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Kotsapas M, Giotis D, Zampeli F, Giannatos V, Koutserimpas C, Kokkalis Z, Karadimos D, Koukos C. Anatomical considerations, diagnosis, and treatment of medial and posterolateral elbow rotatory instability in athletes: an arthroscopic perspective and literature review. INTERNATIONAL ORTHOPAEDICS 2025; 49:1439-1450. [PMID: 40047874 DOI: 10.1007/s00264-025-06485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2025] [Accepted: 02/28/2025] [Indexed: 05/14/2025]
Abstract
PURPOSE Elbow joint instability results from the disruption of one or more stabilizing anatomical structures. The two most common forms of instability are posterolateral rotatory instability (PLRI) and medial elbow instability (MEI), particularly in athletes. This review aims to explore the anatomical foundations, diagnostic methods, and therapeutic approaches for PLRI and MEI in athletes. METHODS A comprehensive literature review was performed to investigate the study objective. RESULTS Regarding the anatomical background, the primary stabilizing structures of the elbow joint include the humeroulnar joint (trochlea, olecranon, and coronoid process), the medial collateral ligament (MCL), and the lateral ulnar collateral ligament (LUCL). PLRI is primarily caused by LUCL insufficiency, while MEI results from MCL dysfunction. A thorough clinical evaluation, combined with advanced imaging-magnetic resonance imaging (MRI) or MR arthrography is essential for an accurate diagnosis. For high-level athletes, surgical intervention is often required, with the timing and type of surgery tailored to the athlete's specific needs, expectations, and the chronicity of the injury. CONCLUSION PLRI and MEI present diagnostic and therapeutic challenges, especially in athletes. Advanced imaging and clinical evaluation are crucial for the diagnosis. Surgical intervention, particularly arthroscopy, is often required for optimal outcomes.
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Affiliation(s)
- Michail Kotsapas
- Department of Orthopaedics and Traumatology, General Hospital of Naoussa, Naoussa, Greece
| | - Dimitrios Giotis
- Orthopaedic Department, General Hospital of Ioannina, Ioannina, Greece.
| | - Frantzeska Zampeli
- Hand-Upper Limb-Microsurgery Department, KAT Attica General Hospital, Kifissia, Greece
| | - Vasileios Giannatos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Orthopedics and Traumatology, University Hospital of Patras, Patras, Greece
| | - Christos Koutserimpas
- Orthopedic Surgery and Sports Medicine Department, Croix-Rousse University Hospital, Lyon, France
- Department of Surgical Anatomy, Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Zinon Kokkalis
- Department of Orthopedics and Traumatology, University Hospital of Patras, Patras, Greece
| | - Dimitrios Karadimos
- Department of Orthopaedics and Traumatology, General Hospital of Ptolemaida, Ptolemaida, Greece
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Yang C, Dong J, Liu F, Zhao X, Xu J, Yu Z, Lu S, Xu W, Li L, Dong J. Comparative study of open elbow arthrolysis with and without hinge external fixation for the treatment of post-traumatic elbow stiffness. BMC Musculoskelet Disord 2024; 25:1016. [PMID: 39696197 DOI: 10.1186/s12891-024-08167-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Accepted: 12/06/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND The present study aimed to compare the functional outcomes of hinged external fixators and non-external fixation in open elbow arthrolysis (OEA) for post-traumatic elbow stiffness (PTES) and to evaluate their applicability and limitations in patients with posttraumatic elbow stiffness. METHODS The clinical data of patients with PTES treated with OEA at our hospital between March 2015 and June 2022 were retrospectively analyzed. The assessed variables were the operation time, intraoperative blood loss volume, duration of hospitalization, and treatment costs. The elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), shortened disabilities of the arm, shoulder and hand questionnaire (Q-DASH) score, Oxford Elbow score (OES), Broberg and Morrey score (BMS), visual analog scale (VAS) for pain, and complications such as pin tract infection and heterotopic ossification were compared between patients with and without hinge external fixation. We also compared the baseline characteristics and functional outcomes of patients with and without hinge external fixation. RESULTS A total of 156 patients (48 patients with hinged external fixators and 108 patients without external fixators) diagnosed with PTES were included in this study. The mean follow-up was 15.8 ± 3.6 months. Compared with patients without external fixators, those with external fixators showed significantly greater improvements in elbow flexion and extension ROM (59.6° ± 26.1° vs. 46.2° ± 26.2°, p = 0.004) but had a significantly longer duration of hospitalization (p < 0.001), significantly longer operation time (p < 0.001), significantly higher treatment costs (p < 0.001), and significantly greater intraoperative blood loss volume (p < 0.001). There were no significant differences between the two groups in terms of improvement in elbow rotation ROM, MEPS score, VAS score for pain, OES score, Q-DASH score, BMS score, or incidence of complications. CONCLUSION The use of a hinged external fixator in open arthrolysis for posttraumatic elbow stiffness may result in short-term improvements in flexion-extension range of motion but is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs. Further studies are needed to confirm these findings. CLINICAL TRIAL NUMBER Not applicable.
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Affiliation(s)
- Changhao Yang
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Jinye Dong
- Department of Ultrasound, Weifang People's Hospital, No. 151 of Guangwen Street, Weifang, Shandong, 261041, China
| | - Fanxiao Liu
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Xuehui Zhao
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Jiajun Xu
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Zhanchuan Yu
- Department of Orthopedics Surgery, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
| | - Shun Lu
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Weicheng Xu
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Lianxin Li
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Jinlei Dong
- Department of Orthopedics Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China.
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Schamberger CT, Grossner T, Rehnitz C, Findeisen S, Ferbert T, Suda AJ, Schmidmaier G, Stein S. The HuRaA Trial-The Radiocapitellar Line Shows Significant Posterior Translation in Healthy Elbows: A Prospective Analysis of 53 Healthy Individuals. Biomedicines 2024; 12:2660. [PMID: 39767567 PMCID: PMC11726721 DOI: 10.3390/biomedicines12122660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 11/15/2024] [Accepted: 11/19/2024] [Indexed: 01/16/2025] Open
Abstract
Background: The elbow joint is stabilized by complex interactions between bony structures and soft tissues, notably the lateral and medial collateral ligaments. Posterolateral rotatory instability (PLRI), a form of elbow instability, is challenging to diagnose due to overlapping symptoms with other conditions. The radiocapitellar line (RCL) is a radiographic tool for assessing humeroradial alignment and elbow stability, but its diagnostic accuracy remains debated. This study aims to provide normative data on RCL deviations in healthy individuals to improve diagnostic criteria for PLRI. Methods: A prospective study was conducted with 53 healthy individuals (27 males, 26 females) aged 18-45 years. MRI scans of the participants' elbows were performed in maximum extension and supination to assess radiocapitellar deviations (RCDs). Two orthopedic surgeons independently analyzed the images to evaluate RCDs and assess interobserver reliability. Statistical analyses, including independent t-tests and Pearson correlations, were used to explore the relationship between RCDs, demographic factors, and elbow stability. Results: The average RCD in the cohort was 1.77 mm (SD 1.06 mm). Notably, 62.9% of participants had deviations greater than 1.2 mm, while 12.9% exceeded 3.4 mm, thresholds traditionally used to diagnose PLRI. Gender and age did not significantly influence RCD values. The interobserver reliability was almost good (ICC = 0.87), supporting the consistency of the RCL measurements. Conclusions: Significant RCDs occur even in asymptomatic individuals, challenging the current diagnostic thresholds for PLRI based solely on RCL measurements. A comprehensive assessment that includes clinical, anatomical, and functional evaluations is essential for accurate diagnosis. These findings highlight the need for refined diagnostic criteria and further research into elbow stability.
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Affiliation(s)
- Christian T. Schamberger
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Tobias Grossner
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Christoph Rehnitz
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Sebastian Findeisen
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Thomas Ferbert
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Arnold J. Suda
- Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, 68167 Mannheim, Germany
| | - Gerhard Schmidmaier
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
| | - Stephan Stein
- Clinic for Trauma and Reconstructive Surgery, University Hospital Heidelberg, 69118 Heidelberg, Germany
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Schinnerl C, Weber MA, Benninger E, Fischer TS, Falkowski AL. MRI of the Elbow - Update 2024. ROFO-FORTSCHR RONTG 2024. [PMID: 39532120 DOI: 10.1055/a-2416-1491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
Elbow pain can result in significant morbidity. MRI can help diagnosing the cause of elbow pain.Based on a systematic literature search as well as knowledge gained through frequent participation in conferences dedicated to advances in musculoskeletal imaging, this review aims to give a brief overview of normal anatomy and common pathologies of tendons and ligaments of the elbow on magnetic resonance imaging.Stabilization of the elbow joint is provided by osseous structures and passive ligamentous and active muscular support. Loss of these important stabilizers, due to trauma and overuse, can result in elbow instability. Additional MR views or intra-articular contrast media can be useful for the detection of specific pathologies.MRI is frequently used to detect posttraumatic or chronic conditions, which can lead to posterolateral or posteromedial elbow instability. Knowledge of normal anatomy, variants, pathologies, as well as appropriate imaging is crucial to make the diagnosis. · Epicondylitis occurs due to chronic degeneration with tendinosis and partial tendon tearing and is not related to an acute inflammatory reaction.. · Posterolateral or posteromedial elbow instability can be the result of trauma with loss of passive ligamentous and active muscular stabilization.. · The most common elbow instability is posterolateral rotatory instability with the LUCL being the most important stabilizer affected by injury.. · Schinnerl C, Weber M, Benninger E et al. MRI of the Elbow - Update 2024. Fortschr Röntgenstr 2024; DOI 10.1055/a-2416-1491.
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Affiliation(s)
- Christoph Schinnerl
- Clinic of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Emanuel Benninger
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Tim S Fischer
- Clinic of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Anna L Falkowski
- Clinic of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Zurich, Zurich, Switzerland
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Arrigoni P, Ribolzi RR, Vismara V, Cassin S, Beltrame G, Nyarambi T, Zaolino C, Luceri F, Randelli PS. Proximal radioulnar joint, but not posterolateral, instability in patients with symptomatic minor instability of the lateral elbow. J Shoulder Elbow Surg 2024; 33:2264-2270. [PMID: 38815733 DOI: 10.1016/j.jse.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like symptomatic minor instability of the lateral elbow (SMILE) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathologic condition. MATERIALS AND METHODS Twenty-eight patients were included in this study: half of them were operated for suspected SMILE whereas the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, 4 parameters were analyzed: annular drive through (ADT), ulnar-humeral stressed distance (UHSD) at 45° and 30° of flexion, and loose collar sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to take measurements. RESULTS Statistically significant differences were found for LCS (P = .0003) and ADT (P = .000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly. DISCUSSION AND CONCLUSIONS Progressive stretching of the RLCL and annular ligament may lead to their elongation, resulting in a pathologic anteroposterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radioulnar instability. The study shows how RLCL and annular ligament are elongated in SMILE patients compared with controls, causing instability of the proximal radioulnar joint and confirming that ligament incompetency is involved in the SMILE condition.
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Affiliation(s)
- Paolo Arrigoni
- Orthopedic and Traumatology Department, Clinica Ortopedica, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy.
| | - Romeo R Ribolzi
- Scuola Di Specializzazione in Ortopedia e Traumatologia Università Degli Studi Di Milano, Milan, Italy
| | - Valeria Vismara
- Scuola Di Specializzazione in Ortopedia e Traumatologia Università Degli Studi Di Milano, Milan, Italy
| | - Simone Cassin
- Scuola Di Specializzazione in Ortopedia e Traumatologia Università Degli Studi Di Milano, Milan, Italy
| | - Giulia Beltrame
- Scuola Di Specializzazione in Ortopedia e Traumatologia Università Degli Studi Di Milano, Milan, Italy
| | - Taurayi Nyarambi
- Orthopedic and Traumatology Department, University of Zimbabwe, Harare, Zimbabwe
| | - Carlo Zaolino
- Orthopedic and Traumatology Department, Clinica Ortopedica, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Francesco Luceri
- Orthopedic and Traumatology Department, Clinica Ortopedica, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Pietro Simone Randelli
- Orthopedic and Traumatology Department, Clinica Ortopedica, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy; Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Milan, Italy; Research Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Milan, Italy
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Masouros P, Christakakis PC, Georgiadou P, Kourtzis D, Moustakalis I, Papazotos N, Garnavos C. Coronoid fractures and complex elbow instability: current concepts. Orthop Rev (Pavia) 2024; 16:118439. [PMID: 38846340 PMCID: PMC11152979 DOI: 10.52965/001c.118439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 06/09/2024] Open
Abstract
Fractures of the coronoid process typically occur as part of more complex injury patterns, such as terrible triads, trans-olecranon fracture-dislocations, posteromedial rotatory injuries or Monteggia-like lesions. Each pattern is associated with a specific type of coronoid fracture with regard to shape and size and specific soft-tissue lesions. O' Driscoll classification incorporates those associations identifying three major types of fractures: tip, anteromedial facet, and basal fractures. The objective of this study is to review the most common types of complex elbow instability, identify the indications for coronoid fixation and guide the appropriate management. Tip fractures as those seen in terrible triads can conditionally left untreated provided that elbow stability has been restored after radial head fixation and ligaments repair. Anteromedial facet fractures benefit from a buttress plate, while large basilar fractures can be effectively secured with posteroanterior screws. Coronoid reconstruction with a graft should be considered in post-traumatic cases of chronic coronoid deficiency.
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Monteleone V, Vismara V, Cassin S, Luceri F, Zaolino C, Kulkarni C, Randelli PS, Arrigoni P. A 70° Arthroscope Provides Better Visualization of the Medial Side of the Elbow Than a 30° Arthroscope. Arthrosc Sports Med Rehabil 2024; 6:100865. [PMID: 38328531 PMCID: PMC10844937 DOI: 10.1016/j.asmr.2023.100865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 12/14/2023] [Indexed: 02/09/2024] Open
Abstract
Purpose To assess and quantify the improvement in visualization of humeral insertion of the medial collateral ligament (MCL) using a 70° scope compared with a 30° scope during elbow arthroscopy. Methods Twenty patients undergoing elbow arthroscopy for different pathologic conditions were enrolled in this single-center study. Visualization of the medial gutter of the elbow was evaluated by using both the 70° and the 30°scope. During the procedure, a needle was inserted at 45° with respect to the axis of the forearm, directed toward the intra-articular humeral emergence of the MCL. Four areas were established: the body (Z1), the lanceolate part (Z2), the tip of the needle (Z3), and the medial portion of the trochlea (Z4). The visible areas during arthroscopy using 2 different scopes were collected. Results The 70° scope allowed the detection of the first 3 areas in all patients (Z1, Z2, and Z3) and the visualization of the last area (Z4) in 19 patients (95%). On the other hand, the 30° scope allowed the detection of Z1 in 85% of patients, Z2 in 60% of patients, and Z3 in only 5% of patients. The medial portion of the trochlea was never visualized with the 30° scope. These findings were statistically significant. Conclusions The 70° scope improves visualization of the medial elbow compartment during elbow arthroscopy compared to the 30° scope, enhancing the extent of joint visualization and potentially permitting the detection of otherwise missed injuries in the difficult-to-reach areas of the joint. Level of Evidence Level II, diagnostic, prospective, cohort study.
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Affiliation(s)
- Valerio Monteleone
- Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Valeria Vismara
- Scuola Di Specializzazione in Ortopedia e Traumatologia Università Degli Studi Di Milano, Milan, Italy
| | - Simone Cassin
- Scuola Di Specializzazione in Ortopedia e Traumatologia Università Degli Studi Di Milano, Milan, Italy
| | - Francesco Luceri
- Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Carlo Zaolino
- Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Chandan Kulkarni
- Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Pietro Simone Randelli
- Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Milan, Italy
- Research Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Milan, Italy
| | - Paolo Arrigoni
- Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
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Breulmann FL, Lappen S, Ehmann Y, Bischofreiter M, Lacheta L, Siebenlist S. Treatment strategies for simple elbow dislocation - a systematic review. BMC Musculoskelet Disord 2024; 25:148. [PMID: 38365699 PMCID: PMC10874000 DOI: 10.1186/s12891-024-07260-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/04/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Current treatment concepts for simple elbow dislocation involve conservative and surgical approaches. The aim of this systematic review was to identify the superiority of one treatment strategy over the other by a qualitative analysis in adult patients who suffered simple elbow luxation. STUDY DESIGN A systematic review in accordance with the PRISMA guidelines and following the suggestions for reporting on qualitative summaries was performed. A literature search was conducted using PubMed and Scopus, including variations and combinations of the following keywords: elbow, radiohumeral, ulnohumeral, radioulnar, luxation, and therapy. Seventeen studies that performed a randomized controlled trial to compare treatment strategies as conservative or surgical procedures were included. Reviews are not selected for further qualitative analysis. The following outcome parameters were compared: range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand outcome measure (Quick-DASH), recurrent instability, pain measured by visual analog scale (VAS) and time to return to work (RW). RESULTS Early mobilization after conservative treatment strategies showed improved ROM compared to immobilization for up to 3 weeks after surgery with less extension deficit in the early mobilization group (16° ± 13°. vs. 19.5° ± 3°, p < 0.05), as well as excellent clinical outcome scores. Surgical approaches showed similar results compared to conservative treatment, leading to improved ROM (115 vs. 118 ± 2.8) and MEPS: 95 ± 7 vs. 92 ± 4. CONCLUSION Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. The surgical procedure provides similar outcomes compared to conservative treatment regarding MEPS and ROM for patients with slight initial instability in physical examination and radiographs. People with red flags for persistent instability, such as severe bilateral ligament injuries and moderate to severe instability during initial physical examination, should be considered for a primary surgical approach to prevent recurrent posterolateral and valgus instability. Postoperative early mobilization and early mobilization for conservatively treated patients is beneficial to improve patient outcome and ROM.
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Affiliation(s)
- Franziska Lioba Breulmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Lappen
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Yannick Ehmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Martin Bischofreiter
- Department of Orthopedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Linz, 4010, Austria
- Department of Orthopedics and Traumatology, Klinik Diakonissen Schladming, Schladming, 8970, Austria
| | - Lucca Lacheta
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany.
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Albayrak M. Simple lateral elbow dislocation: A case report. World J Surg Proced 2023; 13:7-13. [DOI: 10.5412/wjsp.v13.i2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/19/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Simple lateral elbow dislocation (SLED) is a rare type of elbow dislocation; however, its treatment may be complicated by accompanying soft tissue or neurovascular damage. Herein, we report a rare case of SLED managed secon-darily with open reduction and soft tissue repair following failure of closed reduction.
CASE SUMMARY A 67-year-old woman suffered SLED after falling on her outstretched left hand with her elbow extended. She developed pain, swelling, and movement restriction in the elbow; there were no neurovascular symptoms, except for numbness in the 4th and 5th digits. Radiologic investigation confirmed the SLED, and a closed reduction under anesthesia was performed. The follow-up radiographs at 1-wk revealed failure of reduction; accordingly, open reduction with lateral collateral ligament and common extensor origin repair were carried out. The patient regained full elbow range of motion by six weeks.
CONCLUSION Adequate concentric reduction for SLED, conservatively or surgically, reduces complications and provides a more functional joint.
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Affiliation(s)
- Mehmet Albayrak
- Department of Orthopaedics and Traumatology, Ozel Tekirdag Yasam Hospital, Tekirdag 59020, Turkey
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10
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Ellenbogenfrakturen. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00596-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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11
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Acute operative stabilization of an elbow dislocation and associated brachial artery injury: A case report. CURRENT ORTHOPAEDIC PRACTICE 2023. [DOI: 10.1097/bco.0000000000001195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Melzner M, Pfeifer C, Süß F, Dendorfer S. Musculoskeletal simulation of elbow stability for common injury patterns. J Orthop Res 2022; 41:1356-1364. [PMID: 36203348 DOI: 10.1002/jor.25460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/26/2022] [Accepted: 09/22/2022] [Indexed: 02/04/2023]
Abstract
Elbow stability is derived from a combination of muscular, ligamentous, and bony structures. After an elbow trauma the stability of the joint is an important decision criterion for the subsequent treatment. The decision regarding nonoperative/operative care depends mostly on subjective assessments of medical experts. Therefore, the aim of this study is to use musculoskeletal simulations as an objective assessment tool to investigate the extent to which failure of different stabilizers affects the elbow stability and how these observations correspond to the assessment from clinical practice. A musculoskeletal elbow simulation model was developed for this aim. To investigate the stability of the elbow, varus/valgus moments were applied under 0°, 45°, and 90° flexion while the respective cubital angle was analyzed. This was performed for nine different injury scenarios, which were also evaluated for stability by clinical experts. With the results, it can be determined by which injury pattern and under which flexion angle the elbow stability is impaired regarding varus/valgus moments. The scenario with a complete failure of the medial and lateral ligaments and a fracture of the radial head was identified as having the greatest instability. The study presented a numerical determination of elbow stability against varus/valgus moments regarding clinical injury patterns, as well as a comparison of the numerical outcome with experience gained in clinical practice. The numerical predictions agree well with the assessments of the clinical specialists. Thus, the results from musculoskeletal simulation can make an important contribution to a more objective assessment of the elbow stability.
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Affiliation(s)
- Maximilian Melzner
- Laboratory for Biomechanics, Ostbayerische Technische Hochschule (OTH) Regensburg, Regensburg, Germany.,Regensburg Center of Biomedical Engineering, OTH and University Regensburg, Regensburg, Germany
| | - Christian Pfeifer
- Trauma, Orthopaedics and Hand Surgery, Innklinikum Altötting, Altotting, Germany.,Clinic of Trauma Surgery, University of Regensburg, Regensburg, Germany
| | - Fran Süß
- Laboratory for Biomechanics, Ostbayerische Technische Hochschule (OTH) Regensburg, Regensburg, Germany.,Regensburg Center of Biomedical Engineering, OTH and University Regensburg, Regensburg, Germany
| | - Sebastian Dendorfer
- Laboratory for Biomechanics, Ostbayerische Technische Hochschule (OTH) Regensburg, Regensburg, Germany.,Regensburg Center of Biomedical Engineering, OTH and University Regensburg, Regensburg, Germany
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13
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Rein S, Esplugas M, Garcia-Elias M, Kremer T, Siemers F, Lühmann P. Immunofluorescence analysis of sensory nerve endings in the periarticular tissue of the human elbow joint. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04604-0. [PMID: 36070088 DOI: 10.1007/s00402-022-04604-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To investigate the dynamic aspects of elbow stability, we aimed to analyze sensory nerve endings in the ligaments and the capsule of elbow joints. MATERIALS AND METHODS The capsule with its anterior (AJC) and posterior (PJC) parts, the radial collateral ligament (RCL), the annular ligament (AL), and the ulnar collateral ligament with its posterior (PUCL), transverse (TUCL) and anterior parts (AUCL) were dissected from eleven human cadaver elbow joints. Sensory nerve endings were analyzed in two levels per specimen as total cell amount/ cm2 after immunofluorescence staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, S-100 protein and 4',6-Diamidin-2-phenylindol, Carbonic anhydrase II and choline acetyltransferase on an Apotome microscope according to Freeman and Wyke's classification. RESULTS Free nerve endings were the predominant mechanoreceptor in all seven structures followed by Ruffini, unclassifiable, Golgi-like, and Pacini corpuscles (p ≤ 0.00001, respectively). Free nerve endings were observed significant more often in the AJC than in the RCL (p < 0.00002). A higher density of Ruffini endings than Golgi-like endings was observed in the PJC (p = 0.004). The RCL contained significant more Ruffini endings than Pacini corpuscles (p = 0.004). Carbonic anhydrase II was significantly more frequently positively immunoreactive than choline acetyltransferase in all sensory nerve endings (p < 0.05). Sensory nerve endings were significant more often epifascicular distributed in all structures (p < 0.006, respectively) except for the AJC, which had a pronounced equal distribution (p < 0.00005). CONCLUSION The high density of free nerve endings in the joint capsule indicates that it has pronounced nociceptive functions. Joint position sense is mainly detected by the RCL, AUCL, PUCL, and the PJC. Proprioceptive control of the elbow joint is mainly monitored by the joint capsule and the UCL, respectively. However, the extreme range of motion is primarily controlled by the RCL mediated by Golgi-like endings.
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Affiliation(s)
- Susanne Rein
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Delitzscher Straße 141, 04129, Leipzig, Germany. .,Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
| | - Mireia Esplugas
- Kaplan Hand Institute, Paseo de la Reina Elisenda 17, 08034, Barcelona, Spain
| | - Marc Garcia-Elias
- Kaplan Hand Institute, Paseo de la Reina Elisenda 17, 08034, Barcelona, Spain
| | - Thomas Kremer
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Delitzscher Straße 141, 04129, Leipzig, Germany
| | - Frank Siemers
- Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.,Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost, Merseburger Straße 165, 06112, Halle (Saale), Germany
| | - Paul Lühmann
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.,Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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14
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Kenmoku T, Nakai D, Nagura N, Onuma K, Sukegawa K, Tazawa R, Otake Y, Takahira N, Takaso M. Tenodesis with bone marrow venting under local anesthesia for recalcitrant lateral epicondylitis: Results of 2 years of follow-up. JSES Int 2022; 6:696-703. [PMID: 35813152 PMCID: PMC9264004 DOI: 10.1016/j.jseint.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hypothesis We hypothesized that the treatment of recalcitrant lateral epicondylitis requires accurate identification of the painful area to promote remodeling of the degenerated extensor insertion and to stabilize the tendon origin during tendon healing. Thus, we performed tenodesis with bone marrow venting under local anesthesia for recalcitrant lateral epicondylitis. Methods Twenty patients (21 elbows) were treated with bone marrow venting at the painful area of the lateral epicondyle of the elbow and tenodesis using 2 soft anchors lateral to the capitellum (immediately distal to the painful area) and were followed up for ≥2 years. Patients were assessed using the numerical rating scale for pain and the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and objective evaluation included active range of motion. Results The mean preoperative and postoperative pain scores were 7.5 and 0.5, respectively, indicating significant pain relief (P < .001). The mean preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 44.2 and 1.0, respectively (P < .001). Two elbows had a slightly positive Thomsen test at the final visit. No recurrence of intra-articular symptoms induced by synovial fringe impingement was observed. Patients experienced more pain at the bone-tendon junction of extensors than at the tendon parenchyma. Conclusion Tenodesis with bone marrow venting under local anesthesia was effective for subjective patient satisfaction and positive clinical outcomes at ≥2 years of follow-up in patients with recalcitrant lateral epicondylitis. Intra-articular symptoms can be improved by stabilization of the lateral soft tissue without treatment for intra-articular lesions.
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15
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Roebke AJ, Samade R, Altman PR, Jain SA, Goyal KS, Speeckaert AL. Role of Dynamic Stabilizers of the Elbow in Radiocapitellar Joint Alignment: A Prospective In Vivo Study. J Hand Surg Am 2022:S0363-5023(22)00052-1. [PMID: 35337695 DOI: 10.1016/j.jhsa.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/08/2021] [Accepted: 01/19/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the effect of dynamic stabilizers of the elbow on radiocapitellar joint alignment, before and after the administration of regional anesthesia. METHODS At a single institution, 14 patients were prospectively enrolled in a study using a within-subjects control design. Before performing a supraclavicular regional block, 10 fluoroscopic images (1 anteroposterior and 9 lateral views) of the elbow were obtained for each patient. The lateral images were obtained with the forearm in maximal supination, neutral rotation, and maximal pronation, and these forearm positions were repeated for 3 elbow positions: (1) full extension; (2) flexion to 90°, with 0° of shoulder internal rotation; and (3) flexion to 90°, with 90° of shoulder internal rotation. After obtaining the 10 initial images, a block was performed to achieve less than 3/5 motor strength of the imaged extremity, followed by obtaining the same 10 images in each patient. Radiocapitellar ratio, defined as the minimal distance between the right bisector of the radial head and the center of the capitellum divided by the diameter of the capitellum, was measured in each image. RESULTS The 14 patients had a mean age of 47.8 ± 15.7 years, and 10 (71.4%) patients were women. A difference between radiocapitellar ratios measured before and after the regional block administration was observed for all lateral images (-1.0% ± 7.2% to -2.2% ± 8.0%), although this difference was less than the minimum clinically important difference. CONCLUSIONS Paralysis of the dynamic stabilizers of the elbow produces a difference in the radiocapitellar joint alignment, but this did not reach the minimum clinically important difference. CLINICAL RELEVANCE Paralysis of the dynamic stabilizers of the elbow via a supraclavicular nerve block produces no clinically relevant effect on the radiocapitellar alignment of uninjured elbows.
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Affiliation(s)
- Austin J Roebke
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Richard Samade
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Perry R Altman
- Department of Orthopaedic Surgery, Beaumont Orthopedic Institute, Royal Oak, MI
| | - Sonu A Jain
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH; Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kanu S Goyal
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amy L Speeckaert
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH.
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16
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Kilgus S, Eder C, Siegert P, Moroder P, Zimmermann E, Thiele K. The inter-individual anatomical variation of the trochlear notch as a predisposition for simple elbow dislocation. Arch Orthop Trauma Surg 2022; 142:3405-3413. [PMID: 34953138 PMCID: PMC9522744 DOI: 10.1007/s00402-021-04284-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Besides the multi-layered capsule-ligamentous complex of the elbow joint the high bony congruence in the ulnohumeral joint contributes to elbow stability. Therefore, we assume that specific anatomical configurations of the trochlear notch predispose to dislocation. In case of ligamentous elbow dislocation both conservative and surgical treatment is possible without a clear treatment algorithm. Findings of constitutional bony configurations could help deciding for the best treatment option. METHODS In this retrospective matched-pair analysis we compared MRI imaging from patients sustaining a primary traumatic elbow dislocation (instability group) with patients suffering from chronic lateral epicondylitis (control group), treated between 2009 and 2019. Two independent observers measured different anatomical landmarks of the trochlear notch in a multiplanar reconstructed standardized sagittal trochlear plane (SSTP). Primarily, opening angle and relative depth of the trochlear notch were determined. After adjustment to the proximal ulnar rim in the SSTP, coronoid and olecranon angle, the articular angle as well as the ratio of the tip heights of the trochlear notch were measured. RESULTS We compared 34 patients in the instability group (age 48 ± 14 years, f/m 19/15) with 34 patients in the control group (age 47 ± 16 years, f/m 19/15). Instability group showed a significantly larger opening angle (94.1° ± 6.9° vs. 88.5° ± 6.9°, p = 0.0002), olecranon angle (60.9° ± 5.3° vs. 56.1° ± 5.1°, p < 0.0001) and articular angle (24.7° ± 6.4° vs. 22.3° ± 5.8°, p = 0.02) compared to the control group. Measuring the height from the coronoid (ch) and olecranon (oh) tip also revealed a significantly larger tip ratio (tr = ch/oh) in the instability group (2.7 ± 0.8 vs. 2.2 ± 0.5, p < 0.0001). The relative depth (61.0% ± 8.3% vs. 62.7% ± 6.0%, p = 0.21) of the trochlear notch as well as the coronoid angle (32.8° ± 4.5° vs. 31.7° ± 5.2°, p = 0.30) showed no significant difference in the instability group compared to the control group. The interrater reliability of all measurements was between 0.83 and 0.94. CONCLUSION MRI of patients with elbow dislocation show that there seems to be a bony anatomical predisposition. According to the results, it seems reasonable to include predisposing bony factors in the decision-making process when surgical stabilization and conservative treatment is possible. Further biomechanical studies should prove these assumptions to generate critical bony values helping surgeons with decision making. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sofia Kilgus
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
| | - Christian Eder
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
| | - Paul Siegert
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany ,Orthopedic Hospital Speising, Speisinger Street 109, 1130 Vienna, Austria
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
| | - Elke Zimmermann
- Department of Radiology, Charité-University Medicine Berlin, Chariteplatz 1, Berlin, 10117 Germany
| | - Kathi Thiele
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
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17
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Current concepts in diagnosis, classification, and treatment of acute complex elbow dislocation: a review. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Xiao D, Gong M, Chen C, Zha Y, Li T, Ji S, Hua K, Sun W, Jiang X. Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness. BMC Musculoskelet Disord 2021; 22:941. [PMID: 34758796 PMCID: PMC8582181 DOI: 10.1186/s12891-021-04796-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To evaluate and compare the functional outcomes of combined medial-lateral approach open arthrolysis with and without hinged external fixation. METHODS We retrospectively collected and analyzed the clinical data of patients with severe elbow stiffness who were treated in our institution from January 2018 to January 2019. All of them were treated with combined medial-lateral approach arthrolysis. There were 20 patients who had the hinged external fixation placed and 29 patients without the placement of the external fixation. Their baseline characteristics and functional outcomes were evaluated and compared. RESULTS The average follow-up time was 28.4 ± 3.7 months. There were no significant differences in the ROM of the elbow, MEPS, VAS, DASH, or complications between the two groups. The operation time and treatment cost of the patients without external fixation were significantly lower than patients with external fixation. CONCLUSION Combined medial-lateral approach open elbow arthrolysis without external fixation is a safe and effective way to treat elbow stiffness. LEVEL OF EVIDENCE Therapeutic Level III; Retrospective Cohort Comparison; Treatment Study.
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Affiliation(s)
- Dan Xiao
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Maoqi Gong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Chen Chen
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yejun Zha
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Shangwei Ji
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Kehan Hua
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Weitong Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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19
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Alidina S, Alidina J, Souza F, Kalandiak S, Subhawong TK. Radiographic Evaluation of Elbow Fractures. Semin Musculoskelet Radiol 2021; 25:529-537. [PMID: 34706382 DOI: 10.1055/s-0041-1731083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.
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Affiliation(s)
- Sameer Alidina
- University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Jasim Alidina
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Felipe Souza
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Steven Kalandiak
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
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20
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Reichert ILH, Ganeshamoorthy S, Aggarwal S, Arya A, Sinha J. Dislocations of the elbow - An instructional review. J Clin Orthop Trauma 2021; 21:101484. [PMID: 34367909 PMCID: PMC8321949 DOI: 10.1016/j.jcot.2021.101484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/20/2021] [Indexed: 11/27/2022] Open
Abstract
Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.
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Affiliation(s)
- Ines LH. Reichert
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Saurabh Aggarwal
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Anand Arya
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | - Joydeep Sinha
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
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21
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The role of the brachialis muscle in elbow stability with collateral ligament injury: A biomechanical investigation. Clin Biomech (Bristol, Avon) 2021; 89:105478. [PMID: 34517193 DOI: 10.1016/j.clinbiomech.2021.105478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/21/2021] [Accepted: 09/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The brachialis muscle lies in close anatomic relation to the anterior capsule of the elbow joint. The contribution of the brachialis muscle to elbow stability has not yet been fully investigated. Therefore, the aim of this biomechanical in-vitro study was to analyze its influence on joint stability. METHODS Nine fresh frozen cadaveric elbows were evaluated for stability against valgus and varus/posterolateral rotatory forces. Brachialis loading was measured indirectly using strain gauges. Three distinct scenarios were analyzed: A) with intact lateral ulnar and ulnar collateral ligaments B) with a ruptured lateral ulnar collateral ligament C) with ruptured lateral ulnar and ulnar collateral ligaments. FINDINGS In all scenarios, an increased strain was observed under posterolateral rotatory/varus forces. The maximum measured strain occurred with elbow flexion of 30° and pronation of the forearm. The strain was significantly higher with dual-ligament rupture (mean - 210.5 μm/m; min. 97.8 μm/m; max. -310 μm/m; SD 107.8 μm/m; p = .034) compared to intact ligaments (mean - 106.9 μm/m; min. -32.51 μm/m, max. -287 μm/m; SD 100.2 μm/m) and single-ligament rupture (mean - 109.5 μm/m; min. - 96.7 μm/m; max - 130.4 μm/m; SD 18.2). INTERPRETATION A strain of the brachialis muscle was observed under varus/posterolateral rotatory forces with a pronated forearm and the strain increased significantly in the event of a dual-ligament rupture. This suggests that the brachialis muscle may influence varus/posterolateral rotatory stability of the elbow. Hence, a concomitant tear of the brachialis muscle might result in pronounced instability following simple elbow dislocation. LEVEL OF EVIDENCE Basic Science Study, Biomechanics.
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22
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Dunham CL, Steenbock H, Brinckmann J, Reiter AJ, Castile RM, Chamberlain AM, Lake SP. Increased volume and collagen crosslinks drive soft tissue contribution to post-traumatic elbow contracture in an animal model. J Orthop Res 2021; 39:1800-1810. [PMID: 33258516 PMCID: PMC7744303 DOI: 10.1002/jor.24781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/29/2020] [Accepted: 06/12/2020] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint contracture (PTJC) in the elbow is a biological problem with functional consequences. Restoring elbow motion after injury is a complex challenge because contracture is a multi-tissue pathology. We previously developed an animal model of elbow PTJC using Long-Evans rats and showed that the capsule and ligaments/cartilage were the primary soft tissues that caused persistent joint motion loss. The objective of this study was to evaluate tissue-specific changes within the anterior capsule and lateral collateral ligament (LCL) that led to their contribution to elbow contracture. In our rat model of elbow PTJC, a unilateral surgery replicated damage that commonly occurs due to elbow dislocation. Following surgery, the injured limb was immobilized for 42 days. The capsule and LCL were evaluated after 42 days of immobilization or 42 days of immobilization followed by 42 days of free mobilization. We evaluated extracellular matrix protein biochemistry, non-enzymatic collagen crosslink content, tissue volume with contrast-enhanced micro-computed tomography, and tissue mechanical properties. Increased collagen content, but not collagen density, was observed in both injured limb capsules and LCLs, which was consistent with the increased tissue volume. Injured limb LCLs exhibited decreased normalized maximum force, and both tissues had increased immature collagen cross-links compared to control. Overall, increased tissue volume and immature collagen crosslinks in the capsule and LCL drive their contribution to elbow contracture in our rat model.
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Affiliation(s)
- Chelsey L. Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, MO
| | - Heiko Steenbock
- Institute of Virology and Cell Biology, University of Lübeck, Germany
| | - Jürgen Brinckmann
- Institute of Virology and Cell Biology, University of Lübeck, Germany;,Department of Dermatology, University of Lübeck, Germany
| | - Alex J. Reiter
- Department of Mechanical Engineering, Washington University in St. Louis, MO
| | - Ryan M. Castile
- Department of Mechanical Engineering, Washington University in St. Louis, MO
| | | | - Spencer P. Lake
- Department of Biomedical Engineering, Washington University in St. Louis, MO;,Department of Mechanical Engineering, Washington University in St. Louis, MO;,Department of Orthopaedic Surgery, Washington University in St. Louis, MO
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Wang F, Jia S, Li M, Pan K, Zhang J, Fan Y. Effect of the medial collateral ligament and the lateral ulnar collateral ligament injury on elbow stability: a finite element analysis. Comput Methods Biomech Biomed Engin 2021; 24:1517-1529. [PMID: 33715549 DOI: 10.1080/10255842.2021.1898601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ligaments are the most important stabilizer of elbow. However, the stress of ligaments is hard to measure because of the complex biomechanical environment in the elbow. Our objective was to develop a human elbow finite element model and to validate it by a comparison with previous experimental data. Then several different ligaments injury conditions and elbow flexion were simulated to analyse the elbow instability and to stress the biomechanical consequences. The computational investigation of different effects of ligament constraints of elbow was studied by means of finite element analysis. The stress of the anterior bundle was almost greater than other ligaments in all conditions, which played the most important role during the elbow flexion. The posterior bundle was the secondary stabilizer during flexion after the anterior bundle. The lateral ulnar collateral ligament (LUCL) injury could result in an increase of the ulnar cartilage stress. The anterior bundle and the LUCL were recommended to be repaired in elbow joint dislocations and fractures. This study could help understand the dynamic effects of ligaments on the joint over the entire extension by investigating the tissue stress.
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Affiliation(s)
- Fang Wang
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China.,Tianjin Key Lab of Integrated Design and On-line Monitoring for Light Industry & Food Machinery and Equipment, Tianjin, China.,National Research Centre for Rehabilitation Technical Aids, No. 1, Ronghuazhonglu, BDA, Beijing, China.,Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, No.1, Ronghuazhonglu, BDA, Beijing, China
| | - Shuoqi Jia
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China
| | - Mingxin Li
- Department of Traumatic Orthopaedics, Tianjin Hospital, No. 406, Jiefang Nanlu, Hexi District, Tianjin, China
| | - Kui Pan
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China
| | - Jianguo Zhang
- College of Mechanical Engineering, Tianjin University of Science & Technology, No. 1038, Dagu Nanlu, Hexi District, Tianjin, China.,Tianjin Key Lab of Integrated Design and On-line Monitoring for Light Industry & Food Machinery and Equipment, Tianjin, China
| | - Yubo Fan
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Chinese Education Ministry, School of Biological Science and Medical Engineering, Beihang University, No.37, Xueyuan Road, Haidian District, Beijing, China.,School of Engineering Medicine, Beihang University, No.37, Xueyuan Road, Haidian District, Beijing, China
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24
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Biomechanical comparison of screw osteosyntheses and anatomical plating for coronoid shear fractures of the ulna. Arch Orthop Trauma Surg 2021; 141:1509-1515. [PMID: 33044707 PMCID: PMC8354969 DOI: 10.1007/s00402-020-03621-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 09/30/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Among the few techniques described for the treatment of coronoid fractures, osteosynthesis techniques include screw osteosynthesis from anterior to posterior (AP) or from posterior to anterior (PA) and plate osteosynthesis. The aim of this study was to test the biomechanical stability of screw osteosynthesis and plate osteosynthesis using anatomical plates in coronoid process fractures. MATERIALS AND METHODS On a total of 25 biomechanical synthetical ulnae, a coronoid shear fracture including 70% of the coronoid height was simulated. Osteosynthesis was then performed using two 2.7 mm screws from anterior, posterior and with use of three different anatomical plates of the coronoid process. For the biomechanical testing, axial load was applied to the fragment with 1000 cycles from 5 to 250 N, load to failure and load at 100 µm displacement. Displacements were measured using a point-based three-dimensional motion analysis system. RESULTS Osteosynthesis using the PA-screw showed significant more displacement during cyclic loading compared with all other osteosyntheses (0.99 mm), whereas AP-screw showed the smallest displacement (0.10 mm) during cyclic loading. The PA-screw technique showed a significant lower load to failure compared to all other osteosynthesis with the highest load in AP-screw osteosynthesis. The load for 100 µm displacement was the smallest in PA-screw with a significant difference to the AP-screw and one plate osteosynthesis. CONCLUSION Osteosynthesis of large coronoid shear fractures with two small-fragment screws from anterior allows stable fixation that is not inferior to anterior plate osteosynthesis and might be an alternative in specific fracture types. Posterior screw fixation was found as the weakest fixation method. LEVEL OF EVIDENCE Basic science study.
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Marinelli A, Graves BR, Bain GI, Pederzini L. Treatment of elbow instability: state of the art. J ISAKOS 2020; 6:102-115. [PMID: 33832984 DOI: 10.1136/jisakos-2019-000316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 11/03/2022]
Abstract
The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.
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Affiliation(s)
| | - Benjamin R Graves
- Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory Ian Bain
- Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
| | - Luigi Pederzini
- Department of Orthopaedic and Arthroscopic Surgery, New Sassuolo Hospital, Sassuolo, Italy
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Roulet S, Charruau B, Mazaleyrat M, Ferembach B, Marteau E, Laulan J, Bacle G. Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy. Tech Hand Up Extrem Surg 2020; 25:84-88. [PMID: 32868694 DOI: 10.1097/bth.0000000000000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.
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Affiliation(s)
- Steven Roulet
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Bertille Charruau
- Department of Upper Limb and Hand Surgery, Clinique de l'Essonne, Cedex, France
| | - Matthieu Mazaleyrat
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Benjamin Ferembach
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Emilie Marteau
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Jacky Laulan
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Guillaume Bacle
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
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Abstract
Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases. The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis. The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA. Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues. In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint. Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055
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Affiliation(s)
- Izaäk F Kodde
- Orthopedic Center Antwerp, AZ Monica Hospital, Antwerp, Belgium.,Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Jetske Viveen
- Department of Orthopedic Surgery, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands
| | - Bertram The
- Department of Orthopedic Surgery, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands
| | | | - Denise Eygendaal
- Department of Orthopedic Surgery, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands.,Department of Orthopedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
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Giannicola G, Sessa P, Calella P, Gumina S, Cinotti G. Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature. J Shoulder Elbow Surg 2020; 29:e103-e117. [PMID: 32197771 DOI: 10.1016/j.jse.2019.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 11/10/2019] [Accepted: 11/16/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature. METHODS We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13, Monteggia-like lesion in 6, humeral shear fracture-dislocation in 1, and radial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively. RESULTS The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases. CONCLUSIONS CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome-Policlinico Umberto I, Rome, Italy
| | - Pasquale Sessa
- Department of Orthopedics and Traumatology, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy.
| | - Piergiorgio Calella
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome-Policlinico Umberto I, Rome, Italy
| | - Stefano Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Polo Pontino, Latina, Italy
| | - Gianluca Cinotti
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome-Policlinico Umberto I, Rome, Italy
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Podgórski AP, Kordasiewicz B, Pomianowski S. The column procedure preserves elbow stability on biomechanical testing. INTERNATIONAL ORTHOPAEDICS 2020; 44:911-918. [PMID: 32047962 PMCID: PMC7190588 DOI: 10.1007/s00264-020-04494-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 01/30/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE The effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers. METHODS We assessed elbow joint laxity in 39 patients who underwent an open contracture release via the 'column procedure' described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints. RESULTS Mean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°-4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable. CONCLUSIONS Our experiment confirmed that the 'column procedure' is a safe procedure which does not compromise the stability of the elbow joint.
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Affiliation(s)
- Andrzej P Podgórski
- Department of Traumatology and Orthopaedic Surgery, Adam Gruca Clinical Hospital, Center for Postgraduate Medical Education, Otwock, Poland. .,Department of Neurosurgery, Military Institute of Medicine, ul. Szaserów 128, 04-141, Warsaw, Poland.
| | - Bartłomiej Kordasiewicz
- Department of Traumatology and Orthopaedic Surgery, Adam Gruca Clinical Hospital, Center for Postgraduate Medical Education, Otwock, Poland
| | - Stanisław Pomianowski
- Department of Traumatology and Orthopaedic Surgery, Adam Gruca Clinical Hospital, Center for Postgraduate Medical Education, Otwock, Poland
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Case Series of All-Arthroscopic Treatment for Terrible Triad of the Elbow: Indications and Clinical Outcomes. Arthroscopy 2020; 36:431-440. [PMID: 31866278 DOI: 10.1016/j.arthro.2019.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 09/02/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the results of all-arthroscopic treatment of the terrible triad of the elbow, a combination of elbow dislocation, radial head dislocation, and coronoid process fracture, and its complications. METHODS We performed a retrospective review of consecutive patients with terrible triad who underwent all-arthroscopic treatment between January 2011 and December 2016. All-arthroscopic treatment was performed in the unstable elbows after manual reduction. Clinical evaluation was performed at least 2 years postoperatively. Patients with another fracture in the upper extremity and previous fracture of the affected elbow were excluded. A radial head fracture that was stable enough to reduce or involved less than 25% of the articular surface for partial excision and Regan-Morrey classification type I and type II coronoid process fractures were treated arthroscopically. Range of motion, radiologic outcomes, surgical complications, and the Mayo Elbow Performance Score were evaluated at the final follow-up. The Mann-Whitney test was used for statistical analysis. RESULTS A total of 24 patients met the inclusion criteria, and the average age was 47.6 years. Coronoid process fractures were fixed in all patients, by use of Kirschner wires in 15 (62.5%) and pullout sutures in 9 (37.5%). Radial head fractures were treated using screw or K-wire fixation in 4 patients (16.7%); only the fragment of the fracture was resected in 11 patients (45.8%). In all 24 cases (100%), the lateral collateral ligaments were repaired. At the final follow-up, the mean flexion contracture angle was 4.8° ± 1.1° and the mean flexion angle was 132.5° ± 6.3°. Clinical scores were satisfactory, with a mean Mayo Elbow Performance Score of 93 points. However, nonunion of coronoid fractures was observed in 4 patients (16.7%). There was 1 case of pin-site irritation. CONCLUSIONS All-arthroscopic treatment for the terrible triad can provide an excellent safety profile without the need for a large incision if the indications are met. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Severe traumatic valgus instability of the elbow: pathoanatomy and outcomes of primary operation. J Orthop Surg Res 2019; 14:347. [PMID: 31703693 PMCID: PMC6839221 DOI: 10.1186/s13018-019-1374-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/13/2019] [Indexed: 11/30/2022] Open
Abstract
Background The objective of the study was to depict the pathoanatomy of traumatic valgus instability of the elbow and to report clinical outcomes of primary operation. Methods Thirty-one patients presented with traumatic valgus instability of the elbow without dislocation. Thirty-one patients underwent surgical intervention of radial head fractures (28 open reduction and internal fixation and 3 radial head resection) and anatomical repair of the anterior bundle of medial collateral ligament (AMCL) with suture anchors. Twenty patients with disruption of the flexor-pronator tendon (FPT) and 14 patients with tears of the anterior capsule had primary repair of the FPT and anterior capsule simultaneously. Clinical outcomes were evaluated with the Mayo Elbow Performance Score (MEPS), modified hospital for special surgery assessment scale (HSS), and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results The median follow-up was 37.3 months (range, 15–53 months). Radial head fractures and complete avulsion of the medial collateral ligament (MCL) from its humeral footprint were confirmed in all patients intraoperatively. Intraoperative findings indicated disruption of the FPT in 20 patients and tears of the anterior capsule in 14 patients. Twenty-nine of 31 patients returned to previous activity and work levels within 6 months after surgery. The MEPS, modified HSS, and DASH score were 94 ± 4, 91 ± 5, and 8 ± 2 at the latest follow-up. Conclusions Radial head fractures with avulsion of the MCL can lead to severe valgus instability of the elbow. Primary operation to repair these disrupted structures, especially repair of the AMCL, can effectively restore valgus stability.
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Badre A, Axford DT, Banayan S, Johnson JA, King GJW. The effect of torsional moments on the posterolateral rotatory stability of a lateral ligament deficient elbow: An in vitro biomechanical investigation. Clin Biomech (Bristol, Avon) 2019; 67:85-89. [PMID: 31078898 DOI: 10.1016/j.clinbiomech.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 04/09/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Clinical tests for posterolateral rotatory instability of the elbow apply external torsional moments to the forearm; however, biomechanical studies of lateral collateral ligament injuries and their surgical repair, reconstruction and rehabilitation have primarily relied on varus gravity loading to quantify instability. The aim of this investigation was to determine the effect of torsional moments on the posterolateral rotatory instability of the lateral ligament deficient elbow. METHODS Six cadaveric arms were tested in an elbow motion simulator with the arm in the varus position. A threaded outrigger was inserted on the dorsal aspect of the proximal ulna to suspend 400 g, 600 g, and 800 g of weight to allow torsional moments of 0.12, 0.18, and 0.23 Nm respectively on the ulna. An injured model was created by sectioning of the common extensor origin, and the lateral collateral ligament. FINDINGS During simulated active flexion with the arm in varus, the injured model resulted in a significant increase in external rotation of the ulnohumeral articulation with the forearm both pronated and supinated (pronation: P = .021; supination: P = .015). The application of torsional moments to the lateral ligament deficient elbow resulted in a significant increase in the posterolateral rotatory instability of the elbow. INTERPRETATION This investigation demonstrates that the application of even small amounts of external torsional moments on the forearm with the arm in the varus position increases the rotational instability of the lateral ligament deficient elbow. During clinical examination for posterolateral rotatory instability and biomechanical studies of lateral ligament injury, the application of external torsion to the forearm should be considered to detect subtle instability. LEVEL OF EVIDENCE Basic Science Study.
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Affiliation(s)
- Armin Badre
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, Ontario, Canada.
| | - David T Axford
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada.
| | - Sara Banayan
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - James A Johnson
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada.
| | - Graham J W King
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada; Division of Orthopaedic Surgery, Department of Surgery, London, Ontario, Canada.
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Guss MS, Hess LK, Baratz ME. The naked capitellum: a surgeon's guide to intraoperative identification of posterolateral rotatory instability. J Shoulder Elbow Surg 2019; 28:e150-e155. [PMID: 30713062 DOI: 10.1016/j.jse.2018.10.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/18/2018] [Accepted: 10/28/2018] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS This study's purpose was to provide a reproducible way for surgeons to intraoperatively assess the elbow's lateral ulnar collateral ligament origin and determine whether there is posterolateral rotatory instability (PLRI) despite an intact common extensor origin (CEO). We hypothesized that we could re-create clinically relevant disruption of lateral supporting structures despite an intact CEO and illustrate progressive elbow PLRI. METHODS The relationship of the lateral capsule to the capitellum articular surface was noted in 8 cadaveric upper extremities. The lateral capsule and extensor origin were sequentially sectioned at 4 stages: intact, release to the lateral epicondyle, release of the posterior capsular insertion, and release of the CEO. Posterior and lateral translation of the radial head (RH) relative to the capitellum was measured with the forearm in extension and supination. RESULTS The average specimen age was 78.9 years. The lateral capsule originated within 1 to 2 mm of the capitellum articular surface. Lateral capsular sectioning to the 6-o'clock position of the lateral epicondyle created an unstable elbow with posterior and lateral RH translation. Sequential sectioning of the posterior capsular insertion created significant additional RH translation posteriorly (P < .05). With release of the capsule and the extensor origin, the elbow was grossly unstable. CONCLUSIONS The elbow's lateral capsuloligamentous complex plays an important role in preventing PLRI. Larger degrees of elbow laxity are associated with further peel back of the capsuloligamentous complex despite an intact CEO. The surgeon must retract the extensor origin intraoperatively to assess for lateral ulnar collateral ligament and/or lateral capsule disruption to prevent a missed case of PLRI.
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Affiliation(s)
- Michael S Guss
- Hand Surgery P.C., Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, MA, USA.
| | - Lindsay K Hess
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark E Baratz
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Brownhill JR, Pollock JW, Ferreira LM, Johnson JA, King GJW. The effect of implant linking and ligament integrity on humeral loading of a convertible total elbow arthroplasty. Shoulder Elbow 2019; 11:45-52. [PMID: 30719097 PMCID: PMC6348587 DOI: 10.1177/1758573217728292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 05/22/2017] [Accepted: 07/19/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Both unlinked and linked total elbow arthroplasty (TEA) implants have been employed with no consensus as to the optimal design. The present study aimed to evaluate the effect of collateral ligament integrity and implant linkage on wear-inducing loads in a convertible TEA. METHODS Eight fresh frozen upper extremities were tested in an elbow motion simulator. A convertible TEA with an instrumented humeral stem was inserted using computer navigation. Elbow kinematics and humeral loading were recorded with the TEA both linked and unlinked. The collateral ligaments were then sectioned and testing was repeated. RESULTS In the dependent position, there was no effect of implant linkage or ligament sectioning on humeral loading. Humeral loading was significantly greater following sectioning of the collateral ligaments but not after linking the TEA with the arm in the valgus position. Humeral loading was significantly greater after linking the TEA but not after sectioning of the collateral ligaments and with the arm in the varus position. CONCLUSIONS Collateral ligament integrity reduces wear-inducing loads for both an unlinked and linked TEA. Linkage of a convertible TEA increases humeral loading, which may have detrimental effects on implant longevity.
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Affiliation(s)
- James R Brownhill
- Department of Mechanical Engineering, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - J Whitcomb Pollock
- Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - Louis M Ferreira
- Department of Mechanical Engineering, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada,Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - James A Johnson
- Department of Mechanical Engineering, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada,Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada
| | - Graham JW King
- Department of Surgery, The University of Western Ontario, The Roth McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St Joseph’s Health Care – London, London, Ontario, Canada,Graham J. W. King, 268 Grosvenor Street, The Hand and Upper Limb Centre, London, Ontario N6A 4L6, Canada.
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Bartoli M, Pederzini LA, Severini G, Serafini F, Prandini M. Elbow Medial Ulnar Collateral Ligament chronic isolated insufficiency: anatomical M-UCL reconstruction technique and clinical experience in a mid-term follow-up. Musculoskelet Surg 2018; 102:75-83. [PMID: 30343469 DOI: 10.1007/s12306-018-0559-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/24/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE This study aims to clinically evaluate, at mid-term follow-up, a group of patients treated by the senior author in the last 6 years with our anatomical double-bundle reconstruction surgical technique for the medial ulnar collateral ligament (M-UCL) insufficiency. METHODS In this study, we included only patients affected by chronic valgus elbow instability, diagnosed with an accurate clinical evaluation combined with an MRI, without associated fractures that had been surgically treated in the past and without additional instability detected during the first checkup and in the preoperative evaluation under anesthesia. The nine patients enrolled were operated by the senior author between 2011 and 2014 (from 16 to 49 years old at surgery, all amateur sportsmen). The average follow-up is 4 years (47.6 months). The values of the range of movement were recorded and compared. Pain assessment was performed using the VAS scoring system. The recovery of daily activities was evaluated through the validated MEPS and Quick-DASH score scales. All patients underwent an X-ray in two standard projections and a preoperative and follow-up MRI. RESULTS The recovery of the range of motion was complete in six cases. The remaining three patients had minor loss of extension. None of the patients reported flexion deficits nor pronation-supination at follow-up. All patients achieved subjectively perceived stability and clinically objectified stability at follow-up. Five patients referred a total lack of pain at follow-up. Seven patients achieved full marks in the Mayo Elbow Performance Score and an excellent improvement in the Quick-DASH score. CONCLUSIONS Excellent functional results indicate that M-UCL isolated reconstruction with autologous hamstrings described in this study is a reliable and replicable technique with a reduced incidence of complications. Resuming sports is consistently successful in our patients.
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Affiliation(s)
- M Bartoli
- Orthopaedics and Traumatology Department, Università Cattolica del Sacro Cuore - Fondazione Policlinico Gemelli, Largo Agostino Gemelli 8, 00168, Rome, RM, Italy.
| | - L A Pederzini
- Orthopaedics and Traumatology Unit, Nuovo Ospedale Civile di Sassuolo, Via Francesco Ruini 2, 41049, Sassuolo, MO, Italy
| | - G Severini
- Orthopaedics and Traumatology Department, Università Cattolica del Sacro Cuore - Fondazione Policlinico Gemelli, Largo Agostino Gemelli 8, 00168, Rome, RM, Italy
| | - F Serafini
- Orthopaedics and Traumatology Unit, Nuovo Ospedale Civile di Sassuolo, Via Francesco Ruini 2, 41049, Sassuolo, MO, Italy
| | - M Prandini
- Orthopaedics and Traumatology Unit, Nuovo Ospedale Civile di Sassuolo, Via Francesco Ruini 2, 41049, Sassuolo, MO, Italy
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Temporal Patterns of Motion in Flexion-extension and Pronation-supination in a Rat Model of Posttraumatic Elbow Contracture. Clin Orthop Relat Res 2018; 476:1878-1889. [PMID: 30001292 PMCID: PMC6259801 DOI: 10.1097/corr.0000000000000388] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The elbow is highly susceptible to contracture, which affects up to 50% of patients who experience elbow trauma. Previously, we developed a rat model to study elbow contracture that exhibited features similar to the human condition, including persistently decreased ROM and increased capsule thickness/adhesions. However, elbow ROM was not quantitatively evaluated over time throughout contracture development and subsequent mobilization of the joint. QUESTIONS/PURPOSES The purposes of this study were (1) to quantify the time-dependent mechanics of contracture, including comparison of contracture after immobilization and free mobilization; and (2) to determine what changes occur in capsule and joint surface morphology that may support the altered joint mechanics. METHODS A total of 96 male Long-Evans rats were randomized into control and injury (unilateral soft tissue injury/immobilization) groups. Flexion-extension and pronation-supination joint mechanics (n = 8/group) were evaluated after 3, 7, 21, or 42 days of immobilization (IM) or after 42 days of IM with either 21 or 42 days of free mobilization (63 or 84 FM, respectively). After measuring joint mechanics, a subset of these limbs (n = 3/group) was prepared for histologic analysis and blinded sections were scored to evaluate capsule and joint surface morphology. Joint mechanics and capsule histology at 42 IM and 84 FM were reported previously but are included to demonstrate the full timeline of elbow contracture. RESULTS In flexion-extension, injured limb ROM was decreased compared with control (103° ± 11°) by 21 IM (70° ± 13°) (p = 0.001). Despite an increase in injured limb ROM from 42 IM (55° ± 14°) to 63 FM (83° ± 10°) (p < 0.001), injured limb ROM was still decreased compared with control (103° ± 11°) (p = 0.002). Interestingly, ROM recovery plateaued because there was no difference between injured limbs at 63 (83° ± 10°) and 84 FM (73° ± 19°) (p > 0.999). In pronation-supination, increased injured limb ROM occurred until 7 IM (202° ± 32°) compared with control (155° ± 22°) (p = 0.001), representative of joint instability. However, injured limb ROM decreased from 21 (182° ± 25°) to 42 IM (123° ± 47°) (p = 0.001), but was not different compared with control (155° ± 22°) (p = 0.108). Histologic evaluation showed morphologic changes in the anterior capsule (increased adhesions, myofibroblasts, thickness) and nonopposing joint surfaces (surface irregularities with tissue overgrowth, reduced matrix), but these changes did not increase with time. CONCLUSIONS Overall, flexion-extension and pronation-supination exhibited distinct time-dependent patterns during contracture development and joint mobilization. Histologic evaluation showed tissue changes, but did not fully explain the patterns in contracture mechanics. Future work will use this rat model to evaluate the periarticular soft tissues of the elbow to isolate tissue-specific contributions to contracture to ultimately develop strategies for tissue-targeted treatments. CLINICAL RELEVANCE A rat model of posttraumatic elbow contracture quantitatively described contracture development/progression and reiterates the need for rehabilitation strategies that consider both flexion-extension and pronation-supination elbow motion.
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Janßen R, Falkowski AL, Hirschmann A. [Assessment of ligament and tendon injuries of the elbow using magnetic resonance imaging]. Radiologe 2018; 58:996-1003. [PMID: 30105535 DOI: 10.1007/s00117-018-0441-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
An overview about the normal anatomy and frequent pathologies of tendons and ligaments of the elbow using MRI will be provided. The unique joint configuration and articulation, as well as passive ligamentous and active muscle structures as well as the unique configuration of the articulating components of the elbow contribute to joint stabilization. MRI is an essential imaging modality in patients with ligamentous injuries including the sequelae of joint dislocation as well as chronic pathologies such as long-standing and refractory tendinopathies. Ideally, when reporting MRI of the elbow, the joint is separated into its four compartments, anterior, posterior, medial and lateral, allowing precise, comprehensive and structured reporting.
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Affiliation(s)
- R Janßen
- Muskuloskelettale Radiologie, Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz.
| | - A L Falkowski
- Muskuloskelettale Radiologie, Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
| | - A Hirschmann
- Muskuloskelettale Radiologie, Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
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40
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Dunham CL, Castile RM, Chamberlain AM, Galatz LM, Lake SP. Pronation-Supination Motion Is Altered in a Rat Model of Post-Traumatic Elbow Contracture. J Biomech Eng 2018; 139:2621591. [PMID: 28418515 DOI: 10.1115/1.4036472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Indexed: 11/08/2022]
Abstract
The elbow joint is highly susceptible to joint contracture, and treating elbow contracture is a challenging clinical problem. Previously, we established an animal model to study elbow contracture that exhibited features similar to the human condition including persistent decreased range of motion (ROM) in flexion-extension and increased capsule thickness/adhesions. The objective of this study was to mechanically quantify pronation-supination in different injury models to determine if significant differences compared to control or contralateral persist long-term in our animal elbow contracture model. After surgically inducing soft tissue damage in the elbow, Injury I (anterior capsulotomy) and Injury II (anterior capsulotomy with lateral collateral ligament transection), limbs were immobilized for 6 weeks (immobilization (IM)). Animals were evaluated after the IM period or following an additional 6 weeks of free mobilization (FM). Total ROM for pronation-supination was significantly decreased compared to the uninjured contralateral limb for both IM and FM, although not different from control limbs. Specifically, for both IM and FM, total ROM for Injury I and Injury II was significantly decreased by ∼20% compared to contralateral. Correlations of measurements from flexion-extension and pronation-supination divulged that FM did not affect these motions in the same way, demonstrating that joint motions need to be studied/treated separately. Overall, injured limbs exhibited persistent motion loss in pronation-supination when comparing side-to-side differences, similar to human post-traumatic joint contracture. Future work will use this animal model to study how elbow periarticular soft tissues contribute to contracture.
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Affiliation(s)
- Chelsey L Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130 e-mail:
| | - Ryan M Castile
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO 63130 e-mail:
| | - Aaron M Chamberlain
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO 63130 e-mail:
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY 10029 e-mail:
| | - Spencer P Lake
- Mem. ASME Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO 63130;Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO 63130;Department of Biomedical Engineering, Washington University in St. Louis, 1 Brookings Drive, Campus Box 1185, St. Louis, MO 63130 e-mail:
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Aquilina AL, Grazette AJ. Clinical Anatomy and Assessment of the Elbow. Open Orthop J 2017; 11:1347-1352. [PMID: 29290874 PMCID: PMC5721323 DOI: 10.2174/1874325001711011347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 07/16/2017] [Accepted: 07/18/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The elbow is a complex synovial hinge joint comprising of three articulations. Satisfactory function and stability are provided by bony and soft tissue stabilising structures. Injuries around the elbow joint are common. METHODS A literature search was performed and the authors' personal experiences reported. RESULTS The article discusses the osseous and ligamentous anatomy around the elbow joint and their relevance when assessing and managing elbow injuries. CONCLUSION Knowledge of the intricate anatomy around the elbow joint is essential to successfully assessing and managing elbow injuries and restoring good function.
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Affiliation(s)
- Alexander L Aquilina
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Andrew J Grazette
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, CV2 2DX, Coventry, UK
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42
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Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder Elbow 2017; 9:195-204. [PMID: 28588660 PMCID: PMC5444606 DOI: 10.1177/1758573217694163] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 01/02/2023]
Abstract
The elbow is the second most commonly dislocated major joint in adults. Good long-term outcomes have been reported after non-operative management; however, a small proportion (<10%) of patients have a poor outcome and some do require surgical intervention. A review of the anatomy, pathoanatomy, management and outcomes of simple elbow dislocations is presented. Emphasis is placed on emerging concepts regarding the soft tissue injury, the stabilising structures that are injured, the sequence and mechanism of injury and the relationship to elbow stability. The benefits of nonsurgical and surgical management are discussed and a treatment algorithm based on the pathoanatomy is proposed.
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Affiliation(s)
- Paul M. Robinson
- Paul M. Robinson, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough City Hospital, Bretton Gate, Peterborough, Cambridgeshire PE3 9GZ, UK.
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43
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Pathologies of the shoulder and elbow affecting the overhead throwing athlete. Skeletal Radiol 2017; 46:873-888. [PMID: 28299434 DOI: 10.1007/s00256-017-2627-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/02/2017] [Accepted: 03/05/2017] [Indexed: 02/08/2023]
Abstract
The overhead-throwing athlete is susceptible to a variety of predictable disease entities affecting the shoulder and elbow. While the pathophysiology and nomenclature of these diseases are ubiquitous throughout the clinical literature, this information is sparse within the radiology domain. We provide a comprehensive review of these unique injuries with accompanying imaging features in an effort to enhance the role of the radiologist during the management of the overhead thrower. When appropriately recognized and described, the imaging features aid in establishing a diagnosis and ultimately the implementation of appropriate clinical management.
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Dunham CL, Castile RM, Havlioglu N, Chamberlain AM, Galatz LM, Lake SP. Persistent motion loss after free joint mobilization in a rat model of post-traumatic elbow contracture. J Shoulder Elbow Surg 2017; 26:611-618. [PMID: 28081997 PMCID: PMC5502529 DOI: 10.1016/j.jse.2016.09.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/19/2016] [Accepted: 09/29/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Post-traumatic joint contracture (PTJC) in the elbow is a challenging clinical problem due to the anatomical and biomechanical complexity of the elbow joint. METHODS We previously established an animal model to study elbow PTJC, wherein surgically induced soft tissue damage, followed by 6 weeks of unilateral immobilization in Long-Evans rats, led to stiffened and contracted joints that exhibited features similar to the human condition. In this study, after 6 weeks of immobilization, we remobilized the animal (ie, external bandage removed and free cage activity) for an additional 6 weeks, after which the limbs were evaluated mechanically and histologically. The objective of this study was to evaluate whether this decreased joint motion would persist after 6 weeks of free mobilization (FM). RESULTS After FM, flexion-extension demonstrated decreased total range of motion (ROM) and neutral zone length, and increased ROM midpoint for injured limbs compared with control and contralateral limbs. Specifically, after FM total ROM demonstrated a significant decrease of approximately 22% and 26% compared with control and contralateral limbs for injury I (anterior capsulotomy) and injury II (anterior capsulotomy with lateral collateral ligament transection), respectively. Histologic evaluation showed increased adhesion, fibrosis, and thickness of the capsule tissue in the injured limbs after FM compared with control and contralateral limbs, which is consistent with patterns previously reported in human tissue. CONCLUSION Even with FM, injured limbs in this model demonstrate persistent joint motion loss and histologic results similar to the human condition. Future work will use this animal model to investigate the mechanisms responsible for PTJC and responses to therapeutic intervention.
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Affiliation(s)
- Chelsey L. Dunham
- Department of Biomedical Engineering, Washington University, St. Louis, MO
| | - Ryan M. Castile
- Department of Mechanical Engineering & Materials Science, Washington University, St. Louis, MO
| | - Necat Havlioglu
- Department of Pathology, John Cochran VA Medical Center, St. Louis, MO
| | | | - Leesa M. Galatz
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Spencer P. Lake
- Department of Biomedical Engineering, Washington University, St. Louis, MO,Department of Mechanical Engineering & Materials Science, Washington University, St. Louis, MO,Department of Orthopaedic Surgery, Washington University, St. Louis, MO,Corresponding Author: Spencer P. Lake, Ph.D., 1 Brookings Drive, Campus Box 1185, St. Louis, MO 63130,
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Tarassoli P, McCann P, Amirfeyz R. Complex instability of the elbow. Injury 2017; 48:568-577. [PMID: 24161720 DOI: 10.1016/j.injury.2013.09.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 09/02/2013] [Accepted: 09/19/2013] [Indexed: 02/02/2023]
Abstract
Injuries to the elbow are commonly encountered in orthopaedic practice. They range from low energy, simple isolated fractures, to high energy complex fracture dislocations with severe ligamentous disruption. Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. This article discusses the important osseous and ligamentous stabilisers of the elbow joint and provides management protocols for the common patterns of complex injury encountered by the practising surgeon.
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Affiliation(s)
- Payam Tarassoli
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom.
| | - Philip McCann
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom
| | - Rouin Amirfeyz
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom
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Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. J Hand Surg Am 2017; 42:118-126. [PMID: 28160902 PMCID: PMC5821063 DOI: 10.1016/j.jhsa.2016.11.025] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 11/15/2016] [Indexed: 02/02/2023]
Abstract
The elbow comprises a complex of bony and ligamentous stabilizers that provide both primary and secondary constraints to elbow instability. Through trauma and overuse, classic instability patterns arise by loss of these important stabilizers. The diagnosis of elbow instability can made using specific examination maneuvers and testing to diagnose the clinical pattern. This article reviews the elbow's unique anatomy and biomechanical characteristics and these are applied when reviewing the maneuvers and testing used to diagnose elbow instability.
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Hatta T, Nobuta S, Aizawa T, Sasajima K, Nakajima S, Honda M, Oki G, Yamanaka Y, Itoi E. Comparative Analysis of Surgical Options for Medial Collateral Ligament Repair in Terrible Triad Injury of the Elbow. Orthop Rev (Pavia) 2016; 8:6666. [PMID: 27761222 PMCID: PMC5066112 DOI: 10.4081/or.2016.6666] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/27/2016] [Indexed: 11/23/2022] Open
Abstract
The aim of our study is to evaluate the clinical and radiologic outcomes in patients with terrible triad injury, who underwent surgical treatment with or without the medial collateral ligament (MCL) repair. Fourteen patients who underwent surgery with a minimum of 12-month follow-up (mean, 17 months) were reviewed. Based on the systematic treatment protocol, radial head fracture, lateral collateral ligament, and coracoid fracture were treated. Subsequently, torn MCL was repaired in 7 patients, whereas in the remaining 7 patients, the MCL was not treated. Range of motion, elbow function, and radiographs regarding the arthrosis and heterotopic ossification were assessed. At final follow-up, no significant differences were found in elbow motion or function between the groups with and without MCL repair; except the pronation and supination which had superior range in repair group. In contrast, radiologic findings such as the arthrosis were seen more frequently in patients without MCL repair than those with repair. Our results indicate the effect of MCL repair on elbow motion and function might be small, whereas osteoarthritic changes occurred more frequently in elbows without MCL repair.
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Affiliation(s)
- Taku Hatta
- Department of Orthopedic Surgery, Tohoku University School of Medicine
| | - Shingo Nobuta
- Department of Orthopedic Surgery, Tohoku Rosai Hospital
| | - Toshitake Aizawa
- Department of Orthopedic Surgery, Iwaki Kyoritsu General Hospital
| | - Koichi Sasajima
- Department of Orthopedic Surgery, Iwaki Kyoritsu General Hospital
| | | | - Masahito Honda
- Department of Orthopedic Surgery, Takeda General Hospital
| | - Gosuke Oki
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine
| | - Yoshiaki Yamanaka
- Department of Orthopedic Surgery, University Hospital of Occupational and Environmental Health , Japan
| | - Eiji Itoi
- Department of Orthopedic Surgery, Tohoku University School of Medicine
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Shimura H, Nimura A, Nasu H, Fujishiro H, Imatani J, Okawa A, Akita K. Joint capsule attachment to the coronoid process of the ulna: an anatomic study with implications regarding the type 1 fractures of the coronoid process of the O'Driscoll classification. J Shoulder Elbow Surg 2016; 25:1517-22. [PMID: 27039672 DOI: 10.1016/j.jse.2016.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 01/16/2016] [Accepted: 01/22/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The attachment of the anterior joint capsule on the ulnar coronoid process is not yet completely understood. The purpose of this study was to clarify the anatomic relationship between the anterior capsule of the elbow joint and the tip of the coronoid process. METHODS Seventeen embalmed elbows were used for this anatomic study. The anterior capsule of the elbow joint was reflected, and the attachment of the capsule on the coronoid process was exposed. The attachment of the joint capsule on the coronoid process was macroscopically and histologically observed, its relationship to the coronoid tip was assessed, and the length of the attachment of the joint capsule was measured. RESULTS The length of the capsule attachment at the radial side of the coronoid (11.9 mm) was greater than that at the ulnar side (6.1 mm). The bone thickness on the coronoid tip from the proximal edge of the joint capsule attachment was 1.9 mm; together, the cartilage and bone thickness was 4.7 mm. At the radial side of the coronoid, the thickness of the joint capsule at the proximal aspect of the attachment of 2 samples was 0.6 mm and 0.3 mm, and that at the tip of the coronoid was 2.6 mm and 1.7 mm, respectively. CONCLUSIONS The anterior capsule of the elbow joint had a substantial attachment on the radial side of the coronoid process. The subtype 2 tip fractures of the O'Driscoll classification included the joint capsule attachment, joint cartilage, and subchondral bone.
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Affiliation(s)
- Haruhiko Shimura
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan; Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Hisayo Nasu
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hitomi Fujishiro
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junya Imatani
- Department of Orthopaedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Effect of Anconeus Muscle Blocking on Elbow Kinematics: Electromyographic, Inertial Sensors and Finite Element Study. Ann Biomed Eng 2016; 45:775-788. [PMID: 27573695 PMCID: PMC5331076 DOI: 10.1007/s10439-016-1715-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/15/2016] [Indexed: 12/30/2022]
Abstract
The specific contribution of the anconeus muscle to elbow function is still uncertain. This study aimed to investigate the effect on elbow kinematics and kinetics of blocking anconeus using lidocaine. Ten healthy volunteers performed experimental trials involving flexion–extension and supination–pronation movements in horizontal and sagittal planes. Inertial sensors and surface electromyography were used to record elbow kinematics and kinetics and electrical activity from the anconeus, biceps and triceps brachii before and after blocking anconeus. Moreover, a finite element model of the elbow was created to further investigate the contribution of anconeus to elbow kinematics. The electrical activity results from the trials before blocking clearly indicated that activity of anconeus was increased during extension, suggesting that it behaves as an extensor. However, blocking anconeus had no effect on the elbow kinematics and kinetics, including the angular velocity, net torque and power of the joint. The electrical activity of the biceps and triceps brachii did not alter significantly following anconeus blocking. These results suggest that anconeus is a weak extensor, and the relative small contribution of anconeus to extension before blocking was compensated by triceps brachii. The finite element results indicated that anconeus does not contribute significantly to elbow kinematics.
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50
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Soma DB. Opening the Black Box: Evaluating the Pediatric Athlete With Elbow Pain. PM R 2016; 8:S101-12. [DOI: 10.1016/j.pmrj.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/02/2016] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Affiliation(s)
- David B. Soma
- Department of Pediatric and Adolescent Medicine and Department of Sports Medicine, Mayo Clinic, Rochester, MN
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