Residual increased valgus stress angulation and posterolateral rotatory translation after simple elbow dislocation

Simple acute postero-lateral elbow dislocation: A historical perspective

PURPOSE

The aims of this study were to summarize (1) the historical knowledge of the posterolateral elbow dislocation (PLED) pattern and the biomechanical, radiographic, and clinical data that engendered its evolution; and (2) to help clinicians better understand the management of PLED.

METHODS

A literature search was performed using Ovid, Scopus and Cochrane Library, and the Medical Subject Headings vocabulary. Results are discussed as a chronologic review of the relevant literature between 1920-2022.

RESULTS

In 1966 Osborn and Cotterill were the first to describe posterolateral rotatory instability (PLRI) causing the PLED. Several theories on PLED were then published by others surgeons as our understanding of elbow biomechanics continued to improve. Multiple treatment protocols have been designed based on the aforementioned theories. Conservative and surgical treatment for PLED provides excellent functional outcomes. However, high rates of persistent pain stiffness and instability have been reported long-term, and no single approach to treatment has been widely accepted.

CONCLUSION

Despite a growing body of biomechanical evidence, there is no consensus surgical indication for the treatment of PLED. Both conservative and surgical management result in satisfactory functional outcomes after PLED. However, elevated rates of residual pain, and instability have also been described and may limit heavy labor and sports participation. The next challenge for elbow surgeons will be to identify those patients who would benefit from surgical stabilization following PLED.

Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases

BACKGROUND

The treatment of simple elbow dislocations (SEDs) has become more functional last decade with a tendency to shorter immobilization of the elbow, whereas simultaneously, surgical stabilization has been promoted by some authors. The primary aim of this study was to systematically review the literature and analyze the outcomes and complications of different treatment options for acute and persistent SEDs, including operative and nonoperative treatments with varying immobilization periods.

METHODS

A literature search was performed based on the online medical databases MEDLINE, Embase, and the Cochrane databases. Articles presenting patients with a SED were eligible for inclusion. When an SED persists for >3 weeks, it is categorized as persistent. Various outcome measures were assessed, including the range of motion (ROM), patient-reported outcome measures, and complication rates. To get insight into the severity of complications, all complications were categorized as minor or major. The Methodological Index for Nonrandomized Studies was used to assess the methodological quality of nonrandomized studies. The risk of bias in the randomized studies was assessed with the Cochrane risk-of-bias tool.

RESULTS

A total of 37 articles were included with 1,081 dislocated elbows (1,078 patients). A fair quality of evidence was seen for the nonrandomized studies and a low risk of bias for the randomized study. Nonoperative treatment was administered to 710 elbows, with 244 elbows treated with early mobilization, 239 with 1- to 3-week immobilization, and 163 with ≥3-week immobilization. These groups showed a ROM flexion-extension arc (ROM F/E) of 137, 129, and 131°, respectively. Surgical treatment as open reduction and ligament repair or reconstruction was performed in 228 elbows and showed a ROM F/E of 128°. All persistent SEDs were treated surgically and showed a ROM F/E of 90°.

CONCLUSION

The early mobilization treatment showed the most consistent satisfactory outcomes in the literature compared with the other treatment options. Nevertheless, there remains ambiguity regarding which patients would benefit more from surgery than nonoperative treatment.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute elbow dislocation: a critical appraisal of the literature

Background

The purpose of this study was to perform a narrative review of acute elbow dislocation (AED). There are certain aspects of the management of AED that are controversial, including type and length of immobilization, indications for surgery, type of surgery, and new evidence available.

Material and methods

A literature search was performed using MEDLINE and Embase databases for studies regarding AED. Preference was given to studies according to their level of evidence. Studies regarding the outcome of conservative and surgical treatment, including patient-reported outcomes, complications, and conversion to stabilization or revision surgery were included.

Results

We found only 1 level I study and 3 level II randomized clinical trials. The rest consisted of level III-V evidence. Conservative care continues to be the standard of care for stable AEDs. Shorter immobilization periods are favored when possible. A consensus definition of an unstable elbow still needs to be improved. Unstable simple elbow dislocation may benefit from surgical intervention with different techniques showing similar outcomes. Advances in surgical procedures and suture designs, including tapes, and ligament augmentation, need to prove their role in managing acute elbow instability.

Conclusion

There is a need for higher quality studies after the reduction of an AED, including discerning the outcome of specific patterns of injury and particular groups of patients like high-level athletes or people with preoperative laxity. Comparison between different surgical techniques is warranted, including arthroscopic techniques and types of ligament augmentation to promote early motion and reduce postoperative stiffness.

Arthroscopic Modified Elbow Lateral Collateral Ligament Imbrication: An Operative Technique

When the lateral collateral ligament (LCL) complex fails to support the radiocapitellar and ulnohumeral joints in advanced stages of insufficiency, the patient experiences posterolateral rotatory instability (PLRI). Open lateral ulnar collateral ligament repair with a ligamentous graft has been the standard treatment for PLRI. Despite producing good clinical stability rates, this method is associated with significant lateral soft-tissue dissection and a lengthy recovery period. By fastening the LCL to its humeral insertion, arthroscopic imbrication of the LCL can increase stability. The senior author modified this technique. With the aid of a passer, the LCL complex, lateral capsule, and anconeus may be weaved with a single (doubled) suture, secured with a Nice knot. LCL complex imbrication may be used to restore stability and improve pain and function in patients with grade I and II PLRI.

[Elbow joint dislocation : Frequent concomitant injuries and current treatment concepts]

Dislocations of the elbow joint are among the most prevalent dislocation injuries in the human body after shoulder joint dislocations and represent a challenge in the clinical routine because of the concomitant injuries and complications. They predominantly affect young adults who become injured during athletic or daily activities. A distinction is generally made between a simple elbow dislocation and a dislocation fracture of the elbow; however, a uniform classification or treatment algorithm has not yet been established, especially for simple elbow dislocations with associated ligamentous, muscular and capsular concomitant injuries. Due to this and the complexity of this injury, a standardized approach is needed to initiate the optimal treatment at an early stage and to correctly select the narrow treatment pathway between impending chronic instability and elbow stiffness.

Patient satisfaction, joint stability and return to sports following simple elbow dislocations: surgical versus non-surgical treatment

PURPOSE

While conservative management is commonly promoted for simple elbow dislocations, the importance of primary surgical treatment in these injuries is still undetermined. The objective of this study was to report patient-reported outcome measures (PROMs), return to sports (RTS) and joint stability using ultrasound in patients following conservative or surgical treatment after simple elbow dislocation.

METHODS

Patients with a minimum follow-up of 24 months after conservative (CT) or surgical treatment (ST) following simple elbow dislocation were included in this retrospective study. To evaluate patients' postoperative outcome and satisfaction, the Elbow Self-Assessment Score (ESAS) was used, and validated scores such as the Mayo elbow performance score (MEPS), the Quick Disability of Arm and Shoulder Score (Quick-DASH) and RTS were assessed. For objective assessment of residual joint instability, a standardized clinical examination as well as a dynamic ultrasound evaluation of the affected and the contralateral elbow was performed.

RESULTS

Forty-four patients (26 women, 18 men) with an average age of 41.5 ± 15.3 years were available for follow-up survey (65.5 ± 30.4 months; range 26-123). 21 patients were treated conservatively and twenty-three patients received surgical treatment. CT and ST resulted in similar outcome with regard to ROM, ESAS (CT: 99.4 ± 1.5; ST: 99.8 ± 0.3), MEPS (CT: 97.3 ± 6.8 points; ST: 98.7 ± 3.3) and Quick-DASH (CT: 7.8 ± 10.4; ST: 6.3 ± 7.9) (n.s.). There was no difference in elbow stability and laxity measured by ultrasound between the study groups and compared to the healthy elbow (n.s.). Two patients of the CT group (10%) complained about persistent subjective elbow instability. RTS was faster after surgical compared to conservative treatment (p = 0.036).

CONCLUSION

Both, conservative and surgical treatment results in high patient satisfaction and good-to-excellent functional outcome after simple elbow dislocation. Even though ultrasound evaluation showed no significant differences in joint gapping between groups, 10% of conservatively treated patients complained about severe subjective instability. Surgically treated patients returned faster to their preoperatively performed sports. Thus, primary surgical treatment may be beneficial for high demanding patients.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results

INTRODUCTION

Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up.

METHODS

We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n = 20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests.

RESULT

Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P < .001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P < .001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots.

CONCLUSION

As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.

Does sonography allow an objective and reproducible distinction between stable, hypermobile, and unstable elbow joints?

BACKGROUND

The diagnosis of residual or chronic elbow instability is often challenging. Sonography allows a dynamic examination of the elbow joint without any radiation exposure. The purpose of this prospective single-center study was to investigate the application of sonography for the evaluation of ligamentous instabilities of the elbow joint. Therefore, asymptomatic (stable) and acute dislocated (unstable) elbows were examined by sonography.

METHODS

A total of 72 elbows in 36 participants (23 women and 13 men; mean age, 40 ± 17 years [range, 18-82 years]) were examined. Group 1 (G1 [normal]) included 40 unaffected, asymptomatic elbow joints; 28 elbows belonged to 14 voluntary participants (bilateral), whereas 12 asymptomatic elbows belonged to patients who had an acute elbow dislocation (contralateral elbow). Group 2 (G2 [hypermobile]) included 20 hypermobile elbow joints in 10 participants (bilateral), and group 3 (G3 [unstable]) included 12 acute unstable elbow joints without bony lesions. Radiographic assessment included sonography of both elbow joints with standardized measurements of the neutral and stressed radiocapitellar and ulnohumeral distances (calculated as Δ values). Two investigators independently performed all measurements. Additionally, plain radiographs and magnetic resonance imaging of the affected elbow joints were obtained in G3.

RESULTS

On the radial side, the mean radiocapitellar Δ was statistically higher in G3 (2.2 ± 1.6 mm) than in G1 (0.5 ± 0.4 mm, P < .01) or G2 (0.8 ± 0.6 mm, P < .01). G3 also showed an increased ulnohumeral Δ (2.7 ± 0.7 mm) compared with G1 (1.0 ± 0.7 mm, P < .01) or G2 (0.9 ± 0.3 mm, P < .01). No significant differences in the mean radiocapitellar Δ (P = .06) and ulnohumeral Δ (P = .26) were found between G1 and G2. Within G3, Δ was significantly higher at the affected elbow joint than at the contralateral, unaffected elbow joint (P = .04 for the radial side and P = .04 for the ulnar side). The inter-rater correlation coefficient was 0.82 for the radial side and 0.74 for the ulnar side. Patients with collateral ligament injuries, diagnosed on magnetic resonance imaging, showed higher Δ values than those with intact collateral ligaments, although no significant difference was found.

CONCLUSION

Sonography of the elbow joint is a valuable imaging tool for the assessment of ligamentous instability. Nevertheless, a distinction between healthy and hypermobile elbow joints is not possible, and therefore, obtaining a complete clinical history and examination is vital. We further recommend comparing the affected elbow joint with the contralateral side to access intraindividual differences.