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Safety of arthroscopic removal of heterotopic ossification around the elbow
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Table 1
J Shoulder Elbow Surg June 2016
ROM comparison between control athletes and athletes with little league shoulder and little league elbow
Total Controls Dominant Arm Humeral Torsion External Rotation Internal Rotation Total Arc of Motion Horizontal Adduction
N 47 47 47 47 47
Mean 11.9 129.0 36.4 165.4 7.5
Little League Shoulder SD 15.7 15.9 14.6 24.8 15.8
N 23 23 23 23 23
Mean 21.8* 115.3* 35.0 144.0* 2.0
Little League Elbow SD 6.7 11.6 14.5 35.6 12.2
N 26 26 26 26 26
Mean 14.0† 121.6§ 29.0 145.6* 0.0§
SD 12.8 12.5 15.8 34.9 13.0
P value .04 .001 .1 .005 .08
* Tukeys post hoc demonstrates significant different when comparing LLS /LLE to control group. † Tukeys post hoc demonstrates trend toward significant difference when comparing the LLS to the LLE group. § Tukeys post hoc demonstrates trend toward significant difference comparing LLS/LLE to control group.
120
40 35
100
30
80
25
60
20 15
40
10
20 0
5 Flex-Ext Arc
MEPS
0
in range of motion, patients with posttraumatic arthritis have a wider variability in clinical outcomes. Ulnar nerve symptoms were relieved more consistently in those with osteoarthritis. The OK procedure is an effective and safe way of treating both posttraumatic arthritis and osteoarthritis of the elbow.
Paper #37 SAFETY OF ARTHROSCOPIC REMOVAL OF HETEROTOPIC OSSIFICATION AROUND THE ELBOW
Daniel R. Bachman, MD, James S. Fitzsimmons, BSc, Shawn W. O’Driscoll, PhD, MD, Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA Objective: Arthroscopic elbow heterotopic ossification (HO) removal has only briefly been described in the literature. However, intuitive application of fundamental arthroscopic principles as well as safety-driven novel techniques have the potential to reduce complications of open HO removal around the elbow. Although the complications of open heterotopic ossification removal, including nerve injuries and infection, have been described, the prevalence and severity of complications following arthroscopic removal have not been explored to date. The purpose of this study was to evaluate the safety of arthroscopic vs open HO removal with respect to serious and minor complications in a large series of patients treated for HO around the elbow. Methods: A retrospective review was conducted of 223 elbow cases where HO removal was indicated to restore range of motion in 211 patients over an eighteen year period. Of the 223 cases, 194 (87%) had follow up of six weeks or more. The most common final
Pain
Function
Stability
diagnoses (each patient could have more than one diagnosis) other than HO were post-traumatic contracture (172), nerve palsy, neuritis, or neuropathy (138), osteoarthritis (37), contracture—OA, RA or other (24), malunion (20), and instability (14). HO was removed arthroscopically in 41 cases, open in 158 procedures and 24 cases used both. Considering combined cases as ½ open and ½ arthroscopic, 53 scopes and 170 open procedures resulted. Results: 11 serious complications: 7 joint space infections, 2 cases of AVN, 1 case of with a neuropathic pain syndrome worsened with surgery and 1 permanent partial nerve injury occurred. 10 were after open HO removal and the patient experiencing worsened neuropathic pain occurred following a combined case. No major complications were experienced with the arthroscopic-only HO removal. For both open and arthroscopic procedures, minor complications occurred after fortynine cases (23%). These included transient nerve palsies in 22(9 ulnar n.: 5 Delayed-Onset Ulnar Neuritis (DOUN), 5 radial n., 4 tourniquet related multiple nerve, and 4 cutaneous nerve palsies) hematoma or seroma in 20, instability for 8, wound dehiscence or superficial infections after 7, HO recurrence with ROM loss from surgery after 2, and post-operative fracture in 2. Excluding complications resolved by aspirations, local wound care, or ulnar nerve transposition for DOUN, now considered preventable, the complications requiring revision were 3/53 for arthroscopic cases (6%) and 14/170 (8%) open cases (P = .77). Conclusions: Serious or permanent complications were more frequent in open than arthroscopic HO removals in this series. Removal of elbow HO in the hands of a skilled arthroscopist, staying within the limits of their technical ability, should be considered safe. Efficacy should be evaluated in a subsequent study (Fig. 1).
Table 1
J Shoulder Elbow Surg June 2016
ROM comparison between control athletes and athletes with little league shoulder and little league elbow
Total Controls Dominant Arm Humeral Torsion External Rotation Internal Rotation Total Arc of Motion Horizontal Adduction
N 47 47 47 47 47
Mean 11.9 129.0 36.4 165.4 7.5
Little League Shoulder SD 15.7 15.9 14.6 24.8 15.8
N 23 23 23 23 23
Mean 21.8* 115.3* 35.0 144.0* 2.0
Little League Elbow SD 6.7 11.6 14.5 35.6 12.2
N 26 26 26 26 26
Mean 14.0† 121.6§ 29.0 145.6* 0.0§
SD 12.8 12.5 15.8 34.9 13.0
P value .04 .001 .1 .005 .08
* Tukeys post hoc demonstrates significant different when comparing LLS /LLE to control group. † Tukeys post hoc demonstrates trend toward significant difference when comparing the LLS to the LLE group. § Tukeys post hoc demonstrates trend toward significant difference comparing LLS/LLE to control group.
120
40 35
100
30
80
25
60
20 15
40
10
20 0
5 Flex-Ext Arc
MEPS
0
in range of motion, patients with posttraumatic arthritis have a wider variability in clinical outcomes. Ulnar nerve symptoms were relieved more consistently in those with osteoarthritis. The OK procedure is an effective and safe way of treating both posttraumatic arthritis and osteoarthritis of the elbow.
Paper #37 SAFETY OF ARTHROSCOPIC REMOVAL OF HETEROTOPIC OSSIFICATION AROUND THE ELBOW
Daniel R. Bachman, MD, James S. Fitzsimmons, BSc, Shawn W. O’Driscoll, PhD, MD, Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA Objective: Arthroscopic elbow heterotopic ossification (HO) removal has only briefly been described in the literature. However, intuitive application of fundamental arthroscopic principles as well as safety-driven novel techniques have the potential to reduce complications of open HO removal around the elbow. Although the complications of open heterotopic ossification removal, including nerve injuries and infection, have been described, the prevalence and severity of complications following arthroscopic removal have not been explored to date. The purpose of this study was to evaluate the safety of arthroscopic vs open HO removal with respect to serious and minor complications in a large series of patients treated for HO around the elbow. Methods: A retrospective review was conducted of 223 elbow cases where HO removal was indicated to restore range of motion in 211 patients over an eighteen year period. Of the 223 cases, 194 (87%) had follow up of six weeks or more. The most common final
Pain
Function
Stability
diagnoses (each patient could have more than one diagnosis) other than HO were post-traumatic contracture (172), nerve palsy, neuritis, or neuropathy (138), osteoarthritis (37), contracture—OA, RA or other (24), malunion (20), and instability (14). HO was removed arthroscopically in 41 cases, open in 158 procedures and 24 cases used both. Considering combined cases as ½ open and ½ arthroscopic, 53 scopes and 170 open procedures resulted. Results: 11 serious complications: 7 joint space infections, 2 cases of AVN, 1 case of with a neuropathic pain syndrome worsened with surgery and 1 permanent partial nerve injury occurred. 10 were after open HO removal and the patient experiencing worsened neuropathic pain occurred following a combined case. No major complications were experienced with the arthroscopic-only HO removal. For both open and arthroscopic procedures, minor complications occurred after fortynine cases (23%). These included transient nerve palsies in 22(9 ulnar n.: 5 Delayed-Onset Ulnar Neuritis (DOUN), 5 radial n., 4 tourniquet related multiple nerve, and 4 cutaneous nerve palsies) hematoma or seroma in 20, instability for 8, wound dehiscence or superficial infections after 7, HO recurrence with ROM loss from surgery after 2, and post-operative fracture in 2. Excluding complications resolved by aspirations, local wound care, or ulnar nerve transposition for DOUN, now considered preventable, the complications requiring revision were 3/53 for arthroscopic cases (6%) and 14/170 (8%) open cases (P = .77). Conclusions: Serious or permanent complications were more frequent in open than arthroscopic HO removals in this series. Removal of elbow HO in the hands of a skilled arthroscopist, staying within the limits of their technical ability, should be considered safe. Efficacy should be evaluated in a subsequent study (Fig. 1).