Reconstruction of the Lateral Collateral Ligament

April 24th, 2007

Posterolateral rotatory instability is the most common pattern of elbow instability, particularly that which is recurrent. Posterolateral rotatory instability can be considered a spectrum consisting of three stages according to the degree of soft tissue disruption, or may develop as a complication of a preceding surgery such as tennis elbow debridement or following radial head repair or replacement if the lateral collateral ligament (LCL) is injured (figure 1).

Patients typically present with a history of recurrent painful clicking, snapping, clunking, or locking of the elbow and careful examination reveals that this occurs in the extension portion of the arc of motion with the forearm in supination. The most sensitive provocative test is the the lateral pivot-shift test, performed with the elbow is supination as an axial and valgus stress is applied moving from extension to flexion (figure 2). In supination, and with valgus stress, the forearm externally rotates, pivots on the intact MCL, and subluxates posteriorly. This results in a visible dimple laterally.

Surgical treatment may involve tightening a stretched LCL or more commonly, reconstruction using tendon graft or allograft. Though the original technique described the use of bone tunnels, newer tenodesis screws allow fixation without relying on tunnels. Postoperatively, a splint immobilizes the elbow in 90 degrees for 3 weeks at which time therapy begins.

Related Photos:

Fig 1. Injury to the lateral collateral ligament results in Posterolateral Rotary Instability

Fig 2. Pivot shift test

Lateral xray before rotary subluxation occurs

Lateral xray after posterolateral rotary subluxation occurs

Posterolateral subluxation results in a dimple behind the radial head

Reconstruction of the LCL may rely on the creation of bone tunnels

Lateral xray shows that the radial head implant is posterior to the capitellum. This patient had an incompetent LCL, and intermittent subluxation caused damage to the capitellum

Supinator tubercle is exposed as the initial anchor site of tibialis anterior allograft reconstruction of the LCL

Completed LCL reconstruction

Postoperative lateral xray shows that the radial head lines up with the capitellar replacement

Related Videos:

LCL reconstruction utilized tibialis anterior allograft and biotenodesis screws to correct PL instability 1 year following radial head arthroplasty for fracture. Capitellar arthrosis was addressed with a capitellar replacement, but removal/exchange of the radial head implant was not possible