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Acute arthroscopic repair of the RUHL allows high-demand patients to quickly return to activities
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Elbow dislocations are a rare, but debilitating injury. Conservative treatment in a brace usually results in favorable outcomes. However, residual pain, stiffness, instability, and time lost from work and sports represent real problems for patients.
Stiffness is the most common complication of conservative treatment, and Anakwe reported up to 60% of patients complained of persistent stiffness 7 years after their elbow dislocation. Residual instability is always a concern, and posterolateral rotatory instability (PLRI) in particular can occur in up to 7% of patients. PLRI, as described by O’Driscoll, results from incompetence of the radial ulnohumeral ligament (RUHL), also known as the lateral ulnar collateral ligament. Josefsson showed that the ligament usually avulses off the humerus during dislocation, and when this ligament fails to heal PLRI can result. Josefsson showed that acute open repair is safe, and while there was no functional difference between conservative treatment and early surgery, none of his patients experienced recurrent instability.
Time missed from work and sport is worrisome for patients. There is little published data on guidelines for when these athletes and workers can return to full activities. Ramsey and Parsons suggested that it may take 6 weeks for athletes to return to play, and Rettig suggested it may take up to 10 weeks for tears on both the medial and lateral sides. Protzman’s study on active military recruits showed that some patients take up to 24 weeks of disability before returning to full active duty. This timeframe is challenging for in-season athletes as well as professionals who require the use of both arms to perform their jobs.
This exact scenario lead us to consider acute arthroscopic repair of the RUHL following elbow dislocation in the high-demand patient to allow for early return to activities. Acute repair stabilizes the elbow, allowing for early aggressive range of motion, and should decrease the risk of residual stiffness and instability. “High demand” is defined as in-season athletes and professionals who cannot miss substantial time away from work. We retrospectively reviewed 14 patients who underwent this all-arthroscopic procedure, seven in the acute period (less than 3 weeks) and seven in the subacute period (between 5 weeks and 12 weeks). Tegner scores ranged from five (manual laborer) to 10 (professional athlete). All patients returned to full activities at their previous activity level and no patients developed residual instability. Average time to return to full activities in and out of a brace was 2.7 weeks and 6.6 weeks in the acute group, and 4.6 weeks and 8.9 weeks in the subacute group, respectively. Postoperative Mayo Elbow Performance Scores were excellent (range 95 to 100) in all 14 elbows. We encountered one postoperative complication of heterotopic bone formation that did not require any additional surgery as the patient was satisfied with his outcome.
Figure 1. This image demonstrates an arthroscopic view of the anterior compartment of a left elbow 4 days following elbow dislocation. The arthroscope is in a proximal anteromedial viewing portal, with the radiocapitellar joint on the left side of the image. Hematoma is visualized in the anterior compartment. There is laxity of the annular ligament around the radial head, and the radial head is subluxated posteriorly on the capitellum. The right side of the image shows tearing in the anterior capsule with exposed brachialis muscle fibers.
Figure 2. A view down the posterolateral gutter in the same left elbow with the arthroscope in a posterior trans-tendon viewing portal. The proximal radioulnar joint is seen on the right side of the image. The avulsed RUHL is in the center of the image, sitting at the level of the radial head.
Images: O’Brien MJ; Savoie FH
The surgical repair has been previously described by Savoie and colleagues. The author’s preferred technique is to perform the surgery in the prone position with the operative arm supported by a bolster on an arm board. In the subacute patient, PLRI is confirmed with a lateral pivot-shift test under anesthesia. At the time of arthroscopy, abundant hematoma is encountered in the joint following an acute dislocation. In the anterior compartment, laxity can be visualized in the annular ligament, and forearm supination causes posterior subluxation of the radial head on the capitellum, confirming PLRI (Figure 1). In the posterior compartment, the arthroscope can easily be driven down the posterolateral gutter due to incompetence of the lateral collateral ligament (LCL) complex. The torn RUHL can be visualized down the posterolateral gutter at the level of the radial head (Figure 2). The site of ligament avulsion can be seen on the humerus as a bare area on the posterior aspect of the lateral epicondyle. The arthroscope can be driven across the ulnohumeral joint from the lateral gutter into the medial gutter, the so-called arthroscopic “drive through sign of the elbow” (Figure 3). This is not possible in a stable elbow.
The site of avulsion on the humerus is lightly debrided with a shaver, taking great care not to damage the avulsed ligament. A double-loaded suture anchor is placed at the anatomic humeral origin. A suture retriever through a posterolateral portal is used to place the sutures down the posterolateral gutter. A percutaneous suture passer placed through a distal soft spot portal then retrieves the sutures, placing two mattress sutures in the healthy portion of the ligament (Figure 4). The sutures are retrieved subcutaneously through the soft spot portal with a crochet hook, and tied with an arthroscopic knot pusher. As the sutures are tied, the lateral ligament complex is re-tensioned, which has the effect of pushing the arthroscope out of the posterolateral gutter. Placing the arthroscope back in the anterior compartment reveals that tension has been restored to the annular ligament, and the radial head no longer subluxates on the capitellum.
Figure 3. The arthroscopic “drive through sign of the elbow” is seen. The arthroscope is in a posterior trans-tendon portal and is sitting in the ulnohumeral joint. The articular cartilage of the distal humerus is at the top of the image, with the proximal radioulnar joint at the bottom of the image. The radial head is seen on the left, with hematoma in the proximal radioulnar joint. Tearing in the anterior capsule can be seen in the anterior compartment. This view is not possible in the stable elbow.
Figure 4. A view down the posterolateral gutter in the same left elbow after suture passage. The arthroscope is in the posterior trans-tendon viewing portal, and the radial head is at the bottom of the image. A double-loaded suture anchor has been placed at the site of avulsion of the RUHL on the posterior aspect of the lateral epicondyle of the humerus. Two mattress sutures have been placed through the healthy portion of the RUHL on the left side of the image. Sutures are placed through a distal soft spot portal to capture the healthy ligament at the level of the radial head. As these sutures are tensioned, the arthroscope will be pushed out of the posterolateral gutter as tension is restored to the LCL complex.
After surgery, patients are immediately placed into a splint with the elbow in 90° of flexion and full forearm pronation to relax tension on the repair. The first postoperative visit occurs within 1 week of the surgery. The patient is placed into a hinged elbow brace that allows comfortable movement and physical therapy is initiated to focus on elbow range of motion in a pain-free range. Strengthening exercises are allowed as long as they do not produce pain in the elbow. Patients are allowed to return to full activities in a brace when they demonstrate full pain-free range of motion and adequate strength to protect their arm.
Conservative treatment remains the gold standard for the majority of simple elbow dislocations. However, certain active patients with elbow instability may benefit from a more aggressive approach. Acute arthroscopic repair of the RUHL is a safe and effective procedure that restores stability to the elbow and quickly allows high demand individuals to return to full activities.
References:
O’Driscoll SW. Clin Orthop Relat Res. 1992;280:186-197.
O’Driscoll SW. J Bone Joint Surg. 1991;73:440-446
Protzman RR. J Bone Joint Surg. 1978; 60:539-541.
Rettig AC. Orthop Clin North Am. 2002;33:509-522.
Savoie FH 3rd. Hand Clin. 2009; 25:323-329.
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Disclosures: O’Brien is a paid consultant for Smith & Nephew, and receives research support from DePuy Mitek and Smith & Nephew. Savoie receives research support from DePuy Mitek and Smith & Nephew.