Pediatric elbow arthroscopy: indications and safety

An increase in paediatric arthroscopy in Europe: Experience of the EPOS Sport Study Group

Purpose

Paediatric musculoskeletal injuries in association with increased participation in sports activities continue to increase. Arthroscopy is recognized as a safe and effective procedure in children. This study aims to identify trends in European paediatric sports centres over 20 years.

Methods

A survey was performed across the European Paediatric Orthopaedic Society (EPOS) Sports Study Group focusing on 3 years (2000, 2009 and 2019). Centres were divided into two groups: Group 1 (n = 5, with data for 2000, 2009 and 2019) and Group 2 (n = 8, with data for 2009 and 2019). Data were analysed as the total annual number of cases and separately by anatomical region and patient demographics. A descriptive analysis was performed to characterize the trends.

Results

Data from eight centres across Europe showed an increase in total annual arthroscopy cases (G1 from 53 to 202 and G2 from 393 to 615, p-value < 0.001) and as a percentage of paediatric orthopaedic surgeries (G1 from 1.6% to 5.2%; G2 from 5.1% to 6.8%) in seven out of eight centres. The knee remained the most commonly treated joint (G1 from 79.2% to 83.3%; G2 from 78.9% to 84.4%), despite the rise of others such as the elbow (p-value = 0.020) and decline of the shoulder (p-value = 0.014). Cases involving paediatric patients over 11 years increased while there was no gender distinction among paediatric patients.

Conclusion

Paediatric arthroscopy procedures in Europe have increased in number over the past 3 decades. Technological advancements have allowed a surge in procedures and applications to new anatomical areas.

Level of evidence

IV - retrospective database review.

Pediatric Patients Who Underwent Elbow Arthroscopy Had an 86% Return-to-Sport Rate, a 12% Reoperation Rate, and a 3.7% Complication Rate

Purpose

To assess the applicability and safety of elbow arthroscopy in the pediatric population at our institution by analyzing the indications and complications in a large pediatric patient series.

Methods

We retrospectively identified all patients who underwent elbow arthroscopy at age 18 years or younger from 2006 to 2017 performed by a single fellowship-trained surgeon. The exclusion criteria were follow-up shorter than 8 weeks and open surgical procedures (not fully arthroscopic). Medical records were reviewed for baseline characteristics, indications for elbow arthroscopy, range of motion, complications, and reoperations.

Results

In total, 191 patients (64 boys and 127 girls) were included, with a median age of 15.5 years (interquartile range, 14.0-16.7 years). Indications for arthroscopic surgery were grouped into treatment of osteochondritis dissecans (60%), debridement for bony or soft-tissue pathology (35%), contracture release (3%), and diagnostic arthroscopy (3%). The complication rate was 3.7%, including 4 minor complications (3 superficial wound problems and 1 case of transient ulnar neuropathy) and 3 major complications (1 case of manipulation under anesthesia for stiffness, 1 deep infection, and 1 [unplanned] reoperation for persistent locking within 1 year of the index procedure). Subsequent surgery was required in 23 patients (12%) because of newly developed, persisting or recurring elbow problems. Of the patients, 86% were able to return to sports.

Conclusions

Pediatric elbow arthroscopy performed by an experienced surgeon using a standardized technique for a wide variety of elbow conditions has an acceptable complication rate that is similar to rates in the previously published literature on elbow arthroscopy in the pediatric and adult populations; however, a significant proportion of patients needed subsequent surgery in the following years.

Level of Evidence

Level IV, therapeutic case series.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

Sequelae of childhood elbow fracture

Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be overlooked, due to young age and the cartilaginous nature of the joint. There is little bone remodeling in the elbow and displacement fracture, and especially supracondylar or lateral condyle fracture, has to be corrected rigorously, notably in older children. In case of lateral tilt in fracture of the neck of the radial head, on the other hand, remodeling is effective. Deformity in cubitus varus and cubitus valgus leads to neurological lesions and instability. Treatment should be early, with adapted surgery in expert hands. Post-traumatic stiffness is rare. Early intensive physiotherapy is unsuited to children and could worsen the stiffness due to inflammation. Lateral condyle non-union is a classic complication of fracture. Simple percutaneous screwing is a useful option. The equivalent in the medial epicondyle is well-tolerated, and simple monitoring now suffices. Late posterolateral rotational instability is a poorly known complication. It should be considered in case of cubitus varus that becomes painful after a long asymptomatic course. Radiocapitellar subluxation is seen on X-ray. Residual radial head dislocation after primary treatment (Monteggia lesion) responds well to the Bouyala technique of ulnar flexion osteotomy associated to annular ligament repair, without requiring ligament reconstruction.

Complications of Elbow Arthroscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Elbow arthroscopic surgery has been popularized and has made significant progress during the past 3 decades. The elbow joint is relatively small and is in close proximity to many neurovascular structures. These factors make elbow arthroscopic surgery technically demanding and liable to complications.

PURPOSE

To evaluate the rate of complications after elbow arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis. PubMed, Web of Science, and Embase were searched up to July 2021. All clinical studies that reported complications after elbow arthroscopic surgery were included; a total of 1208 articles were initially found. Case reports, reviews, abstracts, imaging studies, technique studies, nonclinical studies, and those not reporting postoperative complications were excluded. Complication rates were pooled across studies and reported as percentages. Complications were expressed as weighted proportions with 95% CIs.

RESULTS

A total of 95 studies (14,289 elbows) were included in the meta-analysis. The overall weighted complication rate was 11.0% (95% CI, 8.8%-13.5%), with postoperative stiffness being the most commonly encountered complication (4.5% [95% CI, 2.1%-7.6%]; 158/8818 procedures). The second most encountered complication was the need for subsequent surgery with a weighted proportion of 4.1% (95% CI, 2.9%-5.6%; 177/8853 procedures) followed by nerve injury with a weighted proportion of 3.4% (95% CI, 2.6%-4.3%; 267/13,725 procedures). The ulnar nerve was the most commonly injured nerve (2.6% [95% CI, 1.9%-3.4%]; 123/6290 procedures).

CONCLUSION

The results of this study showed that elbow arthroscopic surgery is a relatively safe procedure with low complication rates.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up

BACKGROUND

Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up.

MATERIALS AND METHODS

In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated.

RESULTS

In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected.

CONCLUSIONS

Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries.

LEVEL OF EVIDENCE

Level IV-case series.

Arthroscopy of the Pediatric Elbow: Review of the Current Concepts

As surgeons have become more familiar with elbow arthroscopy, the indications for arthroscopy of the pediatric elbow have expanded to include contracture releases, fracture fixation, treatment of osteochondritis dissecans (OCD) lesions, correction of elbow deformity, and debridement of soft tissue and bony pathologies. The treatment of various pathologies via an arthroscopic approach demonstrates equal, if not better, efficacy and safety as open surgery for the pediatric elbow. Arthroscopy provides the unique advantage of enabling the performance of extensive surgeries through a minimally-invasive approach, and it facilitates staged interventions in cases of increased complexity. For fracture work, arthroscopy enables direct visualization to assess reduction for percutaneous fixations. While future research is warranted to better evaluate the indications and outcomes of pediatric elbow arthroscopy, this update article presents a review of the current literature, as well as several innovative cases highlighting the potential of arthroscopy.

The Use of Elbow Arthroscopy for Management of the Pediatric Elbow: A Systematic Review of Indications and Outcomes

PURPOSE

The purpose of this review was to systematically examine the literature surrounding elbow arthroscopy for pediatric patients and to assess indications, functional outcomes, and complication rates.

METHODS

This systematic review was carried out in accordance with PRISMA guidelines. EMBASE, PubMed, and MEDLINE were searched for relevant literature from inception until December 2019, and studies were screened by 2 reviewers independently and in duplicate for those investigating elbow arthroscopy in a pediatric population (<18 years). Editorials, review articles, and case reports were excluded. Demographic data and data on surgical indications, treatment outcomes, and complications were recorded. A methodological quality assessment was performed for all included studies using the Methodological Index for Non-Randomized Studies.

RESULTS

Overall, 19 studies, all of level IV evidence, were identified with a total of 492 patients (513 elbows). The patient population was 22.3% female with a mean age of 14.0 years (range, 4.0-15.7) and a mean follow-up time of 33.0 months (range, 7.4-96 months). Twelve studies (263 patients) exclusively recruited patients with osteochondritis dissecans (OCD), although other indications for elbow arthroscopy included arthrofibrosis (50 patients), elbow fracture (37 patients), medial ulnar collateral ligament injury (31 patients), and posterior impingement (17 patients). All 13 reporting studies showed a significant improvement in the elbow flexion-extension arc, and 4 of 5 that reported a functional outcome score before and after surgery demonstrating a significant improvement. Last, the overall complication rates ranged from 0% to 23.8%, with a total of 8 instances of neurological injury (5 ulnar, 2 radial, 1 unspecified), all being transient and resolving within 3 to 6 months.

CONCLUSION

Although elbow arthroscopy is primarily being performed for OCD in children and adolescents, there is evidence surrounding several other potential indications. Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Editorial Commentary: Elbow Arthroscopy in the Pediatric Patient-Small Lesions in a Small Joint but With a Big Impact

Elbow arthroscopy has evolved to be a powerful tool for the treatment of a broad spectrum of pathologies over the past almost 40 years. The small joint with a complex arthroscopic anatomy demands special training and exceptional skills from the orthopaedic surgeon. On the basis of this fact and in light of the close proximity of the neurovascular structures, complication rates are somewhat higher compared with other large joints such as the knee and the shoulder. Nevertheless, elbow arthroscopy has also found its way into the treatment of joint pathologies in pediatric patients. The spectrum of pathologies differs from that in the adult population, with fewer degenerative changes and many growth-related issues such as osteochondral lesions (osteochondritis dissecans) of the capitellum. Generally speaking, clinical outcomes, return to sports, and patient satisfaction are excellent and complication rates are low. The latter remains a target for further improvement in light of the many years those pediatric elbow joints have ahead.

Does Sawbone-Based Arthroscopy Module (SBAM) Can Help Elbow Surgeons?

INTRODUCTION

The use of elbow arthroscopy is becoming increasingly common in orthopaedic practice; nevertheless, it is still considered a difficult procedure with a long learning curve. The aim of the study is to evaluate the role of a new elbow Sawbone-Based Arthroscopy Module (e-SBAM) in the training of elbow surgeons.

METHODS

Fourteen surgeons were classified as "Expert" (n: 7; more than 10 years of experience in arthroscopic surgery) and "Not-expert" surgeons (n: 7; less than 10 years of experience). During a dedicated arthroscopic session, using the Sawbones Elbow model (Sawbones Europe AB®), all participants were asked to perform an arthroscopic round and to touch three specific landmarks. An independent observer measured the time that each participant needed to perform this task (Performance 1). The same measurement was repeated after two weeks of eSBAM training (Performance 2).

RESULTS

"Not-expert" surgeons needed significantly more time (41 s; range 26-120) than "Expert" ones (13 s; range 8-36) to complete Performance 1. One "Not-expert" surgeon did not complete Performance 1 and needed more than 120 s for Performance 2. The whole study group required a median of 5 s less to complete Performance 2. A tendency towards an improvement was observed in the group of the non-experienced surgeons as compared with the experienced ones.

CONCLUSIONS

The simulation training can be advantageous in the learning curve of young elbow surgeons and helpful for experienced surgeons. E-SBAM can be used as an effective tool for the current stepwise arthroscopic elbow training programs with the aim of improving arthroscopic elbow skills.

LEVEL OF EVIDENCE

Basic Science Study.

Complications of Elbow Arthroscopy in a Community-Based Practice

PURPOSE

The purpose of this study was to report the complications of elbow arthroscopy in a large community practice with multiple surgeons and to analyze potential risk factors for these complications.

METHODS

Patient demographic information, surgical variables, surgeon variables, and complications were retrospectively reviewed for all elbow arthroscopies performed within the health network from 2006 to 2014. Inclusion criteria included patients of any age undergoing a primary and revision elbow arthroscopy, which may have been performed in conjunction with other procedures. Exclusion criteria included incorrectly coded procedures where arthroscopy was not performed and no postoperative follow-up. Statistical calculations were performed using a binary logistic regression analysis to fit a logistic regression model.

RESULTS

560 consecutive elbow arthroscopies in 528 patients performed between 2006 and 2014, by 42 surgeons at 14 facilities, were reviewed. 113 procedures were performed in pediatric patients under the age of 18. The average age was 38.6 years (range: 5-88). There were 444 males. The average length of follow-up was 375.8 days (2 to 2,739 days). Overall, heterotopic ossification occurred in 14 of 560 cases (2.5%) (all males), and 20 of 560 (3.5%) cases developed transient nerve palsies (8 ulnar, 8 radial, 1 median, 3 medial antebrachial cutaneous). There were 3 (0.5%) deep and 11 (2%) superficial infections. There were no vascular injuries, compartment syndrome, deep vein thrombosis, or pulmonary embolism. Elevated blood sugar was a significantly higher risk for infection (odds ratio [OR] 4.11, 95% confidence interval [CI] 1.337 to 12.645; P = .0136). Previous elbow surgery (OR 3.57, 95% CI 1.440 to 8.938; P = .006) and female sex (OR 4.05; 95% CI 1.642 to 9.970; P = .002) had a significantly higher risk for nerve injury. Relative to pediatric patients, there were higher odds in adults for nerve injury, infection, and heterotopic ossification, but none reached significance.

CONCLUSIONS

Elbow arthroscopy is a safe procedure with low complication rates. Diabetes is a risk factor for infection. Prior surgery and female sex are risk factors for nerve injury.

LEVEL OF EVIDENCE

Case series, level 4.

Closed manipulation under anesthesia for pediatric post-traumatic elbow arthrofibrosis

BACKGROUND

Post-traumatic elbow arthrofibrosis (PEA) and its associated limitations to elbow range of motion (ROM) are a recognized consequence of trauma to the pediatric elbow. Closed manipulation under anesthesia (CMUA) of the elbow can be performed in pediatric patients as a nonoperative attempt to improve dysfunctional ROM. Minimal outcome data to support CMUA exist. The study evaluates the efficacy of CMUA for PEA in pediatric patients.

METHODS

Patients younger than 18 years who underwent CMUA (Current Procedural Terminology code 24300) for PEA between 2005 and 2015 at 3 institutions were included. A retrospective chart review was performed to collect demographic data and ROM premanipulation and at last follow-up. Paired 2-tailed t tests were used to compare pre- and postmanipulation elbow ROM.

RESULTS

Thirteen patients with a mean age of 12.2 ± 2.6 years (range 6.7-15.6 years) met the inclusion criteria. Median time to CMUA from initial surgery was 4.2 months (interquartile range [IQR] 3.6-8.4, range 1.4-19.7 months). Median follow-up time was 6 months with an IQR of 3.3-10.0 months. At last follow-up, there was significant improvement in elbow flexion of 22° ± 17° (P < .001) and extension of 29° ± 21° (P < .001). The average premanipulation motion arc of 60° ± 24° significantly increased to 110° ± 22° at final assessment (P < .001).

CONCLUSION

CMUA appears to be a valuable alternative and reliable procedure for improving PEA in pediatric patients who exhaust nonoperative interventions.

Current Concepts in the Treatment of Lateral Condyle Fractures in Children

Lateral condyle fractures of the humerus are the second most common fracture about the elbow in children. The injury typically occurs as a result of a varus- or valgus-applied force to the forearm with the elbow in extension. Plain radiographs are sufficient in making the diagnosis; however, an elbow arthrogram permits optimal visualization of the articular surface in minimally displaced fractures. Traditionally, nonsurgical management is indicated for fractures with ≤2 mm of displacement and a congruent articular surface. Closed reduction and percutaneous pinning is performed for fractures with >2 mm of displacement with an intact cartilaginous hinge at the articular surface. Open reduction and internal fixation is often necessary for fractures with ≥4 mm of displacement or if there is articular incongruity. Complications include malunion, delayed presentation, fishtail deformity, lateral spurring, and growth arrest. Evolving management concepts include relative indications for surgical management, the optimal pin configuration, and the use of cannulated screw and bioresorbable fixation.

Determining the effective timing of an open arthrolysis for post-traumatic elbow stiffness: a retrospective cohort study

Background

Following trauma, the elbow is the most susceptible to restricted motion among all joints. Open arthrolysis is often performed for post-traumatic elbow stiffness if that stiffness does not improve with non-operative management. However, the optimal timing for performing an open arthrolysis remains controversial. The purpose of this study was to compare the outcome (elbow motion and function) and the rate of complications among patients who had undergone early, median and late release procedures to establish an optimal time interval following the injury, after which, an effective open arthrolysis can be performed.

Methods

In this retrospective cohort study, we included total 133 patients, who had undergone open arthrolysis for post-traumatic elbow stiffness. The subjects were divided into 3 groups, with 31 patients in the early release group (arthrolysis performed at 6–10 months after injury), 78 patients in the median release group (at 11–20 months), and 24 patients in the late release group (at > 20 months). The release procedure in all patients was performed by the same surgeon, using the same technique. The general data, functional performance, and complications, if any, were retrospectively documented for all patients and statistically analysed.

Results

The demographic data and disease characteristics of all patients were comparable at baseline. Postoperatively, no significant differences were found among the three groups with respect to the range of motion (p = 0.067), Mayo Elbow Performance Score (p = 0.350) and its ratings (p = 0.329), visual analog scale score for pain (p = 0.227), Dellon classification for ulnar nerve symptoms (p = 0.497), and each discrete complication (all p values > 0.05).

Conclusions

At the final follow-up, our results showed no significant difference in the postoperative elbow motion capacities, functional scores and the rates of complications among patients who had undergone an early, median, and late release. Therefore, we have recommended that an early arthrolysis would be preferable due to its multiple advantages, and the conventionally observed interval of > 1 year after the injury, could be shortened.

Level of evidence

Level III; Retrospective Cohort Design; Therapeutic Study.

Proper elbow arthroscopy portal placement in pediatric and adolescent patients

We sought to evaluate proper elbow arthroscopy portal placement in pediatric and adolescent patients. Overall, 109 pediatric and adolescent patients who underwent elbow arthrography were included. Condylar width was measured and the proximal anterior joint capsule location was determined using the ulna-capsular distance. Condylar width and Bone mass index(BMI) also had a high positive correlation coefficient with the proximal joint capsule location. Proximal ulnar border is recommended new bony landmark in pediatric and adolescent patients who undergo elbow arthroscopy. In particular, condylar width and BMI were found to have a high positive correlation with the proximal joint capsule location.