1
|
Koukos C, Kotsapas M, Sidiropoulos K, Traverso A, Bilsel K, Montoya F, Arrigoni P. A Novel Surgical Treatment Management Algorithm for Elbow Posterolateral Rotatory Instability (PLRI) Based on the Common Extensor Origin Integrity. J Clin Med 2024; 13:2411. [PMID: 38673685 PMCID: PMC11051432 DOI: 10.3390/jcm13082411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Here, we introduce a comprehensive treatment algorithm for posterolateral rotatory instability (PLRI) of the elbow, a condition affecting elbow mobility. We outline a diagnostic approach and a novel surgical management plan through the arthroscopic surgeon's point of view. Methods: The central focus of this management approach is the integrity of common extensor origin (CEO). High clinical suspicion must be evident to diagnose PLRI. Special clinical and imaging tests can confirm PLRI but sometimes the final confirmation is established during the arthroscopic treatment. The most appropriate treatment is determined by the degree of CEO integrity. Results: The treatment strategy varies with the CEO's condition: intact or minor tears require arthroscopic lateral collateral ligament imbrication, while extensive tears may need plication reinforced with imbrication or, in cases of retraction, a triceps tendon autograft reconstruction of the lateral ulnar collateral ligament alongside CEO repair. These approaches aim to manage residual instability and are complemented using a tailored rehabilitation protocol to optimize functional outcomes. Conclusion: PLRI is a unique clinical condition and should be treated likewise. This algorithm offers valuable insights for diagnosing and treating PLRI, enhancing therapeutic decision-making.
Collapse
Affiliation(s)
- Christos Koukos
- Medical Center Wuppertal, 42329 Wuppertal, Germany;
- Sports Trauma and Pain Ιnstitute, 54655 Thessaloniki, Greece
| | - Michail Kotsapas
- Orthopaedic Department, General Hospital of Naousa, 59200 Naousa, Greece
| | - Konstantinos Sidiropoulos
- Medical School of Patras, University of Patras, 26504 Patras, Greece
- Emergency Department, Papageorgiou General Hospital of Thessaloniki, 54635 Thessaloniki, Greece
| | - Aurélien Traverso
- Orthopaedic Department, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
- ASST Pini-CTO, 20122 Milan, Italy
| | - Kerem Bilsel
- Faculty of Medicine, Acibadem Mehmet Ali Aydınlar University, 34752 Instanbul, Turkey;
- Orthopaedics and Traumatology Department, FulyaAcibadem Hospital, 34349 Instanbul, Turkey
| | - Fredy Montoya
- Sanatorio Aleman Clinic, Universidad de Concepcion, Concepcion 4070386, Chile;
| | | |
Collapse
|
2
|
Sax AJ. Osseous Stress Injuries: Treatment Algorithms and Return to Play. Semin Musculoskelet Radiol 2024; 28:130-138. [PMID: 38484765 DOI: 10.1055/s-0043-1778030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Osseous stress injuries are common in athletes. Specifically, lower extremity injuries are prevalent in running athletes and upper extremity injuries are prevalent in throwing athletes. Such injuries are suspected when there is focal bone tenderness and increased pain with the inciting activity. In elite athletes, osseous stress injuries are a relatively common culprit in lost play time. Thus rapid diagnosis and treatment is imperative to expedite return to play (RTP). The radiologist's role in these cases is not only for diagnosis, but also to grade the injury, which has implications in determining a treatment regimen. The high sensitivity and specificity of magnetic resonance imaging is thus the preferred imaging modality. This article discusses common osseous stress injuries, the imaging findings, and how different treatment regimens affect RTP.
Collapse
Affiliation(s)
- Alessandra J Sax
- The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island
| |
Collapse
|
3
|
Grezda K, Lama A, Kusari D, Hajdari Q. Olecranon fossa osteoid osteoma excision through arthroscopy: surgical technique. J Surg Case Rep 2024; 2024:rjad720. [PMID: 38239375 PMCID: PMC10795925 DOI: 10.1093/jscr/rjad720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024] Open
Abstract
In the elbow joint, occurrences of intra-articular osteoid osteoma are uncommon. We detail the case of a 21-year-old male who experienced pain, inflammation, and a restricted ability to move his elbow. For a few months, the diagnoses was missed and the patient was treated for idiopathic synovitis. After a contrast MRI, the tumor was revealed. During an arthroscopic examination of the elbow, a distinct red lesion was observed after the removal of the pale reactive bone in the olecranon cavity. This was subsequently removed in its entirety with the aid of a specialized bone tool. Histopathology confirmed the diagnosis of osteoid osteoma. Remarkably, the individual reported alleviation from the symptoms just a day following the operation and regained full range of motion 5 weeks after the surgery. This case underscores the efficacy of arthroscopy in addressing intra-articular osteoid osteoma, with a focus on accurately pinpointing the lesion.
Collapse
Affiliation(s)
- Kushtrim Grezda
- Department of Orthopedics and Traumatology, University Clinical Centre of Kosova, Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
- University Hospital of Basel, 4031 Basel, Switzerland
| | - Arber Lama
- Department of Orthopedics and Traumatology, University Clinical Centre of Kosova, Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
- Evidence Synthesis Group, 10000 Prishtina, Kosovo
| | - Dren Kusari
- Department of Orthopedics and Traumatology, University Clinical Centre of Kosova, Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
| | - Qendrim Hajdari
- Department of Orthopedics and Traumatology, University Clinical Centre of Kosova, Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
| |
Collapse
|
4
|
Valencia M, Foruria AM. The role of arthroscopy in the management of adult elbow trauma. J Exp Orthop 2023; 10:144. [PMID: 38133719 PMCID: PMC10746683 DOI: 10.1186/s40634-023-00710-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Fractures around the elbow are often challenging to treat and in most cases require an extensive approach. Since the development of elbow arthroscopy, most authors have pointed out the potential advantages of a less invasive technique that can be useful for visualization and reduction of the articular fragments with an eventual percutaneous fixation. Arthroscopic techniques provide a limited exposure that may lead to a faster wound healing, lower rate of complications and thus, better recovery of range of motion. However, elbow arthroscopy is also a demanding technique, especially in a swollen and fractured joint, and it is not exempt of risks. The overall rate of complications has been rated from 1.5% to 11% and nerve injury rates from 1.26-7.5%.The objective of this review is to present the arthroscopic setup and general surgical technique for the management of elbow trauma and to define some clear indications. Patient positioning and operating room display is key in order to obtain success. In addition to the arthroscopic equipment, fluoroscopy is almost always necessary for percutaneous fixation and precise preparation is mandatory. In the last decade, literature regarding new portals or surgical tips for arthroscopic treatment of elbow fractures have been published.The main indications for fracture arthroscopic-assisted fixation are those articular fractures involving the coronoid, distal humerus shear fractures in the coronal plane (trochlear and capitellum fractures) and, more controversially, those affecting the radial head. The treatment of these type of fractures all arthroscopically is exponentially demanding as it might also require ligament repair. For coronoid fractures, it can be useful in Morrey type II and III, and O´Driscoll anteromedial facet fractures associated to a posteromedial instability pattern that also require a repair of the LCL. Although excellent results have been published, comparative series are scarce. Radial head fractures can also be approached arthroscopically in simple non-comminute fractures that can be fixed percutaneously.In conclusion, arthroscopy of the elbow is an excellent tool to better understand and visualize articular fractures of the elbow. However, despite the advances in surgical technique, whether it improves clinical and radiological results is still to be proven.
Collapse
Affiliation(s)
- Maria Valencia
- Division of Shoulder and Elbow Surgery, Hospital Universitario Fundación Jiménez Díaz, Avenida Reyes Católicos Nº2, Madrid, 28040, Spain
| | - A M Foruria
- Head of Division of Shoulder and Elbow Surgery Unit, Hospital Universitario Fundación Jiménez Díaz, Avenida Reyes Católicos Nº2, Madrid, 28040, Spain.
| |
Collapse
|
5
|
de Klerk HH, Verweij LPE, Sierevelt IN, Priester-Vink S, Hilgersom NFJ, Eygendaal D, van den Bekerom MPJ. Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review. Arthroscopy 2023; 39:2363-2387. [PMID: 37146664 DOI: 10.1016/j.arthro.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE To perform a systematic review of complications associated with elbow arthroscopy in adults and children. METHODS A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool. RESULT A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication. CONCLUSIONS Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates. LEVEL OF EVIDENCE Level IV; systematic review of Level I-IV studies.
Collapse
Affiliation(s)
- Huub H de Klerk
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.; Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, the Netherlands.
| | - Lukas P E Verweij
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam UMC, Amsterdam, the Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - Inger N Sierevelt
- Specialized Centre for Orthopedic Research and Education (SCORE), Xpert Clinics, Orthopedic Department, Amsterdam, the Netherlands; Department of Orthopaedics, Spaarne Gasthuis Academie, Hoofddorp, the Netherlands
| | - Simone Priester-Vink
- Medical Library, Department of Research and Epidemiology, OLVG, Amsterdam, the Netherlands
| | - Nick F J Hilgersom
- Department of Orthopaedic Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
| |
Collapse
|
6
|
Siemensma MF, van der Windt AE, van Es EM, Colaris JW, Eygendaal D. Management of the stiff elbow: a literature review. EFORT Open Rev 2023; 8:351-360. [PMID: 37158372 PMCID: PMC10233805 DOI: 10.1530/eor-23-0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient's activities of daily living. Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness. In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended. Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications. Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months. This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.
Collapse
Affiliation(s)
- Mark F Siemensma
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Anna E van der Windt
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Eline M van Es
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Joost W Colaris
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Ellenbogenfrakturen. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00596-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
|
8
|
Substantiation of safe and effective arthroscopic approaches to the elbow joint in case of enthesopathy of the distal humerus. TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2022. [DOI: 10.17816/2311-2905-1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background: With the development of arthroscopic surgical techniques, diagnostic and therapeutic possibilities have significantly expanded, but they have not become widely used in everyday clinical practice in the treatment of elbow joint pathology. This is due to the small volume of the joint, the close location of the neurovascular formation and the complexity of manipulation. Elbow arthroscopy is a dynamic procedure with a change in the ratio of neurovascular structures and portals in different elbow positions. The risk of damage to neurovascular formations during arthroscopy of the elbow joint is up to 14%.
Purpose: determination of the safest areas promising for the formation of arthroscopic approaches to the elbow joint in the treatment of patients with enthesopathy of the distal humerus..
Methods: To achieve this goal, a complex topographic- anatomical and clinical study was performed on 30 non-fixed anatomical preparations of the upper limb, which included 4 stages, where the topographic and anatomical features of the tendon-muscular and neurovascular structures forming the elbow joint were studied, depending on the angle of flexion of the elbow joint at 3 different levels: level I - 5 cm above the joint space, level II - joint space, level III - the neck of the radius, additionally the above structures were studied using MRI studies in 30 patients.
Results: When the elbow joint is flexed to 90, the brachial artery at level I moves away from the bone and is located at a distance from 27,8 (27.7-28,1) mm to 28,6 (28,4-28,7). The radial nerve at the II level from СMEL is located at 16,4 (16,5-18,8) mm. Median nerve from СMEL by 17,5 (16,6-18,1) mm. The brachial artery is 23,7 (20,522,8) mm distant from the СMEL. The anterior bundle of the MCL has: an average proximal width of 6,2 1,4 mm, an average width of the middle part of 6,5 1,5 mm, an average distal width of 9,3 1,4 mm. The average area of attachment on the medial epicondyle of the humerus is 45,5 9,3 mm, it has a rounded shape. The radial collateral ligament has an average length of 20,5 1.9 mm and a bundle width of 5,2 0,8mm. The average area of attachment on the humerus is 13,6 mm. The average area of ECRB on the lateral epicondyle of the humerus was 53,1 3,7mm. The mean area of the FCR on the medial epicondyle was 58,3 6.3mm. The distance from the entrance of the deep branch of the radial nerve to the canalis sapinatorius to the joint space is 28 (25,529,6) mm.
Conclusion: The results of this study allow the operating surgeon to decide on the choice and placement of arthroscopic access to the elbow joint, which in turn helps to minimize the risk of damage to neurovascular structures.
Collapse
|
9
|
Preoperative Evaluation and Surgical Simulation for Osteochondritis Dissecans of the Elbow Using Three-Dimensional MRI-CT Image Fusion Images. Diagnostics (Basel) 2021; 11:diagnostics11122337. [PMID: 34943574 PMCID: PMC8700753 DOI: 10.3390/diagnostics11122337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022] Open
Abstract
We used our novel three-dimensional magnetic resonance imaging-computed tomography fusion images (3D MRI-CT fusion images; MCFIs) for detailed preoperative lesion evaluation and surgical simulation in osteochondritis dissecans (OCD) of the elbow. Herein, we introduce our procedure and report the findings of the assessment of its utility. We enrolled 16 men (mean age: 14.0 years) and performed preoperative MRI using 7 kg axial traction with a 3-Tesla imager and CT. Three-dimensional-MRI models of the humerus and articular cartilage and a 3D-CT model of the humerus were constructed. We created MCFIs using both models. We validated the findings obtained from the MCFIs and intraoperative findings using the following items: articular cartilage fissures and defects, articular surface deformities, vertical and horizontal lesion diameters, the International Cartilage Repair Society (ICRS) classification, and surgical procedures. The MCFIs accurately reproduced the lesions and correctly matched the ICRS classification in 93.5% of cases. Surgery was performed as simulated in all cases. Preoperatively measured lesion diameters exhibited no significant differences compared to the intraoperative measurements. MCFIs were useful in the evaluation of OCD lesions and detailed preoperative surgical simulation through accurate reproduction of 3D structural details of the lesions.
Collapse
|