Bilateral brachial artery infiltration by tumoral calcinosis: A case report.

We, herein, presented a rare case of bilateral brachial artery infiltration by tumoral calcinosis located on both elbows. A 58-yearold man presented with a history of painless, palpable solid mass restricting the range of motion of both elbows. These masses were located on the anterior aspect of the elbows and gradually enlarged. After clinical, laboratory and radiological examinations, tumoral calcinosis was suspected, and excisional biopsy was planned for a definite diagnosis. Surgery was first performed on the left elbow. The median nerve was found to be compressed but not infiltrated by the mass. Interestingly, the brachial artery was totally infiltrated throughout the entire mass. Occlusion was observed in the brachial artery located within the mass. The tumor on the left elbow, 8.5 × 5.5 × 2.5 cm in size, was totally excised with approximately 12-cm brachial artery segment. The artery was resected until the healthy tissue was reached. The defect was reconstructed with saphenous vein graft obtained from the ipsilateral lower extremity. The same surgical procedure was performed on the right elbow after 3 months. The tumor size on the right elbow was 7 × 3.5 × 1.7 cm. Approximately 15-cm brachial artery segment was excised, and the defect was reconstructed with saphenous vein graft. Tumoral calcinosis is a rare benign condition that can be located in close relationship with neurovascular structures. In such cases, detailed neurologic and vascular examination, including imaging modalities, for arterial flow is essential to establish a more accurate surgical plan and avoid any unexpected situation during surgery.

Accessory bones of the elbow: Prevalence, localization and modified classification.

Accessory bones in the region of the elbow are rare variants with high clinical significance as they may be confused with avulsion fractures. We investigated their prevalence and performed a statistical analysis to support their congenital origin. Their localization was mapped to show their exact site of occurrence. We evaluated anteroposterior and lateral X-ray images of 2413 elbows in a Central European population from which a group of accessory bony structures was selected. Their character was evaluated, and accessory bones were identified. We used logistic regression to evaluate the potential relationship between the occurrence of accessory bones, the age of patients, and the occurrence of calcar olecrani. The prevalence of accessory bones of the elbow in the sample was 0.77%. Our results did not show a statistically significant relationship with the occurrence of calcar olecrani or with the age of patients. The most common type was os subepicondylare mediale (type V) in 0.46%, which was located distal to the medial epicondyle of the humerus, followed by os subepicondylare laterale (type III; 0.21%), situated laterally to the lateral epicondyle of the humerus. In comparison with previous reports, os sesamoideum mediale (type IV) was located more distally. Our data suggest that congenital accessory bones are a rare entity. Knowledge of their exact localization should be considered during diagnosis of avulsion fractures and other unclear diagnoses including accessory bony structures in the elbow region.

Anatomical study of the anterior neurovascular interval approach to the elbow: observation of the neurovascular interval and relevant branches.

BACKGROUND: The aim of the study was to investigate the anatomy of the anterior nerve and artery of the elbow joint to provide reference on the relevant surgical approach to the elbow joint, and determine a simple better surgical approach for the treatment of part of the fractures of the elbow joint. MATERIALS AND METHODS: The upper extremities of 10 adult cadavers fixed by formaldehyde and perfused with red latex in the artery were observed to investigate the anatomic structure of the anterior approach to the elbow joint. From the clearance of the brachioradialis and pronator teres muscle to the approach of the neurovascular interval, we observed the states of the median nerve, the brachial, radial and ulnar arteries, and its branches through anatomical layers and measurement methods. RESULTS: Through the anterior neurovascular interval approach to the elbow, nerve and artery can be protected, and the anterior structures of the elbow, such as the ulna coronoid process, humeroulnar joint and trochlea of the humerus, can be exposed. CONCLUSIONS: This study demonstrates that the anterior anatomical structure of the elbow joint including the trochlea of the humerus, coronoid process of the ulna and the front capsule of the elbow can be exposed through the anterior neurovascular approach to the elbow.

Safety of Anteromedial Portals in Elbow Arthroscopy: A Systematic Review of Cadaveric Studies.

PURPOSE: To systematically review available literature comparing location and safety of 2 common anteromedial portals with nearby neurovascular structures in cadaveric models and to determine the correct positioning and preparation of the joint before elbow arthroscopy. METHODS: The review was devised in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of original, cadaveric studies performed by experienced surgeons on male or female elbows evaluating anteromedial portal placement with regard to proximity of the arthroscope to neurovascular structures. Exclusion criteria consisted of case reports, clinical series, non-English language studies, and noncadaveric studies. Statistical analysis was done to measure reviewer reliability after scoring of each study. RESULTS: During screening, 2,596 studies were identified, and 10 studies met final inclusion as original, cadaveric investigations of anteromedial portal proximity to neurovascular structures. The difference in distance between proximal and distal portals was <1 mm for the brachial artery and <1.5 mm for the medial antebrachial cutaneous nerve, whereas the ulnar nerve was 4.17 mm further from the distal portal and the median nerve was 5.07 mm further from the proximal portal. Joint distension increased the distances of neurovascular structures to portal sites, with the exception of the ulnar nerve in distal portals. Elbow flexion to 90° increased distances of all neurovascular structures to portal sites. CONCLUSION: The results show that the proximal anteromedial portal puts fewer structures at risk compared with the distal portal. Elbows in 90° flexion with joint distension carry a lower risk for neurovascular injury during portal placement. These findings suggest the proximal anteromedial portal to be the safer technique in anteromedial arthroscopy of the elbow. CLINICAL RELEVANCE: Discrepancies in placement of portals have existed in the literature, indicating differing safety margins regarding surrounding neurovascular anatomy. The present study aims to link together the literature-based evidence to describe the safest anteromedial portal variation.

Vascularized Composite Allotransplantation of the Elbow Joint: A Cadaveric Study.

BACKGROUND: Surgical options for the unreconstructable elbow are limited to arthrodesis, total arthroplasty, or osteoarticular allograft reconstruction. Each of these options is limited by severe functional impairment and/or high complication rates. Vascularized allotransplantation of the elbow joint has the potential to mitigate these complications. In this study, we describe our technique for harvesting the elbow for vascularized joint transplantation and demonstrate the flap's vascularity using contrast angiography. METHODS: Anatomical studies were used to design and harvest a vascularized elbow joint flap pedicled on the brachial vessels in 10 cadaveric arms. Diaphyseal blood supply is provided by 3 nutrient arteries, and periarticular supply arises from the various collateral arteries of the arm and recurrent arteries of the forearm. The brachialis and supinator, and their respective nerves, were included as functional muscles because of their intimate association with critical vasculature. Tendinous insertions of the biceps and triceps, as well as the flexor/pronator and extensor origins, were preserved for repair in the transplant recipient. Both lateral arm and radial forearm flaps were preserved to aid in soft tissue inset as well as vascular/immunologic monitoring. Contrast angiography of each dissected specimen was performed to assess the location of the nutrient vessels and assess flap vascularity, as indicated by filling of the critical extraosseous and endosteal vessels. RESULTS: Angiographic imaging of 10 specimens demonstrated that this flap dissection preserves the nutrient endosteal supply to the humeral, radial, and ulnar diaphysis, in addition to the critical extraosseous arterial structures perfusing the elbow joint and periarticular tissues. From proximal to distal, these arteries are the musculoperiosteal radial, posterior branch of the radial collateral, inferior ulnar collateral, recurrent interosseous, radial recurrent, and the anterior and the posterior ulnar recurrent. CONCLUSIONS: Vascularized composite allotransplantation of the elbow joint holds promise as a motion and function preserving option for young, high-demand patients with a sensate and functional hand, who would otherwise be limited by the restrictions of total elbow arthroplasty or fusion. In this study, we propose a flap design and technique for harvest and also offered vascular imaging-based evidence that this flap is adequately vascularized.

Elbow vascularized composite allotransplantation-surgical anatomy and technique.

BACKGROUND: Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA. METHODS: We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique. RESULTS: The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs. CONCLUSIONS: Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.

The cardiovascular response to passive movement is joint dependent.

The cardiovascular responses to passive limb movement (PLM) at the knee are well established, however, responses to PLM at other joints involving smaller muscle volume are unknown. To compare the cardiovascular responses to passive movement at other joints, 10 participants underwent a PLM protocol in which the wrist, elbow, ankle, and knee joints were passively extended and flexed at 1 Hz for 1 min. Heart rate (HR), mean arterial blood pressure (MAP), and arterial blood flow to that limb segment (BF) were measured and vascular conductance (VC) was calculated for a 30-sec baseline period and for 3-sec intervals throughout PLM protocols. PLM of the knee and elbow resulted in significant increases in BF and VC from baseline values with peak values 180% (P < 0.001) greater than baseline. PLM of the elbow resulted in significant increases in BF and VC from baseline values with peak values 109% and 115% (P < 0.001) greater than baseline, respectively. No changes in BF and VC were observed in the ankle and wrist. Furthermore, the greater increase in blood flow per limb segment volume in the thigh and upper arm (62.8 ± 36.5 and 55.5 ± 30.3 mL min(-1) L(-1), respectively) compared to the forearm and lower leg (23.6 ± 16.7 and 19.1 ± 10.3 mL min(-1) L(-1), respectively) indicates the limb volume is not solely responsible for the differences in the hyperemic responses. These data indicate that the use of PLM to assess vascular function or as a rehabilitation modality to maintain vascular health may be most appropriate for the muscles that span the elbow and knee.

Cadaveric study of anterior and posterior elbow endoscopy portals for endoscopic distal biceps repair: comparative anatomy-at-risk.

PURPOSE: The purpose of this study was to describe neurovascular structures-at-risk during establishment of five portals for access to distal biceps tendon (DBT) in cubital fossa, and to establish relative safety of these portal sites for such access. We hypothesized that all five portals are safe for endoscopic DBT exploration. METHODS: Ten fresh frozen cadaveric elbows were dissected after placement of portals at five potential sites (four anterior, one posterior). Nine neurovascular structures (CV, cephalic vein; LCN, lateral cutaneous nerve; LV, leash of vessels; RN, radial nerve; SRN, superficial radial nerve; PIN, posterior interosseous nerve; RA, radial artery; BA, brachial artery; MN, median nerve) were dissected, and their distances from portal sites were measured. Statistical analysis was performed to determine relative portal safety, and risk of injury to neurovascular structures in relation to each portal was analyzed. RESULTS: Structures that were significantly "at risk" were RA (p = 0.006), SRN (p = 0.002), and PIN (p = 0.004). RA was significantly "at risk" of injury from portal 4 (p = 0.009). Similarly, SRN was "at risk" from portal 3 (p = 0.036), and the PIN was "at risk" from portal 2 (p = 0.003). CONCLUSIONS: Portal 1 (parabiceps portal) was safe for all neurovascular structures, however, portals 2-4 were significantly closer to neurovascular structures. RA, SRN, and PIN were significantly "at risk" as compared to other structures amongst the portals studied. Portal 5 was relatively safe for SRN and PIN. CLINICAL RELEVANCE: Portals 1 (parabiceps portal) and 5 (distal posterior) can be safely placed for endoscopic access to the DBT. Portal 4 (open distal anterior) may be used after careful open dissection and under direct vision. Portals 2 and 3 are not recommended for elbow endoscopy.

Persistent Vascular Remodeling and Leakiness are Important Components of the Pathobiology of Re-bleeding in Hemophilic Joints: Two Informative Cases.

OBJECTIVE: It is unclear if vascular remodeling in hemophilic joints perpetuates bleeding because it is difficult to gauge leakiness in the setting of low clotting factor levels. Two patients provided the unique opportunity to demonstrate that vascular changes directly contribute to joint bleeding. APPROACH AND RESULTS: Two patients had severe hemophilic arthropathies; joint vascularity and bleeding were studied during periods of normalized plasma clotting factor activities with MSKUS and PD. One patient was "cured" of hemophilia with liver transplantation. Abnormal elbow vascularization persisted despite normalization of coagulation status and was associated with severe bleeding years after transplant. Dynamic vascular changes were detected prior to and during bleeding; angiography revealed enlarged, thickened vessels consistent with remodeling, and required arterial embolization. The second patient had continued knee bleeding and fluctuating vascular changes for months following knee replacement, unresponsive to intense daily factor treatment. Subsequently, new bleeds developed in other joints associated with similar vascular changes despite continued factor replacement. CONCLUSIONS: Vascular remodeling contributes to perpetuated hemophilic joint bleeding and therefore contributes to progressive arthropathy. Intra-articular or systemic administration of anti-angiogenic drugs, such as vascular endothelial growth factor antagonists, might be of benefit in such patients, but requires study.

Importance of the ultrasound in cubital tunnel syndrome.

We report a case of a patient with cubital tunnel syndrome caused by presence of a non-thrombotic vein in the cubital tunnel. Cubital tunnel syndrome is a symptom complex caused by the compression of the ulnar nerve at the elbow. It is the second most common peripheral compression neuropathy. Ulnar compression at the elbow can be clinically diagnosed; however, an electroneurographic examination is necessary to confirm the diagnosis. Sonography and MRI may be required to locate nerve lesions, but primarily to evaluate the causes of compression. We decided to report this case because it shows the importance of the ultrasound in the diagnosis of the cause of compressions, including those rare and unexpected.

Elbow defects reconstruction using pedicled perforator flaps.

Soft tissue defects around the elbow are a real challenge in the field of reconstructive surgery. This anatomical region is passed by superficial noble anatomical structures (arteries, veins, nerves) that are often exposed in post-traumatic or post-excisional defects. The elbow joint has a high tendency to stiffness or ankylosis even after short immobilization. The pedicled perforator flaps, based on source vessels from the anastomotic arcades of the elbow seem to be an efficient and reliable reconstructive choice. The flap offers a good local coverage, replacing "like with like", has minor donor site morbidity and contrary to the free flaps, allows the very early beginning of physical therapy starting with the first postoperative day. This paper represents a review of the literature concerning this problem.

Vascular remodeling underlies rebleeding in hemophilic arthropathy.

Hemophilic arthropathy is a debilitating condition that can develop as a consequence of frequent joint bleeding despite adequate clotting factor replacement. The mechanisms leading to repeated spontaneous bleeding are unknown. We investigated synovial, vascular, stromal, and cartilage changes in response to a single induced hemarthrosis in the FVIII-deficient mouse. We found soft-tissue hyperproliferation with marked induction of neoangiogenesis and evolving abnormal vascular architecture. While soft-tissue changes were rapidly reversible, abnormal vascularity persisted for months and, surprisingly, was also seen in uninjured joints. Vascular changes in FVIII-deficient mice involved pronounced remodeling with expression of α-Smooth Muscle Actin (SMA), Endoglin (CD105), and vascular endothelial growth factor, as well as alterations of joint perfusion as determined by in vivo imaging. Vascular architecture changes and pronounced expression of α-SMA appeared unique to hemophilia, as these were not found in joint tissue obtained from mouse models of rheumatoid arthritis and osteoarthritis and from patients with the same conditions. Evidence that vascular changes in hemophilia were significantly associated with bleeding and joint deterioration was obtained prospectively by dynamic in vivo imaging with musculoskeletal ultrasound and power Doppler of 156 joints (elbows, knees, and ankles) in a cohort of 26 patients with hemophilia at baseline and during painful episodes. These observations support the hypothesis that vascular remodeling contributes significantly to bleed propagation and development of hemophilic arthropathy. Based on these findings, the development of molecular targets for angiogenesis inhibition may be considered in this disease.

Presentation of the vascular supply of the proximal ulna using a sequential plastination technique.

PURPOSE: The purpose of this study was to demonstrate the peri- and intraosseous vascular supply of the proximal ulna. METHODS: Eleven fresh human cadaveric elbows were sequentially plastinated beginning with arterial injection, followed by block and secondary slice plastination of the whole elbow. With this technique, we obtained completely transparent cadaveric slices in which the peri- and intraosseous vascular architecture could be studied. RESULTS: Proximal ulna vascularization is due to an arterial network: a superior and inferior collateral ulnar artery and the profunda brachial artery climbing to the olecranon from proximal. An anterior artery and a posterior recurrent artery climb up distally to the medial parts of the ulna and an interosseous recurrent artery is responsible for the lateral and posterolateral proximal part of the ulna. The intraosseous vascularization is due to directly penetrating branches out of the posterior recurrent ulnar artery and a vascular plexus at the olecranon tip. In addition, we saw a major distal bone penetration branch coming from the recurrent posterior artery, climbing intraosseously without junction to the proximal penetrating branches. CONCLUSION: The peri- and intraosseous vascularization of the proximal ulna was shown. A transitional zone of the intraosseous vascularization of the proximal ulna was detected.

The effect of vascular pedicle preservation on blood flow and clinical outcome following ulnar nerve transposition.

PURPOSE: To evaluate the efficacy of a technique to preserve the extrinsic vascular supply to the ulnar nerve after transposition and its effect on blood flow and clinical outcome. METHODS: We included 36 patients with cubital tunnel syndrome. The patients were randomly selected to undergo vascular pedicles-sparing surgery for anterior ulnar nerve transposition (VP group) or nerve transposition and artery ligation (non-VP group). Blood flow to the ulnar nerve was estimated intraoperatively at 3 locations in the cubital tunnel before and after transposition using a laser Doppler flowmeter. Clinical results at 3, 6, and 12 months after surgery were also compared between the 2 groups. RESULTS: The blood flow before ulnar nerve transposition was not significantly different between the groups. Blood flow at all 3 locations after the ulnar nerve transposition was significantly higher in the VP group than in the non-VP group. Blood flow in the non-VP group reduced to values between 28% and 52% from the pre-transposition baseline values. After surgery, no significant differences were observed in the clinical results between the groups, except for the Disabilities of the Arm, Shoulder and Hand scores at 12 months after surgery, which was greater in the non-VP group. CONCLUSIONS: The procedure of preserving the extrinsic vascular pedicles can prevent compromise of blood flow to the ulnar nerve immediately after nerve transposition. However, this procedure had no correlation to improved recovery of ulnar nerve function after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

[Pediatric supracondylar fractures of the humerus]. / Suprakondyläre Humerusfrakturen im Kindesalter.

Supracondylar fractures are on the of the most common injuries in paediatric patients. Therapeutic consequences depend on the one hand on the degree of the osseous displacement according to the Gartland classification. On the other hand, the diagnosis of concomitant neuro-vascular injuries is crucial to prevent long term impairment. Never the less, clinical diagnosis can be challenging. In-depth knowledge of pediatric supracondylar humerus fractures is a prerequisite to achieve a functionally and cosmetically satisfactory long-term outcome.

The pedicled reverse-flow lateral arm flap for coverage of complex traumatic elbow injuries.

PURPOSE: The pedicled reverse-flow lateral arm flap has been described primarily for the reconstruction of nontraumatic elbow wounds. We describe our experience using this flap in staged operations for soft tissue coverage after elbow trauma, including acute coverage of open fractures and salvage of infected hardware. METHODS: Review of patients who underwent staged pedicled reverse-flow lateral arm flap transfer for coverage of traumatic elbow defects. RESULTS: Three patients were identified; all underwent 2-stage repair with flap delay for coverage of traumatic elbow injuries. Each patient had stable wound coverage with this flap. The only complication was 5% distal flap necrosis in 1 patient. CONCLUSIONS: The pedicled reverse-flow lateral arm flap provides reliable soft tissue coverage of traumatic elbow defects with minimal donor-site morbidity.

The emergent assessment of supracondylar fractures of the paediatric humerus.

Supracondylar fractures of the distal humerus are a common and serious paediatric injury, often accompanied by neurovascular compromise. Accurate neurovascular evaluation of the injured limb is essential in order to guide emergent treatment. To assess whether trainees are proficient in the assessment and management of supracondylar fractures, performance was audited against objective standards drawn from the literature.

Medial epicondyle fractures in the pediatric population.

Humeral medial epicondyle fractures in the pediatric population account for up to 20% of elbow fractures, 60% of which are associated with elbow dislocation. Isolated injuries can occur from either direct trauma or avulsion. Medial epicondyle fractures also occur in combination with elbow dislocations. Traditional management by cast immobilization increasingly is being replaced with early fixation and mobilization. Relative indications for surgical fixation include ulnar nerve entrapment, gross elbow instability, and fractures in athletic or other patients who require high-demand upper extremity function. Absolute indications for surgical intervention are an incarcerated fragment in the joint or open fractures. Radiographic assessment of these injuries and their true degree of displacement remain controversial.

Vascular anatomy of the proximal ulna.

PURPOSE: To describe the intraosseous arterial anatomy of the proximal ulna. METHODS: We used 9 fresh-frozen, above-elbow amputations to map the intraosseous arterial supply using the Spalteholtz technique. We treated 3 additional above-elbow amputations similarly, and then dissected them to map the extraosseous arterial supply. We recorded the extraosseous arterial patterns and compared them with the intraosseous arterial findings. RESULTS: The intraosseous arterial supply to the proximal ulna is derived primarily from a large nutrient vessel, a branch of the ulna artery, entering the anterior cortex of the ulna distal to the coronoid base, and from 2 medium-sized branches of the posterior and medial arcade entering near the olecranon tip. A watershed area is seen between these 2 vessel groups, halfway between the tips of the olecranon and coronoid. CONCLUSIONS: The arterial supply of the proximal ulna is relatively consistent and flows in opposite directions from the 2 separate areas.