Reliability of Magnetic Resonance Imaging Signs of Posterolateral Rotatory Instability of the Elbow

doi:10.1016/j.jhsa.2015.04.029

The Journal of Hand Surgery

Volume 40, Issue 7, July 2015, Pages 1428-1433

https://doi.org/10.1016/j.jhsa.2015.04.029 Get rights and content

Purpose

To evaluate radiographic signs of posterolateral rotatory instability (PLRI) on magnetic resonance imaging (MRI). The goal was to establish objective radiographic criteria to aid in the diagnosis of PLRI.

Methods

The MRI scans of 60 patients were evaluated retrospectively. Two study groups were compared. Group 1 (n = 30) consisted of unstable elbows in which PLRI was confirmed by clinical examination and arthroscopy. Group 2 (stable; n = 30) served as the control group. Patients in group 2 had transient epicondylitis without clinical suspicion of instability. Joint incongruity was analyzed for sagittal views through the radial head and the coronoid tip and for coronal and axial views. Interobserver and intra-observer reliability were evaluated.

Results

In the sagittal view through the radial head, average radiocapitellar incongruity differed significantly between groups 1 and 2. In addition, mean ulnohumeral incongruity in an axial view through the motion axis of the distal humerus showed significant differences between groups. Sagittal views through the tip of the coronoid and coronal views did not reveal significant differences in patients with unstable elbows compared with the control group.

Conclusions

The current study provides useful MRI criteria indicative of PLRI when combined with physical examination. Cutoff points of 1.2 mm for radiocapitellar incongruity (sagittal view) and 0.7 mm for axial ulnohumeral incongruity (axial view) are suitable to screen for PLRI. Radiocapitellar incongruity greater than 2 mm and axial ulnohumeral incongruity greater than 1 mm are highly suspicious of elbow instability.

Type of study/level of evidence

Diagnostic IV.

Section snippets

Patient selection and inclusion criteria

We retrospectively evaluated intravenous contrast MRIs of the elbows of 60 patients. All were referred to our clinic for lateral elbow pain. The MRI studies were performed according to a standardized protocol in extension and supination. Group 1 consisted of 30 patients with preoperative MRI studies of clinically and arthroscopically proven unstable elbow joints. These clinical findings confirmed the diagnosis of PLRI: chronic elbow pain (more than 6 wk), patient history of elbow trauma,

Results

Patients in group 1 (n = 30) had ages of 42 years on average (range, 19 – 74 y); 18 (60%) were women. Mean time between onset of symptoms and MRI was 5 months. Twenty-one patients had PLRI stage 2 and 9 had PLRI stage 3a according to O’Driscoll et al.¹⁰ A total of 25 patients underwent subsequent reconstruction of the lateral ulnar collateral ligament (LUCL). The remaining 5 patients underwent repair of the LUCL. In 11 cases, additional repair of the common extensor origin was necessary.

Discussion

Albert¹¹ described chronic instability of the elbow in 1881, when little was known about the pathoanatomy and even less about possible treatment options. Reichenheim¹² and Wainwright¹³ tried to restore stability by augmenting the coronoid process, but it was Osborne and Cotteril¹⁴ who recognized that instability was mainly caused by ligamentous insufficiency and could be treated by soft tissue repair.

O’Driscoll et al9, 10 described posterolateral rotatory instability, which provided a better

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Cited by (42)

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow
2024, Journal of Shoulder and Elbow Surgery
Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes.
Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs).
Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes.
The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.
Sensitivity and specificity of the posterolateral rotatory drawer test in the diagnosis of lateral collateral ligament insufficiency of the elbow
2023, Journal of Shoulder and Elbow Surgery
Numerous clinical tests are described for the diagnosis of chronic lateral collateral ligament (LCL) insufficiency of the elbow; however, none of these tests have been adequately assessed for sensitivity, with at most 8 patients included in previous studies. Furthermore, no test has had specificity assessed. The posterolateral rotatory drawer (PLRD) test is thought to have improved diagnostic accuracy over other tests in the awake patient. The aim of this study is to formally assess this test using reference standards in a large cohort of patients.
A total of 106 eligible patients were identified for inclusion from a single-surgeon database of operative procedures. Examination under anesthetic (EUA) and arthroscopy were chosen as the reference standards to compare the PLRD test against. Only patients with a clearly documented PLRD test finding performed preoperatively in the clinic, and a clearly documented EUA and/or arthroscopic findings from surgery were included. A total of 102 patients underwent EUA, 74 of whom also underwent arthroscopy. Twenty-eight patients had EUA, and then an open procedure without arthroscopy. Four patients had arthroscopy without a clearly documented EUA. Sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were calculated with 95% confidence intervals.
Thirty-seven patients had a positive PLRD test, and 69 had a negative test. Compared to the reference standard of EUA (n = 102), the PLRD test had a sensitivity of 97.3% (85.8%-99.9%) and a specificity of 98.5% (91.7%-100%) (PPV = 0.973, NPV = 0.985). Compared to the reference standard of arthroscopy (n = 78), the PLRD test had a sensitivity of 87.5% (61.7%-98.5%) and a specificity of 98.4% (91.3%-100%) (PPV = 0.933, NPV = 0.968). Compared to either reference standard (n = 106), the PLRD test has a sensitivity of 94.7% (82.3%-99.4%) and a specificity of 98.5% (92.1%-100%) (PPV = 0.973, NPV = 0.971).
The PLRD test demonstrated an overall sensitivity of 94.7% and specificity of 98.5% with high positive and negative predictive values. This test is recommended as the primary diagnostic tool for LCL insufficiency in the awake patient and should be widely incorporated into surgical training.
Intraoperative arthroscopic classification tool for posterolateral elbow instability
2023, JSES International
Introducing and implementing an arthroscopic classification tool for posterolateral elbow instability.
Thirty arthroscopies were performed on 30 patients, and all recordings were collected, blinded, and labeled. Three orthopedic surgeons reviewed and scored all 30 recordings three times with a period of at least seven days in between to analyze the intraobserver and interobserver reliability. The classification consisted of five different grades.
Indications for elbow arthroscopy included impingement (n = 7), osteochondritis dissecans (n = 5), pain (n = 7), osteoarthritis (n = 6), and other (n = 5). The kappa value for intrarater reliability was 0.71, indicating good reliability, while the kappa value for inter-rater reliability was 0.38 indicating fair reliability.
This new classification is a tool for an arthroscopic assessment of PLRI and can be used as a standardized grading system for further research and communication between orthopedic surgeons. We demonstrated good intrarater reliability (k = 0.71) with fair inter-rater reliability (k = 0.38). However, further research is necessary to study the clinical significance.
Ultrasound assessment of the posterolateral elbow ulnohumeral gap in normal subjects with and without posterolateral drawer testing
2023, JSES International
Posterolateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability, and current imaging to aid PLRI diagnosis is limited. Thus, we sought to define use of ultrasound (US) to determine normal lateral ulnohumeral joint measurements, with and without posterolateral drawer testing to provide an insight into how US may aid diagnosis.
Sixty elbows were evaluated in thirty healthy volunteers. The lateral ulnohumeral gap (LUHG) was measured with US in the resting position while the posterolateral drawer stress test maneuver was applied. Joint laxity was calculated as the difference between maximum stress and average rest measurements. Two independent readers assessed each elbow with comparison performed between stress and rest positions.
Differences in the LUHG were evident between stress and rest conditions (reader 1: P < .0001 and reader 2: P = .0002). At rest, median LUHG values were 2.31 mm and 2.05 mm for readers 1 and 2 respectively, while at stress 2.88 mm and 2.9 mm for readers 1 and 2. Median joint laxity was 0.8 mm for reader 1 and 1.1 mm for reader 2. Pearson correlation was r = 0.457 (absolute intraclass correlation coefficient [ICC] = 0.608) while under stress and r = 0.308 (absolute intraclass correlation coefficient [ICC] = 0.417) at rest. Median joint laxity demonstrated a Pearson correlation of r = 0.161 and absolute intraclass correlation coefficient [ICC] = 0.252.
This study demonstrates a dynamic US assessment for PLRI, which aimed to assess the usefulness and feasibility of a laxity measurement after the application of a posterolateral drawer stress maneuver in a healthy population. Although establishing concordance between readers in measuring an LUHG under stress, the utility of a laxity measurement alone is not clear as correlation of measurements is not excellent; hence, an upper limit of normal for the ulnohumeral gap under stress may be more useful. Further evaluation of this technique is required in patients with PLRI.
Lateral ulnar collateral ligament reconstruction enhancing secondary stabilizers in chronic PLRI of the elbow provides good to excellent clinical results with no recurrent instability
2023, Journal of Orthopaedic Science
The adopted treatment for chronic elbow PLRI is lateral ulnar collateral ligament reconstruction. However, the most frequently reported complication after primary reconstruction is recurrent instability – up to 25 %. It was thus hypothesized that enhancing the secondary stabilizers will provide successful results with a lower rate of recurrent instability in comparison to techniques with primary reconstruction only. This study aimed to demonstrate a novel surgical technique involving secondary stabilizers.
In this retrospective study of 29 cases with chronic PLRI the mean duration of symptoms was 39.6 ± 4.9 months. The mean age was 47.9 years with mainly male patients. The surgeries were performed by one senior surgeon at a single institution. The Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) were recorded.
The mean follow-up was 36.8 ± 7.7 months. The MEPS score improved significantly from 59.8 ± 13.1 to 84.7 ± 7.6 (p < 0.001). 23/29 patients (79.2 %) had converted to good and excellent results (MEPS >75 points). The DASH score improved from 40.8 ± 4.6 to 20.9 ± 7.2 (p < 0.001). The total complication rate was 10.3 % (N = 3). No recurrent instability was recorded in comparison to 12.2 % for primary reconstruction only, as reported in the literature (p < 0.05).
Enhancing the secondary stabilizers by utilizing an adjacently located autograft provided good and excellent results with no recurrent instability. This novel surgical procedure is easy to reproduce and provides a safe and reliable alternative in cases of chronic PLRI when compared to techniques with primary reconstruction only.
ACR Appropriateness Criteria® Chronic Elbow Pain
2022, Journal of the American College of Radiology
Citation Excerpt :
Additionally, a more distal ligamentous insertion of the UCL (T sign) has recently been suggested to result from repetitive overhead activity and injury rather than representing a normal anatomic variant [42]. In patients with posterolateral rotatory instability, MR arthrography can assess the integrity of the ulnar band of the radial collateral ligament [43] and demonstrate radiocapitellar incongruity [44]. A 3T MR arthrography is more accurate than noncontrast MRI elbow for the detection of collateral ligament injuries [38].
Chronic elbow pain can be osseous, soft tissue, cartilaginous, and nerve related in etiology. Imaging plays an important role in differentiating between these causes of chronic elbow pain. This document provides recommendations for imaging of chronic elbow pain in adult patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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: M.H. and K.W. contributed equally to this work.

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Scientific articleReliability of Magnetic Resonance Imaging Signs of Posterolateral Rotatory Instability of the Elbow

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Patient selection and inclusion criteria

Results

Discussion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

J Hand Surg Am

Ligamentous reconstruction around the elbow using triceps tendon

Acta Orthop Scand

Posterolateral rotatory instability of the elbow in association with lateral epicondylitis: a report of three cases

J Bone Joint Surg Am

Systematic diagnosis and therapy of lateral elbow pain with emphasis on elbow instability

Arch Orthop Trauma Surg

Classification and evaluation of recurrent instability of the elbow

Clin Orthop Relat Res

Diagnostik und Therapie der ligamentären Ellenbogeninstabilitäten

Obere Extremität

Posterolateral rotatory instability of the elbow

J Bone Joint Surg Am

Elbow subluxation and dislocation: a spectrum of instability

Clin Orthop Relat Res

Scientific article
Reliability of Magnetic Resonance Imaging Signs of Posterolateral Rotatory Instability of the Elbow