Arthroscopy of the elbow

Avoidance of Direct Posterior Portal During Elbow Arthroscopic Surgery in Posterior Compartment

Arthroscopic surgery for the posterior compartment in elbow has been used in the treatment of many pathologies. The direct posterior portal has been commonly used for this compartment. However, this portal involves penetrating the triceps brachii tendon responsible for extensor mechanism. This can possibly lead to poor performance during recovery and portal wound sensation with scar formation. An accessory posterolateral portal can be used as a substitute with adequate viewing and working space in all areas of the posterior compartment. This report describes in detail on how to manage pathologies in the posterior compartment without using direct posterior portal and instead using accessory posterolateral, posterolateral, and direct lateral portals.

Lateral epicondylitis of the elbow: an up-to-date review of management

Lateral epicondylitis, also known as tennis elbow, is an overuse tendinopathy of the common extensor origin of the elbow in patients involved in repetitive movement of the wrist and forearm. Lateral epicondylitis is a self-limiting condition, with operative management only recommended in severe, recalcitrant cases. This article reviews the recent updates on operative and non-operative management of lateral epicondylitis.

Comparison of arthroscopy versus percutaneous radiofrequency thermal ablation for the management of intra- and juxta-articular elbow osteoid osteoma: case series and a literature review

BACKGROUND

Today, intra-articular and juxta-articular osteoid osteomas are treated with arthroscopy and radiofrequency thermal ablation. However, for the case of an elbow joint, arguments are made for the use of a minimally invasive technique to be the optimal choice. This study aims to analyse our experiences of arthroscopically treated elbow osteoid osteomas and to compare it with the published results of both techniques.

METHODS

The retrospective study analyses the patients who underwent elbow arthroscopy ablation of an elbow osteoid osteoma at a single institution from January 2014 until March 2020. Clinical and diagnostic features, success and treatment failure rates, complications and tumour recurrence rates were all compared to 13 studies of intra-articular elbow osteoid osteoma arthroscopic ablation and 15 studies involving radiofrequency thermal ablation of intra-articular osteoid osteoma within different joints.

RESULTS

Four males and two females, with a mean age of 19.3 years, were encompassed. All the patients had immediate postoperative pain relief and improved range of motion. No tumour recurrences were observed during a median of 21.7 months. The literature review yielded 86.4% success rate, 68.2% successful biopsies, one minor complication and no recurrences following the arthroscopic ablation of an elbow osteoid osteoma; while radiofrequency thermal ablation of an intra-articular elbow osteoid osteoma yielded 96.3% success rate, 33.3% successful biopsies, no complications and 3.7% recurrence rate.

CONCLUSIONS

Our results are consistent with the published literature proving that arthroscopic ablation is an efficient method with low treatment failure rates and no recurrences in treating intra- and juxta-articular elbow osteoid osteomas. Advantages of arthroscopic ablation stem from the ability to visualise and safely deal with the lesion and the joint's reactive changes resulting in high biopsy rates, no recurrences and better postoperative elbow's range of motion. Still, the technique selection should be personalised considering the medical expertise of every institution.

Complications in Elbow Arthroscopy: Management and Prevention

With advances in the understanding of elbow anatomy, pathologies of the elbow, arthroscopic instrumentation, and surgical techniques over recent decades, elbow arthroscopy has become a valuable treatment modality for a variety of conditions. Elbow arthroscopy has gained utility for treating problems such as septic arthritis, osteoarthritis, synovitis, osteophyte and loose body excision, contracture release, osteochondral defects, select fractures, instability, and lateral epicondylitis. Accordingly, precise knowledge of the neurovascular anatomy, safe arthroscopic portal placement, indications, and potential complications are required to maximize patient outcomes and assist in educating patients. This comprehensive review provides the reader an understanding of the potential complications associated with arthroscopic procedures of the elbow and to describe strategies for prevention and management.

Elbow arthroscopy - Indications and technique

Throughout the years, elbow arthroscopy has advanced tremendously due to improvements in technology and surgical techniques. It is now considered a safe and effective treatment for a variety of elbow disorders. Due to the small working space and nearby neurovascular structures, it is a technically challenging procedure. It can be used to successfully treat complaints caused by loose bodies, osteoarthritis, arthrofibrosis, OCD, lateral epicondylitis, VEOS and fractures. The most devastating complication of elbow arthroscopy is (permanent) nerve injury. Therefore, distortion of the anatomy of the elbow joint and transposition of the ulnar nerve can be a contra-indication for elbow arthroscopy due to the higher risk of postoperative complications. The results of the arthroscopy depend on the experience, knowledge, technique and expertise of the performing surgeon.

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.

Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy

Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.

Modified anteromedial and anterolateral elbow arthroscopy portals show superiority to standard portals in guiding arthroscopic radial head screw fixation

PURPOSE

Arthroscopic fixation of radial head radial head fractures is an appealing alternative to open reduction and internal fixation, which presents the advantage of minimal surgical trauma. The aim of this study was to evaluate if modifications to the standard anteromedial (AM) and anterolateral (AL) portals could allow screw placement for radial head fracture osteosynthesis closer to the plane of the radial head articular surface.

METHODS

Eight fresh-frozen specimens were prepared to mimic arthroscopic setting. Standard AL (ALst) and AM (AMst) and distal AL (ALdi) and AM (AMdi) portals were established. Eleven independent examiners were asked to indicate the optimal trajectory, when aiming to place a cannulated screw parallel to the radial head surface for radial head osteosynthesis. A three-dimensional digital protractor was used to measure the angle between the indicated position and a Kirschner wire placed parallel to the radial head articular surface (α). The Shapiro-Wilk normality test was used to evaluate the normal distribution of the samples. Means, standard deviations, and 95% confidence intervals (95% CI) were calculated for each portal. A coefficient of variation (CoV) was calculated to determine agreement among observers and intra-observer variability.

RESULTS

Mean α angles were 25.1 ± 11.5° for AMst, 13.8 ± 4.8° for AMdi, 17.1 ± 13.4° for ALst, -2.6 ± 9.2° for ALdi. No overlapping in the 95% CI of ipsilateral standard and distal portals was observed, indicating that the difference between these means was statistically significant. The distal portals showed smaller inter-observer CoV as compared to the standard ones (AMst: 10.0%; AMdi: 4.6%; ALst: 12.5%; ALdi: 10.6%). Intra-observer CoV was similar for all portals (AMst: 5.5%; AMdi: 6.1%; ALst: 7.7%; ALdi: 7.1%).

CONCLUSIONS

The use of distal AM and AL portals permits to obtain α angles closer to the radial head articular surface than standard AM and AL portals. This is expected to allow screw placement in a flatter trajectory, which should correlate with a superior biomechanical performance of fixation. Good reproducibility of Kirschner wire placement from distal portals was observer among different examiners. Modifications to the standard AM and AL elbow arthroscopy portals allow to place screws for radial head fracture osteosynthesis in a position which should guarantee superior biomechanical performance of fixation.

Avoiding Neurological Complications of Elbow Arthroscopy

Elbow arthroscopy is an increasingly common procedure performed in orthopaedic surgery. However, because of the presence of several major neurovascular structures in close proximity to the operative portals, it can have potentially devastating complications. The largest series of elbow arthroscopies to date described a 2.5% rate of postoperative neurological injury. All of these injuries were transient nerve injuries resolved without intervention. A recent report of major nerve injuries after elbow arthroscopy demonstrated that these injuries are likely under-reported in literature. Because of the surrounding neurovascular structures, familiarity with normal elbow anatomy and portals will decrease the risk of damaging important structures. The purpose of this Technical Note is to review important steps in performing elbow arthroscopy with an emphasis on avoiding neurovascular injury. With a sound understanding of the important bony anatomic landmarks, sensory nerves, and neurovascular structures, elbow arthroscopy can provide both diagnostic and therapeutic intervention with little morbidity.

Modified Anterolateral Portals in Elbow Arthroscopy: A Cadaveric Study on Safety

PURPOSE

To evaluate the proximity to the radial nerve on cadaveric specimens of 2 modified anterolateral portals used for elbow arthroscopy.

METHODS

Ten fresh cadaveric elbow specimens were prepared. Four-millimeter Steinman pins were inserted into 3 anterolateral portal sites in relation to the lateral epicondyle: (1) the standard distal anterolateral portal, (2) a modified direct anterolateral portal, and (3) a modified proximal anterolateral portal. These were defined as follows: direct portals 2 cm directly anterior to the lateral epicondyle, and proximal portals 2 cm proximal and 2 cm directly anterior to the lateral epicondyle. Each elbow was then dissected to reveal the course of the radial nerve. Digital photographs were taken of each specimen, and the distance from the Steinman pin to the radial nerve was measured.

RESULTS

The modified proximal anterolateral and direct anterolateral portals were found to be a statistically significant distance from the radial nerve compare to the distal portal site (P = .011 and P = .0011, respectively). No significant difference was found in the proximity of the radial nerve between the modified proximal and direct anterolateral portals (P = .25). Inadequate imaging was found at a single portal site for the proximal site; 9 specimens were used for analysis of this portal with 10 complete specimens for the other 2 sites.

CONCLUSIONS

In cadaveric analysis, both the modified proximal and direct lateral portals provide adequate distance from the radial nerve and may be safe for clinical use. In this study, the distal anterolateral portal was in close proximity of the radial nerve and may result in iatrogenic injury in the clinical setting.

CLINICAL RELEVANCE

This is a cadaveric analysis of 2 modified portal locations at the anterolateral elbow for use in elbow arthroscopy. Further clinical studies are needed prior to determining their absolute safety in comparison to previously identified portal sites.

Arthroscopic R-LCL plication for symptomatic minor instability of the lateral elbow (SMILE)

PURPOSE

Minor instability has been proposed as a possible aetiology of lateral elbow pain. This study presents the results of the arthroscopic plication of the radial component of the lateral collateral ligament (R-LCL) to reduce minor instability of the lateral elbow.

METHODS

Twenty-seven patients with recalcitrant lateral epicondylitis who had failed conservative therapy and who had no previous trauma or overt instability, were included. R-LCL plication was performed in the presence of at least one sign of lateral ligamentous patholaxity and one intra-articular abnormal finding. Single-assessment numeric evaluation (SANE), Oxford Elbow Score (OES), quickDASH (Disabilities of the Arm, Shoulder, Hand), patient satisfaction and post-operative range of motion were evaluated.

RESULTS

SANE improved from a median of 30 [2-40] points pre-operatively to 90 [80-100] at final follow-up (p < 0.0001), and 96.3% patients obtained good or excellent subjective results. Post-operative median quickDASH was 9.1 [0-25] points and OES 42 [34-48]. Median post-operative flexion was 145°, and extension was 0°. Post-operative flexion was restrained in seven patients and extension in eight patients; 59% of patients reached full ROM at final follow-up.

CONCLUSIONS

R-LCL plication produces subjective satisfaction and positive clinical results in patients presenting with a symptomatic minor instability of the lateral elbow (SMILE) at 2-year median follow-up. A slight limitation in range of motion is a possible undesired consequence of this intervention.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Portal placement in elbow arthroscopy by novice surgeons: cadaver study

PURPOSE

In this anatomical cadaver study, the distance between major nerves and ligaments at risk for injury and portal sites created by trainees was measured. Trainees, inexperienced in elbow arthroscopy, have received a didactic lecture and cadaver instruction prior to portal placement. The incidence of iatrogenic injury from novice portal placement was also determined.

METHODS

Anterolateral, direct lateral, and anteromedial arthroscopic portals were created in ten cadavers by ten inexperienced trainees in elbow arthroscopy. After creating each portal, the trajectory of the portal was marked with a guide pin. Subsequently, the cadavers were dissected and the distances between the guide pin in the anterolateral, direct lateral, and anteromedial portals and important ligaments and nerves were measured.

RESULTS

The difference between the distance of the direct lateral portal and the posterior antebrachial cutaneous nerve (PABCN) (22 mm, p < 0.001), the lateral antebrachial cutaneous nerve (4.0 mm, p < 0.001), and the radial nerve (25 mm, p < 0.001) was different from the average reported distances in the literature. A difference was found between the distance of the anterolateral portal and the PABCN (32 mm, p < 0.001) compared to previous studies. Three major iatrogenic complications were observed, including: laceration of the posterior bundle of the medial ulnar collateral ligament, lateral ulnar collateral ligament midsubstance laceration, and median nerve partial laceration.

CONCLUSION

Surgeons increasingly consider arthroscopic treatment as an option for elbow pathology. In the present study a surgical complication rate of 30 % was found with novice portal placement during elbow arthroscopy. Furthermore, as the results from this study have indicated, accurate, precise, and safe portal placement in elbow arthroscopy is not easily achieved by didactic lecture and cadaver instruction session alone. Level of evidence V.

Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE)

PURPOSE

Lateral epicondylitis is generally considered an extra-articular condition. The role of minor instability in the aetiology of lateral elbow pain has rarely been considered. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain.

METHODS

Thirty-five consecutive patients aged between 20 and 60 years with recalcitrant lateral epicondylitis who had failed conservative therapy and had no previous trauma or overt instability, were included. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. The relative incidence of each of these was calculated, and the correlation between patholaxity and intra-articular pathology was evaluated.

RESULTS

At least one sign of lateral ligamentous laxity was observed in 48.6% of the studied cohort, and 85.7% demonstrated at least one intra-articular abnormal finding. Radial head ballottement was the most common sign of patholaxity (42.9%). Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). A significant correlation was found between the presence of lateral ligamentous patholaxity signs and capitellar chondropathy (p = 0.0409), as well as anteromedial synovitis (p = 0.0408).

CONCLUSIONS

Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. The most frequent intra-articular findings are synovitis and lateral capitellar chondropathy, which correlate significantly with the presence of lateral ligamentous patholaxity. The fact that several patients demonstrated multiple intra-articular findings in relation to laxity provides support to a sequence of pathologic changes that may result from a symptomatic minor instability of the lateral elbow (SMILE) condition.

LEVEL OF EVIDENCE

III.

Tendinopathies around the Elbow Part 1: Lateral Elbow Tendinopathy

Tendinopathies of the elbow and in particular of the common extensor origin are a common cause of elbow pain. Part one of this two part review of tendinopathies of the elbow will focus on the pathophysiology and management of lateral elbow tendinopathy, frequently referred to as tennis elbow. Lateral elbow tendinopathy is a common condition with an incidence of 1 – 2%. The pathology arises from the origin of extensor carpi radialis brevis where changes, consistent with all tendinopathies, of angiofibroblastic hyperplasia occur secondary to repetitive micro trauma. It is not an inflammatory condition. Clinical history and examination is usually sufficient for diagnosis although MRI and ultrasound can be used. The many treatment options that have been proposed have a mixed quality of supporting evidence. Thus management protocols are difficult to define. Treatment depends on the length of symptoms. Acute presentation is managed through conservative measures including activity modification, topical NSAIDs and physiotherapy. For patients with recalcitrant symptoms, injection therapy with, for example, platelet rich plasma can be used. Alternatively surgical excision of the diseased tissue can be performed. This review article will consider the available evidence in order to identify both treatments that are effective and those that are not.

The Safety of Using Proximal Anteromedial Portals in Elbow Arthroscopy With Prior Ulnar Nerve Transposition

PURPOSE

To report the safety of using the proximal anteromedial portal, using a simplified ulnar nerve management strategy derived from an earlier study, in a series of patients with previously transposed ulnar nerves.

METHODS

A retrospective review of all elbow arthroscopies performed by a single surgeon from 2009 to 2014 was performed. The following techniques were used if, by palpation, localization of the ulnar nerve was considered to be certain (group 1) or uncertain (group 2): In group 1 (certain) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (uncertain) a 1- to 3-cm incision was made at the planned proximal anteromedial portal site, and blunt dissection down to the capsule was performed without identification of the nerve. The nerve was not visualized but sometimes was palpated through the wound to confirm its location anteriorly or posteriorly. If there was a disparity between the prior operative records and the physical examination findings, the nerve was explored through a 3- to 4-cm incision.

RESULTS

We reviewed 394 elbow arthroscopy cases, 22 of which had a prior transposed ulnar nerve (21 subcutaneous and 1 submuscular) that required anterior-compartment arthroscopic surgery. Group 1 (certain location) consisted of 9 elbows (41%), whereas group 2 (uncertain location) consisted of 13 (59%). In 2 cases in group 2, the ulnar nerve was explored because of the disparity between the previous medical records and the physical examination findings. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal.

CONCLUSIONS

The proximal anteromedial portal was able to be used safely in patients with prior transposition of the ulnar nerve. This was achieved by using an algorithm based on the degree of certainty with which the nerve can be localized in the region of the planned portal by clinical palpation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Neurological Complications Related to Elective Orthopedic Surgery: Part 1: Common Shoulder and Elbow Procedures

Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic-based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery.

WHAT'S NEW

As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.

Complications of Lateral Epicondylar Release

Reported complication rates are low for lateral epicondylitis management, but the anatomic complexity of the elbow allows for possible catastrophic complication. This review documents complications associated with lateral epicondylar release: 67 studies reporting outcomes of lateral epicondylar release with open, percutaneous, or arthroscopic methods were reviewed and 6 case reports on specific complications associated with the procedure are included. Overall complication rate was 3.3%. For open procedures it was 4.3%, percutaneous procedures 1.9%, and arthroscopic procedures 1.1%. In higher-level studies directly comparing modalities, the complication rates were 1.3%, 0%, and 1.2%, respectively.

The first 100 elbow arthroscopies of one surgeon: analysis of complications

BACKGROUND

Elbow arthroscopy is technically challenging and prone to complications especially due to the close relation of nerves and vessels. Complication rates up to 20% are reported, depending on indication and how complications are defined. This study analyzes the complications of the first 100 elbow arthroscopies done by 1 fellowship- and cadaver-trained surgeon.

MATERIALS AND METHODS

From September 2004 to April 2009, 100 consecutive elbow arthroscopies were performed, and thus consequently standardized, by 1 surgeon in 1 institution. The clinical data of all patients were retrospectively analyzed for indication-specific complications. Complications were divided into minor (transient) and major (persistent or infection).

RESULTS

Included were 65 male and 35 female patients (mean age, 41 years; range, 12-70 years) with a minimum follow-up of 12 months (clinical or telephone). The following indications were documented (several per patient were possible): osteoarthritis in 29, stiffness in 27, loose bodies in 27, tennis elbow in 24, traumatic sequelae in 19, and others in 24. No major complications occurred, but 6 minor complications occurred in 5 patients (5%), comprising 2 hematoma, 2 transient nerve lesions, 1 wound-healing problem, and 1 complex regional pain syndrome. No revision surgery was necessary. Complications were not significantly associated with the indication for operation or the surgeon's learning curve.

CONCLUSION

This study shows an acceptable complication rate of the first 100 elbow arthroscopies from a single surgeon. A profound clinical education, including cadaver training as well as standardization of patient position, portals, and surgery, help to achieve this.

Elbow arthroscopy: the basics

Elbow arthroscopy has become an accepted surgical option for treating numerous conditions of the elbow, including septic, degenerative, or traumatic arthritis; capsular release; removal of loose bodies; synovectomy or plica excision; and chondral lesions of the capitellum. Surgeon experience, knowledge of elbow anatomy, patient positioning, and portal selection and placement are important factors for successful arthroscopy and avoiding complications. This article describes the basic surgical setup and technique for elbow arthroscopy.

Osteochondritis dissecans of the capitellum

Osteochondritis dissecans of the capitellum is a well-recognized cause of elbow pain and disability in the adolescent athlete. This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities. The true cause, natural history, and optimal treatment of osteochondritis dissecans of the capitellum remain unknown. Suspicion of this condition warrants investigation with proper radiographs and magnetic resonance imaging. Prompt recognition of this disorder and institution of nonoperative treatment for early, stable lesions can result in healing with later resumption of sporting activities. Patients with unstable lesions or those failing nonoperative therapy require operative intervention with treatment based on lesion size and extent. Historically, surgical treatment included arthrotomy with loose body removal and curettage of the residual osteochondral defect base. The introduction of elbow arthroscopy in the treatment of osteochondritis dissecans of the capitellum permits a thorough lesion assessment and evaluation of the entire elbow joint with the ability to treat the lesion and coexistent pathology in a minimally invasive fashion. Unfortunately, the prognosis for advanced lesions remains more guarded, but short-term results after newer reconstruction techniques are promising.

Anteromedial elbow arthroscopy portals in patients with prior ulnar nerve transposition or subluxation

PURPOSE

The purpose of this study was to document management strategies and complications relating to the use of anteromedial portals for elbow arthroscopy in a series of patients with subluxating or previously transposed ulnar nerves.

METHODS

A review of 913 elbow arthroscopies showed that 59 elbows with a subluxating or previously transposed ulnar nerve required anterior compartment arthroscopic surgery. The patients with subluxating nerves had proximal anteromedial portals established by reducing and holding the nerve behind the epicondyle with a thumb while establishing or entering the portal. In cases of prior nerve transposition, the following techniques were used if, by palpation, localization of the ulnar nerve was considered to be (1) unequivocal, (2) equivocal, or (3) impossible: In group 1 (unequivocal) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (equivocal) a 1-cm incision was made at the planned proximal anteromedial portal site and blunt dissection down to the capsule was performed without identification of the nerve. In group 3 (impossible) a 2- to 4-cm skin incision was made and the nerve was identified before placement of the portal.

RESULTS

We found that 59 elbows in 56 patients had a subluxating ulnar nerve (31 elbows) or previous ulnar nerve transposition (28 elbows). The transposition had been subcutaneous in 21 and submuscular in 7. The proximal anteromedial portal was used in all but 3 cases (2 patients) of submuscular transposition that were early in the series. In those cases only 2 lateral portals were used for anterior compartment surgery. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal.

CONCLUSIONS

Neither elbow arthroscopy nor specifically the use of the proximal anteromedial portal is contraindicated in patients with prior transposition or subluxation of the ulnar nerve. The management of the nerve can be based on the degree of certainty with which the nerve can be localized by palpation in the region of the planned portal.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Lateral epicondylitis of the elbow

Lateral epicondylitis is a diagnostic term that describes a pattern of pain and localized tenderness at the lateral epicondyle of the distal humerus. The disorder was originally termed tennis elbow in 1883. This term remains in use despite the fact that most affected people are not tennis players. The incidence of lateral epicondylitis is equal among men and women. The average peak age distribution is 42 years (range, 30-50 years). Acute onset of symptoms is much more common in young athletes, and the chronic, recalcitrant pattern most often occurs in older people.This paper discusses the pathology, clinical presentation, and treatment of lateral epicondylitis. A brief description of nonoperative treatment is followed by an in-depth discussion of operative techniques for treating this disorder and a concise report on postoperative care, results, and failures.

Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis

PURPOSE

To evaluate outcomes of arthroscopic tennis elbow release in a population of patients with chronic, recalcitrant symptoms, a large number of workers' compensation claims, and high occupational demands using standardized outcome measures, including a detailed objective assessment of workplace demands.

METHODS

We treated 36 patients with chronic lateral epicondylitis with an arthroscopic release. A standardized protocol was used to measure strength, motion, and outcomes (American Shoulder and Elbow Surgeons Elbow [ASES-e] score, Short Form-12, Patient-Rated Tennis Elbow evaluation [PRTEE], and Work Limitations Questionnaire-26).

RESULTS

The mean duration of symptoms before surgery was 30 months. A total of 25 of 36 patients were employed in heavy or repetitive occupations and 23 of 36 were involved in a workers' compensation claim. The final overall results were favorable, with 30 of 36 subjects reporting improvement with surgery. The final mean Mayo Elbow Performance Index score was 78.6 +/- 16.5 (22 = good to excellent, 9 = fair, and 5 = poor). The average total PRTEE was 26.2 +/- 24.3 out of 100. The average ASES-e pain score was 16.1 +/- 15.0 and the average ASES-e function score was 27.9 +/- 8.8. Patients in heavy or repetitive occupations and those with workers' compensation claims had significantly worse outcome scores (Mayo Elbow Performance Index, ASES, and PRTEE). Based on Work Limitations Questionnaire-26 scores, patients with workers' compensation claims had significantly greater difficulties with physical (36.8 vs 3.2, p < .001), output (40.8 vs 3.1, p = .002), mental (36.0 vs 9.0, p = .05), and social (27.7 vs 6.3, p = .05) workplace demands.

CONCLUSIONS

Arthroscopic tennis elbow release provides symptomatic improvement in most patients with lateral epicondylitis. Patient selection and reported occupational demands have an important role in determining outcomes. More work is required to identify factors predicting outcome in this difficult subgroup.

Elbow arthroscopy

Arthroscopy of the elbow was originally considered to be an unsafe procedure because of the small size of the elbow joint capsule and its proximity to several crucial neurovascular structures. Over the past decade, however, the procedure has become safer and more effective. These improvements can be attributed to a better understanding of elbow anatomy and of the disorders about the elbow as well as to advances in arthroscopic equipment and surgical technique. The most common indications for elbow arthroscopy include removal of loose bodies, synovectomy, débridement and/or excision of osteophytes, capsular release, and the assessment and treatment of osteochondritis dissecans. More recent advances have expanded the indications of elbow arthroscopy to include fracture management (eg, radial head fractures) and the treatment of lateral epicondylitis.

The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study

Symptoms of lateral epicondylitis (LE) are attributed to degenerative changes and inflammatory reactions in the common extensor tendon induced by microscopic tears in the tissue after repetitive or overload functions of the wrist and hand extensor muscles. Conventional treatments, provided on the premise of inflammatory basis of LE, have shown 39-80% failure rate. An alternative approach suggests that symptoms of LE could be due to active tender points developed in the origin of hand and wrist extensor muscles after overuse or repetitive movements. Oscillating-energy Manual Therapy (OEMT), also known as V-spread, is a craniosacral manual technique that has been clinically used for treating tender points over the suture lines in the skull. Considering symptoms of LE may result from active tender points, the purpose of this study was to investigate the effect of OEMT on pain, grip strength, and functional abilities of subjects with chronic LE. Twenty-three subjects with chronic LE (>3mo) between ages of 24 and 72 years participated in this study. Before their participation, all subjects were screened to rule out cervical and other pathologies that could possibly contribute to their lateral elbow pain. Subjects who met the inclusion criteria were randomized into treatment and placebo treatment groups by a second (treating) therapist. Subjects were blinded to their group assignment. Subjects in the treatment group received OEMT for six sessions. During each treatment session, first a tender point was located through palpation. After proper hand placement, the therapist focused the direction of the oscillating energy on the localized tender point. Subjects in the placebo group underwent the same procedure, but the direction of the oscillating energy was directed to an area above or below the tender points, not covering the affected area. Jamar Dynamometer, Patient Specific Functional Scale (PSFS), and Numeric Rating Scale (NRS) were used to measure grip strength, functional status, and pain intensity and limited activity due to pain, respectively. The screening therapist who was blinded to the subjects' group assignment performed pretest, posttest, and six-month follow-up measurements. Subjects in the treatment group showed both clinically and statistically significant improvement in grip strength (p=0.03), pain intensity (p=0.006), function (p=0.003), and limited activity due to pain (p=0.025) compared with those in the placebo group. Follow-up data, collected after six months, showed no significant difference between posttest and follow-up measurements in functional activity (p=0.35), pain intensity (p=0.72), and activity limitation due to pain (p=0.34). Of all the subjects contacted for follow-up assessment, 91% maintained improved function and 73% remained pain free for at least six months. OEMT seems to be a viable, effective, and efficient alternative treatment for LE.

Extra-articular arthroscopic lateral elbow release

We describe a unique extra-articular approach for arthroscopic lateral release for lateral epicondylitis. An arthroscopic extra-articular approach allows better direct visualization of diseased structures with a 30 degrees arthroscope and only requires a small hole in the joint capsule. The camera is placed into the joint through the middle anterolateral portal. The camera is then pulled back through a small rent in the capsule over the lateral radiocapitellar joint to provide an extra-articular view of the diseased structures. The shaver is then placed 1.5 cm proximal to the camera in a proximal anterolateral portal. Debridement of the common extensor fiber tendinosis and decortication of the lateral epicondyle are performed under direct visualization. This is different from the intra-articular technique, where visualization with the 30 degrees arthroscope is more difficult despite a large capsulotomy to aid visualization. The advantage of this extra-articular technique is 2-fold. First, the extra-articular viewing portal allows direct visualization of diseased structures, improving accuracy for debridement compared with an intra-articular viewing portal. The intra-articular technique uses the 30 degrees arthroscope to work around a corner after a large capsulectomy. The second advantage of the extra-articular viewing portal is that it only requires a small capsulotomy. The small capsulotomy decreases the risk of transient radial nerve palsy associated with a capsulectomy. The small capsulotomy also results in less fluid extravasation into the soft tissues. Less fluid extravasation decreases swelling and the risk of compartment syndrome.

[Arthroscopic treatment of acute elbow fractures.]

Surgical management of the rare thrue articular fractures of the elbow remain difficult: the surgeon must achieve anatomical reconstruction with a reliable fixation allowing mobilisation of the joint for early rehabilitation. Arthroscopic treatment of elbow fractures (capitellum, coronoid, olecranous and radial head) gives an excellent intra articular view with few soft tissue damage. Cartilage damage, intra articular loose bodies and capsulolabral injuries are then well adressed. Arthroscopic management of elbow fracture is potentially dangerous for the neuro-vascular structures and requiere good knowleges in elbow arthroscopic technique. We routinely use lateral approach, trying to avoid the medial approach in traumatology. This article relates the differents surgical techniques. A preoperative computed tomography is needed to select the eligible fractures for those techniques.

Sports-related injuries of the elbow

Sports-related injuries about the elbow occur commonly and are often managed by a wide variety of health care providers. It is particularly important that a surgeon well versed in arthroscopy, reconstructive trauma, and peripheral nerve techniques evaluates potentially complex injuries. It is equally imperative that the preoperative care regimen and postoperative management be conducted by an experienced therapist who understands elbow biomechanics and function. Acute pathology, such as fracture or severe ligamentous and tendinous injury, usually warrants operative treatment. A thorough understanding of the anatomy and biomechanics of the elbow is crucial since the expected recovery in the nonathlete will not suffice for the competitive athlete. Demanding activities, such as the overhead-throwing motion cycle, require a much more complete recovery than simple return to activities of daily living. Chronic elbow problems in the athlete can often be managed with appropriate therapy and modification to the training protocol. Poor response to conservative means should lead to a more thorough evaluation by an experienced elbow surgeon as these injuries can often be career ending. The spectrum of commonly seen lesions in the athlete's elbow is described here, as are conservative care measures, operative treatments, and postoperative management.

[Extra-articular elbow arthroscopy.]

Extra-articular elbow arthroscopy has to be considered as the evolution of the elbow surgery to a mini invasive endoscopically assisted surgery developed by the recent advance of the elbow arthroscopy. Various pathologies, such as lateral epicondylitis, ulnar nerve entrapment, distal Biceps tendon rupture, synovial cysts, or olecranon bursitis have been treated arthroscopically. Extra-articular pathologies can be treated through an intra-articular endoscopic approach. The true endoscopic extra-articular technique is proced through a real anatomical space or inside a space of work created de novo by the surgeon. The difficulty of using endoscopy in extra-articular pathologies of the elbow is related to the vasculo-nervous structures sourrounding the articulation wich are directly subject to potential injury. Elbow extra-articular endoscopy must be considered as a difficult and sometimes dangerous procedure reserved to experimented elbow arthroscopic surgeons. Those techniques are yet to demonstrate their superiority in term of results and security compare to the open techniques.

Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: report of three adolescent gymnasts

The aim of this paper is to report on three cases of symptomatic osteochondritis dissecans of the humeral capitellum in adolescent gymnasts, two females and one male. In all the cases arthroscopic surgery was performed. During arthroscopy, loose osteochondral fragments were removed, the defect was debrided and microfractures were performed. All the three patients regained the full range of motion of the affected elbow, and returned to the high-level gymnastics within a period of 5 months. At 12 months follow-up, all the three patients remained symptomless and were participating in high-level gymnastics. A combination of arthroscopy and the microfracture technique is a reliable method with excellent short-term results in the treatment of the osteochondritis dissecans of the elbow.

Arthroscopic treatment of lateral epicondylitis: indication, technique and early results

The purpose of this study is to present the results of the arthroscopic treatment of lateral epicondylitis. Twenty patients with lateral epicondylitis (mean age 42 years) were treated arthroscopically. The average duration of symptoms prior to surgery was 14 months. The arthroscopic joint inspection showed an intact capsule in seven patients (type-I lesion), in eight patients a linear capsule tear (type-II lesion) and in six patients a complete rupture of the capsule (type-III lesion). An associated intraarticular pathology was documented in eight patients. Within an average follow-up period of 1.8 years, local pain and function were documented and analyzed. Subjective pain at rest was reduced from 5.0 to 0.5 points, pain at daily living activities from 6.0 to 1.0 points and pain at athletic activities from 7.3 to 1.2 points in the VAS score. Function increased from 5.2 to an average value of 10.9 (max. 12 points). Patients returned back to work after 3.2 weeks. In conclusion, the arthroscopic release in patients with radial epicondylitis is a reproducible method with a marked postoperative increase in function within a short rehabilitation period.

Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies

Clinical and cadaveric studies were done to investigate the role of a degenerative fringe of the radiocapitellar complex subluxating in the radiocapitellar joint in patients with lateral epicondylitis. In the clinical study, arthroscopic resection of this capsular complex was done. Thirty patients with recalcitrant symptoms of lateral epicondylitis for a minimum of 9 months had surgery. In all patients at arthroscopy, a collar-like band of radiocapitellar capsular complex was found to impinge on the radial head and subluxate into the radiocapitellar joint with manipulation under direct vision. Histologic analyses of the resected tissue showed hyaline degeneration and fibrosis. There were no complications in this series. Twenty-eight patients had complete relief of symptoms by this procedure within 2 weeks of surgery. The average time until return to work was 7 days. Elbow arthroscopy was done in 34 cadaveric elbows to examine the relationship of the annular ligament, the lateral joint capsule, and the radial head. A degenerative capsular fold impinging on the radial head was seen in 15 elbows. A classification system, based on the relationship of the capsular fold to the radial head is described. In Type 1 (19 elbows), the radial head is completely exposed. In Type 2 (six elbows), there is partial coverage of the radial head by the capsuloligamentous complex without interposition into the joint in any position. In Type 3 elbows (six elbows), there is subluxation of the capsular edge into the joint, whereas in Type 4 elbows (three elbows), the radial head is completely obscured throughout the range of motion. The lesion was equally prevalent in men and women. The arthroscopic findings at the time of surgery in the clinical group were the same as the Grade 2 and Grade 3 changes that were seen in cadaveric specimens.

Return to sport following elbow surgery

Although less common than injuries to the knee or shoulder, elbow injuries can be a substantial challenge to sports medicine providers. Many elbow problems respond to routine nonoperative measures including periods of activity modification and physical therapy, but others may ultimately require surgery. Following surgery, appropriate attention to rehabilitation is important to achieve optimal function. This article addresses some of the more common sports-related operative elbow pathology, basic principals of surgery (with an emphasis on techniques only where it may impact rehabilitation or return-to-sport decisions), and return-to-play decisions (including typical "targeted" time frames). The emphasis is on an understanding of sport-specific functional demands and the difficult assessment of reinjury risk following surgery.

Lateral epicondylitis

Satisfactory treatment of lateral epicondylitis results from correct diagnosis followed by a well-controlled operative or nonoperative treatment program. Many options for nonoperative and operative treatment exist for lateral epicondylitis. More study is needed on outcomes of both nonoperative treatment and operative treatment so that each patient can attain maximal improvement. Balanced assessments of specific patient populations, along with definitions of the optimal treatment for each group, are required. This will allow physicians to integrate the available information and improve patient care.

Arthroscopic release for lateral epicondylitis

PURPOSE

This study was performed to review the results of our early experience with recalcitrant lateral epicondylitis treated arthroscopically.

TYPE OF STUDY

This study is a case series consisting of consecutive patients with lateral epicondylitis treated arthroscopically by 1 surgeon.

METHODS

Patients failing a minimum of 6 months of conservative treatment underwent arthroscopic release of the extensor carpi radialis brevis (ECRB) origin using the proximal medial and proximal lateral portals. Associated intra-articular pathology was noted and addressed. The ECRB lesions were classified according to their gross morphology and resected with a shaver. The lateral epicondyle was then decorticated with a burr.

RESULTS

Sixteen patients with recalcitrant lateral epicondylitis were treated with arthroscopic release of the ECRB origin on the lateral epicondyle. Of the 16 elbows undergoing surgery, 5 (31.3%) were noted to have a type I lesion, characterized as fraying of the undersurface of the ECRB. Five (31.3%) had a type II lesion noted by linear tears within the ECRB, and 6 (37.5%) had a type III lesion, consisting of a partial or complete avulsion of the ECRB origin. Concurrent intra-articular pathology (synovitis, osteophytes) was noted in 3 of 16 elbows (18.8%) and was addressed arthroscopically. All patients were followed-up for a minimum of 1 year; however, 4 patients were lost to follow-up for this retrospective review due to military reassignment. Follow-up was obtained on 12 of 16 (75%) of patients at an average length of 24.1 months (range, 15 to 33 months). All patients reported improvement with the procedure. The average return to unrestricted work was 6.0 days (range, 0 to 28 days).

CONCLUSIONS

Arthroscopic release effectively treats lateral epicondylitis while also affording visualization of the joint space to address associated intra-articular pathology. Additionally, arthroscopic release is minimally invasive and allows early rehabilitation and return to normal activities.

Heterotopic ossification following elbow arthroscopy

With advances in technique and skills, the indications for elbow arthroscopy continue to expand. The authors report a case of heterotopic ossification following arthroscopic debridement of the elbow. Surgeons need to be aware of this potential complication of elbow arthroscopy.

Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results

We assessed the clinical utility of 42 arthroscopic releases for lateral epicondylitis in 40 patients (average age, 43 years) with an average of 14 months of symptomatic history before surgery. At arthroscopy, we found 15 type I lesions (intact capsule), 15 type II lesions (linear capsular tear), and 12 type III lesions (complete capsular tear), and associated disorders were found in 69% of the patients. At an average follow-up of 2.8 years, patients were asked to report on elbow pain and function. Subjectively, the patients rated their pain at rest as an average of 0.9 (0 = no pain; 10 = severe pain). They rated their pain with activities of daily living as 1.4 and their pain with sports and work as 1.9. Functionally, they averaged 11.1 of 12 possible points. Of the 39 elbows in the 37 patients who were available for follow-up, 37 were rated "better" or "much better." Patients returned to work in an average of 2.2 weeks. Grip strength averaged 96% of the strength of the unaffected limb. Arthroscopic tennis elbow release is a reliable treatment that allows patients an expedited return to work and may result in greater postsurgical grip strength.