Rob Hartzler:
Welcome to the Arthroscopy Association's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
Rob Hartzler:
Greetings, this is Rob Hartzler with TSAOG Orthopedics in San Antonio. Today on the podcast we have the pleasure of speaking with a man who certainly needs no introduction. Dr Larry Field, current President of ANA, the Arthroscopy Association of North America and a shoulder and elbow specialist at Mississippi Sports Medicine and Orthopedic Center. Dr. Field, welcome to the podcast.
Dr. Larry Field:
Well, thank you Rob, thanks for the opportunity. I look forward to participating.
Rob Hartzler:
Today we're going to be discussing your article and infographic from July, 2019, entitled Elbow Arthroscopy Made Simple, Indications and Techniques. First Dr. Field, congratulations on this infographic.
Dr. Larry Field:
Well thank you again Rob. It was a pleasure and honor to be invited to contribute. And these infographics I just have to say are exciting. They are new form of this kind of graphic visual representations of information, the arthroscopy journal has done a great job, there are a lot of infographics. I encourage Journal of Arthroscopy subscribers to enjoy those, they're really informative.
Rob Hartzler:
Yeah, I think the infographics are great. I mean they certainly convey information very quickly and efficiently and hopefully drive the reader observer to a further study on the topic. So I think they're great too. Before we get started on the actual infographic, I just wanted to go over kind of your history... in getting ready for the podcast, I was looking back over your training and I had forgotten or maybe never known that you did fellowship up at HSS in New York.
Dr. Larry Field:
Correct.
Rob Hartzler:
Is that where you got started doing elbow arthroscopy, were they doing that at that time there? How you learn how to do this?
Dr. Larry Field:
Yeah, I did. There are a couple of individuals that come to mind, they're very influential to me as it relates to elbow arthroscopy. One was David Altchek at the Hospital for Special Surgery. David was a great surgeon and did a lot of innovative procedures arthroscopically at that time. And also at HSS, had an opportunity to do some elbow arthroscopy research, looking at what's capable of being seen and what procedures can be done arthroscopically. So that was really a great way to get started. And then subsequently I had the luxury and the pleasure to serve as a practicing partner with Dr. Buddy Savoie for over 10 years when he was here in Mississippi. And Buddy, as you know, is a superstar in everything including elbow arthroscopy and his education training and really he was just an inspirational person helping me to learn how to do elbow arthroscopy and encouraging me to increase my own portfolio, if you will, of arthroscopic procedures.
Rob Hartzler:
Well, what's your favorite elbow arthroscopy to do nowadays?
Dr. Larry Field:
Well it's interesting. Honestly, to me, arthroscopic tennis elbow release is my favorite operation and the reason it's my favorite is a number of reasons. One, it's really simple and easy to do and it's very rewarding because patients do almost universally extremely well. Also, importantly, it expands the indications to perform elbow arthroscopy. A lot of people may have interest in it and yet it's hard to come across enough cases that are indications for scar procedures. We all see the occasional elbow arthritis patient, we may see the capsular contracture patient, but almost all of us that see upper extremity patients see lots and lots and lots of tennis elbow problems and certainly most of those patients can be treated conservatively.
Dr. Larry Field:
But for those that need an operation, I encourage people when I give talks on this to think about and try to perform arthroscopic tennis elbow release because it works and because it provides opportunities to do this operation in clinical settings that really aren't complex elbows, they're not super contracted or scarred, et cetera. And we trained a number of fellows, five sports fellows here and we in part do this operation to help give them opportunities as well. So I think it's a good operation to do for a variety of reasons. I also like to do elbow arthritis debris cases. Those are a lot of fun as well.
Rob Hartzler:
Excellent. Well on the infographic, I mean number one, you have down there palpated ulnar nerve to confirm its location. I think we would all agree on that. Number two, you say select proximal interior portals and the number four graphic that you have really has a very top down view where you're seeing the whole trochlea, the capitellum. Very nice view of the anterior compartment articular surfaces. Is that because you're moving those proximal portals more proximal? Have you found that over the years?
Dr. Larry Field:
Yeah. One of the research projects that I actually did in New York was to look at portal locations both laterally and medially, especially laterally. And what we found was that if we put our portals more proximately, especially on the lateral side, but also the medial side, we became further and further away from the radial nerve laterally and the medial nerve medially. And so the reality is that a more proximal portal, both laterally and medially in the anterior compartment is further from the nerves and I guess theoretically safer. But you don't compromise any visualization. In fact, you can see a little better I think from more proximal portals and Dr. Savoie, who recently just did a podcast interestingly on an article they published, puts their portals even more anteriorly on the anterior compartment. So I think there's some wiggle room for us to place portals safely in the anterior compartment.
Rob Hartzler:
You talked about distension of the joint as a maneuver to increase safety. Any words of wisdom on that? Any technical tips or pointers?
Dr. Larry Field:
Yeah, I think that it's very important to insufflate the joint before you start elbow arthroscopy, especially if you start in the anterior compartment because we know that if we insufflate the elbow joint, we push the neurovascular structures anteriorly away from the trocar that we're going to use to enter the joint. So by default we're going to be further away again from those neurovascular structures. But also, and I think for more practical perspective, because we in full insufflate the joint, we tighten the capsule. And capsule or penetration can be difficult in elbow arthroscopy if we don't insufflate the joint because if you don't have a tight capsule and you're trying to insert that trocar in a relatively parallel orientation compared to the capsule, it's difficult to get in and we know all the bad stuff is just anterior to the capsule, so it's important that we enter that capsule reliably and consistently. Also, if you insufflate the joint, you're going to get that backflow of fluid when you remove the trocar helping to confirm that you're actually in the joint.
Rob Hartzler:
Any thoughts on positioning? Are you a prone position for elbow arthroscopy?
Dr. Larry Field:
I, by default, use the prone position. I like it because I liked the orientation of the elbow and I think it provides a little more stability of the shoulder girdle and the shoulder compared to the lateral decubitus position. But with that said, I think the prone and lateral decubitus positions are just interchangeable. The orientation of the anatomy is the same and I actually do the operations in both positions. I just tend to kind of default to the prone position.
Rob Hartzler:
Another thought that I had was, in those cases, arthritis what have you, where you're going to be in both the anterior and posterior compartments, which one do you start with?
Dr. Larry Field:
Yeah, it's a good question. To me it depends on where the bulk of the work is going to be done. If for example, there are tons of posterior compartment, loose bodies and lots of osteophytes around the joint, et cetera. Then I'll often start in the posterior compartment. Conversely, if most of the work needs to be done in the anterior compartment or even an equivalent amount of work needs to be done in the anterior compartment, I'll typically start anteriorly because I found that swelling is just a part of elbow arthroscopy no matter what technique you use. And so if I have a lot of work to do posteriorly, I'm concerned about my ability to have access to an ability to maneuver in the anterior compartment. So I'll usually start anteriorly in that situation.
Rob Hartzler:
What do you think about simulator training in elbow arthroscopy? I mean we talked before about how there can be a paucity of cases in the general orthopedics practice or really even for upper extremity specialists. You can lack cases for being proficient. What do you see see in the future? Is simulator training going to be going to be part of the educational armamentarium?
Dr. Larry Field:
Oh, I think that simulators are the future for surgical education, especially arthroscopic education. There's just no doubt in my mind that over time, who knows what that window is, that simulators would just be a standard way that orthopedic surgeons or orthopedic residents and fellows practice and train doing these procedures. Not just elbow but shoulder and really all procedures. There are a lot of relatively sophisticated simulators being developed. In fact, Orthopedic Learning Center in Chicago where ANA has a lot of it's courses every year, there's a company called VirtaMed, that Anna has a contractual relationship with and is in fact helping them to develop very sophisticated simulator models for a number of procedures, mainly in the shoulder but also knee and hip and so the future is here and that it's going to become evermore sophisticated I think.
Dr. Larry Field:
And we'll be able to practice a lot of the techniques with happy feedback and a lot of things that really we're not even accustomed to or can't even imagine. With that said though, I would say that cadaver training, especially for something relatively technically demanding like elbow arthroscopy is really indispensable. I think that courses, again like the learning center courses and ANA courses really are going to give you an opportunity to really work one on one with master surgeons that are really experienced in these techniques and you can learn just lots and lots in a very short period of time with that learning environment.
Rob Hartzler:
Well, get out your crystal ball for us, what do you think about the future of elbow arthroscopy? Are there going to be operations coming down the pipeline that we need to be aware of techniques that you think are evolving that are exciting? What's the future hold for us?
Dr. Larry Field:
Well, I think in all of surgery the future is hard to see, but lots of innovative things happen and I think, just off the top of my head, I think that in the future arthroscopic surgeons will be using, I think improved instrumentation. I think the instruments will be smaller. I think even arthroscopes will be much smaller, it'll provide improved access that I think, in part, will encourage surgeons to perform elbow arthroscopy more than they might currently. I think there's that, I guess bad rap, even misperception that elbow arthroscopy is unsafe. It's really not unsafe, it's very safe. If you look at the literature, it's statistically a very safe intervention. I remember, seems like maybe 2012 or 2013 Sean O'Driscoll published an article in [inaudible 00:12:08] to have about 500 elbow arthroscopy consecutively performing no permanent nerve injuries. In my whole career I've likewise had no permanent nerve injury, so it's a good operation and I think that as we continue to educate and become more experienced, more and more surgeons will do it.
Dr. Larry Field:
I think as far as procedures go, again, I would plug this arthroscopic lateral epicondylitis release for the reasons that I've just discussed. It provides opportunities to practice and to be able to continue to improve your skills in a good clinical environment. Also, I think fracture surgery is going to be increasingly performed arthroscopically. I do a number of fractures with the camera radiohead, some coronoid process fractures, even a terrible triad fractures on occasion. A lateral collateral ligament repair and reconstruction is an operation that's been described. Dr Savoie has been instrumental in developing those techniques. I use those techniques in appropriately indicated people. I think that's another operation for the future. OCD is often done open. I think there are opportunities to do even some of the more technically complex OCD procedures purely or at least arthroscopically assisted. So maybe there are a number of things in the future that are going to improve our indications and opportunities to do elbows scopes.
Rob Hartzler:
Well, I think that we all owe you a debt of gratitude for all of the work that you done over the years in research and education and elbow arthroscopy and I've certainly learned a lot from you and look forward to your continuing work. And again, congratulations on this infographic and I would encourage everybody who's listening to check that out.
Dr. Larry Field:
Rob, thank you for the opportunity to do the podcast and this is the exciting venue. I love to listen to these and I look forward to more great things from the Arthroscopy Journal and you and your peers and all the great work that you guys are doing. So thank you very much for everything you do.
Rob Hartzler:
This infographic from the July, 2019, issue of Arthroscopy, Elbow Arthroscopy Made Simple. Indications and Techniques, can be found on the Arthroscopy Journal's website at arthroscopyjournal.org. Please remember to subscribe to the podcast and give us a five star review. Thank you.