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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

Kyle Anderson, MD, (Detroit, MI) discusses tips and tricks for elbow arthroscopy. Topics covered include operating room set-up, patient positioning options, portal placements and the relevant instruments and equipment available from Arthrex® to complete each procedure. Dr. Anderson also shows imaging options to best diagnose pathology and common arthroscopic elbow procedures.

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Advances in Elbow Arthroscopy Techniques

Elbow always seems to get thrown in at the end, even though I love it. In terms of positioning, I think we've already seen a couple of things that can be really useful. I like the idea that Bill presented with the TRIMANO for prone positioning. I find myself doing mostly supine positioning. Because most of the elbow arthroscopy I do is with something else, like a ligament or something like that. And I've used the TRIMANO for the supine position and can bring it down onto the hand table pretty quickly. We have a little extender at Beaumont that raises the clerk up, so that the TRIMANO gives you a little bit more excursion with that, but it's kind of nice and simple. I think we've all seen that if we're going to scope the elbow, obviously the proximity of our neurovascular structures is a greater issue than other joints that we deal with. So distension can be quite important regardless of position. And Lynch back in 86 showed us that we can have tremendous improvement in that safety if we get the elbow distended for a neutral position. So I don't want to ever lose sight of that. I was trained and still like the proximal lateral portal for my initial portal. I know a lot of us in the room like a medial portal as our starting portal, but this one gives me a lot of flexibility. I think the safety factor is is quite good, so I like the proximal lateral portal just anterior to the supracondylar ridge just above the epicondyle. Nice little soft spot there. And and again, quite safe. Everything that I do in the elbow. One of the exciting things for me is everything that I do arthroscopically can be done in either the arthroscopy tray that Arthrex now has, or the UCL tray that gives us a variety of options and for UCL reconstruction. But for the elbow arthroscopy, I've got everything in one set and that makes it really nice. Probably our most common indication for elbow arthroscopy is loose body removal. I think that's the bulk of what we do in an isolated arthroscopy arthroscopic procedure. And and so I guess it's fitting to put this first here, you see one in the anterior compartment right in there. I will use occasionally a spinal needle to localize it. I'll still go back and sometimes use outflow from the from my grasper cannula to bring the loose bodies toward me. I think it's a simple little thing to do that can make things quite nice. So we either have to do some dilation, which in the elbow can be dangerous. So there is a way of, of doing this more safely now with the dilation instrumentation that you see here. And again, I think that's quite nice. But I prefer to just break these up sometimes with a scissor. You can see we're going through with the one here. And then just take them out and fragments. And again, the Arthrex set has nice graspers that will let us take those out quite easily. Probably for me, the second most common excuse for elbow arthroscopy would be posteromedial impingement. This is almost exclusively with ligament reconstruction. I'm really hesitant to do any kind of decompression. In a thrower who is not also having a ligament reconstruction, I think it's a set up for a problem. We've seen that the stresses across the UCL go up, especially if we're removing normal bone. So I, I think it's a it's a UCL problem until proven otherwise. But fragmentation is notoriously negative on imaging. And even in when I was with David Walczak, we found that 38% was even missed on the MRI. So sometimes we'll get lucky and see it on this hyper flexion external rotation view where you see this little fragment here. And it's almost like a little mini nonunion. I'm going to skip through some of some of this very quickly. So we'll I really want you to use caution when you're doing any kind of resection of bone in the on the posterior medial olecranon, especially if you're not reconstructing the ligament. But I'll do the work through trans triceps portal while we're viewing from posterolaterally just lateral to the triceps tendon. And what we'll frequently see is this little fragment that again, it's almost like a little mini nonunion. It can be very easily missed because it becomes covered in fibrous tissue. If you see here, we'll kind of get in and look posterolaterally this one there in the obviously a supine position. And we'll this arthroscopic view will pick up in a second. You see where the spinal needle I don't know how well that this is kind of an old video, but you see that little fragment can move around and look fairly normal on your imaging. But yet I do think that causes a lot of grinding and a lot of pain. So I think it's really important, at least for me to look back here on every ligament that we do, we'll take a take a peek in the back, and then we'll come through and and debris that again trying not to remove a whole lot of normal bone. I think we've got pretty good evidence now that that's dangerous for our ligament. But those can be those can be very elusive. And also one of the things that we want to make sure we're doing is, is checking for a good valgus test. As soon as we do our initial assessment of the elbow. And very few of them are as obvious as this one here, where it really opens up quite a bit with, with with pronation and valgus stress. But in my hands, any opening basically is showing any significant opening. Here is a is a positive test. The problem is that you can have a symptomatic UCL and they don't open up a great deal, but you're reproducing their pain. So it's different than than our comparisons in the knee. Tennis elbow. I have to admit, is one thing that I go back and forth between whether I want to do this arthroscopically or open. I think it's compelling since the majority of the pathology is on the deep surface. Plus, we get to assess for other pathology. It is nice to do an arthroscope, but it's also quite gratifying and very simple to do it open and put a little split and then we can get a nice repair done open. Like excision is another one that's not extremely rare. For me and Neil and others have done some good work to show that golfers are a group that we see this in. I find it easiest to work through a posterolateral portal or I'm sorry, look through a posterolateral portal and work through a mid lateral portal. To to breed this. And actually the Torpedo shaver is great for this one. Just the entry is really nice with that. And so we can get that out of there and get rid of that painful clunk. And then lastly OCD lesions are something that less commonly need. At least for me. I'm not doing a great deal of this, but it's nice to do a microfracture of these. Again, working for me, mostly posterolateral because they're distal and addressing these. If I'm doing plugs, I'm usually opening for that. So but something that I certainly think in the right hands can be done. Arthroscopically. And then lastly capsule release or contracture release. I still like to work off of the humerus. I know there's a lot of people that can be very aggressive in removing capsule, but to me, if we if we're coming off of the humerus, I think our safety factor goes way up rather than what you see on the right, coming across straight across the capsule anteriorly. I don't think that the brachialis provides the protection that some people rely on. So we go ahead and do those capsule releases off the humerus. And again, I think the safety factor is much better for me. That's it. Nice and quick.

Dr. Scott Steinmann from the Mayo Clinic (Rochester, MN) describes helpful tips for operative set up, patient positioning as well as methods to establish safe portals for common elbow arthroscopy procedures. Several new products are highlighted to assist surgeons in elbow positioning, tissue retraction, capsulotomy, and novel instrumentation for osteophyte removal. Dr. Steinmann also presents an interesting approach to traumatic elbow dislocation injuries that may provide better patient compliance and outcomes.

Elbow Arthroscopy and Arthroscopic Tennis Elbow

Thank you, Brian. Thank you. Reinhold. I would like to echo what Gus was saying about the UCL. Said. I think it's really made a big, big difference. And I use it on the lateral and medial side of the elbow. And the last thing we're working on is making a smaller Chinese finger trap to help pull it through. I think a lot of us have had trouble. You put the whip stitches in, you try and pull the graft through and it gets caught. And with the Chinese finger trap, you can pull it through a lot, a lot easier. So I don't think that'll that'll really help. And as you heard, there's a lot of new new products coming out. Arm holders. And what I'll talk about is I'll kind of go through the arthroscopic part a little, little bit quick. I think we kind of have an idea about elbow arthroscopy, and I'll just focus on some, some new things that we can do with, with some of the new products. Well, it's obviously becoming more common for elbow arthroscopy with the continued advancement in techniques, I think we're becoming much better at dealing with arthritis in the elbow and dealing with all areas of arthritis in the elbow. There's still a real risk of neurovascular injury with elbow arthroscopy. I think that's the key thing that we've been trying to do is to try to try and make this technique safer, and therefore more available to more surgeons that don't do arthroscopy, the elbow that commonly. Typically you see an x ray like this, but if you actually get a CT scan, it gives you a real roadmap of a 3D CT to kind of see what you need to go osteophytes in the railhead, fossa loose bodies by the coronoid, and then posteriorly you can see osteophytes coming off of the sides of the electron. And I'll show a video in a little bit. But the, the new PoweRasp that was developed primarily for the shoulder, actually, I think is a great new product for the elbow because it makes taking out that osteophyte there safe, whereas I typically use a round bur which can easily wrap up the ulnar nerve that lives right, right over here, and we'll be able to see that later. Not wrapping up the ulnar nerve, but I tend to use general anesthesia in the in the lateral decubitus position. Here's a typical setting. You can see the armhole that we'll talk about tilting the table a little bit toward the surgeon itself, trying to get that dependent arm out of the way of your knee and hip so you can actually get into the patient a little bit more ergonomically. And the ability to move this arm holder both in and away and up and down. So if you have a female patient you can adjust it. And a male patient and potentially a fairly inexpensive product for most hospitals. You can see here we're tilting the patient toward the surgeon as something I've sort of noticed over the years that as you do a long case, the patient will tend to pull backward from you, and then suddenly you'll have the arm holder in the antecubital fossa, which is obviously inhibiting your ability to get anteriorly in the elbow. And you want to make sure also that you can actually flex the elbow up. Particularly important when you're working in the back and in the back of the elbow. I always like to say the elbow should be the highest thing in the room. So when you're prepped and draped, if you have a shaver in here, you're not banging against the side of the body, but you have 360 access to the elbow, and the elbow is not down here, in which case your shaver, your camera bangs into the side of the body. Looks like that just before you're about to start. There are no wrong portals in the elbow. You kind of have to have a imagine a three dimensional view in your mind of where the nerves are. It's all about avoiding the nerves. As long as you're not going through a nerve or an artery, it's a safe portal. And so it really doesn't matter to me whether you start medial, lateral or posterior. I'll start in the back of the elbow. If there's more work to do in the back of the elbow, usually it's more to do in the front, but if there's more to do in the back based on the CT scan, that's that's where I'll start. There's no limit on the number of portals, but I think it's best to try and just make the portals you need, just as in the shoulder, to avoid blowing up the blowing up the joint, and to mark out all your potential portals. First we're looking at the lateral side there. I tend to do an anterolateral portal first, because that's the portal that's going to be closest to a major nerve, the radial nerve. If I get that portal done out of the way before the elbow swollen at all. All the elbow portals are easier to start from that. I think insufflating the elbow is a very important aspect. I don't do that in the shoulder and you can see why here. If you don't insufflate the elbow and you come with your trocar, you will slide across. Most of the time, the capsule inflating the joint just allows you to pop in. It doesn't move the nerve further away. It's still right on the capsule, but allows you just easier to get in and get started. Typically easier to do that right over the radar BioPatella joint itself. And so that's where we typically do the anterolateral portal first. If I feel I'm in the joint just to speed things up, I'll just push straight across and then take a scalpel and cut down on that side. You can see here we're just. I can tell that. I can tell that I'm in the joint. So I just immediately cut down and then we're off and going and get things started. Thinking about the elbow arthroscopy set that makes it makes us all a little bit, a little bit easier. Do a switching stick to get to the to the other side. I find this articulating retractor that's also in the set that we developed. Helpful, particularly to get the ulnar nerve sort of out of the way. If you're in the back of the elbow, you can bring that in close to the nerve and lift up rather than just lever down. And I think that's very helpful when you're working, particularly if you've got osteophytes on the medial side steps. We kind of went through anterolateral portal first, at least in my practice. Do your bony work first. Here you see a burr, which is obviously we'll talk about the PoweRasp in a little bit. Take out your loose bodies, then do a capsular resection. And I've learned that it's not important to take out all the capsule, but I usually leave a large postage stamp, so to speak, over where the radial nerve is coming down over the radial head. I think that's important. There's really no no need to take out all the capsule just off of the humerus and off of the insertion down onto the ulna. Protecting your radial nerve as you do that. Now, switching this is actually looking in the posterior medial gutter. So this is posteriorly. Right behind the PoweRasp is the ulnar nerve right behind the capsule. Now imagine having a burr right there. Yeah it'd be scary. But with the with the PoweRasp you can see this osteophyte just melts away. And it's important to get these osteophytes out if you really want to do a good job. Taking just a tip of the electron as it comes into olecranon fossa is not enough. You go down both sides of the olecranon to really clean it, clean out the elbow, and you can see here we've. We have the ulnar nerve on the other side. And then if this was a stiff elbow then I would release the capsule here exposing the ulnar nerve. But don't do that until you've finished taking the osteophytes off. So I'm not worried about the ulnar nerve. We're just a short while ago I would be. So I think that's a that's a big help toward making elbow arthroscopy a safer for for all of us. You can watch it again if you want. And again, as I mentioned, just above the radial head, there's a fat pad. You can see that at arthroscopy. And the radial nerve is right there. This is not always part of a standard part of the elbow arthroscopy formula. But you can you can see radial head down here. The radial nerve. Truly when you do a complete capsule ectomy as I did here kind of it almost doesn't want to go back, see. But it just wants to hang out there. That's when you see that fat pad. That's when you need to slow down and preserve that part of the capsule that's right there. On the nerve. As I was showing the PoweRasp, I was working down here and you can tell the ulnar nerve is right on the other side there. So you need to preserve that OCD just briefly. These lesions are often hard to get. People complain to me. It's hard to get there. It's really not that hard to get if you if you do an ergonomic 9090 approach going underneath the anconeus, giving you a view such as that so you can look at your lesion and very easy to microfracture and debris that if you just go under the anconeus the head up into. That region and just. Briefly on on tennis elbow. Some people say it should be called Rover's Elbow because it was described actually the sculling way before people were playing lawn tennis or whatever tennis was called back then. I think this is an important article by Marty Bowyer and Jill Hastings. If you think of the attachments on the lateral side of the elbow between two sides of a mountain, the sort of the safe side where the CRB and EDC complexes, that's what we're supposedly reading. And the lower half you can see here is the danger zone. This is where the lateral ligament would be. And you want to avoid taking that down. But just concentrating on the upper half of the capitellum when you're doing a release. I think we've kind of seen this. I'll just show the very, very beginning. But if you want to see from the medial side is this, and you want to be coming in reading the tissue off the lateral capitellum there, and that will give you a good, a good. Exposure. And just to finish up just something we've been we've been doing actually just for the past past few weeks. But if you have a traumatic patient that has a very traumatic dislocation of their elbow. Just to switch from arthroscopy for a moment, typically we've been using external fixers to hold these patients in place, and we've argued whether we should be using a hinged or static ex-fix as I've moved on just to static. Much easier, easier to put on, but I think using some of some of the techniques that we've learned, maybe this InternalBrace. But this is this was an elbow from a traumatic car accident. I didn't do any dissection. The patient did it themselves. Very unstable, exploded both the medial and lateral aspects of the elbow. But by putting a in this case we used a 3.5 SwiveLock with two FiberTape. And what we're going to do is pull that up and then put a 4.75 SwiveLock in here. This is an elbow that in the old days, which was not long ago, I would have put an external fixator on statically for just about 3 to 4 weeks. But here we're using this very strong fixation. Pulling that up. Repairing. Even putting an extra, extra number two FiberWire through. And we'll use those two number two fibers to secure the soft tissues. Using this as an internal ex-fix or brace to hold the elbow together, anticipating that it's not going to last, you know, six, eight weeks. But I don't really want it to. I just want to last until the soft tissues here heal. And we're going to stitch the muscle back together. That was all exploded. And then look at the medial side of the elbow, but very stable right out of the box. And this patient actually went back. You can see an open wound over here for some plastic surgery procedures. And multiple times at least two times back to the Or undergoing anesthesia. And you worry obviously about them pulling the elbow out during that time frame. I just saw her back in the clinic and she was doing fine. So I think I think potentially we were just in the lab a little while ago working on that. So I think this might be, in certain instances, a way to avoid using an ex-fix for the very traumatized elbow situation. Thank you very much.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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