The functional and clinical outcomes of primary and metastatic malignancies of the elbow.

OBJECTIVES: This study aims to investigate the etiological distribution of primary and metastatic malignancies around the elbow and the effect of surgical and adjuvant treatments on clinical outcome. PATIENTS AND METHODS: Between January 2006 and December 2020, medical records of a total of 33 patients with elbow neoplasm (15 males, 18 females; median age: 55 years; range, 39 to 71 years) who underwent surgical treatment and with or without clinical treatment were retrospectively analyzed. The outcomes and frequencies of the elbow metastatic and primary malignancies were evaluated. Data were collected from patients' medical and radiological documents, and a dedicated archive was created for this study. RESULTS: Most tumors occurred on the right side and were intra-articular or distal to the humerus. A total of 75.8% (25/33) of the patients had tumors of any diameter ≥5 cm. Most patients were treated with extensive resection. A total of 81.8% (27/33) of the patients had wide resected tumor margins, and 18.2% (6/33) had intralesional tumor margins. The median follow-up was 42 (range, 1 to 83) months. Synovial sarcoma and malignant peripheral nerve sheath tumors were the most common soft tissue sarcomas, and pulmonary adenoma and multiple myeloma were found in metastatic lesions. CONCLUSION: Elbow surgery is particularly challenging due to the interrelationship of major neurovascular structures. Synovial sarcoma and malignant peripheral nerve sheath tumors are the most common soft tissue sarcomas, and pulmonary adenoma and multiple myeloma are found in metastatic lesions. Limb-sparing surgery is the gold-standard method recently.

Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology.

AIM: To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI). MATERIALS AND METHODS: Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported. RESULTS: FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01). CONCLUSION: Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

Reconstruction of the proximal radius with 3D-printed personalized prosthesis after tumor resection: case series.

BACKGROUND: Giant cell tumor of bone (GCTB) (Campanacci III) or malignant tumors extend to the epiphyseal region of the proximal radius, and intra-articular resection of the proximal radius is often needed. In the present study, we present the patients who underwent reconstruction of the proximal radius with 3D-printed personalized prosthesis after tumor resection, aiming to describe the prosthesis design and surgical technique and evaluate the clinical outcomes of this method. METHODS: Between November 2018 and January 2021, 9 patients received radial hemiarthroplasty with 3D-printed personalized prostheses after tumor resection. The pathologic diagnosis was GCTB (Campanacci III) in 7 patients, osteosarcoma (IIB) in 1 patient, and synovial sarcoma (IIB) in 1 patient. The range of motion (ROM) and strength in terms of elbow flexion/extension and forearm supination/pronation were evaluated. Pain was assessed by the visual analog scale (VAS) preoperatively and at each follow-up visit. To evaluate the functional outcome, the Mayo Elbow Performance Score (MEPS) system and the Musculoskeletal Tumor Society (MSTS) scoring system were administered at each follow-up visit. Complications and oncological outcomes were recorded. RESULTS: The patients were followed from 24 to 51 months, with a median follow-up of 35 months. No patients were lost to follow-up. During the follow-up, local recurrence and metastasis were not observed. The VAS score improved from a median of 5 points (range 4-7) preoperatively to 1 point (range 0-2) at the last follow-up visit. The mean MEPS score was 88.5% (83-93), and the mean MSTS score was 25.3 (24-27) at the last follow-up visit. No complications such as infection and aseptic loosening were detected. CONCLUSIONS: The implantation of a 3D-printed personalized prosthesis after proximal radial resection showed excellent oncologic outcomes and postoperative function at short-term follow-up and is a viable alternative method for reconstruction of the proximal radius bone defect after tumor resection.

Ewing's sarcoma in a young man mimicking lateral elbow pain: A case report with 2 years follow-up.

BACKGROUND AND PURPOSE: Lateral elbow pain represents a common musculoskeletal disorder, mostly non-specific and benign. In rare cases, it can be the first symptom of a severe disease such as Ewing's sarcoma (ES). ES is the second most common primary malignant bone tumor in the young population, with a high probability of an unfavourable prognosis. CASE PRESENTATION: This case report presents the history of a young man presenting to the physical therapist with a diagnosis of "epicondylitis" in the right elbow, which was later revealed to be an aggressive ES of the ulna. Findings raising clinical doubts were (a) constant pain even at night and not dependent on load, (b) significant loss of function, (c) patient's young age, and (d) a palpable mass in the elbow. RESULTS: After diagnosis, the patient received medical (chemotherapy, radiotherapy and surgery) and a rehabilitation program. After treatment, the patient improved elbow function, decreased disability and returned to social participation, maintaining positive outcomes at the 2-year follow-up. DISCUSSION: In summary, this case report emphasizes the importance of differential diagnosis and screening for referral of red flags in physical therapy. Moreover, it describes the rehabilitation of a patient with ES, enriching the scientific literature in the field.

Epithelioid malignant peripheral nerve sheath tumour of the ulnar nerve around the elbow: a diagnostic and therapeutic challenge.

Epithelioid malignant peripheral nerve sheath tumour (EMPNST) is a rare histological subtype of malignant peripheral nerve sheath tumour (MPNST), accounting for 5% to 17% of MPNSTs. The clinical and MRI findings of EMPNST mimic those of nerve abscesses, similar to the presentation in Hansen's disease. We present one such case with this kind of diagnostic dilemma. Intraoperative findings suggest a tumour changed the course of management subsequently. The development of neurological deficits postoperatively after tumour resection was a reconstructive challenge. To provide motor power and sensation through a procedure that provides a complete functional outcome for a young patient, distal nerve transfers were chosen. This provided an improvement in the quality of life and hastened the neurological recovery of the involved limb. Level of evidence: V.

A malignant proliferating trichilemmal cyst arising on the elbow of a man: A case report and review of the literature.

INTRODUCTION: Trichilemmal cysts (TCs) are common benign cysts that form from the hair follicles in the skin. Proliferating trichilemmal cysts (PTCs) are rare types of TCs characterized by rapid cellular proliferation. Malignant transformation of PTC (MPTC) is a rare adnexal tumor that account for <0.1% of all skin cancers. TCs and PTCs are benign tumors; however, MPTCs grow rapidly and are prone to metastasis. CASE PRESENTATION: A 77-year-old man was referred to our hospital with a solitary pinkish mass on his left elbow. Trichilemmal carcinoma arising from a PTC was confirmed through excisional biopsy, and wide excision was performed. One month postoperatively, a cystic mass was observed and was suspected to have local recurrence; however, bursitis was confirmed after excisional biopsy. After 1 year of follow-up, the patient maintained an improvement without recurrence or any other surgical complications. CONCLUSIONS: In addition to being a very rare disease, MTPC occurred in the elbow of a man who does not fit the general etiology; therefore, it is considered an interesting case, and we report this case for academic contribution.

[Arthroscopic debridement of the extensor carpi radialis brevis]. / Arthroskopisches Débridement bei lateraler Epikondylitis.

Surgical treatment of lateral epicondylitis is reserved for patients who, despite extensive conservative therapy, do not experience satisfactory relief of symptoms. As an alternative to the open procedure, arthroscopic debridement of the extensor carpi radialis brevis (ECRB) muscle is a simple and standardized procedure. The arthroscopic approach also enables the additional treatment of intra-articular pathologies such as loose bodies or osteochondral lesions. After diagnostic arthroscopy, the attachment of the ECRB is visualized via the anteromedial portal, so that under visual control the debridement of the tendon fibers of the ECRB and its bony insertion site can be performed via the anterolateral portal. Postoperatively, there is no restriction of movement of the elbow joint. The outcome after arthroscopic ECRB debridement described in the literature is equivalent to that of other surgical techniques.

Rhabdomyosarcoma presenting as intramuscular haematoma due to brachioradialis tear after trauma.

A man in his 40s with a history of neurofibromatosis type 1 presented to the emergency department with worsening anterior elbow pain and swelling after falling from a chair 2 months prior. An X-ray showed soft tissue swelling without fracture and the patient was diagnosed with a rupture of the biceps muscle. MRI of the right elbow showed a brachioradialis tear with a large haematoma along the humerus. This was initially thought to be a haematoma; therefore, wound evacuation was done twice. When the injury failed to resolve, a tissue biopsy was performed. This revealed a grade 3 pleomorphic rhabdomyosarcoma. It is important to consider malignancy in the differential diagnosis with rapidly growing masses even if the initial presentation is suggestive of a benign condition. Neurofibromatosis type 1 is also associated with a higher risk of malignancy than the general population.

Use of Ultrasonography in Diagnosis of Medial Compartment Disease of the Elbow in Dogs.

OBJECTIVE: The objective of this prospective study was to evaluate the use of ultrasonography in the diagnosis of medial coronoid process disease in unclear cases. STUDY DESIGN: Fifteen elbows (on thirteen dogs) for which radiography and computed tomography did not lead to a clear diagnosis of medial coronoid process disease were included. On each elbow, ultrasonography was performed with a high frequency linear transducer (12-18Hz). Then, arthroscopic examination of the joint was performed by a surgeon who was unaware of ultrasonographic findings to confirm medial coronoid process disease. RESULTS: At least one ultrasonographic lesion was detected in 13 out of 15 elbows. The main reported ultrasonographic lesions were joint effusion (10/15 elbows) and an abnormal shape of the medial coronoid process (irregular, ill-defined or fragmented) (9/15). CONCLUSION: Ultrasonography can be a helpful additional diagnostic tool to confirm medial coronoid process disease of the elbow joint before performing arthroscopy in unclear cases. Further studies will be needed to evaluate the use of higher frequency transducers and determine if it could improve the diagnostic value of ultrasonography.

Anterior Elbow Heterotopic Ossification in Patient With Pemphigus Vulgaris: An Unheard Complication of a Rare Condition.

Pemphigus vulgaris is a potentially fatal disease within the epidermis with rare noncutaneous manifestations. Heterotopic ossification has not been previously described as one of the inherent complications of this skin pathology. A 44-year-old man presented with severe pemphigus vulgaris involving 80 to 90% of his body surface area. He had an extended time to wound closure of 5 months, as well as two additional months bed bound due to related infectious and respiratory complications. He progressively developed a worsening range of motion at his bilateral elbows. X-ray demonstrated bilateral anterior elbow heterotopic ossification. Passive and active range of motion exercises were initiated early in the course of his treatment and only yielded a small positive effect. Thus, screening for heterotopic ossification may be warranted when a significant joint range of motion is lost in cases of autoimmune cutaneous disease, and even more in the presence of severe open wounds with delayed wound closure.

Lipoma Arborescens of the Upper Extremity With Anatomic Variation of the Palmaris Longus: A Case Report.

CASE: We present a case of a patient who suffered from wrist swelling and had symptoms of carpal tunnel syndrome. The patient underwent ultrasound and magnetic resonance imaging, in which signs of joint effusion and a fatty synovial lesion were presented. The treatment included open excision of the tumor. In addition, the palmaris longus muscle had an anatomic variation with proximal and distal tendon portions. The histopathological examination disclosed lipoma arborescens of the synovial membranes of the joints. CONCLUSION: The recognition of this entity and its characteristics are important not only for correct diagnosis but also for the appropriate treatment.

Validation of a novel magnetic resonance imaging classification and recommended treatment for lateral elbow tendinopathy.

BACKGROUND: Lateral epicondylitis is one of the most common upper extremity problems presented to orthopedic surgeons. Despite a rapid and accurate arrival at a diagnosis by clinical examination, there exists no consensus classification for this condition, which hampers clinical approaches for treatment of the disease based on its severity. Thus, the aim of this study was to propose and valiadate a new magnetic resonance imaging (MRI) classification of lateral epicondylitis, staging by tendinosis, the degree of thickness tears of the common extensor tendon (CET) and bone bruise lesion. METHOD: MRI assessment of the elbow of 75 patients (57 women and 18 men; mean age:51.4 years (range,34-73) from Jan 2014 to Jan 2021 who were diagnosed with lateral epicondylitis were included in the study. MR images were reviewed retrospectively by two independent upper extremities orthopedists and one musculoskeletal radiologist. Inter- and intra-observer reliabilities for the classification were calculated using kappa statistics for the analysis of interrater agreement. Correlation between the stage of the disease and the duration of symptom before MRI was calculated using Kruskal-wallis test. RESULTS: Various degrees of CET lesions were demonstrated in this population (Stage I-17, IIA-7, IIB-22 and III-29). Intra-observer agreements of MRI staging were substantial to satisfactory. Inter-observer agreements were moderate to substantial. There was no significant correlation between the disease stage and the patient age or the duration of symptom before MRI. CONCLUSION: Our MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. At the end, we have suggeted a clearer direction for understanding the disease pathology as well as an appropriate management protocol for each stage of the disease in line with the recent body of literature.

Umbilicated papulonodules on the elbows with purpuric papules on the fingers.

This case describes an unusual cutaneous presentation. Our patient had purpuric papules on the fingers and umbilicated nodules over the elbows, and interestingly, both lesion types showed similar histopathological features of necrobiotic granuloma with neutrophils.

Comparison of arthroscopy versus percutaneous radiofrequency thermal ablation for the management of intra- and juxta-articular elbow osteoid osteoma: case series and a literature review.

BACKGROUND: Today, intra-articular and juxta-articular osteoid osteomas are treated with arthroscopy and radiofrequency thermal ablation. However, for the case of an elbow joint, arguments are made for the use of a minimally invasive technique to be the optimal choice. This study aims to analyse our experiences of arthroscopically treated elbow osteoid osteomas and to compare it with the published results of both techniques. METHODS: The retrospective study analyses the patients who underwent elbow arthroscopy ablation of an elbow osteoid osteoma at a single institution from January 2014 until March 2020. Clinical and diagnostic features, success and treatment failure rates, complications and tumour recurrence rates were all compared to 13 studies of intra-articular elbow osteoid osteoma arthroscopic ablation and 15 studies involving radiofrequency thermal ablation of intra-articular osteoid osteoma within different joints. RESULTS: Four males and two females, with a mean age of 19.3 years, were encompassed. All the patients had immediate postoperative pain relief and improved range of motion. No tumour recurrences were observed during a median of 21.7 months. The literature review yielded 86.4% success rate, 68.2% successful biopsies, one minor complication and no recurrences following the arthroscopic ablation of an elbow osteoid osteoma; while radiofrequency thermal ablation of an intra-articular elbow osteoid osteoma yielded 96.3% success rate, 33.3% successful biopsies, no complications and 3.7% recurrence rate. CONCLUSIONS: Our results are consistent with the published literature proving that arthroscopic ablation is an efficient method with low treatment failure rates and no recurrences in treating intra- and juxta-articular elbow osteoid osteomas. Advantages of arthroscopic ablation stem from the ability to visualise and safely deal with the lesion and the joint's reactive changes resulting in high biopsy rates, no recurrences and better postoperative elbow's range of motion. Still, the technique selection should be personalised considering the medical expertise of every institution.

Conservative treatment for stable osteochondritis dissecans of the elbow before epiphyseal closure: effectiveness of elbow immobilization for healing.

BACKGROUND AND HYPOTHESIS: Stable lesions of osteochondritis dissecans (OCD) of the capitellum have been treated with activity restriction (AR), and the complete healing requires 1 or 2 years. Little is known about the effectiveness of elbow immobilization. We hypothesized that elbow immobilization would have positive effects on healing of stable OCD. METHODS: The study subjects were 43 patients (mean age: 12.2 years) with 43 stable OCD lesions of the prematured elbow (mean skeletal age score: 17.1 points of 0-27 points system). The subjects were divided into 3 groups: group A, AR without elbow immobilization, 22 cases; group B, splint (mean: 8.8 weeks) followed by AR, 9 cases; and group C, cast (mean: 3.7 weeks) followed by splint (mean: 7.3 weeks) and AR, 12 cases. The mean nonoperative observation period was 17.5 months (minimum three months). On anteroposterior radiographs of the elbow at 45 degrees of flexion, 5 observers independently assessed the healing of the capitellum, and the interobserver and intraobserver reliabilities were examined. The differences in outcomes among 3 groups were also examined. RESULTS: The interobserver and intraobserver reliabilities of the radiographic assessment were almost perfect (Cohen kappa value: 0.82 and 0.91, respectively). There were no significant differences in age, sports played, or stage of the lesion before the treatment. The proportion of patients returning to sports and the mean period required were 77% and 8.2 months in group A, 78% and 5.7 months in group B, and 83% and 4.4 months in group C, respectively. The proportion of patients showing ossification in the central aspect of the capitellum and the mean period required were 67% and 8.2 months in group A, 63% and 4.9 months in group B, and 91% and 1.9 months in group C, respectively. The proportion of patients showing complete healing and the mean period required were 41% and 16.4 months in group A, 67% and 7.0 months in group B, and 92% and 5.5 months in group C, respectively. Compared to group A, group C showed a significantly earlier return to sports (P = .034), a significantly shorter period required for ossification (P < .001), and significantly higher proportion of patients with complete healing (P = .012) within a significantly shorter period (P = .009). CONCLUSION: Elbow immobilization had positive effects on healing and enabled both an early return to sports and complete healing. Cast immobilization is recommended as a first choice of nonoperative treatment for stable OCD lesions of the elbow before epiphyseal closure.

Monarticular rheumatoid arthritis of the elbow.

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterised by symmetric inflammatory polyarthritis. However, RA limited to a single joint is extremely rare. Here, we report a middle-aged woman who presented with insidious right elbow arthritis. She had no other peripheral joint pain, tenderness or swelling. She had high-positive anti-cyclic citrullinated peptide antibodies. An MRI of the right elbow showed capsular distension, joint effusion and bone marrow oedema. Synovial biopsy revealed hyperplasia with lymphoplasmacytic infiltrate consistent with RA. Therapy with methotrexate 7.5 mg orally weekly was effective to control her inflammatory arthritis. This case highlights the relevance of synovial tissue analysis for patients presenting with chronic inflammatory monarthritis when the cause is not clinically evident, and the importance of considering RA even in the absence of polyarticular involvement. Delayed diagnosis and treatment of inflammatory monarthritis can lead to joint destruction and disability.

Radiocapitellar incongruity of the radial head in magnetic resonance imaging correlates with pathologic changes of the lateral elbow stabilizers in lateral epicondylitis.

OBJECTIVE: Post-traumatic posterolateral rotatory instability (PLRI) can be shown as radiocapitellar incongruity or posterior translation (PT) of the radial head in magnetic resonance imaging (MRI). We aimed to evaluate whether PT correlated with pathologic changes of lateral elbow stabilizers in patients with lateral epicondylitis. MATERIALS AND METHODS: In MRIs of 160 patients with lateral epicondylitis, we measured PT of the radial head in the sagittal images. We qualitatively graded five lesions of the lateral elbow structures that included common extensor tendon (CET) lesion (grade 1-3), lateral collateral ligament complex (LCLC) insufficiency (grade 0-2), and absence or presence of bone marrow signal change, osteochondral lesion, and calcification. We analyzed whether the PT correlated with pathologic changes of the lateral elbow stabilizers and evaluated the diagnostic value of the PT for severe lesions. RESULTS: The average PT was 1.9 mm. The PT correlated with both the CET lesion (p < 0.001) and LCLC insufficiency (p < 0.001). The optimal cutoff values of the PT for grade 3 CET lesion and grade 2 LCLC lesion were 2.6 and 2.8 mm, respectively. When potential PLRI was defined as the PT of > 3.4mm as suggested for post-traumatic PLRI, 21 patients had potential PLRI. The positive predictive values of the PT > 3.4mm were 76% for grade 3 CET lesions and 67% for grade 2 LCLC insufficiency. CONCLUSION: This study demonstrates that PT of the radial head correlates with pathological changes of the lateral elbow stabilizers. As radiocapitellar incongruity is easy to measure quantitatively, it can be used for screening potential PLRI in patients with lateral epicondylitis.

Kitchen elbow sign predicts surgical outcomes in adults with spinal deformity: a retrospective cohort study.

Kitchen elbow sign (KE-Sign) is a skin abnormality on the extensor side of the elbow and forearm that is often observed in patients with adult spinal deformity (ASD). The significance of KE-Sign in surgical cases was investigated. Overall, 114 patients with ASD treated with long spinal fusion were reviewed and divided into KE-Sign positive and negative groups. The preoperative and 1-year follow-up evaluations included radiographic parameters [C7 sagittal vertical axis (SVA), pelvic incidence (PI) and lumbar lordosis (LL)], the Oswestry Disability Index (ODI), visual analogue scales (VASs) for low back pain, leg pain, and satisfaction, and Short Form 36 questionnaire (SF-36). Multi-regression analysis was performed to identify patient satisfaction predictors and improvement in the ODI as dependent variables and preoperative background factors as independent variables. Preoperative characteristics showed no significant difference between both groups. Improvement in the ODI and VAS for satisfaction were significantly superior in the KE-Sign positive group. In multiple regression analysis, KE-Sign and preoperative ODI were significantly associated with improvement in the ODI; age, KE-Sign, preoperative low back pain VAS, and leg pain VAS were significantly associated with satisfaction. KE-Sign can be a predictor of better surgical outcomes in ASD patients.