Elbow Arthroscopy Research Articles

Elbow Arthroscopy: Pearls to Avoid Nerve Injuries

Elbow arthroscopy is a useful tool that can be applied in a variety of surgical indications. However, performing the procedure safely demands a thorough understanding of the proximity of neurovascular structures around the elbow. Although nerve injuries in elbow arthroscopy are rare, complications can further be avoided by adhering to a set of principles designed to protect the surrounding neurovascular structures. Before making portals, the surgeon should palpate and mark the ulnar nerve to confirm its location in the groove. Next, the joint should be insufflated with fluid to distend the joint capsule and increase the distance between instruments and the anterior neurovascular structures. Anterior portals ideally should be made proximal to the medial and lateral epicondyles, thereby increasing distance from the median and radial nerve, respectively. Once in the joint, it is critical to stay oriented by maintaining instruments and the articular surfaces in the same view. Special caution should be exercised when in proximity to the capsule in the posteromedial gutter to protect the ulnar nerve. Similarly, the anterior inferior capsule should be approached with caution, as its violation puts branches of the radial nerve, specifically the posterior interosseous nerve, at risk. Elbow arthroscopy can be safely performed with proper knowledge and application of anatomy around the elbow when making portals and understanding at-risk areas beyond the capsule when working within the joint.

Does tranexamic acid reduce elbow swelling and improve early function following arthroscopic arthrolysis? A double-blind randomized controlled trial

BackgroundTranexamic acid (TXA) reduces bleeding and hematoma rates in open elbow arthrolysis. However, its effects on arthroscopic elbow arthrolysis remain unclear. This study aims to evaluate the effect of TXA on elbow arthroscopic procedures and compare bleeding volume, hemarthrosis, visual analog scale (VAS) for pain, range of motion (ROM), and Mayo Elbow Performance Score (MEPS) in the early postoperative period between patients who received intra-articular TXA and those who did not. MethodsA prospective, double-blind, randomized controlled trial enrolling 80 patients with stiff elbows who underwent arthroscopic arthrolysis was performed from January 2021 to December 2022. Intra-articularly, 1 g of TXA in 100 ml of saline or placebo (control group) was administered after the arthroscopic operation according to randomization. Parameters were recorded and compared between the groups, including bleeding volume of drainage, hemoglobin (Hgb) level, ratio of arm and forearm circumference of the surgical side to the contralateral side, grading of hematoma, VAS, ROM and MEPS within one week postoperatively. And during one year follow-up, ROM and MEPS were recorded. ResultsAll patients enrolled in this study demonstrated significant improvements in ROM (flexion-extension) and MEPS one week postoperatively, with no significant differences observed between the two groups. Compared to the control group, the TXA group exhibited significant differences in the bleeding volume of drainage (61.45±47.7 ml vs. 89.8±47.0 ml, p=0.030) and a higher Hgb level 24 hours postoperatively (13.5±1.5 g/dL vs. 12.6±1.8 g/dL p=0.049). While the ratio of arm and forearm circumferences significantly increased 24 hours postoperatively compared to preoperative values in TXA group (1.05±0.06 vs. 1.02±0.04 and 1.02±0.06 vs. 0.98±0.04, with p=0.019 and p=0.005, respectively), this difference vanished one week postoperatively for the ratio of arm circumference. However, it persisted for the ratio of forearm circumference (1.02±0.07 vs. 0.98±0.04, p=0.003). Furthermore, there was no significant difference in MEPS, VAS or ROM between the two groups one week postoperatively. ConclusionPatients with stiff elbows who underwent arthroscopic arthrolysis achieved satisfactory clinical outcomes very early postoperatively. Compared to the control group, patients who underwent arthroscopic elbow arthrolysis with intra-articular administration of TXA exhibited significantly less bleeding volume of drainage and slightly higher Hgb levels postoperatively. One week postoperatively, slightly more swelling in the upper arm region was noted in the control group compared to the TXA group. These findings suggest that the intra-articular injection of TXA after arthroscopic release for elbow stiffness may statistically reduce complications related to postoperative bleeding. However, it’s clinical relevance needs further investigation.

The temperature profile in elbow arthroscopy using radiofrequency ablation.

Over the last decades, arthroscopic surgery has become increasingly relevant as its minimally invasive approach offers many benefits. To investigate the risks of orthoscopic surgery at the elbow, this study aimed to investigate the development of temperatures in elbow joints while performing radiofrequency ablation in arthroscopic surgery. We performed standard arthroscopic surgeries with posterolateral, transtricipital and anterolateral approaches on seven cadaveric elbows and performed ablation on predefined locations with or without irrigation. Two temperature probes were positioned into the olecranon fossa and between the ulnar nerve and the medial joint capsule. The temperature data were recorded using a real-time data logger. A bipolar radiofrequency ablation (bRFA) device was used at the medial and lateral recess and in the fossa olecrani over a defined period. Data was then analyzed using Matlab. Using bRFA without irrigation results in rapidly increasing temperature within the joint. A significant temperature increase was found within only 5s without irrigation (p = 0.0052) in the fossa olecrani. We did not observe critical temperatures above 41°C close to the ulnar nerve within 30s under constant irrigation (p = 0.0747). Radiofrequency ablation (RFA) can be safely used in elbow arthroscopy with irrigation. The continuous use without irrigation should be limited to 3s. Despite the anatomical proximity of the ulnar nerve and capsule, we were able to show that a possible rise in temperature most likely does not affect the ulnar nerve.

Impact of arthroscopy on post-procedure intra-articular elbow injections: A cadaveric study.

To determine the influence of arthroscopy and injection volume on post-procedure intra-articular (IA) injection extravasation. Ex vivo prospective study. A total of 40 paired canine cadaver forelimbs. After radiographs and computed tomography (CT) scans with three-dimensional (3D) digital bone model reconstructions, elbows were randomly assigned to the arthroscopy or control group and randomly assigned to receive an IA injection of 2 or 4 mL of contrast. Elbow arthroscopy was performed on assigned specimens, followed by IA injections of contrast in all elbows, and imaging was repeated. 3D digital model volumes were compared. Images were interpreted and scored for extravasation by a radiologist unaware of treatment and volume assignments. Based on CT images and regardless of treatment group, IA injections of 4 mL resulted in a mean extravasation score of 2.25 (SD 0.97) versus 1.55 (SD 1.05) (p = .02) for 2 mL IA injections. The change in 3D model volumes after IA injections was a mean of 13.2 cm3 (SD 5.85) after 4 mL injections, compared to 6.97 cm3 (SD 6.28) (p = .003) after 2 mL injections. On radiographic evaluation, but not CT, the mean extravasation scores were 2.45 (SD 1.15) for the arthroscopy group and 1.25 (SD 0.79) for the control group (p < .001). A larger volume of IA injection resulted in higher CT extravasation scores and larger 3D volumes regardless of arthroscopic treatment. IA injections performed immediately after arthroscopy resulted in 50% or less extravasation, especially with a smaller IA injection volume.

Pediatric Patients Who Underwent Elbow Arthroscopy Had an 86% Return-to-Sport Rate, a 12% Reoperation Rate, and a 3.7% Complication Rate

PurposeThe purpose of this study was to assess the applicability and safety of elbow arthroscopy in the pediatric population at our institution by analyzing the indications and complications in a large pediatric patient series. MethodsAll patients who underwent elbow arthroscopy at 18 years of age or younger from 2006 to 2017 by a single fellowship-trained surgeon were retrospectively identified. Exclusion criteria were a follow-up shorter than eight weeks and open surgeries (not fully arthroscopic). Medical records were reviewed for baseline characteristics, indications for elbow arthroscopy, range of motion, complications, and reoperations. Results191 patients (64 boys and 127 girls) were included with a median age of 15.5 years (IQR 14.0-16.7). Indications for arthroscopic surgery were grouped into treatment of osteochondritis dissecans (60%), debridement for bony or soft tissue pathology (35%), contracture release (3%), and diagnostic arthroscopy (3%). The complication rate was 3.7%, including 4 minor complications (3 superficial wound problems, 1 transient ulnar neuropathy) and 3 major complications (1 manipulation under anesthesia for stiffness, 1deep infection, 1 (unplanned) reoperation for persistent locking within 1 year of the index procedure). 23 patients (12%) needed subsequent surgery because of newly developed, persisting or recurring elbow problems. 86% were able to return to sports. ConclusionsPediatric elbow arthroscopy performed by an experienced surgeon using a standardized technique for a wide variety of elbow conditions has an acceptable complication rate that is similar to previously published literature on elbow arthroscopy in the pediatric and adult populations; however, a significant proportion of patients needed subsequent surgery in the following years.

Evaluating effectiveness of cadaveric arthroscopic training for orthopaedic residents: A comparison of joints and training levels.

This study aimed to evaluate the effects and interactions of training level and different joints on the outcomes of cadaveric arthroscopic training courses for orthopaedic residents. This prospective study enrolled 16 orthopaedic residents who voluntarily participated in a cadaveric training programme involving the shoulder, elbow, wrist, knee and ankle joints. Outcomes were quantitatively assessed using task-specific checklists and the Arthroscopic Surgery Skill Evaluation Tool. Two-way analysis of variance (ANOVA) was conducted to determine the significance of the interactions between joint and years of training. Resident scores significantly increased after the dedicated lectures in all five joints (p = 0.003 for the shoulder module, p < 0.001 for the other joints). Two-way ANOVA revealed that the progress made after the dedicated lectures was significantly impacted by the joint (p = 0.006) and training level × joint interaction (p = 0.005) but not by the training level (p = 0.47). The simple effect of the joint was examined using Sidak's multiple comparison test. Among junior residents, the dedicated lectures resulted in more substantial progress in elbow and wrist arthroscopy when compared to shoulder arthroscopy (p = 0.020 and p = 0.043, respectively). The results suggest that, in cadaveric arthroscopic training courses for orthopaedic residents, training outcomes are primarily impacted by the specific joint being trained rather than the training level. Specifically, junior residents demonstrated greater improvement with training in procedures that are less commonly encountered during on-the-job training, such as elbow and wrist arthroscopy. These findings suggest the need to prioritise wrist and elbow arthroscopic training for junior residents to optimise educational outcomes. Level III.

Proximal radioulnar joint, but not posterolateral, instability in patients with symptomatic minor instability of the lateral elbow

IntroductionThe elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament (LUCL) and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like SMILE (Symptomatic Minor Instability of the Lateral Elbow) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathological condition. Materials and MethodsTwenty-eight patients were included in this study: half of them were operated for suspected SMILE while the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, four parameters were analyzed: Annular Drive Through (ADT), Ulnar-humeral Stressed Distance (UHSD) at 45° and 30° of flexion, and Loose Collar Sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to do measurements. Results and DiscussionA statistically significative difference was found for LCS (p value 0,0003) and ADT (p value 0,000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly. Progressive stretching of the RLCL and annular ligament may lead to their elongation, allowing a pathological antero-posterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radio-ulnar instability. ConclusionsRLCL and annular ligament are elongated in SMILE patients compared to controls, causing instability of the proximal radio-ulnar joint (PRUJ) and confirming that ligament incompetency is involved in SMILE condition.

30-Day complications, operative time, and overnight admission following elective elbow arthroscopy

Background Although arthroscopic procedures are generally considered safer than open procedures, they are not without complications. This study's purpose is to characterize patient demographics, medical complications, overnight admissions, and prolonged operative times for patients undergoing elective elbow arthroscopy using a national database. Methods This retrospective study used the ACS NSQIP database with data from 2015 to 2020. Patients undergoing elbow arthroscopy were identified, and those undergoing emergent surgery were excluded. Patient demographics, clinical characteristics, medical comorbidities, 30-day complications, overnight admission rates, and operative times were recorded and analyzed. Results Overall, 815 patients undergoing elective elbow arthroscopy were included. The mean age was 46.8 years. Mean BMI was 29.7 kg/m2, and 75.2% (n = 613) were male sex. The most common comorbidity was smoking (14.8%, n = 121). The cumulative complication rate was 2.5% (n = 20). The most common complication was surgical site infection (n = 7, 0.9%). 10.7% of patients required at least one overnight hospital stay. 20.2% of patients had a prolonged operative time ≥ 120 min. Conclusion Elbow arthroscopy is not without complications and morbidity despite being a minimally invasive procedure and advances made in surgical technique. Surgeons should use this information to facilitate shared-surgical decision making, preoperative patient counselling, and preoperative patient optimization.

It is time to move forward: a bibliometric analysis of top 50 cited articles in elbow arthroscopy

ObjectivesTo analyze the bibliometric characteristics of the top 50 cited articles in elbow arthroscopy. MethodsThe Web of Science Core Collection was employed to systematically retrieve publications related to elbow arthroscopy. Subsequently, the top 50 cited articles meeting the predefined inclusion criteria were meticulously documented and subjected to comprehensive bibliometric analysis. ResultsThe top 50 cited articles spanned the years 1999–2017, with the 2010s emerging as the most prolific decade. Citations per article varied from 24 to 211, and citation density ranged from 1.61 to 9.17. The United States dominated in article production and citations. Predominantly, the articles took the form of case series and expert opinions, with a notable absence of level I or II evidence. The keywords with the highest frequencies were “arthrofibrosis,” “complications,” and “release.” These keywords formed five main clusters: stiff elbow, osteoarthritis, osteochondritis dissecans, and lateral epicondylitis. ConclusionsThe majority of the top 50 cited articles in elbow arthroscopy comprised case series exhibiting Level IV or V evidence. Despite a dynamic development post-2010, elbow arthroscopy articles showed lower mean citations and citation density compared to other joints, potentially influenced by concerns about complications. However, with the increasing prevalence of elbow arthroscopy procedures, it is anticipated that higher-level articles, particularly those focusing on complications and exploring additional indications, will supersede some of the articles included in this analysis. Level of evidenceIV

Basic to advanced elbow arthroscopy: the history, basic set up, and indications.

Elbow arthroscopy presents challenges; however, its indications and advantages over traditional open surgery are swiftly evolving. Despite being less widely performed than on other joints such as the knee, shoulder, ankle, and hip, arthroscopic management of the elbow has potential. The goals of this review are to describe and broaden the current applications of elbow arthroscopy. Additionally, we will provide insights and strategies to enhance the effectiveness of elbow arthroscopy.

Perioperative steroid injection in elbow arthroscopy.

The goal of the present study was to evaluate the incidence of infection after perioperative intra-articular steroid injection during elbow arthroscopy. Starting from May 2019, we prospectively included all patients that underwent an elbow arthroscopy for various indications. All patients received preoperative antibiotics intravenously and a corticosteroid injection immediately after portal closure. Patients who needed ligamentous repair and aged below 18 years old were excluded. Final follow up of all patients was 3 months. In total, 108 elbow arthroscopies were performed in 100 patients. No major complications and 1 minor complication were seen. One patient developed a seroma that resolved spontaneously after 14 days without intervention or antibiotics. In this patient group, a perioperative corticosteroid injection following elbow arthroscopy did not increase the chance of infection.

Open versus arthroscopic treatment of the rheumatoid elbow arthritis: a comparison of complications at two years utilizing a nationally representative database.

Symptomatic rheumatoid arthritis (RA) can be addressed surgically with open procedures or elbow arthroscopy. Previous studies comparing outcomes of open to arthroscopic arthrolysis for the management of RA did not utilize a large database study. The aim was to compare demographics and two-year complications, in RA patients undergoing open or arthroscopic elbow arthrolysis. A retrospective, cohort study was performed utilizing a private, nationwide, all-payer database. We queried the database to identify patients undergoing open (n = 578) or arthroscopic (n = 379) arthrolysis for elbow RA. The primary goal of the study was to compare complications at two-years. Categorical variables were assessed utilizing the chi-squared test; while, continuous variables were analyzed using the Student's t-test. Multivariable logistic regression was performed to assess risk factors for infection following open or arthroscopic arthrolysis. RA patients undergoing open elbow arthrolysis were older (55 vs. 49years, p < 0.001), predominately female (61.6% vs 60.9%, p = 0.895), and likely to have chronic kidney disease (20.4 vs. 12.9%), and DM (45.2 vs. 32.2%) (both p < 0.005). Open elbow arthrolysis was also associated with higher rates of infection (31.7 vs. 4.7%) and wound complications (26.8 vs. 3.4%) (both p = 0.001). Nerve injury rates were found to be similar (8.3 vs. 9.0%, p = 0.81). On multivariable logistic regression, open elbow procedures were associated with the highest risk for infection (OR: 8.43). Patients undergoing open arthrolysis for RA were at a higher risk of infection and wound complications compared to arthroscopic arthrolysis utilizing a nationally representative database. While there appears to be a difference in outcomes following these two procedures, higher level evidence is needed to draw more definitive conclusions. Retrospective, Level III.

Arthroscopically assisted closed reduction for displaced lateral humeral condyle fractures over 4 mm in children

IntroductionLateral humeral condyle fractures (LHCFs) are the most common intra-articular fracture occurring at the elbow in children. Conventional treatment for displaced pediatric LHCFs is open reduction and percutaneous pinning, and few studies have regarded the efficacy of arthroscopic-assisted techniques. We aimed to evaluate the efficacy of anatomic reduction via elbow arthroscopy for pediatric humeral lateral condyle fractures with displacements >4 mm. MethodsA total of 32 children with LHCFs featuring displacements >4 mm were enrolled in this retrospective study. Arthroscopically assisted reduction was performed as the primary treatment approach. For simple displaced fractures, arthroscopically assisted reduction was directly employed with intermittent intra-articular irrigation. For fractures with distal fragment rotation, the rotated fragments were firstly realigned into a simple displaced position under fluoroscopy before proceeding with arthroscopy. The success rate of arthroscopically assisted reduction and clinical outcomes at the latest follow-up were assessed, and complications related to the procedure were monitored. ResultsTwenty-nine of 32 (90.62 %) enrolled cases were successfully treated with arthroscopically assisted reduction. Failure cases were attributed to soft tissue swelling, which hindered the manipulation of the fracture fragments for reduction or fixation. We subsequently adapted the surgical procedure, resulting in a significant increase in the success of arthroscopically assisted reduction, rising from 71.43 % to 96 %. Among the 29 successfully treated cases, excellent functional outcomes were observed in 18 cases, and 11 cases showed good outcomes. Regarding the carrying angle outcomes, 28 patients achieved excellent results, with one patient having a good outcome. The most frequent radiographic finding after surgery was lateral spur formation without further negative effects. Only one case of superficial infection occurred, promptly healing with topical management. No significant complications such as neurovascular injury or compartment syndrome were observed. ConclusionArthroscopically assisted anatomic reduction provides a promising alternative to open reduction for LHCFs with displacements exceeding 4 mm, offering direct visualization of the articular surface and minimizing soft tissue dissection.

Accessibility of osteochondral lesion at the capitellum during elbow arthroscopy: an anatomical study.

Osteochondrosis dissecans (OCD) at the capitellum is a common pathology in young patients. Although arthroscopic interventions are commonly used, there is a lack of information about the accessibility of the defects during elbow arthroscopy by using standard portals. An elbow arthroscopy using the standard portals was performed in seven fresh frozen specimens. At the capitellum, the most posterior and anterior cartilage surface reachable was marked with K-wires. Using a newly described measuring method, we constructed a circular sector around the rotational center of the capitellum. The intersection of K-wire "A" and "B" with the circular sector was marked, and the angles between the K-wires and the Rogers line, alpha angle for K-Wire "A" and beta angle for K-wire "B", and the corridor not accessible during arthroscopy was digitally measured. On average, we found an alpha angle of 53° and a beta angle of 104°. Leaving a sector of 51° which was not accessible via the standard portals during elbow arthroscopy. Non-accessible capitellar lesions during elbow arthroscopy should be considered preoperatively, and the informed consent discussion should always include the possibility of open procedures or the use of flexible instruments.

Reliability and Usefulness of YouTube as a Source of Informative Media for Arthroscopic Tennis Elbow Surgery: A Systematic Review of the Published Videos.

Over the last decade, YouTube has been extensively used as a learning tool for both physicians and patients, but the reliability of this information remains questionable. The purpose of this study was to look for the reliability and quality of videos on tennis elbow arthroscopy on YouTube. We used three search terms on YouTube "tennis elbow arthroscopic surgery," "Arthroscopic ECRB release," and "Arthroscopic debridement for tennis elbow," and screened the first 50 videos according to popularity. The videos were included from 2009 to date. Only videos in the English language were included. Repeated videos and videos without sound were excluded. A total of 74 videos were selected for this study and reliability was checked with DISCERN and journal of the American medical association (JAMA) scores. The quality was assessed with the Global Quality Score Criteria (GQSC) score and TEARS (a novel score). Popularity was tested with the video power index (VPI). A pilot study was conducted using 20 videos to validate the TEARS score. In the pilot study, TEARS showed results in accordance with other scores used. The average number of views was 41,644.97, and the average duration was 5.03 ± 3.39 years. The mean value of DISCERN and JAMA was found to be 21.47 ± 6.28 and 1.05 ± 0.92, respectively. GQSC, TEARS, and VPI were found to be 1.70 ± 0.82, 4.17 ± 2.62, and 769,936.9 ± 6,538,851.37. Most of the videos were educational and physicians were targeted. The USA was the major contributor to such videos. The reliability and quality of these videos were found to be of poor quality. The video popularity was however found to be relatively high. The inter-observer reliability was good. Based on the findings, we conclude that the videos are not reliable and could not be used for learning.

Arthroscopic-Assisted Fracture Fixation About the Elbow.

Arthroscopic-assisted fracture fixation can be used for some adult elbow fractures. In particular, for articular fractures of the anterior elbow (coronoid/capitellum), elbow arthroscopy can provide excellent visualization of fracture fragments using a less invasive surgical exposure. Meticulous adherence to safe techniques and utilization of specialized equipment can help maximize safety and facilitate reproducible surgical results.

Prevalence, Timing, Locational Distribution, and Risk Factors for Heterotopic Ossification After Elbow Arthroscopy

Background: Arthroscopic techniques aim to reduce complications and accelerate recovery of the elbow after treatments for posttraumatic stiffness, arthritis diseases, lateral epicondylitis, ligament reconstruction, and elbow trauma. However, data on the true prevalence and characteristics of heterotopic ossification (HO) formation after elbow arthroscopy are limited. Purpose: To investigate the prevalence, timing, locational distribution, and risk factors of HO after elbow arthroscopy. Study Design: Cohort study; Level of evidence, 4. Methods: Data on 205 patients undergoing elbow arthroscopy by a single senior elbow surgeon at a single institution between May 2011 and January 2022 were retrospectively reviewed. The patients were evaluated at 2 weeks, 8 weeks, 6 months, and then annually after surgery or more frequently if HO developed, with a minimum of 1 year of postoperative follow-up. Postoperative anteroposterior and lateral elbow radiographs were taken at 2 weeks to rule out fracture and at 8 weeks to identify HO. The clinical outcomes were evaluated based on the pain visual analog scale; the shortened version of the Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and the Single Assessment Numeric Evaluation scores before and after surgery. Bivariate logistic regression analyses were used to determine factors affecting HO prevalence. Results: Thirteen (12 male, 1 female) of 205 (6.3%) patients developed HO, with 10 (76.9%) with HO that formed on the medial compartment of the elbow. Ten (76.9%) patients were diagnosed at 8 weeks after arthroscopic surgery, 1 (7.7%) at 6 months after surgery, and 2 (15.4%) at 12 months after surgery. HO was not found at 2 weeks after surgery in any patient. The mean follow-up time was 3.5 years (range, 1.0-11.8 years). Eleven asymptomatic patients were treated nonoperatively, and 2 symptomatic patients underwent HO excision arthroscopically or had a combination of open surgery and arthroscopy. Age was a protective factor for HO formation (odds ratio [OR], 0.953; 95% CI, 0.910-0.999; P = .047). The risk factors for HO formation were tourniquet time (OR, 1.042; 95% CI, 1.019-1.065; P < .001) and surgical time (OR, 1.026; 95% CI, 1.011-1.041; P < .001). Conclusion: Among 205 patients who underwent elbow arthroscopy, HO was a minor complication of elbow arthroscopy, with a prevalence rate of 6.3%, and was usually located on the medial compartment of the elbow. Although the presence of HO may not affect the clinical outcomes in most patients, it should be carefully monitored for a minimum of 8 weeks postoperatively. Younger age, longer tourniquet time, and longer surgical time contributed to HO formation after elbow arthroscopy.

The posterolateral ligament of the elbow: anatomy and clinical relevance

The posterolateral capsule was recognized in the past as an important structure for elbow stability but was later disregarded. Two recent biomechanical studies demonstrated its role in preventing posterolateral instability, and thus it should be identified as a distinct ligament: the posterolateral ligament (PLL). This study includes 2 parts: an anatomic study of the PLL's footprint and a collection of 5 cases of pathologic lesions of the PLL. Six cadaveric upper limbs were assessed. The attachments of the PLL were dissected, the footprints were marked and photographed, and the 2-dimensional area and length were measured. The mean proximal attachment dimensions were a length of 13 mm and an area of 101 mm2, and the mean distal attachment dimensions were 19 mm and 111 mm2, respectively. There were 2 cases of posterolateral elbow pain in professional cricket bowlers, diagnosed radiographically as enthesopathy of the PLL's proximal attachment on the posterior capitellum, probably due to repeated forced hyperextension of the elbow. Both patients were treated by débridement of the posterior capitellum and reattachment of the PLL, with complete resolution of symptoms. In addition, there were 3 cases of clinical posterolateral rotatory instability in young patients. Two athletes had an isolated acute tear of the PLL, and on physical examination, both had positive posterior draw test results but negative pivot-shift test results. Both underwent elbow arthroscopy and repair of the PLL with resolution of symptoms. The third patient had long-standing recurrent elbow instability, following a failed lateral ulnar collateral ligament reconstruction, in the presence of an Osborne-Cotterill lesion. He underwent revision lateral ulnar collateral ligament reconstruction, bone grafting of the bony lesion, and reattachment of the PLL, with complete resolution of symptomatic posterolateral rotatory instability. The PLL of the elbow has a significant role in the elbow's posterolateral stability. Its footprints were described, and its clinical significance was demonstrated in cases of elbow instability caused by acute ligament tears and elbow pain due to ligament enthesopathy. Surgeons should be aware of this structure and potential pathology related to its injury.

Arthroscopic Techniques to Recognize and Quantify Subtle Medial and Lateral Elbow Instability

The diagnosis and treatment of elbow instability can be challenging for surgeons. Although history, physical examination, radiographs, and advanced imaging such as stress ultrasound scanning and magnetic resonance imaging are helpful, diagnostic arthroscopy is a valuable tool in the armamentarium of an elbow surgeon. Elbow arthroscopy is not only a diagnostic tool but also has the added therapeutic benefits that are not available with other diagnostic modalities. The purpose of this article and associated video is to present 3 arthroscopic techniques to help elbow surgeons arthroscopically recognize and quantify medial and lateral elbow instability.

Incidence of Repeat Elbow Capsular Release After Arthroscopic Elbow Capsular Release.

Elbow capsular release can be performed arthroscopically or through an open method to improve range of motion (ROM). However, it is unclear how frequently patients require an open capsular release after unsatisfactory results from an arthroscopic release. The purpose of this study was to determine the percentage of patients who underwent an arthroscopic elbow release for loss of motion who then required a repeat elbow capsular release or other subsequent surgery on the same elbow. It was hypothesized that patients who underwent arthroscopic elbow release would rarely (<5%) require a subsequent elbow release. Case series; Level of evidence, 4. Patients who underwent arthroscopic elbow capsular release from January 1, 2010, to December 31, 2019, were identified by chart review and procedure code. Demographic parameters, pre- and postoperative ROM, and surgical history were collected by chart review. Follow-up data included patient satisfaction and the Timmerman-Andrews (TA) elbow score. Data were compared between patients who did and those who did not require subsequent elbow surgery. Overall, of 140 study patients (116 male, 24 female; mean age, 49.6 years), 18 (12.9%) required subsequent surgery, including 6 capsular releases (4.3%; 1 open and 5 arthroscopic). The most common follow-up procedure was ulnar nerve releases/transpositions (n = 7). Total arc of elbow motion (flexion to extension) improved by a mean of 51.4°. The mean TA score was 76.5 ± 20.4 at a mean of 5.25 years postoperatively. Mean satisfaction score was 77.6 ± 26.3. In this study, 82.4% of patients stated that their symptoms either improved or resolved completely. Patients who required subsequent surgery had a significantly lower preoperative total arc of elbow motion versus those who did not require subsequent surgery (P = .046). There was no difference between the groups in symptom resolution, satisfaction, ROM, or TA score (P ≥ .279 for all). After arthroscopic elbow release, <5% of patients required a repeat elbow capsular release, 12.9% required some form of follow-up elbow surgery, and 4.3% had a new injury of the elbow. Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release.