ELBOW ARTHROPLASTY: A PRACTICAL PROCEDURE
From Evaluation and Treatment of the Injured Athlete: Sports Medicine Update 2005, sponsored by the Boston
University School of Medicine
| ELBOW ARTHROSCOPY: WHAT CAN AND CANNOT BE DONE —Felix H. Savoie, MD, Co-Director, Upper Extremity
Service, Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi
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| Introduction: original elbow arthroplasty indications for diagnosis and loose bodies; prone positioning—resembles
knee arthroscopy, with front of elbow like back of knee and back of elbow like front of knee; provides adequate visibility
and room for instruments; expanding indications—meanwhile, as in early days of knee and shoulder arthroscopy,
indications often not recognized
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| Osteochondritis dissecans (OCD): repetitive-motion disorders in young athletes present with motion loss and pain, along
with popping and locking; OCD pathology—bone necrosis (detected on magnetic resonance imaging [MRI]); posterolateral
synovitis; cartilage flaps; loose bodies; mechanism—avascular necrosis (AVN) causes softening of cartilage,
leading to synovitis and inflammation, which increases pressure (and pain), resulting in osteonecrosis of elbow; therapeutic
response—remove OCD lesion; also eliminate synovitis responsible for symptom; bracing—double-hinged
off-loading brace; set at point symptoms appear, eg, -30°; allow return to sports while wearing brace; gradually extend
brace, following with serial x-rays and concluding with MRI; ≈80% of patients improve without surgery
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 | Indications for surgery: failure of bracing; initial MRI shows disease progression beyond x-rays; radiocapitellar
changes; cartilage flap; loose body
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| Procedure: prone position; 70° arthroscope (panoramic view) down posterolateral gutter; instrument through soft spot;
excise synovium; remove loose cartilage cap; excise necrotic bone
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| Arthritis treatment: synovectomy—in rheumatoid arthritis (RA), remove diseased tissue; avoid penetration of brachialis
muscle (risking injury to median nerve and brachial artery); spur excision—coronoid and olecranon spurs; hyperflex
elbow (using knee); tip of spur not cause of motion loss; remove medial and lateral aspects to avoid
impingement in flexion; radial head excision—alone or with arthritis procedure; fossa fenestration; primary radiocapitellar
problems lead to arthritis of elbow; when early arthritic changes appear, removal of radial head may prevent
progressive degeneration; avoid damaging posterior interosseous nerve (runs anterior to capsule, then adjacent
distally); through anterolateral portal, remove anterior aspect of radial head (6 mm for radiocapitellar problem
alone, more if also proximal radioulnar joint problem); continue with spinal needle and shaver through soft-spot
portal; position canula or retractor to prevent burr penetration of anterior capsule; advantage of arthroscopy—
preserves lateral capsular structures
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| Fossa fenestration: ulnohumeral arthroplasty; arthroscopy eliminates residual bone, leading to recurrence of loss of motion
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| Fractures: radial head—spinal needle through soft-spot portal; fix, reduce, and debride through posterolateral portal;
unicondylar humerus—avoid disrupting normal anatomy during reduction with wire and screws; advantages of
arthroscopy—permits inspection of fracture and ability to convert to open procedure as required
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| Instability: diagnosis—valgus instability; varus instability (drive-through sign; arthroscope goes between olecranon
and humerus to medial gutter); repair—reconstruction for posterolateral instability (tightening sutures lifts ulna back
towards humerus)
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| Triceps tendon repair: series of 5 currently; single anchor or double anchor; debride joint; anchor at proximal triceps
tendon insertion; second anchor at olecranon bursa, with stitches across
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| Concluding comments on elbow arthroscopy: does not replace clinical examination; bounded by nerves; time constraints
(avoid compartment syndrome; after 60-65 min, convert to open procedure); what you can do—anything intra-articularly;
extra-articularly from posteromedial to lateral elbow
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| TENNIS ELBOW —Anthony A. Romeo, MD, Associate Professor, Department of Orthopaedic Surgery, Rush Medical
College, and Rush-Presbyterian-St. Luke’s Medical Center, Chicago, and Rush Oak Park Hospital, Oak Park, Illinois
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| Introduction: procedure easily performed by surgeons inexperienced in elbow arthroscopy; lateral epicondylitis most
common problem in elbow; meta-analysis of studies of nonoperative management found little evidence of change in
natural history of disease; orthopaedists need surgical options for patients who fail conservative approach
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| Open surgery: Nirschl developed open resection of extensor carpi radialis brevis (ECRB) tendon; identify lateral epicondyle;
split between ECRL and extensor aponeurosis; resect ECRB origin; decorticate lateral condyle; open surgery
based on resection and debridement; both easily done arthroscopically
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| Reasons for failed surgical management: inadequate resection (failure to identify anatomy); excessive resection; radial
nerve and intra-articular deficiencies; arthroscopic approach may avoid problems (provides good visibility)
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| Problem faced: literature describes techniques in which “sufficient tendinous tissue is removed”; fails to define what is to
be removed; no study has defined anatomy surrounding ECRB origin; speaker’s anatomic findings—origin of ECRB
easier to see from inside out; ECRB just above lateral collateral ligament (LCL); measured exact area to be cleaned of
tendinous tissue during surgery; provided basis for teaching procedure
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| Anatomy and surgery: ECRB anterior to midline; sits just in front of longitudinal ridge; ECRB origin diamond-shaped,
with length slightly >1 cm, width ≈7 mm; ulnar collateral ligament below can be resected, avoiding damage to LCL
(common complication); posterior interosseous nerve not adjacent to origin, but can be damaged when shaver (with
suction) turned up to anterior capsule; keep shaver and burr pointed to bone
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| Arthroscopic procedure: retractors being developed for protecting tissues and capsule (presently, elevator can be used
as retractor); speaker places lateral portal above ECRB; developed 4-step procedure for teaching; step 1—release
capsule; step 2—resect above ECRB, at level of articular surface at capitellum; step 3—resect inferiorly down to
LCL; step 4—resect 7 to 8 mm posteriorly until ECRB released; points on procedure—prone positioning allows
flexibility; draw surface landmarks; use 18-gauge needle to mark capitellum; debride joint as needed; arthroscopy facilitates
use of shaver to separate layers between LCL and ECRB; clinical series—30 patients; includes workers’
compensation cases; previous surgery, 3; complete capsular disruption, 2; synovitis, 9; pathologic plica, 2; average
follow-up 2 yr; no reoperations or complications; pain scores good; in separate study comparing open and arthroscopic
surgery, authors reported results equal, although arthroscopy probably better
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| Additional procedure: Dr. Savoie performs office-based percutaneous release of ECRB; report accepted for publication;
compares percutaneous release with arthroscopic and open procedures; arthroscopy indicated in plica, synovitis,
and other problems in lateral gutter; open surgery indicated if other problems addressed, eg, release of posterior interosseous
nerve; percutaneous results good
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| Introduction: stiff elbow defined as—range of motion <30° to 120°; functional limitations; pain; etiology—
multifactorial; extrinsic factors (surgery may not help, eg, burns, spasticity, nerve involvement); intrinsic factors (severe
osteoarthritis; loose bodies; postfracture spur formation and adhesions)
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| Treatment decisions: nonoperative management—corticosteroid injections; physical therapy; static splinting (dynamic
splinting harmful); surgical risks—damage to nerves and arteries; presence of metal from previous surgery;
patient selection—parents’ desire to correct deformity unrealistic without child’s commitment to improvement; patient
must understand necessity of postoperative therapy; insurance may limit reimbursement for required physical
therapy, eg, ≤20 sessions (requires alternative means of covering cost); indications for surgery—pain; functional impairment;
cooperative patient
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| Surgical procedure: anterior aspects—capsular excision; bone contouring (eg, debriding coronoid process, excising
radial fossa, excising radial head; determine preoperatively; modify operatively); intraoperative risks (posterior interosseous
nerve adjacent to capsule, anterior to radial neck; brachial artery and median nerve anterior to brachialis);
portal placement limits risks (proximal lateral; proximal medial); fat strip on front of radial head demarcates posterior
interosseous nerve (place retractor); debride radial fossa (check by flexing elbow); radial head fracture heals with mushroom-like
deformity (impedes extension; corresponding spur on coronoid; trim anterior aspect; finish excision by
planing back and forth); posterior aspects—debride olecranon fossa; excise olecranon tip; fossa fenestration; debride
medial gutter; possible medial collateral ligament release; debride lateral gutter; protect ulnar nerve (release indicated
when short arc of motion has remained fixed for some time; consider using retractor); elevate triceps tendon to restore
flexion
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| Results: almost 400 cases; average improvement in extension from -45° to -5°, in flexion from 90° to 135°;
complications—posterior interosseous nerve damage early in series; after anterior displaced radial head fracture,
fragments may penetrate capsule and stick to nerve; if history of this fracture, exploration of nerve indicated; 2 ulnar
neuropathies (resolved); 1 tardy ulnar nerve palsy (if arc of motion ≤40°, release nerve with punch)
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| Concluding comments: consider open surgery to remove metal from older fracture repair; capsular release can cause
instability (reconstruct during surgery or evaluate later); speaker uses brace instead of external fixator; avoiding
complications—“stay beneath your skill curve”; elbow not “forgiving joint”; consider opening and placing retractor
to protect nerve; “for the stiff elbow, there is no question that at this time, arthroscopic management is the treatment of
choice”
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| DISTAL BICEPS TENDON ANATOMY AND SURGERY —Augustus D. Mazzocca, MD, Assistant Professor,
Shoulder/Elbow Surgery and Sports Medicine/Arthroscopy, Department of Orthopaedic Surgery, University of Connecticut,
Farmington
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| Background: reported incidence of biceps tendon rupture increasing; 25,000 procedures in 1995; surgical history—2-
incision repair modified by Morrey in 1985; suture anchor appeared in 1995; EndoButton in 2000; interference screw
developed by speaker in 2003; operative complications—especially with 2-incision procedure; heterotopic calcification;
nerve damage; infection
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| Evaluation: physical findings—deformity; ecchymosis; weakness in supination with elbow flexed 90°; tenderness; palpable
tendon discontinuity; radiography—plain x-rays usually normal; MRI (sagittal for retraction; axial for supination);
ultrasonography operator-dependent
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| Anatomy of biceps tendon: strongest supinator of forearm; assists brachialis in flexion and in initiating flexion; subjected
to tension, and pressure and shearing; 2 histologic areas (ulnar side, type 1 collagen and tenocytes; radial side,
type 2 collagen and fibrocartilage); blood supply from cubital artery (hypovascular area at fibrocartilage or transition
zone [likely site of rupture on radial side])
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| Pathogenesis of rupture: 1) injury at hypovascular area; 2) increased bursal size; roughening of tuberosity, followed by
repetitive stress or failure against bony excrescence or ridge
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| New findings: from speaker’s investigations; tendon twists ≈90° before insertion on ulnar side of tuberosity (site of insertion
incorrect in previous literature); insertion footprint—comma-shaped “ribbon”; length ≈14.3 mm; width ≈1.8
mm; ridge types on ulnar side—bifid; smooth (no ridge); small; medium; big; possible association between incidence
of rupture and ridge type under investigation; osteology of tuberosity—unrelated to sex, race, or age; mean
measurement ≈12 mm
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| Current surgical techniques: 2-incision bone tunnel (Morrey); advantage of single-incision approach (direct access to
tuberosity; on pronation, tuberosity ridge may force reconstruction too far proximally); single-incision bone tunnel
(Yu and Caputo); suture anchor; EndoButton (Bain); interference screw (Mazzocca); biomechanical evaluation—
speaker compared 4 techniques; after cyclic loading, displacement least with suture anchor and interference screw; after
load-to-failure, EndoButton strongest
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| New procedure: speaker used combination of techniques with best biomechanical characteristics; tendon sutured to secure
EndoButton; interference screw inserted after EndoButton deployed; construct ensures tendon stays on ulnar
side; postoperative rehabilitation—patients instructed to gain full range of motion before suture removal; no heavy
lifting for ≈12 wk; results—15 cases; 8- to 36-mo follow-up; 1 complication (radius fracture after fall); Dr. Savoie’s
experience—30 patients; 1 failure (rupture proximal to fixation); normal strength and range of motion within 8 wk;
good-to-excellent scores on Andrews-Carson rating scale
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Educational Objectives
| The goal of this program is to educate orthopaedists about elbow arthroscopy. After hearing and assimilating this program,
the orthopaedic surgeon will be better able to:
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| 1. Identify indications for elbow arthroscopy.
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| 2. Acquire the surgical skills required for elbow arthroscopy.
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| 3. Perform arthroscopic surgery for lateral epicondylitis.
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| 4. Manage stiff elbow using nonoperative, open, and arthroscopic techniques.
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| 5. Treat distal biceps tendon ruptures based on an understanding of the anatomy and effective surgical procedures.
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Suggested Reading
Bain GI et al: Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg
9:120, 2000; Baker CL Jr et al: Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results.
J Shoulder Elbow Surg 9:475, 2000; Bisset L et al: A systematic review and meta-analysis of clinical trials on
physical interventions for lateral epicondylalgia. Br J Sports Med 39:411, 2005; Cohen M, Romeo A: Lateral Epicondylitis:
Open and Arthroscopic Treatment. J Am Soc Surg Hand 1:3, 2001; Koch S et al: The distal tendon of the biceps
brachii. Structure and clinical correlations. Ann Anat 177:467, 1995; Kuklo TR et al: Arthroscopic release for
lateral epicondylitis: a cadaveric model. Arthroscopy 15:259, 1999; Mazzocca AD et al: Subpectoral biceps tenodesis
with interference screw fixation. Arthroscopy 21:896, 2005; Morrey BF: Biceps tendon injury. Instr Course
Lect48:405, 1999; Norberg FB et al: Arthroscopic treatment of arthritis of the elbow. Instr Course Lect49:247, 2000;
Pereira DS et al: Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques. Am J
Sports Med 30:432, 2002; Romeo AA et al: Arthroscopic biceps tenodesis. Arthroscopy 20:206, 2004; Savoie FH 3rd
et al: Arthrofibrosis and complications in arthroscopy of the elbow. Clin Sports Med 20:123, 2001; Savoie FH 3rd et
al: Arthroscopic management of the arthritic elbow: indications, technique, and results. J Shoulder Elbow Surg 8:214,
1999; Savoie FH 3rd: Total elbow arthroplasty: salvage of unsuccessful previous elbow operations. J Miss State Med
Assoc 34:259, 1993; Steinmann SP et al: Arthroscopic treatment of the arthritic elbow. J Bone Joint Surg Am 87:2114,
2005; Yadao MA et al: Osteochondritis dissecans of the elbow. Instr Course Lect53:599, 2004; Yadao MA et al: Posterolateral
rotatory instability of the elbow. Instr Course Lect53:607, 2004;
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has
been disclosed: Dr. Romeo—Arthrex; Dr. Mazzocca—Arthrex (research grant).
Drs. Savoie, Romeo, and Mazzocca were recorded at Evaluation and Treatment of the Injured Athlete: Sports Medicine
Update 2005, sponsored by the Boston University School of Medicine on August 1-5, 2005, at Martha’s Vineyard,
Massachusetts. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production
of this program.
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