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

Most common elbow condition

Lateral elbow pain

30 –50 year olds

Dominant arm

Insidious onset

INTRODUCTION

Tendinosis of ECRB origin

Histopathology

•Vascular proliferation

•Hyaline degeneration

•“Angiofibroblastic

hyperplasia”

Lateral Epicondylitis

INTRODUCTION

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

Lateral Epicondylitis

EVALUATION

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

NON-OPERATIVE TREATMENT

Surgical indications

•Pain that interferes with daily activity and

occupation

•Failure of non-operative treatment for 6

months

Lateral Epicondylitis

SURGERY

Resect pathological tissue

•Tendinosis (ECRB, EDC)

Address any intra-articular pathology

Minimize morbidity

Lateral Epicondylitis

GOALS OF SURGERY

1) Split between ECRL and extensor

aponeurosis

2) Resect ECRB origin

3) Decorticate lateral epicondyle

Lateral Epicondylitis

OPEN RESECTION

(NIRSCHL)

Excellent results

•Nirschl

95% –97% success

•Jobe

88% - 93% success

Lateral Epicondylitis

OPEN RESECTION

Arthroscopic Treatment

Why convert to

arthroscopic approach for

lateral epicondylitis

release?

Less pain

Faster recovery

Easier rehabilitation

Intra-articular pathology

•Synovitis

•Radiocapitellar plica

Arthroscopic Treatment of Lateral

Epicondylitis

WHY CHANGE?

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”

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

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%)

Solheim et al (Arthroscopy, 2013)

ECRB

•Beneath ECRL

•Blends with capsule

Arthroscopic Treatment of Lateral

Epicondylitis

ANATOMY

Lateral Ulnar Collateral Ligament

•Inferior to ECRB

•Below equator of radial

head

Arthroscopic Treatment of Lateral

Epicondylitis

ANATOMY

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

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

SURGICAL TECHNIQUE

Create window in capsule

Exposes the ECRL and

ECRB

Arthroscopic Treatment of Lateral

Epicondylitis

ARTHROSCOPIC RESECTION

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

Arthroscopic Treatment of Lateral

Epicondylitis

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

Surgical 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

Bayonet Technique

ARTHROSCOPIC RELEASE

BAYONET TECHNIQUE

No specific limitations or restrictions

PT for stretching and gentle strengthening

RTW as tolerated

•Several days to 3 months

Arthroscopic Treatment of Lateral

Epicondylitis

POSTOPERATIVE PROTOCOL

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

THANK YOU

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

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

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

9/2/2014

DISTAL REPAIR: 1st anchor

DISTAL REPAIR: 1st stitch

LATERAL REPAIR: 2nd stitch

• •

9/2/2014

LATERAL REPAIR: 2nd anchor

CONTINUE REPAIR

• •

OUTSIDE VIEW / RETRIEVAL

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

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

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

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

9/2/2014

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

ARTHROSCOPY FOR RHEUMATOID

ARTHRITIS OF THE ELBOW

Graham JW King MD, MSc, FRCSC

ADVANCED ELBOW ARTHROSCOPY

VUMEDI WEBINAR

SEPTEMBER 2014

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

Synovitis

Mechanical

100

Stage I Stage II Stage

III Stage

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

•Complex anatomy

•Congruent joint

–limits distraction

–small capsular volume

–small working space

•Elbow arthroscopy experience often limited

Ulnar Nerve Capsule

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

•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

TECHNIQUE

57 Y/O FEMALE RA

40 –125°, INTRACTABLE SYNOVITIS

ARTHROSCOPIC SYNOVECTOMY

10 DAYS POSTOP

30 –135°, MINIMAL PAIN

30 –140°, PAINFUL ROTN 50 - 50°, SYNOVITIS

52 Y/O FEMALE RA

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

•Worn at night

•Frequently remolded

•Flexion Cuff

•Daytime use

•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

•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

OPEN vs ARTHROSCOPIC

SYNOVECTOMY

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

Graham JW King MD, MSc, FRCSC

ADVANCED ELBOW ARTHROSCOPY

VUMEDI WEBINAR

SEPTEMBER 2014

Julie E. Adams MD, MS

Associate Professor

Orthopaedic Surgery

University of Minnesota

Arthroscopic Treatment of Osteochondral

Lesions of the Elbow

Osteochondral lesions about the elbow

The following relationships exist:

Royalties: Biomet, Arthrex

Consulting: Arthrex, Acumed, Synthes

Other: Elsevier

•Lateral compression injury in the throwing athlete

•Increased load at the radiocapitellar joint during

valgus stress - late cocking and early acceleration

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

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

Osteochondritis Dissecans

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 long-

term prognosis excellent

Panner’s disease

Osteochondritis Dissecans

•Fissuring, size &

fragmentation entire

capitellum

•Natural history is

typically regeneration

and reconstitution of

the capitellum

•No residual deformity

is seen

Panner’s disease OCD

•Focal lucency

surrounded by

subchondral sclerosis

•Classic semilunar

demarcation called the

“crescent zone”

•Localized lesion may

remain in situ or detach

Lesion

Natural

History

Osteochondritis Dissecans

Classification of OCD of Capitellum

•IA Intact/Stable - no loss of subchondral stability

•IB Intact/Unstable - impending collapse subchondral bone

•II Open/Unstable - cartilage fracture/partial displacement

•III 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

Osteochondritis Dissecans

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 -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

Results of treatment-OCD

Osteochondritis Dissecans

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

Osteochondritis Dissecans

Osteochondral Autograft

•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

Yamamoto et al, AJSM, 2006

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

JBJS 2007; 89:2188-94

Osteochondritis Dissecans

•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

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

Osteochondritis Dissecans

•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

Osteochondritis Dissecans

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

Conclusions

THANK YOU!

Scott P. Steinmann M.D.

Professor of Orthopedic Surgery

MAYO CLINIC

Elbow Arthroscopy

for

Arthritis

Disclosure –consultation- from Arthrex, Elsevier,

Acumed, Biomet, Synthes

Royalty- Biomet, Arthrex

ELBOW ARTHROSCOPY

-Becoming a more common procedure

-Indications evolving

-Continuing advancement in techniques

ELBOW ARTHROSCOPY

New techniques:

-Contracture release

-Treatment of arthritis

with this… a potential for neurovascular injury

Neuroanatomy

-Fear of nerve injury is what makes us most hesitant

(appropriate)

-Clearly under reported- only a few cases in the

literature

-I have heard of every nerve injured (by good

surgeons)

ELBOW ARTHROSCOPY

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)

Open Debridement:

Still a good option

Lateral Exposure

Radial Head

Lateral Approach

Posterior

ELBOW ARTHROSCOPY

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

-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

Portals

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

Anatomy Anterior Capsule

Radial Nerve

Humerus

Radial Head

Radial Nerve Anatomy

Anatomy Anterior Capsule

Median Nerve

Anatomy Posterior

Ulnar Nerve

Proximal

Distal

ELBOW ARTHROSCOPY

Loose Bodies

IMPORTANT:

-Single loose body removal

does not help many patients.

-Often a clue to the presence

of osteophytes and arthritis.

Clinical Studies

•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

Arthroscopic Treatment of Elbow Arthritis

Adams, JSES, 2008

Arthroscopic Treatment of Elbow Arthritis

Preoperative Postoperative Pvalue

Flexion 117.3°(range: 30-145°) 131.6°(range 90-150°) <0.0001

Extension 21.4°(range 0-50°) 8.4°(range 0-30°) <0.0001

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

Elbow Arthritis with Ulnar Neuropathy-

Release of Posteromedial Capsule

Ulnar Nerve

Biter

Arthroscopic Ulnar Nerve Decompression in the

Setting of Elbow Osteoarthritis

Kovachevich and Steinmann, JHS, 2012

Posteromedial Capsule Release

Arthroscopic Ulnar Nerve Decompression in the

Setting of Elbow Osteoarthritis

Kovachevich and Steinmann, JHS, 2012

Arthroscopic Studies

•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;

REMEMBER:

Small Cases ...

...before Big Cases

Gonda Building - Rochester

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Advanced Elbow Arthroscopy Syllabus

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