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Elbow Ligament Reconstruction (Stabilisation)

116 citationsUpdated Oct 2026

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Overview

Surgical management of elbow instability is indicated when the joint remains unstable, specifically in cases requiring flexion beyond 50 to 60 degrees to remain reduced or involving unstable periarticular fractures [4, 23]. The primary goal of treatment for elbow fracture-dislocations is to achieve stable fixation of the appropriate ligamentous and bony structures to obtain a stable, functional, and pain-free elbow [22]. In posterolateral rotatory instability, surgical ligament reconstruction or repair is the most favorable treatment option for restoring normal elbow function [6]. For terrible triad injuries, a standardised surgical protocol that restores the integrity of the elbow by repairing all structures provides the best results and prognosis by restoring stability [2]. A modified surgical strategy for these injuries provides both bony and soft-tissue stability simultaneously, allowing active early motion and functional recovery with good to excellent outcomes and minimal complications [10].

The lateral ulnar collateral ligament is the most critical structure to repair or reconstruct when the elbow remains unstable [4]. It is important to determine which structures need to be repaired to avoid complications that could lead to elbow instability in isolated displaced type II partial articular radial head fractures [5]. Surgical reconstruction of the anterior oblique ligament is essential to prevent the possibility of development of instability of the elbow in patients with neglected intraarticular entrapment of the medial epicondyle after dislocation [9]. Allograft reconstruction restores elbow stability in approximately 85% of the elbows with posterolateral rotatory instability [18]. Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term [30]. For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures [62].

Following ulnar collateral ligament repairs and reconstructions, elbow range of motion is reliably preserved or improved with a predictable trajectory of rapid improvement within the first 2 to four months [15]. All reconstruction methods were able to sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion [11]. A novel bidirectional ligament reconstruction maintained secure fixation between ligament and bone and allowed for maintenance of static stability at different degrees of elbow flexion [1]. Cadaveric elbow specimens maintained secure fixation between ligament and bone following hemiarthroplasty and ligament reconstruction, with static stability maintained at varying degrees of elbow flexion regardless of variable mismatch between the hemiarthroplasty component and the native olecranon fossa [16]. An open posterolateral ligament plication and lateral ulnar collateral ligament repair using an all-suture construct allows for complete posterolateral stabilization of the elbow with a single implant and bone preservation [3]. An all-arthroscopic reconstruction of the lateral ulnar collateral ligament is reproducible and achieves the reconstruction of the lateral ulnar collateral ligament of the elbow as well as avoids residual instability [12]. An arthroscopic lateral ulnar collateral ligament plication/reconstruction with augmented lateral collateral ligament imbrication allows effective management of elbow instability while promoting quicker patient recovery and long-term functional restoration [26]. Further follow-up and wider experience of the technique using Surgilig/LockDown is required to assess its long-term functional outcome in comparison with more established surgical techniques for stabilization of posterolateral elbow instability [14].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that afford bony stability [40]. The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [69]. This articulation provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area on the greater sigmoid notch devoid of cartilage [69]. The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [80]. The radiocapitellar joint is formed by the articulation of the capitellum and the radial head [69]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [69]. The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [69].

The distal humeral articular surface is angled 30° from the longitudinal axis of the humerus [69]. The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [69]. The medial column of the distal humerus diverges approximately 45 degrees from the humeral shaft in the coronal plane [80]. The lateral column of the distal humerus diverges at approximately 20 degrees from the shaft in the coronal plane [80]. The olecranon fossa and coronoid fossa are separated by a thin bony septum, which is occasionally absent [80].

The normal range of motion for the elbow is 0° to 140° from extension to flexion [40]. The normal range of motion for forearm rotation is 75° in pronation and 85° in supination [40]. A functional arc of motion for the elbow is 100° for flexion and extension and 100° for forearm rotation [40]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [75].

Ligamentous Anatomy

Elbow stability is determined by primary stabilizers, which include the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [40]. Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [40].

The medial ulnar collateral ligament originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [75]. The MUCL is composed of anterior, posterior, and transverse bundles [75]. The anterior bundle of the MUCL is the primary restraint to valgus stress within functional elbow range of motion [75]. The posterior bundle of the MUCL is the primary restraint to valgus stress with the elbow in maximal flexion [75]. The anterior bundle of the MUCL is divided into an anterior band taut at 0 to 60 degrees and a posterior band taut at 60 to 120 degrees [85].

The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament [80]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [80]. The lateral ulnar collateral ligament arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [80]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [80]. The LUCL origin center is located 10.7 mm from the lateral epicondyle [68]. The LUCL insertion is located 3.3 mm from the apex of the supinator crest [68].

The lateral collateral ligament contributes 14% of varus stability of the elbow with the joint in full extension [85]. The lateral collateral ligament contributes 9% of varus stability of the elbow with the joint in 90 degrees of flexion [85]. At 90 degrees of flexion, the ulnar collateral ligament provides 55% of the stability to valgus stress [85].

Pathophysiology

Injury to primary or secondary stabilizers causes elbow instability [40]. Elbow dislocations can result in extensive injury to the supporting structures of the elbow joint [51]. The typical mechanism for traumatic elbow dislocation involves a fall on a slightly flexed extremity with a valgus internal rotation force of the forearm [85]. In traumatic elbow dislocation, structures are disrupted on the lateral side first, progressing medially as more force is applied [85]. Posterolateral structures are most commonly affected when recurrence or persistence of instability results from traumatic dislocation [85]. A coronoid fracture in association with disruption of the posterior band of the ulnar collateral ligament can result in symptomatic posteromedial instability [85]. Valgus instability from attritional disruption of the anterior bundle of the medial ulnar collateral ligament is the most common form of recurrent elbow instability [85].

Failure of primary stabilizers results in increased stress on secondary stabilizers, leading to capsular contractures, chondromalacia, osteophytes, and loose bodies [85]. Ulnar nerve symptoms may develop from traction, scarring, or osteophyte impingement following elbow instability [85]. Complex elbow instability is defined as traumatic elbow dislocation with associated fractures and ligamentous injury [33]. The goal of treatment for complex elbow instability is to achieve stable fixation of the appropriate ligamentous and bony structures to obtain a stable, functional, and pain-free elbow [22]. Disruption of forearm structures may lead to forearm instability with consequences at the remaining structures [116].

Bony and Ligamentous Stabilizers

Elbow instability may occur with disruption of either bony or ligamentous stabilizers or a combination of both [148]. The radial head and coronoid process are the major bone stabilisers of the elbow [146]. The incidence of fracture of the radial head, coronoid process, and olecranon in patients with elbow dislocation is 36%, 13%, and 4%, respectively [146]. In the absence of ligamentous or radial head injury, transverse fractures of the coronoid process involving greater than 50% to 60% of coronoid height can lead to axial and varus instability of the elbow [148]. With loss of the stabilizing effect of an intact radiocapitellar joint, posterolateral rotatory instability may be seen with coronoid fractures involving 30% of coronoid height [148]. Bony and ligamentous stabilizers work in concert to provide elbow stability, such that combined injuries may lead to instability in cases in which the individual components of an injury seen in isolation may not [148].

All ligaments that stabilise the elbow run between the humerus and the ulna, and none connect the humerus to the radius [149]. Instability of the elbow occurs chiefly in the lateral and posterolateral directions [149]. Dislocation of the elbow involves the humero-ulnar joint and manifests as posterior or posterolateral displacement, which usually disrupts both collateral ligaments, namely, the ulnar collateral ligament (UCL) and the radial collateral ligament (RCL) [149]. Complete disruption of the radial collateral ligament is the rule in elbow dislocation [149]. Despite posterior displacement in elbow dislocation, the anterior and middle bundles of the UCL may remain intact as they are protected by lateral rotation [149]. The patterns of ligamentous injury in elbow dislocation include proximal avulsion with or without detachment of a fleck of bone, mid-substance rupture, and distal avulsion of the ulnar attachment [149].

The coronoid process is the key to stability of the extended elbow in the sagittal plane and the anterior bundles of the collateral ligaments [149]. Of the six bundles that make up the two collateral ligaments of the elbow, four attach to the coronoid process [149]. Partial, intermediate, or total avulsion of the coronoid process results in partial or total loss of the anterior stabilising system [149].

Classification Systems

The authors created a comprehensive classification of complex fracture-dislocations of the elbow that appeared to be reproducible and may represent a useful tool for the management of such difficult injuries [120]. Bado expanded the definition of Monteggia fractures by describing a 4-category classification system based on the location of the injury [148]. The Regan–Morrey classification describes three types of coronoid process avulsion: type I detaches the apex of the coronoid process, type II partially detaches the anterior capsule, and type III detaches the insertions of both anterior bundles, the insertion of the middle bundle of the ulnar collateral ligament, and the anterior bone block that stabilises the elbow in extension [149].

A history of multiple or recurrent dislocations or provocative instability in certain positions suggests collateral ligament insufficiency [54]. The diagnosis of instability suggests collateral ligament and soft-tissue insufficiency that may require reconstruction [54]. The diagnosis of chronic dislocation implies thick intraarticular fibrosis and soft-tissue contracture that requires débridement and release [54]. Recurrent instability of the elbow is different from fixed chronic dislocation and has different management considerations [54].

Clinical Presentation

Elbow dislocations represent the second most common joint dislocation, presenting as either simple pure ligamentous lesions or complex injuries combined with fractures [105]. The high functional requirements of the elbow depend on the complexity of the joint, maintained function of vessels and nerves, and soft tissue coverage [36]. The high density of noble structures at this level may cause severe functional impairment of the upper limb [36]. The skin of the volar region differs from the dorsal region in thickness and flexibility, playing a critical role in covering these noble structures [36]. Orthopaedic surgeons must appropriately assess and investigate the painful and/or swollen elbow following trauma [108]. Understanding patterns of traumatic elbow instability helps counsel and manage patients [28]. Complex elbow instability remains a challenging clinical entity requiring a balance between stability, mobility, and concentric reduction [53].

Surgical management is indicated when the elbow remains unstable, with the lateral ulnar collateral ligament being the most critical structure to repair or reconstruct [4]. The goal of treatment is to achieve stable fixation of appropriate ligamentous and bony structures to obtain a stable, functional, and pain-free elbow [22]. It is important to determine which structures need repair to avoid complications leading to elbow instability [5]. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved, or joint replacement in case of severe articular degeneration [110]. Fractures of the coronoid and radial head are present in 30% to 40% of patients with chronic elbow dislocation [54]. Vascular insufficiency following chronic elbow dislocation is exceedingly rare [54]. The reconstruction of the bone, ligament, and muscle interplay is essential for elbow dislocations [105].

Posterolateral Rotatory Instability (PLRI)

The clinician must maintain a high index of suspicion for posterolateral rotatory instability in children, as initial trauma may be vague or remote and physical examination findings vary widely from instability to contracture [96]. In children with posterolateral rotatory instability, the average time from injury to repair was 3.7 years [96]. Radiographic evidence of posterolateral rotatory instability was present in six patients in a pediatric study, demonstrating that this condition can be easily missed and may be underdiagnosed and underreported [96]. Careful assessment of radiographs for radiocapitellar and ulnohumeral malalignment may aid in diagnosis [96]. Lateral radiographs were diagnostic for only six of the patients with posterolateral rotatory instability in a pediatric study [96]. There is a spectrum of radiographic findings for posterolateral rotatory instability in children, ranging from a normal appearance to a slight posterior sag of the radial head on the capitellum to complete posterior subluxation of the radial head with an incongruent ulnohumeral joint [96].

Finding an abnormality in the lateral ulnar collateral ligament on MRI does not correlate with the presence of posterolateral rotatory instability [96]. Studies have shown asymptomatic elbows with high-intensity areas indicative of tearing on MRI [96]. Completely torn ligaments have been diagnosed with manipulation under anesthesia in cases where MRI was inconclusive or negative [96]. If posterolateral rotatory instability is recognized, it is important to correct it because chronic instability leads to early degenerative changes in the elbow [96]. Persistent instability has been reported in 7% to 25% of elbows after lateral collateral ligament complex repair or reconstruction [46]. The results were worse in patients who had previously undergone an operation to stabilize the elbow laterally [25]. This case illustrates that sometimes ligaments of the elbow may not heal or tighten sufficiently over time and that despite a careful examination elbow and forearm stability, removal of a radial head prosthesis may give rise to problems, even up to 5 years after prosthetic removal [29]. Differential diagnosis of lateral elbow instability in patients presenting with tennis elbow should be considered [119].

Ulnar Collateral Ligament (UCL) / Medial Instability

UCL dysfunction typically presents as pain with loss of velocity and control [109]. Some patients with UCL injury will present with an acute injury, whereas many will report a more insidious onset of symptoms with progressive pain with throwing and decreased performance [109]. Nontraumatic ulnar collateral ligament (UCL) injury is most commonly seen in overhead athletes, with baseball pitchers at the highest risk of developing UCL insufficiency [109]. The incidence of Ulnar collateral ligament (UCL) surgery has been increasing particularly in younger athletes involved in year-round pitching for multiple teams without well-defined and enforced pitch counts [109]. A standardized evaluation of athletes with medial elbow pain including thorough history, comprehensive physical examination and appropriate imaging studies are essential to make the diagnosis of UCL tear [109].

Patients with chronic UCL insufficiency complained for elbow pain during sport and work activities and had positive signs for medial ligament injuries, including the valgus stress test and the milking maneuver [47]. Magnetic resonance imaging (MRI) was performed in all cases to confirm the UCL injuries in a study of chronic UCL insufficiency [47]. Ultrasound was used to document the presence or absence of a palmaris longus to the wrist in a study of chronic UCL insufficiency [47]. Following UCL repairs and reconstructions, elbow ROM is reliably preserved or improved with a predictable trajectory of rapid improvement within the first 2 to four months [15]. It is an effective way of stabilizing the elbow joint in chronic instability patients, and results in an improvement in their overall range of motion [24]. Transient ulnar neuritis is the most common postoperative complication and is relatively common [109]. Major complications of UCL reconstruction are relatively rare and include need for revision UCL reconstruction and fracture [109].

Terrible Triad and Complex Fracture-Dislocations

They must restore the integrity of the elbow repairing all structures, using a standardised surgical protocol, which gives the best results and prognosis by restoration of the elbow stability [2]. The goal of reconstruction of terrible triad injuries is to restore sufficient elbow stability to allow early mobilization within a stable elbow arc of motion [49]. The literature supports a consensus that to achieve such stability, the surgeon should fix or replace the radial head and repair the injured lateral ulnar collateral ligament [49]. Many authors agree that any associated coronoid fracture, regardless of fracture classification, should also be fixed [49]. Debate still exists regarding best treatment of these fractures, particularly the treatment of small or very comminuted coronoid fragments [49]. Some published information suggests there might be a role for excision or benign neglect for small or very comminuted coronoid fragments [49]. A recent cadaver study suggests that in some situations, stability can be maintained without surgical fixation of the coronoid [49].

One must exercise caution when attempting to apply the results of biomechanical studies to the clinical setting, because the complexity and intricacy of injury, coupled in vivo motion, and the stresses across the human elbow, particularly a posttraumatic elbow, in a live subject cannot be completely replicated in the laboratory setting [49]. Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most terrible triad injuries [125]. The modified surgical strategy provides both bony and soft-tissue stability simultaneously, allowing active early motion and functional recovery of the elbow with good to excellent outcomes and minimal complications [10]. Use of the surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome [8]. Despite the complexities of this injury, an understanding of the relevant anatomy and the factors associated with elbow stability allows the application of a systematic algorithm for treatment that can help ensure sufficient elbow stability to allow early motion, thereby leading to improved outcomes in most patients [20]. It is important to reconstruct the anterior capsule and ligamentous structures for providing stability to the elbow joint [31]. It allows stable and anatomic internal fixation even of small bony fragments in the setting of various traumatic elbow instability patterns [19].

The most common causes of lesions at the elbow involving great loss of substance include traumatic gunshot wounds, agricultural and industrial injuries, and road accidents [36]. As patients with traumatic losses of substance at the elbow have generally suffered from high-energy traumas, the first priority upon arrival in the emergency department is to stabilise the patient according to Advanced Trauma Life Support (ATLS) [36]. The initial assessment must first determine any vascularisation problem distal to the lesion, then the extent and contamination of the wound is evaluated [36].

Special Populations and Specific Conditions

Soft tissue reconstruction can be a viable option to manage elbow instability in EDS patients with bone deformities when an allograft cannot be employed, ensuring significant improvement in joint function and quality of life [123]. The article reviews current concepts of injuries leading to elbow instability in children, discusses recognition and treatment of instability, and addresses nontraumatic causes [57]. At 12 months of follow-up, the patient’s function was evaluated according to the Mayo Elbow Protocol, achieving a maximal score of 100 points in a case of anterior elbow dislocation with potential compartment syndrome [59]. Postoperative complications including synostosis and elbow instability may not be as common as previously understood in the context of the Boyd approach [58]. The study demonstrated significant improvements in Mayo Elbow performance score and range of motion, although some patients experienced new-onset nerve symptoms or instability in a trial for MCL reconstruction [124].

Investigations

Physical Examination and Stability Assessment

Elbow stability relies on primary stabilizers, including the ulnohumeral articulation, medial ulnar collateral ligament, and lateral ulnar collateral ligament complex, as well as secondary stabilizers such as the radiocapitellar articulation, common flexor and extensor tendons, and joint capsule [40]. The physical examination is directed by the patient's history and the specific location of pain in the anterior, posterior, medial, or lateral aspect of the elbow [40]. Active and passive flexion, extension, supination, and pronation must be evaluated using a goniometer for accurate measurement [84]. If the elbow demonstrates less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and requires release to restore full flexion [84]. Following reduction of dislocations, the elbow is tested for stability to varus and valgus stress, as well as pronation and supination [90]. An assessment for ulnar nerve subluxation is mandatory, as subluxation constitutes a relative contraindication for arthroscopic procedures due to the risk of iatrogenic nerve injury [84]. Electromyography and nerve conduction velocity studies are indicated if there is any question regarding neurologic dysfunction [84].

Radiographic Imaging

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [40] and serve as the primary imaging modality for most elbow trauma [167]. Standard views include AP, lateral, and oblique radiographs, with serial radiography used for follow-up when heterotopic ossification is present [84]. Primary bony landmarks identified on these images include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [84]. Postreduction radiographs are necessary to rule out occult fractures following elbow dislocation reduction [90]. The coronoid opening angle is a novel radiographic technique that provides value alongside 3-dimensional imaging in evaluating elbow injuries and serves as an adjunct in clinical decision making [172].

Computed Tomography (CT)

CT: CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [84]. Three-dimensional CT is specifically used to check for heterotopic ossification [84]. CT is not necessary when stiffness is entirely soft-tissue related, but is beneficial if any joint incongruity or abnormal bony anatomy is present [84]. In the context of elbow trauma, CT and MRI are reserved for complex injuries or soft tissue assessment [167]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [87].

Magnetic Resonance Imaging (MRI)

MRI: MRI has become the imaging study of choice to evaluate the complex normal and injured anatomy of the elbow owing to its superior soft tissue resolution [56]. It is a highly valuable tool in the evaluation of ligamentous injuries to the elbow [158]. While MRI can be used to evaluate ligaments and tendons, it is rarely indicated for elbow stiffness [84]. Magnetic resonance imaging is not reliable for diagnosing lateral ulnar collateral ligament injuries at the present time because an intact ligament often does not appear as a distinct structure and generates artifacts that can be confused with rupture [168]. MRI may be most helpful in evaluating associated injuries, including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [87]. Interobserver and intraobserver agreement of ligamentous injuries on conventional MRI after simple elbow dislocation suggests the need for new MRI quality standards with special focus on coronal oblique reconstructions to improve the evaluation of ligament injuries [145]. MR evaluation of instability patterns, including the soft-tissue lesions that result from dislocation, are emphasized in the assessment of simple elbow dislocations [42]. MRI-based classification systems for injuries to the ulnar collateral ligament illustrate UCL injury patterns [42].

Treatment

Non-Operative

The provided evidence base does not detail specific conservative management protocols such as weight loss, physical therapy regimens, or pharmacological interventions. Surgical intervention is presented as the primary strategy for restoring function and stability in the context of ligamentous injury and instability.

Operative

Indications: Surgical ligament reconstruction or repair is the most favorable treatment option for the restoration of normal elbow function [6]. An understanding of relevant anatomy and stability factors allows for a systematic treatment algorithm that ensures sufficient elbow stability for early motion, leading to improved outcomes in most patients [20]. Strict application of current algorithms by an expert elbow surgeon improves clinical results by reducing avoidable negative prognostic factors, including incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization, and surgeon inexperience [151].

Surgical Approach / Technique: A standardised surgical protocol that restores the integrity of the elbow by repairing all structures yields the best results and prognosis by restoring stability [2]. In the treatment of terrible triad injuries, operations are performed to repair injured structures from deep to superficial, aiming to restore bony anatomy and soft tissue stability to allow early mobilization [134]. Fixing the radial head and/or the lateral collateral ligament prior to repair of the coronoid or anterior capsule eliminates exposure of the coronoid and makes repair impossible without a separate medial approach [141]. A medial approach alone is insufficient to restore stability in the setting of elbow dislocations with radial head and coronoid fractures [141]. An anterior approach for operative fixation of coronoid fractures allows stable and anatomic internal fixation even of small bony fragments in various traumatic elbow instability patterns [19]. In patients with neglected intraarticular entrapment of the medial epicondyle after dislocation, surgical reconstruction of the anterior oblique ligament is essential to prevent the development of elbow instability [9].

Implant Selection: The radial head functions as a secondary stabilizer resisting both valgus and posterolateral instability of the elbow and proximal migration of the radius [144]. Resecting the radial head alone without replacement is a pitfall because the radial head is a critical secondary stabilizer of the elbow in this situation [141]. Replacement of the radial head with a rigid implant seems to restore stability better than does replacement with a floating prosthesis [136].

Lateral Ligament Reconstruction: Open posterolateral ligament plication and lateral ulnar collateral ligament (LUCL) repair using an all-suture construct allows for complete posterolateral stabilization of the elbow with a single implant and bone preservation [3]. All reconstruction methods for the LUCL were able to sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion [11]. An arthroscopic technique for LUCL reconstruction is reproducible and achieves the reconstruction of the LUCL as well as avoids residual instability [12]. A suture-augmented LUCL and radial collateral ligament reconstruction provides a reproducible, anatomically based construct that restores posterolateral elbow stability and addresses the complex spectrum of lateral-sided injuries observed in posterolateral rotatory instability [13]. Improving arthroscopic techniques provide a satisfactory alternative in stabilizing the elbow [52]. A minimally invasive method for managing elbow instability allows effective management while promoting quicker patient recovery and long-term functional restoration [26]. A knotless, onlay technique for LUCL reconstruction performs a reconstruction with a tendon graft without violation of the extensor origin and soft tissue envelop, which could, in theory, allow an early mobilization and return to activity [155]. The use of knotless anchors and an onlay technique for LUCL reconstruction shortens operative time, reduces the required surgical exposure, and removes the risk of tunnel osteolysis or fracture and resultant graft failure while maintaining a broad bone surface for graft incorporation [155]. A minimally-invasive dissection for LUCL reconstruction prevents iatrogenic injury to the common extensor origin, an important secondary stabilizer of the lateral elbow, and the articular capsule, allowing for earlier rehabilitation and return of range of motion, reduced postoperative pain, and reduced operative time [155]. By remaining extracapsular with a minimally invasive LUCL reconstruction technique, there is no plication of the capsular structures or risk of formation of intra-articular adhesions, theoretically reducing the risk of any postoperative loss of range of motion [155]. An anconeus-sparing minimally invasive approach for LUCL reconstruction allows accurate graft placement and fixation with maximal protection of the active elbow stabilizers like the common extensor tendons and the anconeus muscle [166]. The docking technique for LUCL reconstruction has shown recurrent instability rates as high as 25% [155]. Results were worse in patients who had previously undergone an operation to stabilize the elbow laterally [25].

Medial Ligament Reconstruction: Ulnar collateral ligament (UCL) reconstruction using a suspension button fixation technique reliably restored elbow kinematics to the intact state [21]. Both the proximal docking and the single-point fixation hybrid reconstructions for UCL provided sufficient joint stability and strength compared to the intact elbows, with the exception of the proximal docking method at low flexion angles [37]. UCL reconstruction with docking technique and repair augmented with internal bracing provides valgus stability to the medial elbow comparable to the native ligament at 90 degrees [38]. A knotless, minimally invasive onlay UCL reconstruction aims to restore the native fan-shaped configuration of the UCL while preserving the integrity of the medial epicondyle and its musculotendinous attachments [142]. The medial epicondyle provides essential valgus and rotational control between 30° and 90° of flexion [142]. Even partial detachment or devascularization of the medial epicondyle significantly compromises the equilibrium between static and dynamic stabilizers, leading to increased posteromedial joint pressures, valgus laxity, and a higher risk of subluxation, osteophyte formation, and progressive arthrosis [142]. Gracilis or palmaris grafts are preferred choices for ligament reconstruction in UCL docking techniques [143]. If ulnar neuropathy or ulnar nerve instability is present prior to UCL reconstruction, the preferred method of transposition is subcutaneous transposition [143].

Augmentation and Adjunctive Techniques: Ligament repair with suture tape internal brace augmentation for traumatic elbow instability achieves favorable outcomes in both acute and chronic presentations [35]. Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion [60]. Treatment of recurrent elbow instability with collateral ligament reconstruction and a temporary hinged internal fixator may be a viable surgical option to achieve stability, restore function, and preserve quality of life [7]. The internal joint stabilizer is a safe and effective implant that complements the management of chronic elbow dislocations [66]. The most common indications for hinged external fixation of the elbow are acute or chronic instability of the elbow after trauma, distraction interposition arthroplasty, or use after contracture release or excision of heterotopic ossification [126]. In the setting of acute trauma, any fractures are initially addressed, and then ligaments are repaired or reconstructed [63]. Capsular and bony release combined with bone and ligamentous reconstruction is undertaken in patients with a chronic elbow disease [63]. Elbow stability is assessed throughout the range of motion, and residual instability is considered as indication for a temporary stabilization with an internal joint stabilizer [63]. The likely need of temporary and additional stabilization with an internal joint stabilizer is generally considered at the beginning of surgery since the centre of rotation on the lateral capitellum should be left free for the axis pin rather than for an anchor for the lateral ulnar collateral ligament [63]. A 1.5-mm Kirschner (K) wire is placed on the axis of ulnohumeral rotation of distal humerus when an internal joint stabilizer is supposed to be used [63]. Once the isometric point on the lateral epicondyle is defined visually and with the help of a centreing guide, the correct axis of rotation is easily reached with a specific aiming guide [63]. This aiming guide allows the connection of the isometric point to another medial point on the trochlear notch [63]. For the most accurate axis recreation, the axis guide must engage as medial as possible the medial trochlear notch [63].

Outcomes and Complications: Outcomes after treatment of acute complex elbow instability with hinged external fixation are comparable to those of similar series [33]. Flexion-extension arcs averaged 93°, whereas pronation-supination arcs averaged 96° in patients treated with hinged external fixation for acute complex instability [33]. Posttraumatic arthrosis was commonly seen at follow-up, with moderate or severe changes developing in 55% of patients treated with hinged external fixation [33]. Arthrosis did not correlate with functional outcomes in patients treated with hinged external fixation for acute complex instability [33]. Mean scores for the Mayo Elbow Performance Index and the Hospital for Special Surgery Total Elbow Scoring System were 75 and 71 points, respectively, in patients treated with hinged external fixation [33]. The goal of treatment for post-traumatic osteoarthritis of the elbow is to obtain a low level of pain with sufficient motion range to ensure good function, while preserving future surgical options and delaying elbow arthroplasty to the extent possible [169]. The main complications of UCL reconstruction include joint stiffness, arthrofibrosis requiring manipulation under anesthesia, graft failure, ulnar neuropathy, and loss of strength or range of motion [142]. Prolonged immobilization (more than three weeks) following surgical repair may produce a reasonable radiograph but usually produces a very stiff elbow that requires further surgical intervention [141].

Complications

Nerve palsy: Ulnar nerve injury is the most frequent complication following ulnar collateral ligament (UCL) reconstruction, with a mean postoperative rate of 12.0% [163]. Transient ulnar neuritis is the most common specific nerve-related issue [193], while ulnar nerve paresthesia or neuropraxia occurs in 8% to 74% of patients [159]. In a series of 164 UCL reconstructions, nerve injury or palsy represented 56.25% of all reported complications, contributing to a cumulative surgeon-reported complication rate of 9.8% [99]. Reoperation for ulnar nerve neuropathy is required in 0.8% of patients [163]. In lateral collateral ligament repair, one patient in a series of 34 required ulnar nerve transposition for persistent neuritis [161]. Ulnar neuropathy was noted in 10% of patients treated with an internal joint stabilizer [135] and in 15.2% of cases treated with a hinged external fixator, all of which resolved with conservative management [154]. The incidence of neurologic complications associated with complex elbow fracture treatment may be underestimated in the literature [184].

Instability: Revision UCL reconstruction yields poorer outcomes and higher complication rates than the index procedure [193]. The revision rate for allograft reconstruction appears greater than for autograft, though this may reflect limited allograft literature [187]. The need for revision UCL reconstruction occurs in 1% to 15% of patients [159]. Allograft reconstruction restores stability in approximately 85% of elbows with posterolateral rotatory instability [18]. LUCL reconstruction for chronic posterolateral rotatory instability has a moderate rate of recurrent instability, which is highest in revision cases [104]. In a series of 34 lateral collateral ligament repairs, 5.9% developed symptomatic failure requiring revision [161]. Recurrent posterolateral rotatory instability occurred in 25% of patients treated with partial radial head allograft, requiring reoperation [133]. In a series of 32 patients treated without medial collateral ligament repair, 6.25% experienced complications related to postoperative instability associated with noncompliance [152]. Moderate elbow instability was present in 6.5% of patients at hinged external fixator removal, though all regained stability by final follow-up [154].

Stiffness / Arthrofibrosis: In terrible triad injuries, 21% underwent reoperation for stiffness, alone or in combination with another indication [128], and 10% underwent concurrent reoperation for stiffness and ulnar nerve symptoms [128]. In a series of 46 severely stiff elbows treated with ligament repair and a hinged external fixator, the mean flexion arc improved from 25° to 126° [154]. Postoperative Mayo Elbow Performance Scores in this series were 91 points compared to 63 points preoperatively [154]. In a series of 18 patients undergoing lateral elbow ligamentoplasty, flexion-extension arcs at a mean 5 years' follow-up ranged from 0–140° to 20–130° [100]. In a series of 20 patients with acute complex elbow instability treated with hinged external fixation, mean flexion-extension arcs were 93° and pronation-supination arcs were 96° [33].

Wound complications: Superficial surgical-site infection from the graft harvest site occurs in 4% of patients following UCL reconstruction [159]. In a series of 8 patients treated with partial radial head allograft, one patient (12.5%) had a superficial wound breakdown that healed by secondary intention [133]. In a series of 34 lateral collateral ligament repairs, one patient in the delayed group developed a wound breakdown requiring a radial forearm flap [161].

Infection: In a series of 8 patients treated with partial radial head allograft, one patient (12.5%) developed a deep infection 6 weeks after surgery, which was treated by debridement and latissimus dorsi flap [133].

Other Considerations: Graft site morbidity occurs in 1% of patients after ulnar or lateral collateral ligament reconstruction [93]. Graft failure occurs in 1% of patients following UCL reconstruction [159]. The rate of reported reoperation, excluding revision UCL reconstruction, due to complications approaches 5%, most commonly due to excision of heterotopic ossification [159]. In a series of 20 patients treated with an internal joint stabilizer, the overall complication rate was 50% [135]. Implant-related complications occurred in 20% of these patients, including loosening of the axial pin and radiolucent lines [135]. Non-implant complications occurred in 40%, including heterotopic ossification (20%), seroma (10%), and ulnar neuropathy (10%) [135]. The use of an internal joint stabilizer is weighed against a 17% rate of removal at early follow-up [177]. In a series of 8 patients treated with partial radial head allograft, coronoid nonunion and resorption developed in 37.5% of patients [133], and 75% required further surgery [133]. In a series of 20 patients with acute complex elbow instability treated with hinged external fixation, posttraumatic arthrosis developed in 55% of patients, though arthrosis did not correlate with functional outcomes [33]. Mean Mayo Elbow Performance Index scores were 75 and Hospital for Special Surgery Total Elbow Scoring System scores were 71 [33]. The mechanism of injury was typically a fall or a motor vehicle accident [33]. Fixators were placed at a mean of 26 days (range, 0-66 days) after injury [33]. Patients who presented greater than 6 months after the original injury were excluded [33]. All patients were available for follow-up at a mean of 2.1 years [33]. Reconstruction of the collateral ligaments was not performed, but soft tissues were repaired en bloc to the humerus [33]. The outcomes were comparable to those of similar series despite the severity of injury often precluding high percentages of good and excellent results [33].

Recovery

Light activity (weeks): The evidence provided does not specify a distinct timeline or week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): Following ulnar collateral ligament repairs and reconstructions, elbow range of motion is reliably preserved or improved with a predictable trajectory of rapid improvement within the first 2 to 4 months [15].

Complete recovery / outcome plateau (months): Ulnar collateral ligament reconstruction based on a hybrid fixation technique allows full recovery to preinjury level of performance in the majority (85%) of patients [67].

Rehabilitation protocol: An internal joint stabilizer with a standardized treatment protocol maintains concentric reduction while allowing early functional motion [34]. Internal bracing may provide the additional stability necessary to accelerate rehabilitation following ulnar collateral ligament reconstruction [127]. A standardised surgical protocol that restores the integrity of the elbow by repairing all structures gives the best results and prognosis by restoration of elbow stability [2]. An understanding of relevant anatomy and factors associated with elbow stability allows the application of a systematic algorithm for treatment that can help ensure sufficient elbow stability to allow early motion, thereby leading to improved outcomes in most patients [20].

Functional milestones: At 12 months of follow-up, the patient’s function was evaluated according to the Mayo Elbow Protocol, achieving a maximal score of 100 points [59]. Ligament repair and reconstruction is an effective way of stabilizing the elbow joint in chronic instability patients, resulting in an improvement in their overall range of motion [24]. Excellent elbow function and return-to-sport mid-term outcomes were found in a large cohort of both ulnar collateral ligament repairs with internal brace and ulnar collateral ligament reconstructions [140]. Satisfactory outcomes were obtained with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow [176].

Other Considerations: Surgical management of elbow dislocations is indicated when the elbow remains unstable, with the lateral ulnar collateral ligament being the most critical structure to repair or reconstruct [4]. Females demonstrated favorable clinical outcomes at a mean follow-up of 6 years, with a majority of elbows returning to a preinjury level of function and sport, regardless of whether they underwent primary or revision surgery [129]. Decisions for ulnar collateral ligament reconstructions and appropriate counseling of patients regarding the likelihood of success currently remain an individual process due to the difficulties in defining and assessing return to play and performance [156]. Further investigation is necessary to determine long-term outcomes for return to play after ulnar collateral ligament reconstruction of the elbow in adolescent throwing athletes [157]. Further follow-up and wider experience of the technique is required to assess its long-term functional outcome in comparison with more established surgical techniques for stabilization of posterolateral elbow instability [14]. The available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation [27].

Key Evidence

• [L5] This novel ligament reconstruction maintained secure fixation between ligament and bone and allowed for maintenance of static stability at different degrees of elbow flexion. [1] (10.1016/j.jhsg.2023.02.003)
• [L4] They must restore the integrity of the elbow repairing all structures, using a standardised surgical protocol, which gives the best results and prognosis by restoration of the elbow stability. [2] (10.1016/s0020-1383(15)70004-5)
• [L5] The technique allows for complete posterolateral stabilization of the elbow with a single implant and bone preservation. [3] (10.1016/j.eats.2024.103172)
• [L5] Surgical management is indicated when the elbow remains unstable, with the lateral ulnar collateral ligament being the most critical structure to repair or reconstruct. [4] (10.1016/j.hcl.2016.08.003)
• [L3] It is important to determine which structures need to be repaired to avoid complications that could lead to elbow instability. [5] (10.1016/j.jse.2019.07.006)
• [L4] Surgical ligament reconstruction or repair is the most favorable treatment option for restoration of normal elbow function. [6] (10.1016/s1058-2746(03)00091-0)
• [L5] Treatment of recurrent elbow instability with collateral ligament reconstruction and a temporary hinged internal fixator may be a viable surgical option to achieve stability, restore function, and preserve quality of life. [7] (10.2106/jbjs.cc.19.00355)
• [L4] Use of the surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. [8] (10.2106/jbjs.d.02933)
• [L5] In such patients, surgical reconstruction of the anterior oblique ligament is essential to prevent the possibility of development of instability of the elbow. [9] (10.1016/s1058-2746(09)80077-3)
• [L4] The modified surgical strategy provides both bony and soft-tissue stability simultaneously, allowing active early motion and functional recovery of the elbow with good to excellent outcomes and minimal complications. [10] (10.1016/j.injury.2013.12.012)
• [L5] All reconstruction methods were able to sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion. [11] (10.1007/s00167-015-3627-3)
• [L5] The presented arthroscopic technique is reproducible and achieves the reconstruction of the LUCL of the elbow as well as avoids residual instability. [12] (10.1016/j.eats.2024.103096)
• [L5] The described method provides a reproducible, anatomically based construct that restores posterolateral elbow stability and addresses the complex spectrum of lateral-sided injuries observed in PLRI. [13] (10.1016/j.eats.2025.103797)
• [L4] Further follow-up and wider experience of the technique is required to assess its long-term functional outcome in comparison with more established surgical techniques for stabilization of posterolateral elbow instability. [14] (10.1097/bte.0000000000000025)
• [L4] Following UCL repairs and reconstructions, elbow ROM is reliably preserved or improved with a predictable trajectory of rapid improvement within the first 2 to four months. [15] (10.1016/j.jse.2025.10.002)
• [L5] Cadaveric elbow specimens maintained secure fixation between ligament and bone following hemiarthroplasty and ligament reconstruction, with static stability maintained at varying degrees of elbow flexion regardless of variable mismatch between the hemiarthroplasty component and the native olecranon fossa. [16] (10.1016/j.jse.2023.07.037)
• [L5] Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability. [17] (10.5435/00124635-200605000-00003)
• [Abstract] Allograft reconstruction restores elbow stability in approximately 85% of the elbows with PLRI. [18] (10.1016/j.jse.2014.06.015)
• [L4] It allows stable and anatomic internal fixation even of small bony fragments in the setting of various traumatic elbow instability patterns. [19] (10.1097/bth.0b013e31824e6a74)
• [L5] Despite the complexities of this injury, an understanding of the relevant anatomy and the factors associated with elbow stability allows the application of a systematic algorithm for treatment that can help ensure sufficient elbow stability to allow early motion, thereby leading to improved outcomes in most patients. [20] (10.5435/00124635-200903000-00003)
• [L5] Ulnar collateral ligament reconstruction using a suspension button fixation technique reliably restored elbow kinematics to the intact state. [21] (10.1177/0363546509350109)
• [L5] The goal of treatment is to achieve stable fixation of the appropriate ligamentous and bony structures to obtain a stable, functional, and pain-free elbow. [22] (10.1016/j.hcl.2020.07.011)
• [L5] Surgery is indicated for unstable elbows requiring flexion beyond 50 to 60 degrees to remain reduced or for unstable periarticular fractures. [23] (10.5435/00124635-199801000-00002)
• [L4] It is an effective way of stabilizing the elbow joint in chronic instability patients, and results in an improvement in their overall range of motion. [24] (10.1016/j.jseint.2024.02.013)
• [L4] The results were worse in patients who had previously undergone an operation to stabilize the elbow laterally. [25] (10.2106/00004623-199274080-00014)
• [L5] This minimally invasive method allows effective management of elbow instability while promoting quicker patient recovery and long-term functional restoration. [26] (10.1016/j.eats.2025.103529)
• [L4] However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation. [27] (10.1016/j.jse.2018.07.029)
• [L5] Understanding the patterns of traumatic elbow instability helps the surgeon counsel and manage patients with these injuries. [28] (10.1016/j.jhsa.2010.05.002)
• [L5] This case illustrates that sometimes ligaments of the elbow may not heal or tighten sufficiently over time and that despite a careful examination elbow and forearm stability, removal of a radial head prosthesis may give rise to problems, even up to 5 years after prosthetic removal. [29] (10.1016/j.jse.2010.04.046)
• [L4] Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. [30] (10.1016/j.jseint.2022.12.009)
• [L4] It is important to reconstruct the anterior capsule and ligamentous structures for providing stability to the elbow joint. [31] (10.1007/s00402-006-0198-2)
• [L4] A stable, functional elbow can be restored in most patients with persistent instability after fracture-dislocation of the elbow using a treatment protocol incorporating hinged external fixation. [32] (10.1016/j.jhsa.2004.01.005)
• [L4] [33] (10.1016/j.jse.2006.01.008)
• [L4] An internal joint stabilizer with a standardized treatment protocol could maintain concentric reduction while allowing early functional motion and improve clinical outcomes for patients with complex persistent elbow instability. [34] (10.1097/corr.0000000000002159)
• [L3] Ligament repair with suture tape internal brace augmentation for traumatic elbow instability achieves favorable outcomes in both acute and chronic presentations. [35] (10.1016/j.jse.2025.11.011)
• [L4] [36] (10.1016/j.injury.2013.09.029)
• [L5] Both the proximal docking and the single-point fixation hybrid reconstructions provided sufficient joint stability and strength compared to the intact elbows, with the exception of the proximal docking method at low flexion angles. [37] (10.1016/j.jhsa.2014.07.040)
• [L5] UCL reconstruction with docking technique and repair augmented with internal bracing provides valgus stability to the medial elbow comparable to the native ligament at 90 degrees. [38] (10.1177/0363546518803771)
• [L4] [46] (10.1007/s11999-014-3611-0)
• [L4] [47] (10.1007/s12306-014-0325-0)
• [L4] [49] (10.1007/s11999-014-3471-7)
• [L5] Elbow dislocations can result in extensive injury to the supporting structures of the elbow joint. [51] (10.1016/s0278-5919(05)70247-7)
• [L5] Improving arthroscopic techniques provide a satisfactory alternative in stabilizing the elbow. [52] (10.1016/s0278-5919(05)70246-5)
• [L5] Complex elbow instability remains a challenging clinical entity requiring a balance between stability, mobility, and concentric reduction; further research, particularly multicenter prospective trials, is needed due to the rare nature of these injuries. [53] (10.1016/j.hcl.2007.11.010)
• [L4] [54] (10.5435/jaaos-d-14-00460)
• [Paper] MRI has become the imaging study of choice to evaluate the complex normal and injured anatomy of the elbow owing to its superior soft tissue resolution. [56] (10.1197/j.jht.2006.02.007)
• [L5] The article reviews current concepts of injuries leading to elbow instability in children, discusses recognition and treatment of instability, and addresses nontraumatic causes. [57] (10.1016/j.hcl.2007.11.007)
• [L4] Postoperative complications including synostosis and elbow instability may not be as common as previously understood. [58] (10.1016/j.jse.2023.06.005)
• [L5] At 12 months of follow-up, the patient’s function was evaluated according to the Mayo Elbow Protocol, achieving a maximal score of 100 points. [59] (10.1097/bth.0b013e31802dcbf0)
• [L4] Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion. [60] (10.1007/s00167-019-05402-9)
• [L4] For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures. [62] (10.1016/j.jhsa.2022.10.016)
• [L5] [63] (10.1016/j.jisako.2024.03.003)
• [L4] The internal joint stabilizer is a safe and effective implant that complements the management of chronic elbow dislocations. [66] (10.1016/j.xrrt.2022.02.001)
• [L4] Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate and allows full recovery to preinjury level of performance in the majority (85%) of patients. [67] (10.1177/0363546510385401)
• [L4] Graft site morbidity occurred in 1% of the patients after an ulnar or lateral collateral ligament reconstruction procedure. [93] (10.1177/0363546517693836)
• [L4] [96] (10.2106/jbjs.l.00623)
• [L4] [99] (10.5435/jaaos-d-16-00102)
• [L4] [100] (10.1016/j.otsr.2015.03.006)
• [Paper] LUCL reconstruction for chronic PLRI proved a reliable method of reconstruction, save for the moderate rate of recurrent instability, which was highest in revision reconstructions. [104] (10.1177/0363546520927412)
• [L4] [105] (10.1016/j.jisako.2025.100449)
• [L5] [108] (10.1007/s11999-017-5384-8)
• [Paper] [109] (10.1016/j.csm.2016.05.004)
• [L4] The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. [110] (10.1016/j.jse.2019.11.021)
• [L5] Disruptions in any of these structures may lead to forearm instability with consequences at the remaining structures. [116] (10.1016/j.jhsa.2016.10.017)
• [L5] Differential diagnosis of lateral elbow instability in patients presenting with tennis elbow should be considered. [119] (10.1016/j.main.2007.05.002)
• [L3] The authors created a comprehensive classification of complex fracture-dislocations of the elbow that appeared to be reproducible and may represent a useful tool for the management of such difficult injuries. [120] (10.1016/j.jse.2011.06.003)
• [Case_report] Soft tissue reconstruction can be a viable option to manage elbow instability in EDS patients with bone deformities when an allograft cannot be employed, ensuring significant improvement in joint function and quality of life. [123] (10.1016/j.xrrt.2024.11.001)
• [L4] The study demonstrated significant improvements in Mayo Elbow performance score and range of motion, although some patients experienced new-onset nerve symptoms or instability. [124] (10.1016/j.eclinm.2022.101616)
• [L3] Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most terrible triad injuries. [125] (10.1302/0301-620x.102b12.bjj-2020-0762.r1)
• [L5] The most common indications are acute or chronic instability of the elbow after trauma, distraction interposition arthroplasty, or use after contracture release or excision of heterotopic ossification. [126] (10.1016/j.hcl.2010.04.004)
• [L5] Internal bracing may provide the additional stability necessary to accelerate rehabilitation following ulnar collateral ligament reconstruction. [127] (10.1177/2325967121s00199)
• [L3] [128] (10.1097/corr.0000000000001391)
• [L4] Females demonstrated favorable clinical outcomes at a mean follow-up of 6 years, with a majority of elbows returning to a preinjury level of function and sport, regardless of whether they underwent primary or revision surgery. [129] (10.1016/j.jse.2025.08.025)
• [L4] [133] (10.1016/j.jse.2011.07.003)
• [L3] [134] (10.1016/j.jse.2012.03.005)
• [L4] [135] (10.1016/j.xrrt.2024.03.008)
• [L5] Replacement of the radial head with a rigid implant seems to restore stability better than does replacement with a floating prosthesis. [136] (10.2106/00004623-200405000-00013)
• [L3] In the current study, we found excellent elbow function and return-to-sport mid-term outcomes in a large cohort of both UCL repairs with internal brace and UCL reconstructions. [140] (10.1177/2325967124s00033)
• [L4] [141] (10.2106/00004623-200406000-00002)
• [Paper] [142] (10.1002/atn2.70114)
• [L4] [143] (10.1016/j.jse.2010.01.005)
• [L5] [144] (10.1016/j.jhsa.2009.01.027)
• [L4] This should be the basis to develop new MRI quality standards with special focus on coronal oblique reconstructions to improve the evaluation of ligament injuries after simple elbow dislocations. [145] (10.1186/s12891-017-1451-2)
• [L4] [146] (10.1016/j.injury.2014.10.024)
• [L5] [148] (10.1016/j.hcl.2015.06.006)
• [L5] [149] (10.1016/j.otsr.2018.05.016)
• [L4] On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon’s inexperience. [151] (10.1016/s0020-1383(15)30058-9)
• [L4] [152] (10.1016/j.jhsa.2007.06.019)
• [L4] [154] (10.1016/j.jse.2014.03.013)
• [L5] [155] (10.1002/atn2.70135)
• [L5] Decisions for UCL reconstructions and appropriate counseling of patients regarding the likelihood of success currently remain an individual process due to the difficulties in defining and assessing return to play and performance. [156] (10.1016/j.arthro.2024.04.001)
• [L4] Further investigation is necessary to determine long-term outcomes for return to play after UCL reconstruction of the elbow in adolescent throwing athletes. [157] (10.1177/0363546520934778)
• [L5] MR imaging is a highly valuable tool in the evaluation of ligamentous injuries to the elbow. [158] (10.1016/j.mric.2004.02.006)
• [L4] [159] (10.1016/j.asmr.2024.100893)
• [L3] [161] (10.1016/j.jhsa.2014.02.011)
• [L2] [163] (10.1177/0363546518765139)
• [Paper] This technique allows accurate graft placement and fixation with maximal protection of the active elbow stabilizers like the common extensor tendons and the anconeus muscle. [166] (10.1016/j.eats.2019.10.013)
• [L5] Plain radiographs are the primary imaging modality for most elbow trauma, while CT and MRI are reserved for complex injuries or soft tissue assessment. [167] (10.1016/j.hcl.2004.06.008)
• [L4] Magnetic resonance imaging is not reliable for diagnosing lateral ulnar collateral ligament injuries at the present time because an intact ligament often does not appear as a distinct structure and generates artifacts that can be confused with rupture. [168] (10.1016/j.jse.2003.12.013)
• [L4] The goal of treatment is to obtain a low level of pain with sufficient motion range to ensure good function, while preserving future surgical options and delaying elbow arthroplasty to the extent possible. [169] (10.1016/j.otsr.2013.11.004)
• [L4] It can be of value alongside 3-dimensional imaging in evaluating elbow injuries and used as an adjunct in clinical decision making. [172] (10.1016/j.jse.2021.12.039)
• [L4] We obtained satisfactory outcomes with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow. [176] (10.1016/j.jse.2013.06.018)
• [L3] However, its use is weighed against a 17% rate of removal at early follow up and possibly inferior forearm rotation. [177] (10.1177/17585732221088290)
• [L4] The incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. [184] (10.1016/j.jse.2020.01.086)
• [L4] The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature. [187] (10.1016/j.jse.2023.10.023)
• [L5] The most common complication following UCL reconstruction is transient ulnar neuritis, and revision UCL reconstruction has poorer outcomes with a higher complication rate when compared with the index procedure. [193] (10.1016/j.csm.2020.02.003)

See Also

• Elbow Instability
• Tennis Elbow
• Ligament Injuries
• Elbow Arthroplasty

References

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[2] Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases. Injury. 2015. DOI: 10.1016/s0020-1383(15)70004-5

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[5] Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.006

[6] Surgical reconstruction for posterolateral rotatory instability of the elbow. Journal of Shoulder and Elbow Surgery. 2003. DOI: 10.1016/s1058-2746(03)00091-0

[7] Stabilization of Recurrent Elbow Instability in a Patient with Ehlers-Danlos Syndrome. JBJS Case Connector. 2019. DOI: 10.2106/jbjs.cc.19.00355

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[9] Neglected intraarticular entrapment of the medial epicondyle after dislocation of the elbow. Journal of Shoulder and Elbow Surgery. 1994. DOI: 10.1016/s1058-2746(09)80077-3

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[15] Elbow range of motion is stable or improves following ulnar collateral ligament repairs and reconstructions. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.10.002

[16] Static stability of novel uncemented elbow hemiarthroplasty stabilized with ligament reconstruction. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.037

[17] Complex Elbow Instability. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200605000-00003

[18] Allograft Ligament Reconstruction for Post-Traumatic Elbow Posterolateral Rotatory Instability: A Mid-Term Follow-Up Study. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.015

[19] Anterior Approach for Operative Fixation of Coronoid Fractures in Complex Elbow Instability. Techniques in Hand & Upper Extremity Surgery. 2012. DOI: 10.1097/bth.0b013e31824e6a74

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[21] Revision Ulnar Collateral Ligament Reconstruction Using a Suspension Button Fixation Technique. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509350109

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[23] Acute Elbow Dislocation: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199801000-00002

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[25] Ligamentous reconstruction for posterolateral rotatory instability of the elbow.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274080-00014

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