Research progress of posteromedial rotatory instability of the elbow_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LONG Nengji , HE Shukun , WU Shizhou ,  HUANG Fuguo

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

HUANG Fuguo, Email: huang-f-g@163.com

Keywords：

Elbow joint; posterolateral rotatory instability; lateral collateral ligament complex; medial collateral ligament complex

DOI：

10.7507/1002-1892.201710101

Video：

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Objective To summarize the research progress in posteromedial rotatory instability (PMRI) of the elbow joint. Methods The recent researches about the management of PMRI of the elbow joint from the aspects of pathological anatomy, biomechanics, diagnosis, and therapy were analyzed and summarized. Results The most important factors related to PMRI of the elbow joint are lateral collateral ligament complex (LCLC) lesion, posterior bundle of the medial collateral ligament complex (MCLC) lesion, and anteromedial coronoid fracture. Clinical physical examination include varus and valgus stress test of the elbow joint. X-ray examination, computed tomography, particularly three-dimensional reconstruction, are particularly useful to diagnose the fracture. Also MRI, arthroscopy, and dynamic ultrasound can assistantly evaluate the affiliated injury of the parenchyma. It is important to repair and reconstruct LCLC and MCLC and fix coronoid process fracture for recovering stability of the elbow joint. There are such ways to repair ligament injury as in situ repairation and functional reconstruction, which include direct suturation, borehole repairation, wire anchor repairation, and transplantation repairation etc. The methods for fixation of coronal fracture include screw fixation, plate fixation, unabsorbable suture fixation, and arthroscopy technology. Conclusion It is crucial that recovering the stability of the elbow joint and early functional exercise for the treatment of PMRI. Individual treatment is favorable to protect soft tissue, reduce surgical complications, and improve the functional recovery and the quality of life.

Citation： LONG Nengji, HE Shukun, WU Shizhou, HUANG Fuguo. Research progress of posteromedial rotatory instability of the elbow. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(4): 505-510. doi: 10.7507/1002-1892.201710101 Copy

1.	O’Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect, 2003, 52: 113-134.
2.	Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg (Am), 2000, 82-A(12): 1749-1753.
3.	Beingessner DM, Dunning CE, Stacpoole RA, et al. The effect of coronoid fractures on elbow kinematics and stability. Clin Biomech (Bristol, Avon), 2007, 22(2): 183-190.
4.	Hull JR, Owen JR, Fern SE, et al. Role of the coronoid process in varus osteoarticular stability of the elbow. J Shoulder Elbow Surg, 2005, 14(4): 441-446.
5.	董洪先, 黄富国. 尺骨冠状突前内侧骨折与肘关节外侧副韧带复合体损伤对肘关节后内侧旋转稳定性影响的生物力学研究. 中国修复重建外科杂志, 2017, 31(2): 176-179.
6.	Seki A, Olsen BS, Jensen S, et al. Functional anatomy of the lateral collateral ligament complex of the elbow: configuration of Y and its role. J Shoulder Elbow Surg, 2002, 11(1): 53-59.
7.	Bellato E, Kim Y, Fitzsimmons JS, et al. Role of the lateral collateral ligament in posteromedial rotatory instability of the elbow. J Shoulder Elbow Surg, 2017, 26(9): 1636-1643.
8.	Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am, 2008, 39(2): 141-154.
9.	Dugas JR, Ostrander RV, Cain EL, et al. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg, 2007, 16(5): 657-660.
10.	Shukla DR, Golan E, Nasser P, et al. Importance of the posterior bundle of the medial ulnar collateral ligament. J Shoulder Elbow Surg, 2016, 25(11): 1868-1873.
11.	Pollock JW, Brownhill J, Ferreira LM, et al. Effect of the posterior bundle of the medial collateral ligament on elbow stability. J Hand Surg (Am), 2009, 34(1): 116-123.
12.	Golan EJ, Shukla DR, Nasser P, et al. Isolated ligamentous injury can cause posteromedial elbow instability: a cadaveric study. J Shoulder Elbow Surg, 2016, 25(12): 2019-2024.
13.	Sard A, Dutto E, Rotini R, et al. The posterior bundle of the elbow medial collateral ligament: biomechanical study and proposal for a new reconstruction surgical technique. Musculoskelet Surg, 2017, 101(Suppl 2): 181-186.
14.	Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg (Am), 1989, 71(9): 1348-1354.
15.	Sanchez-Sotelo J, Morrey M. Complex elbow instability: surgical management of elbow fracture dislocations. EFORT Open Rev, 2016, 1(5): 183-190.
16.	Copas D, Talbot JC. Clinical assessment of the elbow. Orthopaedics and Trauma, 2016, 30(4): 291-300.
17.	Chen FS, Diaz VA, Loebenberg M, et al. Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop Surg, 2005, 13(3): 172-185.
18.	O’Driscoll SW, Lawton RL, Smith AM. The ‘moving valgus stress test’ for medial collateral ligament tears of the elbow. Am J Sports Med, 2005, 33(2): 231-239.
19.	Savoie FH, O’Brien M. Chronic medial instability of the elbow. EFORT Open Rev, 2017, 2(1): 1-6.
20.	O’Driscoll SW. Stress radiographs are important in diagnosing valgus instability of the elbow. J Bone Jiont Surg (Am), 2002, 84-A(4): 686.
21.	Cohen SB, Valko C, Zoga A, et al. Posteromedial elbow impingement: magnetic resonance imaging findings in overhead throwing athletes and results of arthroscopic treatment. Arthroscopy, 2011, 27(10): 1364-1370.
22.	Cotten A, Jacobson J, Brossmann J, et al. MR arthrography of the elbow: normal anatomy and diagnostic pitfalls. J Comput Assist Tomogr, 1997, 21(4): 516-522.
23.	De Maseneer M, Brigido MK, Antic M, et al. Ultrasound of the elbow with emphasis on detailed assessment of ligaments, tendons, and nerves. Eur J Radiol, 2015, 84(4): 671-681.
24.	Ciccotti MG, Atanda A Jr, Nazarian LN, et al. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med, 2014, 42(3): 544-551.
25.	Pollock JW, Brownhill J, Ferreira L, et al. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg (Am), 2009, 91(6): 1448-1458.
26.	Chan K, Faber KJ, King GJ, et al. Selected anteromedial coronoid fractures can be treated nonoperatively. J Shoulder Elbow Surg, 2016, 25(8): 1251-1257.
27.	Moon JG, Bither N, Jeon YJ, et al. Non surgically managed anteromedial coronoid fractures in posteromedial rotatory instability: three cases with 2 years follow-up. Arch Orthop Trauma Surg, 2013, 133(12): 1665-1668.
28.	Van Der Werf HJ, Guitton TG, Ring D. Non-operatively treated fractures of the anteromedial facet of the coronoid process: a report of six cases. Shoulder Elbow, 2010, 2(1): 40-42.
29.	Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg (Am), 2006, 88(10): 2216-2224.
30.	Doornberg JN, de Jong IM, Lindenhovius AL, et al. The anteromedial facet of the coronoid process of the ulna. J Shoulder Elbow Surg, 2007, 16(5): 667-670.
31.	Wells J, Ablove RH. Coronoid fractures of the elbow. Clin Med Res, 2008, 6(1): 40-44.
32.	Yang X, Chang W, Chen W, et al. A novel anterior approach for the fixation of ulnar coronoid process fractures. Orthop Traumatol Surg Res, 2017, 103(6): 899-904.
33.	彭世彬, 徐立, 梁军. Hotchkiss入路治疗尺骨冠突骨折的手术疗效. 创伤外科杂志, 2017, 19(4): 294-296.
34.	Manidakis N, Sperelakis I, Hackney R, et al. Fractures of the ulnar coronid process. Injury, 2012, 43(7): 989-998.
35.	Iannuzzi NP, Paez AG, Parks BG, et al. Fixation of regan-morrey type Ⅱ coronoid fractures: a comparison of screws and suture lasso technique for resistance to displacement. J Hand Surg (Am), 2017, 42(1): e11-e14.
36.	Moon JG, Zobitz ME, An KN, et al. Optimal screw orientation for fixation of coronoid fractures. J Orthop Trauma, 2009, 23(4): 277-280.
37.	刘观赕, 潘志军, 马维虎, 等. 伴有前内侧冠状突骨折的肘关节" 三联征”手术治疗策略. 中华创伤骨科杂志, 2017, 19(7): 578-583.
38.	Sanchez-Sotelo J, O’Driscoll SW, Morrey BF. Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elbow Surg, 2006, 15(5): e5-8.
39.	Park SM, Lee JS, Jung JY, et al. How should anteromedial coronoid facet fracture be managed? A surgical strategy based on O’Driscoll classification and ligament injury. J Shoulder Elbow Surg, 2015, 24(1): 74-82.
40.	Ouyang K, Wang D, Lu W, et al. Arthroscopic reduction and fixation of coronoid fractures with an exchange rod-a new technique. J Orthop Surg Res, 2017, 12(1): 9.
41.	Vernet E, Bacle G, Marteau E, et al. Lateral elbow ligamentoplasty by autologous tendon graft in posterolateral rotatory instability: Results in 18 cases at a mean 5 years’ follow-up. Orthop Traumatol Surg Res, 2015, 101(4 Suppl): S199-202.
42.	Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg (Am), 1986, 68(8): 1158-1163.
43.	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.
44.	Rohrbough JT, Altchek DW, Hyman J, et al. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med, 2002, 30(4): 541-548.
45.	Olsen BS, Søjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg (Br), 2003, 85(3): 342-346.
46.	Stein JA, Murthi AM. Posterolateral rotatory instability of the elbow: Our approach. Oper Tech Orthop, 2009, 19(4): 251-257.
47.	Erickson BJ, Harris JD, Chalmers PN, et al. Ulnar collateral ligament reconstruction: anatomy, indications, techniques, and outcomes. Sports Health, 2015, 7(6): 511-517.
48.	Camp CL, Sanchez-Sotelo J, Shields MN, et al. Lateral ulnar collateral ligament reconstruction for posterolateral rotatory instability of the elbow. Arthrosc Tech, 2017, 6(4): e1101-e1105.
49.	Jones KJ, Dodson CC, Osbahr DC, et al. The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes. J Shoulder Elbow Surg, 2012, 21(3): 389-395.
50.	Kim JW, Yi Y, Kim TK, et al. Arthroscopic lateral collateral ligament repair. J Bone Joint Surg (Am), 2016, 98(15): 1268-1276.
51.	O’Brien MJ, Savoie FH 3rd. Arthroscopic and open management of posterolateral rotatory instability of the elbow. Sports Med Arthrosc Rev, 2014, 22(3): 194-200.
52.	Alaia MJ, Shearin JW, Kremenic IJ, et al. Restoring Isometry in Lateral Ulnar Collateral Ligament Reconstruction. J Hand Surg (Am), 2015, 40(7): 1421-1427.
53.	Wilk KE, Macrina LC, Cain EL, et al. Rehabilitation of the overhead athlete’s elbow. Sports Health, 2012, 4(5): 404-414.

1. O’Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect, 2003, 52: 113-134.
2. Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg (Am), 2000, 82-A(12): 1749-1753.
3. Beingessner DM, Dunning CE, Stacpoole RA, et al. The effect of coronoid fractures on elbow kinematics and stability. Clin Biomech (Bristol, Avon), 2007, 22(2): 183-190.
4. Hull JR, Owen JR, Fern SE, et al. Role of the coronoid process in varus osteoarticular stability of the elbow. J Shoulder Elbow Surg, 2005, 14(4): 441-446.
5. 董洪先, 黄富国. 尺骨冠状突前内侧骨折与肘关节外侧副韧带复合体损伤对肘关节后内侧旋转稳定性影响的生物力学研究. 中国修复重建外科杂志, 2017, 31(2): 176-179.
6. Seki A, Olsen BS, Jensen S, et al. Functional anatomy of the lateral collateral ligament complex of the elbow: configuration of Y and its role. J Shoulder Elbow Surg, 2002, 11(1): 53-59.
7. Bellato E, Kim Y, Fitzsimmons JS, et al. Role of the lateral collateral ligament in posteromedial rotatory instability of the elbow. J Shoulder Elbow Surg, 2017, 26(9): 1636-1643.
8. Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am, 2008, 39(2): 141-154.
9. Dugas JR, Ostrander RV, Cain EL, et al. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg, 2007, 16(5): 657-660.
10. Shukla DR, Golan E, Nasser P, et al. Importance of the posterior bundle of the medial ulnar collateral ligament. J Shoulder Elbow Surg, 2016, 25(11): 1868-1873.
11. Pollock JW, Brownhill J, Ferreira LM, et al. Effect of the posterior bundle of the medial collateral ligament on elbow stability. J Hand Surg (Am), 2009, 34(1): 116-123.
12. Golan EJ, Shukla DR, Nasser P, et al. Isolated ligamentous injury can cause posteromedial elbow instability: a cadaveric study. J Shoulder Elbow Surg, 2016, 25(12): 2019-2024.
13. Sard A, Dutto E, Rotini R, et al. The posterior bundle of the elbow medial collateral ligament: biomechanical study and proposal for a new reconstruction surgical technique. Musculoskelet Surg, 2017, 101(Suppl 2): 181-186.
14. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg (Am), 1989, 71(9): 1348-1354.
15. Sanchez-Sotelo J, Morrey M. Complex elbow instability: surgical management of elbow fracture dislocations. EFORT Open Rev, 2016, 1(5): 183-190.
16. Copas D, Talbot JC. Clinical assessment of the elbow. Orthopaedics and Trauma, 2016, 30(4): 291-300.
17. Chen FS, Diaz VA, Loebenberg M, et al. Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop Surg, 2005, 13(3): 172-185.
18. O’Driscoll SW, Lawton RL, Smith AM. The ‘moving valgus stress test’ for medial collateral ligament tears of the elbow. Am J Sports Med, 2005, 33(2): 231-239.
19. Savoie FH, O’Brien M. Chronic medial instability of the elbow. EFORT Open Rev, 2017, 2(1): 1-6.
20. O’Driscoll SW. Stress radiographs are important in diagnosing valgus instability of the elbow. J Bone Jiont Surg (Am), 2002, 84-A(4): 686.
21. Cohen SB, Valko C, Zoga A, et al. Posteromedial elbow impingement: magnetic resonance imaging findings in overhead throwing athletes and results of arthroscopic treatment. Arthroscopy, 2011, 27(10): 1364-1370.
22. Cotten A, Jacobson J, Brossmann J, et al. MR arthrography of the elbow: normal anatomy and diagnostic pitfalls. J Comput Assist Tomogr, 1997, 21(4): 516-522.
23. De Maseneer M, Brigido MK, Antic M, et al. Ultrasound of the elbow with emphasis on detailed assessment of ligaments, tendons, and nerves. Eur J Radiol, 2015, 84(4): 671-681.
24. Ciccotti MG, Atanda A Jr, Nazarian LN, et al. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med, 2014, 42(3): 544-551.
25. Pollock JW, Brownhill J, Ferreira L, et al. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg (Am), 2009, 91(6): 1448-1458.
26. Chan K, Faber KJ, King GJ, et al. Selected anteromedial coronoid fractures can be treated nonoperatively. J Shoulder Elbow Surg, 2016, 25(8): 1251-1257.
27. Moon JG, Bither N, Jeon YJ, et al. Non surgically managed anteromedial coronoid fractures in posteromedial rotatory instability: three cases with 2 years follow-up. Arch Orthop Trauma Surg, 2013, 133(12): 1665-1668.
28. Van Der Werf HJ, Guitton TG, Ring D. Non-operatively treated fractures of the anteromedial facet of the coronoid process: a report of six cases. Shoulder Elbow, 2010, 2(1): 40-42.
29. Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg (Am), 2006, 88(10): 2216-2224.
30. Doornberg JN, de Jong IM, Lindenhovius AL, et al. The anteromedial facet of the coronoid process of the ulna. J Shoulder Elbow Surg, 2007, 16(5): 667-670.
31. Wells J, Ablove RH. Coronoid fractures of the elbow. Clin Med Res, 2008, 6(1): 40-44.
32. Yang X, Chang W, Chen W, et al. A novel anterior approach for the fixation of ulnar coronoid process fractures. Orthop Traumatol Surg Res, 2017, 103(6): 899-904.
33. 彭世彬, 徐立, 梁军. Hotchkiss入路治疗尺骨冠突骨折的手术疗效. 创伤外科杂志, 2017, 19(4): 294-296.
34. Manidakis N, Sperelakis I, Hackney R, et al. Fractures of the ulnar coronid process. Injury, 2012, 43(7): 989-998.
35. Iannuzzi NP, Paez AG, Parks BG, et al. Fixation of regan-morrey type Ⅱ coronoid fractures: a comparison of screws and suture lasso technique for resistance to displacement. J Hand Surg (Am), 2017, 42(1): e11-e14.
36. Moon JG, Zobitz ME, An KN, et al. Optimal screw orientation for fixation of coronoid fractures. J Orthop Trauma, 2009, 23(4): 277-280.
37. 刘观赕, 潘志军, 马维虎, 等. 伴有前内侧冠状突骨折的肘关节" 三联征”手术治疗策略. 中华创伤骨科杂志, 2017, 19(7): 578-583.
38. Sanchez-Sotelo J, O’Driscoll SW, Morrey BF. Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elbow Surg, 2006, 15(5): e5-8.
39. Park SM, Lee JS, Jung JY, et al. How should anteromedial coronoid facet fracture be managed? A surgical strategy based on O’Driscoll classification and ligament injury. J Shoulder Elbow Surg, 2015, 24(1): 74-82.
40. Ouyang K, Wang D, Lu W, et al. Arthroscopic reduction and fixation of coronoid fractures with an exchange rod-a new technique. J Orthop Surg Res, 2017, 12(1): 9.
41. Vernet E, Bacle G, Marteau E, et al. Lateral elbow ligamentoplasty by autologous tendon graft in posterolateral rotatory instability: Results in 18 cases at a mean 5 years’ follow-up. Orthop Traumatol Surg Res, 2015, 101(4 Suppl): S199-202.
42. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg (Am), 1986, 68(8): 1158-1163.
43. 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.
44. Rohrbough JT, Altchek DW, Hyman J, et al. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med, 2002, 30(4): 541-548.
45. Olsen BS, Søjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg (Br), 2003, 85(3): 342-346.
46. Stein JA, Murthi AM. Posterolateral rotatory instability of the elbow: Our approach. Oper Tech Orthop, 2009, 19(4): 251-257.
47. Erickson BJ, Harris JD, Chalmers PN, et al. Ulnar collateral ligament reconstruction: anatomy, indications, techniques, and outcomes. Sports Health, 2015, 7(6): 511-517.
48. Camp CL, Sanchez-Sotelo J, Shields MN, et al. Lateral ulnar collateral ligament reconstruction for posterolateral rotatory instability of the elbow. Arthrosc Tech, 2017, 6(4): e1101-e1105.
49. Jones KJ, Dodson CC, Osbahr DC, et al. The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes. J Shoulder Elbow Surg, 2012, 21(3): 389-395.
50. Kim JW, Yi Y, Kim TK, et al. Arthroscopic lateral collateral ligament repair. J Bone Joint Surg (Am), 2016, 98(15): 1268-1276.
51. O’Brien MJ, Savoie FH 3rd. Arthroscopic and open management of posterolateral rotatory instability of the elbow. Sports Med Arthrosc Rev, 2014, 22(3): 194-200.
52. Alaia MJ, Shearin JW, Kremenic IJ, et al. Restoring Isometry in Lateral Ulnar Collateral Ligament Reconstruction. J Hand Surg (Am), 2015, 40(7): 1421-1427.
53. Wilk KE, Macrina LC, Cain EL, et al. Rehabilitation of the overhead athlete’s elbow. Sports Health, 2012, 4(5): 404-414.

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