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Abstract

Background:

The aim of surgical treatment for posterolateral rotatory instability (PLRI) of the elbow is to restore the integrity of the lateral ulnar collateral ligament (LUCL), with ligamentous reconstruction being the preferred option for recurrent symptomatic PLRI. However, there is no clinical evidence demonstrating the superiority of reconstruction versus repair. Treatment options currently depend on the cause of the LUCL injury and surgeon preference.

Purpose:

To review studies comparing surgical outcomes of LUCL reconstruction versus repair in treating PLRI of the elbow.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was conducted on PubMed, Medline (via EBSCO), ProQuest, and ScienceDirect databases using the following keywords: “(lateral ulnar collateral ligament reconstruction)” OR “(lateral ulnar collateral ligament repair)” AND “(outcome).” Excluded were studies in languages other than English, those that included terrible triad injury, transolecranon fracture, radial head arthroplasty involvement, associated procedures, animal studies, and biomechanical studies. A total of 193 studies were identified after the initial search. The primary outcome measure was the Mayo Elbow Performance Score, which was compared between studies using a random-effects model.

Results:

Overall, 20 studies (N = 646 patients) were included, with 445 of 646 patients (68.8%) in the LUCL reconstruction group and 201 of 646 patients (31.1%) in the LUCL repair group. All injuries in the included studies were traumatic. The LUCL reconstruction group had a longer follow-up period compared with the LUCL repair group (72.05 ± 43.51 vs 36.86 ± 21.19 months, respectively). The postoperative range of motion arc was similar in both the repair and reconstruction groups (135.02°± 15.33° vs 133.60°± 8.84°, respectively). Both LUCL repair and LUCL reconstruction resulted in good to excellent outcomes on patient-reported outcome measures; however, a superior rate of return to activity and a lower complication rate were found after LUCL reconstruction versus LUCL repair (8.3% vs 14.9%). Ulnar nerve event (2.3%) was the most common complication in both groups.

Conclusion:

Findings indicated that LUCL reconstruction had a superior rate of return to activity and a lower complication rate compared with LUCL repair.

Keywords

elbow instability lateral ulnar collateral ligament reconstruction repair

Posterolateral rotatory instability (PLRI) is a common form of recurrent elbow instability that was described by O’Driscoll²⁵ in 1994, implicating the lateral ulnar collateral ligament (LUCL) as a primary restraint for PLRI. The condition occurs as a result of axial loading, valgus force, and forearm supination.³ This is relatively due to the internal rotation of the humerus on a fixed forearm. However, the functional anatomy of the remaining lateral elbow stabilizing structures indicates that PLRI constitutes a more complex problem. A more recent biomechanical cadaveric study suggested that damage to the lateral collateral ligamentous complex as a whole may be responsible for PLRI.²⁷

Although PLRI generally occurs after elbow trauma, other causes include tardy PLRI secondary to cubitus varus deformity, severe lateral epicondylitis—especially after repeated corticosteroid injections, or iatrogenic injury after lateral elbow surgery. In most cases, the mechanism involves a combination of axial load, valgus force, and supination on the forearm, resulting in the disruption of the LUCL from its humeral origin. PLRI itself gives a spectrum of mechanical symptoms, such as pain, clicking, recurrent subluxations, and dislocations. If PLRI is left untreated, posttraumatic arthritis may develop as a result of joint incongruency and cartilage damage. Establishing the diagnosis of PLRI may be difficult and is often delayed because of its variable presentation.^7,30

The restoration of LUCL integrity is the main purpose of the surgical treatment of PLRI. Treatment options depend on the cause of the LUCL injury and the surgeon's preference. The choice to perform repair versus reconstruction typically depends on the chronicity of the injury and the quality of tissue available at the time of surgery. Surgical repair is more favorable for acute traumatic cases or in occasions where the tissue is still viable and has good healing potential.²⁴ Jones et al^{15, 16} showed that UCL repair with internal bracing was more resistant under fatigue loading compared with UCL reconstruction. Meanwhile, the main approach for addressing recurring PLRI involves the restoration of the LUCL. Reconstruction is the recommended surgical treatment when there is long-term weakening or a notable insufficiency in the ligament tissue, particularly among athletes performing overhead activities and persons who are engaged in strenuous manual labor.²³ There is no clinical evidence demonstrating the superiority of either LUCL repair or reconstruction.

In the present review, we aimed to compare studies on the surgical outcome of LUCL reconstruction versus repair in treating PLRI of the elbow. Based on the existing literature, we hypothesized that the results of LUCL reconstruction and LUCL repair would be comparable and that outcomes would depend on the patients’ circumstances—such as injury severity and time from injury to treatment.

Methods

Search Strategy and Study Selection

This study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA),²⁸ and the study protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023418856). We searched 4 databases—including PubMed, Medline via EBSCO, ProQuest, and ScienceDirect—from inception until September 2022 for relevant studies using the following keywords, which conformed to MeSH (Medical Subject Headings) and Emtree: “(Lateral ulnar collateral ligament reconstruction) OR (Lateral ulnar collateral ligament repair) AND (outcome).” As the number of studies investigating LUCL injury and treatment was limited, we made no restrictions with respect to specific surgical techniques, publication status, or study period. After eliminating duplicate studies, 2 independent reviewers (M.A. and L.C.S.) screened the titles and abstracts for relevant studies according to the inclusion and exclusion criteria.

Inclusion and Exclusion Criteria

All included studies were original research publications in the English language. Studies that included diagnosis, imaging, or treatment with open or arthroscopic LUCL repair or reconstruction for PLRI were included. The exclusion criteria included studies that included terrible triad injury, transolecranon fracture, radial head arthroplasty involvement, associated procedures at the time of surgery, and animal and biomechanical studies. Conference abstracts were also excluded.

Quality Appraisal and Risk-of-Bias Assessment

Two authors (M.A. and L.C.S.) independently performed data extraction and quality assessment. Discrepancies between the authors were resolved by reassessment and discussion with a third author specializing in elbow surgery (E.K.). The level of evidence of each included study was assessed using the guidelines of the Oxford Centre for Evidence-Based Medicine.¹⁴ Quality appraisal and risk of bias were assessed using the Methodologic Index for Non-randomized Studies ¹ (MINORS). The MINORS consists of a 12-item checklist comprising 8 items for noncomparative studies, with 4 additional items for comparative studies. Each item is scored from 0 to 2, with a maximum of 16 points for noncomparative studies and 24 points for comparative studies. Since the scoring system has no predefined cutoff, we considered the studies as high quality if the MINORS score was >60% (9/16 for noncomparative studies).

Data Extraction and Analysis

Data were extracted from the texts, figures, tables, and associated supplementary files and comprised (1) patient characteristics; (2) preoperative characteristics (eg, radiological findings); (3) intraoperative characteristics; and (4) postoperative outcomes (eg, functional outcomes, rate of return to work or sport, patient satisfaction, and complications). Collated data were summarized in tables using Excel (2013; Microsoft Corp). A qualitative assessment was performed to produce a narrative report. Treatment modalities were compared using subgroup analysis. Statistical analysis was conducted using OpenMeta-Analyst software (Brown University CEBM). The I² value was used to identify the heterogeneity between studies.

The primary outcome measure was the functional outcome of the patients as measured using the Mayo Elbow Performance Score (MEPS). MEPS values were provided as scores from 0 to 100 or as categories: poor (<60), fair (60-74), good (75-89), or excellent (90-100). The secondary outcomes were the visual analog scale (VAS; 0-10) for pain, as well as postoperative complications. The MEPS values across relevant studies were assessed using a random-effects model, with forest plots used to identify outcomes. Statistical significance was set at P < .05.

Results

Included Studies

Overall, 20 studies met the inclusion criteria; 18 were level 4 case series, and the remaining 2 were level 3 retrospective cohort studies.^†† Figure 1 shows the PRISMA²⁷ flow diagram of the study inclusion process.

Figure 1.

PRISMA flow diagram of the study inclusion process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Quality Assessment

The mean MINORS score for all 20 studies was 10.1 (Figure 2). Overall, all but 1 study³⁴ were considered high-quality studies with a low risk of bias.

Figure 2.

Distribution of MINORS Score in the included studies. MINORS, Methodologic Index for Non-randomized Studies.

Included Patients

A total of 646 patients (n = 646 elbows) with PLRI were included in 20 studies (Table 1). There were 367 elbows in men (56.8%) and 279 elbows in women (43.2%). The dominant extremity was affected in 27.8% of patients (180/646). The mean waiting time was 18.1 months (range, 3 weeks-51.3 months); the mean follow-up was 4.5 years (range, 1-19 years).

Table 1

Characteristics of the Included Studies (N = 20)^a

Lead Author (Year)	Country	Study Type (LOE)	Elbows, n	Dominant Side Affected	Mean Age (Range), Years	Sex (M/F), n	Mean Waiting Time, Month^b	Mean Follow-up, Month
Chanlalit (2018)⁴	Thailand	Case series (4)	6	NR	46 (39-58)	1/5	32	24.2
Daluiski (2014)⁶	US	Retrosp cohort (3)	34	NR	43.3 (NR)	21/13	12.3	38.1
DeLaMora (2002)⁸	US	Case series (4)	5	NR	NR (22-61)	NR	NR	NR
Eygendaal (2004)⁹	Netherlands	Case series (4)	12	5/12	35 (19-65)	8/4	36	23
Geyer (2022)¹¹	Germany	Retrosp cohort (3)	31	NR	42.4 (18-65)	13/18	51.3	57.7
Greiner (2019)¹²	Germany	Case series (4)	17	NR	38.3 (17-69)	14/3	NR	11
Jones (2012)¹⁶	US	Case series (4)	8	NR	39.8 (17-57)	4/4	0.3	85.2
Jung (2019)¹⁷	Republic of Korea	Case series (4)	21	NR	43.3 (21-59)	16/5	NR	27.4
Kastenskov (2017)¹⁸	Denmark	Case series (4)	15	NR	34 (13-48)	3/12	37	228
Kim (2016)¹⁹	Republic of Korea	Case series (4)	13	NR	43.2 (18-72)	11/2	NA	22.1
Lee (2003)²⁰	Singapore	Case series (4)	10	6/10	34 (20-50)	6/4	10.4	24.1
Lin (2012)²¹	Taiwan	Case series (4)	14	NR	31.6 (18-60)	14/8	2.3	49
O’Brien (2014)²³	US	Case series (4)	13	5/13	26.6 (16-49)	11/2	2.2	29.9
Olsen (1996)²⁶	Denmark	Case series (4)	18	11/18	30 (16-50)	5/13	35	44
Rodriguez (2018)²⁹	US	Case series (4)	23	9/23	31.6 (19-46)	20/3	19.5	55.2
Sanchez-Sotelo (2005)³⁰	US	Case series (4)	44	NR	39.2 (18-80)	24/13	NR	72
Savoie (2008)³¹	US	Case series (4)	60	53/60	17.2 (16-22)	47/13	45	59.2
Schneider (2022)³²	Germany	Case series (4)	72	52/72	46.9 (21-74)	33/39	NR	33.6
Schoch (2022)³³	Germany	Case series (4)	178	NR	31.2 (17-48)	105/73	13	91
Vernet (2015)³⁴	France	Case series (4)	18	NR	37.8 (20-63)	10/8	17	61.1

LOE, level of evidence; NR, not reported; Retrosp, retrospective; US, United States.

Time from injury to surgery.

Preoperative Characteristics

The preoperative characteristics are shown in Table 2. Most patients experienced pain at rest (475; 73.5%) and instability symptoms (532; 82.3%). The most common instability test performed was the pivot-shift test, which was found positive in 40.2% (260/646) of patients, followed by the varus stress test (104/646; 16%) and posterolateral drawer test (56/646; 8.6%). Other instability tests performed include the chair push-up test (29/646; 4.4%) and the tabletop relocation test. The preoperative range of motion (ROM) was only available in 338 patients (52.3%), with limited ROM found in 24 patients (3.7%). All patients underwent standard elbow radiographs; other imaging modalities such as magnetic resonance imaging and computed tomography were performed on 455 (70.4%) and 31 (4.7%) patients, respectively.

Table 2

Preoperative Characteristics of the Included Studies^a

Study	Pain at Rest, n/Total	Instability Symptoms, n/Total	Instability Testing (n/Total)	Preoperative ROM arc, Deg	Imaging Evaluation	Imaging Findings (n/Total)
Chanlalit and Dilokhuttakarn⁴ (2018)	NR	6/6	Varus stress (3/6); pivot-shift (5/6); posterolateral rotatory drawer (1/6); chair push-up (3/6)	NR	Radiograph, MRI	MRI: LCL lesion and concomitant pathologies (pathological plica and lateral epicondylitis) (5/6)
Daluiski et al⁶ (2014)	NR	34/34	Varus stress (34/34); pivot-shift (34/34); posterolateral rotatory drawer (34/34)	NR	Radiograph	NR
DeLaMora and Hausman⁸ (2002)	5/5	5/5	NR	127.5	NR	NR
Eygendaal⁹ (2004)	12/12	12/12	Pivot-shift (NA)	147.9	Radiograph, MRI	MRI: Normal (9/12); cartilage lesion (3/12)
Geyer et al¹¹ (2022)	NR	NR	NR	134.2	MRI	Partial LUCL lesion (17/31)
Greiner et al¹² (2019)	17/17	17/17	Pivot-shift (17/17)	NR	Radiograph, MRI	MRI: LUCL injury (17/17)
Jones et al¹⁶ (2012)	8/8	8/8	Pivot-shift (8/8)	NR	MRI	LUCL injury (8/8)
Jung et al¹⁷ (2019)	21/21	21/21	Varus stress (21/21); posterolateral rotatory drawer (21/21)	133	MRI	Apparent joint space widening (21/21)
Kastenskov et al¹⁸ (2017)	18/18	18/18	Pivot-shift (18/18)	NR	Radiograph	Posterolateral subluxation of the radial head (2/18)
Kim et al¹⁹ (2016)	NR	13/13	Pivot-shift (13/13)	NR	CT, MRI	MRI and CT: tear of the lateral ulnar collateral ligament
Lee et al²⁰ (2003)	5/10	9/10	Pivot-shift (5/10)	117.5	Radiograph	Radiohumeral subluxation (8/10)
Lin et al²¹ (2012)	12/14	3/14	Pivot-shift (10/14)	114.3	Radiograph (stress and plain)	• Stress film: varus instability (9/14) • Plain film: Lateral epicondyle and anterior capsule avulsion fracture (7/14); medial and lateral epicondyle and anterior capsule avulsion fracture (2/14); lateral epicondyle avulsion fracture (1/14); none (4/14)
O’Brien et al²³ (2014)	None	None	Pivot-shift (NA)	NR	MRI	RCL and LCL complex tear proximally off of the lateral epicondyle of the humerus (14/14)
Olsen et al²⁶ (1996)	18/18	4/18	Pivot-shift (18/18); varus stress (7/18)	NR	Radiograph	Posterolateral subluxation of the radial head (2/18)
Rodriguez et al²⁹ (2018)	17/23	18/23	Pivot-shift (18/23)	131.4	Radiograph, MRI	MRI: LUCL injury (17/23)
Sanchez-Sotelo et al³⁰ (2005)	33/44	44/44	Pivot-shift (19/44); varus stress (39/44); chair push-up (26/44)	123.3	NR	NR
Savoie et al³¹ (2008)	41/60	60/60	Pivot-shift (60/60)	NA	MRI	MUCL damage (42/60)
Schneider et al³² (2022)	72	72	NR	NR	Radiograph, MRI	NR
Schoch et al³³ (2022)	178/178	178/178	Pivot-shift (NA), table-top relocation (178/178); chair push-up (178/178)	135.4	Radiograph, MRI	• Radiograph: drop sign • MRI: ligamentous injuries, cartilage lesions
Vernet et al³⁴ (2015)	18/18	10/18	Pivot-shift (18/18)	NR	CT	Posterior subluxation of elbow (5/18); coronoid process fracture non-union (3/18)

CT, computed tomography; LCL, lateral collateral ligament; LUCL, lateral ulnar collateral ligament; MRI, magnetic resonance imaging; MUCL, medial ulnar collateral ligament; NA, not applicable; NR, not reported; RCL, radial collateral ligament; ROM, range of motion.

Intraoperative Characteristics

The intraoperative characteristics of the studies are summarized in Appendix Table A1. Overall, 68.8% (445/646) of patients underwent LUCL reconstruction and 31.1% (201/646) of patients underwent LUCL repair. For the reconstruction procedure, the most common graft used was the triceps tendon autograft (342/445; 76.8%) followed by palmaris tendon autograft (72/445; 16.1%). The other grafts were gracilis tendon autograft (13/445; 2.9%), Achilles tendon allograft (6/445; 1.3%), hamstring tendon autograft (4/445; 0.89%), and flexor carpi radialis autograft (1/443; 0.22%). The most frequently used fixation type was transosseous fixation (197/646; 30.4%), followed by tenodesis screw (178/646; 27.5%), suture anchor (138/646; 21.2%), and suture tape (72/646; 11.1%). Examination under anesthesia (EUA) was performed in 33.7% of patients (218/646). The types of EUA performed were the pivot-shift test (168/218; 77%), posterior drawer test (56/218; 25.6%), and varus stress test (21/218; 9.6%). Arthroscopic examination for instability was performed in 75 patients (11.6%), with a positive result in 45.3% (34/75) of patients.

Postoperative Characteristics

The postoperative outcomes according to the study are detailed in Appendix Table A2, and the results of the subgroup analysis of LUCL repair (n = 201 patients) versus reconstruction (n = 445 patients) are shown in Table 3. The most common functional outcome tool used was the MEPS, with 15 studies including postoperative MEPS values.^‡‡ A total of 44 patients (21.8%) in the repair group and 254 patients (57%) in the reconstruction group reported excellent MEPS outcomes, and 32 patients (15.9%) in the repair group and 124 patients (27.8%) in the reconstruction group reported good outcomes. The remaining 5 patients reported fair outcomes, and 1 patient reported poor outcomes; all of these patients belonged to the reconstruction group. The mean MEPS was 91.58 ± 8.83 in the repair group and 89.8 ± 8.31 in the reconstruction group (Table 3). The VAS pain score was reported in 269 patients (41.6%), none of whom had a VAS score >3. The instability symptoms resolved in 592 patients (89.1%). Residual symptoms were observed in 28 patients (4.3%). The most common residual symptom exhibited was instability (18/28; 64.2%), followed by pain (11/28; 39.2%) and stiffness (5/28; 17.8%). Return to work or sport was reported in 8 studies,^{12,18,23,26,29,31,32,34} with times ranging from 7.7 to 52 weeks. Patient satisfaction was reported in 12 studies,^§§ with 75 patients in the repair group and 212 patients in the reconstruction group satisfied with outcomes. The mean satisfaction rate was 94.40% ± 6.98% in the repair group and 93.69% ± 4.74% in the reconstruction group (Table 3).

Table 3

Subgroup Analysis of LUCL Repair Versus Reconstruction Patients^a

Variable	LUCL Repair (n = 201)	LUCL Reconstruction (n = 445)
Mean age, y	41.11 ± 13.59 (9-80)	36.33 ± 10.03 (10-68)
Mean follow-up, mo	36.86 ± 21.19 (6-174)	72.05 ± 43.51 (9-265)
Mean waiting time, mo	6.32 ± 7.98 (0.13-24)	30.83 ± 22.32 (0.4-108)
Postoperative ROM arc, deg	135.02 ± 15.33 (80-151)	133.60 ± 8.84 (90-170)
Postoperative MEPS	91.58 ± 8.83 (60-100)	89.8 ± 8.31(45-100)
Return to activities rate, %	93.65 ± 4.84 (90-100)	96.28 ± 1.87 (80-100)
Satisfaction rate, %	94.40 ± 6.98 (88.6-100)	93.69 ± 4.74 (86-100)
Complication rate, %	14.9	8.3

Data are presented as mean ± SD (range). LUCL, lateral ulnar collateral ligament; MEPS, Mayo Elbow Performance Score; ROM, range of motion.

Complications were observed in 54 patients (8.3%), with ulnar nerve event being the most common complication (2.3%). Postoperative complications were grouped into wound problems (1.8%)—including hematoma, wound infection, stitch abscess, pin-site irritation, and suture granuloma; ulnar nerve event (2.3%)—including persistent ulnar nerve symptoms, postoperative ulnar nerve injury, cubital tunnel syndrome, and ulnar nerve neuritis; joint problems (2.1%)—including contracture, heterotopic ossification, posttraumatic osteoarthritis, and arthrofibrosis; instability (1.8%)—including medial collateral ligament and flexor pronator tear, graft insufficiency, mild radiocapitellar opening, and reruptured ligament; and other (0.3%)—including deep vein thrombosis and nonunion. A comparison of complications between the reconstruction and repair groups is shown in Figure 3.

Figure 3.

Postoperative complications after LUCL reconstruction versus LUCL repair. LUCL, lateral ulnar collateral ligament.

Functional Outcomes

Results of the meta-analysis of MEPS scores among 4 studies^9,19,23,30 of LUCL repair and 11 studies^‖‖ of LUCL reconstruction indicated that the mean postoperative MEPS was significantly higher in the repair group (91.5 [95% CI, 86.8-96.2]; P = .016; I² = 99.3%) ( Figure 4A) compared with the reconstruction group (89.8 [95% CI, 82.8-96.7]; P < .001; I² = 100%) (Figure 4B).

Figure 4.

The MEPS of the (A) LUCL repair group and (B) LUCL reconstruction group. LUCL, lateral ulnar collateral ligament; MEMPS, Mayo Elbow Performance Score.

Discussion

This review and meta-analysis indicated that both LUCL repair and reconstruction surgery led to good to excellent patient-reported outcome scores. With regard to other outcome measures, LUCL reconstruction was shown to have a superior rate of return to activity and a lower complication rate compared with LUCL repair, while LUCL repair had higher postoperative functional outcomes and ROM arc.

In the acute traumatic setting, LUCL repair is an option if the soft tissues are amenable; however, given the frequent difficulty in diagnosis of PLRI, repair is often not feasible as the soft tissues are irreparable. Therefore, reconstruction of the lateral collateral ligament complex is the recommended choice to restore elbow stability in patients, especially in those with subacute to chronic PLRI. As reported by Sanchez-Sotelo et al,³¹ reconstructions using a tendon graft provided better results than ligament repair, and the results did not appear to deteriorate with time, as satisfactory results were seen in 84% of patients after reconstruction.^3,6,31

With regard to functional outcomes, the postoperative ROM arc and MEPS values were slightly higher in patients who underwent LUCL repair versus reconstruction (ROM: 135.02° vs 133.60°; MEPS: 90.14 vs 89.04). These results may be due to the longer waiting times in the reconstruction group (30.82 months vs 6.30 months in the repair group), since a longer time from diagnosis of PLRI to surgery will result in significant pain, dysfunction, and degenerative changes to the elbow. Concrete diagnosis of PLRI is often delayed since it requires a careful history of elbow trauma in combination with a focused physical examination as well as associated imaging.³³ Among the included studies, Lin et al²² reported a mean time between injury and index surgery of 45 months, and Chanlalit and Dilokhuttakarn⁴ reported that patients with atraumatic PLRI showed inferior results compared with patients with traumatic PLRI due to their longer waiting time.

Our findings are similar to a study by Fares et al,¹⁰ which showed that despite the delayed diagnosis, surgical outcomes after LUCL reconstruction are generally excellent, with 90% of patients reporting a mean MEPS of 89.7 at a long-term follow-up. The rate of return to activities was marginally higher in the LUCL reconstruction group compared with the repair group. Vitale et al³⁵ showed that LUCL reconstruction was effective in returning athletes to sports, with a rate of return of approximately 80%. This finding was also supported by Hechtman et al,¹³ who reported that out of 34 athletes, 29 athletes (85%) had an excellent result, defined as the ability to return to play at or above the preinjury level. Conway et al⁵ also reported that only 50% of patients undergoing a direct repair returned to their previous level of sport compared with 68% of those undergoing a reconstruction. Even worse outcomes were seen in Major League Baseball players in the United States who underwent primary repair, with only 2 of 7 players being able to return to sports.¹³

We cannot conclude from the available studies whether one procedure is superior to another because of the limited number of patients and the heterogeneity of the patient characteristics and mechanisms of injury. LUCL repair may be a viable surgical option in young athletes with acute injuries, as it has excellent outcomes and allows an earlier return to play compared to LUCL reconstruction.²⁹ Savoie et al,³¹ included in this review, showed that the results of primary LUCL repair in patients with acute injury were excellent, with 93% (56/60) of patients returning to sporting activities within 6 months. However, LUCL reconstruction may be more beneficial in patients with subacute, chronic PLRI or in older patients who may have degenerative tissue.^2,17

Limitations

The main strength of this study is that our meta-analysis compares the surgical outcome of LUCL reconstruction versus repair for PLRI, comprising 20 included studies from 4 major databases after a comprehensive literature search. However, this study does have limitations. The analysis demonstrated a lower quality of evidence. However. The heterogeneity of patient characteristics and various mechanisms of injury limited the comparison of the superiority of each technique. Also, many studies did not discuss postoperative rehabilitation, and they had incomplete data as it related to return to preoperative levels of activity. Future studies into the surgical treatment of PLRI with a higher level of evidence, similar patient characteristics, and chronicity of the condition are needed.

Conclusion

This study demonstrated that LUCL reconstruction showed a superior rate of return to activity and a lower complication rate compared with LUCL repair. The patient population and the time from injury to the procedure also contributed to the outcome among the patients. LUCL reconstruction also had a lower complication rate but the ROM among these groups was similar.

Footnotes

Appendix

Table A2

Postoperative outcomes of the Included Studies^a

	Quantitative Assessment		Quantitative Assessment
Study	Outcome Measures	Postop ROM arc, Deg	Resolution of Instability Symptom, n/Total	Recurrence/Residual Symptoms (n/Total)	Return to Work/Sport (Time)	Patient Satisfaction, n/Total (%)	Complications (n)
Chanlalit Chanlalit and Dilokhuttakarn⁴ (2018)	• MEPS: 97.5 • DASH: 7.6	136.8	8/8	—	NR	NR	None
Daluiski et al⁶ (2014)	MEPS: 89.5	135	34/34	—	NR	NR	Postoperative stiffness (1); wound breakdown (1); postoperative arthritis (1); ulnar nerve neuritis (1)
DeLaMora and Hausman⁸ (2002)	NR	125	5/5	—	NR	NR	None
Eygendaal⁹ (2004)	Broberg and Morrey score: excellent (6/12), good-excellent (5/12), good (1/12)	150.4	11/12	Persistent instability (1/12)	NR	NR	None
Geyer et al¹¹ (2022)	• MEPS: 95 • PREE: 15.8 • VAS pain: 1.4 • DASH: 11.8	137.9	29/31	—	NR	28/31 (90.4)	Wound infection (1); persistent ulnar nerve symptoms (2); elbow stiffness (1)
Greiner et al¹² (2019)	• MEPS: 92.4 • DASH: 27.5 • OES: 39.1	130	17/17	—	17/17 (52 wk)	NR	Heterotopic ossification (1)
Jones et al¹⁶ (2012)	• MEPS: 87.5 • Nestor grading system: excellent (4/8), good (4/8)	Full ROM	6/8	Occasional instability (2/8)	NR	8/8	None
Jung et al¹⁷ (2019)	• MEPS: 85 • QuickDASH: 11.4 • NRS: 2	130	19/21	Mild instability (2/21)	NR	NR	Stitch abscess (1)
Kastenskov et al¹⁸ (2017)	• MEPS: 89 • VAS pain: 0 during rest, 3 during activity • OES: 45	136.4	18/18	Mild pain during activity (6/18)	18/18	16/18	Posttraumatic osteoarthritis (5)
Kim et al¹⁹ (2016)	• MEPS: 92 • Nestor grading system: excellent (11), good (2)	141	13/13	—	NR	NR	Pin site irritation (1); delayed union (1); mild widening of the radiocapitellar joint space (1)
Lee et al²⁰ (2003)	Nestor grading system: excellent 3/10, good 5/10, fair 2/10	128.5	10/10	Stiffness (2/10)	NR	10/10 (100)	Postoperative hematoma (1)
Lin et al²¹ (2012)	• MEPS: 93.2 • Nestor grading system: excellent (10/14), good (3/14), fair (1/14)	122.1	13/14	Persistent instability (1/14)	NR	13/14 (93)	MCL tear (1)
O’Brien and Savoie²³ (2014)	MEPS: 100	128.1	13/13	—	13/13 (7.7 wk)	13/13	Heterotopic ossification (1)
Olsen et al²⁶ (1996)	• MEPS: 92 • Modified Constant score: 89	136	18/18	Moderate pain (5); loss of extension (2); loss of flexion (1)	15/18	15/18	Ulnar nerve paralysis (1); deficient triceps tendon graft (1)
Rodriguez et al²⁹ (2018)	• MEPS: excellent (9/23), good (10/23), fair (3/23), poor (1/23)* • VAS pain: 1.34	121	23/23	—	19/23 (19.5 wk)	19/23	Wound infection (1); cubital tunnel syndrome (3); contracture (1)
Sanchez-Sotelo et al³⁰ (2005)	Nestor grading system: excellent (18/37), good (10/37), fair (9/37)	134.8	31/37	Pain and recurrence of instability (6/37)	NR	38/44 (86)	Wound infection (2); heterotopic ossification (1); ulnar nerve compression (2); deep vein thrombosis (1)
Savoie et al³¹ (2008)	Andrews-Carson score: excellent (53/60), good (3/60), fair (3/60), poor (1/60)	NR	NR	NR	58/60 (24 wk)	51/60 (85)	Arthrofibrosis (1); ulnar nerve injury (6); wound infection (2); flexor pronator tear (2)
Schneider et al³² (2022)	• MEPS: 78.6 • SEV: 78.9 • PRTEE: 21.5 • DASH: 20.4	NA	72/72	—	72/72 (18.9 wk)	67/72	Heterotopic ossification (1); insufficient triceps tendon graft (5); suture granuloma (1)
Schoch et al³³ (2022)	• MEPS: 91.3 • VAS pain: 1.8 • OES: 46.5	131.3	178/178	—	NR	NR	Ligament rerupture (2)
Vernet et al³⁴ (2015)	• VAS pain: 2.6 • MEPS: excellent (11/18), good (6/18), fair (1/19)^b	126.7	18/18	—	18/18 (14 wk)	18/18	None

DASH, Disabilities of the Arm, Shoulder and Hand; MEPS, Mayo Elbow Performance Index; NR, not reported; NRS, Numeric Rating Scale; OES, Oxford Elbow Score; PREE, Patient-Rated Elbow Evaluation; preop, preoperative; ROM, range of motion; SEV, Subjective Elbow Value; VAS, visual analog scale.

MEPS scores were categorized as poor (<60), fair (60-74), good (75-89), or excellent (90-100).

Final revision submitted March 30, 2024; accepted April 12, 2024.

The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Notes

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Surgical Outcomes of Lateral Ulnar Collateral Ligament Reconstruction Versus Repair for Posterolateral Rotatory Instability of the Elbow: A Systematic Review and Meta-analysis

Abstract

Background:

Purpose:

Study Design:

Methods:

Results:

Conclusion:

Keywords

Methods

Search Strategy and Study Selection

Inclusion and Exclusion Criteria

Quality Appraisal and Risk-of-Bias Assessment

Data Extraction and Analysis

Results

Included Studies

Quality Assessment

Included Patients

Preoperative Characteristics

Intraoperative Characteristics

Postoperative Characteristics

Functional Outcomes

Discussion

Limitations

Conclusion

Footnotes

Appendix

Notes

References