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Arthroscopie du coude

Indications thérapeutiques
et résultats

Christian Dumontier
Centre de la Main, Guadeloupe

Possibilités techniques

Corps étrangers, plica
Osteochondritis
dissecans


Synovite


L’arthrose du coude

Débridement des
ostéophytes

Les raideurs du coude

Les fractures de la tête
radiale, de la coronoïde,
du capitelum






Les instabilités du coude
Hygroma
Biceps
Tennis elbow
Nerf ulnaire
Arthrite septique

Possibilités techniques

Corps étrangers, plica


Synovite


L’arthrose du coude

Osteochondritis
dissecans

Débridement des
ostéophytes

Les raideurs du coude

= Débridement

Débridement arthoscopique du coude

Corps étrangers
• Meilleure indication au début
• Intérêt diagnostic et thérapeutique (16% des
CE étaient méconnus par le bilan pré-op)

• Technique = celle des CE

90% de bons résultats quand la lésion est isolée

! Les résultats dépendent du degré

d’arthrose associée
! Indolence 85%;
! Disparition du blocage 92%,
! Disparition de l’épanchement 75%
! Mais 30% se plaignaient toujours d’une
crépitation,

12 publications d’ablation isolée de corps
étrangers soit 109 patients et 98 (90%) de bons et
excellents résultats

9 publications d’ablation de CE + débridement soit
150 patients et 110 (73.3%) bons ou excellent
résultats

Yeoh KM et al. Evidence-Based Indications for Elbow Arthroscopy. Arthroscopy, Vol 28, No 2, 2012: pp 272-282

A part: l’ostéochondrite

• Associer à l’ablation du CE un geste sur la cavité ?
• 80 % des athlètes reprennent au même niveau
• Le gain sur la mobilité est de 10 à 20°

Les plicae
Entre tête radiale et capitelum
• Ressaut lors de la pronation entre 90 et
110° de flexion
• Age 36 ans, sex-ratio = 1
• 2 voies postéro-latérales
• 12/14 ont été soulagés

9 publications, avec 39 (88.6%) sur 44 patients ayant un
bon ou excellent résultat

«L’arthrose»


Gestes synoviaux = synovectomie
Gestes osseux = ablation des ostéophytes,
de la tête radiale, creusement des fossettes
Gestes capsulaires = capsulotomie/
capsulectomie

Synovectomie
• Au Shaver, sans aspiration
• 1er temps, pour voir
• Attention près de la capsule +++

scopy.

(a)

(b)

(a)

with all the elbow range of motion exercises. However, lifting
weights and heavy work were restricted for a period of 8
weeks.
(b)
Patient was followed up at 2 weeks, 6 weeks, and 12
weeks and then at 6, 12, and 24 months. Patient regained
full painless range of motion of the elbow at the end of 6
weeks, which was2 maintained at the final followup (Figures
3(a)–3(d)). Patient was permitted to do heavy activities
including lifting weights after 12 weeks. At the final followup,
patient’s pain score on visual analogue scale was 0 during
light activities and 1 during heavy activities.

Débridement cartilagineux

• Découverte de lésions chondrales
(c)

(b)

Case Reports in Orthoped

traitées
par
micro-perforations
Case 2. 27 year male presented with a post-traumatic synovi-

(d) had sustained a trivial injury to
tis of left elbow. The patient
the left elbow 1 year back and he developed a painful swollen
(d)
d) Clinical(c)photographs of the
patient
showing
ROM
at the final
followup.
elbow
which
gradually
progressed
over
a period of time.
Patient
had taken
treatment
from
anfollowup.
orthopaedist which
e 3: (a)–(d) Clinical photographs
of the patient
showing
ROM at the
final
included physiotherapy and anti-inflammatory medications;
(c)
however he had deteriorated progressively. At the time of pre(a)
sentation, patient had a fixed flexion deformity of 80 degrees
Figure 2: (a)-(b) Photographs showing grade 3 chondr
with a painful range of motion being 80 to110 degrees.
on the articular surface of radial head. (c) Photograph
microfracture following the debridement of the loose carti
Supination and pronation were also severely restricted and
painful with a range of 20 degrees each. The elbow was
swollen and extremely
palpation
especially
onelbow
the arthroFigure 1:tender
Clinical to
photograph
showing
portals for
posterolateral aspect.
scopy. The pain score on visual analogue scale
was started on rehabilitation from the first postopera
was 10 during routine activities. There was no neurovascular
and rehabilitation continued on outpatient basis. Pat
deficit. Radiographs and blood investigations were normal
followed up at 2, 6, and 12 weeks and then at 6, 12,
and MRI of elbow
revealed generalized synovitis of elbow.
with all the elbow range of motion exercises. However, lifting
months.
weights and heavy work were restricted for a period of 8
Patient gained 30–120 degrees of range of mo
Diagnostic arthroscopy
of elbow was done using direct
weeks.
elbow with minimal pain on(b)first postoperative day
lateral, posterolateral,
accessory
posterolateral,
and posterior
Patient
was followed
up at 2 weeks,
6 weeks, and 12
a)
(b) There was
(c) 24 (Figure
weeks
and then
at 6, 12,
and
months. 4(a)).
Patient A
regained
range of motion gradually became painless over a p
portals.
diffuse
synovitis
of elbow
(b)
(c)
full painless
range
of motion
the elbow
at the end of 66 weeks. At the final followup after 18 months of surg
well-defined chondral
lesion
ICRS
grade 2ofover
the trochlea
diocapitellar joint. (b) Grade 2 chondral lesion onweeks,
the trochlea.
(c) Debridement
andfinal
abrasion
chondroplasty
which was
maintained at the
followup
(Figures
patient had painless range of motion from 10 to 130
was
detected
(Figure
4(b)).
The
defect
was
debrided
and
ellar joint. (b) Grade 2 chondral lesion on the3(a)–3(d)).
trochlea.Patient
(c) Debridement
abrasion
chondroplasty
was permittedand
to do
heavy activities

Trochlée

Tête radiale

Ablation des ostéophytes

Savoir où ils sont +++
(Scanner 3D)

Abrasion à la fraise /shaver

re large coronoid spurs (A). This spur is excised, usually via a shaver

Scope dans la voie proximo-médiale

Fig. 6. A degenerative radio capitellar joint is visualized via an anterior medial portal (A)
head is excised (B) first, then the soft spot portal is used to co-plane the resection to a smo

Résection antérieure par
voie proximo-latérale

Résection postérieure par voie
postero-latérale (écarteur voie
proximo-latérale)

Savoie FH et al. Arthroscopy for arthritis of the elbow. Hand Clinics 2011; 27: 171-178

Outerbridge-Kashiwagi
• Fenestration par voie postérieure
des fossettes avec contrôle
antérieur

Gestes capsulaires
• A faire en dernier à cause du
risque nerveux (vasculaire)

• Et de la fuite du liquide dans les
parties molles

• Aller jusqu’aux fibres du brachialis
à la pince Basket

Nerf radial

Raideur Post-traumatique

Résultats

Gain moyen: 37° (open) vs 35° (arthroscopic)

• Raideurs mixtes (arthrose et post-trauma)
• Gain moyen: 25° (open) vs 38° (arthroscopic)
• Coude arthrosique
• Gain moyen: 28° (open) vs 30° (arthroscopic)

Enquête SFA
• 138 arthrolyses (80 ouvert vs 58 arthro)
• 2 groupes pratiquement comparables
• pre-op 0-42-111° (107 ouvert-116° Ao)
45
43
41
39

43
40

Arthro

140

Foyer Ouvert

134

37
35
33
31

138
136

130
128

29

126

27

124

25

122

23

120

21

21
19

18

17

129

127

124

118
116

116

114
112

15

110

13

108

11
9

11
9

106

107

104

7

102

5

Préop

132

132

JO

Final

100

Préop

JO

Final

Complications : 13 %

♦ Arthroscopiques : 14%
2 parésies radiales
régressives

♦ Ciel ouvert : 12%
4 parésies ulnaires
1 paralysie radiale

1 lésion nerf interosseux
postérieur

3 sepsis dont 1 profond

2 fistules synoviales

1 ostéome

3 algo-neuro-dystrophies

1 syndrome d’Essex-Lopresti

Résumé Raideurs et Arthrose

! Plus les lésions cartilagineuses sont sévères,
moins bons sont les résultats
! L’indolence est le plus souvent obtenue,
notamment dans l’arthrose
! Le gain sur la mobilité est plus limité dans
l’arthrose, meilleur dans les raideurs posttraumatiques
11 publications en 2012 rapportant 182 patients avec 40
(76.9%) bons ou excellents résultats et 7 (3.8%)
complications

Fractures et arthroscopie
• Résection des fractures
parcellaires de la tête
radiale, du capitulum,...

• Synthèse sous contrôle
arthroscopique

Fixation arthroscopique des fractures de type Regan I
et II, O’Driscoll I et II

Hausman MR. Arthroscopically assisted coronoid fracture fixation. CORR 2008; 466:
3147-31525.

A° et instabilités du coude ?

• Quelques cas rapportés
(diagnostiques ou
thérapeutiques)

A° et tendons autour du coude

Tendon bicipital (synovite et
réinsertion des ruptures)

Epicondyliens

Epicondylite: 2 approches
endoscopiques
Endoscopique (Krämer, 1993 - Grifka, 1995 - Rubenthaler,

2005 - Brooks-Hill, 2008)

Arthroscopique (Baker, 2000, 2008 - Owens, 2001, Cohen,

2001 - Peart, 2004 - Sennoune, 2005 - Mullet, 2005 - Dumontier,
2008)

La seule que je pratique après une imagerie
(écho/IRM) montrant les lésions tendineuses

Les bases théoriques
Toutes les techniques (> 10 variantes) ont en commun
la désinsertion de l’ECRB +/- EDC: Cette désinsertion
est possible en arthroscopie
Le tendon de l’ECRB est visible à travers la capsule

Bases anatomiques
" L’ECRB peut être sectionné (et un débridement osseux
réalisé) sans mettre en danger le ligament collatéral
radial

Avantages
Permet de rechercher et de traiter une pathologie
endo-articulaire associée
11% dans série ouverte de Nirschl
60% dans série arthro de Baker
Trochlée

Coronoide

Tête radiale

Technique
A°scopie du coude
Scope par voie médiale,
instruments par voie latérale
Inspection de la capsule
Section (si intacte) pour voir
l’insertion du tendon conjoint

Classification des lésions
capsulaires

Type I: intacte ≠ 30%

Type II: déchirure longitudinale
≠ 30%

Type III: large déchirure ≠ 30%

Technique (3)
Section du tendon (de la partie haute du capitulum sur
11 mm jusqu’à la tête radiale/lgt annulaire ) en
respectant le LLE

n

FU

Résultats

Baker, 2000

42/13

2

95% améliorés, Douleur 1,9
(sport),RTW 2,2 S

Owens, 2001

16/12

1

Douleur (sport) 3,25 -RTW 6 J

Peart, 2004

33

?

72% de bons/excellents

Sennoune,
Dumontier, 2005

14

1

9 bons/excellents, 1 moyen, 4 échecs

Mullet, 2005

30

2

28/30 guéris en 2 semaines, RTW 7 J

Dumontier, 2008

25/25

4

21 bons/excellents, 1 moyen, 4 échecs

Mieux que la chirurgie à ciel ouvert ?
Cohen et Romeo: 14 pts dans chaque groupe, pas de
différences, 1/3 de mauvais résultats
Peart et al.: 33 arthro vs 42 open. résultats identiques
mais retour au travail plus précoce et moindre morbidité
SFA 2005: 46 arthro vs 189 open - étude rétrospective.
Pas de différence dans la reprise du travail du sport, la
douleur post-op,...

Hygroma
! Surtout les hygromas
liquidiens post-traumatiques
! Résection au shaver, bien
abraser l’olécrane
! Xylocaïne adrénalinée +
points de capiton +
Cohéban® postop
! 86 % des 31 patients sont
indolores
! Reprise travail (10 jours)

Résultats

Variables et difficiles parfois à analyser
(nombre de cas limités)

118



59% (10/17) WC patients with good and excellent
100% (17/17) WC patients better and much better
Good and Excellent Results
– VEO 100% (6/6)
– OCD 83% (5/6)
– Loose body 75% (9/12)
– Lateral epicondylitis 74% (23/31)
– Synovitis 71% (5/7)
– DJD 57% (4/7)
– Posterior impingement 50% (1/2)
– Arthrofibrosis 45% (5/11)
Better and Much Better
– OCD 100% (6/6)
– DJD Baker:
86% (6/7)
Champ
revue de 300 arthroscopies

du coude

48

Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):43-50
48
Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):43-50

Other minor complications include hematoma formation,
when the patient has full range of motion and minimal pain.
minor with
complications
hematoma
when
the to
patient
has full range
of motion
and minimal
pain.
superficialOther
infections
continuousinclude
drainage
from theformation,
Such a plan
leads
a progressive
increase
in activities
to
superficial
continuous
the for
Such
a plan leads
to a progressive
increase in activities to
portals, and
a loss ofinfections
motion ofwith
30° or
less. The drainage
develop- fromprepare
unrestricted
functional
participation.
portals, andossification
a loss of motion
of 30°
or less. The developprepare for unrestricted functional participation.
ment of heterotopic
six weeks
postoperatively
Results
ment
of heterotopic
ossification
weeks
postoperatively
was recently
reported
in a 47-year-old
malesix
who
underwent
Results
was for
recently
reported inThe
a 47-year-old
malerecomwho underwent
debridement
osteoarthritis.
investigators
O’Driscoll and Morrey reported on 71 consecutive arthrosdebridement
for osteoarthritis.
The investigators
O’Driscoll
and Morrey
reported onof71the
consecutive
mended prophylaxis
following
extensive debridement
with recomcopies, with
approximately
three-quarters
patients arthros8
mended
prophylaxis
with
copies,
with approximately
three-quarters
of the patients
indomethacin
for two
weeks.23following extensive debridementreporting
they benefited
from the procedure.
In this study,
23
8
indomethacin
two weeks.
reporting
they benefited
from
In this study,
Other methods
to helpfor
prevent
complications include the
31% benefited
diagnostically,
24%
hadthea procedure.
diagnostic and
Otheralong
methods
help preventaspect
complications
include
the
31%
benefited
diagnostically,
24% benefit
had a diagnostic
and
closure of portals
the to
posterolateral
to prevent
therapeutic
benefit,
and 17%
had therapeutic
only.
closure O’Driscoll
of portals along
the posterolateral
therapeutic
benefit, and
had therapeutic
only.
synovial fistula.
recommends
the use ofaspect
a He-to prevent
The investigators
concluded
that 17%
the ideal
indication benefit
for
synovial
fistula. O’Driscoll
recommends
the use
He- arthroscopy
The investigators
concluded
thatbodies
the ideal
for
movac drain
after excessive
debridement
and 36 hours
of of aelbow
is the removal
of loose
andindication
that
movac
drain
after
excessive
debridement
and
36
hours
of
elbow
arthroscopy
is
the
removal
of
loose
bodies
and
that
elevation and extension splinting to decrease the capsular
posttraumatic or primary degenerative joint disease, in its
and extension
splinting
decrease
the capsular
posttraumatic
or primary
disease, in its
volume.12elevation
The surgeon
should also
realizetothe
limitation
later stages,
is not improved.
Reddy degenerative
and associatesjoint
reported
12
26
volume.
The
surgeon
should
also
realize
the
limitation
later
stages,
is
not
improved.
Reddy
and
associates
of capsular volume in an arthrofibrotic/arthritic elbow and
on 172 patients with a mean follow-up of 42 months. They reported
of
capsular
volume
in
an
arthrofibrotic/arthritic
elbow
and85% good
on 172
with
a mean
of 42 months.26 They
consider deferring to an open procedure if distension is not
had
topatients
excellent
results
andfollow-up
a 1.6% complication
deferring
to an open
procedure
distension
israte,
notwith had
goodulnar
to excellent
results andThe
a 1.6%
complication
practical. consider
To decrease
the chance
of nerve
injury,ifthe
skin
one 85%
complete
nerve transection.
greatest
practical.
To
decrease
the
chance
of
nerve
injury,
the
skin
rate,
with
one
complete
ulnar
nerve
transection.
The greatest
should be properly marked prior to incision, the elbow should
patient improvement was in the pain score. A small percentshould
be
properly
marked
prior
to
incision,
the
elbow
should
patient
improvement
was
in
the
pain
score.
A
small
be flexed to 90°, capsular distension should be achieved
age (15%) of baseball players were not able to return to their percentbe
flexed
to
90°,
capsular
distension
should
be
achieved
(15%) of baseball
players
were not able
to return to their
(increases nerve to bone distance, not nerve to capsule disprior levelage
of competition.
Savoie
and coworkers
published
(increases
nerve
to
bone
distance,
not
nerve
to
capsule
disprior
level
of
competition.
Savoie
and
coworkers
tance), and pronation performed to protect the PIN. Judicious
a two to five year follow-up for ulnohumeral arthroplastypublished
tance),
and
pronation
performed
to
protect
the
PIN.
Judicious
a two
to five year follow-up
for ulnohumeral
arthroplasty
use of retractors during synovectomy or capsulectomy can
and reported
an improvement
of 81° in range
of motion with
27
use
of
retractors
during
synovectomy
or
capsulectomy
can
and
reported
an
improvement
of
81°
in
range
of
motion with
reduce the incidence of nerve injury. If necessary, nerves
no neurovascular complications. Cohen and colleagues
27
reduce
the
incidence
of
nerve
injury.
If
necessary,
nerves
no
neurovascular
complications.
Cohen
and
should be explored and identified to protect them in the
compared the open Outerbridge-Kashiwagi technique tocolleagues
should
be
explored
and
identified
to
protect
them
in
the
compared
the open
technique to
region of a capsulectomy. Of note, Papilion and associulnohumeral
arthroplasty.
WithOuterbridge-Kashiwagi
a diagnosis of osteoarthriregion
of apalsy
capsulectomy.
Of lateral
note, Papilion
and associarthroplasty.
With a diagnosis
ates reported
a PIN
distal to the
epicondyle
tis in 89%ulnohumeral
of the patients,
the open procedure
resultedofinosteoarthria
reported
a PIN palsy
distal
the24 lateral
epicondyle
tis in 89%
of theofpatients,
open
resulted in a
using the ates
standard
anterolateral
portal
of 3tocm.
Stothers
greater increase
in range
motion, the
while
theprocedure
arthroscopic
using recommend
the standardmoving
anterolateral
portal of 3portal
cm.24 Stothers
increase
in range
of motion,inwhile
arthroscopic
and coworkers
the anterolateral
proceduregreater
resulted
in a greater
improvement
pain.28the
They
coworkers
recommend
moving
the anterolateral
resulted
in a greater
improvement
in pain.28 They
proximal and
to the
radial head
to increase
the nerve
to portal portal
reported itprocedure
was difficult
to completely
debride
the olecranon
to the radial
increasebethe
nerve to portal
reported
it was difficult
completely
debride93%
the olecranon
distance.25proximal
They recommend
the head
same to
technique
applied
tip and fossa
with arthroscopy.
Leetoand
Morrey reported
distance.25 They
the same
tip and fossa
withfor
arthroscopy.
Lee in
andpatients
Morreywith
reported 93%
to the anteromedial
portal.recommend
Some authors
prefertechnique
to use anbe applied
good to excellent
results
synovectomy
29
the anteromedial
Some authors
an
good
to excellent
resultsatfor
patients with
osteotometoinstead
of a burr for portal.
bony resection,
as this prefer
allows to use
rheumatoid
arthritis.
However,
42synovectomy
months, this in
figure
29
of a burr for bony resection, as this allows
rheumatoid
at 42 months,
for a moreosteotome
controlledinstead
resection.
dropped to
57%. The arthritis.
conclusionHowever,
by the investigators
wasthis figure
for colleagues
a more controlled
to 57%. The
by arthroscopy
the investigators was
Kelly and
reportedresection.
on 473 arthroscopies, with
that good dropped
results deteriorate
moreconclusion
rapidly using
21 473 arthroscopies, with
and colleagues
reported on
that goodthan
results
deteriorate
more rapidly
usingand
arthroscopy
89% done byKelly
experienced
elbow surgeons.
They reported
for this condition
with
open debridement.
Savoie
21
89%
done
by
experienced
elbow
surgeons.
They
reported
for
this
condition
than
with
open
debridement.
Savoie and
no permanent nerve injuries, 0.8% major complications with
Field reported a study of over 200 patients diagnosed with
no
permanent
nerve
injuries,
0.8%
major
complications
with
Field
reported
a
study
of
over
200
patients
diagnosed
with
wound infection dominating, and 11% minor complications
arthrofibrosis, and showed an average increase in extension
11
wound
infection
dominating,
and
11%
minor
complications
arthrofibrosis,
and
showed
an
average
increase
in
extension
with 2.4% transient nerve palsies. Nerve palsies were most
from -46° to -3° and in flexion from 96° to 138°. There
nerve
palsies.
Nerve
palsies were was
mosta significant
from -46°
to -3° in
and
in flexion
from
96°failures,
to 138°.11 There
frequentlywith
seen2.4%
withtransient
rheumatoid
arthritis
and
contracture.
decrease
pain,
with only
three
frequently seen with rheumatoid arthritis and contracture.
was a or
significant
decrease
in pain, with
only three
where motion
pain was
not controlled.
Phillips
and failures,
Postoperative Rehabilitation
where
motion
or
pain
was
not
controlled.
Phillips and
Strasburger reported on 25 patients with arthrofibrosis who
Postoperative
Rehabilitation
30with arthrofibrosis who
Strasburger
reported
on
25
patients
Most authors recommend splinting the elbow at 90° for the
had a 41° average increase in arc of motion. Larger gains
30
authors recommend
the elbow
the reported
had awith
41° posttraumatic
average increase
in arc of motion.
Larger gains
first threeMost
postoperative
days unless splinting
a contracture
releaseatis90° for
were
degenerative
joint disease
first
three
postoperative
days
unless
a
contracture
release
is
were
reported
with
posttraumatic
degenerative
joint disease
done. When a contracture release is performed, many investhan with degenerative osteoarthritis, and no neurovascular
done.
When
a
contracture
release
is
performed,
many
investhan
with
degenerative
osteoarthritis,
and
no
neurovascular
tigators recommend splinting in extension, while others escomplications were reported.
11
tigators recommend splinting in extension,
while others escomplications were reported.

• Reddy: 172 patients, 42 mois de recul
• 85% sont améliorés
• 1,6% de complications (un nerf ulnaire)
Reddy AS, Kvitne RS,Yocum LA, et al. Arthroscopy of the elbow: A long-term
clinical review. Arthroscopy. 2000;16(6):588-94.

Conclusion

Expérience limitée

Indications (et complexité)
augmentent

Repérage des reliefs osseux - marquage
des voies d’abords avant distension
capsulaire - Flexion du coude à 90°



Résultats encourageants

Incision de la peau uniquement

Bénéfice potentiel important

Pas d’hyperpression articulaire, shaver
sans aspiration

Risques non nuls

PREVENTION +++