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Ligamentous Stabilizers Against Posterolateral Rotatory Instability of the Elbow

Investigation performed at the Bioengineering Research Laboratory, Lawson Health Research Institute, Hand and Upper Limb Centre, St. Joseph’s Health Care London, London, Ontario, Canada
Cynthia E. Dunning, PhD
Zane D.S. Zarzour, MD
James A. Johnson, PhD
Departments of Mechanical and Materials Engineering (C.E.D., J.A.J., and G.J.W.K.), Surgery (Z.D.S.Z., J.A.J., and G.J.W.K.), and Medical Biophysics (J.A.J. and G.J.W.K.), The University of Western Ontario, 1151 Richmond Street, Suite 2, London, ON N6A 4B8, Canada
Graham J.W. King, MD
Bioengineering Research Laboratory, Lawson Health Research Institute, Hand and Upper Limb Centre, St. Joseph’s Health Care London, 268 Grosvenor Street, London, ON N6A 4L6, Canada. E-mail address: gking{at}uwo.ca

Stuart D. Patterson, MBChB
The Bond Clinic, 500 East Central Avenue, Winter Haven, FL 33880-3094

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Medical Research Council of Canada. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: The lateral ulnar collateral ligament, the entire lateral collateral ligament complex, and the overlying extensor muscles have all been suggested as key stabilizers against posterolateral rotatory instability of the elbow. The purpose of this investigation was to determine whether either an intact radial collateral ligament alone or an intact lateral ulnar collateral ligament alone is sufficient to prevent posterolateral rotatory instability when the annular ligament is intact.

Methods: Sequential sectioning of the radial collateral and lateral ulnar collateral ligaments was performed in twelve fresh-frozen cadaveric upper extremities. At each stage of the sectioning protocol, a pivot shift test was performed with the arm in a vertical position. Passive elbow flexion was performed with the forearm maintained in either pronation or supination and the arm in the varus and valgus gravity-loaded orientations. An electromagnetic tracking device was used to quantify the internal-external rotation and varus-valgus angulation of the ulna with respect to the humerus.

Results: Compared with the intact elbow, no differences in the magnitude of internal-external rotation or maximum varus-valgus laxity of the ulna were detected with only the radial collateral or lateral ulnar collateral ligament intact (p > 0.05). However, once the entire lateral collateral ligament was transected, significant increases in internal-external rotation (p = 0.0007) and maximum varus-valgus laxity (p < 0.0001) were measured. None of the pivot shift tests had a clinically positive result until the entire lateral collateral ligament was sectioned.

Conclusions: This study suggests that, when the annular ligament is intact, either the radial collateral ligament or the lateral ulnar collateral ligament can be transected without inducing posterolateral rotatory instability of the elbow.

Clinical Relevance: Surgical approaches to the lateral side of the elbow that violate only the anterior or posterior half of the lateral collateral ligament should not result in posterolateral rotatory instability of the elbow. This is important information for surgeons planning various procedures on the lateral aspect of the elbow, such as reconstruction of a fractured radial head, radial head replacement, or total elbow arthroplasty.

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