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Arthroscopic Treatment for Limitation of Motion of the Elbow: Our Learning Curve in a Series of 120 Cases (SS-52)
ABSTRACTS scores of 100 and rated their elbow as “normal” or “almost normal” on the SOD scale. Conclusion: Retrograde drilling of capitellar OCD lesions resulted in successful healing of five out of five patients in this case series. This technique is a safe and reasonable treatment option to stimulate healing of the subchondral bone without disruption of the articular cartilage. Further study of the optimal surgical technique and long-term outcome is required but the initial results of retrograde drilling for OCD lesions of the capitellum are encouraging. Arthroscopic Treatment of Combined Lateral Epicondylitis and Posterolateral Rotatory Instability of the Elbow (SS-51) Sergey S. Dzugan, M.D., Felix H. Savoie III, M.D., Larry D. Field, M.D., Michael J. O’Brien, M.D. Introduction: Lateral elbow pain has multiple etiologies with the most common being lateral epicondylitis (tennis elbow). Other entities that may produce pain in this area include radio-capitellar arthritis, posterolateral rotatory instability (PLRI), plica syndrome, and radial tunnel syndrome. We report on a rare subset of patients who have chronic lateral epicondylitis and then sustain an acute injury that produces instability in addition to the epicondylitis. Attempted nonoperative management was unsuccessful and all patients required surgical repair of both injuries for a successful result. Our hypothesis is that there is a subset of active patients with preexisting lateral epicondylitis who sustain an additional acute injury that extends the damage to include some or all of the radial ulnohumeral ligament complex. These patients develop persistent symptoms of both epicondylitis and instability which, if unrecognized, will lead to failure of surgical management if only the lateral epicondylitis is repaired. Methods: A retrospective review of 163 elbow arthroscopies over the past 3 years performed by the senior author revealed seven patients with a diagnosis of combined lateral epicondylitis and lateral elbow instability determined by history, physical examination, and MRI testing. Five patients were heavy laborers, one recreational tennis player, and one insurance agent. The data, including Andrews-Carson scores, was collected prospectively in the initial evaluation and at regular postoperative intervals. The patient age range was 29 to 46 (average 40.7 years); all were right-hand-dominant elbows. The follow-up range was from 6 to 18 months. Two patients had previous lateral epicondylitis repair that failed and one had previous ulnar nerve transposition
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that did not resolve the symptoms. The four other patients had nonoperative measures including injections, medications, physical therapy and bracing prior to surgery. The indications for surgery were pain, functional impairment, and a failure of nonoperative or operative treatment. All surgeries were performed on an outpatient basis under general anesthesia in the prone position. Surgical findings included extensor carpi radialis brevis (ECRB) avulsion in two patients and ECRB tear in five patients. Six patients had radial ulnohumeral ligament (RUHL) and/or lateral collateral ligament (LCL) tear, and one patient had a complete RUHL avulsion. Two patients had Baker Type 3 lesion and five patients had Baker Type 2 lesion. Results: Six out of seven patients managed solely via arthroscopic means had significant (p⬍0.05) improvement in total Andrews-Carson score. All patients exhibited full range of motion and objective improvement in strength and function as measured by an independent physical therapist. The remaining patient, a revision workers’ compensation heavy duty mechanic, exhibited objective improvement in all parameters but subjectively still felt unable to return to regular duty. Conclusion: A combined injury pattern of lateral epicondylitis and lateral elbow instability is an important and rare subset of patients who frequently go misdiagnosed as tennis elbow only without recognition of instability. This study is the first case series of patients to date with these combined injuries treated primarily arthroscopically. Surgical correction of both injuries resulted in satisfactory results in a majority of patients. Arthroscopic Treatment for Limitation of Motion of the Elbow: Our Learning Curve in a Series of 120 Cases (SS-52) Hee-Don Han, M.D., Sung-Jae Kim, M.D., Yong-Min Chun, M.D., Sung-Hwan Kim, M.D., Sung-Guk Kim, M.D., Hong-Kyo Moon, M.D. Introduction: The aim of this study was to demonstrate our learning curve in arthroscopic treatment for limitation of motion of the elbow. Methods: To verify the surrogates for learning curve, operative time and motion improvement in 120 consecutive elbows were plotted by case number and the learning curve was illustrated by the best-fit curve. The study population was divided into eight consecutive blocks (15 cases per block). Mean operative time and motion improvement in each block were compared. Once the surrogate for learning curve and its affecting factors had been identified, multiple regression analysis was carried out.
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ABSTRACTS
Results: Mean operative time decreased significantly from the first block to the second block (133 to 98). No further significant change was noted thereafter. Contrarily, no significant increase in motion improvement was identified but a significant decrease was found between the fourth and fifth block (47 to 36). Operative time was negatively correlated with preoperative range of motion (r⫽-0.269, P⫽0.003). Motion improvement was more strongly correlated with preoperative range of motion (r⫽-0.843, PŃ0.001). Finally operative time was determined to describe the learning effect and estimated with a multiple regression equation regarding the case number and the preoperative range of motion. To assess the change by case number in operative time, the regression coefficient of case number was noted. In the first block, the coefficient (⫺11.196) showed a rapid decrease by case number in operative time (PŃ0.001), but thereafter no further significant change was demonstrated. Conclusion: From our experience a learning curve was demonstrated in which a significant decrease in operative time was shown after an initial 15 cases. Motion improvement was not a satisfactory surrogate for learning curve and found to be closely related to preoperative range of motion. Clinical Outcome Measures Following Suture Anchor Repair for Traumatic Rupture of the Distal Triceps Tendon (SS-53) Eric D Bava, M.D., F. Alan Barber, M.D., Earl R. Lund, M.D. Introduction: Rupture of the triceps tendon is an uncommon injury with few published reports of surgical repairs. These publications include case reports and small series, which assess elbow strength and motion, but fail to report any commonly used or validated elbow outcome measures for the patients. These reports all utilize braided polyester sutures through bone tunnels in the olecranon for the reattachment of the distal triceps tendon. While recent publications have described the surgical technique and biomechanical properties of distal triceps tendon repair using suture anchors, there are no published outcomes using this technique. The purpose of this study is to report the clinical outcomes following suture anchor repair of the ruptured triceps tendon with high strength sutures. An extensive literature review failed to identify any other report which evaluated the clinical results using validated elbow outcome measures or to report the clinical results following distal triceps suture anchor repair. Methods: A consecutive series of traumatic distal triceps tendon ruptures from a single institution between 2006
and 2010 was reviewed. All cases were surgically repaired using suture anchors and high strength sutures. The patients were evaluated postoperatively using the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, the Oxford Elbow Score, the American Shoulder and Elbow Surgeons (ASES) elbow assessment form, and the Mayo Elbow Performance index. Results: A total of five male patients with at least six months follow-up underwent suture anchor repair for traumatic rupture of the distal triceps tendon. Of the five distal triceps tendon tears, three involved the dominant arm and two involved the non-dominant arm. The average patient age was 46.8 years (range, 35 to 54) and the average follow-up was 27.4 months (range 6 to 49 months). Postoperatively, the mean DASH score was 2.2 (from 0-100, lower score indicates less disability and better function), the mean ASES elbow score was 99.2 (from 0-100, higher score indicates better outcome), the mean Mayo Elbow Performance Index was 95.8 (from 0-100, higher score indicates better outcome), the mean Oxford Elbow Pain Score was 98.8 (from 0-100, higher score indicates less pain and better outcome), the mean Oxford Elbow Function Score was 100 (from 0-100, higher score indicates better function), and the mean Oxford Elbow Social Score was 96.2 (from 0-100, higher score indicates better outcome). Conclusion: Distal triceps tendon ruptures can be successfully repaired using high strength sutures in suture anchors instead of conventional sutures in bone tunnels. This technique results in minimal pain and excellent elbow function based on validated clinical outcome measures. Anteromedial Impingement in the Ankle Joint: Outcomes Following Arthroscopy in the First One Hundred Cases (SS-54) Christopher D. Murawski, M.D., John G. Kennedy, M.D., F.R.C.S.(Orth) Introduction: Anteromedial impingement (AMI) is a common and chronic ankle joint condition characterized by anteromedial talotibial osteophytes, soft tissue synovial hyperplasia and cicatrization, thereby causing pain and a mechanical obstruction to normal joint motion. AMI is a common condition found primarily in athletes, but particularly soccer players. The first case series of the arthroscopic resection of AMI has been previously described. The current authors’ present an update of an ongoing series with the retrospective results of the first one hundred patients treated arthroscopically for AMI. Methods: Between January 2005 and January 2010, 100 patients underwent arthroscopic resection of AMI under
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that did not resolve the symptoms. The four other patients had nonoperative measures including injections, medications, physical therapy and bracing prior to surgery. The indications for surgery were pain, functional impairment, and a failure of nonoperative or operative treatment. All surgeries were performed on an outpatient basis under general anesthesia in the prone position. Surgical findings included extensor carpi radialis brevis (ECRB) avulsion in two patients and ECRB tear in five patients. Six patients had radial ulnohumeral ligament (RUHL) and/or lateral collateral ligament (LCL) tear, and one patient had a complete RUHL avulsion. Two patients had Baker Type 3 lesion and five patients had Baker Type 2 lesion. Results: Six out of seven patients managed solely via arthroscopic means had significant (p⬍0.05) improvement in total Andrews-Carson score. All patients exhibited full range of motion and objective improvement in strength and function as measured by an independent physical therapist. The remaining patient, a revision workers’ compensation heavy duty mechanic, exhibited objective improvement in all parameters but subjectively still felt unable to return to regular duty. Conclusion: A combined injury pattern of lateral epicondylitis and lateral elbow instability is an important and rare subset of patients who frequently go misdiagnosed as tennis elbow only without recognition of instability. This study is the first case series of patients to date with these combined injuries treated primarily arthroscopically. Surgical correction of both injuries resulted in satisfactory results in a majority of patients. Arthroscopic Treatment for Limitation of Motion of the Elbow: Our Learning Curve in a Series of 120 Cases (SS-52) Hee-Don Han, M.D., Sung-Jae Kim, M.D., Yong-Min Chun, M.D., Sung-Hwan Kim, M.D., Sung-Guk Kim, M.D., Hong-Kyo Moon, M.D. Introduction: The aim of this study was to demonstrate our learning curve in arthroscopic treatment for limitation of motion of the elbow. Methods: To verify the surrogates for learning curve, operative time and motion improvement in 120 consecutive elbows were plotted by case number and the learning curve was illustrated by the best-fit curve. The study population was divided into eight consecutive blocks (15 cases per block). Mean operative time and motion improvement in each block were compared. Once the surrogate for learning curve and its affecting factors had been identified, multiple regression analysis was carried out.
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ABSTRACTS
Results: Mean operative time decreased significantly from the first block to the second block (133 to 98). No further significant change was noted thereafter. Contrarily, no significant increase in motion improvement was identified but a significant decrease was found between the fourth and fifth block (47 to 36). Operative time was negatively correlated with preoperative range of motion (r⫽-0.269, P⫽0.003). Motion improvement was more strongly correlated with preoperative range of motion (r⫽-0.843, PŃ0.001). Finally operative time was determined to describe the learning effect and estimated with a multiple regression equation regarding the case number and the preoperative range of motion. To assess the change by case number in operative time, the regression coefficient of case number was noted. In the first block, the coefficient (⫺11.196) showed a rapid decrease by case number in operative time (PŃ0.001), but thereafter no further significant change was demonstrated. Conclusion: From our experience a learning curve was demonstrated in which a significant decrease in operative time was shown after an initial 15 cases. Motion improvement was not a satisfactory surrogate for learning curve and found to be closely related to preoperative range of motion. Clinical Outcome Measures Following Suture Anchor Repair for Traumatic Rupture of the Distal Triceps Tendon (SS-53) Eric D Bava, M.D., F. Alan Barber, M.D., Earl R. Lund, M.D. Introduction: Rupture of the triceps tendon is an uncommon injury with few published reports of surgical repairs. These publications include case reports and small series, which assess elbow strength and motion, but fail to report any commonly used or validated elbow outcome measures for the patients. These reports all utilize braided polyester sutures through bone tunnels in the olecranon for the reattachment of the distal triceps tendon. While recent publications have described the surgical technique and biomechanical properties of distal triceps tendon repair using suture anchors, there are no published outcomes using this technique. The purpose of this study is to report the clinical outcomes following suture anchor repair of the ruptured triceps tendon with high strength sutures. An extensive literature review failed to identify any other report which evaluated the clinical results using validated elbow outcome measures or to report the clinical results following distal triceps suture anchor repair. Methods: A consecutive series of traumatic distal triceps tendon ruptures from a single institution between 2006
and 2010 was reviewed. All cases were surgically repaired using suture anchors and high strength sutures. The patients were evaluated postoperatively using the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, the Oxford Elbow Score, the American Shoulder and Elbow Surgeons (ASES) elbow assessment form, and the Mayo Elbow Performance index. Results: A total of five male patients with at least six months follow-up underwent suture anchor repair for traumatic rupture of the distal triceps tendon. Of the five distal triceps tendon tears, three involved the dominant arm and two involved the non-dominant arm. The average patient age was 46.8 years (range, 35 to 54) and the average follow-up was 27.4 months (range 6 to 49 months). Postoperatively, the mean DASH score was 2.2 (from 0-100, lower score indicates less disability and better function), the mean ASES elbow score was 99.2 (from 0-100, higher score indicates better outcome), the mean Mayo Elbow Performance Index was 95.8 (from 0-100, higher score indicates better outcome), the mean Oxford Elbow Pain Score was 98.8 (from 0-100, higher score indicates less pain and better outcome), the mean Oxford Elbow Function Score was 100 (from 0-100, higher score indicates better function), and the mean Oxford Elbow Social Score was 96.2 (from 0-100, higher score indicates better outcome). Conclusion: Distal triceps tendon ruptures can be successfully repaired using high strength sutures in suture anchors instead of conventional sutures in bone tunnels. This technique results in minimal pain and excellent elbow function based on validated clinical outcome measures. Anteromedial Impingement in the Ankle Joint: Outcomes Following Arthroscopy in the First One Hundred Cases (SS-54) Christopher D. Murawski, M.D., John G. Kennedy, M.D., F.R.C.S.(Orth) Introduction: Anteromedial impingement (AMI) is a common and chronic ankle joint condition characterized by anteromedial talotibial osteophytes, soft tissue synovial hyperplasia and cicatrization, thereby causing pain and a mechanical obstruction to normal joint motion. AMI is a common condition found primarily in athletes, but particularly soccer players. The first case series of the arthroscopic resection of AMI has been previously described. The current authors’ present an update of an ongoing series with the retrospective results of the first one hundred patients treated arthroscopically for AMI. Methods: Between January 2005 and January 2010, 100 patients underwent arthroscopic resection of AMI under