Arthroscopic debridement for primary elbow osteoarthritis with and without capsulectomy: a comparative cohort study

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

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.

A systematic review of elbow arthroscopy complications : Complications, risk factors, and safety tips

PURPOSE

To determine the complications from elbow arthroscopy for the past 16 years, and to summarize the most reported safety techniques and risk factors.

METHODS

Eligibility criteria included level I to IV evidence articles that were published after 2005 in the English language. Excluded were vet, paediatric, and cadaver studies. Open and arthroscopic-assisted elbow procedures were not included. Two online databases were comprehensively searched (PubMed and PMC) in April 2021. Relevant paper selection was conducted by two independent reviewers. MINORS score, demographic properties, indications, procedure type, complication rates, reoperation rates, reported risk factors, and safety techniques were recorded.

RESULTS

Fifty-two articles met the criteria and were included. No relevant level I to II evidence studies were discovered. The mean age ranged from 31 to 65 years. The average body mass indexes were between 26 and over 40 kg/m². There was a prevalence of male sex (from 50.2 to 79.2%). Most of the studies reported a minimum follow-up (range, 4 weeks-12 months). The most common arthroscopic procedure was debridement (up to 73% in Leong et al.'s study). The average MINORS score was 12 (range, 10-16). The total complications rate ranged from 1.5 to 11%, with a few studies reporting over 25%. Nerve injury rate was 1.26-7.5%. Re-operation rate ranged from none (100 procedures) to 11.8%.

CONCLUSIONS

Elbow arthroscopy is a successful procedure with a low overall complications rate (from 1.5 to 11%), and a low nerve injury rate (from 1.26 to 7.5%). Risk factors include patient-related factors (obesity, female sex, age over 65 years, elevated blood sugar levels, hypercoagulable disorder, tobacco and alcohol use), preoperative elbow impairment/previous surgery, and periprocedural steroid injections. Our review discovered a re-operation rate of 2 to 18%.

Reliable Pain Relief But Variable Return to Play After Arthroscopic Elbow Debridement in Baseball Players

Purpose

We sought to determine the rate of return to play (RTP) in baseball players following arthroscopic elbow debridement for the management of the symptomatic elbow.

Methods

A retrospective case series with prospectively collected data via questionnaire was conducted on all baseball players who underwent an arthroscopic elbow debridement, from July, 15, 2004 to November 1, 2017. A postoperative questionnaire was released at an average 7.25 year follow-up. Data collected included age, gender, laterality, preoperative diagnosis, range of motion, duration and characterization of symptoms, visual analog scale (VAS) pain score, complications, level of play, and RTP.

Results

Follow-up data were available on 18 baseball players. Average age was 19.7 years (range 16-24). Seventeen were pitchers, and 1 was a catcher. Level of play included 12 collegiate athletes, 2 high school athletes, 2 recreational athletes, 1 minor league athletes, and 1 major league athlete. Rate of RTP was 61% (11/18) with 6 returning to a greater level and 5 to an equal level. The length of time to RTP following surgery was most commonly within 6-8 months (44.4%, 8/18). Mean VAS pain score improved from 6.9 to 0.75 (P = <.001). 27.8% (5/18) had repeat surgery secondary to recurrent/persistent stiffness or heterotopic ossification. 77.8% (14/18) of patients rated their final outcome as either “very satisfied” (9/18), or “satisfied” (5/18).

Conclusions

Pain can reliably be relieved following arthroscopic elbow debridement in baseball players. Although patient satisfaction may be high, patients do not always return to their previous level of play. Patients must be counseled on the risk of limited postoperative athletic capacity before the time of surgery.

Level of Evidence

Level IV, therapeutic case series.

The clinical impact of arthroscopic vs. open osteocapsular débridement for primary osteoarthritis of the elbow: a systematic review

BACKGROUND

Primary elbow osteoarthritis (PEOA) is a debilitating disease that can be difficult to treat. Osteocapsular débridement (OD) has been described through various approaches, including arthroscopic and open approaches, with successful outcomes in treating PEOA. There is insufficient evidence in the literature to date to demonstrate the superiority of any approach. The purpose of this review was to compare the clinical results of arthroscopic vs. open OD for PEOA.

METHODS

The online databases PubMed, Embase (Elsevier), and Scopus (Elsevier) were searched from inception through April 1, 2018, for clinical studies reporting on OD. Studies were stratified based on an arthroscopic vs. open approach. Weighted means were calculated for surgical and patient-reported outcomes.

RESULTS

We included 30 studies, reporting on 871 patients and 887 elbows, with a mean follow-up period of 44.3 ± 25.5 months. Of these studies, 15 (420 elbows) reported on open OD, 14 (456 elbows) reported arthroscopic OD, and 1 reported on a cohort of each approach (open in 5 elbows and arthroscopic in 6). The Mayo Elbow Performance Score improved by 28.6 ± 4.57 in the open group vs. 26.6 ± 7.24 in the arthroscopic group. Flexion improved by 19° ± 6° in the open group and 10° ± 6° in the arthroscopic group. Extension improved by 11° ± 5° in the open group and 11° ± 6° in the arthroscopic group.

CONCLUSIONS

Open OD and arthroscopic OD are effective surgical treatment options for patients with symptomatic PEOA, reliably improving flexion, extension, and functional outcome scores with low complication rates.

Arthroscopic treatment of elbow osteoarthritis

Elbow osteoarthritis chiefly affects heavy manual labourers and athletes and may be primary or post-traumatic. Arthroscopic debridement for primary elbow osteoarthritis reliably produces pain relief, motion range gains, and good functional outcomes. Total elbow arthroplasty, in contrast, is considered a salvage option in this patient population, as activities must be restricted to protect the implant. Here, we describe the operative technique used for arthroscopic elbow release in 87 patients with symptomatic elbow osteoarthritis included prospectively at 6 centres in a study that was conducted for a French Arthroscopy Society symposium and whose findings are reported elsewhere. The technique involves exploration of the anterior and posterior compartments with resection of motion-limiting osteophytes; clearing of the fossae; foreign body extraction; and treatment of the posterior and anterior capsule and of the lateral inclines. The indications of ulnar nerve release, radial head excision, release of the posterior band of the medial collateral ligament (MCL), and/or fenestration as described by Outerbridge-Kashiwagi are discussed. After 6 months, 93.5% of patients were satisfied with the procedure. No serious neurological complications were recorded. Wound healing was impaired in 4 patients, of whom 3 responded to local care; the remaining patient required open debridement for surgical-site infection. Complex regional pain syndrome developed in 3 patients. Ulnar nerve transposition was required secondarily in 1 patient and another patient had persistent dysesthesia after ulnar nerve release. This minimally invasive technique provides good short-term outcomes in primary elbow osteoarthritis and is associated with a low complication rate.

Arthroscopic debridement for osteoarthritis of the elbow: Results and analysis of predictive factors

INTRODUCTION

Osteoarthritis is the second most frequent cause of elbow stiffness, after trauma sequelae. Surgical treatment mainly consists of debridement. The main aim of the present study was to assess the efficacy of arthroscopic treatment of osteoarthritis of the elbow on Andrews-Carson score. Secondary objectives comprised assessment of the impact of associated procedures and of epidemiological factors on functional results.

METHOD

A prospective multicenter study involving 8 centers, in a symposium held by the French Society of Arthroscopy (SFA), included patients treated by arthroscopy for primary or secondary osteoarthritis of the elbow between January 2017 and March 2018, with a minimum 6 months' follow-up. Clinical assessment was based on change in Andrews-Carson functional score (AC), specific to osteoarthritis of the elbow, and on other functional scores: QuickDash (QD), Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS) and Self-Evaluation Elbow (SEE). Progression in pain on visual analog scale (VAS) and range of motion (RoM) was also assessed. Initial imaging work-up comprised standard X-ray and CT arthrography; paraclinical follow-up was based on X-ray. The impact of the following procedures associated to arthroscopic debridement was analyzed: radial head resection, ulnar nerve release, humeral fenestration, lateral ramp release, and medial collateral ligament posterior bundle release. The functional impact of epidemiological factors (age, handedness, manual occupation, smoking, body-mass index, and work accident/occupational disease status) and radiographic factors (foreign bodies, joint impingement, osteophytes, and fossa filling) was also assessed.

RESULTS

The series comprised 87 patients: 75 male (86.2%); mean age, 49 years (range, 18-73 years). Arthroscopic debridement significantly improved all functional scores at a minimum 6 months, and notably the specific AC score: 113.6±25.4 (40-180) versus 178.7±20.2 (110-200) (P<0.0001). Pain diminished significantly: 6.4±2.1 (0-10) versus 1.7±1.8 (0-8) (P<0.0001). RoM increased significantly: flexion/extension, 93.44±20.5° (5-130°) versus 124.2±13.8° (90-160°) (P<0.0001); pronation/supination, 147.6±25.6° (60-180°) versus 162.5±20.6° (100-180°) (P<0.0001). Strength (kg) increased in flexion (8.8±4.0 (4 to 20) versus 15.3±5.1 (3 to 32) (P<0.0008) and in grip [33.1±12.3 (10 to 58) versus 42.1±14.0 (2 to 68) (P<0.0001)]. Epidemiologically, males showed better recovery than females for both pain and strength. There was a significant positive impact of manual work on functional recovery, pain and also strength. There was a significant negative impact of work-accident/occupational disease on pain and strength. Regarding associated procedures, lateral ramp debridement improved AC score, with a gain of 75.4±25.3 points (-5 to 110) vs. 49.6±23.5 (10 to 100) (P<0.0001), and pain on VAS, with a fall of -5.6±2.1 points (-10 to -1) vs. -3.6±3.0 (-8.5 to 1) (P=0.0013). Ulnar nerve release, radial head resection and humeral fenestration had no positive impact. Preoperative foreign body was a factor for good prognosis. Cartilage wear, especially in the humeroulnar compartment, was associated with poorer functional results.

DISCUSSION/CONCLUSION

Arthroscopic treatment of osteoarthritis of the elbow significantly improved clinical results at 6 months, with significant improvements in functional scores, pain, strength and range of motion. Gender, type of work and work-accident/occupational disease status influenced clinical results. Lateral ramp release is an often overlooked technical factor improving functional results. Radiologically, the best candidates are those presenting with a foreign body and no humeroulnar impingement.

LEVEL OF EVIDENCE

III, Prospective observational multicenter cohort study.