hot topics in treatment of elbow injuries
TRANSCRIPT
Hot Topics In Treatment of Elbow Injuries
Frank A. Petrigliano, MD
UCLA Department of Orthopaedic Surgery
Disclosures
• Orthopaedic Research and Education Foundation
• Department of Defense
Hot Topics in Elbow Surgery
• Lateral Epicondylitis
– Non-operative management/role of PRP
– Results of open vs. arthroscopic management
• Ulnar Collateral Ligament
– Diagnosis/imaging
– Current techniques/outcomes
• Distal Humerus Fractures
– Locked plating and TEA
Lateral Epicondylitis
• “Lawn tennis elbow” – Major 1883
• Commonly work-related
• Due to repetitive microtrauma resulting in tear of the origin of the ECRB and ECD
Lateral Epicondylitis
• 90% of cases can be treated nonoperatively
– Cessation of offending activity
– PT/braces
– NSAIDS
– Electrophysical modalities
– Injections/iontophoresis/nitric oxide
• Surgery indicated in cases refractory to conservative management
Lateral Epicondylitis
• Injection options include:
– Corticosteroid
– Platelet rich plasma (PRP)
– Botox
– Whole blood
Gosens, AJSM, 2011
Thanasas, AJSM, 2011
• Coombes et al. JAMA 2013
Krogh, AJSM, 2013
• Neither GC or PRP > saline in regards to pain reduction at 3 months
• GC reduces color Doppler activity and tendon thickness
Krogh, AJSM, 2012
• 20 RCT’s
• Moderate evidence for UTZ > Placebo
• Moderate evidence for UTZ + Massage > Laser
• Moderate evidence for Laser > Plyometric exercises
BJSM 2013
MRI
• May be useful tool in preoperative planning
• Increase in intratendinous signal and morpholoic changes in 92% of patients
(Savnik, Eur Radiol,
2004)
• 42 arthroscopic releases
• 37/39 (94%) at 14 months rated as better or much better
• Grip strength 96% of unaffected limb
• At 12.8 years 29/30 (96%) were better or much better
• JSES 2010
Conclusion
• Conflicting data as to the efficacy of corticosteroid, PRP, and other agents as compared to controls for lateral epicondylitis
• If surgery is required, arthroscopic and open approaches yield good results
MCL Reconstruction
First performed by Drs. Jobe and Stark in 1974
Over the past 30 yrs, refinement of the procedure has improved the overall RTP and decreased morbidity
Medial Collateral Ligament
• Three parts – Anterior bundle
• Anterior & posterior bands
– Posterior bundle
– Transverse ligament (oblique)
Anterior bundle is primary
stabilizer to valgus stress – Morrey, AJOSM, 1983 – Feltner, IJSB, 1987 – Hotchkiss, JOR, 1987 – Callaway, JBJS, 1997
Diagnosis
• History
• Physical Exam
Radiographs – Stress x-rays
– CT
– MRI
– U/S
Arthroscopy
“Moving Valgus Stress Test” for MCL Tears of the Elbow O’Driscoll et al, AJOSM, 2005
• Cohort study of 21 pts
– 100% sensitivity (17/17) – 75% specific (3/4)
• Compared to arthroscopic diagnosis “gold standard”
• Pt sitting upright • Shoulder in 90 deg abduction • Start w/ elbow max flexed • Modest valgus torque until shoulder at
max ER • Maintain valgus stress and quickly extend
elbow to 30 deg • Test positive if
– 1) pain reproduced – 2) pain max at 120-70 degrees
Non Operative Treatment
Rettig et al, AJOSM, 2001
• 31 throwing athletes w/ MCL injuries • 29.8 mo f/u • Supervised rehab program
– Phase I: rest 2-3 months, NSAIDS, ice, splint at night, ROM – Phase II: If pain free, progress strengthening, throwing progression
• 41% (13-32) return to level of play at avg. of 24.5 weeks • No significant difference in duration, acuity of symptoms, or
age of pt b/w those able to return to play and those unable
Original Description
Detachment of the flexor-pronator mass
Figure-of-eight graft fixation
Obligatory submuscular ulnar nerve transposition
UCL Reconstruction
Conway, Jobe et al, JBJS, 1992
F/u 68 pts avg. 6.3 years 14 pts direct repair
– 50% (7/14) returned to previous level of competition – 28% (2/7) MLB pitchers
56 reconstruction w/ free tendon graft – 68% (38/56) returned to previous level participation – 75% (12/16) MLB pitchers
21% (15/56) had post-op ulnar nerve symptoms Conway-Jobe criteria
– Excellent result = RTP > 1 yr at same or higher level of preinjury competition
JBJS, 1992
UCL Reconstruction
Andrews & Timmerman, AJSM, 1995
F/u 72 pro baseball players undergoing a/s or open elbow sx at avg. 42 mos – Only 9/12 with UCL reconstruction in the f/u group
Flexor-pronator detachment, figure-of-eight, obligatory SQ UNT
78% (7/9) excellent result 22% (2/9) post-op ulnar nerve symptoms
AJSM, 1995
F/u 91 pts avg. 35 months 13 pts direct repair
–63% (5/8) excellent 78 reconstruction (FP retraction, Fig-8, ob SQ-
UNT) –81% (48/59) excellent
75% (27/37) professional baseball players RTP*
9% (8/91) had complications 1% (1/91) had postop ulnar neuropathy
AJSM, 2000
Two part study
15 Cadaveric elbows
Internervous safe zone
Post 1/3 Common Flexor Mass
22 pts underwent repair/reconstruction of UCL using the muscle splitting approach
No muscle denervation or neuropathy
AJSM, 1996
83 patients (54 pros) undergoing UCL-R through a muscle-splitting approach, Fig-8, no UNT
Of the 33 pts with 2 yr f/u 27 (82%) had an excellent result
26/28 (93%) excellent results for patients undergoing their 1st surgery
4/83 (5%) UN Sx’s
JSES, 2001
Retrospective review 36 pts treated w/ docking technique for MCL reconstruction at 3.3 yrs
Utilized: – muscle splitting
– UNT PRN – arthroscopic assessment – reduced # bone tunnels
resulting in simplified graft tensioning
33/36 (92%) excellent – 1 UN post-op
AJSM, 2002
25 pro & collegiate baseball players, avg follow-up 30 months
Modified 4-strand docking procedure, muscle splitting, symptomatic UNT
23/25 (92%) excellent
1/25 (4%) UN Sx’s
AJSM, 2006
Koh
20 pro & collegiate baseball players, avg follow-up 42 months
2-strand docking construct (n=12) and 3-strand (n=8); muscle splitting, Sx UNT
18/19 (95%) excellent
1/20 (5%) UN sxs
No difference b/t small groups
Arthroscopy, 2006
Dodson
100 consecutive overhead athlete (17 pros), avg follow-up 36 months
docking procedure, muscle splitting, symptomatic UNT (n=22)
90/100 (90%) excellent results
7/100 (7%) good results
2/100 (2%) UN symptoms requiring SQ UNT
JBJS, 2006
Dines
22 pts (20 BB players, 1 pro) avg. f/u 36 mos
19/22 (86%) excellent
2/22 (9%) UN sx post-op
Results comparable to other contemporary techniques
AJSM, 2007
AJSM, 2010
• Figure-of-eight with UNT
• 83% returned to previous level of play
• 20% complication rate
– Ulnar nerve neurapraxia (16%)
Authors N FPM
Approach
Fixation Oblig
UNT
UNT
Tech
Excellent
Results
Complications
Conway 56 Detach Figure 8 Yes Sub M 68% 21% UN
27% total
Andrews 9 Detach Figure 8 Yes Sub
Q
78% 22% UN
Total NR
Azar 59 Retract Figure 8 Yes Sub
Q
81% 1%UN
9% total
Thompson 33 Split Figure 8 No None 82% 5% UN
10% total
Petty 31 Split
Figure 8 Yes Sub
Q
74% 7% UN
11% total
Paletta 25 Split
Docking No Sub
Q
92% 4% UN
8% total
Dodson 100 Split
Docking No Sub
Q
90% 2% UN
3% total
Koh 20 Split
Docking No Sub
Q
95% 5% UN
Dines 22 Split
Dane TJ No Sub
Q
86% 9% UN
17% total
Valgus Extension Overload
• Due to shear forces acting on PM olecranon and trochlea
• Results in PM elbow pain, chonromalacia
• Extension impingment test + imaging useful for diagnosis
• Tx: resection of osteophytes only
• 29/161 patients with combined PMC + UCLR
• RTP
– Level 1: 76%
– Level 2: 14%
– Level 3: 7%
– Level 4: 3%
• Data suggests that players with PMC may have lower RTP as compared to historical controls
CORR 2011
UCLR in Adolescents
Conclusions
These studies represent 3 decades of experience with MCL reconstructions
Overall, 83% excellent results
– 6% post-op UN sxs
In the pts undergoing muscle splitting/docking technique -- 91% excellent results
– 3% post-op UN sxs
Pts without obligatory UNT appear to have a lower rate of ulnar neuropathy post-op
Distal Humerus
• Anatomy – Medial and Lateral
Epicondyle and Condyle
• Displacement of condyles occurs b/c muscles on epicondyles act unopposed
AO Classification Type A
• Extra-articular
AO Classification Type A
AO Classification Type A
AO Classification Type A
AO Classification Type B
• Partial-articular
AO Classification Type B
AO Classification Type B
AO Classification Type C
• Complete-articular
Non-operative Management
• Stable - non-displaced fractures
– Brief period of immobilization
– Early protected motion
– Frequent follow-up
Distal Humerus Fracture--ORIF
• Preop Planning—CT and Draw it.
• Olecranon Osteotomy
• Restore articular surface with interfrag screws
• Medial and posterolateral plates attach condyles to shaft
• Tension band/Kwires for olecranon osteotomy
Approach
• Patient Position
– Prone (or lateral decubitous)
– Tourniquet
Posterior Approach • Olecranon Osteotomy
– Intra-articular - for intra-articular fractures
– Chevron - apex distal
• Ulnar Nerve – Identify / protect
– +/- transposition
Posterior Approach
Posterior Approach
• Olecranon Osteotomy - Repair
– Tension Band
Post-Operative Management
• Splint for comfort
• Active motion within 1 - 2 weeks
– Hinged elbow brace
• Strengthening at 8 - 10 weeks
• PROM if needed at 6 - 8 weeks
Results of ORIF
• What is a good to excellent result
– Stable elbow
– Minimal or no pain
– No deformity
– ROM - 100°
Results of ORIF (Helfet and Schmeling, CORR 1993)
• Literature review
• 75% good or excellent results (65% - 100%)
• Prolonged immobilization or delayed PT
associated with poor results
Complications of ORIF
• 4% HO (range: 3% - 30%)
• 4% infection (range: 3% - 7%)
• 7% ulnar nerve palsy (range: 7% - 15%)
• 5% failure of fixation (range: 5% - 15%)
• 2% non-union (range: 1% - 11%)
• Up to 70% ROH
ALTERNATIVE TREATMENT:
NONOPERATIVE: NURSING HOME, MINIMALLY DISPLACED
TOTAL ELBOW: COMBINATION OF COMMINUTION,
ELDERLY, OSTEOPOROSIS
ALTERNATIVE TREATMENT:
NONOPERATIVE: NURSING HOME, MINIMALLY DISPLACED
TOTAL ELBOW: COMBINATION OF COMMINUTION,
ELDERLY, OSTEOPOROSIS