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PubMed2006

Elbow arthroscopy: treatment of the thrower's elbow.

The athlete's elbow has been described as one of the last frontiers in orthopaedic sports medicine. It has been considered separately from other athletic injuries because of the unique constellation of pathology that results from repetitive overhead throwing. Tremendous gains in understanding the complex interplay between the dynamic and static stabilizers of the athlete's elbow have occurred over the past decade. The desire to treat these injuries in a minimally invasive manner has driven the development of techniques and instrumentation for elbow arthroscopy, a successful and essential technique in the treatment of the thrower's elbow. Medial collateral ligament injuries, ulnar neuritis, valgus extension overload with osteophyte formation and posteromedial impingement, flexor pronator strain, medial epicondyle pathology, and osteochondritis dissecans of the capitellum have all been described as consequences of the overhead throwing motion. In addition, loose body formation, bony spur formation, and capsular contracture can each be present in conjunction with these conditions or as isolated entities. Not all pathology in the thrower's elbow is amenable to arthroscopic treatment; however, the clinician must be familiar with all of these conditions to form a comprehensive differential diagnosis for an athlete with elbow pain. The surgeon treating the athlete's elbow should be comfortable with both open and arthroscopic treatments. An understanding of the anatomy and biomechanics of the thrower's elbow is essential for good patient care. The preoperative evaluation should focus on a thorough history and physical examination, as well as specific diagnostic imaging modalities.

Arthroscopy↗
PubMed2003

[Total elbow arthroplasty. Indications, operative technique and results after implantation of an Acclaim elbow prosthesis].

Total elbow arthroplasty has become a reliable treatment option for patients with rheumatoid arthritis as well as primary or posttraumatic arthrosis. The aim of this study is to present the indications, operative technique and results for the implantation of an Acclaim elbow prosthesis. Case reports are given to demonstrate the indications for prosthesis implantation. Furthermore, the follow-up results are reported for 65 patients after implantation of an Acclaim prosthesis. Pre- and postoperative pain were evaluated using the visual analogue scale. The pain level decreased from 8.0 to 2.3 postoperatively. After implantation of an elbow prosthesis, there was a significant improvement in the range of motion. The mean flexion increased from 103 degrees preoperatively to 140 degrees postoperatively. An increase of 10 degrees was found for both supination and pronation. Complications included temporary ulnary nerve irritation in seven patients, intraoperative fractures in four cases and postoperative elbow dislocation in one case. In conclusion, total elbow arthroplasty results in a reduction of pain and an improvement in elbow movement. However, selection of the right patient is important. Patients are advised not to lift heavy objects or to perform hard physical work. If patients' compliance can not be ensured preoperatively, no total elbow arthroplasty should be performed.

Aged↗
PubMed1998

MR imaging of the major nerves about the elbow: cadaveric study examining the effect of flexion and extension of the elbow and pronation and supination of the forearm.

Magnetic resonance (MR) imaging provides useful information in the evaluation of peripheral nerves. Recent advances in MR imaging allow for detailed depiction of the soft tissue structures of the elbow joint. Three major nerves are present about the elbow. Six cadaveric elbows were imaged to depict the normal anatomy of these nerves and to determine the best plane and position of the elbow for optimal visualization of each nerve. Axial images of the elbow in full extension with the forearm in supination allow identification of all major nerves. Axial images with the elbow in full flexion allow accurate assessment of the cubital tunnel and the ulnar nerve. Axial images of the elbow in full extension with the forearm in pronation are helpful for assessment of the median and radial nerves in the forearm.

Aged↗
PubMed1997

Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results.

Transplantation of total elbow allografts has been used as a salvage procedure in an attempt to provide patients with functional, painless range of motion of the elbow. This procedure is appropriate for patients with massive bone loss after trauma, tumor resection, or revision elbow arthroplasty. During the past 20 years, 23 patients have undergone elbow allograft reconstruction with variable results and a high complication rate. Ten of 14 patients with elbow allografts observed for an average of 7.5 years report satisfactory results. Allograft removal was required in six patients: for infection (two), instability (three), and nonunion and resorption (one). Three patients with instability have since undergone successful total elbow arthroplasty. Two patients have been observed less than 1 year and another patient died during the study period. Complications occurred in 16 of 23 patients. This operation is not recommended for routine use and is viewed as a salvage procedure. The use of allografts in elbow reconstruction does not preclude subsequent reconstruction with another allograft or fusion. In patients with deficient bone stock, the allograft reestablishes bone mass to permit an arthrodesis or reconstructive arthroplasty.

Adult↗
PubMedDate not supplied

Anatomic relationship between elbow arthroscopy portals and neurovascular structures in different elbow and forearm positions.

Twenty fresh cadaveric elbows were used to evaluate the proximity of neurovascular structures to the six arthroscopic portals of the elbow at different positions. After distention of the joint, 4-mm Steinmann pins were introduced into the elbow from the portal's entry points. After surgical dissection, the proximity of the neurovascular structures to the pins was measured in 5 different positions. The radial nerve showed significant proximity to the anterolateral portal in full elbow flexion, full elbow extension, and forearm supination with 10%, 20%, and 10% nerve-pin contacts, respectively. The distance between the median nerve and medial portals was significantly decreased with full extension. This study demonstrated that the distance between the route of the scope and neurovascular structures might diminish significantly during elbow motion. Most of these movements are unavoidable in elbow arthroscopy, but maintaining certain positions for a considerable period of time or angulating the scope forcefully in these positions can cause nerve injury.

Adolescent↗
PubMedDate not supplied

A modified posterior approach to the elbow for total elbow replacement.

Fifty-nine consecutive primary total elbow replacements were performed with the modified posterior approach. The approach differs from other described approaches. The fascia and periosteum over the subcutaneous border of the ulna are preserved, and dissection is carried out on either side of the ulna. This enables a more secure repair of the posteromedial and posterolateral muscle compartments. The ulnar nerve is mobilized to prevent any injury. The distal humerus and proximal ulna can be fully exposed by this approach, giving wide access so necessary for accurate positioning of the prosthesis. The overall complication rate in 59 total elbow replacements was 33.9% including 4 (6.7%) ulnar nerve palsy, 4 (6.7%) wound infections, 2 (3.3%) delayed healing, 4 (11.8%) diminished range of motion in the affected elbow, 2 (3.3%) instability (1 had dislocated elbow and 1 had subluxation), and 1 (1.7%) triceps dehiscence requiring exploration and repair. All the patients could perform active resisted extension of the elbow, indicating continuity of the triceps. The senior author (SCG) has been using this approach for the Roper-Tuke unconstrained total elbow replacement for the last 15 years, and it has been associated with a lower incidence of complications. This approach has not been described before and is recommended for total elbow replacement.

Arthroplasty, Replacement↗
PubMed1996

High prevalence of elbow problems among goalkeepers in European team handball -- 'handball goalie's elbow'.

The aim of this study was to describe elbow problems among goalkeepers in team handball. A questionnaire was sent to the coaches of 449 senior and 32 junior teams in Norway in 1992. Of these, 304 coaches responded (63%) and their teams were included in the study. A total of 329 out of 729 goalkeepers (45+/-1.8%) and 166 out of 4120 court players (4.0+/-0.3%) were reported by their coaches to have current or previous symptoms from one or both elbows when playing handball. In response to a second questionnaire sent to all the goalkeepers (729; response rate 81%), 41+/-2.0% reported current elbow problems and an additional 34+/-2.0% reported previous problems. During a 2-year observation period from 1992 to 1994, 8.6+/-1.8% of the goalkeepers with previously healthy elbows experienced elbow problems. The typical complaint was recurrent pain and disability episodes, each with an acute onset, but with varying duration. The mechanism of injury for the goalkeepers appears to be repeated hyperextension traumas. We conclude that elbow pain and disability is a significant problem for a large number of goalkeepers in team handball. These problems may be described as a syndrome called 'handball goalie's elbow'.

Adolescent↗
PubMed2001

Valgus deformity and proximal subluxation of the rheumatoid elbow: a radiographic 15 year follow up study of 148 elbows.

OBJECTIVE: To evaluate the nature of positional changes of humeroulnar (HU) and humeroradial (HR) joints in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively. METHODS: At the 15 year follow up standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated. The mediolateral HU angle of the elbow was measured from anteroposterior radiographs. The proximal subluxation of the HU joint was measured from lateral radiographs as the distance between the posterior aspect of the olecranon process and the posterior surface of the humerus. The anteroposterior subluxation of the HR joint was measured from lateral radiographs as the relation of the midpoint of head of the radius to the midpoint of the capitellum of the humerus. Destruction of the elbow joints was assessed with the Larsen method on a scale of 0 to 5 and compared with the measurements. RESULTS: Mean HU angle in 148 elbows of patients with RA was 11.5 degrees (SD 6.1), range -21 degrees (varus) to 34 degrees (valgus); 9.9 degrees (SD 4.3) in men and 12.0 degrees (SD 6.4) in women. The mean HU angle, 14.4 degrees (SD 6.0) of the affected joints (Larsen grades 2-4), showed more valgus than the mean 9.8 degrees (SD 2.5) of the non-affected (Larsen grades 0 to 1) joints; totally destroyed and unstable Larsen 5 joints were excluded. Mean HU and HR subluxations, 2.0 mm (SD 3.8) and 0.8 mm, of the affected joints (Larsen 2-5) were greater than the means, -1.1 mm (SD 1.5) and -0.4 mm (SD 0.9), of the non-affected joints. Both the HU proximal subluxation and the HR anterior subluxation correlated, r(s)=0.64 (95% CI 0.53 to 0.73 ) and r(s)=0.48 (95% CI 0.34 to 0.60), with the destruction of the elbow joint. CONCLUSIONS: The elbow seems to turn into valgus during rheumatoid destruction and excision of the radial head may speed up this process. However, totally unstable Larsen grade 5 joints may also have varus deformity owing to mutilating bone destruction. The ulna subluxates proximally in relation to the humerus, whereas the radius moves slightly anteriorly as a consequence of elbow involvement.

Adolescent↗
PubMed1997

Collateral ligaments of the elbow: conventional MR imaging and MR arthrography with coronal oblique plane and elbow flexion.

PURPOSE: To determine the best plane and position of the elbow for optimal visualization of normal and abnormal collateral ligaments with conventional magnetic resonance (MR) imaging and MR arthrography, to determine the normal appearance of the collateral ligaments at MR arthrography and to assess use of MR arthrography in evaluation of collateral ligamentous lesions. MATERIALS AND METHODS: Nine cadaveric elbow specimens were imaged with and without intraarticular administration of gadolinium-containing solution in several planes that were identified as potentially useful in a pilot study in two specimens. MR imaging findings were compared with anatomic findings. RESULTS: Normal and abnormal ligaments were best depicted in a 20 degrees posterior oblique coronal plane in relation to the humeral shaft with the elbows extended and a coronal plane aligned with the humeral shaft with the elbows slightly flexed (20 degrees-30 degrees of flexion). Gadolinium enhancement improved the delineation of normal and abnormal ligaments on T1-weighted images in each case. CONCLUSION: The posterior oblique coronal plane with the elbows extended or the coronal plane aligned with the humeral shaft with the elbows slightly flexed allows accurate assessment of the collateral ligaments. Gadolinium-enhanced MR arthrography of the elbow seems to be a promising technique.

Aged↗
PubMed2005

[Comparison of mixed latency of ulnar and median nerve between wrist and elbow as diagnostic test of ulnar neuropathy in elbow].

INTRODUCTION: Conventional electrodiagnosis of ulnar neuropathy at the elbow is based on abnormalities in motor conduction across the elbow. However, sensory symptoms are predominant, and an accurate determination of the length of the nerve in this segment is difficult to obtain. OBJECTIVE: We present an electrodiagnostic technique which helps to avoid these difficulties. MATERIAL AND METHODS: We compared the mixed latency of ulnar and median nerve between wrist and above the elbow in 172 symptomatic and 407 asymptomatic ulnar nerves. RESULTS: We determined that a difference of the mixed latency of ulnar and median nerve between wrist and above the elbow equal or higher than 1 ms had a sensitivity of 87% to an specificity of 91% for the diagnosis of ulnar neuropathy at the elbow. Moreover, a difference between both arms equal to or higher than 0.3 ms had a sensitivity of 80% and specificity of 91 %. If both conditions are present, the test is very specific (98%). CONCLUSIONS: The measurement of the difference in mixed latency between ulnar and median nerves from wrist to above the elbow is a valuable tool for evaluating patients with suspected ulnar neuropathy at the elbow without motor involvement.

Action Potentials↗
PubMed1995

Short-term complications of the lateral approach for non-constrained elbow replacement. Follow-up of 50 rheumatoid elbows.

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock.

Activities of Daily Living↗
PubMed2004

Minimally constrained elbow implant arthroplasty: the discovery elbow system.

The Discovery Elbow System (Biomet Orthopedics, Warsaw, Ind) is the latest generation of elbow replacement systems. Its minimally constrained design provides more closely matching articular surfaces, avoids use of a true hinge, and anatomically reproduces the axis of elbow motion. Improved instruments facilitate its implantation. The anatomic positioning of the humeral condyles allows for preservation of the ulnar collateral ligament to help share in implant loading. Elbow replacement reliably restores a painless functional arc of motion in almost all patients. Historically, elbow implant survivorship has been better in low-demand patients who have been functionally compromised by diffuse disease than in posttraumatic or osteoarthritic patients who otherwise are active and have no significant disabilities other than their elbows. The decision to proceed with elbow replacement should be made considering both age and activity level.

Journal Article↗
PubMed2000

Total elbow arthroplasty in the treatment of posttraumatic conditions of the elbow.

Posttraumatic arthritis, arthritis secondary to instability, and nonunion or malunion about the elbow may be treated by various methods. Recommended first-line treatment in the younger, more active patient population is nonprosthetic techniques. Total elbow arthroplasty should be considered primarily as a salvage procedure for these patients. Careful patient selection will determine whether total elbow arthroplasty is an acceptable choice, despite its inherent risks and complications. Prosthetic replacement is more applicable for patients with low physical demands who are older than 60 years of age with pain, stiffness, and/or instability of the elbow who will more likely be able to comply with postoperative rehabilitation and strict activity restrictions. Previous incisions, gross instability, periarticular fibrosis with ulnar nerve encasement, loss of bone and/or soft tissue, and previous infections represent obstacles for prosthetic reconstruction in these patients. The use of unlinked total elbow designs require good bone stock with little deformity and stable capsuloligamentous support, which uncommonly is found in elbows after trauma. Linked semiconstrained prostheses have been used most frequently with good short-term results reported in the literature. Reported failure rates after longer followup have led to a search for improvements in prosthetic design, cementing techniques, and better patient selection.

Arthritis↗
PubMed2001

Effect of elbow joint angle on the magnitude of muscle damage to the elbow flexors.

PURPOSE: It has been shown that eccentric actions at a long muscle length result in a larger decrease in force and more muscle tenderness compared with those at a short muscle length. To further investigate the effect of elbow joint angle on the development of muscle damage, this study compared two maximal eccentric exercise regimens in which the starting position of the action was different, but the range of movement was the same. METHODS: One arm of 10 male students performed 24 maximal eccentric actions of the elbow flexors at the elbow joint angle from 0.87 to 2.27 rad (50-130 degrees: S condition) and the other arm at the elbow joint angle from 1.74 to 3.14 rad (100-180 degrees: L condition). Maximal isometric force, range of motion, muscle soreness, plasma creatine kinase activity, upper arm circumference, and B-mode ultrasound pictures of the elbow flexors (US) were measured before and for 5 d postexercise in both conditions. Magnetic resonance imaging (MRI) of the transverse scans of the upper arm was taken at 4 d after exercise. RESULTS: All measures changed significantly (P < 0.01) after exercise for both conditions; however, significantly (P < 0.01) larger changes in the measures were found in the L condition compared with the S condition. MRI and US displayed that only the brachialis was damaged for the S condition but the biceps brachii was also damaged for the L condition. CONCLUSION: The greater development of muscle damage in the L condition compared with the S condition is likely to be associated with the elbow flexors muscles affected by the exercise.

Adult↗
PubMed1993

MR imaging of patients with lateral epicondylitis of the elbow (tennis elbow): importance of increased signal of the anconeus muscle.

OBJECTIVE: The purpose of this study was to determine what changes might be detected on MR images of patients with chronic lateral epicondylitis (tennis elbow) that could explain why some cases are resistant to therapy. SUBJECTS AND METHODS: Seven consecutive patients with chronic lateral epicondylitis were included. The diagnosis was based on symptoms and signs characteristic of the disease, as determined by each patient's orthopedic surgeon. Three volunteers with normal elbows were control subjects. All patients had MR imaging of the involved elbow, and control subjects had MR imaging of the nondominant elbow. Short tau inversion-recovery (STIR) MR imaging was chosen because of its sensitivity to changes in the water content of muscle and its suppression of the fat signal. The images were analyzed visually and on an MR workstation to measure the signal intensity of the elbow muscles. RESULTS: In all seven patients, MR images showed increased signal intensity of the anconeus muscle. This increase in signal intensity was not observed in the control subjects, and to our knowledge it has not been reported previously. CONCLUSION: Increased signal intensity of the anconeus muscle on MR images in patients with chronic lateral epicondylitis suggests involvement of the muscle. Increased signal intensity is seen with edema, granulation tissue, and inflammation, which may explain the findings in this study. Our results are inconclusive as to whether this increased signal intensity contributes to the chronicity of patient symptomatology or is associated with abnormal elbow motion because of the symptoms.

Adult↗
PubMed1989

Position of the elbow in determination of abnormal motor conduction of the ulnar nerve across the elbow.

Routine evaluation of patients for suspected ulnar neuropathy includes testing of motor conduction velocity across the elbow, although the best position of the elbow for this test is controversial. The preferred testing position--elbow flexion or extension--was studied by determining the yield of abnormality at both positions in patients selected for possible ulnar nerve abnormalities unrelated to motor conduction. We found no major differences between the flexed or extended position of the elbow except that normal values for each of these positions varied. The yield of abnormal findings was greatest from measuring absolute motor conduction velocity across the elbow as opposed to comparing the difference in velocities between the elbow and either adjacent segment.

Adolescent↗
PubMed2006

Use of the Liverpool Elbow Score as a postal questionnaire for the assessment of outcome after total elbow arthroplasty.

The Liverpool Elbow Score (LES) is a newly developed, validated elbow-specific score. It consists of a patient-answered questionnaire (PAQ) and a clinical assessment. The purpose of this study was to determine whether the PAQ portion of the LES could be used independently as a postal questionnaire for the assessment of outcome after total elbow arthroplasty and to correlate the LES and the Mayo Elbow Performance Score (MEPS). A series of 51 total elbow replacements were reviewed by postal questionnaire. Patients then attended the clinic for assessment by use of both the LES and the MEPS. There was an excellent response rate to the postal questionnaire (98%), and 44 elbows were available for clinical review. Good correlation was shown between the LES and the MEPS (Spearman correlation coefficient, 0.84; P < .001) and between the PAQ portion of the LES and the MEPS (Spearman correlation coefficient, 0.76; P < .001). We conclude that there is good correlation between the LES PAQ component and the MEPS, suggesting that outcome assessment is possible by postal questionnaire.

Aged↗
PubMed2003

The shape of the force-elbow angle relationship for maximal voluntary contractions and sub-maximal electrically induced contractions in human elbow flexors.

The force-length relationship is a basic property of skeletal muscle. Knowledge of this relationship is necessary for most analyses of human movement, and in simulation models predicting movement control strategies. Studies on animal muscles have shown that force-length relationships for sub-maximal contractions are not related through a simple scaling procedure to the relationship for maximal contractions. Furthermore, potentiation might produce a shift of sub-maximal relative to maximal force-length relationships. In this study, we tested the hypothesis that human force-elbow angle relationships for sub-maximal unpotentiated contractions are shifted to larger elbow angles (i.e. larger muscle lengths) compared to the relationship for maximal voluntary contractions (MVC), and that this shift is reduced, or even abolished, for sub-maximal potentiated contractions. Force-elbow angle relationships (48-160 degrees) were obtained from healthy subjects (n=13). At each of nine tested elbow angles, the test set consisted of a single twitch (ST(pre)) and a doublet twitch (DT(pre)) stimulation of m. biceps brachii, followed by an MVC, followed by another single twitch (ST(post)) and a doublet twitch (DT(post)) stimulation. The single and doublet twitches induced sub-maximal contractions. The force-elbow angle relationships for the pre-MVC (unpotentiated) twitch contractions were shifted to larger angles compared to those obtained for MVC. The force-elbow angle relationships for the post-MVC (potentiated) twitch contractions were shifted to smaller angles compared to those obtained for the unpotentiated twitch contractions. These results support the idea that the shift to larger muscle lengths for the sub-maximal, unpotentiated force-length relationships relative to the relationship for maximal contractions may be caused by a length-dependent Ca(2+) sensitivity that may be offset, at least in part, by potentiation.

Adaptation, Physiological↗