VI. RESPUESTAS A LOS CRITERIOS Y SUBCRITERIOS
4. Gestión del Proyecto y Trabajo en Equipo
Jennifer C. Laine, MD C. Benjamin Ma, MD
Introduction
The lateral side of the elbow is a complex anatomic re- gion that primarily involves the radiocapitellar joint, the lateral ligamentous complex, and the origin of the wrist extensors. Many patients repeatedly load or stress the lateral elbow during sports participation, recreation, or while at work. The three nonacute injuries to the lateral side of the elbow—osteochondritis dissecans (OCD) of the capitellum, posterolateral rotatory instability (PLRI), and lateral epicondylitis—have distinct pathophysiology; appropriate clinical evaluation, treatment options, and recent outcomes are discussed in the literature.
Osteochondritis Dissecans of the Capitellum
OCD is a symptomatic, localized lesion of the capitel- lum that affects the adolescent, most commonly throw- ing athletes and gymnasts. The late cocking and early acceleration phases of throwing create a valgus stress across the elbow, causing substantial shear and com- pressive forces to the capitellum. The compressive force in the lateral compartment is estimated at up to 500 N during throwing. In gymnasts, axial loading of the el- bow contributes to injury. Many authors suggest that repetitive force is the key etiologic factor in OCD. It has been theorized that this repeated abnormal valgus stress on the elbow causes a change in the subchondral blood supply to the capitellum, which is primarily caused by posterior perforating vessels.
Patients typically present with an insidious onset of elbow pain and stiffness, with a history of minor trauma or overuse. They will often describe mechanical symptoms, such as locking and catching. Symptoms are usually aggravated by activity and relieved with rest. The patient history should include not only document- ing the patient’s age and symptoms but also the posi- tion played, the mechanism of injury, any exacerbating factors, and any family history of osteochondroses. The preadolescent with Panner disease, believed by some to be an early stage of OCD, will present with similar symptoms, with the exception of locking and catching. In contrast with OCD, Panner disease is usually a self-
limiting disorder that tends to appear in children ages 5 to 12 years. The physical examination should include careful assessment of the cervical spine, shoulders, el- bows, and wrists. Both elbows should be evaluated for tenderness to palpation, ligamentous stability, range of motion, and carrying angle.
Radiologic assessment should begin with AP, lateral, and oblique radiographs, as well as an AP view of the elbow in 45° of flexion. The earliest radiographic fea- ture is subchondral bone flattening. The radiographic appearance typically involves a focal lucency in the subchondral bone of the anterior capitellum. The lesion is often surrounded by subchondral sclerosis and a characteristic crescent sign. CT, MRI, and ultrasound have been used to further characterize the lesion. Un- stable lesions on T2-weighted MRI are surrounded by a rim of high signal intensity and occasionally a fluid- filled cyst, whereas stable lesions have no surrounding signal abnormality. Studies have shown good correla- tion between MRI and surgical findings.1CT and MRI
can also be used to identify intra-articular loose bodies that could be missed on arthroscopic evaluation alone
(Figure 1).
There are two classification systems for OCD of the elbow: (1) The International Cartilage Repair Society (ICRS) classification system uses radiographic assess- ment of the cartilage covering the bone. An ICRS OCD-I lesion is continuous and intact, OCD-II is in partial discontinuity, OCD-III is in complete disconti- nuity but not significantly displaced, and OCD-IV is dislocated or loose. OCD-I lesions, especially in the pa- tient with an open physis, are considered stable. (2) An arthroscopic classification system was developed for OCD, based on the classification system for lesions of the talus.2Grade I lesions have smooth but soft, ballot-
table articular cartilage. Grade II lesions have fibrillations/fissuring, whereas grade III lesions have ex- posed bone with a fixed osteochondral fragment. Grade IV lesions have a loose but nondisplaced osteo- chondral fragment,and grade V lesions have a displaced fragment with a loose body (Figure 2). For both sys- tems, the grade of the lesion corresponds to the recom- mended treatment.
Long-term sequelae of untreated OCD include pro- gressive articular damage secondary to third body wear,
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decreased range of motion, pain, and degenerative changes with osteophyte formation. Studies have shown that there are very limited indications for non- surgical management of OCD. OCD-I or -II lesions in patients with open physes may heal spontaneously, but it has been shown that most lesions in elbows with closed physes fail to heal with nonsurgical treatment. Conservative management consists mainly of rest. Ac- tivity modification to reduce the repetitive loading of the elbow is crucial. Some authors also recommend a hinged elbow brace. In a 2008 retrospective review of 176 patients with osteochondrosis of the humeral head, a 90.5% healing rate for stage I lesions and a 52% healing rate for stage II lesions treated nonsurgically was reported. Treatment consisted of discontinuation
of heavy use of the elbow for at least 6 months. The mean period of healing was 14.9 months for stage I le- sions and 12.3 months for stage II lesions.3 Patients
with open physes treated with rest showed significantly better healing, greater relief of pain, faster return to sports activity, and favorable radiographic findings than did those patients with closed physes. Also, pa- tients with open physes treated with rest fared signifi- cantly better with respect to pain relief, radiographic findings, and healing in comparison with patients with open physes who continued their activities. Nonsurgi- cal management has typically been described for intact, stable (grade I) lesions. Proposed indications for surgi- cal intervention include persistent symptoms despite rest and activity modification, articular cartilage frac- ture (grade II or greater), symptomatic loose bodies, re- stricted elbow range of motion (greater than 20°), and a closed capitellar physis. A variety of surgical proce- dures have been described, but the choice of surgical procedure remains controversial.
In a retrospective review of 16 patients treated with arthroscopic chondroplasty and removal of loose bod- ies, 13 of 16 returned to their preoperative levels of ac- tivity. Half of the patients showed slight residual flat- tening on radiographs at an average 4 years of follow- up.2 Another retrospective review of 10 baseball
players at average 3.9-year follow-up after arthroscopic treatment reported excellent results on a standard rat- ing scale, but only 4 of 10 returned to play and pro- gressed with their peers.4Studies with longer follow-up
(12 years, 23 years) reported that approximately 50% of the patients with OCD, whether treated with non- surgical or arthroscopic treatment, have residual symp- toms with activities of daily living, most commonly im- paired motion or pain with effort.5,6More than 50% of
Figure 1 A and B, Magnetic resonance arthrograms of the elbow showing OCD of the capitellum. (Courtesy of C. Benjamin
Ma, MD, San Francisco, CA.)
Figure 2 Arthroscopic view of the grade III OCD lesion in the same patient as in Figure 1. (Courtesy of
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patients had evidence of degenerative disease on radio- graphs. Approximately two thirds of patients had en- largement of the radial head diameter.6
Fragment fixation with bone graft has had satisfac- tory outcomes in the literature, although the case series have been small. In one study of four patients who un- derwent fragment fixation with bone graft and dy- namic stapling, all patients achieved bony union, and three of the four returned to competitive baseball. At a mean 7.5-year follow-up, three of the four could throw a ball without pain.7Another study of 11 patients who
underwent fragment fixation with pull-out wiring and bone grafting showed pain relief in all patients at an av- erage 57-month follow-up; 10 of 11 returned to previ- ous throwing levels.8A study of seven patients at 7- to
12-year follow-up after closing wedge osteotomy noted minimal degenerative changes on radiographs, and six of seven patients had returned to play.9
Reconstruction of the articular surface with osteo- chondral autograft pegs has been gaining popularity. The bone pegs are typically taken from the lateral fem- oral condyle or the proximal ulna. It is recommended that from one to three plugs be used, depending on the size of the individual defect. Reconstruction of 50% to 70% of the defect is considered sufficient. A case series of eight patients reported that all but one were pain free at a mean follow-up of 2 years; all but one had ex- cellent or good clinical results. Radiographically, there was a normal contour of the subchondral cortex in all patients on plain radiographs, and the signal intensity had returned to normal on MRI.10A series of 18 base-
ball players at average 3.5-year follow-up showed that 6 of 9 patients with grade III lesions and 8 of 9 patients with grade IV lesions returned to playing baseball at the same level.11 A recent study on the treatment and
outcome of OCD lesions compared patients treated with fragment fixation (12 patients) and osteochondral autografts (33 patients) with those treated with frag- ment excision alone (55 patients). The results of frag- ment fixation or reconstruction were significantly bet- ter than those of fragment excision alone with respect to pain at an average of 8.2 years postoperatively.3,12
There remains a need for randomization in the treat- ment of OCD lesions, as well as long-term follow-up for fragment fixation and osteochondral autograft pro- cedures.
Posterolateral Rotatory Instability
PLRI was first described in 1991 as a distinct clinical entity, with an associated physical examination maneu- ver and surgical treatment.13The instability is often re-
lated to an injury, usually an elbow dislocation. Laxity of the lateral ulnar collateral ligament (LUCL), second- ary to inadequate healing after injury, was traditionally described as the anatomic etiology for this instability. The ligamentous laxity allows a transient external rota- tory subluxation of the ulna on the humerus, with a
valgus displacement. There is also a subluxation or dis- location of the radiocapitellar joint, but the proximal radioulnar joint remains intact with the proximal ulna and radius moving as a unit.
The lateral collateral ligament complex, consisting of the lateral collateral ligament, the LUCL, the annu- lar ligament, and the accessory ligament, originates from the lateral epicondyle(Figure 3). The humeral or- igin of the complex is the isometric point of the lateral elbow. The lateral ligaments insert onto the annular lig- ament and the ulna. The LUCL, often appearing as a thickening of the capsule, extends from the lateral epi- condyle to the supinator crest, serving as a lateral sta- bilizer of the elbow and a posterior restraint to the ra- dial head. PLRI was initially described as being caused by insufficiency of the LUCL, but more recent cadaver studies have challenged this belief, arguing that the en- tire lateral ligament complex shares the responsibility of providing posterolateral constraint. Studies have also shown that the radial head and the coronoid process are major static constraints to posterolateral laxity, and the common extensor origin contributes to stability.
PLRI is a clinical condition that is difficult to diag- nose. Patients with PLRI typically have a history of el- bow dislocation, recurrent sprains, or fracture of the coronoid or radial head. The injury typically occurs during a fall on an outstretched hand, causing axial compression, valgus force, and supination. Although less common, instability can occur from chronic atten- uation of the lateral ligament complex secondary to chronic cubitus varus. PLRI also can be caused by iat- rogenic injury following open or arthroscopic proce- dures on the lateral side of the elbow, such as for radial head fractures or lateral epicondylitis. Patients often re- port pain and discomfort in the elbow, with sensations of catching, clicking, or slipping with flexion and ex- tension. The elbow is often most symptomatic in ap-
Figure 3 The lateral ligamentous complex of the el- bow. (Adapted with permission from Bain GI,
Mehta JA: Anatomy of the elbow joint and surgical approaches, in Baker CL Jr, Plancher KD (eds): Operative Treatment of Elbow Injuries. New York, NY, Springer-Verlag, 2001, pp 1-27.)
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proximately 40° of flexion with forearm supination, such as when pushing on armrests when rising out of a chair. Patients may be asymptomatic during the activity while having frank instability.
The clinical examination is usually unremarkable unless posterolateral instability is specifically tested
(Figure 4). Most patients have a normal-appearing, nontender elbow. The PLRI test is easiest to perform when the patient is under general anesthesia, but it can be performed on an awake patient, with apprehension signifying a positive result. The test is best performed with the patient supine, with the extremity over the pa- tient’s head and the shoulder in full external rotation. The patient’s forearm is then fully supinated, and the examiner slowly flexes the elbow while applying val-
gus, supination, and axial compression. At approxi- mately 40° of flexion, the rotatory displacement is maximized, and a dimple in the skin proximal to the radial head can be seen. As the elbow is placed into fur- ther flexion, a clunk can be felt during sudden reduc- tion of the ulnohumeral and radiohumeral joints. This test is considered analogous to the pivot-shift test in the knee.
Another physical examination maneuver is the pos- terolateral rotatory drawer test, similar to the Lachman test for the knee, in which the extremity is again posi- tioned overhead in the supine patient. The lateral side of the proximal forearm is pulled posteriorly in an at- tempt to subluxate the radial head. The test is consid- ered positive if the patient becomes apprehensive dur-
Figure 4 A, Lateral pivot shift test. The examiner is applying an axial load, external rotation, and valgus. B and C, The table-
top relocation test. The examiner’s thumb prevents displacement of the radial head and apprehension. D, The floor push-up test. E, The chair test. In the presence of instability, the patient will exhibit apprehension when pushing up from the floor or from a chair with the forearms supinated. (Reproduced with permission from
Charalambous CP, Stanley JK: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2008;90:272-279.)
Sample
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ing the test or if a dimple is seen in the skin proximal to the radial head. The prone push-up test, the chair push-up test, and the tabletop relocation test also have been described in the clinical evaluation for PLRI. In both the prone and chair push-up tests, the patient at- tempts to arise from the floor (lying prone) or from a chair with armrests by pushing up on his or her hands, first with the forearms in pronation, followed by supi- nation. The tests are considered positive if the patient is symptomatic with the forearms in supination but not in pronation. In the tabletop relocation test, the patient performs a press-up on a table using one arm with the forearm in supination. The patient then repeats the ma- neuver with the examiner’s thumb pressing on the ra- dial head to prevent subluxation. If the patient is ap- prehensive with the first maneuver only, the test is considered positive.14
The elbow typically appears normal on AP radio- graphs, but slight widening of the ulnohumeral joint may be seen (the drop sign), which is indicative of in- stability. On the lateral radiograph, posterior displace- ment of the radial head relative to the capitellum may be identified. Performing the provocation tests under fluoroscopy or with stress radiographs can be useful in assessing the joint for PLRI, especially after an intra- articular anesthetic has been given. The radiographs should also be assessed for fractures, degenerative changes, and possible impaction defects of the capitel- lar articular surface. The appropriate use of MRI is controversial. There is conflicting data in the literature regarding the correlation between MRI findings and clinical instability. In some instances, when the presen- tation and imaging are not conclusive, the joint can be examined arthroscopically while performing the provo- cation tests to confirm laxity.
By definition, PLRI is a recurrent condition, and rarely does the instability resolve with time. Patients may attempt to prevent episodes of instability by avoid- ing the provocative maneuvers and guarding the elbow, or they may try wearing a brace, but in general, surgery is indicated in patients with symptomatic instability. The goal of surgery is to restore the integrity of the LUCL, whether through repair or reconstruction.
A Kocher approach is typically used, with a lateral Z-arthrotomy performed anteriorly to the LUCL. If ad- equate tissue is present, the lateral ligament complex can be reattached or advanced to the isometric point on the distal humerus, using a Bunnell transosseous suture. If repair is not possible, reconstruction is recom- mended. The palmaris longus, plantaris, and triceps tendons are most frequently described for LUCL recon- struction. The insertion site for the graft is prepared by creating two extra-articular, extracapsular drill holes in the ulna. The first is placed just posterior to the supina- tor tubercle, and the second is drilled 1.25 cm proximal to the first, at the base of the annular ligament. A su- ture is passed through the two drill holes and pulled to- ward the lateral epicondyle with a hemostat. The elbow is then flexed and extended to determine the isometric
ligament origin on the distal humerus, where the site of graft entry is then drilled. A Y-shaped tunnel is placed in the lateral epicondyle. The tendon graft is drawn through the ulnar and humeral tunnels and tied to itself after it recrosses the joint (Figure 5). The sutures are tied with the elbow flexed 30° and with the forearm in full pronation. It is important that the graft is taut in extension, because instability occurs in extension. The extremity is then placed in a long-arm splint with the elbow in 90° of flexion and the forearm in pronation.
Some authors recommend the use of arthroscopy, in addition to open reconstruction, to evaluate the degree of laxity, assess the articular surface, and débride the joint. Arthroscopic treatment of PLRI also has been re- ported for the use of electrothermal shrinkage of the lateral collateral ligament complex15and for tightening
the posterolateral capsule with arthroscopic suturing.16
If the instability is caused by fracture of the radial head, coronoid fracture or long-standing cubitus varus, then the radial head should be replaced or repaired, the coronoid process should be reconstructed, or a humeral osteotomy should be performed, respectively.
The literature reports a good outcome for most pa- tients treated surgically with respect to pain relief, range of motion, and stability. Recent reports have shown that patients undergoing reconstruction tend to have slightly better outcomes than those undergoing re- pair alone. Also, outcomes are not as good in patients with generalized ligamentous laxity or degenerative changes within the joint.
An early series from the Mayo Clinic reported the outcomes of 11 patients treated surgically for PLRI at an average of 42 months. They reported excellent re-