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Editorial Commentary: Elbow Arthroscopy in the Pediatric Patient—Small Lesions in a Small Joint but With a Big Impact

      Abstract

      Elbow arthroscopy has evolved to be a powerful tool for the treatment of a broad spectrum of pathologies over the past almost 40 years. The small joint with a complex arthroscopic anatomy demands special training and exceptional skills from the orthopaedic surgeon. On the basis of this fact and in light of the close proximity of the neurovascular structures, complication rates are somewhat higher compared with other large joints such as the knee and the shoulder. Nevertheless, elbow arthroscopy has also found its way into the treatment of joint pathologies in pediatric patients. The spectrum of pathologies differs from that in the adult population, with fewer degenerative changes and many growth-related issues such as osteochondral lesions (osteochondritis dissecans) of the capitellum. Generally speaking, clinical outcomes, return to sports, and patient satisfaction are excellent and complication rates are low. The latter remains a target for further improvement in light of the many years those pediatric elbow joints have ahead.
      Since the early days of elbow arthroscopy, indications and techniques have evolved from a simple diagnostic procedure and removal of loose bodies to advanced cartilage and fracture treatment and such.
      • Guhl J.F.
      Arthroscopy and arthroscopic surgery of the elbow.
      • Andrews J.R.
      • Carson W.G.
      Arthroscopy of the elbow.
      • Hempfling H.
      Die endoskopische Untersuchung des Ellenbogengelenkes vom dorso-radialen Zugang [Endoscopic examination of the elbow joint from the dorsoradial approach].
      • Eriksson E.
      • Sebik A.
      Arthroscopy and arthroscopic surgery in a gas versus a fluid medium.
      • Poehling G.G.
      • Whipple T.L.
      • Sisco L.
      • Goldman III, B.
      Elbow arthroscopy: A new technique.
      • Kircher J.
      Autologous chondrocyte implantation for post-traumatic cartilage defect of the capitulum humeri.
      • Andelman S.M.
      • Meier K.M.
      • Walsh A.L.
      • Kim J.H.
      • Hausman M.R.
      Pediatric elbow arthroscopy: Indications and safety.
      Some years ago, I was happy to attend an instructional course given by our Editor-in-Chief Emeritus Gary Poehling, who made a strong impact on the development of arthroscopic techniques, especially of the small joints. He told us beginners struggling with orientation and the complex arthroscopic anatomy, “Maybe it’s helpful to think of the elbow like if it were a little knee.” Well, this bon mot reflects on 2 underlying issues: First, the elbow is, in fact, a small joint, about 3 to 4 times smaller than the knee.
      • Shin J.J.
      • Haro M.
      • Yanke A.B.
      • et al.
      Topographic analysis of the capitellum and distal femoral condyle: Finding the best match for treating osteochondral defects of the humeral capitellum.
      ,
      • Misir A.
      • Gunay A.E.
      • Oguzkaya S.
      • et al.
      A comprehensive coronal and axial bone dimension and cartilage thickness evaluation of the distal humerus: Age and sex differences.
      Second, elbow arthroscopy is far less commonly performed than knee arthroscopy, where most young surgeons start their careers as arthroscopists.
      The question of whether the clinical results and complication rates of elbow arthroscopy justify a wide application or even expansion of indications in the very special and vulnerable pediatric patient population is addressed by Gouveia, Zhang, Kay, Memon, Simunovic, Garrigues, Pollock, and Ayeni
      • Gouveia K.
      • Zhang K.
      • Kay J.
      • et al.
      The use of elbow arthroscopy for management of the pediatric elbow: A systematic review of indications and outcomes.
      in this issue with a systematic review of 19 studies, entitled “The Use of Elbow Arthroscopy for Management of the Pediatric Elbow: A Systematic Review of Indications and Outcomes.” Although the quality of the studies is very good, the Methodological Index for Non-Randomized Studies (MINORS) score, with a mean of 10.1 (range, 7-14), is only moderate, which is largely attributed to the fact that all studies were noncomparative, which is comprehensible and hard to change in the future regarding this patient population. A minority of the included studies reported about a consequent use of established outcome scores and comparison of preoperative and postoperative results, which emphasizes the many times repeated but still necessary call for improvement in study design to allow comparability and to increase the value and impact for the scientific community.
      Despite the obvious goals of pain reduction, good clinical function, and a return to sports, which are well documented in the included studies in the review of Gouveia et al.,
      • Gouveia K.
      • Zhang K.
      • Kay J.
      • et al.
      The use of elbow arthroscopy for management of the pediatric elbow: A systematic review of indications and outcomes.
      with postoperative Disabilities of the Arm, Shoulder and Hand scores ranging from 0.5 to 3.0 and Mayo Elbow Performance Index scores ranging from 98.1 to 98.3, there is another even more important long-term objective, which is to avoid early degenerative changes and their progression to full osteoarthritis, especially in light of our still limited capabilities of joint replacement for the elbow. Two-thirds of the included studies in the review of Gouveia et al. were dedicated to the treatment of osteochondritis of the capitellum (osteochondritis dissecans), known as Panner disease.
      • Panner H.J.
      A peculiar affection of the capitulum humeri, resembling Calve-Perthes disease of the hip.
      So, the difficulty here is that we have to deal with arthroscopy for a small osteochondral injury in a small joint in small adolescent patients, and because of technical reasons regarding the approach, some treatments such as osteochondral or chondrocyte transplantation require an additional open approach or a combination of both arthroscopic and open approaches.
      • Kircher J.
      Autologous chondrocyte implantation for post-traumatic cartilage defect of the capitulum humeri.
      ,
      • Shin J.J.
      • Haro M.
      • Yanke A.B.
      • et al.
      Topographic analysis of the capitellum and distal femoral condyle: Finding the best match for treating osteochondral defects of the humeral capitellum.
      ,
      • Logli A.L.
      • Leland D.P.
      • Bernard C.D.
      • et al.
      Capitellar osteochondritis dissecans lesions of the elbow: A systematic review of osteochondral graft reconstruction options.
      ,
      • Lu Y.
      • Li Y.J.
      • Guo S.Y.
      • Zhang H.L.
      Is there any difference between open and arthroscopic treatment for osteochondritis dissecans (OCD) of the humeral capitellum: A systematic review and meta-analysis.
      Because arthroscopic nonreconstructive techniques for osteochondritis dissecans in adolescents have been reported to result in excellent long-term outcomes, the decision for either technique has to be made very cautiously.
      • Zuskov A.
      • Luo T.D.
      • Kyriakedes J.
      • et al.
      Adolescent osteochondritis dissecans: Long-term outcomes after non-reconstructive elbow arthroscopy.
      In their review, Gouveia et al.
      • Gouveia K.
      • Zhang K.
      • Kay J.
      • et al.
      The use of elbow arthroscopy for management of the pediatric elbow: A systematic review of indications and outcomes.
      observed an overall neurologic injury rate of 1.6%, which is lower than in general and all of these injuries resolved, but in this particular patient group, 8 cases are still 8 cases too many.
      • Shamrock A.G.
      • Carender C.N.
      • Fowler T.P.
      • Wolf B.R.
      • Khazi Z.
      • Buckwalter J.A.
      Neurovascular complications in elbow arthroscopy: A systematic review of 5,767 cases.
      One of the most important axioms that I was taught in medical school, frequently attributed to Hippocrates of Kos but rather likely traced back to Thomas Sydenham, an English physician in the 17th century, is primum non nocere, secundum cavere, tertium sanare (first, do no harm, second be careful, third cure).
      • Smith C.M.
      Origin and uses of primum non nocere—Above all, do no harm!.
      This should be our fundamental approach to elbow arthroscopy in general and to the application of this powerful tool but demanding technique for children and adolescents in particular. How to achieve this goal? By using all educational opportunities we can get, attending courses and meetings, and last but not least, reading the relevant literature! To no longer distract the reader from that important yet joyful duty, I will end here and hope we have all learned a great deal from the article of Gouveia et al.

      Supplementary Data

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