue with wrist and hand strengthening Continue shoulder as described earlier

 

 

Active-assisted ROM: 20 to 120 degrees of flexion; keep forearm pronated at all times Stage III (6 to 12 weeks)

 

Discontinue immobilization

 

 

Passive ROM and active-assisted ROM to full motion, including supination Begin unrestricted strengthening of flexor-pronators and extensors

 

Stage IV (3 to 6 months)

 

 

Avoid varus stress to elbow and ballistic movement in terminal elbow ranges

 

 

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Begin shoulder strengthening with light resistance (emphasis on cuff) Start total body conditioning

 

Terminal elbow stretching in flexion and extension

 

Resistive elbow exercises as tolerated

OUTCOMES

Nestor et al10 have shown successful functional outcomes in patients using the figure-8 reconstruction technique with reproducible results.

Our early experience with the split anconeus fascia reconstruction technique has shown excellent results, with no failures to date in 22 patients at an average follow-up of 2 years. All elbows have achieved stability without loss of motion.

 

 

COMPLICATIONS

Recurrent elbow instability in up to 8%2 Elbow stiffness

Infection

Graft harvest site morbidity (if remote autograft is used for reconstruction) Humerus stress fracture through bone tunnels

Ulnar stress fracture through bone tunnels Bone bridge compromise

 

 

REFERENCES

1. Anakwenze OA, Khanna K, Levine WN, et al. Characterization of the supinator tubercle for lateral ulnar collateral ligament reconstruction. Orthop J Sports Med 2014;2(4).

    

    

2. Anakwenze OA, Kwon D, O'Donnell E, et al. Surgical treatment of posterolateral rotatory instability of the elbow. Arthroscopy 2014;30(7):866-871.

    

    

3. Chebli CA, Murthi AM. Lateral collateral ligament complex: anatomic and biomechanical testing. Presented at the 73rd Annual Meeting and Scientific Program of the American Academy of Orthopaedic Surgeons, Chicago, March 2006.

    

    

4. Chebli CM, Murthi AM. Split anconeus fascia transfer for reconstruction of the elbow lateral collateral ligament complex: anatomic and biomechanical testing. Presented at the 22nd Open Meeting of the American Shoulder and Elbow Surgeons, Chicago, March 2006.

    

    

5. Cohen MS, Hastings H II. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.

    

    

6. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA 2013;309(5):461-469.

    

    

7. Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg 2000;82(6):809-813.

    

    

8. Jeon IH, Micic ID, Yamamoto N, et al. Osborne-cotterill lesion: an osseous defect of the capitellum associated with instability of the elbow. AJR Am Roentgenol 2008;191(3):727-729.

    

    

9. Kalainov DM, Cohen MS. Posterolateral rotatory instability of the elbow in association with lateral epicondylitis: a report of three cases. J Bone Joint Surg Am 2005;87(5):1120-1125.

    

    

10. Nestor BJ, O'Driscoll SW, Morrey BF. Ligamentous reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1992;74(8):1235-1241.

     

     

11. O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73(3):440-446.

     

     

12. O'Driscoll SW, Spinner RJ, McKee MD, et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001;83-A(9):1358-1369.