chapter 48, Lateral Collateral Ligament Insufficiency Joaquin Sanchez-Sotelo INTRODUCTION The lateral collateral ligament complex is one of the main structures implicated in the stability of the elbow joint Insufficiency of the lateral collateral ligament com= plex is present in many patients with elbow instability Several basic science and clinical studies have im= proved our understanding of the contributions of the [ateral collateral ligament complex to elbow stability, the etiology of lateral collateral ligament insufficiency, the value of different clinical andl imaging tests for iden= tification of this entity, and the outcome of surgical repait or reconstruction. The term posterolateral rota~ tory instability has been coined to describe the clinical condition that results from lateral collateral ligament complex insufficiency BASIC SCIENCE Several ligamentous structures may be identified on the lateral aspect of the elbow joint (see Chapter 2. The ligamentous fibers connecting the lateral humeral epi= condyle with the lateral aspect of the ulna seem to be the most important for elbow stability on the lateral side. These fibers, commonly referred to as lateral ulnar collateral ligament attach distally into the tubercle of the supinator crest (Fig 48-1). More anterior fibers origi- rnaled at the lateral humeral epicondyle, named by some as radial collateral figarzent, blend with the fibers of the annular ligament. Unlike the medial side of the joint morphologic and histologic studies have not been able to show distinct ligaments on the lateral side of the joint consistently?" Lateral collateral ligament complex insufficiency allows excessive posterolateral displacement of the proximal forearm relative to the distal humerus. The contribution of the lateral collateral ligament complex to elbow stability has been investigated in several cadav- ric models, Release of the whole lateral collateral lige~ Chapter 48 Lateral Collateral Ligament Insufficiency 669 ment complex has been required in most experimental settings to produce a significant increase in varus and posterolateral displacements #2" Isolated section of the ulnar insertion of the lateral ulnar collateral ligament has not been shown to promote dramatic elbow insta bility im all cadaveric studies” However, reconstruc tion of the lateral ulnar collateral ligament with a tendon graft restores varus and posterolateral stability in the laboratory” The overlying common extensor-supinator group has also been shown to play ¢ major role in elbow stability’? There is a complex interplay be- tween the lateral collateral ligament complex and other elbow structures, including the coronoid and radial head" ETIOLOGY TRAUMA ‘The lateral collateral ligament complex may be damaged as a result of trauma to the elbow, resulling in elbow dislocation, fracture-dislocation, subluxation, or liga mentous sprain (Box 48-1). McKee et al reported on the soft tissue injury patterns identified in 10 dislocations and 52 fracture-dislocations treated surgically. The lateral collateral ligament complex was disrupted in all cases proximal avulsion was the most common failure mode, followed by midsubstance rupture. The common exten sor-supinator group was injured in 66) of the cases. ‘The anterior bundle of the medial collateral ligament was injured in approximately 50% of the cases. Less severe injuries causing dislocation or an elbow sprain (usually hyperextension or varus stress) may also damage the lateral collateral ligament complex if they place substantial strain on the ligament fibers. ‘When injured, the medial collateral ligament seems to heal without residual clinically significant medial-sided instability in most patients.” On the contrary, persistent lateral-sided instability seems to be more frequent, but the reasons are unclear: It may be related to a decreased healing potential, as seen in other anatomic locations such as the lateral side of the knee joint; the constant tensile gravitational loads imposed on the injured lateral side with elbow use; or the more common association with additional injuries such as radial head or coronoid fractures, Lateral collateral ligament insufficiency should be suspected in patients with recurrent dislocation, sub= jective instability, lateral-sided pain, and a history of elbow trauma CHRONIC ATTRITION Chronic attrition secondary to repetitive valgus stress is a well-known mechanism leading to medial collateral670 Parti Sports and Overuse Injures tothe Elbow 7 | Annular ligament Radial Accessory cote] ( & ri = aed Lateral unar collateral igament FIGURE 48-1 From a practical perspective, the lateral collateral ligament complex may be divided into three main components: the lateral ulnar collateral ligament, the annular ligament, and the radial collateral ligament. 80x. logy of Lateral Collateral Ligament Insufficiency Trauma + Elbow dislocation, + Elbow fracture-dislocation + Elbow subluxation + Elbow sprain + Cubitus varns deformity + Lateral epicondylitis + Chronic crutch users + Inadvertent sectioning in surgery + Repeated steroid injections Chronic attrition latrogenic injury ligament insufficiency Chronic attrition of the lateral collateral ligament complex may occur in rate situations such as Tong-term:eratch-wallers (paraplegics, poliomyeli- tis). Post-traumatic or congenital eubitus varus dformiy is recognized as a risk factor for chronic attrition of the lateral collateral ligament complex and tardy posterolat- cral rotatory instability'* With varus malalignment, triceps contraction has been hypothesized to force pos terolateral rotatory subluxation and eventually lead to attenuation of the lateral collateral ligament complex. In addition, one cadaveric study has shown increased strain on the lateral collateral ligament complex with more than 25 degrees of varus deformity and lateral joint line opening with more than 20 degrees of varus deformity? In this setting, corrective osteotomy should bee considered as an adjunct to lateral collateral ligament reconstruction to prevent failure. Insufficiency of the lateral collateral ligament has also been identified in patients with tamis dbow and no prior surgery", insuffi- Giency in this setting may be secondary to ligamentous involvement by the same pathologic process affecting the common extensor group* or the detrimental side effects on collagen fibers of repeated steroid injections*”* IATROGENIC INJURY Inadvertent damage of the lateral collateral ligament may occur during surgical procedures on the lateral side of the joint Surgical treatment of tennis elbow may compromise the lateral collateral ligament complex if the release or debridement of the common extensor origin are too extensive, especially when the lateral epicondyle is denuded off soft tissues. Exposure of the radial head or capitellum for fracture fixation or chronic reconstruction may also jeopardize the lateral collateral ligament complex, especially when Kécher’s interval is used or the joint needs to be subluxed or dislocated in order to complete the surgical procedure Special attention is required when performing surgery on the lateral side of the elbow joint to avoid damage to the lateral collateral ligament complex. Formal repair of the damaged ligament should always be part of the wound dosure DIAGNOSIS PRESENTATION The clinical expression of lateral collateral ligament complex insufficiency varies considerably depending on the etiology, severity, associated pathology, previous surgery, and activity level (Box 48-2), Some patients may complain of recurrent episodes of frank elbow disloca- tion, However, most commonly patients complain of more subtle symptoms, including lateral-sided elbow pain, mechanical symptoms (clicking, catching, snap ping, locking) or subjective instability” Patients with ligamentous insufficiency after a fracture-dislocation may present with more severe pain or stillness second ary to the associated injuries. Commonly, most patients with lateral collateral ligament complex insulficiency report @ previous history of trauma or surgery In patients with previous surgery itis important to deter mine if the preoperative symptoms were corrected by the surgery or if on the contrary surgery had no effect or occasioned a whole new constellation of symptoms, Subtle elbow instability is reflected by the inability of the patient to push with the affected upper extremity to stand up from a scat” open a heavy door, or similar activities that require active elbow extension against resistance with forearm supination. However, instability episodes are difficult to identify as such by the patient,al Diagnosis of Lateral Collateral Ligament Complex Insufficiency History + Lateral-sided elbow pain + Mechanical symptoms + Subjective instability + Recurrent dislocation, + Pain over the location of the lateral collateral ligament complex + Apprehension/pain with varus stress + Positive results on posterolateral drawer test + Positive resulls on posterolateral pivoteshift test + Positive results on chair test + Positive resulls on push-up test + Posterolateral subluxation on plain radiographs + Lateral collateral ligament discontinuity on magnetic resonance imaging scan + Stress radiographs oF Auoroscopy + Lateral join line opening > + Posterolateral subluxation + Positive results in posterolateral drawer test + Positive results in pposlerolateral pivot-shift test + Fluoroscopieally proven + Lateral joint line opening > 2mm + Posterolateral subluxation + Excessive lateral jointline ‘opening (drive-through) + Posterolateral subluxation + Lateral capsuloligamentous diet Physical examination, Imaging studies Examination under anesthesia Arthroscopy who often reports pain when attempting to perform the above-mentioned activities, PHYSICAL EXAMINATION A detailed physical examination should help identify basic information such as the specific location of the pain and elbow range of motion (see Chapter 4). The location of previous skin incisions and the presence of deformity should be noted. As mentioned earlier, cubitus varus predisposes to tardy posterolateral rotatory insta~ bility. In addition, lateral skin incisions centered poste- rior to the midcoronal plane may be associated with Chapter 48 Lateral Collateral Ligament insufficiency 671 FIGURE 48-2 Posterolateral rotatory drawer test inadvertent ligamentous damage. The integrity of the medial and lateral collateral ligament complex should be tested in all cases. Examination maneuvers for insta bility may be masked by associated pathology (stiliness or an absent radial head, for example). In the author's experience, pure varus stress does not allow reliable assessment of the competency of the lateral structures. Several other physical examination maneuvers have been described to specifically test the lateral collateral ligament complex Posterolateral Rotatory Drawer Test This test demonstrates posterolateral subluxation of the proximal radius and ulna with forced supination. It is best performed with the patient laying supine and the upper extremity overhead to lock the shoulder in inter nal rotation (Fig 48-2), Forced supination of the forearm in approximately 45 degrees of flexion will induce abnormal excessive posterolateral subluxation of the bow. The test is best demonstrated when forced supination is combined with valgus torque and axial compression. In some cases, subluxation may not be demonstrated but patients show apprehension with the Posterolateral Rotatory Pivot-Shift Test This test demonstrates posterolateral subluxation and relocation of the elbow joint with elbow flexion and extension while applying a valgus and supination moment to the forearm, The patient is examined! in the same position described earlier (Fig, 48-3). Application of valgus, axial compression, and hypersupination to the elbow in approximately 20 degrees of flexion induces posterolateral subluxation seen as prominence of the radial head and dimpling of the skin between the proxi~ mal radius and ulna. Progressive elbow flexion while maintaining the valgus, compression, and supination(672 Part Sports and Overase Injuries tothe Elbow FIGURE 48-3 Posterolateral pivot-shift test torque is accompanied by a sudden rotatory shift and unk as the elbow is reduced with flexion Again, the shift cannot be demonstrated in every patient, but most report apprehension. In patients with an absent radial head, the clunk is less pronounced. Chair and Push-Up Apprehension ‘The chair sign involves having the patient stand up from chair while pushing with the upper extremities and keeping the forearms in supination and the arms abducted to greater than the shoulder width” The test is considered positive if there is reluctance to extend the clbow fully as the patient raises his body using exclu= sively upper extremity force or a dislocation occurs, The pusicup sign involves having the patient perform an active floor or wall push-up with the forearms supi- nated and the arms abducted to greater than the shoulder Width, The testis considered postive if the patient shows reluctance to fully extend the elbow or a dislocation ‘occurs. A similar test has been described with the patient pushing against the top of a table? Patients report appre- hension when asked to perform a press-up with the elbow pointing laterally; pain and apprehension occurs as the elbow reaches approximately 40 degrees of flexion. Symptoms improve when the testis repeated using the thumb of the examiner to push over the radial head, giving support and preventing posterior subluxation. IMAGING STUDIES Plain Radiographs ‘Most patients with isolated lateral collateral ligament complex insufficiency present with notmal plain radio~ graphs. Rarely, severe insufficiency may present with fixed posterolateral subluxation or dislocation. Recur- rent episodes of elbow dislocation documented with radiographs indicate insufficiency of the lateral collateral ligament complex. Most of the time, radiographs are helpful to delineate associated pathology, including post-traumatic changes at the radial head or coronoid, or varus malalignment of the distal humerus Stress Radiographs and Fluoroscopy Radiographic or fluoroscopic imaging of the elbow sub jected to stress is an invaluable diagnostic tool in patients with posterolateral rotatory instability, especially when the patient is under anesthesia. The status of the medial collateral ligament should be documented first by apply ing a valgus load to the extended elbow with the forearm in pronation*; more than 2mm of medial joint lineopening on the anteroposterior view indicates medial collateral ligament insufficiency. The forearm is then placed in full supination a determine the amount of lateral joint line opening, again. more than a 2-mm of opening usually indicates lateral collateral ligament insufficiency However, posterolateral rotatory instability is best demonstrated on the lateral views (Fig 48-0); with forced supination and valgus, the radius and ulna are subluxed posteriorly so that the center of the radial head does no longer align with the center of the capitellum and there is asymmetry and widening of the wlnohumeral joint a varus load is applied to Magnetic Resonance Imaging he different components of the lateral col ment complex may be visualized on magn imaging” Although insufficiency of this ligament com- plex is diagnosed in most patients based on the history. physical examination and stress radiographs or fluoroscopy, magnetic resonance may confirm the pres~ ence of ¢ torn or altenuated complex. Some studies have identified selective deficiency of the posterior fibers of| the complex lateral ulnar collateral ligament® Howe negative findings on magnetic resonance imaging does not exclude the diagnosis of posterolateral rotator instability!” Magnetic resonance imaging may be espe- cially useful in patients with tennis elbow and coexistent igamentous insufficiency’ tral liga~ FIGURE 48-4 Lateral radiograph of a patient with posterolateral rotatory instability demonstrates posterolateral subluxation of the elbow; the radial head and neck are no longer aligned with the center of the capitellum and the ulnohumeral joint line is widened. (Chapter 48 Lateral Collateral Ligament Insufficiency 673 Examination Under Anesthesia and Arthroscopy Positive findings on the posterolateral drawer and shift tests may be dificult to demonstrate in the office due to patient apprehension and guarding. The posterolat- cral rotatory drawer and posterolateral rotatory pivot shift tests are almost universally positive with the patient under anesthesia; fluoroscopic assessment of elbow sta~ bility may also be performed under anesthesia. Arthro= copy may be used when the diagnosis is still not clear after examination under anesthesia, arthroscopic find ings may include excessive lateral joint line openin (sometimes allowing the arthroscope to be drive boetween the radial head and the capitellum), demonstra tion of posterolateral ander nside the joint, and various degrees of capsuloligamentous deficiency as visualized from the inside of the joint subluxation direct TREATMENT ACUTE INJURIES to the lateral collateral ligament complex is found most elbow fracture-dislocations that are treated sur= gicaly (Fig, 48: is recommended. The lateral collateral ligament complex is usually avulsed from the epicondyle or tom in its midsubstance” Our preferred technique for surgical repair of acute injuries involves the use of a heavy nonabsorbable suture through the substance of the lateral collateral ligament complex and into the humeral epicondyle The suture follows the line of tension of the lateral nar collateral ligament. One #2 Fiberwire (Arthrex Inc. Naples, FL) or #5 Ethibond (Ethicon Johnson an Johnson, New Brunswick, N)) suture is placed on the anterior half of the capsuloligamentous fibers in a running locking configuration" from proximal to distal and then from distal to proximal, turning at the ulnar supinator crest (see Fig. 48-58) A second suture is placed in the same fashion on the posterior half of the capsu- loligamentous fibers. These sutures may be passed through the overlying common extensor-supinator fibers to augment the repair, The isometric point of umeral_attad is then located at the geometric center of the capitelhum and bone tunnels are created starting at that point and aiming anteriorly and poste riorly. The sutures are passed through the tunnels and tied on the proximal aspect of the lateral epicondyie. Postoperative management should follow the same ‘general principles described for reconstruction in the chronic setting Al. In these circumstances, formal repair674 Parti Sport and Overus Injuries tothe Elbow FIGURE 48-5 A, Elbow fracture-dislocations usually present with a'complete avulsion of the lateral collateral ligament complex olf the lateral humeral epicondyle, B, Acute injuries are repaired with two heavy nonabsorbable sutures through the substance of the lateral collateral ligament complex and the lateral humeral epicondyle. The sutures follow the lines of tension of the lateral ulnar collateral ligament. The sutures ate partially placed through the common extensor-supinator group fo augment the repair. They are then passed through bone tunnels at the isometric point into the humeral epicondyle CHRONIC INSUFFICIENCY Symptomatic insulliciency of the lateral collateral liga ent complex is best addressed surgically by recon struction using a tendon graft. Ligament repair or imbrication have been shown to provide inferior results in the chronic setting” Surgical Technique Placement of the skin incision depends on the need to address associated pathology. The deep exposure is through the Kocher interval. This interval is best identi- fied distally and developed proximally. The raphe between the anconeus and extensor carpi ulnaris ean usually be felt distally; the fascia is then incised from distal to proximal, airing to the center of the humeral epicondyle. The extensor carpi ulnatis and the anconeus are then elevated off the remaining lateral elbow capsule and lateral collateral ligament complex with sharp dis- section. An effort should be made to preserve capsular flaps, because the tendon graft is best left extra-articular bby suturing the capsular flaps underneath the graft at the eni The tunnels for insertion of the tendon graft into the ulna and humerus are created next (Fig. 48-6A), One hole of the ulnar tunnel is centered over the tubercle of the supinator crest, which can easily be felt by palpation ‘The second hole is placed proximally and posteriorly leaving a bone bridge wide enough to avoid fracture (usually between I and 15 cm). A towel clip or angled curette may be used to clear the tunnel of bone debris. The site for humeral atiachment of the tendon graft is selected so that the reconstruction will be isometric and maintain the same tension throughout the flexion extension, first humeral hole is centered slightly proximal and posterior to the point of isometry. Ustally aint of isometry is located at the geometric ce of the capitellar articular surface, this is confirmed with suture placed through the ulnar tunnel and grasped with a point used to select the point on the surface of the humeral epicondyle, where the suture will maintain the same approximate tension with elbow flexion and extension (see Fig 48-6A). Next, two proximal exit holes are created on the anterior and posterior aspect of the lateral humeral column, and the anterior and posterior humeral tunnels are created (see Fig, 48-68), Several options exist for tendon graft selection. Pal= maris longus autograft was used in the first reports of the technique® Tendon allografis seem to be associated with the same outcome and eliminate the morbidity and additional surgical time associated with autograft har vesting We currently favor the use of plantaris or sem tendinosus allograft depending on the sizeof the patient Two #2 Fiberwire can be placed at the ends of the tendon graft in a running locking configuration to pull the tendon through the tunnels and assist in graft altachment. The graft may be looped through the tunnels in dif- ferent ways, which seem to be equally effective as long as they allow adequate tensioning of the reconstruc tion.” The tendon graft is passed first through the ulnar tunnel Depending. on the size of the graft as well as surgeon preferences, the two ends of the tendon graft can be then docked into the anterior and. posterior humeral tunnels, tying the sutures over the proximal aspect of the humeral epicondyle (sce Fig. 48-6). Alter natively, one end of the tendon graft may be sutured to the opposite limb at the entrance into the humeral 1 reconstructionPostgtor Proximal Point of leomety Chapter 48 Lateral Collateral Ligament Insufficiency 675 FIGURE 48-6 Reconstruction of the lateral collateral ligament complex using a tendon graft. A, The ulnar tunnel is started at the tubercle of the supinator crest and directed proximally and posteriorly A suture placed through the ulnar tunnel may be used to confirm the isometvicity of the point selected for humeral allachment of the tendon graft. B, Two humeral tunnels connect the point of isometry with the anterior and posterior aspects of the lateral humeral column. €, The graft is doubled on itself and passed through the ulnar tunnel. B, The tendon graft ends may be docked into the isometric humeral tunnels and the sutures tied over the humeral epicondyle, tunnels creating a yoke-ike structure. The longer limb is passed though the posterior tunnel, aver the top, and into the anterior tunnel. Traction is then placed at the end. of the yoke and the end of the longer limb to tension the graft Fig, 48-7. Whenever possible, any remaining capsule should be sutured to seal the joint before the graft recor 1s completed so that the graft remains extra-artculay. The graft should be tensioned with the joint in a reduced position, the forearm in full pronation, and the elbow ruction(676 Part VI Sports and Overase Injuries tothe Elbow in approximately 45 degrees of flexion, Jensioning may be increased by suturing the two limbs of the graft together in one or more points. Treatment of Associated Pathology Associated pathology is addressed as needed Com- monly, lateral collateral ligament complex insufficiency is associated to radial head nonunion, malunion or c FIGURE 48-7 A to C, Alternatively, the two limbs of the ‘graft may be sutured together. One end of the graft may be passed through the humeral tunnels, and the reconstruction may be tensioned applying proximal traction to the yoke tendon and distal traction to the Tonger limb of the graf. resection, as well as coronoid deficiency. Radial head replacement or coronoid reconstruction may be required to completely restore elbow stability and function? Patients with posterolateral rotatory instability and associated tennis elbow require débridement and repair of the area of tendinosis at the time of ligamentous reconstruction. Interestingly, some patients may present with 2 combination of stiffness and ligamentous insu ficiency, and require ligamentous reconstruction and contracture release as a single or staged procedure. It is important to understand the need to consider recon struction of the radial head to improve the outcome of treatment Underlying Deformity ‘As mentioned earlier, posterolateral rotatory instability may be secondary to chronic ligamentous attrition sec~ ondary to cubitus varus deformity. Depending on the severity of the deformity and the cosmetics concerns of the patient, a valgus-producing distal humerus osteot- ‘omy may need to be associated to the ligamentous reconstruction, Otherwise, the reconstruction may fail by chronic atuition of the tendon graft subjected to abnormal forces. Osteotomy should probably be con sidered in patients with more than 15 degrees of varus angulation Experimental data in cadavers has shown increased strain on the lateral collateral ligament complex with more than 25 degrees of varus angulation and increased opening of the joint line space with more than 20 degrees of varus angulation’ Postoperative Management ‘The ligamentous reconstruction needs to be protected for the first few weeks after surgery in order to prevent graft stretching and recurrent instability. Elbow exten sion and forearm supination increase tension on the graft; pronation’ and active muscle contraction. protect the graft? Initially after surgery, the elbow is immobi= lized: i 90 degrees of flexion and forearm pronation Motion may be initiated in a few days, as long as a brace is used to neutralize the forces across the elbow, ‘maintain the forearm in pronation, and block extension beyond 50 degrees. However, cast immobilization for three to six weeks should be considered when compli= ance with postoperative protection is questionable, and itis recommended by some surgeons for most patients, provided they do not show a tendency to develop stff= ness, Neutralization using a dynamic external fixator during 5 to 6 weeks should be considered for those cases in which more protection is needed; extemal fixation has occasionally been used as the main treatment modality”® Postoperative management may need to be changed to accommodate associated surgical procedures such as contracture release, in which early motion is more criticalThe patient should understand the detrimental role of gravitational stresses om the lateral collateral ligament complex. Most activities of daily living place the lateral side of the elbow facing upward, the weight of the forearm and any additional weight held by the hand will esult in tensile stresses on the lateral elbow struc~ tures. During the first § months after surgery, the patient should learn how to protect the elbow against gravila~ tional stresses. Active overhead flexion and extension exercises with the forearm in pronation protect the lateral collateral ligament reconstruction by avoiding gravitational stresses and increasing joint stability through active muscle contraction’ Exercises to increase the strength of the extensor-supinator group also help stabilize the joint, and they may be initiated during the first few days after surgery. Unrestricted activities are usually allowed 6 months after surgery. Outcome Nestor et al” reported the initial experience at the Mayo Clinic with 11 consecutive cases followed for a mean of| 55 years (range, 2 to 56 years), The lateral collateral ligament complex was imbricated in three patients and reconstructed with a tendon graft (seven patients) or triceps fascia (one patiend, Stability was obtained in 10 patients, and seven were considered to have an excellent functional result More recently, Sanche7-Sotelo et al” updated the Mayo Clinic experience with 44 cases followed for a mean of 6 yeats (2 to 15 years). Ligament repair or imbrication was performed in 12 cases and formal liga~ ment reconstruction in 32 Surgery restored stability in all but five patients, Results were considered satisfactory in 73% of the cases, and 8649 of the patients were sul jectively satisfied with the procedure, Interestingly, the results were better in patients with traumatic etiology and subjective instability. Tendon reconstruction pro= vided a better result than ligament repair Other authors have reported similar outcomes in the treatment of this condition. Lee et al” reported on 10 patients with posterolateral rolatory instability treated with ligament repair (four cases) or reconstruction (six cases). Instability was corrected in all cases, and results were graded as satisfactory in eight patients. All patients with an excellent result had reconstruction with a tendon graft, a finding consistent with the above-mentioned study from the Mayo Clinie. When patients present with posterolateral rotatory instability and a resected radial head, reconstruction of the lateral collateral ligament complex combined with radial head replacement seems to provide satisfactory results" Arthroscopic capsu- lar plication” and arthroscopic electrothermal shrink age"* have been reported as an alternative to tendon reconstruction, but the findings of better overall results with tendon reconstruction versus ligament repair? Chapter 48 Lateral Collateral Ligament Insutficiency 677 and the concerns raised by the use of electrothermal shrinkage of the shoulder make arthroscopic surgery less attractive for the treatment of posterolateral rotatory instability. ODriscoll etal specifically reported on the outcome of surgical treatment for tardy posterolateral rotatory instability associated with cubitus varus. Twenty-one elbows were treated with osteotomy combined with reconstruction of the lateral collateral ligament complex (even patients), ligament reconstruction alone (10 patients), or osteotomy alone (four patients) and. fol- lowed for a mean of 3 years, Ulnar nerve transposition with or without triceps transposition was required in five patients, At most recent follow-up, three patients had persistent posterolateral rotatory instability, and two of these were rated as poor due to associated arthritis with severe pain SUMMARY Insufficiency of the lateral collateral ligament complex may be secondary to trauma, chronic attrition, or iat= rogenic injury, The resulting posterolateral. rotatory instability may present with recurrent dislocations, mechanical symptoms, ot lateraksided elbow pain. Instability may be demonstrated on physical examina~ tion in the office or with the patient under anesthesia Stress radiographs or fluoroscopy may be used to docu ment the instability. Most patients with chronic symp- tomaticinsufficiency improve with surgical reconstruction Usinga tendon graft. Ligament repair without augmenta- tion does not seem to be as effective in the chronic setting, but the procedure should be an integral part of the surgical treatment of acute elbow fracture dislocations. After surgery, the ligamentous repair or reconstruction should be protected from gravitational stresses and excessive tensile loads, Associated patho ogy affecting the radial head, coronoid, or the rest of the joint should be addressed as needed. Patients with tardy posterolateral rotatory instability secondary to cubitus varus often require association of a distal humerus osteotomy. References 1. Abe, M, Ishizu,T, and Morikawa, |: Posterolateral zotatory instabilty of the elbow after posttraumatic cubitus varus. J. Shoulder Elbow Surg. 6405, 1997 Auvind, CH, and) Hargreaves, D. G: Table top relocation test-New clinical test for posterolateral rotatory instability of the elbow |. Shoulder Elbow Surg, 15500, 2006, 5, Beuerlein, M. J, Reid. J.T, Schemitsch, E H., and McKee, M.D. Fifect of cistal humeral varus deformity on strain