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Pathologie sportive ethyperutilisation - rupture biceps,
tricepsChristian Dumontier
Institut de la main & hopital Saint Antoine, Paris
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Lésions du biceps
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Lésions du biceps
Tendinopathies (souvent associées aux lésions du brachialis)
Ruptures
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Tendinopathies du biceps
Très rares
Sports nécessitant des flexions répétés à partir de l’extension forcée du coude
Gymnastique
Bowling
Haltérophilie
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Tendinopathies du biceps
Douleur antérieure
!!par la flexion/supination contrariée
Radiographies normales
TTT conservateur: repos, AINS, rééducation
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Rupture du biceps 3-10% des ruptures du biceps
Homme de la quarantaine,
Membre dominant,
Flexion forcée à 90° ou extension forcée sur un biceps contracté
Traumatisme violent +++ (corticoïdes)
Diagnostic clinique
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Imagerie ?
Pas de façon habituelle
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Traitement
Toujours chirurgical si on souhaite récupérer force et endurance en supination
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Question: Peut-on ramener le tendon
en position anatomique ?
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Technique(s)
2 voies d’abord pour éviter les lésions du nerf radial (Boyd & Anderson, 1961) mais risque de synostose
the brachialis, therefore, gained popularity in the 1940s and 1950s to avoid theseneurovascular complications [2,6]. In 1961, Boyd and Anderson [46] introduceda two-incision technique to minimize this risk. The approach they developed in-corporated a second posterolateral incision, which by fully pronating the forearm,exposed the radial tuberosity in the second incision and obviated the need fordeep dissection in the antecubital fossa. Reports of radioulnar synostosis began tosurface with the introduction of this technique [33,40,47–49]. It was thereforesubsequently modified by Failla et al [47], who added a muscle splitting approachthrough the common extensor tendon to avoid subperiosteal exposure of the ulna(Fig. 2). Theoretically, this decreased the risk of radioulnar synostosis andheterotopic ossification.
The recent advent of suture anchor technology has brought forth a renewedinterest in the single-incision techniques [18,41,50–54]. Other novel single-
Fig. 2. The two-incision technique, using a limited posterolateral incision and exposure of the radial
tuberosity with pronation of the forearm. (From Morrey BF. Injury of the flexors of the elbow: biceps
in tendon injury. In: Morrey BF, editor. The elbow and its disorders. 3rd edition. Philadelphia: W.B.
Saunders Co.; 2000. p. 473; with permission.)
A.F. Vidal et al / Clin Sports Med 23 (2004) 707–722712
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Technique(s)
1 voie d’abord avec utilisation d’ancres
1 voie d’abord endoscopique
incision variations, such as repair over an Endobutton (Acufex, Microsurgical,Mansfield, Massachusetts) are also being reported [51] (Fig. 3).
Treatment of partial ruptures
Partial biceps tendon ruptures are extremely rare injuries, with fewer than30 described in the literature [14]. They typically result in less of a functional lossthan their complete counterparts when treated nonoperatively [12]. Conservativemanagement is recommended initially for these injuries [12–14,28,30,34,55].Acute partial ruptures can be safely observed, and are typically noted to becomeasymptomatic within 6 weeks [34]. Conservative management entails rest andanti-inflammatory medication. The elbow is typically immobilized for 1 week,followed by dynamic flexion-assisted hinged bracing to protect the injuredtendon. After about 6 to 8 weeks, the brace can be discontinued and strengtheningexercises and unrestricted motion can be started. Full activity can typically beresumed within 4 months [55].
Surgical treatment is reserved for refractory cases [13,14]. Release and de-bridement of the damaged tendon and anatomic reinsertion to the radial tuber-osity, either through a single- or double-incision technique, are recommended[12–14,30]. Bourne and Morrey suggested that tendon release, debridement, andreattachment avoid the persistent pain and weakness that can be associated withsimple primary repair [13].
Fig. 3. Suture anchors being placed in prepared tuberosity using modern single-incision technique
(From Morrey BF. Injury of the flexors of the elbow: biceps in tendon injury. In: Morrey BF, editor.
Master techniques in orthopaedic surgery: the elbow. Philadelphia: Lippincott Williams & Wilkins;
2002. p. 182; with permission.)
A.F. Vidal et al / Clin Sports Med 23 (2004) 707–722 713
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Suites post-op
Immobilisation dans une attelle 6 semaines
Interdiction de flexion forcée pendant 8 à 12 semaines
Reprise du sport 4-6 mois
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Résultats
Bons à très bons sauf chez les sportifs de haut niveau
Mobilité complète
"!30% force et 30% endurance en supination pour les réinsertions anatomiques
"!50% force/endurance en supination et 20-30% en flexion en l’absence de traitement
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Lésions du triceps
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Le triceps est un extenseur du coude
Il est sollicité dans les sports qui nécessitent une extension forcée et répétitive
Sports de lancer
Sports de raquette
Gymnastique
Boxe
Haltérophilie
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Lésions du triceps
Pathologie de l’éperon olécranien
Tendinopathies
Rupture
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PATHOLOGIE DE L'EPERON OLECRANIEN
Sports : lancer, tennis++ Age moyen : 40 ans Brutal (smash), progressif Palpation isométrique Radio : éperon olécranien
Fracture et déplacementTt médical : repos, physio, ains, infiltrationTt chirurgical : excisionSport = 6 semaines
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Tendinopathies du triceps
Douleurs postérieures, ! 1 cm au-dessus de l’olécrane, augmentées par lacontraction contrariée
Radiographies sont normales
Traitement: Repos, AINS, puis rééducation avec renforcement et étirement - Très efficace
Pas d’infiltration
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Chirurgie ?
Très rarement indiquée
Peignage du tendon
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Dg Différentiel ?
Synovite
Palpation du triangle externe
Corps étrangers
Radiographies, arthroscanner, clinique !
Fracture de fatigue de l’olécrane
Sports de lancer (23 ans d’âge)
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Rupture du triceps
Très rares, 0,8% des 1014 lésions tendineuses du membre supérieur (< 50 case report)
Tous âges, moyenne 33 ans
Facteurs favorisants: insuffisance rénale, hyperparathyroïdie, quinolones, infiltrations (corticoïdes), ...
Mécanisme: contraintes excentriques sur un triceps contracté (chute) ou choc direct
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Rupture du triceps
Douleurs, faiblesse de l’extension active - diagnostic difficile
Déficit palpable (16/23)
Test de Thompson “modifié”
Ruptures partielles > totales (15/8 dansla série de la Mayo clinic)
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Rupture du triceps
Fréquents arrachements osseux sur les radiographies
Echo / IRM
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RETROSPECTIVE CHART REVIEWAt our institution, 15 patients with 16 acute closed
ruptures of the triceps tendon were treated from 1976 to2001. Triceps tendon ruptures occurring in patients withprevious total elbow arthroplasties were excluded. The finalcohort consisted of 12 male patients and 3 female patientswith a mean age of 50 years (range, 16-71 years). None ofthe patients had a history of chronic renal failure, dialysis,hyperparathyroidism, or long-term steroid use. Only 1 pa-tient (case report) had a history of past anabolic steroid use.The patients’ occupations varied significantly, and the in-jury occurred during work in 2 patients (Table I). The injury
occurred on the right side in 10 and on the left in 6. Themechanism of injury was associated with trauma in 12patients and without trauma in 3. Two of the atraumaticruptures occurred after septic olecranon bursitis. The mostcommon pattern was an avulsion of the triceps insertion intothe olecranon, occurring in 13 elbows, 3 of which werepartial avulsions at the time of injury and were treatednonoperatively. An intratendinous rupture occurred in 2elbows, and an intramuscular rupture occurred in 1. Preop-erative triceps strength testing was available in 13 of 16elbows. All elbows except 1 had a deficit on examination,ranging from 2/5 to 4/5 on manual muscle strength testing.
Figure 1 A and B, T2-weighted magnetic resonance images of right and left elbows demonstrating completeavulsion of triceps tendon from the olecranon. The triceps has retracted approximately 2 cm on the right andapproximately 1 cm on the left. There is associated soft-tissue edema and fluid collections bilaterally.
Figure 2 A and B, Intraoperative pictures demonstrating repair of triceps tendon to bone with large No. 2Fiberwire sutures, which have been run in a Krakow-type stitch through the detached triceps tendon. The 4 Ethibondtails extending from the torn triceps tendon have been passed through 3 holes from proximal to distal through theolecranon, angling dorsally. The 2 middle limbs were brought through the middle hole, and 1 limb each wasbrought through the medial and lateral hole and tied with the arm held in approximately 35° to 40° of flexion fortensioning. This same type of repair was used in the patient with bilateral triceps tendon ruptures.
J Shoulder Elbow Surg Sierra et al 131Volume 15, Number 1
RETROSPECTIVE CHART REVIEWAt our institution, 15 patients with 16 acute closed
ruptures of the triceps tendon were treated from 1976 to2001. Triceps tendon ruptures occurring in patients withprevious total elbow arthroplasties were excluded. The finalcohort consisted of 12 male patients and 3 female patientswith a mean age of 50 years (range, 16-71 years). None ofthe patients had a history of chronic renal failure, dialysis,hyperparathyroidism, or long-term steroid use. Only 1 pa-tient (case report) had a history of past anabolic steroid use.The patients’ occupations varied significantly, and the in-jury occurred during work in 2 patients (Table I). The injury
occurred on the right side in 10 and on the left in 6. Themechanism of injury was associated with trauma in 12patients and without trauma in 3. Two of the atraumaticruptures occurred after septic olecranon bursitis. The mostcommon pattern was an avulsion of the triceps insertion intothe olecranon, occurring in 13 elbows, 3 of which werepartial avulsions at the time of injury and were treatednonoperatively. An intratendinous rupture occurred in 2elbows, and an intramuscular rupture occurred in 1. Preop-erative triceps strength testing was available in 13 of 16elbows. All elbows except 1 had a deficit on examination,ranging from 2/5 to 4/5 on manual muscle strength testing.
Figure 1 A and B, T2-weighted magnetic resonance images of right and left elbows demonstrating completeavulsion of triceps tendon from the olecranon. The triceps has retracted approximately 2 cm on the right andapproximately 1 cm on the left. There is associated soft-tissue edema and fluid collections bilaterally.
Figure 2 A and B, Intraoperative pictures demonstrating repair of triceps tendon to bone with large No. 2Fiberwire sutures, which have been run in a Krakow-type stitch through the detached triceps tendon. The 4 Ethibondtails extending from the torn triceps tendon have been passed through 3 holes from proximal to distal through theolecranon, angling dorsally. The 2 middle limbs were brought through the middle hole, and 1 limb each wasbrought through the medial and lateral hole and tied with the arm held in approximately 35° to 40° of flexion fortensioning. This same type of repair was used in the patient with bilateral triceps tendon ruptures.
J Shoulder Elbow Surg Sierra et al 131Volume 15, Number 1
Rupture avec rétraction 1 cm Rupture avec rétraction 2 cm
Sierra, JSES 2006
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Rupture du triceps
Les ruptures partielles peuvent être traitées de façon conservative (attelle 4 semaines, 30° flexion)
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Rupture du triceps Les ruptures complètes sont traitées chirurgicalement, les sportifs peuvent reprendre après 12 semaines (3-6-8-12) (force 82% nle, Van Riet 2003)
RETROSPECTIVE CHART REVIEWAt our institution, 15 patients with 16 acute closed
ruptures of the triceps tendon were treated from 1976 to2001. Triceps tendon ruptures occurring in patients withprevious total elbow arthroplasties were excluded. The finalcohort consisted of 12 male patients and 3 female patientswith a mean age of 50 years (range, 16-71 years). None ofthe patients had a history of chronic renal failure, dialysis,hyperparathyroidism, or long-term steroid use. Only 1 pa-tient (case report) had a history of past anabolic steroid use.The patients’ occupations varied significantly, and the in-jury occurred during work in 2 patients (Table I). The injury
occurred on the right side in 10 and on the left in 6. Themechanism of injury was associated with trauma in 12patients and without trauma in 3. Two of the atraumaticruptures occurred after septic olecranon bursitis. The mostcommon pattern was an avulsion of the triceps insertion intothe olecranon, occurring in 13 elbows, 3 of which werepartial avulsions at the time of injury and were treatednonoperatively. An intratendinous rupture occurred in 2elbows, and an intramuscular rupture occurred in 1. Preop-erative triceps strength testing was available in 13 of 16elbows. All elbows except 1 had a deficit on examination,ranging from 2/5 to 4/5 on manual muscle strength testing.
Figure 1 A and B, T2-weighted magnetic resonance images of right and left elbows demonstrating completeavulsion of triceps tendon from the olecranon. The triceps has retracted approximately 2 cm on the right andapproximately 1 cm on the left. There is associated soft-tissue edema and fluid collections bilaterally.
Figure 2 A and B, Intraoperative pictures demonstrating repair of triceps tendon to bone with large No. 2Fiberwire sutures, which have been run in a Krakow-type stitch through the detached triceps tendon. The 4 Ethibondtails extending from the torn triceps tendon have been passed through 3 holes from proximal to distal through theolecranon, angling dorsally. The 2 middle limbs were brought through the middle hole, and 1 limb each wasbrought through the medial and lateral hole and tied with the arm held in approximately 35° to 40° of flexion fortensioning. This same type of repair was used in the patient with bilateral triceps tendon ruptures.
J Shoulder Elbow Surg Sierra et al 131Volume 15, Number 1
RETROSPECTIVE CHART REVIEWAt our institution, 15 patients with 16 acute closed
ruptures of the triceps tendon were treated from 1976 to2001. Triceps tendon ruptures occurring in patients withprevious total elbow arthroplasties were excluded. The finalcohort consisted of 12 male patients and 3 female patientswith a mean age of 50 years (range, 16-71 years). None ofthe patients had a history of chronic renal failure, dialysis,hyperparathyroidism, or long-term steroid use. Only 1 pa-tient (case report) had a history of past anabolic steroid use.The patients’ occupations varied significantly, and the in-jury occurred during work in 2 patients (Table I). The injury
occurred on the right side in 10 and on the left in 6. Themechanism of injury was associated with trauma in 12patients and without trauma in 3. Two of the atraumaticruptures occurred after septic olecranon bursitis. The mostcommon pattern was an avulsion of the triceps insertion intothe olecranon, occurring in 13 elbows, 3 of which werepartial avulsions at the time of injury and were treatednonoperatively. An intratendinous rupture occurred in 2elbows, and an intramuscular rupture occurred in 1. Preop-erative triceps strength testing was available in 13 of 16elbows. All elbows except 1 had a deficit on examination,ranging from 2/5 to 4/5 on manual muscle strength testing.
Figure 1 A and B, T2-weighted magnetic resonance images of right and left elbows demonstrating completeavulsion of triceps tendon from the olecranon. The triceps has retracted approximately 2 cm on the right andapproximately 1 cm on the left. There is associated soft-tissue edema and fluid collections bilaterally.
Figure 2 A and B, Intraoperative pictures demonstrating repair of triceps tendon to bone with large No. 2Fiberwire sutures, which have been run in a Krakow-type stitch through the detached triceps tendon. The 4 Ethibondtails extending from the torn triceps tendon have been passed through 3 holes from proximal to distal through theolecranon, angling dorsally. The 2 middle limbs were brought through the middle hole, and 1 limb each wasbrought through the medial and lateral hole and tied with the arm held in approximately 35° to 40° of flexion fortensioning. This same type of repair was used in the patient with bilateral triceps tendon ruptures.
J Shoulder Elbow Surg Sierra et al 131Volume 15, Number 1
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Epitrochléïte
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Epitrochléïte
4 à 7 fois moins fréquente que l’épicondylite
Golfer’s elbow (javelot, pitchers)
Sujet de la quarantaine (sauf lanceurs 15-25 ans)
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Epitrochléïte
Douleur médiale de l’insertion des épitrochléens sur l’épitrochlée
!!Pronation contrariée (+/- flexion poignet)
Se méfier:
D’une atteinte du nerf ulnaire (60%)
D’une atteinte du LLI chez les lanceurs
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Traitement médical
“Repos”, AINS, Orthèses, agents physiques
Conseils sportifs (échauffement, étirement, travail isométrique, glace)
IF si la douleur persiste
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Neurolyse parfois associée si souffrance nerveuse et/ou
instabilité du nerf
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Résultats
Plutôt bons (! 80-90%) chez les athlètes
Sans lésions nerveuses associées (! 50-60% de bons résultats)
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Epicondylite
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“Tennis elbow”
10 à 50% des joueurs de tennis amateurs
Autour de la quarantaine
Souffrent ou souffriront d’un “tennis elbow”
La moitié 6 mois, l’autremoitié 2 ans 1/2
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Que dire que vous ne sachiez déjà ?
Etre certain du diagnostic !
Il n’existe aucune donnée scientifique validée sur la physiopathologie ou les traitements médicaux !
Que très peu ( < 10%) nécessiteront un geste chirurgical, technique pas plusvalidée que les autres !
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Il n’est pas nécessaire de jouer au tennispour souffrir du coude (95% des patients ne savent pas tenir une raquette)
1 à 3% de la population
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Diagnostic Chez les athlètes, seuls les tennismen souffrent d’un “tennis elbow” (baseball, lancer)
La douleur apparaît lors du revers
Contraintes excentriques sur des muscles contractés
Le coude étant en extension-supination
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Physiopathologie
Inconnue
“Angiofibroblastic tendinosis”
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Diagnostic +
Douleur externe, sur l’insertion du tendon conjoint
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Diagnostic +
! extension (supination) contrariée du poignet, coude en extension et pronation
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Diagnostic +
! extension contrariée du majeur,coude en extension et pronation " souffrance NIOP
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Diagnostic +
Douleur externe, sur l’insertion du tendon conjoint
! extension (supination) contrariée du poignet, coude en extension et pronation
!Parfois déficit d’extension du coude
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Diagnostic associé/différentiel ?
Atteinte intra-articulaire ?
11% dans la série opératoire de Nirschl
60% dans la série arthroscopique de Baker
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Diagnostic associé/différentiel ?
Atteinte du nerf radial ?
5% maximum des cas
Présentation différente (siège des douleurs, horaires)
Notion de mvts répétés de supination
EMG + (?)
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Diagnostics différentiels
Neurologique (musculo-cutané)
Musculaire
Ostéo-articulaire
Vasculaire
Autres ...
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Lésions ostéo-articulaires
Testing isométrique des épicondyliens normal +++
Les radiographies simples sont obligatoires
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Fracture fatigue
Trouble de croissance
Tumeur(s)
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Lésions musculaires
Claquage
Syndrome de loge (d’effort)
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PATHOLOGIE VASCULAIRE
Piégage par une arcade fibreuse
Traitement chirurgical
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Traitement
“facts, myths and vaudoo”
“is there any science out here ?”
Tout a été écrit, y compris son contraire, les résultats sont “bons” dans80% des cas
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Traitement Modification sportive (grip, poids raquette, poids entête, tension du cordage,...)
Limitation des activités physiques
Orthèses
Rééducation (MTP, auto-kiné,...)
Infiltrations
Acupuncture, ostéopathie
Ondes de choc
Injection de sang autologue, Trinitrine, Botox
A essayer plusieurs mois
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Chez le sportif
56% des joueurs reprennent à 6 mois,
77% à 1 an,
90% à 4 ans pratiquent le tennis
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En cas d’échec du TTT médical
Reposer le diagnostic
Imagerie ?
Echographie
IRM
Les radios standards sont faites au début !
Proposer la chirurgie
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Le TTT chirurgical
Section/désinsertion du tendon conjoint
Per-cutané
Ciel ouvert
Arthroscopie
Variantes multiples en fonction des gestes associés (neurolyse du radial, ouverture
articulaire, dénervation épicondyle, plasties
musculaires),
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Le traitement arthroscopique ?
Introduction en 1993, puis 1995 (en Anglais) d’un traitement endoscopique
Introduction en 1998-2000 d’un traitement arthroscopique
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• L’extensor carpi radialis brevis s’insère sur l’épicondyle juste au dessus du ligament annulaire
• Son insertion arthroscopique est parfaitement visible
• Sa désinsertion arthroscopique est
possible
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• Préservation des autres épicondyliens
• Diagnostic et traitement des pathologies intra-articulaires associées (11% dans la série de Nirschl)
• Diminution de la morbidité et de la durée d’incapacité
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Absence de geste associé sur le NIOP
Impossibilité de rattacher l’extensor carpi radialis brevis
Perte de force ?
Risque de déstabilisation latérale
Lésion du LLE ?
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• Arthroscopie du coude
• Prone position de Poehling
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Type I = capsule intacte
Type II = capsule déchiréelongitudinalement
Trois types selon l’état de la capsule
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Type III = rupture capsulaire
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Les instruments sont introduits dans la voie proximo-latérale sinon on passe dans l’ECRB
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Sur le plan pratique
Résection au shaver de la capsule et de l’ECRB
m = 23 mm, (tout l’ECRB)
Débridement à la fraise de l’épicondyle
m = 22 mm, (sans danger pour le lgt latéral)
Dénervation ? Je ne le fais pas habituellement
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