My task is to show some video. I got some disclosures. My additional disclosure is most of what I've learned from the people in this room, especially at this table right here. Valgus extension overload. This is a situation where the olecranon is seeing tremendous force in the back of the elbow. It's severe, and it's compression, and it's repetitive, and it causes problems, and it was recognized as early as the 1950s. It shares some of the burden of valgus load, and there's an interplay between the ligament and this posterior medial aspect of the olecranon. The stadium more explicitly, and this was a hypothesis of Dr. Elitraj, if you got a loose ligament, you're going to have problems with more load on the olecranon, and the olecranon is going to see more problems. The history is that these throwers have posterior and posterior medial elbow pain. It occurs after they let go of the baseball, so it's follow-through. There may be some fragmentation of cartilage or osteophytes, so there's this catching sensation, and it's not the only problem. It could be with other things, such as a UCL injury or ulnar neuritis. I have triceps tendonitis down here because I can do this. I can cross it out. I can't tell you how many trainers say, I got a kid. He's got triceps tendonitis. No kid throwing a baseball gets triceps tendonitis. When it hurts back here, and if they activate their triceps, hunt the spur. The spur is back there or some component of cartilage problem. Here's the exam. This kid actually doesn't have a spur. I can tell you, I know that. Everybody knows that because if he's got a spur like that cracked, he'll let you do it once. You never do it again. It hurts that much. But this is a good exam. I have him lying down. He's very comfortable. Mom and dad, not in the view. They are right behind me. Arm bar test. You can force elbow extension and sustain it, and they may have pain with that too. And it may be an olecranon stress injury, like an olecranon stress fracture. We got him lying down here again, and now we're going to do what's called a chondral shear test. It looks exactly like the moving valgus stress test because it is, except you do it further towards extension. And if they have a cartilage problem in the posterior medial compartment, they will have symptoms as you move the elbow with valgus towards full extension. This is what it looks like on x-ray. You can see there's a osteophyte that looks like it's cracked. You can see it on CT very well. CT is a great study for this. You can see something on MRI scan maybe, but CT is great for this. But MRI is useful because these patients also have other problems. They got UCL tears, they got stress injuries in the olecranon, like stress reactions, and they may have some cartilage damage. And the cartilage sometimes is hard to see in the posterior compartment of the elbow. But if they have some cysts in the bone back there, that's a big clue that they got a cartilage problem. Here's something interesting about this problem, out of all the elbow problems we have. You got a ligament tear, it's a big, big deal. If they got a bone spur in the back of the elbow and it's hurting, you have a chance to get them through the season and maybe even get them better. Rest, ice, medication, it's one of the few times that I inject the elbow, cortisone right in the area. It's not unusual to get somebody through the season and then maybe take care of it at the end of the season. All right, I'm going to show some video. This is a surgical technique, arthroscopy. This kid's got a good UCL. Today, he's got a good UCL, the day of the surgery. It may not be the case going forward. You can see some x-rays here. He's got a big bone spur that's really like an exostosis. It's a growth in the back. You see it on CT scan. Check out this exam. His flexion is magnificent. His extension is limited. He's got tenderness over the posterior medial olecranon, right behind the ulnar nerve, maybe. He doesn't like extension. He doesn't like when you bang him into extension, either straight up or with valgus. I pause here. I want to stop this video for a second because this makes my stomach turn. He has no incision, but his nerve is anterior to the epicondyle. It's not snapping. It just lives there. He's not getting a UCL reconstruction, but if he had an incision for a UCL reconstruction and that wasn't appreciated, he's going to have an injured nerve. Okay, I do these cases without a ligament reconstruction, lateral position. He is lateral. I like it. His arm is hanging. You can see the anatomy. We don't need, you know, with some other cases where you need lots of flexion extension control, such as a stiff elbow. It's very facile. We outline all the bony landmarks. You can see laterally. That's the radial head. And now we got some portals. We got a soft soft portal. We got a direct posterior portal about two centimeters above the olecranon tip. We got two portals lateral to the triceps, one in case we want to put in a retractor. I can't stop feeling that nerve. I mean, it's crazy where it is. And then we do some injection. I'm going to tell you it helps to inject the back part of the elbow. The capsule is so patchless that getting a scope in there if there's no hole in the capsule is a little tricky. It just wants to slide around. If you distend it and then cut it, you just slide your scope right in. Okay, and then we can localize with a spinal needle a direct posterior portal. It's good to localize because you don't want to be too high, can't get an angle on where you want to work. You don't want to be too low because you can't get an angle on where you want to work. It's got to be just right. You're cutting the triceps here. A little bit of cutting. We're splitting the triceps. Not really morbid because it's in line with the fibers. And then we're going to get rid of some synovium, the olecranon fossa, and we're going to set up some visualization. Just trying to get rid of stuff. And we're not shaving medially yet because there's nerve back there. Ablation's great for this. This is the olecranon. We're ablating soft tissue off the olecranon. It's touch ablation. We're not cooking the olecranon because the olecranon is intimate with the nerve. If you sit on the olecranon long enough with that heat, you'll see the nerve get active. Okay. We've got a freer elevator in there. Same one that we're going to use to put underneath the tape when we do our repair on some patient. And we can find that plane of the fragmentation and we can loosen it up. I'm getting bored. Can't get it loose. Go back to some coterie. We're being a little gentle in this area because just on the other side is the ulnar nerve. If I have a resident or fellow with me, I have a fellow who's here, it's guaranteed I'm asking the resident or the fellow where the nerve is there in this case. Okay. So we're dissecting. We're getting it loose enough to get it out. I think it's ready. It's ready. You know what I'm going to do now? I'm going to change the scope from the lateral portal to the direct posterior portal. I'll tell you why. One time I tried to pull out a big piece like that and it got stuck in the triceps tendon. You don't see it in the joint and you don't see it outside the skin and you're like making a big incision. Anyway, when you go lateral, it's easy to get these big pieces out. I do this in arthritis cases too. You're getting big pieces out. Change it to the lateral portal and I'm ready to grab it with something if it doesn't want to come out. I expanded the incision and this one was friendly for the camera. Came right out. Okay. Looks just like the CT scan. I'm going to talk to you about cartilage now. This is that lesion on MRI scan where you see some edema in the bone. There can be flaps of cartilage. You got to clean this up and you got to flex the elbow in order to see it. And sometimes these things are not well appreciated, at least by me on imaging studies. So I always check for back there and every now and then you see one and it haunts you because this is not a good lesion to have. Cartilage restoration, it's the same as in other areas of the body. We're going to clean up the loose cartilage and then we're going to do some marrow stimulation. You could probably get away with abrasion chondroplasty. Some patients, if they're very mature in their career, you know, late 30s, you may not even want to do anything. It has fibrous fill and things like that. You just observe it. It's pretty common to see these things already with fibrous fill. Here's what's a little sobering. I think these patients have a tough time sometimes afterwards, just like all our cartilage problems. Not all of them. A lot of them are just impervious to that process. They get mature. Okay. Another video. Surgical technique. This time a UCL is coming. This kid needs both. The elbow's not upside down. We just changed his position. He is supine now because we're going to do a reconstruction afterwards. Just easier to convert if the patient's supine. So it's suspended in an arm holder. It's the same arm holder I use if I'm doing lateral shoulder arthroscopy. This nerve happens to be in the anatomical location in the cubital tunnel. You can see the portal placement. We're going to inject again. We're going to distend the capsule. And then we're going to cut skin and capsule. We're on the lateral side. And that's where we're going to put the camera in. Okay. Camera slips right in. We get our posterior portal. We do some cleanup. And you've seen this before. It just happens to be the elbow is upside down. And I do cases in two rooms. I'm moving back and forth. And one's down. One's up. I am hypervigilant of the nerve. Okay. We're going to get this piece out. Piece comes out. Here's what it looks like when we free it up just like before. Then we grab it. I pulled that one through the triceps. It was small. And then we do a little cleaning just to make sure nothing else is going to get fragmented. And I want to show you this. Get ready for this. I can tell you, I tried to valgus elbows forever, like valgus and elbow during an arthroscopy to see if it's opening up. All that happens is the humerus rotates. I couldn't get it. You know what you do? You have the scope sheath lever the humerus into valgus because trying to valgus yourself doesn't work. And then you get this pretty cool view of the stress. Okay. The race is on. I'm on the co-band. The fellow is on the portals. This is the beauty of doing it in the supine position because once we're done taking the co-band off, we just lie the elbow down, didn't use the tourniquet before, exsanguinate, put the tourniquet up, and then we go after it. That patient actually got an internal brace. The literature on this is pretty sparse. Brandon to get Erickson to get on this. The literature is not so strong here. But there is a relative release in the study, but look how small the numbers are. I mean, we're publishing on 15 patients, but in general, one of the most satisfying operations you can do is taking out a bone spur. It's like taking out a thorn. They have very quick recovery times with that. Just have to be careful of counseling a patient that their future risk of a UCL injury is actually higher than the normal population. Need to have that conversation ahead of time. Thank you so much.

valgus extension overload

posterior medial elbow pain

diagnostic tests

arthroscopy

bone spur removal