Polymethyl Methacrylate for Elbow Arthroplasty: Is There Another Way?

Polymethyl methacrylate remains the only US Food and Drug Administration-approved method of total elbow arthroplasty fixation and exhibits high aseptic loosening rates that result in challenging revision surgeries and potential morbidity secondary to bone-cement implantation syndrome. In this policy paper, the authors aim to explore the historical background of polymethyl methacrylate and the complications that arise in association with its use. We will review arthroplasty trends in the elbow and lower extremities and the challenges with the US Food and Drug Administration-approval process.

Diversity in Hand Surgery Leadership: The Impact of Mentorship and Bias.

BACKGROUND: Diversity in leadership drives innovation. However, underrepresented minorities may face barriers. The aim of this study is to understand the impact of gender and race on the experience of leaders in hand surgery. METHODS: An anonymous survey was sent to leaders in hand surgery who attained the position of national society president, head of a division/department, or hand fellowship director. The survey assessed demographic information, grit, mentorship, and bias. RESULTS: One hundred twenty-one leaders responded for a response rate of 60.5%. Men represented 81.0% and women 19.0%. Most respondents were white (87.6%) with 7% Asian and 6% any other race. Ninety-one percent of female respondents lived in a dual career household, compared with 53.7% of male respondents (odds ratio [OR] 0.15, P = .017). Female respondents had significantly higher grit compared with male respondents (4.3 vs 4.0, P = .050). Male respondents were more likely to have a male mentor/sponsor than women (95% vs 76%, respectively, P = .001). White respondents were more likely to have a white mentor/sponsor than nonwhite respondents (91% vs 61%, respectively, P = .009). Ninety-five percent of women reported experiencing bias compared with 27% of men (P < .001). Specifically, women reported bias in salary, promotion, nomination, sponsorship, networking, and clinical resources. Nonwhite respondents were significantly more likely to experience bias in promotion (P = .006). CONCLUSIONS: Women and racial minorities face bias and barriers to leadership within hand surgery.

Characterization of Unpublished Manuscripts by Applicants to an Orthopedic Hand Surgery Fellowship.

Purpose: Obtaining a hand surgery fellowship is becoming increasingly competitive, and research is an important factor when assessing applications. Given the competitive nature of the fellowship application process, applicants may feel the need to bolster their application by misrepresenting their research experience. One form of misrepresentation rarely discussed in prior studies is the listing of submitted works under a "Publications" heading in curricula vitae. This study examines the prevalence of misclassification of manuscripts by applicants to a hand surgery fellowship and identifies factors that might be associated with incorrect classification. Methods: A retrospective review of 122 applicants to the 2020-2021 cycle for hand surgery fellowship was performed. Names and identifiable information were redacted prior to review. Demographic data collected included sex, United States Medical Licensing Examination Step 1 score, medical school rank, residency specialty, total publications, presence of submitted manuscripts in the "Publications" section, total number of submitted manuscripts, and total published abstracts and poster presentations. Results: A total of 1,098 listed publications across the 122 applicants were reviewed with a median of five publications per applicant. Submitted manuscripts were listed as publications by 33 applicants (27%). No observable differences by age, United States Medical Licensing Examination Step 1 score, or total number of publications were seen. Misclassification rates were not associated with publication totals. Conclusions: More than one-quarter of applicants incorrectly listed submitted or unaccepted manuscripts as publications. It is our hope that making fellowship applicants aware of this issue will decrease the rates of misrepresentation in future application cycles. Clinical relevance: The competition for hand surgery fellowships has become more intense, and this may explain our finding that 27% of applicants misrepresent the status of research on hand surgery fellowship applications.

Elbow Uncemented Hemiarthroplasty: Surgical Technique.

Management of elbow arthritis in younger and higher demand patients is challenging and may benefit from a distal humerus hemiarthroplasty that employs a noncemented method of implant fixation and stabilizes the elbow through ligament reconstruction. By not replacing both articulating surfaces, hardware longevity may be improved. We describe a novel system that may be indicated for the treatment of posttraumatic or primary osteoarthritis of the distal humerus. The step-by-step technique for surgical implantation of this uncemented distal humerus hemiarthroplasty is described and illustrated.

Midfoot Fusion Using Superconstructs for the Charcot Foot: Current Techniques and Complications.

Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.

Static stability of novel uncemented elbow hemiarthroplasty stabilized with ligament reconstruction.

BACKGROUND: The purpose of this study was to create a model to simulate treatment of unreconstructable distal humerus fractures with hemiarthroplasty. Stability was restored with a latest plate-system that simultaneously tensions medial and lateral collateral ligament grafts. MATERIALS AND METHODS: Static varus and valgus elbow stability was tested in 11 cadaver elbows with intact ligaments and capsule at 5 flexion angles (0°, 30°, 60°, 90°, 120°). The elbows were then destabilized via release of all ligaments and capsular attachments. The distal humerus articular cartilage was excised and replaced with an uncemented hemiarthroplasty. Ligament reconstruction was subsequently performed, and elbow stability was measured and compared to the native state. Dimensions of the hemiarthroplasty component were compared to native elbow dimensions to assess and quantify any existing relationship to elbow stability. RESULTS: A hemiarthroplasty was implanted in all specimens. A size mismatch occurred between the distal humerus trochlea and the olecranon fossa in all specimens and averaged 6.3 mm. Following ligament reconstruction, specimens reproduced the flexion angle-dependent stability of native elbows to both varus and valgus stress. On the medial side, elbow joint stability in mid-flexion was approximately 7% tighter after hemiarthroplasty. Laterally, the elbow was approximately 15% tighter after hemiarthroplasty and demonstrated peak stability in full flexion. The 3 assessed hemiarthroplasty components and bony dimensions did not exhibit any relationship between implant-bone mismatch and elbow stability after ligamentous reconstruction. CONCLUSION: Cadaveric elbow specimens underwent uncemented hemiarthroplasty with soft tissue stabilization with a novel technique for ligament reconstruction. Following hemiarthroplasty and ligament reconstruction, these specimens maintained secure fixation between ligament and bone. Static stability was maintained at varying degrees of elbow flexion regardless of variable mismatch between the hemiarthroplasty component and the native olecranon fossa.

Do Intramedullary Screws Provide Adequate Fixation for Humeral and Ulnar Components in Total Elbow Arthroplasty? A Cadaveric Analysis.

PURPOSE: The objective of this study was to determine the structural properties of the cadaver bone-screw interface for cementless intramedullary screw fixation in the context of total elbow arthroplasty. METHODS: The intramedullary canals of seven humerus and seven ulna specimens from fresh-frozen cadavers were drilled using custom drill bits until the inner cortex was reached and then hand tapped for the corresponding thread size. Titanium screws were advanced into the tapped holes until securely seated. The bones were potted and then mounted on a uniaxial material testing machine. A tensile load was applied, and end-of-test elongation, failure load, energy absorbed, and stiffness were determined. End-of-test load and elongation were defined as the elongation and load experienced by the structure at 3,000 N or failure. Each specimen was inspected for evidence of pullout, loosening, or visible fractures. RESULTS: The end-of-test load and elongation for the humerus specimens were 2721 ± 738 N and 3.0 ± 0.9 mm, respectively. The ulna specimens reached 92% of the humerus specimens' end-of-test load at 2,514 ± 678 N and 120% of their end-of-test elongation (3.6 ± 0.6 mm). The stiffness of the humerus specimens was 1,077 ± 336 N/mm, which was 1.3 times greater than the stiffness of the ulna specimens (790 ± 211 N/mm). Lastly, the energy absorbed by the humerus samples was 3.6 ± 1.6 J, which was 92% of the energy absorbed by the ulna samples at 3.9 ± 1.1 J. One humerus and three ulnas failed before the end-of-test load of 3,000 N. Two failures were caused by screw pullout and two by bone fracture. CONCLUSIONS: Our findings demonstrate that intramedullary screw fixation is successful in withstanding forces that are greater than required for osseointegration. CLINICAL RELEVANCE: Uncemented fixation may be beneficial in elbow arthroplasty.

Computed Tomography-Based Templating of Proximal Ulna Intramedullary Screw Fixation.

BACKGROUND: Intramedullary screw fixation of the proximal ulna can be used for fixation of the ulnar component in total elbow arthroplasty. Our purpose was to use computed tomography (CT) to characterize proximal ulna anatomy with respect to intramedullary screw fixation, and then to validate this templating process by inserting intramedullary screws into 3-dimensional (3D)-printed models. METHODS: Thirty elbow CT scans were reformatted in the axis of the proximal ulna. Screw placement was templated by fixing a length at 78 mm distal to the centerline of ulnohumeral rotation and measuring diameter, and then fixing the screw pitch diameter to 5.5 mm and measuring length. Three-dimensional models were printed for 5 patients, and intramedullary screws were advanced as distal as possible until endosteal fit was achieved. RESULTS: All patients had an anatomic limit for intramedullary screw fixation, due to dorsal angulation, varus angulation, or both. At 78 mm distal to the centerline of rotation, mean screw diameter was 5.4 mm (range, 3.2-8.0). When fixing screw diameter to 5.5 mm, the mean screw length was 79.9 mm (range, 64.2-107.9). All intramedullary screws were placed in the 3D models within 3 mm of the templated length, with correlation coefficient 0.992. CONCLUSION: This study characterized proximal ulna anatomy in the context of intramedullary screw fixation. Templating allows surgeons to predict intramedullary screw sizing, and a broad range of screw lengths and diameters is required when attempting intramedullary screw fixation for placement of the ulnar component in uncemented total elbow arthroplasty.

Comparing Static Stability of Native Elbow With Static Stability of Novel Bidirectional Ligament Reconstruction at Different Degrees of Elbow Flexion.

Purpose: The treatment of bidirectional ligament instability is proposed using a method that simultaneously tensions medial and lateral ligaments. Graft tension is maintained via plates that apply compression between the graft and bone. Methods: We tested static varus and valgus elbow stability in six cadaver elbows with intact ligaments and capsules at five positions, and then created gross instability by dividing all soft tissue attachments. A ligament reconstruction was subsequently performed with and without nonabsorbable ligament augmentation. Elbow stability was measured and compared with the native state. Results: The augmented and the nonaugmented ligament reconstructions provided stability to the lateral side with only 1.0 mm of increased deflection recorded for the augmented ligaments and 0.6 mm for the nonaugmented when compared with the native state. On the medial side, the deflection was greater after reconstruction compared with the native state with the augmented ligaments ranging between 1.0 and 1.8 mm and the nonaugmented ligament reconstruction ranging between 2.4 and 3.3 mm. Conclusions: This novel ligament reconstruction maintained secure fixation between ligament and bone and allowed for maintenance of static stability at different degrees of elbow flexion. Clinical Relevance: Restoring elbow stability using a method that minimizes ligament graft and which may not need to be removed could benefit management of bidirectionally unstable elbows, such as following interposition arthroplasty or substantial trauma.

The spin move to facilitate antegrade coronoid fixation in terrible triad injuries.

BACKGROUND: The role of the coronoid process in elbow instability has been established. When necessary, coronoid fixation can be challenging. Placing fixation perpendicular to the fracture requires achieving a trajectory as close as possible to the midline axis of the proximal ulna, either from anterior to posterior or vice versa. The aim of this study was to determine whether coronoid exposure-and the ability to place fixation from anterior to posterior-is improved via a lateral extensor-splitting approach with forearm supination, that is, the "spin move," with progressive stages of lateral elbow instability. METHODS: The lateral extensor-splitting approach was performed on 9 cadaveric upper extremities. A 0.157-mm (0.062-inch) wire was drilled perpendicularly into the lateral aspect of the humerus just proximal to the lateral epicondyle. A second wire was drilled into the tip of the coronoid, aiming for a drill trajectory as close as possible to the midline axis. The angle between the 2 wires was measured as the initial angle. Three stages of progressive lateral elbow instability were produced by sequential release of the lateral ulnar collateral ligament (LUCL), common extensor origin (CEO), and posterior capsule. At each stage, the spin move was performed and the angle between the 2 wires was measured. The difference between this angle and the initial angle was calculated, with the average value reported as the Δ angle for each stage. The average difference between each stage and the next stage was reported. RESULTS: The spin move resulted in Δ angles of 10.3° with the LUCL released, 20° with the CEO released, and 29.1° with the posterior capsule released. Progressing from LUCL release to CEO release to posterior capsule release, the Δ angle between the K-wires increased an average of 9.6° from the LUCL stage to the CEO stage and 9.1° from the CEO stage to the posterior capsule stage. CONCLUSION: The spin move is a simple maneuver that can improve exposure of the coronoid process regardless of the degree of elbow instability. This may facilitate a more perpendicular screw, bone tunnel, or suture anchor trajectory via the lateral approach, reducing the need for posterior-to-anterior fixation. The improved exposure is inferred from the differences in the K-wire angles with and without the spin move. This study has also quantified the change in coronoid exposure using the angles of the wires with progressive release of the LUCL, CEO, and posterior capsule. If necessary, releasing the CEO or posterior capsule with eventual repair may allow improved coronoid fixation from the lateral approach.

Allyship for Diversity, Equity, and Inclusion in Hand Surgery.

This article endeavors to be a resource to those individuals interested in becoming an ally or educating potential allies in the field of Hand Surgery. The definitions of allyship, its history, and its expected benefits are considered. The qualities of a good ally are enumerated, and approaches to becoming a better ally are described. The authors provide personal experience with impactful allies and describe strategies and resources on a local and national level. The authors conclude with "Bigger Questions": those issues that seem essential to have allyship succeed in expanding diversity, equity, and inclusion in the specialty.

Current Trends in Use of Epinephrine in Hand Surgery.

BACKGROUND: Epinephrine use during hand surgery has been stigmatized due to a fear of digital necrosis. Clinical experience in the past 2 decades has shown epinephrine in local anesthetic to be safe. We sought to analyze the use of epinephrine among hand surgeons and identify variables associated with it. METHODS: A deidentified 21-question survey was distributed via email to the 914 and 415 members of the American Association for Hand Surgery and the Canadian Society for Surgery of the Hand, respectively. Questions included residency type, years of practice, practice setup/ownership, practice leadership, usage of epinephrine, availability of reversal agents, and reasons for or against usage. RESULTS: Of 188 responders, 170 (90%) used epinephrine in local anesthetic for hand surgery procedures. By nationality, 100% (43) of Canadian surgeons and 89% (108) of US surgeons use epinephrine (P = .01). Among surgeons with practice ownership, 88% (102) used epinephrine compared with 93% (85) of those surgeons that we employed (P = .28). Comparing surgeons with teaching responsibilities versus those without training responsibilities showed that surgeons who did not teach used epinephrine at a higher rate (87% vs 98%, P = .04). In addition, plastic surgery-trained surgeons (111) used epinephrine in 97.2% of cases while orthopedic surgery-trained surgeons (57) used epinephrine in 80.2% of cases (P = .0003). No difference was found when examining the use of epinephrine and surgeon age (P = .28). CONCLUSIONS: Most respondents believe that epinephrine is safe. Training background, location, and practice setup are significant factors in the use of epinephrine, whereas practice ownership and physician age are not major factors.

Life Cycle Assessment in Orthopedics.

Covid-19 has led to an increase in the use of PPE, gowns, masks, sanitizers, air circulators, and much more, all contributing to an increase in medical waste. Waste generation is one issue. Emissions are another. The two are linked because waste and emissions are both indicators of consumption. However, waste is not the biggest driver of environmental emissions for healthcare. It is the production of medical equipment, particularly disposables that have a bigger impact. Energy use during care, including heating and cooling our facilities, is another. Environmental emissions like greenhouse gases may not correlate with waste generation, especially if the waste is plastic. Carbon is stored in plastic. Unless you're burning plastic, you're not emitting carbon. Healthcare has a waste issue and healthcare has an emissions issue. They are not necessarily the same thing, however, the strategies to mitigate each overlap. Life cycle assessment quantifies emissions from the creation to disposal of medical supplies. This allows the medical community to make informed choices with respect to the methods and materials that are used in providing care. As other specialties take the lead in reducing their environmental footprint, so too, must orthopedic surgery.

Latissimus Dorsi Tendon Transfer and Superior Capsular Reconstruction for Irreparable, Posterosuperior Rotator Cuff Tears.

BACKGROUND: The purpose of this study was to compare latissimus dorsi tendon transfer (LDTT) and arthroscopic superior capsular reconstruction (SCR) to determine if one is superior to the other regarding improvement in range of motion (ROM) or patient-reported outcomes (PROs). METHODS: A multicenter, retrospective cohort study was conducted on 43 patients with an irreparable, posterosuperior rotator cuff tear who underwent either LDTT or SCR. Preoperative and postoperative forward flexion and external rotation, as well as PROs including ASES, VAS, and SSV, were assessed. Student t-test and chi-square statistical analyses were performed. RESULTS: 16 LDTT, at mean follow-up of 18 months, and 27 SCR, at mean follow-up 15 months, were studied. Mean active forward flexion significantly improved from 85.2° to 137.6° in the SCR cohort (P=0.001). SCR patients demonstrated a significantly greater increase in forward flexion as compared to LDTT patients (52.4° vs 14.1°, P=0.001). Mean active external rotation amongst the LDTT group significantly improved from 41.7° to 61.5° (P=0.032). LDTT demonstrated significantly greater improvement in external rotation as compared to SCR (19.4° vs 0.8°, P=0.011). There were no significant differences in reported ASES, VAS, or SSV scores. CONCLUSION: This study demonstrates successful clinical and patient-reported outcomes with both LDTT and SCR for irreparable, posterosuperior rotator cuff tears, with greater improvement in forward flexion with SCR and greater improvement in external rotation with LDTT.

Elbow Fracture-Dislocations: Determining Treatment Strategies.

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

Hand and Wrist Problems That Can Be Deceptive: Avoiding Snakes in the Grass.

In this chapter, the authors describe hand conditions that can be "bad actors" and provide specific clues to identify these problems, and strategies to assess and successfully treat them. We will review pediatric and adult hand fractures, fractures of the distal radius, and trigger digits.

Subungual Melanoma.

Subungual melanoma is a rare form of melanoma that presents a unique set of challenges largely based on the complex anatomy of the nail unit. Subungual melanoma often first appears with longitudinal melanonychia. Thus, practitioners must have a high clinical suspicion in any patient with longitudinal melanonychia and a low threshold for a biopsy. The "ABCDEF" guide can be a useful tool to aid in screening any lesion of the nail bed. The authors recommend that biopsies of the nail unit be performed by a surgeon with an in-depth understanding of the pathoanatomy of subungual melanoma.

Investigating the effects of Pirfenidone on TGF-ß1 stimulated non-SMAD signaling pathways in Dupuytren's disease -derived fibroblasts.

BACKGROUND: Dupuytren's disease (DD) is a progressive, debilitating condition of the hand that can eventually cause contractures of the affected fingers. Transforming growth factor- ß1 (TGF-ß1) has been reported to play a key role in DD pathology. Increased expression of TGF-ß1 has shown to be the main stimulator of myofibroblast activity and in DD contractures. Pirfenidone (PFD), a small active molecule possess the ability to inhibit TGF-ß1-mediated action in various fibrotic disorders. Our recent published findings show that PFD reduced TGF-ß1-mediated cellular functions implicated in DD through SMAD signaling pathways. In the present study, the effect of PFD on TGF-ß1-mediated non-SMAD signaling pathways were investigated in both carpal tunnel (CT) - and DD-derived fibroblasts. METHODS: Fibroblasts harvested from Dupuytren's disease (DD) and carpal tunnel (CT) tissues were cultured in the presence or absence of TGF-ß1 (10 ng/ml) and/or PFD (800 µg/ml). Cell lysates were analyzed using Western blots. Equal amounts of proteins were loaded to determine the phosphorylation levels of phosphatidylinositol-3 kinase (PI3K/AKT), extracellular regulated kinases (ERK1/2), p38 mitogen-activated protein kinase and Rho family related myosin light chain (MLC). RESULTS: We show that the TGF-ß1-induced phosphorylation of AKT was significantly decreased by the addition of PFD (800 µg/mL) in both CT- and DD-derived fibroblasts. Interestingly, there was no significant difference in the phosphorylation levels of both ERK and p38 on TGF-ß1- induced cells in both CT-and DD-derived fibroblasts. But, PFD significantly decreased the TGF- ß1-induced phosphorylation levels of ERK1/2 in both CT- and DD- cells. In contrast, PFD significantly decreased the basal and TGF- ß1-induced phosphorylation levels of p38 in DD-derived fibroblasts. TGF- ß1-induced phosphorylation levels of MLC was decreased by PFD in DD-derived fibroblasts. CONCLUSIONS: These in-vitro results indicate for the first time that PFD has the potential to inhibit TGF-ß1-induced non-SMAD signaling pathways in both CT- and DD-derived fibroblasts but pronounced statistically significant inhibition on all molecules was observed only in DD-derived fibroblasts. Our previous studies show that PFD can inhibit TGF-ß1- induced SMAD signaling pathway proteins, namely p- SMAD2/SMAD3. These broad and complementary actions suggest PFD as a promising candidate to inhibit the TGF-ß1- mediated molecular mechanisms leading to DD fibrosis.

Percutaneous Release of the Finger Joints and Mini-Open Intrinsic Release With Tenolysis: A Cadaveric Study.

PURPOSE: To evaluate the effectiveness and safety of minimally invasive distal intrinsic release and extensor tenolysis combined with percutaneous release of proximal and distal interphalangeal joint collateral ligaments. METHODS: The procedures were performed on 5 cadaveric upper extremity specimens, followed by a full anatomical dissection to assess completeness of the targeted releases and any damage to surrounding structures. RESULTS: Complete distal intrinsic release, dorsal capsule release, and distal interphalangeal collateral ligament release was performed on all specimens. We achieved complete release of all proximal interphalangeal joint collateral ligaments in 38 of 40 specimens (95%). We noted damage to nontargeted structures in 2 instances (5%). CONCLUSIONS: Minimally invasive and percutaneous techniques can effectively release several structures known to cause finger stiffness with minimal damage to surrounding structures. CLINICAL RELEVANCE: If similar results are seen in clinical trials, this could be a quick and easy way to increase the mobility of a stiff finger with potentially minimal morbidity.

The naked capitellum: a surgeon's guide to intraoperative identification of posterolateral rotatory instability.

HYPOTHESIS: This study's purpose was to provide a reproducible way for surgeons to intraoperatively assess the elbow's lateral ulnar collateral ligament origin and determine whether there is posterolateral rotatory instability (PLRI) despite an intact common extensor origin (CEO). We hypothesized that we could re-create clinically relevant disruption of lateral supporting structures despite an intact CEO and illustrate progressive elbow PLRI. METHODS: The relationship of the lateral capsule to the capitellum articular surface was noted in 8 cadaveric upper extremities. The lateral capsule and extensor origin were sequentially sectioned at 4 stages: intact, release to the lateral epicondyle, release of the posterior capsular insertion, and release of the CEO. Posterior and lateral translation of the radial head (RH) relative to the capitellum was measured with the forearm in extension and supination. RESULTS: The average specimen age was 78.9 years. The lateral capsule originated within 1 to 2 mm of the capitellum articular surface. Lateral capsular sectioning to the 6-o'clock position of the lateral epicondyle created an unstable elbow with posterior and lateral RH translation. Sequential sectioning of the posterior capsular insertion created significant additional RH translation posteriorly (P < .05). With release of the capsule and the extensor origin, the elbow was grossly unstable. CONCLUSIONS: The elbow's lateral capsuloligamentous complex plays an important role in preventing PLRI. Larger degrees of elbow laxity are associated with further peel back of the capsuloligamentous complex despite an intact CEO. The surgeon must retract the extensor origin intraoperatively to assess for lateral ulnar collateral ligament and/or lateral capsule disruption to prevent a missed case of PLRI.