Posterolateral Rotatory Instability Repair
What is Posterolateral Rotatory Instability (PLRI)?
The elbow is the second most commonly dislocated large joint in the body. Posterolateral rotatory instability is the result of damage to the lateral collateral ligament (LCL) in the elbow. PLRI is a the most common form of symptomatic acute and chronic elbow instability.
What causes PLRI?
The most common cause is trauma such as a fall on an outstretched hand, elbow dislocation and sometimes facture dislocation which torques the forearm and its relation to the upper arm bone called the humerus which rotates and causes the LCL to detach or tear.
PLRI is also associated with tennis elbow or other injury including a fracture of the upper arm bone that does not heal in the correct position. In 90% of cases chronic elbow instability results from nonhealing soft tissue injuries or facture dislocations caused by acute trauma. 10% of cases of PLRI can be caused by repetitive stress, congenital or acquired deformities, disease, inflammatory arthritis and as a complication of previous elbow procedures such as corticosteroid injections.
What are the symptoms?
- Pain is the primary symptom
- Mechanical symptoms include snapping or clicking in the joint with elbow extension or when pushing off from an arm of a chair
- Tenderness over the location of the LCL
- Subluxation where the joint is partially dislocated
- a bump
While some patients present with these symptoms soon after the traumatic event, most patients may have these symptoms with chronic PLRI.
How is it diagnosed?
Often symptoms are subtle and require a thorough history and provocative physical exam to diagnose the condition. Dr. Hackett will review your medical history and ask how you injured your elbow, and your symptoms. He will conduct a thorough clinical examination to test elbow mechanics and alignment. As part of the physical examination, he will use specific tests designed to assess the integrity of the LCL and identify PLRI. The primary test is called Posterolateral Rotatory Drawer test. When preforming this test, he will ask you to relax. Relaxation is critical. He will explain what he is doing and that it should not cause pain or allow the elbow to dislocate. He will also order imaging studies including x-rays, MRI to rule out other conditions but will not reveal instability.
Obvious instability is easier to diagnose. However, when the symptoms are subtle arthroscopy is a valuable tool for diagnosis and treatment of PLRI. Arthroscopy allows Dr. Hackett direct vision of the inside of the joint; and based upon his expertise in complex elbow injuries, he can perform arthroscopic surgery at the same time to repair the LCL.
What is the treatment for PLRI?
Nonoperative management of chronic PLRI is frequently unsuccessful. In cases where symptoms are mild or where surgery is contraindicated as when the patient has elbow arthritis, a trial of nonoperative management may be offered.
LCL integrity is the primary restraint that prevents elbow instability. Surgery is the principal treatment to restore LCL integrity. The majority of patients will require surgery. For patients with an acute rupture of the ligament, and good quality tissue, repair of the ligament may be possible. For patients with chronic instability and poor-quality tissue ligament reconstruction is usually required.
Symptomatic PLRI is treated with surgical reconstruction of the ulnar collateral ligament complex with a tendon graft from another area of the patient’ s body or from a donor. During surgery other repairs of bony deformities may be needed.
Arthroscopic reconstruction requires a high level of skill and experience. Dr. Tom Hackett is a specialist in the arthroscopic treatment of PLRI and other complex injuries of the knee, shoulder and elbow. Complications are low. Elbow stability is restored in the vast majority of patients who undergo ligament reconstruction. LCL reconstruction surgery for chronic PLRI is safe and effective, reliable treatment to restore preinjury levels of function for active individuals.
Contact Dr. Tom Hackett to schedule a consultation from an expert in the treatment of this complex condition.