hot topics in treatment of elbow injuries

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