Elbow arthroscopy is a procedure of increasing interest for the treatment of a wide range of acute and chronic elbow pathologies. Despite the wide use of this technique in adults, literature about arthroscopic management of elbow pathologies in pediatric patients is still limited. In recent years, some authors, such as Micheli et al. [9], Vavken et al. [8], and Andelman et al. [3] have shown the main indications and results of elbow arthroscopy in the pediatric population.
In this study, we performed elbow arthroscopy for three main diagnoses: posttraumatic elbow stiffness, osteochondritis dissecans, and posterior impingement.
Our PTS group was made up of children who suffered significant elbow ROM limitation following conservative or surgical treatment for past elbow fracture (75% of cases) or other traumatic injuries: after arthroscopic arthrolysis we found an important ROM improvement for these patient at 60 months follow-up, as expected. These improvement are mainly in flexion, but extension, supination, and pronation also improved significantly. All our patients exceeded the limit of functional arc of motion identified by Morrey et al. [22] and they managed to fulfill all daily activities without any limitation (Fig. 4a, b). In this group, pain limited the ROM preoperatively. Arthroscopic arthrolysis was also effective in pain relief: patients gave an overall VAS score of 0.6 (SD: 0.8, P = 0.0007) points and 93.8 (SD: 8.6, P = 0.0051) points on MEPS, achieving excellent postoperative results. In the literature, we find similar outcomes [3, 9, 23, 24] which confirm our findings about the use of arthroscopic arthrolysis for posttraumatic elbow stiffness in reducing pain and increasing ROM.
Elbow arthroscopy in OCD treatment is considered the gold standard technique in the pediatric population, with excellent clinical results reported in the literature [3, 23, 25,26,27]. We performed arthroscopic debridement associated with microfractures in 56% of the cases, obtaining satisfactory long-term results. Several patients in the OCD group had a significant limitation in both sport and daily activities secondary to pain rather than capsular stiffness. In these patients, we observed the greatest VAS score improvement, from 6.4 points (SD: 1.4) preoperatively to 0.8 points (SD: 0.8, P: < 0.0001) after arthroscopy. As a result of reduced pain, the MEPS score and postoperative ROM also showed a significant improvement that contributed to patient satisfaction, albeit lower than the other groups.
In the PI group, we included patients with osteophytes, olecranon spur, or loose bodies in the posterior compartment that limited the elbow extension. As reported in the literature, this study confirmed a higher incidence in those patients involved sports with overloading of the upper limbs (baseball and volleyball) [17,18,19]. In the PI group, the greatest increase in elbow extension was reported [from 37.5° (SD: 9.6) to 5.0° (SD: 4.1); P = 0.0049], achieving a functional final ROM sufficient to fulfill all the activities of daily living. Interestingly, no patient reported any pain, and postoperative MEPS score was 100 points for all patients.
To make a complete evaluation of the clinical results, it is important not only to evaluate objective data but also consider the patient’s opinion regarding their expectations. For this reason, we decided to investigate patient postoperative satisfaction, finding an average increase of 4.5 points (SD: 0.7) with no dissatisfaction, which confirms the effectiveness of the procedure.
Return to sport was one of the main goals of our patients who suffered from elbow disease. After surgery on a pediatric patient, the full recovery of sport performance is a fundamental element for both the psychic and physical development of the child, and for these reason, we believe this should be considered an important outcome measure. Eighty-seven percent of our patients were able to return to their previous level of sport, continuing their athletic careers without problems. Similar results are presented in pediatric literature, in which most studies reported a high rate of sports performance after elbow arthroscopic surgery [9, 27, 28]. Two of our patients (9%) changed their sport activity after arthroscopy, one from the PTS group and the other from the OCD group. These patients reported a feeling of fear practicing their old sport (volleyball and rugby) rather than a real impossibility related to elbow functionality. For this reason, they changed the type of sport achieving good–excellent results in the new discipline anyway. Byrd et al. [28] reported some similar cases: sometimes young nonprofessional athletes preferred to change sport and start a new career, avoiding the risk of further elbow injuries. In conclusion, in our study, only one patient (4%) was unable to return to their previous sport (baseball) due to the onset of a major complication. These positive results are further evidence of the effectiveness of elbow arthroscopy in the pediatric population. However, we must consider that in our study population, there were only a few professional athletes in disciplines that overload the upper limbs, and this may have positively influenced the results.
In the available literature, the overall complication rate for elbow arthroscopy ranged from 6% to 14% [1, 2, 29,30,31,32] in large series studies in adults. Although these complications were mostly self-resolving, without requiring further surgical procedures, this complication rate is still higher than other joint arthroscopies such as knee, shoulder, or hip. The first studies on pediatric elbow arthroscopy reported a lower complication rate compared with adults: Micheli et al. [9] showed no postoperative complications (0%) while Vavken et al. [8] found a minor complication rate of 8%. However, Andelman et al. [3] reported a complication rate of 17.2%, although this is most likely the result of the high number of complex procedures performed in their study.
We reported a complication rate of 7.7% after long-term follow-up, with a major complication (triceps insertional tendinopathy) that required further open surgery and a minor complication (heterotopic ossifications) treated conservatively.
The major complication was identified in a patient undergoing arthroscopic posterior compartment debridement, removal of osteophytes, and removal of loose bodies for elbow posterior impingement. During the rehabilitation protocol, this patient showed poor results with persistent pain and functional limitation due to triceps insertional tendinopathy highlighted by ultrasound examination. This was subsequently treated with an open debridement of damaged tissues and tendon repair performed a few months after the first procedures. After this second procedure, the patient reached a good functional outcome, with 85 points on MEPS score, returning to the previously level of baseball.
Heterotopic ossifications appear to be a less common finding after elbow arthroscopy than after open procedures, but Gofton et al. [33] predicted an increased incidence due to the expansion of the arthroscopy for more complicated procedures than in the past. In the literature, the reported incidence rate ranges from 0.4% to 2.5% [2, 31, 34] in large adult population studies, with a high percentage of cases requiring reoperation. To our knowledge, only a study by Sodha et al. [35] identified heterotopic ossifications in a young throwing athlete. In our study, we reported a single case of heterotopic ossification in a girl treated with arthroscopic arthrolysis, removal of loose bodies, and osteophytes for posttraumatic stiffness after lateral condyle fractures (Fig. 5a, b). This patient reported excellent outcome measures and no significant ROM limitation. For this reason, a reoperation was not necessary at the final follow-up, unlike in other studies. More studies are needed to determine the increased risk and to identify the appropriate prophylaxis for heterotopic ossifications after elbow arthroscopy in the pediatric population.
We did not detect any other pathological finding with the postoperative X-ray, especially any alteration of the skeletal maturation (malalignments, growth defects), demonstrating the reduced invasiveness and safety profile of elbow arthroscopy.
A significant result of this study was the absence of neurovascular injuries despite the proximity of the arthroscopic portals to these structures. These are the most frequent complications reported in literature after elbow arthroscopy [1, 2, 30, 31]. To avoid risks, exact anatomical knowledge of the complex elbow anatomy and the experience of the surgeon are essential, especially in the pediatric population [29]. Despite the growing practice of elbow arthroscopy, there is a paucity of literature about the surgical learning curve. Only Keyt et al. [36] identified a minimum threshold of 230 elbow arthroscopies to achieve expert level performance. Generally, pediatric elbow arthroscopy is performed only by experienced surgeons to avoid the risk of permanent damage in this particular population. Probably this is a factor that justifies the low complication rate reported in our study, as in in other investigations on the pediatric population [8, 9]. Surgical technique has several constantly developing features, including patient decubitus position (lateral, supine, prone), number of portals (four principals and some accessories portals), procedure stages (anterior or posterior compartment first), and device features. From the analysis of the available literature, it is not possible to identify a gold standard [3, 8, 23, 37]. We believe that, given the difficulty and the experience required to perform these procedures, surgeons who perform a pediatric elbow arthroscopy should choose the surgical technique in which they are most experienced, to minimize the risks.
Our study has some limitations. First of all, this is a retrospective study with no control group. The small sample size is mainly due to the rarity of this pathology. Another important limitation is the heterogeneity of indications for arthroscopic procedures that limits the number of patients for each group and, thus, weakens the statistical significance. The long-term follow-up time is the strength of this work, providing a longer prospective to observe the development of outcomes and complications.
