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Is Elbow Arthroscopy Safe in Patients with a Subluxating ulnar nerve or Previous Ulnar Nerve Transposition? (SS-24)
ABSTRACTS Methods: A retrospective review was performed of 502 consecutive cases of arthroscopic contracture release in 464 patients by one surgeon during a 15 year period. The safety-driven step-wise technique evolved during the first 100 cases from detaching to incising to completely excising the capsule. For the next 402 cases arthroscopic capsulectomy was performed in a standardized sequence: (1) Get In and Establish a View, (2) Create a Space in Which to Work, (3) Bone Removal, and (4) Capsulectomy. Retractors were used to maintain space and to protect the nerves. Suction was detached from the shavers and burrs. Cases included complex and revision contracture releases. Results: Transient sensory motor nerve palsies that resolved within three days developed in three cases (0.6%), two from blunt retraction and one from local anesthetic injection. Two medial antebrachial cutaneous nerve injuries from portal sites occurred but resolved completely within 3 and 18 months respectively. Thus, 5 nerve palsies (1%) occurred as a direct result of the arthroscopy itself. Eleven patients (2.2%) experienced transient diffuse sensory motor nerve palsies involving 2 or 3 major nerves that were associated with prolonged tourniquet times; all resolved within 3 days. Two patients (0.4%) had a transient partial sensory motor after ulnar nerve transposition that resolved completely within 1-3 days. Seven patients experienced sensory dysesthesia of the skin innervated by the posterior branch of the medial antebrachial cutaneous nerve due to a posterior medial incision for decompression of the ulnar nerve. These involved the skin in the region of the olecranon and six of seven (1.4%) resolved completely within three months to two years. The final patient was lost to follow-up. Thus, a total of 19 cases (3.8%) experienced nerve palsies indirectly related to the arthroscopy (due to other factors such as prolonged tourniquet time, ulnar nerve transposition, or a posteromedial skin incision). Overall, 23 of the 502 cases (4.6%) experienced transient nerve palsies that resolved completely with 1 additional patient (0.2%) having a cutaneous nerve dysesthesia but was lost to follow-up. There were no permanent nerve injuries. Conclusions: Temporary nerve injuries are a definite risk with arthroscopic elbow contracture release. They occur due to tourniquet palsies, compression by instruments and retractors. However, under the conditions in this study, we found permanent nerve injuries to be a minimal risk, with a surgeon highly experienced in open and arthroscopic elbow surgery, the adherence to a safety-driven step-wise technique, the routine use of retractors and avoidance of suction on shavers. The risk of nerve injury is more related to the experience and exper-
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tise of the operating team and facility than to the severity of the contracture.
Is Elbow Arthroscopy Safe in Patients with a Subluxating ulnar nerve or Previous Ulnar Nerve Transposition? (SS-24) Shawn W. O’Driscoll, PhD, MD, and Deenesh T. Sahajpal, MD Summary: In a consecutive series of 696 patients undergoing elbow arthroscopy, 37 had a prior ulnar nerve transposition or a subluxating ulnar nerve. Use of the anteromedial portals was able to be safely performed by palpating the nerve, exposing it, dissecting bluntly past it, or by the inside out technique in all patients, except six who had a submuscular transposition. In those patients, only lateral portals were used in the anterior joint. No patient suffered a nerve injury. Elbow arthroscopy is not necessarily contraindicated in patients with a subluxating or transposed ulnar nerve. Introduction: This paper reviewed the complication rate in a series of patients with a subluxating ulnar nerve or previous ulnar nerve transposition who have undergone elbow arthroscopy. Methods: A series of 696 patients who underwent elbow arthroscopy by single surgeon from 1996 to 2006 were reviewed. It was determined that 37 of the patients had a subluxating ulnar nerve or previous ulnar nerve transposition. 12 patients had a subcutaneous transposition and 6 had a submuscular transposition. All patients underwent an arthroscopic evaluation of the anterior and posterior compartments of the elbow. Capsulectomy or osteocapsular arthroplasty was performed in 28 cases. All patients with subluxating or dislocating nerves had proximal anteromedial portals established by holding the nerve in the groove with a thumb while establishing or entering the portal. The following techniques were used according to whether or not the nerve was palpable under the skin. If it was palpable throughout its course around the epicondyle, the proximal anteromedial portal was placed 1 cm anterior or posterior to the nerve (n⫽ 10). If the nerve was not palpable, we either dissected down to the capsule through a mini incision (n⫽2) without seeing the nerve, or exposed the nerve (n⫽4), or gently dissected from inside out with a blunt tipped pointed switching stick (n⫽2) or from outside in with a hemostat (n⫽1). If the nerve had been transposed submuscularly and was not palpable, we did not use any anteromedial portals, just two anterolateral portals (n⫽4). Finally, submuscular transposition was considered a contraindication to arthroscopic anterior capsulectomy (n⫽6).
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ABSTRACTS
Results: All patients were followed for one-year post operatively. There were no operative ulnar nerve injuries or late neurologic sequelae. Conclusions: Elbow arthroscopy is not necessarily contraindicated in these patients. We recommend a low threshold to dissect out the nerve if it is not palpable. Elbow arthroscopy is safe in the face of a subluxating or dislocating ulnar nerve, and after prior ulnar nerve transposition by using modified techniques in theses patients. Submuscular transposition places the nerve on the capsule, so we still consider this a contraindication to anterior capsulectomy.
numbness in the territory of the ulnar nerve at one year follow-up. However this didn’t affect the subjective outcomes (S.P.O.R.T.S. and S.O.D. score 9 point). One of the patients needed three manipulations under anesthesia to maintain the extension. At the last follow up he had full ROM (0-140) and had S.P.O.R.T.S. and S.O.D. scores of 6 and 9, respectively. Conclusions: This series reports for the first time on the restoration of a terminal extension in athletes. Arthroscopic release of contractures is a predictable technique for restoring terminal extension required in high demand athletes.
Restoration of Terminal Extension in Athletes (SS25) Shawn W. O’Driscoll, PhD, MD, Davide Blonna, MD, and Gwo-Chin Lee, MD
Posteromedial Elbow Impingement: MRI Findings in Overhead Throwing Athletes and Results of Arthroscopic Treatment (SS-26) Steven B. Cohen, MD, Courtney Valko, BA, Adam Zoga, MD, and Michael G. Ciccotti, MD
Introduction: Although most people can lead normal lives with a functional arc of motion of the elbow, there is a subpopulation of high demand athletes for whom loss of terminal extension, particularly if it is painful, is impairing and unacceptable. The purpose of this study was to evaluate the efficacy of arthroscopic capsulectomy or osteocapsular arthroplasty for restoration of pain-free terminal extension in high level athletes. Methods: Although most people can lead normal lives with a functional arc of motion of the elbow, there is a subpopulation of high demand athletes for whom loss of terminal extension, particularly if it is painful, is impairing and unacceptable. The purpose of this study was to evaluate the efficacy of arthroscopic capsulectomy or osteocapsular arthroplasty for restoration of pain-free terminal extension in high level athletes. Results: The S.O.D score averaged 9.2, with 10 representing restoration of the elbow to normal and 0 being no improvement from surgery. The average extension improved significantly from 27 to 6 degrees (range ⫺10 - 25). None of the patient complained lack of extension. 25 of the 26 cases had returned to the same sport with an average S.P.O.R.T.S. score of 9/10. Seventeen played at their pre-injury level with no pain, 6 played at their pre-injury level with minor pain that didn’t influence their performance and 2 returned to the same sport but not at their pre-injury level. One athlete could not resume the same sport due to pain. In 25 cases the elbows were rated as normal or near normal. Postoperatively, three patients developed delayed-onset ulnar neuropathy. None of them underwent a prophylactic ulnar nerve decompression or transposition. Two of these three patients consequently underwent a subcutaneous nerve transposition. After the transposition one patient achieved a full recovery within 6 weeks and one still had
Summary: Posteromedial elbow pain as a result of impingement has a reproducible pattern of pathology on MRI in throwing athletes. Arthroscopic debridement, olecranon spur excision, and loose body excision if present allows return to throwing sports, and excellent subjective and objective results. Introduction: Posteromedial elbow pain in throwing athletes may be the result of valgus extension overlead and UCL insufficiency or due to posteromedial impingement due synovitis or olecranon spurring. An MRI with or without intra-articular contrast is the gold standard imaging modality. To date, no pattern of MRI findings has been reported in the setting of clinical posteromedial elbow impingement. The purpose of this study was to define the MRI pattern and assess the results of arthroscopic treatment. Methods: Over an 8 year period, a total of 10 throwing athletes were identified retrospectively, who were diagnosed with posteromedial elbow impingement who had an MRI, and who failed non-operative treatment and ultimately required arthroscopy. Any patients with UCL insufficiency were excluded from the study. Those with a clinical diagnosis of posteromedial elbow impingement underwent an MRI examination using either a standard noncontrast protocol, or a direct MR arthrographic protocol. All MRIs were acquired at 1.5 tesla using a dedicated extremity receiver coil with the patient’s affected arm extended while prone on the scanner in a ‘superman’ position. All studies included edema sensitive T2 weighted fast spin echo fat suppressed sequences in 3 planes, while the direct MR arthrographic studies included high resolution T1 weighted spin echo fat suppressed images in at least two planes. MRIs were re-
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tise of the operating team and facility than to the severity of the contracture.
Is Elbow Arthroscopy Safe in Patients with a Subluxating ulnar nerve or Previous Ulnar Nerve Transposition? (SS-24) Shawn W. O’Driscoll, PhD, MD, and Deenesh T. Sahajpal, MD Summary: In a consecutive series of 696 patients undergoing elbow arthroscopy, 37 had a prior ulnar nerve transposition or a subluxating ulnar nerve. Use of the anteromedial portals was able to be safely performed by palpating the nerve, exposing it, dissecting bluntly past it, or by the inside out technique in all patients, except six who had a submuscular transposition. In those patients, only lateral portals were used in the anterior joint. No patient suffered a nerve injury. Elbow arthroscopy is not necessarily contraindicated in patients with a subluxating or transposed ulnar nerve. Introduction: This paper reviewed the complication rate in a series of patients with a subluxating ulnar nerve or previous ulnar nerve transposition who have undergone elbow arthroscopy. Methods: A series of 696 patients who underwent elbow arthroscopy by single surgeon from 1996 to 2006 were reviewed. It was determined that 37 of the patients had a subluxating ulnar nerve or previous ulnar nerve transposition. 12 patients had a subcutaneous transposition and 6 had a submuscular transposition. All patients underwent an arthroscopic evaluation of the anterior and posterior compartments of the elbow. Capsulectomy or osteocapsular arthroplasty was performed in 28 cases. All patients with subluxating or dislocating nerves had proximal anteromedial portals established by holding the nerve in the groove with a thumb while establishing or entering the portal. The following techniques were used according to whether or not the nerve was palpable under the skin. If it was palpable throughout its course around the epicondyle, the proximal anteromedial portal was placed 1 cm anterior or posterior to the nerve (n⫽ 10). If the nerve was not palpable, we either dissected down to the capsule through a mini incision (n⫽2) without seeing the nerve, or exposed the nerve (n⫽4), or gently dissected from inside out with a blunt tipped pointed switching stick (n⫽2) or from outside in with a hemostat (n⫽1). If the nerve had been transposed submuscularly and was not palpable, we did not use any anteromedial portals, just two anterolateral portals (n⫽4). Finally, submuscular transposition was considered a contraindication to arthroscopic anterior capsulectomy (n⫽6).
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ABSTRACTS
Results: All patients were followed for one-year post operatively. There were no operative ulnar nerve injuries or late neurologic sequelae. Conclusions: Elbow arthroscopy is not necessarily contraindicated in these patients. We recommend a low threshold to dissect out the nerve if it is not palpable. Elbow arthroscopy is safe in the face of a subluxating or dislocating ulnar nerve, and after prior ulnar nerve transposition by using modified techniques in theses patients. Submuscular transposition places the nerve on the capsule, so we still consider this a contraindication to anterior capsulectomy.
numbness in the territory of the ulnar nerve at one year follow-up. However this didn’t affect the subjective outcomes (S.P.O.R.T.S. and S.O.D. score 9 point). One of the patients needed three manipulations under anesthesia to maintain the extension. At the last follow up he had full ROM (0-140) and had S.P.O.R.T.S. and S.O.D. scores of 6 and 9, respectively. Conclusions: This series reports for the first time on the restoration of a terminal extension in athletes. Arthroscopic release of contractures is a predictable technique for restoring terminal extension required in high demand athletes.
Restoration of Terminal Extension in Athletes (SS25) Shawn W. O’Driscoll, PhD, MD, Davide Blonna, MD, and Gwo-Chin Lee, MD
Posteromedial Elbow Impingement: MRI Findings in Overhead Throwing Athletes and Results of Arthroscopic Treatment (SS-26) Steven B. Cohen, MD, Courtney Valko, BA, Adam Zoga, MD, and Michael G. Ciccotti, MD
Introduction: Although most people can lead normal lives with a functional arc of motion of the elbow, there is a subpopulation of high demand athletes for whom loss of terminal extension, particularly if it is painful, is impairing and unacceptable. The purpose of this study was to evaluate the efficacy of arthroscopic capsulectomy or osteocapsular arthroplasty for restoration of pain-free terminal extension in high level athletes. Methods: Although most people can lead normal lives with a functional arc of motion of the elbow, there is a subpopulation of high demand athletes for whom loss of terminal extension, particularly if it is painful, is impairing and unacceptable. The purpose of this study was to evaluate the efficacy of arthroscopic capsulectomy or osteocapsular arthroplasty for restoration of pain-free terminal extension in high level athletes. Results: The S.O.D score averaged 9.2, with 10 representing restoration of the elbow to normal and 0 being no improvement from surgery. The average extension improved significantly from 27 to 6 degrees (range ⫺10 - 25). None of the patient complained lack of extension. 25 of the 26 cases had returned to the same sport with an average S.P.O.R.T.S. score of 9/10. Seventeen played at their pre-injury level with no pain, 6 played at their pre-injury level with minor pain that didn’t influence their performance and 2 returned to the same sport but not at their pre-injury level. One athlete could not resume the same sport due to pain. In 25 cases the elbows were rated as normal or near normal. Postoperatively, three patients developed delayed-onset ulnar neuropathy. None of them underwent a prophylactic ulnar nerve decompression or transposition. Two of these three patients consequently underwent a subcutaneous nerve transposition. After the transposition one patient achieved a full recovery within 6 weeks and one still had
Summary: Posteromedial elbow pain as a result of impingement has a reproducible pattern of pathology on MRI in throwing athletes. Arthroscopic debridement, olecranon spur excision, and loose body excision if present allows return to throwing sports, and excellent subjective and objective results. Introduction: Posteromedial elbow pain in throwing athletes may be the result of valgus extension overlead and UCL insufficiency or due to posteromedial impingement due synovitis or olecranon spurring. An MRI with or without intra-articular contrast is the gold standard imaging modality. To date, no pattern of MRI findings has been reported in the setting of clinical posteromedial elbow impingement. The purpose of this study was to define the MRI pattern and assess the results of arthroscopic treatment. Methods: Over an 8 year period, a total of 10 throwing athletes were identified retrospectively, who were diagnosed with posteromedial elbow impingement who had an MRI, and who failed non-operative treatment and ultimately required arthroscopy. Any patients with UCL insufficiency were excluded from the study. Those with a clinical diagnosis of posteromedial elbow impingement underwent an MRI examination using either a standard noncontrast protocol, or a direct MR arthrographic protocol. All MRIs were acquired at 1.5 tesla using a dedicated extremity receiver coil with the patient’s affected arm extended while prone on the scanner in a ‘superman’ position. All studies included edema sensitive T2 weighted fast spin echo fat suppressed sequences in 3 planes, while the direct MR arthrographic studies included high resolution T1 weighted spin echo fat suppressed images in at least two planes. MRIs were re-