Lateral collateral ligament injuries of the elbow - chronic posterolateral rotatory instability (PLRI)

Chronic posterolateral rotatory instability (PLRI) is the most common form of chronic elbow instability. PLRI usually occurs from a fall on the outstretched hand. On impact, the radial head and ulna rotate externally coupled with valgus displacement of the forearm. This leads to posterior displacement of the radial head relative to the capitellum, thus causing disruption of some or all of the lateral-sided stabilisers. PLRI is mainly a clinical diagnosis with a history of instability, clicking and lateral-sided pain, with a positive clinical examination including the pivot-shift test, push-up, chair and tabletop test. MRI can often help guide diagnosis but more commonly assists in surgical planning. Surgery is indicated in patients with persistent, symptomatic instability of the elbow causing pain or functional deficit. There are several surgical techniques to treat PLRI, often leading to good to excellent results. An open or arthroscopic technique has been successfully used in patients with symptomatic PLRI following one or more episodes of dislocation or subluxation. At the preoperative examination under general anaesthesia, all of our patients had a positive pivot-shift test but not a frank dislocation. We prefer to perform a lateral collateral ligament (LCL) reconstruction with an allograft tendon. The outcomes after repair are good to excellent in the majority of patients. Results of acute repair are generally better compared with reconstruction. This is due to the fact that predictive factors for a poor outcome include the number of previous surgeries and the prevalence of degenerative changes at the elbow. Recurrent instability is not uncommon following repair or reconstruction and has been reported in up to 25% of patients after medium-to longer-term follow-up.