synonyms: PLRI, posterolateral rotatory instability
PLRI Reconstruction CPT
PLRI Reconstruction Anatomy
- Primary restraint to posterolateral rotatory instability of the elbow is the combination of the lateral collateral and annular ligaments. The principal secondary restraints are the extensor muscles with their fascial bands and intermuscular septa. (Cohen MS, JBJS 1997;79A:225), (McAdams TR, JSES, 2005;14:298).
- See also Elbow Anatomy.
PLRI Reconstruction Indications
- Recurrent PLRI of the elbow
PLRI Reconstruction Contraindications
- Acute injury: generally treated with direct repair.
- Supracondylar maluion >15°
- Coronoid deficiency
- Open physis (children): imbrication/advancement indicated.
- Advance osteoarthritis
PLRI Reconstruction Alternatives
- Direct repair (Sanchez-Sotelo J, JBJS 2005;87Br:54).
- Arthroscopic repair (Smith JP III, Clin Sports Med 2001;20:47).
PLRI Reconstruction Pre-op Planning / Special Considerations
- Ensure patient has a palmaris longus tendon. If not determine an alternative graft source.
PLRI Reconstruction Technique
- Sign operative site
- Pre-operative antibiotics, +/- regional block
- General endotracheal anesthesia
- Lateral position. All bony prominences well padded.
- Examination under anesthesia.
- Prep and drape in standard sterile fashion.
- Perform Elbow Arthroscopy .
- Perform lateral pivot shift test to confirm PLRI.
- Perform arthroscopic valgus instability test (apply valgus stress with elbow in 70° of flexion while visualizing the medial ulnohumeral joint. Any opening >1mm indicates Valgus Instability which requires medial reconstruction).
- 10cm lateral Kocher incision
- Incise deep fascia along the supracondylar ridge proximally to the interval between the anconeus and ECU distally.
- Expose supracondylar ridge by partially reflexing the triceps off the posterior humerus and the ECRL anteriorly.
- Reflect the anconeus off the lateral ulna and caspsule.
- Expose the LUCL insertion site near the tubercle on the supinator crest, distal to the annular ligament.
- Graft tensioned with the elbow in 40° of flexion and full pronation.
- Graft fixation may be done with absorbale interference screws. (arthrex biotenodesis)
- Close in layers.
PLRI Reconstruction Complications
- Snapping / irritation of tendon graft
- Continued instability
- Neurovascular injury
PLRI Reconstruction Follow-up care
- Post-op: Elbow is immobilized with a posterior splint with elbow in pronation.
- 7-10 Days: Place in hinged elbow brace with forearm in pronation.
- 6 Weeks: Pt may removed hinged brace for sedentary activities.
- 3 Months: Progress with strengthening and ROM exercises. Sport specific rehab.
- 6 Months: May return to sport.
PLRI Reconstruction Outcomes
- 72% Excellent/good results 89% stable (Sanchez-Sotelo J, JBJS 2005;87Br:54).
PLRI Reconstruction Review References