News Category: Elbow

Injury to the ulnar collateral ligament (UCL) can result in a painful, unstable elbow. This injury occurs in response to chronic overloads along the inside of the elbow. It is on the rise in athletes.

Young players who train and play at a level beyond their anatomic maturity are especially at risk. As a result, the ulnar collateral ligament can become stretched, frayed or torn. The stress of repetitive throwing motions for throwing athletes or weight-bearing for cheerleaders and gymnasts can cause this problem.

Efforts are being made to prevent UCL injuries. Research is focused on finding ways to improve biomechanics and core strengthening. The goal is to decrease stress on joints at risk (especially immature joints in the young athlete). But if the ligament tears (partially) or ruptures (completely), then surgery may be needed.

Reconstruction of the ligament with a tendon graft along the inside of the elbow is one treatment option. But ways to repair the ligament are being investigated. According to this study, ligaments with a single area of injury can be repaired rather than reconstructed. In other words the ligament is only torn at one end or the other. Repairing the damaged ligament may mean a quicker recovery and faster return to the playing field for the athlete.

All patients in this study were younger than 22 years of age. All had sustained a medial (inside the elbow) UCL injury. Baseball players, basketball players, gymnasts, cheerleaders, and other overhead throwing sports athletes were included.

Surgery was done to repair the damaged ligament. Arthroscopy was used to examine the area. At the same time, the surgeon was able to remove any frayed tissue or soft tissue fragments that didn’t belong. The tear was located and repaired. Holes were drilled in the bone. The torn end of the ligament was pulled through the holes and secured with absorbable suture anchors.

Patients were followed for up to five years. Results were measured by function, patient satisfaction, and return to sport. Complications and problems after surgery were noted. Most of the athletes (93 per cent) were back in action within six months.

The authors conclude that repairing a medial UCL tear is possible with young athletes. There is less damage to the joint since they have not been participating in sports very long. Results of the repair are improved because of this.

This study showed that it is not always necessary to reconstruct an unstable elbow with a tendon graft. For patients with this specific kind of ligament injury, repair is quite successful. An agressive rehab program that’s sports-specific is recommended. As long as the elbow remains in a brace during sports-prep, the authors say the recovery process can be speeded up for these injuries.

Although triceps tendon ruptures are not common (less than 1 percent of all tendon ruptures), they must be managed through repair and reconstruction. This article reviews the historical perspective of repair and current repair techniques.

Surgical repair of triceps tendon ruptures were reported as early as 1957. In the first of two reports, the authors reviewed the procedures, the first which involved drilling holes in the olecranon (the bony tip of the elbow) and threading braided stainless steel wire. The second involved creating a periosteal (membrane) flap over the olecranon area and stitching the remaining part of the triceps with a stainless steel suture material.

Later on, in the 60s, surgeons repaired the rupture but didn’t recommend using sutures through the olecranon. They did recommend using an absorbable material to do the repair and then to immobilize the arm for several weeks after. Other surgeons wanted shorter immobilization periods, so they experimented with stronger materials and techniques.

Whether surgery was indicated depends on how the injury occurred and the damage sustained. Indications for surgery include significant muscle weakness and the patients’ dependence on the triceps strength, for work or use of a wheelchair, for example. Contraindications include infection and significant comorbidities that would make surgery too risky.

Where surgery is not indicated, non-operative treatments are available, but can have a failure rate of up to 40 percent if patients use their upper arms for strenuous activities.

Preoperative planning involves determining the extent of the injury and if patients have any tendon-debilitating comorbidities, such as steroid use, rheumatoid arthritis, renal failure, or diabetes.

The surgical repair used now involves advancement of triceps with placement of a locking nonabsorbable suture through the tendon and passing these through drill holes in the olecranon. If necessary, the tendon may be reconstructed using a hamstring tendon autograft (tissue from the patient) or Achilles tendon allograft (donated tissue).

Following surgery, the patient’s arm is immobilized in a 90 degree angle for 24 hours. After the 24 hours, the dressing is removed and the patient’s arm is placed in a sling. Full active elbow range of motion will be permitted at four to six weeks if the repair seems secure, although lifting weight is limited to five pounds during that period. No forced lifting or lifting weights over 10 pounds is permitted before the eighth or tenth week after surgery. At three months follow-up, if all seems fine, the patient is allowed to resume normal daily activities, with heavy lifting and full extension strength allowed at six months after surgery.

If there is a question as to how secure the repair is, more care is given up to the sixth week as to the amount of flexion allowed.

If a ruptured tendon results in very little tendon tissue to work with, there are two techniques of reconstruction that can be used, the choice depending on the site of the rupture, the remaining tissue and its quality. The choice is between the autogenous hamstring tendon (used if some triceps tendon is present but of poor quality) or Achilles tendon allograft if the defect in the muscle or tendon is massive and/or the there is a problem with the olecranon.

Management after these repairs include the splinting of the arm at 30 degrees for 24 hours and only gentle, passive assisted range of motion is allowed during the first four to six weeks after surgery. At six weeks, active flexion and extension can begin but not forced extension until after 12 weeks. At this point, no weight higher than 10 pounds is permitted although gradual use of the arm for daily living activities is allowed. At six months, the patients can begin gradually increasing the extension strength. It can take up to 12 months for full recovery.

Complications to the surgeries include infection, rerupture, ulnar neuropathy, extensor lag or weakness, or continued pain.

Damage to the ulnar collateral ligament (UCL) in overhead (throwing) athletes was once a career-ending injury. But surgery to reconstruct the soft tissue was discovered in the 1980s. And the technique has improved over the years. Today, many of the affected athletes return to their sport. And they do so at a previous or higher level of participation.

In this article, surgeons from Columbia University in New York conduct a systematic review of surgical treatment for acute (recent) UCL injuries. They reviewed all published reports of UCL reconstruction in overhead athletes. The goal was to find out which surgical methods worked best.

Overhead athletes included baseball pitchers, javelin throwers, and tennis players at all levels of competition. Some were high school, others were recreational athletes. Some were at the college or professional level. Most were males between the ages of 17 and 24 years.

Various surgical approaches were described and compared. In the standard procedure, a tendon is harvested from some other part of the body. The donor tissue is used to replace the ruptured ligament. Tunnels are drilled through the humerus (upper arm bone). The graft is placed through the tunnels and attached to the bone. The graft may be attached using a figure-of-eight or a docking technique.

Success of the procedure was measured by the ability of the athlete to return to a preinjury level of play. Results are graded into categories of excellent, good, fair, or poor. A specific rating system called the Conway-Jobe rating was used to decide which category each athlete was in.

The overall results showed 83 per cent of the athletes had an excellent result. Excellent was defined as competition at the same (or higher) level than before the injury for more than one year. About 10 per cent of the players had complications after surgery. The most common problem was ulnar neuropathy. Damage to the ulnar nerve left some patients with persistent numbness, tingling, and other sensory changes.

The authors report that some surgical techniques seem to produce better results than others. The method of graft fixation, placement of tunnels through the bone, and approach to the soft tissues around the elbow made a difference. Surgical methods designed to decrease handling of the ulnar nerve also had lower rates of neuropathy.

This systematic review has shown us how much improvement in results has occurred with new graft fixation techniques. Surgeons will continue to modify methods used to repair a UCL injury. The ability of overhead athletes to return to competitive play will likely continue to improve as well.

Painful and arthritic elbows have been treated with a wide range of measures, ranging from medications to joint replacement. Currently, although primary degenerative arthritis of the elbow is not common, arthroscopic management of the problem is an interesting option for treatment.

Primary osteoarthritis of the elbow has been historically treated with anti-inflammatory medications or lifestyle modifications, while other treatments involved surgery. Total elbow arthroplasty, or replacement has not been very successful in younger patients because of loosening in the joint. Elbow arthrodesis (fusing) has been fairly successful but not always popular because it can restrict range of motion and affect quality of life. Other doctors have used debridement, removing of dead tissue, with some success as well. Arthroscopic debridement is being done more often, with good success in many patients.

For patients with rheumatoid arthritis in the elbow, treatment may involve open synovectomy, removal of the joint lining, and this can be done with arthroscopy with good results for patients with mild to moderate arthritis, limited motion, and pain.

Arthroscopic debridement is the treatment choice for septic arthritis.

For purposes of this article, the authors describe the procedure involved in arthroscopic debridement and then review the postoperative care, which involves keeping a splint in place to keep the arm in full extension and elevated over night. The next day, the splint is removed and after the patient is assessed, full active range of motion is allowed as tolerated.

In a study of patients with rheumatoid arthritis who underwent arthroscopic synovectomy, all 14 patients improved with pain but improvement in range of motion varied. In another study with the same procedure, 76 percent of the patients reported improvements in pain but fewer reported good range of motion. Finally, in a third study that compared arthroscopic synovectomy with open synovectomy, pain relief was superior (70 percent) in the open group than in the arthroscopic group (48 percent).

There was little information available on treatment of patients with septic arthritis, but one study of patients with posttraumatic arthritis showed a 79 percent improvement in pain among patients who underwent arthroscopic debridement.

The authors conclude that arthroscopic debridement is a useful treatment for arthritis in the elbow.

Pain and impaired function of the medial (inside) elbow are common symptoms in the throwing athlete. A tear or rupture of the medial collateral ligament (MCL) along the inside of the elbow can cause these symptoms. Surgery to repair the ligament often uses the palmaris longus tendon as a donor graft.

In this study, male cadaver elbows were used to compare the results using larger grafts. The theory was that larger tendons would resist larger loads on the elbow compared to the currently used palmaris longus docking procedure.

In the docking technique, the graft is held in place by threading it through a tunnel drilled in the bone. This eliminates the need for screws or suture anchors to hold it in place. Previous studies have shown this method requires smaller drill holes, is much stronger, and has less risk of causing fracture of the bone between the drill holes.

The four tendons used as donor grafts included the palmaris longus, gracilis, semitendinosus, and patellar tendon. Each one was subjected to repeated cycles of load until they failed. Other measures used to compare them were stiffness and ability to stretch.

First, the uninjured elbows were tested to find out how much force and load were needed to cause MCL rupture. A digital camera and computer software program were used to measure the distance between markers along the MCL after each set of 10 load cycles. The force of the load was increased after each set of 10 cycles.

The same elbows were repaired using one of the four tendon graft choices. The exact steps used in the docking reconstructive procedure were described. Type, location, and placement of the stitches used to hold the graft in place with the right amount of tension were also discussed.

Analysis of the data showed no difference between the four different types of tendon grafts. The amount of stiffness provided by each one against increasing loads was the same. The normal, healthy tissue was still much stronger than any of the grafts used. Over time and with enough load, the graft tissue stretched out and failed.

The authors concluded there is no added benefit of using a larger graft for MCL repair than the already commonly used palmaris longus tendon. No matter which tendon was used as a donor for the graft, elasticity was the limiting factor in the results of the reconstruction. Graft tendons are too elastic compared with native MCL tissue.

Further research is needed to find a stiffer, stronger graft. The goal is to develop MCL reconstruction with a biomechanical response equal to the native tissue. This would allow a faster, more aggressive rehab program and get the athlete back to competitive throwing sooner.

Studies show that ultrasound can be used to diagnose lateral epicondylitis (tennis elbow). But what about medial epicondylitis (golfer’s elbow)? Can ultrasound be used as easily with as good of results?

The results of this study say, Yes. Ultrasound is informative and accurate in identifying signs of tendon degeneration along the inside of the elbow. In fact, ultrasound was a sensitive, specific, and accurate test for this condition.

Two groups of adults between the ages of 44 and 63 were tested with ultrasound. The first group had medial epicondylitis. All were diagnosed by a physician based on symptoms and physical exam. Tenderness around the elbow, range of motion, and strength were evaluated. Sensory function of the nerve was assessed based on examination of light touch and pinprick.

The second (control) group of adults did not have any elbow pain. There was no history of any elbow problems. X-rays were taken of everyone’s elbows before the ultrasound exam. The ultrasound exam showed areas of tendon thickening, calcification within the tendons, and areas of increased circulation.

The ultrasound results made it possible to diagnose the problem as a tendinosis (tendon degeneration). Irregular surfaces and poorly defined tendon margins were signs other signs of tendinosis. Partial or full-thickness tears of tendon fibers were also visible.

Direction and speed of blood flow to the area could be seen using a special Doppler technique. The Doppler is a device used to measure the frequency and velocity of a moving substance such as blood.

The authors recommend using real-time (not static) ultrasound to diagnose medial epicondylitis. Ultrasound is very suitable for examining tendons. Information on the severity and stage of tendon degeneration can be determined. This information is useful when planning treatment.

The elbow joint is formed by three bones: the bottom of the humerus (upper arm bone), radius, and ulna. The radius and ulna are two bones in the forearm.

The joint is surrounded by a capsule that integrates with the ligaments. Muscles and tendons attach around the joint as well. Injury or trauma that results in elbow fracture and dislocation affects all of these structures. Loss of stability and function can lead to serious disability.

In this article, common patterns of elbow fracture-dislocation are reviewed. These include anterior (forward) or posterior (backward) dislocation with fracture of any (or all) of the three bones. Detailed description of the anatomy affected is provided.

Simple dislocations can be treated with closed reduction. This means the dislocated elbow is manipulated (moved) back into place. But the more complex fracture-dislocations require surgical reduction. Once the elbow is reduced, then the fracture is repaired. Any other soft tissue damage is also repaired.

The surgeon must decide how to repair each individual type of injury. Radial head injuries can be tricky. It may be necessary to use a pin or wires to hold the pieces of bone together until they heal. Normal movement of the radial head is needed for forearm rotation. This is what gives us the ability to turn the palm up and palm down.

If fracture of the radial head is severe with ligament damage, then it may be necessary to replace it. In the past, the radial head was removed. New understanding has led surgeons to fix or replace it instead. The authors describe their surgical approach to each of the complex fracture-dislocations possible. Before and after X-rays are shown.

Rehab is begun as soon as possible. There may be a delay of a week-to-10 days if the repair is unstable. Early motion can be started with a hinged elbow fixator. The surgeon applies this device. A pin is centered in the joint but the rest of the fixator is outside the arm. The main goal is to allow joint motion while protecting the healing ligaments.

Even with good operative procedure, there can be complications with these complex elbow injuries. Instability and stiffness with loss of motion and function can occur. Heterotropic ossification (bone growth in the soft tissues) and arthrosis (joint damage) are other problems that can develop.

Problems that persist over time that can’t be improved with rehab may require an elbow replacement. Older adults who are less active do well with this option. Replacement may not be such a desirable approach in younger patients. Further reconstructive surgery may be tried first instead.

Over the years, scientists have discovered that chronic tennis elbow (known as lateral epicondylitis) isn’t really tendinitis at all. There may have been inflamed tissue in the beginning during the acute phase. But during the chronic phase, analysis of tissue samples shows fibrous scarring called tendinosis.

As a result, orthopedic surgeons are rethinking the treatment approach to this problem. In this study, the authors report the long-term results of arthroscopic surgery for 30 patients with chronic lateral epicondylitis. An earlier report of short-term results for 42 patients (including the original 30) was published by these same authors.

Patients were treated first with nonoperative care. Rest, modifying activities, and anti-inflammatory drugs were used. Bracing, injection, and physical therapy were prescribed as well. But when this did not change their symptoms, then surgery was done to debride (remove) the pathologic tissue. The specific method of debridement was described. Photos taken inside the elbow were included to show partial and complete rupture of the elbow capsule.

Patients were followed up by phone to assess their results up to 14 years later. The rated their elbows as much better, better, same, or worse. More detailed information about pain and function was also gathered and analyzed.

The results showed that patients who were doing well after the first two years were still doing well years later. This is one of the few long-term studies of the results of arthroscopic debridement for chronic tendinitis. Pain was minimal, function was good, and patients were satisfied with the results. No one needed further treatment with injections or surgery. There are other surgical techniques for this condition. Further studies are needed to compare results of all surgical methods to find the best approach.

Lateral epicondylitis or tennis elbow can become a chronic problem with pain and loss of function. For most people, non-operative care prevents the acute problem from becoming chronic. But in a small number of patients, surgery may be needed. There are many operative techniques for the surgical treatment of lateral epicondylitis.

In this study, long-term results of the Nirschl approach are reported. In 1979, Dr. Nirschl and an associate discovered that chronic tennis elbow was not an inflammatory condition. Instead, there are changes at the cellular level that show a degenerative process more accurately called tendinosis.

The Nirschl technique was devised to treat this problem. The tendinosis tissue within the extensor carpi radialis brevis (ECRB) tendon was removed. Any damage to the extensor carpi radialis and extensor digitorum communis (EDC) tendons was repaired. The ECRB was not repaired because that puts the elbow at risk for a flexion contracture. With a flexion contracture, the elbow doesn’t straighten all the way. In other words, there is a loss of elbow extension.

A mini-open approach was used for the Nirschl procedure. This means only a small incision is made. This is a slight modification from how the original Nirschl approach was done in 1979. Short-term results from this surgery were reported as very good to excellent for 85 per cent of the patients. Patients were able to return to full activity. Athletes involved in sports were able to resume an activity level equal to their pre-injury level.

Long-term follow-up was a minimum of 10 years after the operation. Patients were contacted by phone and interviewed about pain, motion, function, and satisfaction. Good to excellent results were reported by 84 per cent of the patients. Good was defined as slight or occasional elbow pain with strenuous activities. Some patients had a sight loss of grip strength. An excellent result meant there was complete pain relief and full grip strength.

The majority of patients (92 per cent) contacted were able to return to full participation in their previous sport. Most were involved in tennis, but others were golfers, weight lifters, racquetball players and martial arts athletes. The authors reported there were some problems collecting follow-up data on many of the patients. But their limited results confirm that removing tendinosis tissue and sparing normal tissue in the lateral elbow (the Nirschl procedure) for epicondylitis gives durable long-term results.

Osteoarthritis (OA) can affect the major joints of the body, including the elbow. Elbow OA is fairly rare but can be disabling. In this article, the authors review tests used to diagnose elbow OA and current treatment options.

Treatment is divided into two basic types: nonsurgical and surgical. The decision about which way to go with treatment depends on what stage of disease is present. There are three stages: early, intermediate, and late.

Each stage is defined by symptoms and changes in the joint seen on X-rays or CT scans. For early elbow OA, there is mild pain with a small loss of motion. Treatment is nonoperative and consists of change in activity, antiinflammatory drugs, and physical therapy. If symptoms persist, then steroid injections may be the next step.

For patients in the intermediate stage of elbow OA, there is moderate pain with a greater loss of motion. There may be nerve symptoms when the patient can no longer extend the elbow fully. The nerve gets pinched by bone spurs or overgrown cartilage.

In both mild and intermediate stages, the patient is taught to avoid activities and positions that put a high amount of stress, force, or load on the elbow. Surgery may be needed when there’s been no improvement or very little change over a six month period of time.

There are several surgical options to choose from. The surgeon may débride the joint. This means any bone spurs, frayed soft tissues, or loose bodies are removed from in or around the joint. Another name for this procedure is ulnohumeral arthroplasty.

The joint capsule may be released or partially removed. This operation is called a capsular arthroplasty. If the nerve is entrapped by scar tissue, the surgeon may gently release the constrictive tissue from around the scar. This is a risky operation as nerve damage occurs easily.

The authors describe four surgical procedures and their clinical outcomes in detail. These include: arthroscopic débridement, open ulnohumeral arthroplasty, distraction interposition arthroplasty, and total elbow arthroplasty (TEA). TEA is an elbow joint replacement.

Over the years, it has been observed that the long-term success of TEA is limited. Problems with instability and loosening have been reported. Fracture of the implant and dislocation of the elbow are common. Younger patients who have higher functional demands on the elbow are especially at risk for these complications.

Older adults who have not been helped by conservative care may be the best candidates for TEA. They must be willing to accept a lower activity level. There are several types of TEA available. Common implant designs are presented with a discussion of the surgical technique for each implant system. Diagrams and photos are provided.

A review of the literature shows that improvements in the débridement techniques have made this a better treatment choice over TEA. Arthroscopic surgery has reduced the rate of nerve injuries. Future studies of elbow OA may include ways to improve surgical techniques and implant design.

Tennis elbow, also known as lateral epicondylitis has been around for hundreds of years. It was first linked with lawn tennis back in the 1800s. Since that time, our knowledge and understanding of the condition has slowly developed. This article presents a summary of the latest information on lateral epicondylitis.

Overexertion, repetitive motion and the use of heavy tools are the most common risk factors. The condition can develop without any of these risk factors.

Local microtrauma of the extensor carpi radialis brevis (ECRB) tendon can cause acute inflammation in the early stages of tennis elbow. If the area doesn’t heal, the condition can become chronic.

Recently, it was discovered that chronic epicondylitis is not an inflammatory condition at all. Degeneration and scarring called fibrosis occur. These changes are observed at the site of the ECRB insertion. This is along the outside of the elbow. The fibrosis and disordered collagen fibers are the result of repeated attempts to heal microinjury from overuse.

Painful symptoms persist because there are nerve endings in the connective tissue around the ECRB. Pain is generated by excitatory chemicals in the tissue around the ECRB. Scientists think this finding explains why steroid injections help even when there is no sign of acute inflammation.

Efforts to diagnose the problem can be very difficult. The physician relies on the patient’s history, a physical exam, and imaging studies. It is important to rule out other conditions such as bone fractures, shoulder problems, or true elbow joint lesions.

Treatment begins with a nonoperative approach. Fostering healing in the acute phase is important. Inflammation is controlled with medication, rest, and ice or other cold compresses. Rest or at least a reduced force or load on the tendon is essential during the acute phase.

Forearm bands and wrist splints may be recommended. Physical therapy may include stretching, strengthening, and eccentric muscle training (EMT). Eccentric muscle contractions occur when the ECRB is in its shortest, fully contracted position and slowly lengthens. This occurs as the wrist moves from an extended position toward neutral and then into a flexed position.

If conservative care is not successful, there is an intermediate step before surgery is considered. Injections, shock wave therapy, and laser light therapy may be helpful. Injections include steroids or botulinum toxin (BOTOX). Botox is a nerve blocker that partially paralyzes the ECRB. Without constant tension on the tendon, healing can take place.

And finally, if all else fails, surgery is a possibility. Surgical options include open or arthroscopic débridement, release or repair of the ECRB, and nerve decompression. Débridement is the term used to describe removing extra tissue and cleansing the area.

The authors describe each surgical technique and the expected postop care. Potential complications are also included for each operation. The results of surgical treatment for lateral epicondylitis reported by numerous studies are good to excellent. Arthroscopic and open approaches yield similar results. When the ECRB is released, recovery is faster if it’s done arthroscopically.

Not everyone is helped by conservative or operative care. In up to 20 per cent of patients, symptoms persist despite all efforts to cure the problem. More studies are needed to focus on finding effective ways to treat patients with lateral epicondylitis.

Tennis elbow, also known as tendinitis, has been renamed tendinosis. Studies show there may have been an inflammatory response at one time, but it was disrupted. Instead, an overgrowth of immature blood cells and fibrous cells developed at the elbow.

Either side of the elbow can be affected. The outside or lateral elbow is involved most often. Tendinosis can occur any time the elbow is exposed to stress and overuse.

There are a wide variety of treatments used for tendinosis. Many patients get better with conservative care. This may include rest, antiinflammatories, cold, and splinting. A physical or occupational therapist may use ultrasound, friction massage, and stretching exercises.

Many times the symptoms come back as soon as the patient uses the elbow again. A new treatment may be on the horizon to help. Surgeons from the Cedars-Sinai Medical Center in California tested a new elbow brace for this condition. The ForeArmed Active implant is an energy dampening active implant elbow brace.

The brace puts pressure on two of the tendons involved (extensor carpi radialis brevis and extensor digitorum communis). The brace also provides shock absorption on both sides of the elbow.

Two groups of patients were compared. Group A wore the implant brace anytime they were physically active for more than one hour. They were allowed to use cold compresses and antiinflammatories as needed. Group B was treated with the standard nonoperative care. This included rest, antiinflammatories, cold compresses, and advice.

Results were measured by pain levels and grip strength. Frequency and severity of pain was recorded while at rest, with resisted wrist extension, and when the wrist and elbow were passively moved into an extended position.

Group A had much better results than group B. Grip strength increased 40.6 per cent in group A compared with 28.4 per cent in group B. A few patients in group A required additional treatment besides just the brace. Combining the brace with a cortisone injection or hand therapy gave good results for those individuals. Three patients in Group A ended up having surgery.

Only seven patients in group B had improved symptoms. Half of this group required additional treatment such as cortisone injections, hand therapy, or surgery.

The authors conclude that the implant brace dampens energy forces coming into the elbow. By reducing the energy wave to the tendon insertion site, the impact of the vibrating energy is less. The brace can be worn to prevent or treat lateral tendinosis. It is easy to use and low cost.

Ulnar collateral ligament (UCL) injuries can end the career of a throwing athlete. Many surgical approaches have been studied to reconstruct this ligament. The results of most methods are unable to give the patient the strength of the normal, uninjured ligament.

In this study, two orthopedic surgeons modified two of the methods in common use. One method was the docking technique. The two ends of the tissue graft used to replace the torn UCL are pushed or docked into one tunnel made through the bone.

The second technique used was the interference screw fixation method. Once the graft was threaded through the tunnel, a special screw was used to hold the graft in place. Combining these two methods, they developed a hybrid approach called the DANE TJ technique.

DA are the initials of the surgeon who developed the docking method. The second two initials (NE) stand for the surgeon who used the interference screw fixation method in UCL reconstruction. TJ stands for the first baseball player who had the first UCL reconstruction ever done in 1986.

There are several possible advantages of the DANE TJ technique. Using a single tunnel (instead of two tunnels often used in other methods) helps restore the anatomy more like the original design. With only one drill hole, there is less risk of bone fracture and nerve injury. A single tunnel is helpful when there isn’t enough bone to form a bone bridge between two tunnels.

Results of the DANE TJ method were excellent for 19 out of 22 patients in this study. Two patients needed a second (revision) operation but had excellent outcomes in the end. Results were equal to (if not better) than those reported in studies using other methods of UCL repair.

The authors conclude the DANE TJ method is a good choice when there is poor bone stock to work with. It is also useful when the patient needs revision surgery to a previous injury that failed.

When a biceps tendon, the tissue that attaches the biceps muscle to the bone, becomes separated or torn away near the elbow, called a distal avulsion, this affects a person’s ability to flex the elbow and to use the arm in ways such as twisting the forearm to use a screwdriver. Given the location of the tendon in relation to the bones, there have been two standard approaches to repairing the avulsion; some surgeons approach the surgery from the back (posterior), while others approach it from the front Ianterior).

The authors of this study investigated the effectiveness of both approaches, comparing them to evaluate if one approach was superior in the avusion repair. In order to do the study, the researchers obtained 11 matched pairs of cadaver arms that had intact biceps tendon, muscles and joints. Each specimen, tested in pairs, was examined with the tendon intact and then re-examined after the tendon had been avulsed and then repaired, one with the anterior approach, the other with the posterior approach.

The elbows were placed at a 90 degree angle and loads were applied and the effectiveness of the forearm was recorded, before and after repairs.

When analyzing the results, the researchers found that there were no statistical significant differences between either approach in terms of flexion or force, although the arms that had the anterior repair, did show a slightly lower force than did those with the posterior repair.

Historically, such surgical repair often included dissection of the soft tissue in the inside part of the elbow, or the cubital fossa. This, however, resulted in many complications. A two-incision approach was introduced in the early 1960s that reduced the need to dissect the soft tissue, and with modifications over the years, the surgery has proven to be quite successful. There is debate as to whether one incision or two is best, but this is the only study that investigated the results of posterior versus anterior approach and the effect on the elbow flexion and force.

The authors conclude that although the data are limited and more study is necessary, these findings indicate no functional differences between either approach.

When a patient experiences a biceps tendon avulsion, or a tearing away of the biceps tendon, it can be hard for a doctor to diagnose, causing a delay in treatment. The senior author of this study has been diagnosing such avulsions with a test that involves hooking a finger underneath the tendon; the researchers sought to identify if such a hook test was reliable in diagnosing the problem.

Forty-four males and one female, average age 49 years, ranging in age from 25 to 72 years, were studied. Among the patients, 14 patients had been injured with 10 days, five patients between 11 and 21 days, and 26 patients were considered to have chronic injury of over 21 days. Thirty-three patients had complete avulsions, while 12 had a partial avulsion. When the researchers tested the arms of the patients using the hook test, they found a 100 percent rate of abnormality among both groups, those with complete and partial tears. This was compared with the test on the opposite, uninjured arm, which was normal in 100 percent of the cases.

The hook test is done on an arm that is flexed to 90 degrees, with the patient either sitting or standing. The doctor places an index finger on the outside part of the antecubital fossa, or the inside of the elbow, and tries to hook the tendon when bending the finger. If the finger can go hook under the bicep and pull it forward, this is a positive result.

The researchers said, prompt diagnosis of such an injury is important to increase the chances for successful surgical repair. They said that treatment delays of more than two to four months may make such a repair impossible. In this case, a tendon graft may be required, however, the success of tendon grafts is questionable.

Three major nerves supply the arm, wrist, and hand: the radial, median, and ulnar nerves. Pressure on the median nerve causes carpal tunnel syndrome. This is the most common type of compression neuropathy affected the upper extremity.

Nerve compression from entrapment of the ulnar nerve is the second most common cause of numbness, tingling, and weakness in the arm. In this article, hand surgeons from the Mayo Clinic provide an in-depth review of this condition.

Anatomy, type of compression syndromes, and long-term effects are discussed. History, exam, and diagnostic tests provide direction for treatment. X-rays of the neck and arm should be taken to look for any bone deformity or anatomical cause of the nerve entrapment. In some cases, an X-ray of the lung may be needed to rule out tumors.

Electromyography (EMG) studies help diagnose the severity of the compression. Nerve signals and electrical impulses from muscle contraction are recorded. The results can also help pinpoint the location of the problem.

Treatment is divided into nonsurgical and surgical approaches. Mild to moderate nerve entrapment may be helped by night splinting of the elbow, padding along the nerve, and anti-inflammatory medications. Many patients respond well to hand therapy. When these methods fail, steroid injections may be tried.

If conservative care doesn’t change the picture, then surgery may be the next step. The surgeon can choose from a wide range of options. The goal is to take pressure off the nerve. This is called decompression. It is accomplished by cutting any bands of connective or fibrous tissue over and around the nerve.

It may be necessary to perform a decompression and medial epicondylectomy. Medial refers to the inside of the elbow closest to the body. With an epicondylectomy, the surgeon removes the bony bump we often refer to as the funny bone. The area is smoothed over and the muscles are reattached.

Transposition (moving) of the nerve may be required to relieve the traction or biomechanical pull exerted on the nerve. Moving the nerve changes the pressure on the nerve from muscle contraction and joint motion.

Surgery provides good to excellent results for many patients with ulnar nerve compression. But there can be problems post-operatively. Symptoms may persist if the nerve wasn’t released fully or from scarring that develops around the nerve. Surgery can injure other nerves causing numbness and/or a painful surgical scar.

Ligaments can be damaged during the transposition process. And adhesions may occur after the nerve transfer when the elbow is immobilized to allow healing of the muscles.

Patients with persistent symptoms or symptoms that come back may need further (revision) surgery. Loss of motor function can result in limitations and disability.

For the most part, treatment for ulnar nerve compression is successful. Symptoms are relieved and motion and function are restored in all age groups. Throwing athletes are able to return to full play.

Lateral epicondylitis also known as tennis elbow is usually treated conservatively. But surgery may be needed for those patients who do not get better with nonoperative care.

Surgery can be open, percutaneous, or arthroscopic. Open refers to an incision that gives the surgeon access to the area. Percutaneous is the release of soft tissue structures by inserting the surgical tools just under the skin. And arthroscopy is the insertion of a special device that allows the surgeon to see the area being operated on.

Which type of surgery works best? Is one of these three choices able to relieve pain, restore strength, and return the patient to work sooner than the others? Those are the questions surgeons from the Division of Sports Medicine at the University of California (San Francisco) try to answer in this study.

There aren’t enough large, single studies to answer these questions directly. Instead, the authors conducted a systematic review of the literature. This means they found and reviewed 33 papers on the subject of surgery for tennis elbow.

Only three of those studies compared surgical methods and reported results. Most of the studies described the outcomes after one of the individual procedures. Good results are reported with surgery. No one technique was better than the others.

The authors suggest that there is a trend to return to work faster with the less invasive operations. This includes percutaneous and arthroscopic surgery. Success of all three methods is about 80 per cent.

Each type of surgery has its own advantages and disadvantages. Until more evidence points to one approach as being superior, surgeons must choose what they think is best for each patient. Further study in this area is needed. Studies of postoperative care should also be done as rehab programs vary and may make a difference in outcomes.

Patients who have osteonecrosis (death of bone tissue) or osteochondral lesions (loose growths) in the elbow present a challenge to doctors. Treatments that have been used include debriding, or clearing the area of dead tissue, or microfracture, which involves drilling small holes in the bone next to the lesions so bone marrow can seep out and seal the area. However, these treatments do not appear to be long-term solutions.

The authors of this study reviewed the best methods to treat this problem. Patients who present with osteochondral lesions are usually children between 6 and 10, who have Panner disease, or adolescents and young athletes who use their arm in repetitive and strong, forceful motions. The patients complain of pain with use, stiffness, pain at night, inability to move the elbow freely, and sometimes a clicking sound from the elbow.

After diagnosing the problem through x-ray, the doctors must stage the damage. Earlier discovery and staging can be done through magnetic resonance imaging (MRI). If the doctors determine the staging to be stage I or II, surgery is usually not performed. Nor is surgery performed on patients with Stage III or IV if the symptoms have only been present for 6 months or less. The patients who do undergo surgery often do not have long-term relief and may be at higher risk of developing arthritis in the elbow later on in life.

The researchers looked at 7 patients who were treated with a transplantation of tissue from the patient’s knee and implanted into the affected elbow. The 3 females and 4 males ranged in age from 15 to 21 years. Five patients were active in competitive sports and the other two in recreational sports. All had stage III or IV level lesions and had tried previous treatment. Pain was assessed through the American Shoulder and Elbow Surgeons (ASES) form; elbow functioned was assessed by the Broberg and Morrey Score. The patients were followed for between 42 and 83 months.

The results showed the patients experienced a significant decrease in pain following the surgery as was their ability to extend their elbow fully. MRIs performed at follow up showed that the grafts healed well.

The authors conclude that the mid-term findings at 2 years are promising with “overall good to excellent results.”

Contracture of the elbow can be described as a stiff elbow joint. It won’t move all the way into flexion, extension, or both. Sometimes the person has trouble turning the hand palm up or palm down. The cause can be from something intra-articular (inside the joint) or extra-articular (outside the joint).

In this article, surgeons from the NYU Hospital for Joint Diseases review the two most common causes of a stiff elbow. They present a brief overview of elbow anatomy. Treatment of elbow contractures is also described.

Trauma and heterotopic ossification (HO) are the most likely causes of elbow contractures. Elbow dislocations and damage to the nerves are the most common results of elbow trauma.

HO is the formation of calcified bone in the soft tissue. It is another potential consequence of elbow injury. But HO can also occur as a result of head injury, burns, and Paget’s disease. Genetics may also play a role in HO. These are extra-articular conditions that do not occur directly in the elbow but affect the elbow.

Nonsurgical and surgical treatment are the main focus of the second half of this review. Nonoperative care is most successful when used within six months of an injury. Reducing inflammation and improving range of motion are very important.

Whenever possible, prevention is the main focus of management for elbow contracture. Exercise and splinting can help prevent loss of motion after trauma. Patients with known risk factors for HO should be treated prophylactically. This means treatment is given ahead of time to prevent the problem from ever occurring. Non-steroidal anti-inflammatory drugs (NSAIDS) and low-dose radiation are used as preventive agents most often.

Some patients may need surgery to restore elbow motion. Surgery can be done arthroscopically or with open release. Care must be taken to preserve and protect the ulnar nerve as it passes alongside the elbow.

In the case of HO, surgery can be done early and safely to remove the bone growth. With any elbow contracture, it may be necessary to cut the tendons or joint capsule in order to regain joint motion and function.

The surgeon takes a detailed history and performs a careful exam before deciding on the best plan of care. Lab values aren’t helpful but X-rays and CT scans may be ordered. Satisfactory results of prevention and management of elbow contractures have been reported.

Tennis elbow, or lateral epicondylitis, is a common injury among people who use their arms in a repetitive motion, particularly their wrists. Researchers have long thought that the cause of tennis elbow is microscopic tears in the tendons, the tissues that connect the muscles to the bones. The tears would then progress and cause tennis elbow.

The authors of this article studied the anatomy of the elbow to see if they could identify contact between bone and tendon or tendon and tendon together, which may cause some abrasion of the tissues.

The researchers gained access to 85 cadaveric elbows from 60 donors for this study. The donors were equally split between male and female; the average age of the donors at death was 73.6 years, but the range was from 53 to 83 years. None of the elbows showed any signs of old injuries or surgeries.

The elbows were dissected so the researchers could identify and measure the location of the tendons and bones. They measured elbow motion checking for tendon movement. The researchers also used dye to mark positioning of the tendons through motion.

After reviewing all the photos and data, the researchers determined that there could be considerable contact between soft tissue of the elbow and the bone that would cause irritation and abrasion to the tissues. They state in the article that they believe this might be a factor that leads to the development of tennis elbow.

The authors point out that such findings can help develop a surgical technique that could treat tennis elbow by cutting or removing the soft tissues that are rubbing on the bone.