Good morning, sorry I can't be with you live but I'm thrilled to talk about some concomitant procedures that are related to UCL reconstruction. So let's get right into it. First here are my disclosures. The first thing I want to talk about is arthroscopy versus no arthroscopy as a combined or concomitant procedure. Let's talk about valgus extension overload. This is what happens. It's been identified as early as the 1950s. You wedge the olecranon into the olecranon fossa. What's interesting about this situation is that there is an interaction between the UCL and the olecranon and they both share load with valgus stress. This issue and what's the pathology? You get exostosis, bone fragments, and you get stress fractures of the olecranon all from the stress in the back part of the elbow. Loose bodies we already mentioned, extremely common. You can get cartilage fragmentation that results in the loose bodies and the loose bodies can easily be removed. It's one of the best indications for elbow arthroscopy and of course this study has always stayed with me, Dr. Andrews, a bunch of professional baseball players, they undergo elbow arthroscopy for post-medial osteophytes, but 25% of them who had the debridement ended up getting valgus instability and required a UCL reconstruction and that's a big deal. A lot of patients who get elbow scopes wind up getting UCL reconstructions down the line. UCL injuries are often underestimated in patients who are presenting with posterior elbow osteophytes. I was interested in this way back when and so we took it to the lab and we put Fuji pressure sensitive film inside the only humeral articulation and when you put it inside and you test an intact, a partial and a full tear of the ligament, you get concentrations of stress, more force over a smaller area and that likely is what's leading to these issues of osteophytes and the posterior medial impingement acting symptomatic. So, all patients with posterior elbow symptoms should have a thorough evaluation of their UCL. The patients must be appropriately counseled if they're undergoing arthroscopy without a UCL reconstruction, for example. Okay, let's put this into real life scenarios now. We got through the biomechanics and the pathology and the etiology. Patients complain of this. They may have some history of UCL problems, a sprain in the past, but when they present to you, they say, my elbow is getting stiff, I can't warm up, it's hurting, it's popping, it's catching, I feel it in the back, I can't extend my elbow, it hurts right here after I release the ball. And they may have mixed pathology, as you said, they may have a little bit of elbow pain, they may have more pain tingling in the fourth and fifth digits, but here's something I pause. Trainers, other people will say, hey, I got a guy with triceps tendonitis, he's pitching, but he's got triceps tendonitis. The thing about triceps tendonitis, it's not that common, usually pain over here that's acting like triceps tendonitis, it's an osteophyte on the olecranon tip, it's not really triceps tendonitis, keep that in mind. Here's an ounce test, we're forcing the elbow into extension, if you've got an osteophyte on the olecranon, they're not going to let you do that more than once. And then you can do an on-bar test here, I like the supine position where you can really get them to relax. This is a modification of the valgus extension overload test. This is to determine if a patient has posterior medial impingement, and this test, instead of pain occurring from 70 to 100 degrees, the pain occurs when you valgus stress them more like 30 degrees to full extension, and it's not over the UCL, it's over the posterior medial olecranon. I just recently had a patient with good imaging, but he kept on having pain with valgus extension towards full extension, we put the camera in, he had a lesion like this and cartilage loss on the cartilage flap right there. So physical exam is important to determine if they have a cartilage lesion on the posterior medial trochlea. You get x-rays, you see things like this, fractured osteophyte, if it's fractured it hurts, that's the thing that Sean O'Driscoll taught us, beware of the one that has a fractured osteophyte, that's the one that hurts. And again, MRI scan, you can see this, but really we get MRI scans to check this, because as we said, there's an association between the impingement and the UCL. Let's talk about surgical technique now. This is how we do a combined arthroscopy for posterior medial impingement and a UCL procedure, the reconstruction repair. This is how we set up, this is the supine position, we have an arm holder holding the arm up, so the patient's head is over here, his body is over here, and this is medial. The first thing we do is outline medial, outline the ulnar nerve, and then we're going to essentially work in the back part of the elbow, so we have a posterior lateral portal and a direct posterior portal. And we inject, we inject with some lidocaine, with epinephrine or saline, and the reason why we're injecting, not like working the anterior compartment to get nerves away from the articulation, we want to fill the capsule up, so when we incise it, we can get the capsule incised, because it's so redundant, it's actually hard to get a camera in, because it's so loose. You fill it up with fluid, you incise it, boom, the camera goes. Okay, so we injected it, now we're making an incision, you can appreciate again the patient's head's here, we're in a suspension device, we've got the arthroscopy equipment here, we incise, and then we can throw the camera in, and we start arthroscopy. You can see we're about 45 degrees of flexion, that gives you enough space to work in the back without flexing too much where the tissues get tight. Okay, we throw the camera inside, and now we use a spinal needle for the direct posterior portal, it's in the central aspect of the triceps tendon. I like using the spinal needle, because we're going to work on the olecranon tip, and it's good to have a good angle on it, so you localise your angle when you're happy, you make your incision. Then we clean up using cautery, the soft tissue off of the olecranon tip, and now you're seeing here the olecranon tip, and we're really pulsing the cautery, why? We don't want to overheat the area, because the ulnar nerve is in proximity, right in this area, so we don't want to heat the nerve, and now we can shave and get soft tissue attachments off the osteophyte, so it's really free to be removed. This is just the arthroscopy visualisation, here we are grasping it, and we can pull it out, if it's really big, don't pull it out through the triceps, you may lose it, sometimes changing the camera, so you can pull out the posterior lateral portal, and view from the central direct posterior portal, is actually better. Get the piece out, and then we might contour the olecranon minimally, so we don't remove normal olecranon, and then here's a valgus stress test, and we said we don't use it that often, but look, this patient needs a reconstruction, we're putting some stress on the ulna and the humerus, and look how much that opens. We sew the portals, I'm asking my resident to sew as fast as we can, and then we take the suspension device off, and then we just simply put them on a hand table, which was already set up, the outline, we exsanguinate, and then we start our UCL isolated arthroscopy. What about scope, and UCL reconstruction, versus just UCL reconstruction, I had this question of my own patients, what if we do a combined scope, is it more of a problem, or a harder recovery, or a change in outcome, so we just looked at it, this is from 2018, all these numbers are tripled, I just don't have them available, but it's the same change, there's really no change in the CAGE op scores, or the outcomes, but the interesting thing is, patients who had arthroscopy, they had a little harder time with recovery, a little bit of stiffness early on, a little bit more pain, a little bit more swelling, and their satisfaction is just not as high as the non-arthroscopy group, interesting. Okay, trochlea chondromalacia, I mentioned it a couple of times, this is what it looks like with the camera inside, you clean it up, it looks like almost an OCD lesion on the capitellum, this is not the capitellum, posterior medial trochlea, but you treat it like a capitellar OCD, you can debride it, and you can even do marrow stimulation, so there's some controversy on whether you should do just abrasion chondroplasty, or marrow stimulation with perforations, we can talk about it in the panel discussion. Okay, here's one report that says if you do manage chondromalacia, your return to play is less compared to others that don't need it with regard to a combined UCL reconstruction, so a small series of patients, but this is worth noting. Okay, I want to illustrate a few cases, and then we'll move on, because the cases are fun and this is how we apply them. Okay, he's 22, he's got posterior elbow pain towards extension, decreased motion, here's this thing, non-tender UCL, negative movement valgus stress test, so his UCL is good on exam, he's got tender posterior medial olecranon, so he's got positive exam, pain forced elbow extension, or posterior medial impingement, he's got an MRI scan that shows this osteo that's here, his UCL looks good, so this is easy, CT scan, you see the fracture, hearing osteophyte, put the camera in, you clean it off, I'm just showing this because you can put an osteotome in easily, and then you can take the osteotome, you find the margin between the osteophyte and the native, we often see that fibrous tissue interface layer there, so you know how much to take without taking normal olecranon, and then you put the elbow on full extension, you see that there's no impingement there, you see where the restriction is, and look, you've got good looking results there, that's what it looks like pre-op, and that's the post-op, and this patient does well. So the summary is, partially fractured osteophyte causes pain, if the UCL is okay, do the scope in isolation, but counsel that they may get a UCL problem in the future, and I, even with this particular patient, down the road, it is not unusual for them to evolve a UCL problem. Okay, here's another case, he's an outfielder, he's a switch hitter, he's got right elbow pain, he throws right, but when he swings left handed, so when he extends his right elbow swing left handed, he gets pain in full extension. UCL is okay, but he's got the tender posterior medial olecranon. What's interesting about this case is, look at this osteophyte, or ossification rather, in his UCL, and he also has productive change on his medial epicondyle. We get a CT scan, that's the UCL, but look, he's got a loose fractured piece, really a loose body in the olecranon. UCL is not showing acute changes, so what do we do with this patient? We do symptomatic treatment, because he's got symptoms, it's mid-season, how do we get him through the symptoms? We give him a cortisone injection. Does cortisone injections work? Well, this guy, and that's my experience, they get symptom relief. He had 12 weeks of symptoms relief, the symptoms came back towards the playoff, we gave him another injection, he did quite well, and then towards the end of the season, the pain was coming back, he had more pain, more tenderness, and so off-season, we took out the loose piece, we did a little contouring to his olecranon. So what's the point of this case? Non-pitchers can get it, you can also have symptoms with hitting, you can play with a loose body, cortisone can be effective, you can get patients through the end of the season, so it's pretty common at the end of the season, you do elbow arthroscopy, and if the UCL is chronic, you don't have to address the UCL. This is the hardest case, this is a high school pitcher, he's got a lot of career and season ahead of him, he's got posterior problems with pain and a positive exam in the back of his elbow, he's got a bad MRI for his UCL, but the issue is, his UCL has never hurt him, he has a negative UCL exam, he may not be able to see the MRI, but his UCL looks terrible. So what do we do in this situation? We underwent arthroscopy, we took the loose piece out, and we did a UCL reconstruction. Why? He's a young pitcher, even though he only had symptoms in the back, and his UCL was in some asymptomatic, we did share decision-making, and the likelihood was that he was going to develop symptoms in the future, and based on his season, his career, he and the family wished to address all of the pathology at that time. So, in summary, arthroscopy is a case-by-case basis, you need information on the ligament, and certainly you can treat posterior impingement arthroscopically. The ulnar nerve is very controversial, whether it's neuritis, neuropathy, and how you handle it, but subluxation is less controversial. Here's an athlete who has a popping sensation in his elbow, and his ulnar nerve subluxes. Be careful of the onconious epitropoiitis, actually you see it pretty commonly if you look for it. This is an exam that's concerning, there's a patient about to have elbow arthroscopy, he's a baseball player, his ulnar nerve is in an anterior position, never had surgery before, it just incites you, it's in an anterior position, and so if you made a portal anterior medial, you could have risked his ulnar nerve if you weren't aware of it, so always know where the ulnar nerve is with elbow arthroscopy. So, here's a typical case, he's 15, he's got a snapping elbow, and he's got numbness and tingling, and here's his exam. When you look closely, you can see that the ulnar nerve is popping over the epicondyle muscular septum. He tends to be a different patient, but what we're doing here is dissecting and freeing the ulnar nerve, as we would do with any ulnar nerve transposition, and what's the interesting part is how we manage the ulnar nerve stabilization. That's what we're going to show here, we're taking the endomuscular septum, we released it approximately high in the arm, we left it attached distally, and we're going to change its orientation and its attachment site on the epicondyle by suturing it a little bit onto the muscle attachment. What does that do? It makes the nerve more medial, so it won't sit right on the epicondyle. You don't like nerves sitting on epicondyles. I have a number of patients whose nerve just got angry in an anterior position because it sits on the epicondyle. You get that pesky, you don't want to break your contiguous nerve out of the way, and look, this is a pretty robust endomuscular septum. It's wide, it's thick, and you can suture it in the right orientation to keep the nerve stable without putting compression on the nerve. In this particular patient, the endomuscular septum is working well. It's not kinking the nerve, it's not putting pressure on the nerve, it's holding it off of the epicondyle, and it's doing it in a broad fashion. You can see with flexion and extension, it's working very well. Where did we get a dissected tree? This particular patient had a... The video's not showing up, so that basically is showing that he's changed his technique now. He doesn't use endomuscular septum anymore. He basically sews it into adipose tissue, which is what I do, where you sew the adipose tissue down to the flexor part of the mast to hold the nerve anteriorly rather than making any type of sling. There was a video here, but it's not playing right now. Big thanks to Dr. Amat for putting that together last night since he couldn't make it here.

UCL reconstruction

arthroscopy

posterior elbow symptoms

MRI scans

ulnar nerve stabilization