Indications
Lateral collateral ligament (LCL) disruption can be a devastating injury. Complete rupture with posterolateral rotatory instability (PLRI) of the elbow can occur with trauma, especially elbow dislocation. Other patients have more subtle injuries to the LCL complex that result in pain and mechanical symptoms, not complete dislocations. This can even occur in patients that have received multiple corticosteroid injections for lateral epicondylitis,1 have had previous lateral-sided elbow procedures,2 or have a cubitus varus deformity after a supracondylar distal humerus fracture.
Patients with more subtle injuries can complain of pain and mechanical symptoms when pushing up from a chair. They are also unable to do pushups with the forearm supinated. The classic physical exam finding is the supine lateral pivot shift test. The patient is placed supine on the table. The examiner stands at the head of the table and brings the patient's arm over his or her head. The arm is extended, supinated, and a valgus stress is applied. In this position the radial can be palpated. The arm is then flexed and the elbow relocates; a clunk can be felt and the radial head is no longer prominent. This is sometimes difficult to do with an awake patient, who may feel apprehensive about having the elbow extended.
Patients with more subtle injuries can benefit from a course of physical therapy with generalized elbow strengthening and modalities. If this fails, then operative intervention can be successful.
Preoperative Planning
After performing the above clinical exams, examine the patient's plain radiographs. These are typically normal unless the patient has suffered a fracture dislocation of the elbow. In cases of acute trauma, look for subtle coranoid fractures or subluxation of the ulnohumeral joint on the plain radiographs.
There should be a low threshold for ordering computerized tomography (CT) with three dimensional reconstructions. Stress radiographs can also be helpful and can demonstrate ulnohumeral subluxation. If these are all normal, a magnetic resonance imaging study with intra-articular dye will typically show a lesion in the lateral collateral complex.
This can be a difficult procedure with intra-operative complications. Surgeons should be familiar with several techniques in case problems occur. If the surgeon plans to utilize autograft, an allograft should also be available in case the autograft is unsuitable or lost.
Positioning
The patient's arm is placed on a hand table with a non-sterile tourniquet. The hand does not need to be prepped. A small bump is placed under the elbow and the surgeon typically sits cephalad (Figure 1).
Figure 1. Patient arm positioning
Techniques
There are multiple options for LCL reconstruction. For acute tears, direct repair can be effective. For more chronic injuries, a reconstruction is necessary. This section will describe the split anconeus fascia transfer.3 This technique will work only if the anconeus fascia is still intact. If it is compromised from previous surgery or injury, then a technique that utilizes a graft must be used.
A 6- to 10-cm incision is made from just proximal to the lateral epicondyle to distal to the supinator crest. Skin flaps are raised, revealing the anconeus fascia and underlying muscle belly. Once the fascia is identified, a 1-cm thick, 8-cm long strip of the fascia is elevated. Care should be taken to avoid disrupting the fascia's ulnar insertion. The graft is then split in half. Krackow stitches with nonabsorbable braided sutures are placed into each band.
A standard Kocher approach is used and the anconeus is split from the extersor carpi ulnaris. This is carried proximal to the supracondylar ridge. An arthrotomy is then made and the capitellum is identified. The isometric point of the capitellum is identified and a 0.5-cm burr hole is made at this point. Both fascial bands are then routed under the anconeus muscle and brought along what remains of the LCL. A small slit is then made in the annular ligament and the anterior band is brought under the ligament. This band will become the radial collateral ligament and the posterior band will become the lateral ulnar collateral ligament.
Using a side cutting burr, drill holes are then made anterior and posterior to the isometric point. A suture lasso is utilized to retrieve the sutures from the two bands, one from each band exiting each drill hole. Make sure to mark the sutures or use different colors so that each strand can be identified.
The arm is then placed at 40 degrees of flexion, full pronation, and a valgus stress is applied. Both fascial bands are brought into the isometric hole and tensioned. The sutures from each band are tied over the bone bridge on the supracondylar ridge. The native LCL can be incorporated into the repair. The Kocher interval is closed.
Pearls and Pitfalls
- Care must be taken when preparing the fascial bands. They can be made too thin or too short.
- When preparing the bone tunnels, leave enough space between them. If the distance is too short, the sutures can pull through, compromising fixation.
Postoperative Care
Patients are placed into a posterior splint in pronation. This is transitioned to a static removable splint at 1 week. Under the care of a therapist, patients are then started on flexion and extension exercises with the forearm in pronation. At 6 weeks the splint is removed. Range of motion exercises are progressed with the anticipation of full range at 3 months. Strengthening begins at 3 months, with return to full activity without restriction at 6 months.
Outcome
Outcomes for this technique are very good, with high patient satisfaction. There are currently no randomized controlled trials comparing split anconeus fascia transfer to other techniques for LCL reconstruction.
Complications
Stiffness is one of the main concerns after all ligament reconstructions around the elbow. Meticulous technique and structured physical therapy are the two main ways to avoid this problem.
References
- 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 87:1120-1125, 2005
- 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 83:1358-1369, 2001
- Chebli CA, 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
