Advanced Elbow Arthroscopy Syllabus
2014-09-03
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ELBOW ARTHROSCOPY FOR LATERAL EPICONDYLITIS Larry D. Field, M.D. Mississippi Sports Medicine Center Jackson, Mississippi DISCLOSURES The following relationships exist: 1. Royalties and stock options None 2. Consulting income Smith & Nephew 3. Research and educational support Arthrex Mitek Smith & Nephew 4. Other support None Lateral Epicondylitis INTRODUCTION Most common elbow condition Lateral elbow pain 30 – 50 year olds Dominant arm Insidious onset 1 Lateral Epicondylitis INTRODUCTION Tendinosis of ECRB origin Histopathology • Vascular proliferation • Hyaline degeneration • “Angiofibroblastic hyperplasia” Lateral Epicondylitis EVALUATION History • Repetitive gripping • Pain localized just below the lateral epicondyle • Gradual in onset • Weakness complaints • Difficulty lifting Lateral Epicondylitis EVALUATION Physical exam • Tenderness over the ECRB origin • Pain reproduced with resisted wrist and finger extension • Grip strength often decreased 2 Lateral Epicondylitis NON-OPERATIVE TREATMENT Therapy Modalities Activity modifications • Workplace • Sport Lateral Epicondylitis NON-OPERATIVE TREATMENT Counterforce bracing • Transfers ECRB origin • Well tolerated Local corticosteroid injections Extensive organized exercises PRP injections Lateral Epicondylitis SURGERY Surgical indications • Pain that interferes with daily activity and occupation • Failure of non-operative treatment for 6 months 3 Lateral Epicondylitis GOALS OF SURGERY Resect pathological tissue • Tendinosis (ECRB, EDC) Address any intra-articular pathology Minimize morbidity Lateral Epicondylitis OPEN RESECTION (NIRSCHL) 1) Split between ECRL and extensor aponeurosis 2) Resect ECRB origin 3) Decorticate lateral epicondyle Lateral Epicondylitis OPEN RESECTION Excellent results • Nirschl 95% – 97% success • Jobe 88% - 93% success 4 Arthroscopic Treatment Why convert to arthroscopic approach for lateral epicondylitis release? Arthroscopic Treatment of Lateral Epicondylitis WHY CHANGE? Less pain Faster recovery Easier rehabilitation Intra-articular pathology • Synovitis • Radiocapitellar plica Arthroscopic Treatment of Lateral Epicondylitis Peart et al, Am J Orthop 2004 • Compared arthroscopic and open release − Level III cohort study − 46 open vs. 29 arthroscopic − Arthroscopic patients had faster return to work and less therapy 8 published level IV case series • Outcomes of arthroscopic release • 189 patients − 174 (92.1%) good to excellent − Only 1 complication (0.5%) o “Forearm paresthesia” 5 Arthroscopic Treatment of Lateral Epicondylitis Baker et al, JSES 2000 37 patients 94% success RTW 2 weeks! No complications Baker et al, AJSM 2008 30 patients Follow-up 11 years 87% satisfied Reliable long term results Arthroscopic vs. Open Tennis Elbow Release Solheim et al (Arthroscopy, 2013) Level III comparison of open and arthroscopic release • 80 open • 225 arthroscopic Follow-up 4 years Failure rate no different No major complications Excellent outcomes higher in arthroscopic group (78% vs 67%) Arthroscopic Treatment of Lateral Epicondylitis ANATOMY ECRB • Beneath ECRL • Blends with capsule 6 Arthroscopic Treatment of Lateral Epicondylitis ANATOMY Lateral Ulnar Collateral Ligament • Inferior to ECRB • Below equator of radial head Arthroscopic Treatment of Lateral Epicondylitis SURGICAL TECHNIQUE Prone or lateral position preferred • Better posterior access • Easier flexion and extension Proximal medial portal • 1-2 cm anterior and proximal to medial epicondyle • Confirm ulnar nerve in groove Arthroscopic Treatment of Lateral Epicondylitis SURGICAL TECHNIQUE Visualize • Coronoid process • Trochlea • Radial head • Capitellum • Lateral capsule Look for other pathology • Radiocapitellar arthrosis • Synovial plica 7 Arthroscopic Treatment of Lateral Epicondylitis SURGICAL TECHNIQUE Capsule classification • Type I – normal • Type II – horizontal rent • Type III – complete rupture of capsule Baker et al JSES 2000 Arthroscopic Treatment of Lateral Epicondylitis SURGICAL TECHNIQUE Anterolateral portal • Localize using spinal needle Arthroscopic Treatment of Lateral Epicondylitis ARTHROSCOPIC RESECTION Create window in capsule Exposes the ECRL and ECRB 8 Arthroscopic Treatment of Lateral Epicondylitis SURGICAL TECHNIQUE Goal • Release tendon • Debride tendon Dissection directly on bone just lateral to articular surface Work from proximal to distal Arthroscopic Treatment of Lateral Epicondylitis SURGICAL TECHNIQUE Arthroscopic retractor may be helpful • Improves “working room” • Protects vital structures Surgical Technique Many variations of arthroscopic release “Bayonet” technique • 221 consecutive patients 5 year period Technique published 2014 • Sharp release of ECRB origin #15 blade “Bayonet” • Arthroscopic resection of detached ECRB 9 Bayonet Technique “Tennis elbow portal” • Very proximal and adjacent to ECRB origin • Localized with spinal needle • Knife blindly releases ECRB origin • Arthroscopic shaver resects ECRB tendon Bayonet Technique No major complications • 221 consecutive cases • 3 minor complications • Portal drainage • Responded to po antibiotics Potential advantages • Quick • Complete release of ECRB • Simplified resection of diseased tissue • 30° arthroscope • No retractor necessary ARTHROSCOPIC RELEASE BAYONET TECHNIQUE 10 Arthroscopic Treatment of Lateral Epicondylitis POSTOPERATIVE PROTOCOL No specific limitations or restrictions PT for stretching and gentle strengthening RTW as tolerated • Several days to 3 months Advantages of Arthroscopic Release Common extensor tendon not divided or taken down Allows for thorough intra-articular evaluation and treatment Patients’ recoveries enhanced • Less pain • Shorter rehab periods Cosmetically superior Summary Arthroscopic lateral epicondylitis release effective • Excellent long term results • Complication rate very low Technique well defined and reproducible • Arthroscopic retractor helpful • Avoid lateral collateral ligament • Conversion to open release simple if technical difficulties arise 11 THANK YOU 12 9/2/2014 ARTHROSCOPIC MANAGEMENT OF ELBOW INSTABILITY Felix H. Savoie III, MD Michael J. O’Brien, MD Tulane University New Orleans, LA COI • Royalties: none • Stock: none • Consultant: DePuy Mitek, Smith & Nephew, Exactech, rotation medical PLRI • Dysfunction of the RUHL complex – Radio-ulnohumeral ligament – Annular ligament – Lateral collateral ligament 1 9/2/2014 DIAGNOSIS • Lateral instability causes impairment of ADL • Shift and pop with supination • Exam: PLRI ( prone ) chair lift, IR push-up Anterior View • Abnormal radial head shift on the capitellum • Laxity of the annular ligament: it will be “dropped down” ANTERIOR VIEW 2 9/2/2014 View of posterolateral gutter • Lateral gapping of olecranon • Entire forearm “moves away” • Easy to “drive through” to medial side ACUTE DISLOCATION ARTHROSCOPIC REPAIR • If we can see it we can fix it! • Requires a 3D conception of where the ligaments are and how they need to be repaired • Current equipment allows very precise anatomical restoration 3 9/2/2014 DISTAL REPAIR: 1st anchor DISTAL REPAIR: 1st stitch LATERAL REPAIR: 2nd stitch • • 4 9/2/2014 LATERAL REPAIR: 2nd anchor CONTINUE REPAIR • • OUTSIDE VIEW / RETRIEVAL 5 9/2/2014 FINAL VIEW: CHECK A/P POST VIEW FINAL FINAL VIEW: CHECK A/P ANT VIEW FINAL ADVANCED: TERRIBLE TRIAD FRACTURE AND LIGAMENT REPAIR 6 9/2/2014 TERRIBLE TRIAD: RADIAL HEAD Evaluate radial head fracture Fixation with headless screws TERRIBLE TRIAD: CORONOID Evaluation and reduction Posterior Screw fixation TERRIBLE TRIAD: CORONOID Evaluation and reduction Posterior Screw fixation 7 9/2/2014 TERRIBLE TRIAD Ligament repair • Localize the RUHL avulsion site (view from posterior) • Establish anchor insertion portal ( lateral) • Retrograde suture retrieval • Tie down to repair ligaments TERRIBLE TRIAD RECONSTRUCTION WITH GRAFT 8 9/2/2014 VIEW OF GRAFT Postop Protocol • • • • • • Splint 1st week Brace 60-90 for 2 weeks Brace 30-90° for 2 weeks Brace 0- full for 2 weeks Progressive therapy for 6 weeks Return to activity @ 4 months RESULTS • Dzugan, et al: 52 pts: PLRI – Acute: 10 Patients: AC score > 190 – Subacute 12 pts: AC score 188, 1 failure – Chronic 30 Pts: AC score 180, 3 failures • Gurley, et al: mixed open & arthroscopic: 88% satisfactory 9 9/2/2014 SUMMARY • Elbow arthroscopy is beneficial in instability • Most lateral instability can be managed by arthroscopy • Elite athletes may do better with early reconstruction • Poor tissue quality, especially in revision cases, may require grafting THANK YOU Ref: AANA book series: The elbow and wrist: Elsevier 10 ARTHROSCOPY FOR RHEUMATOID ARTHRITIS OF THE ELBOW ADVANCED ELBOW ARTHROSCOPY VUMEDI WEBINAR SEPTEMBER 2014 Graham JW King MD, MSc, FRCSC DISCLOSURES I receive royalties and am a consultant for Wright Medical Technology and Tornier Inc. RHEUMATOID ARTHRITIS PATHOLOGY • Synovitis • Cartilage destruction • Bony erosions/deformity • Secondary capsular contracture MAYO CLASSIFICATION DISEASE PROGRESSION 100 50 0 Stage I Mechanical Synovitis Stage II Stage III Stage IV SYNOVECTOMY INDICATIONS • Synovitis not responsive to medical Rx • Pain, stiffness, loss of function • Mayo Stage I & II, IIIa in younger patients SYNOVECTOMY CONTRAINDICATIONS • Inadequate medical management • Severe articular cartilage loss or bony deformity • Mayo Stage III and IV ALTERNATIVE PROCEDURES • Open synovectomy – Extra-articular pannus, severe stiffness, extensive synovitis, lack of arthroscopic experience • Interposition arthroplasty – Advanced articular cartilage loss, younger with pauciarticular disease • Total elbow arthroplasty – Advanced articular cartilage loss, older and lower demand ARTHROSCOPY ADVANTAGES • Less postop pain • Improved articular visualization • Better cosmesis • Decreased morbidity/faster recovery • Less stiffness ARTHROSCOPY PROBLEMS • Close proximity of neurovascular structures to capsule and portals Capsule Ulnar Nerve • Complex anatomy • Congruent joint – limits distraction – small capsular volume – small working space • Elbow arthroscopy experience often limited PATIENT EVALUATION • Skin quality • Ulnar nerve location and function • Elbow and forearm motion • Elbow stability TECHNIQUE • General anaesthesia • Prone or lateral decubitus • Avoid antecubital pressure TECHNIQUE • • • • General anaesthesia Prone or lateral decubitus Avoid antecubital pressure Sterile Tourniquet TECHNIQUE • Release or transpose ulnar nerve if symptomatic or severe loss of flexion • Resect synovium • Debride osteophytes • Excise radial head if symptomatic and restricting forearm rotation (rare) • Capsulectomy if motion limited 57 Y/O FEMALE RA 40 – 125°, INTRACTABLE SYNOVITIS ARTHROSCOPIC SYNOVECTOMY 10 DAYS POSTOP 30 – 135°, MINIMAL PAIN 52 Y/O FEMALE RA 30 – 140°, PAINFUL ROTN 50 - 50° , SYNOVITIS MAYO III ARTHRITIS SYNOVECTOMY & RADIAL HEAD EXCISION SYNOVECTOMY & RH EXCISION 20 – 140°, PAINLESS ROTN 60 - 65° POSTOP MANAGEMENT • Synovectomy alone – outpatient • Synovectomy, capsulectomy and debridement – admit for CPM and pain control with axillary block SPLINTING • Extension splint • Flexion Cuff • Worn at night • Daytime use • Frequently remolded • Frequently adjusted RESULTS: ARTHROSCOPIC SYNOVECTOMY • Horiuchi JBJS 2001 • 71% good to excellent results 2 years • 43% good to excellent results at 8 years • 100% and 71% good to excellent results for Mayo/Larsen grade I and II elbows at 2 & 8 yrs OPEN vs ARTHROSCOPIC SYNOVECTOMY • Tanaka JBJS 2006 • Mayo grade I and II elbows • Arthroscopic outcome equal to open surgery overall • Recurrent synovitis more common with arthroscopy while stiffness/ankylosis more frequent with open surgery • MEPI 50 preop; 78 at 4 years; 67 for scope and 71 for open surgery at 13 years COMPLICATIONS • Nerve injury – posterior interosseous, ulnar, median • Inadequate synovectomy • Recurrent stiffness • Synovial fistula Kelly, O’Driscoll, Morrey, JBJS 2001 SYNOVECTOMY FOR RA • Useful procedure – not the starter elbow • Patients with less articular damage on disease modifying drugs best candidates • Increasing role with more aggressive approach to joint preservation ARTHROSCOPY FOR RHEUMATOID ARTHRITIS OF THE ELBOW ADVANCED ELBOW ARTHROSCOPY VUMEDI WEBINAR SEPTEMBER 2014 Graham JW King MD, MSc, FRCSC Osteochondritis Dissecans Arthroscopic Treatment of Osteochondral Lesions of the Elbow Osteochondral lesions about the elbow • Lateral compression injury in the throwing athlete Julie E. Adams MD, MS Associate Professor Orthopaedic Surgery University of Minnesota The following relationships exist: Royalties: Biomet, Arthrex Consulting: Arthrex, Acumed, Synthes Other: Elsevier • Increased load at the radiocapitellar joint during valgus stress - late cocking and early acceleration Osteochondritis Dissecans Osteochondritis Dissecans • • • • • Described by Koenig in 1888 Osteochondritis - meaning inflammation of the joint surface Dissecans - meaning to separate Currently accepted that inflammation does not play a role More accepted theories include microtrauma and disruption of local vasculature Osteochondritis Dissecans Osteochondritis Dissecans Vs Panner’s disease vs. Panner’s Disease • Lateral compression at the radiocapitellar joint can also result in Panner’s disease • Panner’s disease first described in 1927 • Radiographic fissure and fragmentation of capitellum • 90% boys less than 10 years of age Panner’s Disease Panner’s disease Treatment • Alleviation of symptoms • Reduction in elbow activities • Immobilization for 3 - 4 weeks/anti-inflammatory medications • Symptoms may persist for several months but longterm prognosis excellent Osteochondritis Panner’s disease Dissecans OCD Lesion • Fissuring, size & • fragmentation entire capitellum • Natural history is • Natural typically regeneration History and reconstitution of the capitellum • • No residual deformity is seen Focal lucency surrounded by subchondral sclerosis Classic semilunar demarcation called the “crescent zone” Localized lesion may remain in situ or detach Osteochondritis Dissecans Classification of OCD of Capitellum • • • • IA IB II III Intact/Stable - no loss of subchondral stability Intact/Unstable - impending collapse subchondral bone Open/Unstable - cartilage fracture/partial displacement Detached - loose fragments within the joint Osteochondritis Dissecans • Intact Stable lesions: non-surgical - activity modification – 6/7 heal Takahara, JBJS 2007 • Surgical indications: persistent symptoms • Surgical management: excision of loose bodies or partially attached lesions -Abrasion chondroplasty or subchondral drilling - Internal fixation/osteochondral grafts - results variable EXTRA-ARTICULAR OCD DRILLING EXTRA-ARTICULAR OCD DRILLING EXTRA-ARTICULAR OCD DRILLING Retrograde Drilling Lesion debridement and microfracture 14 yo, 3 y h/o pain. Failed rest. Mechanical symptoms Distal Ulnar Portal Van den Ende, McIntosh, Adams, Steinmann; Arthroscopy, 2011 Osteochondritis Dissecans Results of treatment-OCD Results of treatment - long-term followup: • Bauer: 31 patients - 50% incidence of impaired motion/pain at 23 years F/U (23 with surgery) • Takahara: 53 patients - 50% limitation of elbow function at 13 year F/U (18 with surgery) Bauer et al, CORR, 1992 Takahara et al, CORR, 1999 Osteochondritis Dissecans Osteochondritis Dissecans Dissecans Osteochondritis Osteochondral Autograft Arthroscopic treatment • 10 baseball players (ave. age 13.8 yrs) • Symptoms and objective findings correlated poorly with the radiographic grade of the lesion • Overall excellent results • Follow-up 3.9 yrs average • Only 4 patients returned to organized baseball Byrd and Jones, AJSM, 2002 • 10 athletes (mean age 14.3 yrs) • Cylindrical osteochondral bone plugs - lateral femoral condyle (OATS technique) • Open approach - 2 or 3 plugs ( 5-8mm) • All with bony union at 3 months • Results - excellent 8 poor 2 Shimada et al, CORR, 2005 Osteochondritis Dissecans Osteochondral Autograft Transplantation • 9 baseball players • Mean age 13.6 F/U 3.5 yrs • Kocher’s interval approach • Osteochondral grafts 10mm harvested from the intercondylar notch of the lateral femoral condyle or lateral patellofemoral joint • Casted for 2 weeks • 6 of 9 returned to previous sport level Osteochondritis Dissecans • Retrospective review 7 patients grade II/IV lesions (5 capitellum, 1 trochlea, 1 radial head) • Single osteochondral autograft from knee (9-11mm) • Mean 5 year follow up: – – – – – – 3/7 pain free 7/7 graft incorporation on follow up MRI and no arthritis on radiographs Normal range of motion in all patients All improved and satisfied with procedure No permanent donor site complications All returned to sporting activity without limitation post-operatively Yamamoto et al, AJSM, 2006 • 12 patients (mean age 14.5 yrs) • F/U 3.2 years • Arthroscopic management: partially detached debrided to bleeding cancellous bone • No attempt to drill underlying bone - no short-term advantage seen in this study • 11 patients with minimal symptoms and highly satisfied Ruch et al, Arthroscopy, 1998 JBJS 2007; 89:2188-94 Osteochondritis Dissecans • Retrospective review of 106 patients with OCD of the capitellum • Treatment: – Non-operative: 36 • >50% with mod-severe pain and limitation of activity – Fragment excision: 55 • 35% with mod-severe pain and only 50% returned to competitive sports – Fixation or reconstruction: 15 (12 fixation/bone graft, 3 osteochondral autograft) • 14 patients with mild or no pain, only 1/3 returned to competitive sports • Author Treatment Recommendation: Stable lesions: open physis, grade I lesion, Normal ROM • Activity modification and rest (6/7 Stable lesions healed with rest ) Unstable lesions: closed physis, grade II/III lesion, >20 deg contracture • Treat surgically (specific treatment depends on size, grade and location of lesion JBJS 2007; 89:1205-14 • 27 female gymnasts (age 9-16 years) with 41 arthroscopic surgeries • Average f/u 3.5 years (0.5-7) • Arthroscopic debridement and retrograde drilling • 2 patients antegrade drilling and grafting with intact cartilage surface (failed-both required repeat arthroscopy) • 79% of athletes returned to sport • 40% bilateral • No differences were seen in lesion size between athletes able or not able to return to sport Bartkiw,Hastings, Nassar ASSH annual meeting 2012 Conclusions CONCLUSIONS -The best treatment is prevention and early detection -Arthroscopic debridement is effective treatment of partial or loose lesions -Adjunctive autograft transplantation may help but not shown to be better than simple debridement -Extra-articular drilling can be considered for patients with capitellar OCD and stable lesions THANK YOU! Elbow Arthroscopy for Arthritis Scott P. Steinmann M.D. Professor of Orthopedic Surgery MAYO CLINIC ELBOW ARTHROSCOPY Disclosure –consultation- from Arthrex, Elsevier, Acumed, Biomet, Synthes Royalty- Biomet, Arthrex -Becoming a more common procedure -Indications evolving -Continuing advancement in techniques ELBOW ARTHROSCOPY ELBOW ARTHROSCOPY Neuroanatomy New techniques: -Contracture release -Fear of nerve injury is what makes us most hesitant (appropriate) -Clearly under reported- only a few cases in the -Treatment of arthritis literature -I have heard of every nerve injured (by good with this… a potential for neurovascular injury surgeons) Indications: -Undiagnosed pain -Painful catching or locking (plica) -Loose bodies -Stiffness/Arthritis -Synovectomy -Osteochondritis Dissecans -Lateral Epicondylitis -Fracture -Ulnar neuropathy? -Biceps partial tear debridement? ELBOW ARTHROSCOPY -Preoperative Planning -Standard Radiographs: Anteroposterior Lateral Oblique CT scan (3-D very good for Arthritis and Fracture workup) Lateral Exposure Lateral Approach Radial Head Anterior Open Debridement: Still a good option Posterior ELBOW ARTHROSCOPY Operative Set-up Surgical Technique: -General Anesthesia- preferred -Awkward position for an awake patient -If a block used-you will be unable to ascertain nerve status postop Operative Set-up Operating Room Setup ELBOW ARTHROSCOPY Surgical Technique: -Mark out all portals with surgical pen -Exsanguinate with Esmarch/tourniquet -Inject 20-25 cc saline (direct posterior or anterolateral is easiest) Elbow Arthroscopy Portals -First there is no wrong portal -Just safe portals -Okay to start on Medial, Lateral or Posterior -No limit on the number or portals- use what you need for the job ELBOW ARTHROSCOPY Surgical Portals: Anterolateral -First portal to establish -Place a few mm distal and anterior to radiocapitellar joint sulcus -Incision skin just anterior to RC joint -Assume you are close to the radial nerve (4 mm) Blunt trocar to enter joint Operative Steps Elbow Arthroscopy Anterolateral portal Arthroscopic Anatomy Radial Nerve Anatomy Anatomy Anterior Capsule Anatomy Anterior Capsule Humerus Radial Nerve Median Nerve Radial Head Anatomy Posterior Proximal ELBOW ARTHROSCOPY Loose Bodies IMPORTANT: -Single loose body removal does not help many patients. -Often a clue to the presence of osteophytes and arthritis. Ulnar Nerve Distal Clinical Studies Arthroscopic Treatment of Elbow Arthritis Arthroscopic Treatment of Elbow Arthritis Preoperative • • • • • • 41 patients with Osteoarthritis (42 elbows) Follow-up averaged 176.3 weeks (range: 104-272 weeks) 37 male, 4 female patients Mean age 52.8 years 28 dominant extremities Single surgeon Postoperative Elbow Arthritis with Ulnar NeuropathyRelease of Posteromedial Capsule P value Flexion 117.3° (range: 30-145°) 131.6° (range 90-150°) <0.0001 Extension 21.4° (range 0-50°) 8.4° (range 0-30°) Biter <0.0001 Ulnar Nerve Pronation 72.7° (range: 30-90°) 80.1° (range 20-94°) 0.0937 Supination 70.7° (range 30-90°) 78.6° (range 40-90°) 0.0056 Adams, JSES, 2008 Adams, JSES, 2008 Arthroscopic Ulnar Nerve Decompression in the Setting of Elbow Osteoarthritis Kovachevich and Steinmann, JHS, 2012 Posteromedial Capsule Release Arthroscopic Studies • • • • Arthroscopic Ulnar Nerve Decompression in the Setting of Elbow Osteoarthritis Kovachevich and Steinmann, JHS, 2012 22 patients 42years, mean age Arthroscopic release ROM flexion 122° 141° extension 38°18° Arthroscopic debridement and capsulectomy of the contracted elbow is effective Results are comparable with those of other reports in the literature in which both arthroscopic and open methods were used Nguyen D, Proper SI, MacDermid JC, King GJ, Faber KJ Arthroscopy, 2006. Arthroscopic Studies • Somanchi et al: Acta Orthop Belg 2008: – 26 patients with debridement and capsular release – Functional improvement in 87% – Improved Elbow Functional Assessment score 48 -> 84 • Schubert et al: Acta Orthop Belg 2007 – Improved pain/function at mean 6 yrs in 24 patients – DASH 56.01 Arthroscopic Studies • Krishnan et al JSES 2007 – Arthroscopic Ulnohumeral arthroplasty at 24 mo – Improvement of 73 degrees in f/e arc – High rate of satisfaction • Savoie Arthroscopy 1999: Arthroscopic Ulnohumeral arthroplasty – 92% G E results Evidence-based indications for elbow arthroscopy • Fair-quality evidence in the treatment of rheumatoid arthritis and lateral epicondylitis • Poor-quality evidence for, rather than against, degenerative arthritis, osteochondritis dissecans, radial head resection and loose bodies • Insufficient evidence for or against posterolateral rotatory instability and septic arthritis Yeoh et al, Arthroscopy, 2012 Overview of Arthroscopy for Arthritis • Similar results relative to open procedures • 81-92% G-E results* • Has not been shown to result in sooner return to work, superior outcomes • Does not establish the superiority of this procedure over open procedures *Adams et al JSES 2008; Kelly Arthroscopy 2008; Savoie JSES 1999; Horiuchi et al JBJS 2002; Ogilvie-Harris et al Arhtroscopy 1995; Redden Arthroscopy 1993; Gonda Building - Rochester REMEMBER: Small Cases ... Thank You Thank You ...before Big Cases
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