Medial Epicondylar Osteotomy Research Articles

Entrapment of Median Nerve After Pediatric Elbow Dislocation with a Brief Review of Literature: A Case Study.

We present a case of type II (intraosseous) entrapment of the median nerve in a patient who was diagnosed based on clinical examination and magnetic resonance imaging and who was treated with medial epicondyle osteotomy, neurolysis, and transposition of the nerve to its anatomical position within a month of injury. Our patient made a complete motor and sensory recovery at 5 months with complete functionality and grip strength. Median nerve entrapment after posterolateral elbow dislocation is a rare complication with roughly 40 cases reported in the literature. This case illustrates the importance of prompt diagnosis and treatment.

Extensile Exposures in Revision and Complex Primary Total Knee Arthroplasty: A Review of Anatomy, Biomechanics, and Techniques.

Developing adequate exposure when performing a revision total knee arthroplasty is critical to an efficient and safe intraoperative course. Proper planning and knowledge of the relevant anatomy are important when dissecting scar tissue associated with previous trauma or surgery and navigating bone loss. We present a review of the different total knee arthroplasty extensile exposure techniques that have been described in the literature. Specific exposures discussed include the femoral peel, banana peel, medial epicondylar osteotomy, quadriceps snip, tibial tubercle osteotomy, wandering resident, and the V-Y quadricepsplasty with patella turndown. Furthermore, we review the histological healing potential, biomechanical principles that drive post-operative expectations, post-operative rehabilitation protocols, and reported functional outcomes of each technique.

Extension of the Medial Approach to the Tibial Plateau via an Osteotomy of the Tibial Insertion of the Superficial Medial Collateral Ligament.

The treatment of medial tibial plateau fractures can be challenging due to poor exposure of the articular surface. Therefore, a medial epicondyle osteotomy may be needed. Current methods describe osteotomy of the medial femoral epicondyle. However, this method requires additional detachment of the medial meniscus in order to ensure proper visualization. The aim of this study is to present a new technique using distal osteotomy of the superficial medial collateral ligament and to analyze the area of the exposed articular surface area. On each of eight fresh-frozen human cadaveric knees (mean age: 79.4 ± 9.4 years), an osteotomy and proximal reflection of the distal insertion of the superficial medial collateral ligament combined with a submeniscal arthrotomy was performed, followed by a medial epicondyle osteotomy. Using a three-dimensional measurement arm (Absolute Arm 8320-7, Hexagon Metrology GmbH), the exposed area was analyzed and compared to the entire medial articular surface using ANOVA (p < 0.05). Through the medial epicondyle osteotomy, 39.9 ± 9.7% of the anteromedial articular surface was seen. This area was significantly smaller compared to the osteotomy of the distal insertion of the superficial collateral ligament with an exposed articular surface of 77.2 ± 16.9% (p = 0.004). Thus, the distal osteotomy exposed 37.3% more of the articular surface compared to the medial epicondyle osteotomy. None of these techniques were able to adequately expose the posteromedial- and medial-most aspects of the tibial plateau. A distal superficial collateral ligament osteotomy may be superior to a medial epicondyle osteotomy when an extension of the anteromedial approach to the tibial plateau is required. A distal superficial medial collateral ligament osteotomy combines the advantages of better exposure of the medial articular surface with preservation of the blood supply to the medial meniscus. However, surgeons should carefully consider whether such an extended approach is necessary, as it significantly increases invasiveness.

A comparison of cone beam computed tomography, standard computed tomography and plain radiographs in the evaluation of medial epicondyle humerus fractures.

The ideal technique to measure medial epicondyle humerus fracture displacement minimizes radiation exposure while maximizing measurement accuracy and reliability. This study compares the radiation exposure and accuracy of displacement measurements of the four-view X-ray examination (XR), computed tomography (CT) and in-clinic cone-beam CT (CBCT). A cadaveric humerus underwent medial epicondyle osteotomy. The fragment was fixed to the humerus at clinically relevant displacements (6 to 18 mm). Dosimeters were placed around the distal humerus and simulating thyroid location. XR, CT and CBCT were performed at each displacement. Four pediatric orthopedists measured the maximum linear displacement on each XR and 3D reconstruction of the CT and CBCT images. Focal (elbow location) and thyroid radiation exposure was compared between modalities. Intra- and interclass correlation coefficients (ICC) for displacement measurements were determined. Mean focal radiation exposures for XR, CT and CBCT were 0.008, 2.061 and 0.478 rad, respectively (P = 0.001). Exposures 10 inches from the elbow for XR, CT and CBCT were 0.001, 0.066 and 0.010 rad, respectively (P = 0.006). At 12 inches, there was no significant difference in exposure between XR and CBCT ( P = 0.114). Intra- and interobserver reliabilities were excellent for all measures, except lateral x-ray. CBCT and CT had significantly less deviation from the actual displacement compared to XR ( P < 0.05). In-office CBCT of the elbow exposes patients to significantly less radiation than conventional CT. All X-ray images (except lateral), CT and CBCT had equal reliability in evaluating medial epicondyle fractures, which contrasts with previous evidence.

Primary Results of Medial Epicondylar Osteotomy in Patients with Severe Bilateral Varus Knee Candidate for Total Knee Replacement

Total knee arthroplasty is a challenging task in patients with severe varus deformity. In most of these patients, an extensive medial release is needed that may lead to instability. Medial epicondylar osteotomy may be a better substitute for complete medial collateral release. Fourteen patients with bilateral knee osteoarthritis and severe varus deformity were enrolled in this study. In one side, the patients underwent medial epicondylar osteotomy for mediolateral imbalance if the only option was superficial medial collateral ligament (MCL) release. In contralateral side, the extensive medial release was performed and MCL was released either by pie-crusting technique or by subperiosteally release. The results of the two sides were compared. Patients were followed up for 12 months after the operation. Physical examination, clinical questionnaires, and radiography findings were recorded. Union of the osteotomies fragment and complications was evaluated. The mean varus angle before surgery was 21.6 ± 4.7 degrees, which was corrected to 8.6 ± 2.9 degrees after operation with an extensive medial release. The mean varus angle of contralateral side was 22.6 ± 1.7 degrees, which was corrected to 7.5 ± 2.3 degrees following medial femoral epicondyle osteotomy. There was no significant difference in varus correction (p = 0.1). Medial joint line opening in valgus stress test was 2.7 ± 0.4 mm in the osteotomized side and 3.5 ± 0.9 mm in contralateral side. Mean range of motion for the osteotomized side was 97.8 ± 4.3 degrees and 100.7 ± 2.7 degrees for contralateral side (p = 0.6). Nonunion occurred in a case in the osteotomized side and no medial instability was observed in medial release or osteotomies sides. No statistical difference was recorded based on clinical questionnaires (Oxford and WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index] scores). Medial epicondylar osteotomy is a safe technique with the well-controlled medial extensive release in the patients with severe varus deformity during total knee arthroplasty.

Total knee arthroplasty in the varus knee: tips and tricks.

Varus knee deformity is very common, and it can be classified according to the severity and reducibility of the deformity. Pre-operative planning is mandatory to obtain a good result. Both clinical and radiological planning should be carefully performed, particularly focused on collateral ligament deficiency. In most of the cases, a postero-stabilized implant is necessary, but in the presence of a varus thrust, a midlevel constrained (MLC) implant may be necessary. Rarely, if a severe extra-articular deformity is present, a femoral osteotomy and a high constrain implant may be necessary. In most of the cases, a standard midline approach can be performed. Soft tissue balancing is crucial, avoiding excessive releases of the medial collateral ligament (MCL). In the presence of severe deformity, more aggressive procedure such as tibial reduction osteotomy or sliding medial epicondyle osteotomy can be performed. In literature, good outcomes are reported for total knee arthroplasty (TKA) in varus deformity. In this manuscript, the available literature on TKA in varus deformity is analyzed, and the preferred surgical techniques of the authors are described.

Primary total knee arthroplasty for osteoarthritis: the influence of soft tissue balancing on postoperative contact kinematics

Purpose: Total knee arthroplasty (TKA) is considered the gold-standard surgical treatment for those suffering from end-stage osteoarthritis as it generally produces a functional and stable joint. Soft tissue balancing is recognized as an essential aspect of the procedure, serving to optimize stability and joint kinematics beyond what can be accomplished through implant design and bone cuts alone. The extent of soft tissue balancing completed intraoperatively, whether conservative or extensive, varies between patients. The dissections used depend primarily on the patient's preoperative knee condition and the surgeon's preferred technique. Although intraoperative studies have shown soft tissue balancing accurately produces a mechanically balanced knee, little is known of the postoperative kinematic implications. The aim of this study was to determine if postoperative kinematic differences exist between patients who received varying levels of soft tissue balancing. Methods: Ten patients underwent weight-bearing radiostereometric analysis (RSA) imaging at least one-year post-operation. All patients had received a primary single radius, posterior-stabilized TKA. RSA images were taken in 20° increments of flexion starting at 0°, proceeding to their maximum attainable flexion angle of 100-120°. Model-based RSA software was used to collect kinematic measures of contact location, condylar liftoff, and magnitude of excursion on each condyle. Patients were divided into three groups according to the extent of soft tissue balancing completed intraoperatively. The mild group (n = 3) received mid-coronal plane and osteophyte corrections. The moderate group (n = 3) received deep MCL, posterior capsule, and/or semimembranosus/posterior oblique ligament corrections. The severe group (n = 4) received tibial reduction osteotomy, superficial MCL, and/or medial epicondyle osteotomy corrections. Interim data is presented. Results: Medial condyle anterior-posterior (AP) excursion ranged from 3.2 – 9.3 mm in the mild group, 3.6 – 4.6 mm in the moderate group, and 2.8 – 5.6 mm in the severe group. Lateral condyle AP excursion ranged from 5.6 – 13.1 mm in the mild group, 4.4 – 5.1 mm in the moderate group, and 2.9 – 9.9 mm in the severe group. Condylar liftoff was not seen in patients from the mild or moderate groups, but one patient in the severe group did experience condylar liftoff. Patient demographics between groups were similar. Conclusions: We hypothesized that as the extent of soft tissue balancing is increased, patients would correspondingly experience increases in condylar liftoff and AP excursion because of surgically increased laxity of their stabilizing structures. This would translate to greater risk of implant wear and loosening. However, our interim data was unable to demonstrate the AP excursion aspect of our hypothesis. AP excursion in the mild group was driven largely by a single patient's data. The only patient so far to experience condylar liftoff was in the severe group, which aligns with our expectations of increased instability when extensive soft tissue balancing is completed. Once we reach our expected sample of 12 patients per group we hope to have a better understanding of the postoperative kinematic implications of varying levels of soft tissue balancing.

Clinical and radiologic evaluation of medial epicondylar osteotomy for varus total knee arthroplasty

BackgroundIn varus total knee arthroplasty (TKA), a pathologic contracture of the medial soft tissue should be released for ligament balancing. A medial epicondylar osteotomy has been performed as an alternative method for this. The purpose of this study was to demonstrate the clinical and radiologic results of medial epicondylar osteotomy for varus TKA, focusing on the union type of osteotomy site. MethodsThe study retrospectively evaluated 61 cases with a mean femorotibial angle of 10.4° varus and a mean flexion contracture angle of 8.5±9.8°. Intraoperative medial and lateral gap difference in extension and 90° flexion was accepted at <2mm. Clinical outcomes (Knee Society Scores, range of motion) and radiologic outcomes (coronal alignment and valgus stability) were compared between the two groups divided by the union type of osteotomy site (bony union or fibrous union). ResultsThe clinical and radiologic outcomes were significantly improved at the latest follow-up. Bony union was achieved in 39 (63.9%) patients, whereas 22 patients showed fibrous union. There was no difference in the varus–valgus angle on the stress radiographs between the bony union and fibrous union group (1.6±1.2° vs. 1.6±0.8°, P<0.916). The Knee Society Scores (knee, function), range of motion and radiographic alignment did not differ between the two groups. ConclusionMedial epicondylar osteotomy was a good option for gap balancing during TKA, as it provided satisfactory clinical and radiological results, regardless of union type of the osteotomy site.

A Novel Medial Soft Tissue Release Method for Varus Deformity during Total Knee Arthroplasty: Femoral Origin Release of the Medial Collateral Ligament.

IntroductionNumerous methods of medial soft tissue release for severe varus deformity during total knee arthroplasty (TKA) have been reported. These include tibial stripping of the superficial medial collateral ligament (MCL), pie-crusting technique, and medial epicondylar osteotomy. However, there are inherent disadvantages in these techniques. Authors hereby present a novel quantitative method: femoral origin release of the medial collateral ligament (FORM).Surgical TechniqueFor medial tightness remaining even after the release of the deep MCL and semimembranosus, the FORM is initiated with identification of the femoral insertion area of the MCL with the knee in flexion. Starting from the most posterior part of the femoral insertion, one third of the MCL femoral insertion is released from its attachment. If necessary, further sequential medial release is performed.Materials and MethodsSeventeen knees that underwent the FORM were evaluated for radiological and clinical outcomes.ResultsRegardless of the extent of the FORM, no knees showed residual valgus instability at 24 weeks after surgery.ConclusionsAs the FORM is performed in a stepwise manner, fine adjustment during medial release might be beneficial to prevent inadvertent over-release of the medial structures of the knee.

Limited Medial and Lateral Approaches to Treat Stiff Elbows.

Open arthrolysis is an effective way to treat elbow stiffness. However, previous approaches led to significant surgical trauma. The goal of the current study was to evaluate the outcome of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation to treat elbow stiffness. A total of 18 patients (18 elbows) with elbow stiffness were retrospectively reviewed. The same inclusion and exclusion criteria were used for all patients. Preoperatively, the mean flexion arc was 43°±28° and the mean Mayo Elbow Performance Score was 62 points. Limited medial and lateral approaches were used to provide safe and complete arthrolysis. The other protocols included ulnar nerve transposition, medial epicondyle osteotomy, radial head resection, ligament repair, and hinged external fixation. Patients were encouraged to begin early rehabilitation 24 hours after surgery. At a mean follow-up of 20 months, the flexion arc improved to 130°±11° and the mean Mayo Elbow Performance Score was 97 points (15 excellent, 3 good). One patient had elbow instability, but function met the requirements of his daily life. Transient ulnar nerve palsy without infection occurred in 4 patients. With limited medial and lateral approaches, elbow stiffness can be treated effectively with open arthrolysis. This method is trauma controlled. Furthermore, a hinged external fixator can provide sufficient and safe rehabilitation. The use of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation is an effective and safe method to treat elbow stiffness.

Effect of Medial Epicondylar Osteotomy on Soft Tissue Balancing in Total Knee Arthroplasty

Balancing and surgical exposure of a severe varus knee during total knee arthroplasty (TKA) can be difficult. Use of a medial epicondylar osteotomy to solve these problems has been reported. This study compared knee stability in cadaveric specimens after TKA, after medial epicondylar osteotomy, and after conventional subperiosteal release of the medial collateral ligament (MCL). Five cadaveric knees were tested after TKA, after medial epicondylar osteotomy, and after repair of the osteotomy to compare the results to 5 cadaveric knees that underwent complete subperiosteal release of the MCL. A retrospective review of clinical cases also was performed of 118 varus knees exposed using the standard medial parapatellar approach and subperiosteal release of the MCL to compare results to the literature using a medial epicondylar osteotomy. Coronal and transverse plane laxity increased significantly at 60° and 90° flexion in the knees after medial epicondylar osteotomy. Suture repair of the osteotomy did not affect stability. The knees with MCL release had a significantly lower degree of coronal and transverse plane laxity at 60° and 90° than knees with an epicondylar osteotomy. The retrospective case review found satisfactory exposure and correct ligament balance was achieved in all cases. The findings of this study question the need for an epicondylar osteotomy in severe varus osteoarthritic knees. Because the knee remains unstable in flexion after this technique, an implant with higher constraint should be used.

Comparison of Complete Distal Release of the Medial Collateral Ligament and Medial Epicondylar Osteotomy during Ligament Balancing in Varus Knee Total Knee Arthroplasty

BackgroundDuring ligament balancing for severe medial contracture in varus knee total knee arthroplasty (TKA), complete distal release of the medial collateral ligament (MCL) or a medial epicondylar osteotomy can be necessary if a large amount of correction is needed.MethodsThis study retrospectively reviewed 9 cases of complete distal release of the MCL and 11 cases of medial epicondylar osteotomy which were used to correct severe medial contracture. The mean follow-up periods were 46.5 months (range, 36 to 78 months) and 39.8 months (range, 32 to 65 months), respectively.ResultsThere were no significant differences in the clinical results between the two groups. However, the valgus stress radiograph revealed significant differences in medial instability. In complete distal release of the MCL, some stability was obtained by repair and bracing but the medial instability could not be removed completely.ConclusionsMedial epicondylar osteotomy for a varus deformity in TKA could provide constant medial stability and be a useful ligament balancing technique.

Medial epicondyle osteotomy: a method of choice in severe varus knee arthroplasty

The purpose of this study was to evaluate the results of total knee arthroplasty (TKA) after using medial epicondyle osteotomy (MEO) as a balancing method for severe varus deformity and also to compare these results with those of TKA after using additional resection of the tibial medial plateau to correct this deformity. A total of 60 knees with severe varus deformity underwent TKA between 2006 and 2010. In 30 cases, we used MEO as a balancing method, and in other 30, additional medial tibial plateau resection was performed. The clinical outcomes were measured with the Knee Society score (KSS), the range of the motion and frontal laxity of the knee. The radiological outcomes were measured by anteroposterior simple radiographs to assess: the union state of the osteotomy site, the amount of resected tibial medial plateau bone and the femorotibial angle. The findings of the study show that in the MEO group the KSS improved from 21.13 ± 13.6 to 92.1 ± 7.6 points (P < 0.001). Moreover, the range of motion increased from 70.3° ± 25.3° to 109.3° ± 12.7° (P < 0.001). The femorotibial angle was corrected from a 22.6° ± 5.71° varus to a 4.0° ± 1.38° valgus (P < 0.001) and frontal laxity decreased from 10.83° ± 3.9° to 0.33° ± 1.2° (P < 0.001). No statistically significant differences were found between groups regarding the postoperative outcomes of KSS, range of motion, femorotibial angle and frontal laxity. The amount of resected tibial medial plateau bone was statistically significantly smaller in the MEO group (1.63 ± 0.96 mm in the MEO group and 4.73 ± 2.7 mm in the other group; P < 0.001). In the MEO group, the mean thickness of the polyethylene insert was 12.66 ± 1.21 mm, while in the second group, it was 13.73 ± 1.59 mm, with statistically significant P = 0.005. Fibrous union occurred in all knees in the MEO group. Using medial epicondyle osteotomy for varus knee when performing total knee arthroplasty could be a useful ligament-balancing technique to achieve medial stability of the knee. In addition, it could have considerable advantages towards the additional resection of the tibial medial plateau.

Results of Total Knee Arthroplasty With Medial Epicondylar Osteotomy to Correct Varus Deformity

The clinical results of using medial epicondylar osteotomies to correct varus deformities in total knee arthroplasties were investigated. Unlike the traditional method of subperiosteal stripping of tibial ligaments, this alternative does not damage ligaments. Between 1991 and 1996, the senior author performed medial epicondylar osteotomies in 80 patients (93 knees) with primary total knee arthroplasty; of these, 60 patients (70 knees) were available for 2- to 4-year followup. At followup, no patients reported knee instability. Mean varus and valgus stability measured 14.2 points (Knee Society scale, 0-15 points). The Knee Society clinical score was 93 points, compared with a preoperative score of 42 points. The mean range of motion at followup was 111 degrees, compared with a preoperative mean of 101 degrees. The postoperative tibiofemoral angle on full limb radiographs taken with the patient weightbearing averaged 7 degrees valgus, compared with an average 6 degrees varus preoperative angle. Ninety-five percent of the patients were satisfied and reported less pain and improved knee function. Bone union occurred in 54% of the knees and fibrous union occurred in 46%. Focal tenderness, restricted motion, or other symptoms were not associated with fibrous union. The results show that epicondylar osteotomy for varus knee deformity provides excellent patient satisfaction, knee stability, motion, and deformity correction.

Poster #13 The clinical results of medial epicondylar osteotomy to correct severe varus deformity with total knee arthroplasty

Poster #13 The clinical results of medial epicondylar osteotomy to correct severe varus deformity with total knee arthroplasty

Surgical exposures in revision total knee arthroplasty.

A well-planned operative approach to revision total knee arthroplasty is crucial to a successful outcome. Wide exposure must be achieved to allow component removal, soft-tissue balancing, management of bone loss, and reimplantation without damaging important structures. These structures include skin, the extensor mechanism, the collateral ligaments, the remaining bone stock, and neurovascular structures. Skin necrosis can be avoided by selecting the appropriate incision and dissecting deep to the fascia. Extensile exposure by dissection of scar, quadriceps snip or turndown, tibial tubercle osteotomy, or medial epicondylar osteotomy should be performed early to prevent patellar tendon disruption. In certain cases, the distal femur can be exposed circumferentially by using a quadriceps myocutaneous flap or femoral peel. Special care should be taken with the infected or ankylosed knee.

Cubital tunnel syndrome: anterior transposition with epicondylar osteotomy.

In this article we reviewed nine consecutive patients operated on for cubital tunnel syndrome. They underwent a modification of the Learmonth procedure in which a medial epicondyle osteotomy was performed. The dissection was completed within intermuscular tissue planes to allow the ulnar nerve to be transposed submuscularly. The medial epicondyle was then replaced and secured using two 4.0 mm AO cancellous screws. This article describes an operative technique, which has not been definitively described previously. Eight of nine patients demonstrated both subjected and objective improvement postoperatively. Eight patients returned to work following surgery. We fell that medial epicondylar osteotomy and screw fixation has minimized operative bleeding, subsequent inflammation, and fibrosis. Immediate range of motion activities have been encouraged, and earlier complete rehabilitation demonstrated.

Medial Epicondyle Osteotomy as an Approach to Repair of Medial Femoral Condyle Fractures in the Dog

Fracture of the medial femoral condyle in three dogs is described. This injury resulted in lateral (varus) instability, which was difficult to differentiate from a lateral collateral ligament tear. Radiographs and surgical exploration were necessary to differentiate the two conditions. A medial femoral epicondyle osteotomy was used in two cases to expose the fracture. This exposure technique is advantageous because it allows early return to functional use of the injured limb by eliminating postoperative splintage.