Der Einfluss von Ellenbogenpositionierung und Gelenkinsufflation auf die Lage der Nn. medianus und radialis - eine dreidimensionale bildgestützte Analyse

In der vorliegenden Untersuchung wurden die Lageverhältnisse des N. medianus und N. radialis zu den ossären Strukturen des Ellenbogens bestimmt. Außerdem wurde der Einfluss der Ellenbogen- und Unterarmpositionierung sowie der Gelenkinsufflation untersucht. Die Lagekenntnis der beiden Nerven sind insbesondere bei der Durchführung einer anterioren Kapsulektomie von Bedeutung. Der N. medianus wurde vor dem medialen Viertel der Trochlea humeri gesehen, kann jedoch auch in einigen Fällen medial der Trochleagrenze liegen. Bei der Kapsulektomie des medialen Teils der anterioren Gelenkkapsel muss dies beachtet werden. Der N. radialis medialisiert durch 90° Flexion des Ellenbogens von seiner Lage vor der medialen Grenze des Capitulum humeri in Extension zum medialen Rand des Capitulums. Dieses Wissen kann genutzt werden, um durch eine Extension des Ellenbogens bei der Kapsulektomie vor dem lateralen Rand der Trochlea humeri und eine Flexion während der Kapsulektomie des lateralen Teils der Gelenkkapsel das Verletzungsrisiko des N. radialis zu verringern. Zusätzlich wurde eine Verdopplung der Abstände des N. medianus und des N. radialis zur anterioren Begrenzung der knöchernen Strukturen von Extension auf 90° Ellenbogenflexion sowie eine Verdreifachung nach zusätzlicher Gelenkinsufflation mit 20 ml Flüssigkeit beobachtet. Dies lässt auf ein erhöhtes Risiko iatrogener Nervenverletzungen bei der arthroskopischen Ellenbogenarthrolyse von Patienten mit Arthrofibrose schließen, da bei diesen Patienten die Möglichkeit der Gelenkinsufflation des Ellenbogens reduziert sein kann

All-suture anchors for distal biceps tendon repair: a preliminary outcome study

Introduction: The aim of this study was to retrospectively evaluate the clinical outcome of double intramedullary all-suture anchors’ fixation for distal biceps tendon ruptures. Materials and methods: A retrospective case series of patients who underwent primary distal biceps tendon repair with all-suture anchors was conducted. Functional outcome was assessed at a minimum follow-up of at 12 months based on the assessments of the Mayo Elbow Performance Score (MEPS), Andrews–Carson Score (ACS), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the Visual Analog Scale (VAS) for pain. Maximum isometric strength test for flexion and supination as well as postoperative range of motion (ROM) were determined for both arms. Results: 23 patients treated with all-suture anchors were assessed at follow-up survey (mean age 56.5 ± 11.4 years, 96% male). The follow-up time was 20 months (range Q$_{0.25}$–Q$_{0.75}$, 15–23 months). The following outcome results were obtained: MEPS 100 (range Q$_{0.25}$–Q$_{0.75}$, 100–100); ACS 200 (range Q$_{0.25}$–Q$_{0.75}$, 195–200); QuickDASH 31 (range Q$_{0.25}$–Q$_{0.75}$, 30–31); VAS 0 (range Q$_{0.25}$–Q$_{0.75}$, 0–0). The mean strength compared to the uninjured side was 95.6% (range Q$_{0.25}$–Q$_{0.75}$, 80.9–104%) for flexion and 91.8 ± 11.6% for supination. There was no significant difference in ROM or strength compared to the uninjured side and no complications were observed in any patient. Conclusion: Distal biceps tendon refixation using all-suture anchors provides good-to-excellent results in terms of patient-reported and functional outcome. This repair technique appears to be a viable surgical option, although further long-term results are needed

„Patient-reported outcome measures“ (PROMs) in der Schulter- und Ellenbogenchirurgie

<jats:title>Zusammenfassung</jats:title><jats:p>„Patient-reported outcome measures“ (PROMs) sind Instrumente, mit denen der subjektive Gesundheitszustand eines Patienten gemessen werden kann. Sie gewinnen zunehmend an wissenschaftlicher, klinischer und gesundheitsökonomischer Bedeutung. Man unterscheidet zwischen generischen, gelenkspezifischen und krankheitsspezifischen PROMs. Um das Risiko von Verzerrungen oder erhöhter Variabilität zu vermeiden, müssen geeignete Übersetzungen mit transkulturellen Anpassungen und anschließender Validierung gemäß definierten Richtlinien durchgeführt werden. Für viele gängige Schulter- und Ellenbogenwerte existiert bis dato noch keine validierte Übersetzung. Die weltweit am häufigsten verwendeten Schulter-PROMs sind der Constant-Murley Score, der American Shoulder and Elbow Surgeons Shoulder Form und der Simple Shoulder Test. Studien zu Ellenbogenpathologien verwenden am häufigsten den Mayo Elbow Performance Score und den Disabilities of the Arm, Shoulder and Hand Score. Derzeit besteht jedoch kein wissenschaftlicher Konsens über die Verwendung von Schulter- und Ellenbogen-PROMs.</jats:p&gt

Treatment strategies for simple elbow dislocation - a systematic review

Abstract Background Current treatment concepts for simple elbow dislocation involve conservative and surgical approaches. The aim of this systematic review was to identify the superiority of one treatment strategy over the other by a qualitative analysis in adult patients who suffered simple elbow luxation. Study design A systematic review in accordance with the PRISMA guidelines and following the suggestions for reporting on qualitative summaries was performed. A literature search was conducted using PubMed and Scopus, including variations and combinations of the following keywords: elbow, radiohumeral, ulnohumeral, radioulnar, luxation, and therapy. Seventeen studies that performed a randomized controlled trial to compare treatment strategies as conservative or surgical procedures were included. Reviews are not selected for further qualitative analysis. The following outcome parameters were compared: range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand outcome measure (Quick-DASH), recurrent instability, pain measured by visual analog scale (VAS) and time to return to work (RW). Results Early mobilization after conservative treatment strategies showed improved ROM compared to immobilization for up to 3 weeks after surgery with less extension deficit in the early mobilization group (16° ± 13°. vs. 19.5° ± 3°, p < 0.05), as well as excellent clinical outcome scores. Surgical approaches showed similar results compared to conservative treatment, leading to improved ROM (115 vs. 118 ± 2.8) and MEPS: 95 ± 7 vs. 92 ± 4. Conclusion Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. The surgical procedure provides similar outcomes compared to conservative treatment regarding MEPS and ROM for patients with slight initial instability in physical examination and radiographs. People with red flags for persistent instability, such as severe bilateral ligament injuries and moderate to severe instability during initial physical examination, should be considered for a primary surgical approach to prevent recurrent posterolateral and valgus instability. Postoperative early mobilization and early mobilization for conservatively treated patients is beneficial to improve patient outcome and ROM

Partial ruptures of the distal triceps tendons show only slightly lower ultimate load to failure: a biomechanical study

Abstract Objective Partial ruptures of the distal triceps tendon are usually treated surgically from a size of > 50% tendon involvement. The aim of this study was to compare the ultimate load to failure of intact triceps tendons with partially ruptured tendons and describe the rupture mechanism. Methods Eighteen human fresh-frozen cadaveric elbow specimens were randomly assigned to two groups with either an intact distal triceps tendon or with a simulated partial rupture of 50% of the tendon. A continuous traction on the distal triceps tendon was applied to provoke a complete tendon rupture. The maximum required ultimate load to failure of the tendon in N was measured. In addition, video recordings of the ruptures of the intact tendons were performed and analysed by two independent investigators. Results A median ultimate load to failure of 1,390 N (range Q0.25—Q0.75, 954 – 2,360) was measured in intact distal triceps tendons. The median ultimate load to failure of the partially ruptured tendons was 1,330 N (range Q0.25—Q0.75, 1,130 – 1.470 N). The differences were not significant. All recorded ruptures began in the superficial tendon portion, and seven out of nine tendons in the lateral tendon portion. Discussion Partial ruptures of the distal triceps tendon demonstrate a not statistically significant lower ultimate load to failure than intact tendons and typically occur in the superficial, lateral portion of the tendon. This finding can be helpful when deciding between surgical and conservative therapy for partial ruptures of the distal triceps tendon

The risk of suprascapular and axillary nerve injury in reverse total shoulder arthroplasty: An anatomic study

Purpose: Implantation of a reverse total shoulder arthroplasty (rTSA) places the axillary and suprascapular nerves at risk. The aim of this anatomic study was to digitally analyse the location of these nerves in relation to bony landmarks in order to predict their path and thereby help to reduce the risk of neurological complications during the procedure. Methods: A total of 22 human cadaveric shoulder specimens were used in this study. The axillary and suprascapular nerves were dissected, and radiopaque threads were sutured onto the nerves without mobilizing the nerves from their native paths. Then, 3D X-ray scans of the specimens were performed, and the distance of the nerves to bony landmarks at the humerus and the glenoid were measured. Results: The distance of the inferior glenoid rim to the axillary nerve averaged 13.6 mm (5.8-27.0 mm, +/- 5.1 mm). In the anteroposterior direction, the distance between the axillary nerve and the humeral metaphysis averaged 8.1 mm (0.6-21.3 mm, +/- 6.5mm). The distance of the glenoid centre to the suprascapular nerve passing point under the transverse scapular ligament measured 28.4 mm (18.9-35.1 mm, +/- 3.8 mm) in the mediolateral direction and 10.8 mm (+/- 4.8 to 25.3 mm, +/- 6.1 mm) in the anteroposterior direction. The distance to the spinoglenoid notch was 16.6 mm (11.1-24.9 mm, +/- 3.4 mm) in the mediolateral direction and +/- 11.8 mm posterior (+/- 19.3 to +/- 4.7 mm, +/- 4.7 mm) in the anteroposterior direction. Conclusions: Implantation of rTSA components endangers the axillary nerve because of its proximity to the humeral metaphysis and the inferior glenoid rim. Posterior and superior drilling and extraosseous screw placement during glenoid baseplate implantation in rTSA place the suprascapular nerve at risk, with safe zones to the nerve passing the spinoglenoid notch of 11 mm and to the suprascapular notch of 19 mm. (C) 2017 Elsevier Ltd. All rights reserved

Annular ligament reconstruction with the superficial head of the brachialis: surgical technique and biomechanical evaluation

The purpose of this study was to perform biomechanical testing of annular ligament (AL) reconstruction using the superficial head of the brachialis tendon (SHBT) as a distally based tendon graft. We hypothesized that posterior translation of the radial head following AL reconstruction with an SHBT graft does not significantly differ from intact specimens. Six fresh-frozen elbow specimens were used. The stability of the radial head against posterior translation forces (30 N) was evaluated in 0A degrees, 45A degrees, 90A degrees and 120A degrees of elbow flexion. Posterior translation was obtained for the intact AL, the sectioned AL and the reconstructed AL. Cyclic loading (100 cycles) in 90A degrees of elbow flexion was performed for the intact and the reconstructed AL. Posterior translation of the radial head decreased during elbow flexion in native specimens. Sectioning of the AL significantly increased instability over the full range of motion. AL reconstruction with the SHBT restored the stability of the proximal radius but-other than the native AL-was not influenced by elbow flexion. In 120A degrees of flexion the native AL provided significantly more stability when compared to the reconstructed AL. Cyclic loading did not provide significant differences between native and reconstructed specimens. We provide a feasible technique for AL reconstruction using the SHBT. The biomechanical results obtained in this study confirm the efficacy of the procedure. AL reconstruction restores the stability of the proximal radius, yet it cannot fully mimic the complex features of the intact AL

The course of the median and radial nerve across the elbow: an anatomic study

Nerve transection has been described as complication of arthroscopic elbow arthrolysis. Therefore, the goal of this study was to define bony landmarks for intraoperative orientation regarding the location of the median and radial nerve. In 22 formalin-fixated upper extremities, the radial and median nerves were dissected and marked with respect to their native course. A 3D X-ray scan was performed. The distances of the radial nerve to the radial head (R1), the capitulum (R2), and its lateral border (RC) were measured. The location of the radial nerve in relation to the transversal diameter of the humeral condyle (HC) was calculated. Similarly, the distances of the median nerve to the trochlea (M1), the medial border of the trochlea (M2), and its relation to HC were calculated. The mean value for R1 was 8 mm (+/- 2.9 mm), for R2 was 11.3 mm (+/- 3.8 mm), and for RC was 10.6 mm (+/- 5.1 mm). RC/HC averaged 24 % (+/- 11 %). M1 averaged 11.7 mm (+/- 5.2 mm), and M2 was 2.4 mm (+/- 4.1 mm). M2/HC averaged 6 % (+/- 9 %). The radial nerve is located ventral to the central third of the capitulum. The median nerve lies ventral to the medial quarter of the humeral condyle. When performing arthroscopic arthrolysis, this information should be kept in mind during anterior capsulectomy

Elbow Positioning and Joint Insufflation Substantially Influence Median and Radial Nerve Locations

The median and radial nerves are at risk of iatrogenic injury when performing arthroscopic arthrolysis with anterior capsulectomy. Although prior anatomic studies have identified the position of these nerves, little is known about how elbow positioning and joint insufflation might influence nerve locations. In a cadaver model, we sought to determine whether (1) the locations of the median and radial nerves change with variation of elbow positioning; and whether (2) flexion and joint insufflation increase the distance of the median and radial nerves to osseous landmarks after correcting for differences in size of the cadaveric specimens. The median and radial nerves were marked with a radiopaque thread in 11 fresh-frozen elbow specimens. Three-dimensional radiographic scans were performed in extension, in 90A degrees flexion, and after joint insufflations in neutral rotation, pronation, and supination. Trochlear and capitellar widths were analyzed. The distances of the median nerve to the medial and anterior edge of the trochlea and to the coronoid were measured. The distances of the radial nerve to the lateral and anterior edge of the capitulum and to the anterior edge of the radial head were measured. We analyzed the mediolateral nerve locations as a percentage function of the trochlear and capitellar widths to control for differences regarding the size of the specimens. The mean distance of the radial nerve to the lateral edge of the capitulum as a percentage function of the capitellar width increased from 68% +/- 17% in extension to 91% +/- 23% in flexion (mean difference = 23%; 95% confidence interval [CI], 5%-41%; p = 0.01). With the numbers available, no such difference was observed regarding the location of the median nerve in relation to the medial border of the trochlea (mean difference = 5%; 95% CI, -13% to 22%; p = 0.309). Flexion and joint insufflation increased the distance of the nerves to osseous landmarks. The mean distance of the median nerve to the coronoid tip was 5.4 +/- 1.3 mm in extension, 9.1 +/- 2.3 mm in flexion (mean difference = 3.7 mm; 95% CI, 2.04-5.36 mm; p < 0.001), and 12.6 +/- 3.6 mm in flexion and insufflation (mean difference = 3.5 mm; 95% CI, 0.81-6.19 mm; p = 0.008). The mean distance of the radial nerve to the anterior edge of the radial head increased from 4.7 +/- 1.8 mm in extension to 7.7 +/- 2.7 mm in flexion (mean difference = 3.0 mm; 95% CI, 0.96-5.04 mm; p = 0.005) and to 11.9 +/- 3.0 mm in flexion with additional joint insufflation (mean difference = 4.2 mm; 95% CI, 1.66-6.74 mm; p = 0.002). The radial nerve shifts medially during flexion from the lateral to the medial border of the inner third of the capitulum. The median nerve is located at the medial quarter of the joint. The distance of the median and radial nerves to osseous landmarks doubles from extension to 90A degrees flexion and triples after joint insufflation. Elbow arthroscopy with anterior capsulectomy should be performed cautiously at the medial aspect of the joint to avoid median nerve lesions. Performing arthroscopic anterior capsulectomy in flexion at the lateral aspect of the joint and in slight extension at the medial edge of the capitulum could enhance safety of this procedure

Course of the Radial Nerve in Relation to the Center of Rotation of the Elbow-The Need for a Rational Safe Zone for Lateral Pin Placement

Purpose To investigate the course and variability of the radial nerve along the lateral humerus in relation to the center of rotation of the elbow joint in the context of lateral pin placement for hinged external fixation. Methods A total of 95 formalin-fixed upper extremities were dissected. The course of the radial nerve along the lateral aspect of the humerus was measured at 3 landmarks with respect to the center of rotation of the elbow. We analyzed the data and the landmark positions correlated with the length of the humerus. Results The measured positions of 3 landmarks of the radial nerve in the lateral aspect of the humerus ranged from 19% to 43% of the length of the humerus and were located, on average, 6.0, 9.7, and 13.5 cm from the lateral center of rotation. Conclusions These data help predict the humeral course of the radial nerve and define a safe zone for pin implantation. However, because of variability in the course of the radial nerve, a safe zone cannot fully ensure prevention of iatrogenic injury to the nerve. The safest method of pin application remains mini-open dissection and visual implantation. Clinical relevance Based on this cadaveric study, it is not possible to define a rational safe zone. The safest method of pin application for dynamic external fixation of the elbow is to perform a mini-open dissection with direct visualization. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved