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Posterolateral Rotatory Instability Develops Following the Modified Kocher Approach and Does Not Resolve Following

Stephen D Daniels1, Thomas J France1, Kacy J Peek2

  • 1Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, Colorado.

The Journal of Bone and Joint Surgery. American Volume
|August 24, 2023
PubMed
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The Kocher approach for lateral elbow surgery causes posterolateral rotatory instability (PLRI) that persists after repair. The extensor digitorum communis (EDC)-splitting approach is a safer alternative for lateral elbow procedures.

Area of Science:

  • Orthopedic Surgery
  • Anatomy
  • Biomechanical Engineering

Background:

  • Lateral elbow approaches, including the Kocher and extensor digitorum communis (EDC)-splitting intervals, are standard surgical techniques.
  • Iatrogenic injury to the lateral ulnar collateral ligament during these approaches can lead to posterolateral rotatory instability (PLRI).

Purpose of the Study:

  • To evaluate lateral elbow stability after utilizing Kocher and EDC-splitting surgical approaches in cadavers.
  • To assess the diagnostic accuracy of static lateral elbow radiographs for detecting PLRI.

Main Methods:

  • Ten matched-pair cadaveric upper extremities were dissected using either the Kocher or EDC-splitting approach.
  • Lateral elbow stability was assessed using the pivot-shift maneuver pre- and post-dissection and repair.

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  • Radiographic evaluation of radiocapitellar displacement was performed using the hanging arm test and 30° flexion lateral radiographs.

    • Main Results:

    • All specimens (10/10) undergoing the Kocher approach developed PLRI post-dissection, which persisted after repair.
    • No specimens (0/10) in the EDC-splitting group exhibited instability.
    • The hanging arm test did not reliably detect radiocapitellar displacement, while 30° flexion radiographs showed significant displacement in the Kocher group post-repair.

    Conclusions:

    • The Kocher approach for lateral elbow exposure results in iatrogenic PLRI that does not resolve after surgical repair.
    • The EDC-splitting approach is a stable alternative, causing neither clinical nor radiographic instability.
    • Static lateral elbow radiographs, particularly the hanging arm test, are unreliable for diagnosing PLRI.