Avoiding Neurological Complications of Elbow Arthroscopy

Arthroscopic-Assisted Fracture Fixation About the Elbow

Arthroscopic-assisted fracture fixation can be used for some adult elbow fractures. In particular, for articular fractures of the anterior elbow (coronoid/capitellum), elbow arthroscopy can provide excellent visualization of fracture fragments using a less invasive surgical exposure. Meticulous adherence to safe techniques and utilization of specialized equipment can help maximize safety and facilitate reproducible surgical results.

Intra-Articular Ultrasonography Probe for Minimally Invasive Upper Extremity Arthroscopic Surgery: A Phantom Study

BACKGROUND

Upper extremity arthroscopic surgery is a highly technique-dependent procedure that requires the surgeon to assess difficult cartilage conditions and manage the risk of iatrogenic damage to nerves and vessels adjacent to the joint capsule in a confined joint space, and a device that can safely assist in this procedure has been in demand.

METHODS

In this study, we developed a small intra-articular ultrasound (AUS) probe for upper extremity joint surgery, evaluated its safety using underwater sound field measurement, and tested its visualization with a phantom in which nerves and blood vessels were embedded.

RESULTS

Sound field measurement experiments confirmed the biological safety of the AUS probe's output, while confirming that sufficient output power level performance was obtained as an ultrasound measurement probe. In addition, images of blood vessels and nerves were reconstructed discriminatively using A-mode imaging of the agar phantom.

CONCLUSIONS

This study provides proof-of-concept of the AUS probe in upper extremity surgery. Further studies are needed to obtain approval for use in future medical devices.

Have Elbow Arthroscopy Hospitalizations Decreased over the Years? An Epidemiological Italian Study from 2001 to 2016

This study describes the trends of elbow arthroscopy in Italy and other countries in order to evaluate the yearly rates of EA. Its purpose is for future epidemiological studies to be able to compare their data between countries in order to understand the reasons for the increasing and decreasing trends. Data for this study were obtained from National Hospital Discharge records (SDO) at the Italian Ministry of Health (INHS). Data regarding sex, age, region of residence, region of surgery, length of hospitalization, and procedure codes were included. In total, 2414 elbow arthroscopies were performed in Italy from 2001 to 2016 in the adult population. The highest number of procedures was found in the 40-44 and 45-49 years age groups. Males represented the majority of patients undergoing EA both in total and over the years. An increase from 2001 to 2010 and a decrease from 2010 to 2016 were reported in the present analysis. According to other studies, males of 40-44 and 45-49 years age groups represent the most treated patients. Further epidemiological studies would provide data that could be compared between countries, reaching a general consensus on the best indications for this procedure.

No Difference in Complication or Reoperation Rates Between Arthroscopic and Open Debridement for Lateral Epicondylitis: A National Database Study

PURPOSE

To compare complication rates and 5-year reoperation rates between open debridement (OD) and arthroscopic debridement (AD) for lateral epicondylitis.

METHODS

The PearlDiver MUExtr database (2010-2019) was reviewed for patients diagnosed with lateral epicondylitis (queried by International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision [ICD-10] codes) undergoing OD or AD of the common extensor tendon without repair (queried by Current Procedural Terminology codes). Patients were stratified into 2 cohorts: those who underwent AD and those who underwent OD. Nonoperative treatment modalities were reported for both groups within 1 year before index procedure. The rates of 90-day postoperative complications were compared, and multivariate logistic regression analysis was used to identify risk factors for complications. The 5-year reoperation rates, using laterality-specific ICD-10 codes, were also compared between the 2 groups.

RESULTS

In total, 19,280 patients (OD = 17,139, AD = 2,141) were analyzed in this study. The most common nonoperative treatments for patients who underwent OD or AD were corticosteroid injections (49.5% vs 43.2%), physical therapy (24.8% vs 25.7%), bracing (2.8% vs 3.2%), and platelet-rich plasma injections (1.3% vs 1.0%). There were no significant differences in radial nerve injuries, hematomas, surgical site infections, wound dehiscence, and sepsis events between the 2 procedures (P = .50). The 5-year reoperation rate was not significantly different between the AD (5.0%) and OD (3.9%) cohorts (P = .10).

CONCLUSIONS

For lateral epicondylitis, both AD and OD of the extensor carpi radialis brevis (without repair) were found to have low rates of 90-day adverse events, with no significant differences between the 2 approaches. Similarly, the 5-year reoperation rate was low and not statistically different for those treated with OD or AD.

LEVEL OF EVIDENCE

Level III, cross-sectional study.

Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment

Arthroscopy of the shoulder, elbow, hip, and knee has become increasingly utilized due to continued advancements in technique, training, and instrumentation. In addition, arthroscopy is generally safe and effective in the utilization of joint preservation surgical techniques. The arthroscopist must utilize a thorough understanding of the surgical anatomy, detailed care with patient positioning, and safe instrumentation portals to prevent associated neurological injury. In the event of postoperative neurological complications, the physician must carefully document the patient history and physical examination while considering the utilization of additional imaging, testing, or surgical nerve exploration with a specialized team depending upon the severity of neurological injury. In this review, we discuss the prevention, evaluation, and treatment of neurological complications related for arthroscopic procedures of the shoulder, elbow, hip, and knee.

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.

The evolution of virtual reality in shoulder and elbow surgery

Virtual Reality (VR) in orthopedic surgery has significantly increased in popularity in the areas of preoperative planning, intraoperative usage, and for education and training; however, its utilization lags behind other surgical disciplines and industries. The use of VR in orthopedics is largely focused on education and is currently endorsed by North American and European training committees. The use of VR in shoulder and elbow surgery has varying levels of evidence, from I to IV, and typically involves educational randomized controlled trials. To date, however, the terms and definitions surrounding VR technology used in the literature are often redundant, confusing, or outdated. The purpose of this review, therefore, was to characterize previous uses of VR in shoulder and elbow surgery in preoperative, intraoperative, and educational domains including trauma and elective surgery. Secondary objectives were to provide recommendations for updated terminology of immersive VR (iVR) as well as provide a framework for standardized reporting of research surrounding iVR in shoulder and elbow surgery.

Arthroscopic osteocapsular arthroplasty for advanced-stage primary osteoarthritis of the elbow using a computed tomography-based classification

HYPOTHESIS

Arthroscopic osteocapsular arthroplasty for stage III osteoarthritis (advanced stage) shows worse clinical and radiologic outcomes compared with stage I or II according to computed tomography (CT)-based classification.

METHODS

Clinical and radiologic outcomes in 65 patients treated with arthroscopic osteocapsular arthroplasty were retrospectively analyzed for range of motion (ROM) arc, functional score (Mayo Elbow Performance Score [MEPS]), and pain score (visual analog scale [VAS]). Patients were classified into stage I or II (n = 44) and stage III (n = 21) groups according to CT-based classification, and postoperative clinical outcomes and complications were analyzed.

RESULTS

Mean follow-up duration was 32.9 ± 13.7 months (range, 24-69). The average patient age was 52 ± 10 years (range, 40-63). Improvements from preoperative to final follow-up were seen in the overall ROM-flexion from 94° ± 19° to 129° ± 14° (P < .01), ROM-extension from 25° ± 12° to 14° ± 7° (P < .01), MEPS from 45 ± 13 to 78 ± 14 (P < .01), and VAS score from 6.3 ± 1.6 to 3.1 ± 1.4 (P < .01). Subgroup analysis using the CT-based classification revealed that stage III led to worsened VAS score and MEPS than stage I or II.

CONCLUSIONS

Arthroscopic osteocapsular arthroplasty can be recommended for its favorable overall treatment outcomes for elbow osteoarthritis. However, stage III shows worse clinical and radiologic outcomes compared with stage I or II according to CT-based classification.

Comparison of arthroscopic debridement and open debridement in the management of lateral epicondylitis: A systematic review and meta-analysis

BACKGROUND

Previous studies have reported that both arthroscopic debridement (AD) and open debridement (OD) of extensor carpi radialis brevis are effective in the treatment of lateral epicondylitis. Despite this, few studies have focused on the comparative outcomes of these 2 procedures. The aim of this study was to assess whether AD is superior to OD in managing lateral epicondylitis.

METHODS

A systematic search of the literature was conducted to identify relevant articles that were published in MEDLINE, Embase, and Cochrane Library databases during January 2019. All studies comparing the efficacy of AD and OD in terms of failure rate, complication rate, and clinical outcome measures were included. Statistical analysis was performed using Review Manager.

RESULTS

Six clinical trials were included in the current meta-analysis. There was no significant difference with regard to disabilities of the arm, shoulder, and hand scores, visual analog scale, and failure rate. There was a statistically significant difference in surgical time in favor of the OD (mean difference [MD], -11.45, 95% confidence interval [CI], -12.45 to -10.44, I = 0%, P < .001). There was no significant difference of complication rate between the OD group (0.6%) and the AD group (1.0%) (MD, 0.62; 95% CI, 0.12-3.06; P = .55) CONCLUSION:: There was no significant difference between arthroscopic and open surgery with regards to failure rate, functional outcome score, and complication rate. The current meta-analysis found that arthroscopic surgery had a longer surgical time than open surgery for lateral epicondylitis.

Surgical outcomes for post-traumatic stiffness after elbow fracture: comparison between open and arthroscopic procedures for intra- and extra-articular elbow fractures

HYPOTHESIS

We hypothesized that arthroscopic osteocapsular arthroplasty has a comparable outcome to that of the corresponding open procedure.

METHODS

Patients treated with osteocapsular arthroplasty for post-traumatic stiffness were assigned to open procedure (OPEN) and arthroscopic procedure (ARTHRO) groups. The clinical outcomes were measured based on range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) score. Based on the initial trauma, the patients were grouped into either intra-articular fracture (I) or extra-articular fracture (E) groups, followed by comparison of the 2 groups.

RESULTS

The overall, ROM, VAS, and MEPS scores showed improvement in both groups. Preoperative VAS scores improved from 6.6 ± 1.4 to 2.2 ± 0.9 following OPEN and from 6.5 ± 1.2 to 2.1 ± 1.0 following ARTHRO. Preoperative flexion improved from 88° ± 14° to 113° ± 17° following OPEN and from 102° ± 15° to 122° ± 8° following ARTHRO. Preoperative extension improved from 36° ± 14° to 17° ± 12° following OPEN and from 30° ± 8° to 15° ± 7.4° following ARTHRO. Preoperative MEPS improved from 48.9 ± 11.5 to 80.0 ± 14.8 following OPEN and from 52.3 ± 12.2 to 80.8 ± 7.9 following ARTHRO. All values for the clinical outcomes were worse in group I than in group E.

CONCLUSIONS

Arthroscopic osteocapsular arthroplasty is comparable to the corresponding open procedure with regard to the use of our indications. The clinical outcomes in the intra-articular fracture group as a previous trauma were worse than those in the extra-articular fracture group.

[Performance control after arthroscopic arthrolysis with capsulectomy in fresh-frozen elbow joints]

BACKGROUND AND OBJECTIVE

Posttraumatic or postoperative movement restrictions in elbow joints can often occur (including capsular contracture) and can generate everyday limitations. In persistent elbow stiffness, arthroscopic arthrolysis with removal of the dorsal and ventral capsule portions can be carried out. The purpose of this study was to assess the efficacy of arthroscopic capsulectomy by means of an in vitro anatomical study.

METHODS

A standardized elbow arthroscopy with ventral and dorsal capsulectomy was performed and image-documented in five fresh-frozen elbow specimens. Subsequently, open dissection of the elbow joint was performed to analyze the amount of residual capsule by means of photodocumentation of the specimens.

RESULTS

Regardless of the surgeon and surgical experience, anterior and posterior remnants of the capsule remained in all specimens. Dorsal capsule strands around the standard arthroscopy portals were noticed particularly more often in the area of the high dorsolateral camera portal. An incomplete capsulectomy was seen on the ulnar side at the level of the posterior medial ligament (PML) in the immediate vicinity of the ulnar nerve. Ventrally, a capsulectomy was performed from the radial side and also the ulnar side until the brachialis muscle and additionally a complete capsulectomy as far as the anterior medial ligament (AML) and radial collateral ligament (RCL) was achieved. The capsule was completely resected in a proximal direction. Distally, irrelevant capsular remnants were found in the region of the annular ligament and distal of the tip of the coronoid process.

CONCLUSION

Arthroscopic arthrolysis can be performed with a high degree of radicality. The radicality must be self-critically taken into account in one's own action. The radicality of the portal change may even be higher ventrally than with an isolated column procedure. On the other hand, it must be critically considered that posteriorly, the PML cannot be adequately addressed by means of arthroscopy due to the risk of ulnar nerve injury. Portal changes might help to enable a more complete visualization of the joint capsule and may avoid leaving possibly relevant remnants of the capsule. If a release of the PML is required, this may have to be carried out in combination with an ulnar nerve release in a mini-open technique.