Transcript OPERATING ROOM SET-UP AND EQUIPMENT

ELBOW CONTRACTURES
ARTHROSCOPIC RELEASE
Nguyen Trong Anh et al
INTRODUCTION
ELBOW CONTRACTURES:
• Extra/intra-articular causes
• Most contractures are mild, involve
terminal extension, not significantly
alter function.
• Certain athletes complain lack of
terminal extension after performance.
• Functional arc of motion: 30-130 deg.
• Arc of motion less than 100 deg. not
well tolerated.
• Functional use of hand depends on the
elbow.
-50% loss of elbow motion80% loss
of function to upper extremity.
• Loss of elbow flexion not well tolerated.
Females: inability to style their hair,
make-up.
Males: inability to fix a tie, shave
CAUSES
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Trauma: acute, chronic.
Heterotopic ossification.
Osteoarthritis.
Inflammatory arthritis.
Post-op scars.
Infection.
Burns.
Intra-articular finding lesions
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Capsular contractures
Osteophytes: olecranon, coronoid.
Loose bodies.
OCD capitellum.
Chondromalacia radial head.
Adhesions
Synovitis.
Surgical treatment:
1.
Open: medial(Hotchkiss)/lateral(Hastings)
approach to anterior and posterior compartment.
Effective with extra-articular contracture
Technically demanding, significant morbidity,
prolonged rehab.
2.
Arthroscopy:
Anterior capsular release, loose body removal,
osteophyte excision, olecranon fossa débridement
 to reach functional ROM.
Faster, easier, more effective (The most technique
and experience demanding)
3.
Combined technique: arthroscopyanterior
compartment. Miniopen with tenotomyposterior
Arthroscopic release:
• Timmerman 1994:
29 mo f/u: 79% good-excellent.
• Phillips 1998: 10 DJD, 15 post trauma
18 mo f/u: 25 pts increase ROM, decrease pain.
• Kim 1995: 25 pts
25 mo f/u: 92% pt satisfied.
• Savoie 1993:
22 mo f/u: all satisfied.
ELBOW ARTHROSCOPY:
• 1930 Burman used arthroscopy to study
elbow joint on cadaver.
• Late 1970s: diagnostic and treatment elbow
arthroscopy
• 1988, elbow arthroscopy only 0.77% in 10.000
arthroscopy cases  small joint capacity and
dangerous proximity to neurovascular
structures
• Late 1990s until now: more understanding
of portals, surgery techniques and
pathology, elbow arthroscopy has
significantly progressed in diagnosis and
treatment of many elbow lesions.
• AAOS(2003): 7% orthopedic surgeons
perform elbow scope.
Common applications:
• Loose body removal.
• Synovitis debridement.
• Osteochondral lesion treatment.
• Assessment and treatment of
undiagnosed or chronic elbow pain.
• Spur or osteophyte excision.
• Arthroscopy-assissted management of
fractures around elbow joint.
• Stiff elbow release
Indication
1. Loss of functional ROM (30-120) with:
• Capsular contractures.
• Bone impingement: Osteophyte:
ocleranon, coronoid process
• Combined lesions: OCD, chondromatosis,
synovitis, loose bodies…
Failure to improve w physical therapy.
2. Pt requires specific ROM for
occupation.(sport players)
Contraindication
• Active infection
• Bone/fibrous ankylosis  prevents safe
introduction of arthroscope.
• Previous surgery alters normal anatomy,
joint congruity, extra-articular
contractures.
• Intracapsular space severely constricted
 capsular distention NV damage
risks.
History
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Chief complaints: ROM limit, pain.
Trauma?
Repeated heavy use of arms.
Sports.
Mechanical impingement, pain at
extremes of motion (ext>flex) or heavy
carry.
Physical exam
• Skin scars, burn.
• ROM
• Soft /hard end points  soft tissue
constraint/bone impingement.
• Painful arc or extremes  joint
incongruity/degeneration or bone impingement.
• Neurovascular exam: ulnar
nerve(pathology/location)
Xray, CT scan, MRI
MATERIALS
06/2005 - 10/2010: 36 cases
• 15 post-trauma.
• 7 sport related.
• 1 radial head malunion.
• 1 previous intercondylar fracture surgery. (27 yr)
• 6 loose bodies.
• 4 OA.
• 1 RA.
• 1 gout
OR SETUP
• Scope: 4mm, 300
• Water pump w 4050mmHg.
• Shaver and burr
blades:4-5mm
• Arthrocare
radiofrequency.
• Grasper, cutter
PATIENT SET-UP
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General anesthesia
Regional block.
EUA for pROM, ulnar n.
Prone/ LDP w free arm on
holder. Supine?
• Tourniquet.
• All bone prominence
padded.
PORTALS
1. Anterior:
1. Proximal lateral
2. Proximal medial
2. Posterior
1. mid / direct lateral.
2. Central posterior
3. posterolateral
Cutaneous nerve branches around
elbow  hazardous mine traps!!!!
Proximal medial
Proximal lateral
Mid lateral
Straight posterior
Posterolateral
Technique procedures
• Tourniquet.
• Initial join distention w 20-30cc NS.
• Proximal medial portal: Evaluating whole
anterior compartment.
• Posterolateral/ direct posterior: Evaluating
whole posterior compartment.
Surgical steps
Anterior compartment:
• Adhesion release.
• Loose body removal.
• Coronoid process and fossa spur resection.
• Capsular incision/resection from lateral to
medial, to visualize brachialis fibers.
Posterior compartment:
• Ocleranon, fossa spur resection (± miniopen w
osteotome).
• Medial/lateral column impingement check
• Post capsular, medial and lateral gutter release.
+ Tourniquet time !!!
+ Closed drainage
Post op:
• Ice scrubbing.
• Nerve deficit and compartment
syndrom evaluation.
• Early motion exercises as
tolerated.
CASE 1
CASE 2
F/U 6 mo
CASE 3
CASE 4
CASE 5
• M, 38, 5y injury,
elbow pain. ROM
limit.
PRE-OP
POST-OP
CASE 6
CASE 7
F, 56 yo, 7 mo fall
injury
ROM: pre-op:60-110
post-op: 45-160
CASE 7
M, 38 yo, 6mo of
elbow arthritis
PRELIMINARY RESULT
>6 mo F/U
• 24 Patients satisfy w surgery: no pain,
ROM improvement.
• 2 nerve deficit. (Ulnar/ Radial n)
CONCLUSION
• Elbow arthroscopy allowed to perform
accurate diagnosis and appropriate
treatment to most intra-articular
pathologies causing elbow pain and
stiffness.
• Significant ROM improvement, less
morbidity, earlier postop rehab are
provided.
• Combined arthroscopic and miniopen
releases are effective in selective hard
cases
• Anatomy comprehension and
experience are required to avoid
neurovascular structure damage and
improve long term results.
• Good results need selective indication,
early and long-term postop rehab.