Elbow and Forearm
Indications and Goals: Elbow arthroscopy is a valuable treatment modality in a variety of pathologic conditions, including loose body removal, synovectomy, osteophyte debridement, treatment of osteochondral injuries (usually of the capitellum), evaluation of joint stability, and even radial head excision and extensor carpi radialis brevis (ECRB) release for tennis elbow.
Procedure and Technique: On the basis of the surgeon’s preference, the patient can be placed in the lateral decubitus, prone, or supine position. There are seven portals that have been most commonly described for elbow arthroscopy and that can be further divided into anterior and posterior portals. Anterior portals are the proximal medial portal, the anterolateral portal, and the proximal lateral portal. The posterior portals consist of the midlateral (soft spot) portal, the posterior lateral portal, the transtriceps portal, and the accessory lateral portal. Anterior portals must be made with the elbow in flexion in order to reduce the risk of injury to the neurovascular structures.
Anterior Portals: The proximal medial portal is usually the first portal created as it provides visualization of the entire anterior compartment. It is located 2 cm proximal to the medial epicondyle and anterior to the intermuscular septum. The septum protects the ulnar nerve while the trochar is advanced into the central portion of the elbow against the anterior margin of the humerus. Any history of a subluxating or previously transposed ulnar nerve must be obtained as these conditions place the ulnar nerve at risk and require exposure and protection of the nerve under direct visualization. This portal provides the best access to the radial head and capitellum.
The proximal lateral portal is 2 cm proximal to the lateral epicondyle of the humerus and lies on the anterior margin of the humerus. It is considered the safest of all anterior portals. This portal can access the distal humerus, trochlear ridges, and coronoid process.
The anterolateral portal is located 2 cm distal and 1 cm anterior to the lateral epicondyle. It is less commonly used as it puts the radial nerve at risk. If used, it is safest to create this portal with an inside-out technique to reduce the risk of injury to the radial nerve. This portal can access the distal humerus, trochlear ridges, coronoid process, and radial head.
Posterior Portals: The midlateral or soft spot portal is located at the center of a triangle bordered by the olecranon, the lateral epicondyle, and the radial head. It is used initially for insufflation (approximately 20 mL) before arthroscopy and for visualization and instrumentation of the inferior radiocapitellar joint and the proximal radioulnar joint.
The posterolateral portal is created at the level of the tip of the olecranon and just lateral to the border of the triceps. The posterior lateral portal is the main viewing portal for the posterior compartment of the elbow.
The transtriceps portal is created 3 cm proximal to the tip of the olecranon and is used for visualization and instrumentation of the tip of the olecranon, the humeral fossa, and the humeral trochlea.
The accessory or adjacent lateral portal is made in the area of the soft spot portal and is used for visualization and instrumentation of the radiocapitellar joint, in particular for osseous and chondral procedures related to osteochondritis dissecans of the joint.
Post-surgical Precautions/Rehabilitation: Rehabilitation following an elbow arthroscopy that does not involve tissue repair can be relatively progressive. Performed as an outpatient procedure, an individual can utilize a compression wrap to reduce postoperative swelling. Range of motion exercises can be begun immediately as needed to restore normal movement. Splints and immobilization braces are usually not needed. Scar management and pain control can be addressed from the onset, and a return to participation and/or activity can occur on an individual basis as one feels comfortable. If the original condition was the result of a repetitive stress injury, then education regarding appropriate biomechanics ergonomics may need to occur to prevent against a recurrence.
Expected Outcomes: If diligent attention is paid to anatomic detail, arthroscopy of the elbow is safe and effective, with success rates for various procedures around 90%. An overall complication rate of 12.6% has been reported, but this can be minimized by limiting joint distension by limiting fluid pressure, placing portals with the elbow flexed at 90 degrees, recognizing that the radial nerve is at greatest risk at the anterior lateral portal, and avoiding posterior medial and direct anterior portals.
Return to Play: Depends upon the procedure. Procedures that do not affect the structural integrity of the joint may allow return within weeks and more extensive procedures months. Throwing athletes who have more extensive procedures including ligament reconstruction may require several months before the athlete can return to play.
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Elbow Articular Cartilage Surgery
Indications and Goals: Articular cartilage problems in the elbow include osteochondritis dissecans (OCD), which typically involves the capitellum in younger patients, traumatic chondral injuries, and arthrosis.
OCD of the capitellum occurs primarily in adolescent throwing athletes or upper extremity weight-bearing athletes such as gymnasts as a result of repetitive compressive microtrauma, resulting in injury to the subchondral blood supply, osteonecrosis, and loose body formation. Surgical options after a failed period of rest include removal of loose bodies, debridement and chondroplasty, microfracture, or fragment fixation.
More recently, a technique for osteochondral mosaicplasty using autograft transplantation from the knee has been described. It is indicated for large capitellar lesions that comprise greater than 50% of the capitellar surface area. These lesions typically involve the lateral aspect of the capitellum and result in the loss of the lateral buttress to the radial head.
Procedure and Technique: Typically, arthroscopy is carried out and the problem is characterized. Most commonly, the technique used involves loose body removal and abrasion chondroplasty or microfracture. The midlateral, anterolateral, and proximal medial portals are used. Visualization from the proximal medial portal with instruments that enter from the lateral portals allows good access to fragments. Following removal of the fragment(s), the resulting defect is microfractured with a 45-degree awl.
If mosaicplasty is chosen, an open technique using a Kocher approach between the anconeus and extensor carpi ulnaris muscles is performed. The lateral collateral ligament is preserved and the forearm is pronated to protect the posterior interosseous nerve. The defect is drilled and appropriately sized osteochondral plugs are transplanted from the ipsilateral knee using an osteochondral transplant system.
Post-surgical Precautions/Rehabilitation: Rehabilitation following elbow articular cartilage surgery is very similar to an elbow arthroscopy with the addition of tissue that has been intentionally insulted to enhance a bleeding response for healing. Performed as an outpatient procedure, an individual can utilize a compression wrap to reduce postoperative swelling. Range of motion exercises can be begun immediately for the elbow, as well as the shoulder and wrist as needed to restore normal movement. Splints and immobilization braces are not typically necessary. However, depending upon which bone was microfractured, there may be a 2-week period of limited complete extension in an attempt to reduce bone-to-bone compression at the elbow. Scar management and pain control can be addressed from the onset, and a return to participation and/or activity can occur on an individual basis as one feels comfortable.
For mosaicplasty procedures, the patient’s elbow is immobilized at 90 degrees with the forearm in neutral rotation for 3 weeks, after which active and passive range of motion exercises are initiated. Strengthening exercises are commenced in the third postoperative month.
Expected Outcomes: In general, patients with loose bodies causing mechanical symptoms will have the most significant improvement in symptoms after elbow arthroscopy and loose body removal. Complications are generally minimal. If the original condition was the result of a repetitive stress injury, then education regarding appropriate biomechanics and ergonomics may need to occur to prevent against a recurrence. Early results of mosaicplasty procedures are promising, but longer term follow-up is needed.
Return to Play: Depends upon the size of the lesion and the procedure. In the best circumstances, 6 to 8 months may be required.
Brownlow HC, O’Connor-Read LM, Perko M. Arthroscopic treatment of osteochondritis dissecans of the capitellum. Knee Surg Sports Traumatol Arthrosc. 2006;14(2):198-202.
Davis JT, Idjadi JA, Siskosky MJ, ElAttrache NS. Dual direct lateral portals for treatment of osteochondritis dissecans of the capitellum: An anatomic study. Arthroscopy. 2007;23(7):723-728.
Iwasaki N, Kato H, Ishikawa J, Saitoh S, Minami A. Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients. Am J Sports Med. 2006;34(8):1233-1239. Epub 2006 Mar 27.
Rahusen FT, Brinkman JM, Eygendaal D. Results of arthroscopic debridement for osteochondritis dissecans of the elbow. Br J Sports Med. 2006;40(12):966-969. Epub 2006 Sep 15.
Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. J Bone Joint Surg Am. 2007;89(6):1205-1214.
Wahegaonkar AL, Doi K, Hattori Y, Addosooki A. Technique of osteochondral autograft transplantation mosaicplasty for capitellar osteochondritis dissecans. J Hand Surg [Am]. 2007;32(9):1454-1461.
Elbow Ulnar (Medial) Collateral Ligament Reconstruction (Tommy John Procedure)
Indications and Goals: This procedure is usually indicated for torn or stretched elbow ulnar (medial) collateral ligaments in throwing athletes. The goal is to allow the athlete to return to play.
Procedure and Technique: The patient is positioned supine on the operating table with the arm extended on a hand table. A 10 cm posteromedial longitudinal incision, centered on the joint line, is made and the ulnar nerve is exposed. Typically, the nerve is mobilized and transposed subcutaneously. The flexorpronator tendon is split between its anterior and middle thirds and the medial epicondyle and coronoid process are exposed. The palmaris longus tendon is harvested through a transverse incision at the wrist and a whipstitch is placed at both ends. Converging drill holes (typically 3.2 mm) are made in the coronoid process and diverging drill holes are made in the medial epicondyle. The tendon is weaved through the tunnels in a figure-of-eight fashion and sutured to itself. Alternatively, the docking technique can be used. With this technique, the ulnar tunnels are made as described above and the humeral tunnels are designed so that the free ends of the tendon are pulled into (docked) the tunnels and are secured by tying the free ends over a bony bridge on the medial epicondyle. Small bioabsorbable interference screws can also be used on one or both sides of these reconstructions.
Post-surgical Precautions/Rehabilitation: Following surgery, a long arm splint in 90 degrees of flexion at the elbow is worn. During the first 2 to 3 weeks, elbow range of motion is encouraged between 30 and 120 degrees of flexion, while shoulder and wrist motions are maintained. Both supervised and independent range of motion exercises should be performed daily, with pronation and supination being added as tolerated. Light grip strengthening activities can be performed using putty or other rehabilitation devices, with wrist flexor and forearm pronation strengthening exercises added between weeks 3 and 4. The brace can be adjusted to increase 10 degrees of extension movement each week past week 3, and complete range of motion at the elbow should be achieved within 6 weeks. Most of the exercises should be performed with the protection of the brace, though it can be removed several times daily for controlled, gentle range of motion exercises only. The brace can typically be discontinued if complete range of motion is achieved by the sixth postoperative week. While resistive exercise demand is increased over the first 3 to 4 months, forces that place a valgus stress on the elbow should be avoided during this time. Functional elbow braces may be worn when returning to an activity, job, or sport depending upon the feasibility. For throwers, a gradual increase in return to throwing must be supervised for compliance. This should be closely guided by the surgeon and may include an incremental increase in technique and objects utilized to throw with. For example, lighter objects that place less stress on the elbow may be used initially, progressing to a baseball or football.
Expected Outcomes: Average time to return to pre-injury status with throwers is approximately 1 year. While many have successful outcomes, others may experience ulnar nerve neurapraxia symptoms. If the goal of the individual is not to return to an activity that requires continued stress to the medial aspect of the elbow, then conservative care may be adequate for functional needs.
Return to Play: Six months to a year. In fact, the best results are often the following year. Competitive athletes may never return to their pre-injury status.
Armstrong AD, Dunning CE, Ferreira LM, Faber KJ, Johnson JA, King GJ. A biomechanical comparison of four reconstruction techniques for the medial collateral ligament-deficient elbow. J Shoulder Elbow Surg. 2005;14(2):207-215.
Dodson CC, Thomas A, Dines JS, Nho SJ, Williams RJ 3rd, Altchek DW. Medial ulnar collateral ligament reconstruction of the elbow in throwing athletes. Am J Sports Med. 2006;34(12):1926-1932. Epub 2006 Aug 10.
Gibson BW, Webner D, Huffman GR, Sennett BJ. Ulnar collateral ligament reconstruction in major league baseball pitchers. Am J Sports Med. 2007;35(4):575-581. Epub 2007 Jan 31.
Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986;68(8): 1158-1163.
Koh JL, Schafer MF, Keuter G, Hsu JE. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy. 2006;22(11): 1187-1191.
McAdams TR, Lee AT, Centeno J, Giori NJ, Lindsey DP. Two ulnar collateral ligament reconstruction methods: The docking technique versus bioabsorbable interference screw fixation—a biomechanical evaluation with cyclic loading. J Shoulder Elbow Surg. 2007;16(2):224-228. Epub 2007 Jan 24.
Paletta GA Jr, Wright RW. The modified docking procedure for elbow ulnar collateral ligament reconstruction: 2-year follow-up in elite throwers. Am J Sports Med. 2006;34(10):1594-1598. Epub 2006 Jul 10.
Purcell DB, Matava MJ, Wright RW. Ulnar collateral ligament reconstruction: A systematic review. Clin Orthop Relat Res. 2007;455:72-77.
Lateral Elbow Collateral Ligament Reconstruction
Indications and Goals: Lateral-sided injuries are less common than medial collateral ligament injuries and often follow elbow instability (dislocations). The recurrent instability and the posterolateral rotatory instability (PLRI) are most likely caused by failure of the lateral complex to heal in its anatomic position on the lateral epicondyle following nonoperative treatment of an elbow dislocation. Patients with PLRI may describe recurrent elbow dislocations with normal daily activities, such as pushing on armrests while rising from a chair. This instability can be recreated by the lateral pivot shift test by starting with the elbow in supination and extension and slowly flexing the elbow while applying a slight valgus force and axial load, and is best performed with examination under anesthesia. Arthroscopy may be used as an adjunct to further assess the degree of instability, evaluate for osteochondral injury to the trochlea and radial head, and debride the joint. Reconstruction of the lateral ulnar collateral ligament may need to be carried out in isolation or in conjunction with surgical repair of other injuries, including the “terrible triad” injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), transolecranon fracture-dislocations, and the posterior Monteggia lesion. The goal of reconstruction is early mobilization within a stable arc of motion.
Procedure and Technique: The Kocher approach utilizing the interval between the anconeus and extensor carpi ulnaris muscles is performed with the forearm in pronation to protect the posterior interosseous nerve. The lateral epicondylar origin of the Lateral Collateral Ligament is exposed by incising the capsule transversely, proximal to the annular ligament. If adequate ligamentous tissue is present, primary repair can be performed to reconstitute elbow stability. If adequate tissue is not present, a ligamentous graft such as palmaris longus is harvested and utilized for reconstruction. Two converging 3.2 mm drill holes are drilled in the supinator tubercle 1 cm apart and a suture is passed through them. Isometry is checked by holding the suture ends over the lateral epicondyle and flexing and extending the elbow. Diverging drill holes in the lateral epicondyle are created, originating from the isometric point. The palmaris graft is weaved through the drill holes and sutured to itself.
Post-surgical Precautions/Rehabilitation: Postoperatively, the arm is immobilized in full pronation with the elbow in 90 degrees of flexion for the first week to 10 days. This is replaced with a hinged brace and a 30-degree extension block is set for the first 4 weeks. The brace is then unlocked for 2 weeks and then discontinued at 6 weeks. From the onset, shoulder and wrist range of motion should be maintained with exercises. Scar and pain management should be addressed to reduce sensitivity concerns. Elbow loading in extension and supination is avoided for the first 3 months. A graduated strengthening program is initiated at that point with a goal of achieving full extensor power by 6 to 9 months and unrestricted activity at 12 months.
Expected Outcomes: Results from this procedure generally demonstrate good outcomes. If there is no degenerative arthritis and the radial head is intact, then approximately 90% of patients have a satisfactory outcome. Less reliable results have been reported with synthetic or triceps grafts. Considerable care is required to prevent fracture of the bony bridges with the reconstruction. Recovery time is typically 1 year for activities that place stress on the reconstructed ligament, and possible residual scarring may be found.
Return to Play: Six months to a year or more. Competitive athletes may never return to their pre-injury status.
King GJ, Dunning CE, Zarzour ZD, Patterson SD, Johnson JA. Single-strand reconstruction of the lateral ulnar collateral ligament restores varus and posterolateral rotatory stability of the elbow. J Shoulder Elbow Surg. 2002;11(1):60-64.
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