id
stringlengths 32
43
| title
stringlengths 16
1.29k
| content
stringlengths 1
69.2k
| contents
stringlengths 29
69.3k
|
|---|---|---|---|
statpearls_NBK430685\article-101263_7 | Cancer Antigen 125 -- Diagnostic Tests | Two tests are available to measure the levels of CA125. The original test is a radioimmunoassay using OC125 monoclonal antibody, which recognizes the antigenic determinants on the CA125 glycoprotein. The second-generation CA125 test uses two antibodies, OC125 and M11. [22] This test has shown a higher level of precision and improved sensitivity with a lower number of false-positive results. However, subsequent research comparing the two tests did not indicate the superiority of one over the other. [23] | Cancer Antigen 125 -- Diagnostic Tests. Two tests are available to measure the levels of CA125. The original test is a radioimmunoassay using OC125 monoclonal antibody, which recognizes the antigenic determinants on the CA125 glycoprotein. The second-generation CA125 test uses two antibodies, OC125 and M11. [22] This test has shown a higher level of precision and improved sensitivity with a lower number of false-positive results. However, subsequent research comparing the two tests did not indicate the superiority of one over the other. [23] |
statpearls_NBK430685\article-101263_8 | Cancer Antigen 125 -- Diagnostic Tests | These tests are made available by different commercial manufacturers in different versions, such as immunoradiometric assay (IRMA) and enzyme immunoassay (EIA). When using these tests to monitor patients longitudinally, the tests should preferably be from the same manufacturer and the same version, as different kits and versions can result in different absolute values and test sensitivity. [8] | Cancer Antigen 125 -- Diagnostic Tests. These tests are made available by different commercial manufacturers in different versions, such as immunoradiometric assay (IRMA) and enzyme immunoassay (EIA). When using these tests to monitor patients longitudinally, the tests should preferably be from the same manufacturer and the same version, as different kits and versions can result in different absolute values and test sensitivity. [8] |
statpearls_NBK430685\article-101263_9 | Cancer Antigen 125 -- Diagnostic Tests | Efforts have been made to enhance the specificity of the CA125 test by testing for CA125 glycoforms more strongly associated with ovarian malignancy. For instance, the CA125-Tn ELISA-based test demonstrated almost a two-fold increase in specificity with no change in sensitivity. [24] Similarly, Other studies have shown an improved performance of certain CA125 glycoforms over the conventional CA125 test. [25] | Cancer Antigen 125 -- Diagnostic Tests. Efforts have been made to enhance the specificity of the CA125 test by testing for CA125 glycoforms more strongly associated with ovarian malignancy. For instance, the CA125-Tn ELISA-based test demonstrated almost a two-fold increase in specificity with no change in sensitivity. [24] Similarly, Other studies have shown an improved performance of certain CA125 glycoforms over the conventional CA125 test. [25] |
statpearls_NBK430685\article-101263_10 | Cancer Antigen 125 -- Testing Procedures | The original CA125 test is a homologous double-determinant assay with the same capture and tracer antibodies. The OC125 antibody is adsorbed onto the solid phase (capture antibody), followed by the addition of the serum. The OC125 moieties on the CA125 antigen then bind to the antibody. Finally, a second radiolabeled (IRMA) or an enzyme-labeled (EIA) antibody (tracer antibody) is added, which binds to the antigen-antibody complexes. [8] The second-generation CA125 test is a heterologous double-determinant assay, where the capture antibody is a monoclonal M11 antibody, and the tracer antibody is the OC125 antibody. Since the two antibodies do not have to bind to the same epitope, there is no competition for the same binding site, thus allowing for potentially higher sensitivity. [26] | Cancer Antigen 125 -- Testing Procedures. The original CA125 test is a homologous double-determinant assay with the same capture and tracer antibodies. The OC125 antibody is adsorbed onto the solid phase (capture antibody), followed by the addition of the serum. The OC125 moieties on the CA125 antigen then bind to the antibody. Finally, a second radiolabeled (IRMA) or an enzyme-labeled (EIA) antibody (tracer antibody) is added, which binds to the antigen-antibody complexes. [8] The second-generation CA125 test is a heterologous double-determinant assay, where the capture antibody is a monoclonal M11 antibody, and the tracer antibody is the OC125 antibody. Since the two antibodies do not have to bind to the same epitope, there is no competition for the same binding site, thus allowing for potentially higher sensitivity. [26] |
statpearls_NBK430685\article-101263_11 | Cancer Antigen 125 -- Interfering Factors | The original CA125 assay uses murine monoclonal OC125 antibody as both the capture and the tracer antibodies. Although it should bind to the corresponding epitope on the CA125 antigen, some individuals demonstrate the presence of the human anti-mouse antibody or human anti-murine antibody. [26] These antibodies may interfere with the test by binding to the capture and tracer antibodies, leading to falsely elevated CA125 levels. Human anti-murine antibodies are observed in patients exposed to murine monoclonal antibodies for therapeutic or diagnostic purposes. This interference is less observable in the newer assays. [27] | Cancer Antigen 125 -- Interfering Factors. The original CA125 assay uses murine monoclonal OC125 antibody as both the capture and the tracer antibodies. Although it should bind to the corresponding epitope on the CA125 antigen, some individuals demonstrate the presence of the human anti-mouse antibody or human anti-murine antibody. [26] These antibodies may interfere with the test by binding to the capture and tracer antibodies, leading to falsely elevated CA125 levels. Human anti-murine antibodies are observed in patients exposed to murine monoclonal antibodies for therapeutic or diagnostic purposes. This interference is less observable in the newer assays. [27] |
statpearls_NBK430685\article-101263_12 | Cancer Antigen 125 -- Interfering Factors | Pre-analytical errors while testing for tumor markers such as CA125 are related to simple specimen-related errors such as incorrect sample processing, an insufficient sample, and inappropriate handling. When conducting tests involving CA125, specific attention should be paid to the timing of specimen collection. [19] Blood collection should be avoided during menstruation, which can lead to falsely elevated levels (up to three-fold). Caution is needed when interpreting elevated CA125 results in women with suspected endometriosis, pregnancy, and ascites. [28] [29] | Cancer Antigen 125 -- Interfering Factors. Pre-analytical errors while testing for tumor markers such as CA125 are related to simple specimen-related errors such as incorrect sample processing, an insufficient sample, and inappropriate handling. When conducting tests involving CA125, specific attention should be paid to the timing of specimen collection. [19] Blood collection should be avoided during menstruation, which can lead to falsely elevated levels (up to three-fold). Caution is needed when interpreting elevated CA125 results in women with suspected endometriosis, pregnancy, and ascites. [28] [29] |
statpearls_NBK430685\article-101263_13 | Cancer Antigen 125 -- Interfering Factors | Human anti-murine antibodies are known to interfere with the test, and adding non-immune murine serum can neutralize this interference. [23] [26] For patients undergoing monitoring with serial CA125 levels, it is important to use the same manufacturer and laboratory, preferably. If a different manufacturer or testing method needs to be employed, the recommendation is to carry out parallel testing by both methods to establish a new baseline for the patient. [30] | Cancer Antigen 125 -- Interfering Factors. Human anti-murine antibodies are known to interfere with the test, and adding non-immune murine serum can neutralize this interference. [23] [26] For patients undergoing monitoring with serial CA125 levels, it is important to use the same manufacturer and laboratory, preferably. If a different manufacturer or testing method needs to be employed, the recommendation is to carry out parallel testing by both methods to establish a new baseline for the patient. [30] |
statpearls_NBK430685\article-101263_14 | Cancer Antigen 125 -- Results, Reporting, and Critical Findings | In the original CA125 IRMA test, the cut-off point for the upper limit of normal was arbitrarily set at 35 U/mL. This threshold was chosen because only 1% of the healthy population had CA125 levels greater than 35 U/mL. However, this was reduced to 0.2% of the healthy population when the cut-off point for the upper limit was raised to 65 U/mL. [7] The second-generation CA125 has shown to be more clinically reliable with greater precision in values less than 35 U/mL, leading to higher values compared to the original CA125 test. [22] A meta-analysis comparing various studies using a CA125 threshold of greater than 35 U/mL for preoperative identification of an adnexal mass suspicious for ovarian cancer revealed an overall sensitivity and specificity of 78.7% and 77.9%, respectively. [31] | Cancer Antigen 125 -- Results, Reporting, and Critical Findings. In the original CA125 IRMA test, the cut-off point for the upper limit of normal was arbitrarily set at 35 U/mL. This threshold was chosen because only 1% of the healthy population had CA125 levels greater than 35 U/mL. However, this was reduced to 0.2% of the healthy population when the cut-off point for the upper limit was raised to 65 U/mL. [7] The second-generation CA125 has shown to be more clinically reliable with greater precision in values less than 35 U/mL, leading to higher values compared to the original CA125 test. [22] A meta-analysis comparing various studies using a CA125 threshold of greater than 35 U/mL for preoperative identification of an adnexal mass suspicious for ovarian cancer revealed an overall sensitivity and specificity of 78.7% and 77.9%, respectively. [31] |
statpearls_NBK430685\article-101263_15 | Cancer Antigen 125 -- Results, Reporting, and Critical Findings | Study results have shown that the test exhibits a higher sensitivity and specificity in postmenopausal women compared to premenopausal women. [32] [33] The low sensitivity is due in part to the fact that CA125 is elevated only in half of the patients with early-stage epithelial ovarian cancer and rarely elevated in patients with mucinous carcinomas of the ovary. The low specificity, especially among premenopausal women, is due to the elevation caused by benign conditions such as fibroids, endometriosis, and pregnancy. [4] However, the test is relatively sensitive and specific among patients who have completed treatment for ovarian cancer. Patients who appear to be clinically free of the tumor with elevations in CA125 (>35 U/mL) almost always have a tumor in second-look surgery. [8] | Cancer Antigen 125 -- Results, Reporting, and Critical Findings. Study results have shown that the test exhibits a higher sensitivity and specificity in postmenopausal women compared to premenopausal women. [32] [33] The low sensitivity is due in part to the fact that CA125 is elevated only in half of the patients with early-stage epithelial ovarian cancer and rarely elevated in patients with mucinous carcinomas of the ovary. The low specificity, especially among premenopausal women, is due to the elevation caused by benign conditions such as fibroids, endometriosis, and pregnancy. [4] However, the test is relatively sensitive and specific among patients who have completed treatment for ovarian cancer. Patients who appear to be clinically free of the tumor with elevations in CA125 (>35 U/mL) almost always have a tumor in second-look surgery. [8] |
statpearls_NBK430685\article-101263_16 | Cancer Antigen 125 -- Clinical Significance | CA125 plays a significant role as a tumor marker, particularly in the preoperative assessment of patients with an adnexal mass and suspected to have an ovarian malignancy. [31] Around 80% of the patients diagnosed with ovarian epithelial carcinoma show elevated CA125 levels, and levels are monitored post-treatment to assess the progression of the disease. [34] The use of CA125 for preoperative assessment is more valuable among postmenopausal women compared to its use among premenopausal women. [4] Although an elevated CA125 level above 35 U/mL is utilized in assessing postmenopausal women, earlier guidelines from the American College of Obstetricians and Gynecologists had recommended using an arbitrary cutoff of 200 U/mL; this was, however, not supported by any research evidence. [35] | Cancer Antigen 125 -- Clinical Significance. CA125 plays a significant role as a tumor marker, particularly in the preoperative assessment of patients with an adnexal mass and suspected to have an ovarian malignancy. [31] Around 80% of the patients diagnosed with ovarian epithelial carcinoma show elevated CA125 levels, and levels are monitored post-treatment to assess the progression of the disease. [34] The use of CA125 for preoperative assessment is more valuable among postmenopausal women compared to its use among premenopausal women. [4] Although an elevated CA125 level above 35 U/mL is utilized in assessing postmenopausal women, earlier guidelines from the American College of Obstetricians and Gynecologists had recommended using an arbitrary cutoff of 200 U/mL; this was, however, not supported by any research evidence. [35] |
statpearls_NBK430685\article-101263_17 | Cancer Antigen 125 -- Clinical Significance | Current guidelines suggest using formal risk assessment tests such as the risk of malignancy index or the risk of ovarian malignancy algorithm while assessing the need for gynecological referral in premenopausal women. [4] CA125 is successfully used for disease monitoring and evaluating the progression of the disease. A significant correlation exists between the disease progression and serum CA125 levels, with doubling or halving serum values considered clinically significant. [8] | Cancer Antigen 125 -- Clinical Significance. Current guidelines suggest using formal risk assessment tests such as the risk of malignancy index or the risk of ovarian malignancy algorithm while assessing the need for gynecological referral in premenopausal women. [4] CA125 is successfully used for disease monitoring and evaluating the progression of the disease. A significant correlation exists between the disease progression and serum CA125 levels, with doubling or halving serum values considered clinically significant. [8] |
statpearls_NBK430685\article-101263_18 | Cancer Antigen 125 -- Clinical Significance | CA125 levels also indicate the tumor status. Most patients with CA125 levels greater than 35 U/mL demonstrate disease recurrence on second-look surgery, and those with CA125 levels less than 35 U/mL have minimal residual disease among half of the patients. [8] CA125 levels also act as an early predictor of outcomes where a deviation from the ideal CA125 regression curve suggests a poor outcome. Among patients who had undergone complete remission, elevation in CA125 occurred before the tumor recurrence in 75% of the patients. [2] However, using CA125 as a screening test for patients with ovarian cancer is not feasible. In subsequent studies evaluating the benefit of using multimodal screening combined with transvaginal ultrasound for ovarian cancer screening, no benefit in improving mortality was found. [36] | Cancer Antigen 125 -- Clinical Significance. CA125 levels also indicate the tumor status. Most patients with CA125 levels greater than 35 U/mL demonstrate disease recurrence on second-look surgery, and those with CA125 levels less than 35 U/mL have minimal residual disease among half of the patients. [8] CA125 levels also act as an early predictor of outcomes where a deviation from the ideal CA125 regression curve suggests a poor outcome. Among patients who had undergone complete remission, elevation in CA125 occurred before the tumor recurrence in 75% of the patients. [2] However, using CA125 as a screening test for patients with ovarian cancer is not feasible. In subsequent studies evaluating the benefit of using multimodal screening combined with transvaginal ultrasound for ovarian cancer screening, no benefit in improving mortality was found. [36] |
statpearls_NBK430685\article-101263_19 | Cancer Antigen 125 -- Clinical Significance | CA125 may also have a role in monitoring response to chemotherapy. Serial measurements of CA125 are found to correlate with clinical disease outcomes in 89% of 531 patients. [21] There is a consensus among current guidelines to use CA125 to monitor the response to chemotherapy. The Gynecologic Cancer Intergroup defines response as a 50% reduction in CA125 concentration compared to a pretreatment sample. [37] [38] The response should be confirmed and sustained for at least 20 days. Patients can only be diagnosed if they have a CA125 concentration in a pretreatment sample that is twice the upper reference limit and taken 2 weeks before initiation of therapy. Additional samples are recommended at 2 to 4 weeks during treatment and at intervals of 2 to 3 weeks during follow-up. The same method should be used to monitor the patient throughout, and patients who receive immunotherapy (mouse antibodies) cannot be diagnosed. [39] The Food and Drug Administration approved the serial measurement of CA125 to aid in monitoring therapeutic response. [40] | Cancer Antigen 125 -- Clinical Significance. CA125 may also have a role in monitoring response to chemotherapy. Serial measurements of CA125 are found to correlate with clinical disease outcomes in 89% of 531 patients. [21] There is a consensus among current guidelines to use CA125 to monitor the response to chemotherapy. The Gynecologic Cancer Intergroup defines response as a 50% reduction in CA125 concentration compared to a pretreatment sample. [37] [38] The response should be confirmed and sustained for at least 20 days. Patients can only be diagnosed if they have a CA125 concentration in a pretreatment sample that is twice the upper reference limit and taken 2 weeks before initiation of therapy. Additional samples are recommended at 2 to 4 weeks during treatment and at intervals of 2 to 3 weeks during follow-up. The same method should be used to monitor the patient throughout, and patients who receive immunotherapy (mouse antibodies) cannot be diagnosed. [39] The Food and Drug Administration approved the serial measurement of CA125 to aid in monitoring therapeutic response. [40] |
statpearls_NBK430685\article-101263_20 | Cancer Antigen 125 -- Clinical Significance | Preoperative and postoperative CA125 concentrations may be of prognostic significance. [41] After primary surgery and chemotherapy, persistent elevations of CA125 concentrations are associated with poor prognosis. Patients with preoperative CA125 concentrations greater than 65 U/mL are reported to have a lower 5-year survival rate and a 6.37-fold risk of death compared to patients with CA125 levels less than 65 U/mL. [21] The half-life of the CA125 antigen is reported to have an additional prognostic value. A half-life of less than 20 days is associated with improved survival compared to a half-life of more than 20 days. [26] Normalization of CA125 levels after 3 cycles of combination therapy also correlates with improved survival. Importantly, CA125 concentration is not elevated in 10% to 20% of patients with advanced ovarian cancer. For these patients, using radiological imaging techniques and monitoring other tumor markers are necessary. [42] | Cancer Antigen 125 -- Clinical Significance. Preoperative and postoperative CA125 concentrations may be of prognostic significance. [41] After primary surgery and chemotherapy, persistent elevations of CA125 concentrations are associated with poor prognosis. Patients with preoperative CA125 concentrations greater than 65 U/mL are reported to have a lower 5-year survival rate and a 6.37-fold risk of death compared to patients with CA125 levels less than 65 U/mL. [21] The half-life of the CA125 antigen is reported to have an additional prognostic value. A half-life of less than 20 days is associated with improved survival compared to a half-life of more than 20 days. [26] Normalization of CA125 levels after 3 cycles of combination therapy also correlates with improved survival. Importantly, CA125 concentration is not elevated in 10% to 20% of patients with advanced ovarian cancer. For these patients, using radiological imaging techniques and monitoring other tumor markers are necessary. [42] |
statpearls_NBK430685\article-101263_21 | Cancer Antigen 125 -- Quality Control and Lab Safety | For non-waived tests, laboratory regulations require, at the minimum, analysis of at least 2 levels of control materials once every 24 hours. If necessary, laboratories can more frequently assay quality control (QC) samples to ensure accurate results. QC samples should be assayed after calibration or maintenance of an analyzer to verify the correct method performance. [43] To minimize QC when performing tests for which manufacturers’ recommendations are less than those required by the regulatory agency, such as once per month, the labs can develop an individualized quality control plan. This plan involves performing a risk assessment of potential sources of error in all testing phases and putting in place a QC plan to reduce the likelihood of mistakes. [44] Westgard multi-rules are used to evaluate the QC runs. In case of a rule violation, proper corrective and preventive action should be taken before patient testing. [45] | Cancer Antigen 125 -- Quality Control and Lab Safety. For non-waived tests, laboratory regulations require, at the minimum, analysis of at least 2 levels of control materials once every 24 hours. If necessary, laboratories can more frequently assay quality control (QC) samples to ensure accurate results. QC samples should be assayed after calibration or maintenance of an analyzer to verify the correct method performance. [43] To minimize QC when performing tests for which manufacturers’ recommendations are less than those required by the regulatory agency, such as once per month, the labs can develop an individualized quality control plan. This plan involves performing a risk assessment of potential sources of error in all testing phases and putting in place a QC plan to reduce the likelihood of mistakes. [44] Westgard multi-rules are used to evaluate the QC runs. In case of a rule violation, proper corrective and preventive action should be taken before patient testing. [45] |
statpearls_NBK430685\article-101263_22 | Cancer Antigen 125 -- Quality Control and Lab Safety | The laboratory must participate in the external QC or proficiency testing program because it is a regulatory requirement published by the Centers for Medicare and Medicaid Services in the Clinical Laboratory Improvement Amendments regulations. This practice is helpful to ensure the accuracy and reliability of the laboratory compared to other laboratories performing the same or comparable assays. [46] The PT plan should be included in the quality assessment plan and the laboratory's overall quality program. [47] | Cancer Antigen 125 -- Quality Control and Lab Safety. The laboratory must participate in the external QC or proficiency testing program because it is a regulatory requirement published by the Centers for Medicare and Medicaid Services in the Clinical Laboratory Improvement Amendments regulations. This practice is helpful to ensure the accuracy and reliability of the laboratory compared to other laboratories performing the same or comparable assays. [46] The PT plan should be included in the quality assessment plan and the laboratory's overall quality program. [47] |
statpearls_NBK430685\article-101263_23 | Cancer Antigen 125 -- Quality Control and Lab Safety | The intricate tests conducted in clinical laboratories are the cornerstone of patient diagnosis and treatment. However, this crucial work does not come without risks. These facilities handle various potentially hazardous materials, from infectious agents to toxic chemicals. Strict adherence to safety protocols is essential to prevent accidental exposure or contamination, which includes proper handling, storing, and disposing of these materials to safeguard laboratory personnel, minimizing patient transmission risks, and ensuring the integrity of diagnostic tests. [48] | Cancer Antigen 125 -- Quality Control and Lab Safety. The intricate tests conducted in clinical laboratories are the cornerstone of patient diagnosis and treatment. However, this crucial work does not come without risks. These facilities handle various potentially hazardous materials, from infectious agents to toxic chemicals. Strict adherence to safety protocols is essential to prevent accidental exposure or contamination, which includes proper handling, storing, and disposing of these materials to safeguard laboratory personnel, minimizing patient transmission risks, and ensuring the integrity of diagnostic tests. [48] |
statpearls_NBK430685\article-101263_24 | Cancer Antigen 125 -- Quality Control and Lab Safety | Beyond material safety, meticulous equipment maintenance plays a critical role. Keeping laboratory instruments and safety devices, such as eyewash stations and fume hoods, in top condition is crucial for optimal functionality and mitigating potential hazards. Equally important are established and practiced emergency response plans. These plans enable staff to react swiftly and effectively in the event of accidents or incidents. [49] | Cancer Antigen 125 -- Quality Control and Lab Safety. Beyond material safety, meticulous equipment maintenance plays a critical role. Keeping laboratory instruments and safety devices, such as eyewash stations and fume hoods, in top condition is crucial for optimal functionality and mitigating potential hazards. Equally important are established and practiced emergency response plans. These plans enable staff to react swiftly and effectively in the event of accidents or incidents. [49] |
statpearls_NBK430685\article-101263_25 | Cancer Antigen 125 -- Quality Control and Lab Safety | Continuous education and training are vital for the laboratory staff to stay abreast of evolving safety procedures and best practices. In addition, this fosters a culture of safety consciousness and accountability within the institution. Prioritizing lab safety does not just protect the workforce; it also strengthens the overall quality and trustworthiness of healthcare delivery. This comprehensive approach to safety includes employing appropriate personal protective equipment such as gloves, lab coats, and respirators, adhering to biosafety levels for specific infectious agents, following a dedicated chemical hygiene plan for safe chemical handling, and ensuring the proper segregation and disposal of biohazardous and chemical waste. [50] | Cancer Antigen 125 -- Quality Control and Lab Safety. Continuous education and training are vital for the laboratory staff to stay abreast of evolving safety procedures and best practices. In addition, this fosters a culture of safety consciousness and accountability within the institution. Prioritizing lab safety does not just protect the workforce; it also strengthens the overall quality and trustworthiness of healthcare delivery. This comprehensive approach to safety includes employing appropriate personal protective equipment such as gloves, lab coats, and respirators, adhering to biosafety levels for specific infectious agents, following a dedicated chemical hygiene plan for safe chemical handling, and ensuring the proper segregation and disposal of biohazardous and chemical waste. [50] |
statpearls_NBK430685\article-101263_26 | Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes | CA125 serves a crucial role as a tumor marker in diagnosing patients suspected of having ovarian cancer and monitoring disease progression. According to guidelines, it is an essential criterion for referring patients with an adnexal mass suspicious of malignancy to a gynecological oncologist. Although it has a higher specificity when used in postmenopausal women, very high levels in premenopausal women require referral. In addition, patient outcomes have been observed to improve when treatment is provided by specialized gynecological oncologists and conducted in hospitals with necessary consult services and multidisciplinary collaboration. [51] | Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes. CA125 serves a crucial role as a tumor marker in diagnosing patients suspected of having ovarian cancer and monitoring disease progression. According to guidelines, it is an essential criterion for referring patients with an adnexal mass suspicious of malignancy to a gynecological oncologist. Although it has a higher specificity when used in postmenopausal women, very high levels in premenopausal women require referral. In addition, patient outcomes have been observed to improve when treatment is provided by specialized gynecological oncologists and conducted in hospitals with necessary consult services and multidisciplinary collaboration. [51] |
statpearls_NBK430685\article-101263_27 | Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes | Interprofessional team care involves multiple disciplines, such as primary care physicians, gynecological oncologists, nurses, and pathologists. Each of them has an essential role in providing care for individuals with suspected ovarian cancer or monitoring the disease status, thus influencing disease management. Clinicopathologic meetings involving discussions between pathologists and clinicians are a form of interprofessional care. Interprofessional team care has been shown to improve the accuracy of the diagnosis, achieve accurate staging and grading of the disease, and thus improve the management of the patient's disease. In addition to improving patient care, it provides a learning opportunity for the team members. [52] | Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes. Interprofessional team care involves multiple disciplines, such as primary care physicians, gynecological oncologists, nurses, and pathologists. Each of them has an essential role in providing care for individuals with suspected ovarian cancer or monitoring the disease status, thus influencing disease management. Clinicopathologic meetings involving discussions between pathologists and clinicians are a form of interprofessional care. Interprofessional team care has been shown to improve the accuracy of the diagnosis, achieve accurate staging and grading of the disease, and thus improve the management of the patient's disease. In addition to improving patient care, it provides a learning opportunity for the team members. [52] |
statpearls_NBK430685\article-101263_28 | Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes | Nurses involved in the care of a patient with ovarian cancer are in a unique position to provide information and education to the patient and their family about the disease. In addition, they may be able to identify patients needing psychological support and counseling, thereby improving the quality of life for their patients by coordinating referrals with nutritionists, physiotherapists, and psychologists. [53] Evidence shows that patients treated under interprofessional team care involving clinicians and physicians from different specialties had a significant survival advantage. [54] | Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes. Nurses involved in the care of a patient with ovarian cancer are in a unique position to provide information and education to the patient and their family about the disease. In addition, they may be able to identify patients needing psychological support and counseling, thereby improving the quality of life for their patients by coordinating referrals with nutritionists, physiotherapists, and psychologists. [53] Evidence shows that patients treated under interprofessional team care involving clinicians and physicians from different specialties had a significant survival advantage. [54] |
statpearls_NBK430685\article-101263_29 | Cancer Antigen 125 -- Review Questions | Access free multiple choice questions on this topic. Comment on this article. | Cancer Antigen 125 -- Review Questions. Access free multiple choice questions on this topic. Comment on this article. |
statpearls_NBK430685\article-101401_0 | Epithelial Downgrowth -- Continuing Education Activity | Epithelial downgrowth is a potentially visually devastating complication of intraocular surgery or trauma characterized by the invasion of epithelial cells and growth into intraocular structures. This activity reviews etiological factors, clinical presentation, diagnostic nuances, and comprehensive management strategies of epithelial downgrowth. Various forms of epithelialization are discussed, and the clinical significance of its aggressive nature is emphasized, particularly the sheet-like invasion culminating in secondary glaucoma and potential vision loss. | Epithelial Downgrowth -- Continuing Education Activity. Epithelial downgrowth is a potentially visually devastating complication of intraocular surgery or trauma characterized by the invasion of epithelial cells and growth into intraocular structures. This activity reviews etiological factors, clinical presentation, diagnostic nuances, and comprehensive management strategies of epithelial downgrowth. Various forms of epithelialization are discussed, and the clinical significance of its aggressive nature is emphasized, particularly the sheet-like invasion culminating in secondary glaucoma and potential vision loss. |
statpearls_NBK430685\article-101401_1 | Epithelial Downgrowth -- Continuing Education Activity | This session also covers the diverse diagnostic methodologies and treatment modalities available for epithelial downgrowth, weighing their pros and cons. Insights into differentiating epithelial downgrowth from fibrous downgrowth are provided, elucidating subtle yet pivotal distinctions critical for accurate diagnosis and management planning. Finally, the role of the interprofessional team is emphasized, as is the need for a collaborative approach to ensure optimal patient outcomes in managing this visually threatening condition. | Epithelial Downgrowth -- Continuing Education Activity. This session also covers the diverse diagnostic methodologies and treatment modalities available for epithelial downgrowth, weighing their pros and cons. Insights into differentiating epithelial downgrowth from fibrous downgrowth are provided, elucidating subtle yet pivotal distinctions critical for accurate diagnosis and management planning. Finally, the role of the interprofessional team is emphasized, as is the need for a collaborative approach to ensure optimal patient outcomes in managing this visually threatening condition. |
statpearls_NBK430685\article-101401_2 | Epithelial Downgrowth -- Continuing Education Activity | Objectives: Identify the primary etiology of epithelial downgrowth involving intraocular surgery or penetrating ocular trauma, leading to the migration of epithelial cells into the anterior chamber and subsequent proliferation into intraocular structures. Apply knowledge of various diagnostic studies for epithelial downgrowth to guide treatment plans and establish surveillance protocols, ensuring timely interventions and improved patient outcomes. Apply evidence-based management approaches for epithelial downgrowth, from noninvasive measures to complete surgical excision, considering their risks and limitations. Collaborate with various healthcare professionals involved in the care of patients with epithelial downgrowth, promoting a shared decision-making process and mutual understanding of treatment goals to improve outcomes and reduce complications. Access free multiple choice questions on this topic. | Epithelial Downgrowth -- Continuing Education Activity. Objectives: Identify the primary etiology of epithelial downgrowth involving intraocular surgery or penetrating ocular trauma, leading to the migration of epithelial cells into the anterior chamber and subsequent proliferation into intraocular structures. Apply knowledge of various diagnostic studies for epithelial downgrowth to guide treatment plans and establish surveillance protocols, ensuring timely interventions and improved patient outcomes. Apply evidence-based management approaches for epithelial downgrowth, from noninvasive measures to complete surgical excision, considering their risks and limitations. Collaborate with various healthcare professionals involved in the care of patients with epithelial downgrowth, promoting a shared decision-making process and mutual understanding of treatment goals to improve outcomes and reduce complications. Access free multiple choice questions on this topic. |
statpearls_NBK430685\article-101401_3 | Epithelial Downgrowth -- Introduction | Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. In this disease, epithelial cells enter the anterior chamber and proliferate into intraocular structures. Stratified squamous epithelium is not ordinarily present in the interior of the eye but can grow into nearly any intraocular structure. Epithelialization can appear in 3 forms: pearls, cysts, and sheets. [1] | Epithelial Downgrowth -- Introduction. Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. In this disease, epithelial cells enter the anterior chamber and proliferate into intraocular structures. Stratified squamous epithelium is not ordinarily present in the interior of the eye but can grow into nearly any intraocular structure. Epithelialization can appear in 3 forms: pearls, cysts, and sheets. [1] |
statpearls_NBK430685\article-101401_4 | Epithelial Downgrowth -- Introduction | The sheet-like, diffuse form is the most common and most aggressive and more frequently leads to complications like secondary glaucoma. The cystic form, on the other hand, has a more benign course. [2] However, the natural course of epithelial downgrowth leads to extensive epithelial invasion, resulting in inflammation, secondary glaucoma, hemorrhage, and ultimately permanent vision loss or loss of the eye. [3] | Epithelial Downgrowth -- Introduction. The sheet-like, diffuse form is the most common and most aggressive and more frequently leads to complications like secondary glaucoma. The cystic form, on the other hand, has a more benign course. [2] However, the natural course of epithelial downgrowth leads to extensive epithelial invasion, resulting in inflammation, secondary glaucoma, hemorrhage, and ultimately permanent vision loss or loss of the eye. [3] |
statpearls_NBK430685\article-101401_5 | Epithelial Downgrowth -- Introduction | This article presents a brief overview of the etiology, pathophysiology, and risk factors for epithelial downgrowth with a broader discussion of the many diagnostic and therapeutic options, along with the advantages and disadvantages of each. The terms epithelial downgrowth and epithelial ingrowth are sometimes used interchangeably in the literature. However, this article will not discuss epithelial ingrowth that occurs after procedures such as laser-assisted in situ keratomileusis (LASIK), where there is ingrowth of epithelium into the corneal flap interface. | Epithelial Downgrowth -- Introduction. This article presents a brief overview of the etiology, pathophysiology, and risk factors for epithelial downgrowth with a broader discussion of the many diagnostic and therapeutic options, along with the advantages and disadvantages of each. The terms epithelial downgrowth and epithelial ingrowth are sometimes used interchangeably in the literature. However, this article will not discuss epithelial ingrowth that occurs after procedures such as laser-assisted in situ keratomileusis (LASIK), where there is ingrowth of epithelium into the corneal flap interface. |
statpearls_NBK430685\article-101401_6 | Epithelial Downgrowth -- Introduction | Epithelial downgrowth should also be distinguished from fibrous downgrowth. These 2 conditions are quite similar in terms of etiology, risk factors, and complications and are often managed in the same way. However, there are subtle but important differences between the two that will be further discussed in the Differential Diagnosis section. | Epithelial Downgrowth -- Introduction. Epithelial downgrowth should also be distinguished from fibrous downgrowth. These 2 conditions are quite similar in terms of etiology, risk factors, and complications and are often managed in the same way. However, there are subtle but important differences between the two that will be further discussed in the Differential Diagnosis section. |
statpearls_NBK430685\article-101401_7 | Epithelial Downgrowth -- Etiology | Epithelial invasion was first described in 1832 by Dr. William Mackenzie as a semitransparent cyst in the anterior chamber of a patient after a perforating intraocular injury. [4] Since then, epithelial downgrowth has mostly been reported following ocular trauma and cataract surgery, though it has been associated with other procedures such as penetrating keratoplasty, pterygium excision, aspiration of aqueous, and retinal detachment surgery. [5] [6] Although modern surgical techniques have reduced the risk, epithelial downgrowth has been reported after clear cornea phacoemulsification [2] , Descemet's stripping automated endothelial keratoplasty (DSAEK), [7] Descemet's membrane endothelial keratoplasty (DMEK), [1] glaucoma implant surgery, [8] and type 1 Boston keratoprosthesis (KPro). [9] | Epithelial Downgrowth -- Etiology. Epithelial invasion was first described in 1832 by Dr. William Mackenzie as a semitransparent cyst in the anterior chamber of a patient after a perforating intraocular injury. [4] Since then, epithelial downgrowth has mostly been reported following ocular trauma and cataract surgery, though it has been associated with other procedures such as penetrating keratoplasty, pterygium excision, aspiration of aqueous, and retinal detachment surgery. [5] [6] Although modern surgical techniques have reduced the risk, epithelial downgrowth has been reported after clear cornea phacoemulsification [2] , Descemet's stripping automated endothelial keratoplasty (DSAEK), [7] Descemet's membrane endothelial keratoplasty (DMEK), [1] glaucoma implant surgery, [8] and type 1 Boston keratoprosthesis (KPro). [9] |
statpearls_NBK430685\article-101401_8 | Epithelial Downgrowth -- Epidemiology | Intracapsular and extracapsular cataract surgery have been reported in the literature as the most common cause of epithelial downgrowth with an average reported incidence of 0.076% to 0.12%, [5] but with ranges from 0% to 1.1%. [10] The incidence of this condition after penetrating keratoplasty has been reported as 0.25%. [11] Most cases of epithelial downgrowth present within the first year following intraocular surgery, but there have been reports of cases presenting decades after surgery or trauma. [5] [12] [13] | Epithelial Downgrowth -- Epidemiology. Intracapsular and extracapsular cataract surgery have been reported in the literature as the most common cause of epithelial downgrowth with an average reported incidence of 0.076% to 0.12%, [5] but with ranges from 0% to 1.1%. [10] The incidence of this condition after penetrating keratoplasty has been reported as 0.25%. [11] Most cases of epithelial downgrowth present within the first year following intraocular surgery, but there have been reports of cases presenting decades after surgery or trauma. [5] [12] [13] |
statpearls_NBK430685\article-101401_9 | Epithelial Downgrowth -- Pathophysiology | Epithelial downgrowth occurs when nonkeratinized epithelial cells are introduced through a traumatic or surgical wound and proliferate in the inner structures of the eye. Proposed pathophysiologic mechanisms include implantation of the epithelium, the introduction of a conjunctival flap into a wound, or delayed closure. [14] These cells can come from the conjunctiva or cornea and grow over the cornea, iris, trabecular meshwork, ciliary body, crystalline, artificial lens, and retina. | Epithelial Downgrowth -- Pathophysiology. Epithelial downgrowth occurs when nonkeratinized epithelial cells are introduced through a traumatic or surgical wound and proliferate in the inner structures of the eye. Proposed pathophysiologic mechanisms include implantation of the epithelium, the introduction of a conjunctival flap into a wound, or delayed closure. [14] These cells can come from the conjunctiva or cornea and grow over the cornea, iris, trabecular meshwork, ciliary body, crystalline, artificial lens, and retina. |
statpearls_NBK430685\article-101401_10 | Epithelial Downgrowth -- Pathophysiology | Risk factors potentially allowing for epithelial entry and proliferation include multiple intraocular surgeries, delayed wound healing, gaping wound edges, wound fistulas, iris or vitreous incarceration, and full-thickness sutures. [2] [5] Additionally, damaged or denuded endothelium may pose a risk for epithelial migration secondary to loss of contact inhibition. [15] This invasion of epithelium leads to an inflammatory reaction and tissue damage. | Epithelial Downgrowth -- Pathophysiology. Risk factors potentially allowing for epithelial entry and proliferation include multiple intraocular surgeries, delayed wound healing, gaping wound edges, wound fistulas, iris or vitreous incarceration, and full-thickness sutures. [2] [5] Additionally, damaged or denuded endothelium may pose a risk for epithelial migration secondary to loss of contact inhibition. [15] This invasion of epithelium leads to an inflammatory reaction and tissue damage. |
statpearls_NBK430685\article-101401_11 | Epithelial Downgrowth -- History and Physical | Patients with epithelial downgrowth will usually present within a year of the inciting event with a variety of symptoms, including decreasing visual acuity, redness, pain, tearing, and photophobia. [5] [16] The sheet-like form more commonly presents with marked inflammation and pain. [2] These findings are nonspecific, making the clinical diagnosis of epithelial downgrowth challenging. Slit-lamp examination classically reveals a translucent growth with a scalloped, advancing margin on the posterior surface of the cornea or anterior iris, or a cyst emanating from a wound site. [17] Gonioscopy may reveal epithelium covering the iris and angle, often resulting in glaucoma. [3] However, intraocular pressure is variable and is normal in many cases due to the presence of a fistula. [18] | Epithelial Downgrowth -- History and Physical. Patients with epithelial downgrowth will usually present within a year of the inciting event with a variety of symptoms, including decreasing visual acuity, redness, pain, tearing, and photophobia. [5] [16] The sheet-like form more commonly presents with marked inflammation and pain. [2] These findings are nonspecific, making the clinical diagnosis of epithelial downgrowth challenging. Slit-lamp examination classically reveals a translucent growth with a scalloped, advancing margin on the posterior surface of the cornea or anterior iris, or a cyst emanating from a wound site. [17] Gonioscopy may reveal epithelium covering the iris and angle, often resulting in glaucoma. [3] However, intraocular pressure is variable and is normal in many cases due to the presence of a fistula. [18] |
statpearls_NBK430685\article-101401_12 | Epithelial Downgrowth -- Evaluation | Many diagnostic tools for detecting epithelial downgrowth have been reported in the literature. Certain modalities may be more useful when specific risk factors or anatomical involvement are suspected. For example, Seidel testing may help identify fistulas, which are commonly cited risk factors for epithelial downgrowth. [5] For suspected iris involvement, argon laser photocoagulation (100-200 micrometers, 0.1 to 0.2 s, 100 to 200 mW) can detect epithelium. [19] A normal iris usually turns dark upon photocoagulation, but the presence of epithelial cells will produce a pathognomonic fluffy white reaction. [8] This method is only helpful in diagnosing iris involvement. Cytology can be performed from an anterior chamber aspirate if free-floating cells are present. Papanicolaou staining may reveal cells of epithelial origin. [20] | Epithelial Downgrowth -- Evaluation. Many diagnostic tools for detecting epithelial downgrowth have been reported in the literature. Certain modalities may be more useful when specific risk factors or anatomical involvement are suspected. For example, Seidel testing may help identify fistulas, which are commonly cited risk factors for epithelial downgrowth. [5] For suspected iris involvement, argon laser photocoagulation (100-200 micrometers, 0.1 to 0.2 s, 100 to 200 mW) can detect epithelium. [19] A normal iris usually turns dark upon photocoagulation, but the presence of epithelial cells will produce a pathognomonic fluffy white reaction. [8] This method is only helpful in diagnosing iris involvement. Cytology can be performed from an anterior chamber aspirate if free-floating cells are present. Papanicolaou staining may reveal cells of epithelial origin. [20] |
statpearls_NBK430685\article-101401_13 | Epithelial Downgrowth -- Evaluation -- Specular Microscopy | This noninvasive diagnostic test reveals a pattern consisting of a sharply defined border between endothelium and epithelial downgrowth. [3] When adjusted to focus on a deeper plane, the microscope will also show a pattern of interlacing borders representing the cell margins of the epithelium. [3] However, this test may be ineffective in the presence of corneal edema. [21] | Epithelial Downgrowth -- Evaluation -- Specular Microscopy. This noninvasive diagnostic test reveals a pattern consisting of a sharply defined border between endothelium and epithelial downgrowth. [3] When adjusted to focus on a deeper plane, the microscope will also show a pattern of interlacing borders representing the cell margins of the epithelium. [3] However, this test may be ineffective in the presence of corneal edema. [21] |
statpearls_NBK430685\article-101401_14 | Epithelial Downgrowth -- Evaluation -- Confocal Microscopy | This noninvasive modality allows the observer to image living tissue at higher resolutions than specular microscopy and is less affected by corneal edema. [21] Visualization of round, hyperreflective nuclei is characteristic of epithelial cell invasion. Confocal microscopy can also help distinguish between fibrous and epithelial downgrowth in the presence of a retrocorneal membrane. It may be able to detect changes in the appearance of epithelium after treatment, which could be helpful in following the clinical course of epithelial downgrowth. Confocal microscopy may be more sensitive than light microscopy in detecting residual epithelial downgrowth. [21] | Epithelial Downgrowth -- Evaluation -- Confocal Microscopy. This noninvasive modality allows the observer to image living tissue at higher resolutions than specular microscopy and is less affected by corneal edema. [21] Visualization of round, hyperreflective nuclei is characteristic of epithelial cell invasion. Confocal microscopy can also help distinguish between fibrous and epithelial downgrowth in the presence of a retrocorneal membrane. It may be able to detect changes in the appearance of epithelium after treatment, which could be helpful in following the clinical course of epithelial downgrowth. Confocal microscopy may be more sensitive than light microscopy in detecting residual epithelial downgrowth. [21] |
statpearls_NBK430685\article-101401_15 | Epithelial Downgrowth -- Evaluation -- Anterior Segment Optical Coherence Tomography | Anterior segment optical coherence tomography (AS-OCT) is another noninvasive imaging modality that has been shown to aid in diagnosing epithelial downgrowth after DSAEK and penetrating keratoplasty. [22] [23] Epithelial downgrowth will appear as a hyperreflective layer. | Epithelial Downgrowth -- Evaluation -- Anterior Segment Optical Coherence Tomography. Anterior segment optical coherence tomography (AS-OCT) is another noninvasive imaging modality that has been shown to aid in diagnosing epithelial downgrowth after DSAEK and penetrating keratoplasty. [22] [23] Epithelial downgrowth will appear as a hyperreflective layer. |
statpearls_NBK430685\article-101401_16 | Epithelial Downgrowth -- Evaluation -- Histopathologic Analysis | Histopathologic analysis is the gold standard to confirm epithelial downgrowth. Diagnosis is based on the classic finding of 1 to 3 layers of stratified, nonkeratinized squamous epithelium on the posterior cornea and anterior iris; however, any intraocular structure can be involved. [5] The source of the epithelium may also be distinguished. If the epithelium contains goblet cells, this indicates conjunctival rather than corneal origin. [16] | Epithelial Downgrowth -- Evaluation -- Histopathologic Analysis. Histopathologic analysis is the gold standard to confirm epithelial downgrowth. Diagnosis is based on the classic finding of 1 to 3 layers of stratified, nonkeratinized squamous epithelium on the posterior cornea and anterior iris; however, any intraocular structure can be involved. [5] The source of the epithelium may also be distinguished. If the epithelium contains goblet cells, this indicates conjunctival rather than corneal origin. [16] |
statpearls_NBK430685\article-101401_17 | Epithelial Downgrowth -- Evaluation -- Immunohistochemistry | Immunohistochemistry may also be used, but the evidence is limited. Cornea and conjunctival cells can be located by the expression of AE1/AE3, which are anticytokeratin antibodies found in almost all epithelia. [20] However, corneal endothelium may also express cytokeratins, making it difficult to distinguish between attenuated squamous epithelium and a single layer of corneal endothelium using this method alone. [16] | Epithelial Downgrowth -- Evaluation -- Immunohistochemistry. Immunohistochemistry may also be used, but the evidence is limited. Cornea and conjunctival cells can be located by the expression of AE1/AE3, which are anticytokeratin antibodies found in almost all epithelia. [20] However, corneal endothelium may also express cytokeratins, making it difficult to distinguish between attenuated squamous epithelium and a single layer of corneal endothelium using this method alone. [16] |
statpearls_NBK430685\article-101401_18 | Epithelial Downgrowth -- Treatment / Management | Historically, many therapeutic modalities have been used to treat epithelial downgrowth. These include surgical interventions such as iridectomy, vitrectomy, cautery, penetrating keratoplasty, cryotherapy, photocoagulation, and mechanical debridement. Medical treatments historically include radiation, alcohol, steroids, and antibiotics. Many of these are no longer used due to complications or high recurrence rates. [2] Regardless, the management of epithelial downgrowth depends on the extent of the involvement and whether it is the cystic or the diffuse, sheet-like form. Aggressive surgical management is often required; however, some of the more conservative approaches listed below may be used alone or in conjunction with others. | Epithelial Downgrowth -- Treatment / Management. Historically, many therapeutic modalities have been used to treat epithelial downgrowth. These include surgical interventions such as iridectomy, vitrectomy, cautery, penetrating keratoplasty, cryotherapy, photocoagulation, and mechanical debridement. Medical treatments historically include radiation, alcohol, steroids, and antibiotics. Many of these are no longer used due to complications or high recurrence rates. [2] Regardless, the management of epithelial downgrowth depends on the extent of the involvement and whether it is the cystic or the diffuse, sheet-like form. Aggressive surgical management is often required; however, some of the more conservative approaches listed below may be used alone or in conjunction with others. |
statpearls_NBK430685\article-101401_19 | Epithelial Downgrowth -- Treatment / Management -- Cryotherapy | Cryotherapy can be used to eliminate epithelium if localized to the posterior cornea, drainage angle, or ciliary body. [19] This approach can be combined with other surgical techniques, such as penetrating keratoplasty (PKP), fistula resection, or DMEK, to restore clarity and vision. [2] [24] Although cryotherapy typically spares other intraocular structures, different success rates have been reported, and endothelial loss should be anticipated, possibly necessitating corneal transplantation later. [2] | Epithelial Downgrowth -- Treatment / Management -- Cryotherapy. Cryotherapy can be used to eliminate epithelium if localized to the posterior cornea, drainage angle, or ciliary body. [19] This approach can be combined with other surgical techniques, such as penetrating keratoplasty (PKP), fistula resection, or DMEK, to restore clarity and vision. [2] [24] Although cryotherapy typically spares other intraocular structures, different success rates have been reported, and endothelial loss should be anticipated, possibly necessitating corneal transplantation later. [2] |
statpearls_NBK430685\article-101401_20 | Epithelial Downgrowth -- Treatment / Management -- Transcorneal Photocoagulation | Transcorneal photocoagulation with an argon laser is typically used for the cystic form of epithelial downgrowth but, in rare cases, has shown effectiveness in treating the diffuse form. [25] This procedure is less invasive than cryotherapy, leading to less inflammation. However, several disadvantages exist, including the need for multiple sessions and a rise in intraocular pressure caused by the release of cyst contents, subsequently blocking the trabecular meshwork. [26] Applying photocoagulation to the posterior surface of the iris or in the angle can also be technically difficult. [2] Endoscopic photocoagulation with a diode laser has been shown to allow for better visualization and precision and, thus, complete treatment, especially in the setting of corneal opacification. [27] [28] However, all forms of photocoagulation reportedly risk rupturing the cyst, potentially leading to the development of the diffuse, sheet-like form. | Epithelial Downgrowth -- Treatment / Management -- Transcorneal Photocoagulation. Transcorneal photocoagulation with an argon laser is typically used for the cystic form of epithelial downgrowth but, in rare cases, has shown effectiveness in treating the diffuse form. [25] This procedure is less invasive than cryotherapy, leading to less inflammation. However, several disadvantages exist, including the need for multiple sessions and a rise in intraocular pressure caused by the release of cyst contents, subsequently blocking the trabecular meshwork. [26] Applying photocoagulation to the posterior surface of the iris or in the angle can also be technically difficult. [2] Endoscopic photocoagulation with a diode laser has been shown to allow for better visualization and precision and, thus, complete treatment, especially in the setting of corneal opacification. [27] [28] However, all forms of photocoagulation reportedly risk rupturing the cyst, potentially leading to the development of the diffuse, sheet-like form. |
statpearls_NBK430685\article-101401_21 | Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections | Intracameral injections of antimetabolites such as 5-fluorouracil (5-FU) and Mitomycin-C (MMC) have also been reported as potentially effective treatments for epithelial downgrowth. [28] [29] [30] These injections offer an alternative to more aggressive surgical management. The pyrimidine analog 5-FU inhibits cell proliferation and may alter the appearance of epithelial cells on histopathology. [21] Reported dosages range from 40 to 1000 mcg in single or sequential doses. [29] [30] One protocol described an initial injection of 1000 mcg/0.1mL of 5-FU combined with 0.1 mL viscoelastic, followed 3 weeks later by another injection of 5-FU at 500 mcg/0.1mL with 0.1mL of viscoelastic. [30] | Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections. Intracameral injections of antimetabolites such as 5-fluorouracil (5-FU) and Mitomycin-C (MMC) have also been reported as potentially effective treatments for epithelial downgrowth. [28] [29] [30] These injections offer an alternative to more aggressive surgical management. The pyrimidine analog 5-FU inhibits cell proliferation and may alter the appearance of epithelial cells on histopathology. [21] Reported dosages range from 40 to 1000 mcg in single or sequential doses. [29] [30] One protocol described an initial injection of 1000 mcg/0.1mL of 5-FU combined with 0.1 mL viscoelastic, followed 3 weeks later by another injection of 5-FU at 500 mcg/0.1mL with 0.1mL of viscoelastic. [30] |
statpearls_NBK430685\article-101401_22 | Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections | This sequential dose pattern was designed to eradicate rapidly proliferating cells with the first injection. The second injection targets cells in the rest phase that may have proliferated after the drug had cleared. This is similar to a protocol used by Lai and Haller in which 500 mcg of 5-FU was injected into the anterior chamber after a fluid-gas exchange, followed by a second injection of 500 mcg 2 weeks later without gas. [31] | Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections. This sequential dose pattern was designed to eradicate rapidly proliferating cells with the first injection. The second injection targets cells in the rest phase that may have proliferated after the drug had cleared. This is similar to a protocol used by Lai and Haller in which 500 mcg of 5-FU was injected into the anterior chamber after a fluid-gas exchange, followed by a second injection of 500 mcg 2 weeks later without gas. [31] |
statpearls_NBK430685\article-101401_23 | Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections | Intraocular injections offer several potential advantages over subconjunctival injections, including the ability to use smaller doses with decreased risk of toxic side effects to the cornea. [32] In some cases, these injections completely resolve epithelial downgrowth, but complications include epithelial defect and corneal decompensation. [29] [30] | Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections. Intraocular injections offer several potential advantages over subconjunctival injections, including the ability to use smaller doses with decreased risk of toxic side effects to the cornea. [32] In some cases, these injections completely resolve epithelial downgrowth, but complications include epithelial defect and corneal decompensation. [29] [30] |
statpearls_NBK430685\article-101401_24 | Epithelial Downgrowth -- Treatment / Management -- MMC | MMC is a DNA cross-linking antineoplastic agent which also inhibits RNA and protein synthesis. It has been hypothesized that applying MMC in the cystic form of epithelial downgrowth damages the epithelial cells that secrete cyst fluid, leading to regression of the cyst. [26] Yu et al described a protocol beginning with aspirating an epithelial cyst with a 30-gauge needle followed by an injection of MMC at a concentration of 0.0002 mg/mL into the drained cyst. [26] However, MMC can have devastating effects if it leaks into the anterior chamber, so this procedure must be performed with caution. | Epithelial Downgrowth -- Treatment / Management -- MMC. MMC is a DNA cross-linking antineoplastic agent which also inhibits RNA and protein synthesis. It has been hypothesized that applying MMC in the cystic form of epithelial downgrowth damages the epithelial cells that secrete cyst fluid, leading to regression of the cyst. [26] Yu et al described a protocol beginning with aspirating an epithelial cyst with a 30-gauge needle followed by an injection of MMC at a concentration of 0.0002 mg/mL into the drained cyst. [26] However, MMC can have devastating effects if it leaks into the anterior chamber, so this procedure must be performed with caution. |
statpearls_NBK430685\article-101401_25 | Epithelial Downgrowth -- Treatment / Management -- Intravitreal Methotrexate | Lambert et al. reported a case of recurrent epithelial downgrowth refractory to membrane peeling, endolaser photocoagulation, and 5-FU injection that was treated successfully with intravitreal methotrexate (400 mcg/0.1mL). [33] The protocol was derived from the treatment of intraocular lymphoma. The first injection was performed with an additional membrane peel and endolaser treatment, followed by injections weekly for 4 weeks and then every other week for a total of 12 injections. | Epithelial Downgrowth -- Treatment / Management -- Intravitreal Methotrexate. Lambert et al. reported a case of recurrent epithelial downgrowth refractory to membrane peeling, endolaser photocoagulation, and 5-FU injection that was treated successfully with intravitreal methotrexate (400 mcg/0.1mL). [33] The protocol was derived from the treatment of intraocular lymphoma. The first injection was performed with an additional membrane peel and endolaser treatment, followed by injections weekly for 4 weeks and then every other week for a total of 12 injections. |
statpearls_NBK430685\article-101401_26 | Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures | More aggressive surgical procedures for epithelial downgrowth vary greatly in technique and success rates and depend on the location and structures affected. In some situations, epithelial cysts can be treated more conservatively, which may be recommended in children to preserve intraocular structures and manage amblyopia. One such technique consists of the viscodissection of the cyst with the aspiration of cyst contents and photocoagulation. [34] These procedures still run the risk of recurrence or converting a cyst into the diffuse form. Therefore, complete excision of cysts along with affected intraocular structures with full-thickness corneoscleral grafting may provide the most definitive surgical management. [17] [35] [36] | Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures. More aggressive surgical procedures for epithelial downgrowth vary greatly in technique and success rates and depend on the location and structures affected. In some situations, epithelial cysts can be treated more conservatively, which may be recommended in children to preserve intraocular structures and manage amblyopia. One such technique consists of the viscodissection of the cyst with the aspiration of cyst contents and photocoagulation. [34] These procedures still run the risk of recurrence or converting a cyst into the diffuse form. Therefore, complete excision of cysts along with affected intraocular structures with full-thickness corneoscleral grafting may provide the most definitive surgical management. [17] [35] [36] |
statpearls_NBK430685\article-101401_27 | Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures | Although the diffuse, sheet-like form may be effectively treated conservatively in rare cases with photocoagulation or epithelial membrane peeling, a more aggressive surgical approach is also usually necessary. [25] [37] [25] Surgical removal of the cystic form is more likely to be successful due to implanted cells being circumscribed within the cyst. These approaches seek to completely remove the epithelium and the intraocular structures involved but run the risk of collateral damage to ocular structures. | Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures. Although the diffuse, sheet-like form may be effectively treated conservatively in rare cases with photocoagulation or epithelial membrane peeling, a more aggressive surgical approach is also usually necessary. [25] [37] [25] Surgical removal of the cystic form is more likely to be successful due to implanted cells being circumscribed within the cyst. These approaches seek to completely remove the epithelium and the intraocular structures involved but run the risk of collateral damage to ocular structures. |
statpearls_NBK430685\article-101401_28 | Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures | To prevent epithelial downgrowth, a meticulous approximation of wound edges and attention to incisions intraoperatively and postoperatively are crucial. Wound leaks should also be evaluated and repaired when applicable. | Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures. To prevent epithelial downgrowth, a meticulous approximation of wound edges and attention to incisions intraoperatively and postoperatively are crucial. Wound leaks should also be evaluated and repaired when applicable. |
statpearls_NBK430685\article-101401_29 | Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth | The term retrocorneal membrane can encompass both epithelial downgrowth and fibrous downgrowth. Both can be a result of trauma or intraocular surgery; for example, fibrous downgrowth has been reported after cataract surgery, [38] rigid Schreck anterior chamber lens implantation, [39] intraocular telescope implantation, [40] and traumatic corneoscleral wound dehiscence. [41] Risk factors appear similar, including prolonged inflammation, wound dehiscence, and delayed wound closure. Symptoms in each are nonspecific, and both appear as translucent retrocorneal membranes. | Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth. The term retrocorneal membrane can encompass both epithelial downgrowth and fibrous downgrowth. Both can be a result of trauma or intraocular surgery; for example, fibrous downgrowth has been reported after cataract surgery, [38] rigid Schreck anterior chamber lens implantation, [39] intraocular telescope implantation, [40] and traumatic corneoscleral wound dehiscence. [41] Risk factors appear similar, including prolonged inflammation, wound dehiscence, and delayed wound closure. Symptoms in each are nonspecific, and both appear as translucent retrocorneal membranes. |
statpearls_NBK430685\article-101401_30 | Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth | Complications of fibrous downgrowth are like that of epithelial downgrowth, including glaucoma. [42] However, there are a few distinctions. The membrane in fibrous downgrowth may be vascular and is predominately fibrous instead of cellular. [14] [19] Fibrous downgrowth is also more common than epithelial downgrowth and tends to progress more slowly. There are few adjunctive tests to confirm the presence of fibrous downgrowth. However, there are reports that immunohistochemical positive staining for α-smooth muscle actin can help sway the diagnosis toward fibrous downgrowth. [43] | Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth. Complications of fibrous downgrowth are like that of epithelial downgrowth, including glaucoma. [42] However, there are a few distinctions. The membrane in fibrous downgrowth may be vascular and is predominately fibrous instead of cellular. [14] [19] Fibrous downgrowth is also more common than epithelial downgrowth and tends to progress more slowly. There are few adjunctive tests to confirm the presence of fibrous downgrowth. However, there are reports that immunohistochemical positive staining for α-smooth muscle actin can help sway the diagnosis toward fibrous downgrowth. [43] |
statpearls_NBK430685\article-101401_31 | Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth | Management mainly appears to be similar between epithelial and fibrous downgrowth using photocoagulation, surgical excision, and intracameral metabolites. Bevacizumab has been suggested as a unique treatment for fibrous downgrowth. Mansour reports using combined intracorneal (0.05 mL; 1.25 mg) and subconjunctival (0.1 mL; 2.5 mg) injections of bevacizumab in a patient to halt vascularization within the fibrous membrane to reduce intraocular bleeding. [14] Intracorneal and subconjunctival routes of injection were chosen instead of intracameral due to the presence of glaucoma and intravitreal silicone oil. | Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth. Management mainly appears to be similar between epithelial and fibrous downgrowth using photocoagulation, surgical excision, and intracameral metabolites. Bevacizumab has been suggested as a unique treatment for fibrous downgrowth. Mansour reports using combined intracorneal (0.05 mL; 1.25 mg) and subconjunctival (0.1 mL; 2.5 mg) injections of bevacizumab in a patient to halt vascularization within the fibrous membrane to reduce intraocular bleeding. [14] Intracorneal and subconjunctival routes of injection were chosen instead of intracameral due to the presence of glaucoma and intravitreal silicone oil. |
statpearls_NBK430685\article-101401_32 | Epithelial Downgrowth -- Differential Diagnosis -- Pseudophakic Bullous Keratopathy | Pseudophakic bullous keratopathy (PBK) is the development of irreversible corneal edema after cataract surgery and postoperative inflammation. This corneal edema occurs due to the loss of corneal endothelium secondary to surgical trauma. PBK can clinically resemble epithelial downgrowth with reduced visual acuity, tearing, and pain. However, signs of PBK include stromal edema and subepithelial bullae. Epithelial downgrowth should be considered in patients undergoing penetrating keratoplasty for presumed diagnoses of PBK, and these may be distinguished immunohistochemically with the presence of anticytokeratin antibodies in epithelial downgrowth. [20] | Epithelial Downgrowth -- Differential Diagnosis -- Pseudophakic Bullous Keratopathy. Pseudophakic bullous keratopathy (PBK) is the development of irreversible corneal edema after cataract surgery and postoperative inflammation. This corneal edema occurs due to the loss of corneal endothelium secondary to surgical trauma. PBK can clinically resemble epithelial downgrowth with reduced visual acuity, tearing, and pain. However, signs of PBK include stromal edema and subepithelial bullae. Epithelial downgrowth should be considered in patients undergoing penetrating keratoplasty for presumed diagnoses of PBK, and these may be distinguished immunohistochemically with the presence of anticytokeratin antibodies in epithelial downgrowth. [20] |
statpearls_NBK430685\article-101401_33 | Epithelial Downgrowth -- Differential Diagnosis -- Secondary Endothelial Proliferation | Secondary endothelization usually arises from ischemia and can also present after multiple intraocular surgeries. The endothelial cells can proliferate in the angle and anterior surface of the iris. This can be considered a precursor to rubeosis iridis (neovascularization of the iris), which can lead to neovascular glaucoma, a form of secondary glaucoma. Clinically, this can appear as neovascularization of the iris. Histologically, this can be differentiated from epithelial downgrowth by a lack of stratification. [16] | Epithelial Downgrowth -- Differential Diagnosis -- Secondary Endothelial Proliferation. Secondary endothelization usually arises from ischemia and can also present after multiple intraocular surgeries. The endothelial cells can proliferate in the angle and anterior surface of the iris. This can be considered a precursor to rubeosis iridis (neovascularization of the iris), which can lead to neovascular glaucoma, a form of secondary glaucoma. Clinically, this can appear as neovascularization of the iris. Histologically, this can be differentiated from epithelial downgrowth by a lack of stratification. [16] |
statpearls_NBK430685\article-101401_34 | Epithelial Downgrowth -- Prognosis | Visual outcome after a diagnosis of epithelial downgrowth is generally poor due to recurrence, refractory glaucoma, and corneal decompensation. [15] Prognosis tends to be worse in the diffuse, sheet-like form because it is more difficult to identify and requires more extensive surgical procedures. [2] Many cases have historically ended in enucleation, most commonly due to severe secondary glaucoma. [5] In one retrospective study from 1953 to 1983, enucleation occurred in 52% of patients treated with surgery and 95% of those without surgery. [5] | Epithelial Downgrowth -- Prognosis. Visual outcome after a diagnosis of epithelial downgrowth is generally poor due to recurrence, refractory glaucoma, and corneal decompensation. [15] Prognosis tends to be worse in the diffuse, sheet-like form because it is more difficult to identify and requires more extensive surgical procedures. [2] Many cases have historically ended in enucleation, most commonly due to severe secondary glaucoma. [5] In one retrospective study from 1953 to 1983, enucleation occurred in 52% of patients treated with surgery and 95% of those without surgery. [5] |
statpearls_NBK430685\article-101401_35 | Epithelial Downgrowth -- Prognosis | In a series of 52 patients from 1980 to 1996 treated with en bloc excision and corneoscleral grafting, the mean visual acuity at the final follow-up visit was 20/100 in the cystic-type cases and 20/200 in the diffuse-type cases. [44] In this study, there were no reported cases of recurrence or enucleation. Although many cases require early and aggressive intervention to prevent permanent vision loss, there are rare case reports of epithelial downgrowth spontaneously regressing. [45] | Epithelial Downgrowth -- Prognosis. In a series of 52 patients from 1980 to 1996 treated with en bloc excision and corneoscleral grafting, the mean visual acuity at the final follow-up visit was 20/100 in the cystic-type cases and 20/200 in the diffuse-type cases. [44] In this study, there were no reported cases of recurrence or enucleation. Although many cases require early and aggressive intervention to prevent permanent vision loss, there are rare case reports of epithelial downgrowth spontaneously regressing. [45] |
statpearls_NBK430685\article-101401_36 | Epithelial Downgrowth -- Complications | Complications include chronic inflammation, secondary glaucoma, corneal decompensation, and, in severe cases, phthisis bulbi. Glaucoma is common with the diffuse sheet-like form and may occur due to blockage of the trabecular meshwork by the epithelium directly or by mucin from conjunctival goblet cells. [42] Inflammation can also lead to peripheral anterior synechiae and trabeculitis, worsening aqueous drainage. This secondary glaucoma is often refractory to medical management and is a major cause of irreversible vision loss in epithelial downgrowth. | Epithelial Downgrowth -- Complications. Complications include chronic inflammation, secondary glaucoma, corneal decompensation, and, in severe cases, phthisis bulbi. Glaucoma is common with the diffuse sheet-like form and may occur due to blockage of the trabecular meshwork by the epithelium directly or by mucin from conjunctival goblet cells. [42] Inflammation can also lead to peripheral anterior synechiae and trabeculitis, worsening aqueous drainage. This secondary glaucoma is often refractory to medical management and is a major cause of irreversible vision loss in epithelial downgrowth. |
statpearls_NBK430685\article-101401_37 | Epithelial Downgrowth -- Complications | Management usually centers around combining topical intraocular pressure–lowering medications with a glaucoma drainage device and possibly cryoablation procedures. Epithelium can also progress to the posterior chamber in the setting of aphakia, lens luxation, trauma, or scleral buckle insertion. [9] This can lead to proliferation onto the inner retina, causing tractional retinal detachment and epiretinal membranes. [46] | Epithelial Downgrowth -- Complications. Management usually centers around combining topical intraocular pressure–lowering medications with a glaucoma drainage device and possibly cryoablation procedures. Epithelium can also progress to the posterior chamber in the setting of aphakia, lens luxation, trauma, or scleral buckle insertion. [9] This can lead to proliferation onto the inner retina, causing tractional retinal detachment and epiretinal membranes. [46] |
statpearls_NBK430685\article-101401_38 | Epithelial Downgrowth -- Deterrence and Patient Education | Patients should be informed of treatment options for epithelial downgrowth and that recurrence is common. They should also be educated that, depending on the extent of the disease, the goal of treatment may not be to restore visual acuity and function completely but rather to achieve stability and comfort. If surgery is pursued, patients should be encouraged to follow postoperative safety measures to improve outcomes. | Epithelial Downgrowth -- Deterrence and Patient Education. Patients should be informed of treatment options for epithelial downgrowth and that recurrence is common. They should also be educated that, depending on the extent of the disease, the goal of treatment may not be to restore visual acuity and function completely but rather to achieve stability and comfort. If surgery is pursued, patients should be encouraged to follow postoperative safety measures to improve outcomes. |
statpearls_NBK430685\article-101401_39 | Epithelial Downgrowth -- Pearls and Other Issues | Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. It ranges in the severity of presentation but can include decreasing visual acuity, redness, pain, tearing, and photophobia. A thorough history and physical examination, in addition to supplemental studies like imaging and histopathology, is crucial to diagnose epithelial downgrowth accurately. Treatment options depend on the extent of involvement and growth pattern and vary from conservative measures to surgical excision with corneoscleral transplantation. | Epithelial Downgrowth -- Pearls and Other Issues. Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. It ranges in the severity of presentation but can include decreasing visual acuity, redness, pain, tearing, and photophobia. A thorough history and physical examination, in addition to supplemental studies like imaging and histopathology, is crucial to diagnose epithelial downgrowth accurately. Treatment options depend on the extent of involvement and growth pattern and vary from conservative measures to surgical excision with corneoscleral transplantation. |
statpearls_NBK430685\article-101401_40 | Epithelial Downgrowth -- Enhancing Healthcare Team Outcomes | Epithelial downgrowth is a rare pathology, but clinicians should be able to identify it promptly to minimize severe complications. [2] Managing epithelial downgrowth requires a team of medical professionals. Physicians, eye care specialists, nurses, technicians, and medical assistants should be thorough when performing the history and physical, paying particular attention to previous intraocular surgeries or trauma. Clinicians should be aware of relevant testing to expedite the diagnosis of epithelial downgrowth, as it is progressive and carries a poor prognosis. Patients should be adequately informed of the diagnosis, treatment options, and complications. | Epithelial Downgrowth -- Enhancing Healthcare Team Outcomes. Epithelial downgrowth is a rare pathology, but clinicians should be able to identify it promptly to minimize severe complications. [2] Managing epithelial downgrowth requires a team of medical professionals. Physicians, eye care specialists, nurses, technicians, and medical assistants should be thorough when performing the history and physical, paying particular attention to previous intraocular surgeries or trauma. Clinicians should be aware of relevant testing to expedite the diagnosis of epithelial downgrowth, as it is progressive and carries a poor prognosis. Patients should be adequately informed of the diagnosis, treatment options, and complications. |
statpearls_NBK430685\article-101401_41 | Epithelial Downgrowth -- Review Questions | Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article. | Epithelial Downgrowth -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article. |
statpearls_NBK430685\article-101404_0 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Introduction | The elbow is a hinge joint comprised of bony and ligamentous stabilizers. Specifically, the elbow contains two collateral ligaments: the medial collateral ligament (MCL, also known as ulnar collateral ligament, or UCL) and the lateral collateral ligament (LCL). Each of these two ligaments is made up of smaller ligamentous portions. These structures provide stability for the elbow joint and constant tension through elbow motion. The constant tension and torque experienced by these ligaments leave them prone to injury, especially the MCL. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Introduction. The elbow is a hinge joint comprised of bony and ligamentous stabilizers. Specifically, the elbow contains two collateral ligaments: the medial collateral ligament (MCL, also known as ulnar collateral ligament, or UCL) and the lateral collateral ligament (LCL). Each of these two ligaments is made up of smaller ligamentous portions. These structures provide stability for the elbow joint and constant tension through elbow motion. The constant tension and torque experienced by these ligaments leave them prone to injury, especially the MCL. [1] |
statpearls_NBK430685\article-101404_1 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The elbow's ranges of motion (ROM) are flexion, extension, pronation, and supination. In healthy individuals, flexion lies between 130 to 154 degrees, extension from -6 to 11 degrees, pronation from 75 to 85 degrees, and supination from 80 to 104 degrees. [2] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The elbow's ranges of motion (ROM) are flexion, extension, pronation, and supination. In healthy individuals, flexion lies between 130 to 154 degrees, extension from -6 to 11 degrees, pronation from 75 to 85 degrees, and supination from 80 to 104 degrees. [2] |
statpearls_NBK430685\article-101404_2 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The bony anatomy of the elbow joint requires a brief description to lay the framework for the collateral ligaments of the elbow. Three bony structures create multiple articulations within the elbow complex. The three bony structures include the distal humerus, proximal radius, and proximal ulna. The distal humerus contains two main structures, the trochlea, and the capitellum. The medial epicondyle of the humerus provides a site of connection for ligamentous and muscular structures. | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The bony anatomy of the elbow joint requires a brief description to lay the framework for the collateral ligaments of the elbow. Three bony structures create multiple articulations within the elbow complex. The three bony structures include the distal humerus, proximal radius, and proximal ulna. The distal humerus contains two main structures, the trochlea, and the capitellum. The medial epicondyle of the humerus provides a site of connection for ligamentous and muscular structures. |
statpearls_NBK430685\article-101404_3 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The proximal ulna also has two articulations, the greater and lesser sigmoid notches. The trochlea and greater sigmoid notch have 180 degrees of articular contact during the elbow range of motion (ROM). The lesser sigmoid notch articulates with the radius at the proximal radioulnar joint. The radial head and capitellum form the raidiocapitellar joint. The radial head allows for pronation and supination of the elbow. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The proximal ulna also has two articulations, the greater and lesser sigmoid notches. The trochlea and greater sigmoid notch have 180 degrees of articular contact during the elbow range of motion (ROM). The lesser sigmoid notch articulates with the radius at the proximal radioulnar joint. The radial head and capitellum form the raidiocapitellar joint. The radial head allows for pronation and supination of the elbow. [1] |
statpearls_NBK430685\article-101404_4 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The MCL has three ligamentous portions: the anterior bundle (AMCL), the posterior bundle, and the transverse ligament (Cooper ligament). The AMCL and posterior bundle originate from the medial epicondyle of the distal humerus, on the posterior side of the elbow; this creates ligamentous tension with elbow flexion. The insertion site of the AMCL is the sublime tubercle on the coronoid process of the ulna, and the posterior bundle inserts on at the medial olecranon of the ulna. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The MCL has three ligamentous portions: the anterior bundle (AMCL), the posterior bundle, and the transverse ligament (Cooper ligament). The AMCL and posterior bundle originate from the medial epicondyle of the distal humerus, on the posterior side of the elbow; this creates ligamentous tension with elbow flexion. The insertion site of the AMCL is the sublime tubercle on the coronoid process of the ulna, and the posterior bundle inserts on at the medial olecranon of the ulna. [1] |
statpearls_NBK430685\article-101404_5 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The transverse ligament originates from the olecranon process inserts on the sublime tubercle of the ulna. [3] As mentioned, the MCL acts as a primary stabilizer of the elbow, but specifically during valgus stress. For this reason, the MCL is the most commonly injured ligament in overhead throwing athletes; this is due to the mechanics of throwing motion that cause extreme valgus stress at high velocities. The anterior and posterior bundles provide reciprocal function, as the anterior portion is tight in extension, and the posterior portion is tight in flexion. During flexion of the elbow, the MCL also limits internal rotation. [4] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The transverse ligament originates from the olecranon process inserts on the sublime tubercle of the ulna. [3] As mentioned, the MCL acts as a primary stabilizer of the elbow, but specifically during valgus stress. For this reason, the MCL is the most commonly injured ligament in overhead throwing athletes; this is due to the mechanics of throwing motion that cause extreme valgus stress at high velocities. The anterior and posterior bundles provide reciprocal function, as the anterior portion is tight in extension, and the posterior portion is tight in flexion. During flexion of the elbow, the MCL also limits internal rotation. [4] |
statpearls_NBK430685\article-101404_6 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The MCL also functions as a restraint in posteromedial rotatory instability, specifically the AMCL. Further evaluating the MCL and the specifics of valgus stress, the MCL provides one-third of the valgus restraint in extension, and one half in 90 degrees of elbow flexion. The MCL coincides with the flexor and pronator forearm musculature in dynamic stability. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The MCL also functions as a restraint in posteromedial rotatory instability, specifically the AMCL. Further evaluating the MCL and the specifics of valgus stress, the MCL provides one-third of the valgus restraint in extension, and one half in 90 degrees of elbow flexion. The MCL coincides with the flexor and pronator forearm musculature in dynamic stability. [1] |
statpearls_NBK430685\article-101404_7 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The LCL contains four ligamentous portions: the lateral ulnar collateral ligament (LUCL), radial collateral ligament (RCL), annular ligament, and accessory collateral ligament. The LUCL and RCL originate from the inferior surface of the lateral epicondyle of the humerus. These two ligaments provide consistent tension through elbow ROM. The LUCL inserts at the proximal ulna and the RCL attached to the annular ligament. The annular ligament wraps around the radial head and attaches to the anterior snd posterior margins of the lesser sigmoid notch of the proximal ulna. The RCL and annular ligaments provide stabilization for the radial head. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The LCL contains four ligamentous portions: the lateral ulnar collateral ligament (LUCL), radial collateral ligament (RCL), annular ligament, and accessory collateral ligament. The LUCL and RCL originate from the inferior surface of the lateral epicondyle of the humerus. These two ligaments provide consistent tension through elbow ROM. The LUCL inserts at the proximal ulna and the RCL attached to the annular ligament. The annular ligament wraps around the radial head and attaches to the anterior snd posterior margins of the lesser sigmoid notch of the proximal ulna. The RCL and annular ligaments provide stabilization for the radial head. [1] |
statpearls_NBK430685\article-101404_8 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function | The accessory collateral ligament runs from the medial portion of the supinator crest (on the proximal ulna) and attaches to the inferior portion of the annular ligament. [5] The LCL functions to primarily resist posterolateral rotatory instability, and to a lesser extent, the LCL resists varus stress. The ulnohumeral joint provides the majority of stability when the elbow is under varus stress application; the LCL resists just 10% of varus stress. Within the LCL unit, the LUCL appears to be the primary stabilizer, but the entire four-ligament complex is required to provide radiohumeral, radioulnar, and ulnohumeral joint stability. The extensor forearm musculature coincides with the LCL ligament to provide stability with dynamic motion. the LCL is most vulnerable in the supinated position. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The accessory collateral ligament runs from the medial portion of the supinator crest (on the proximal ulna) and attaches to the inferior portion of the annular ligament. [5] The LCL functions to primarily resist posterolateral rotatory instability, and to a lesser extent, the LCL resists varus stress. The ulnohumeral joint provides the majority of stability when the elbow is under varus stress application; the LCL resists just 10% of varus stress. Within the LCL unit, the LUCL appears to be the primary stabilizer, but the entire four-ligament complex is required to provide radiohumeral, radioulnar, and ulnohumeral joint stability. The extensor forearm musculature coincides with the LCL ligament to provide stability with dynamic motion. the LCL is most vulnerable in the supinated position. [1] |
statpearls_NBK430685\article-101404_9 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology | The elbow joint develops in three phases, the homogenous interzone, three-layered interzones, and cavitation. Chondrogenic areas are termed homogenous interzone around six weeks, and cartilaginous development increase via appositional growth. Homogenous zones convert into three-layered interzones at seven weeks. Mesenchymal tissue will condense into a fibrous capsule, and vascular mesenchyme becomes incorporated into the joint as synovial mesenchyme. This synovial mesenchyme will form the synovial tissue as well as the intracapsular ligaments. Cavitation, occurring at eight weeks, is when the articular cavity will form. Cavitation is initially independent of movement, but articular motion is necessary for full differentiation and development of the cavity. [6] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology. The elbow joint develops in three phases, the homogenous interzone, three-layered interzones, and cavitation. Chondrogenic areas are termed homogenous interzone around six weeks, and cartilaginous development increase via appositional growth. Homogenous zones convert into three-layered interzones at seven weeks. Mesenchymal tissue will condense into a fibrous capsule, and vascular mesenchyme becomes incorporated into the joint as synovial mesenchyme. This synovial mesenchyme will form the synovial tissue as well as the intracapsular ligaments. Cavitation, occurring at eight weeks, is when the articular cavity will form. Cavitation is initially independent of movement, but articular motion is necessary for full differentiation and development of the cavity. [6] |
statpearls_NBK430685\article-101404_10 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology | There is a discrepancy when the collateral ligaments are first visible. Studies have demonstrated visualization of the collateral ligaments in as early as 56 days in a 31 mm fetus. Yet other studies mention requiring fetuses of 270mm or larger for visualization of the collateral ligaments. Merida-Velasco et al. found that during week 12, vascular canals became apparent in the humerus, trochlear notch of the ulna, and radial head. It was at this time that the lateral ligaments began to develop into small densities of the outer aspect of the articular capsule. [6] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology. There is a discrepancy when the collateral ligaments are first visible. Studies have demonstrated visualization of the collateral ligaments in as early as 56 days in a 31 mm fetus. Yet other studies mention requiring fetuses of 270mm or larger for visualization of the collateral ligaments. Merida-Velasco et al. found that during week 12, vascular canals became apparent in the humerus, trochlear notch of the ulna, and radial head. It was at this time that the lateral ligaments began to develop into small densities of the outer aspect of the articular capsule. [6] |
statpearls_NBK430685\article-101404_11 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics | The elbow joint receives its blood supply from peri-articular anastomoses. Specifically, the brachial, deep brachial, ulnar, and radial arteries have collateral and recurrent branches to provide continuous blood flow. Superior collateral branches include superior collateral, inferior ulnar, and radial collateral arteries. The inferior collateral branches include the anterior and posterior ulnar recurrent arteries, the recurrent interosseous artery, and the radial recurrent artery. The venous outflow is provided by the radial, ulnar, basilic, and brachial veins. [7] [8] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics. The elbow joint receives its blood supply from peri-articular anastomoses. Specifically, the brachial, deep brachial, ulnar, and radial arteries have collateral and recurrent branches to provide continuous blood flow. Superior collateral branches include superior collateral, inferior ulnar, and radial collateral arteries. The inferior collateral branches include the anterior and posterior ulnar recurrent arteries, the recurrent interosseous artery, and the radial recurrent artery. The venous outflow is provided by the radial, ulnar, basilic, and brachial veins. [7] [8] |
statpearls_NBK430685\article-101404_12 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics | Specifically, the blood supply to the medial collateral ligament is unknown. A descriptive laboratory study utilizing 18 fresh-frozen male cadaveric elbows injected 60 mL of India ink into the brachial artery of each elbow. The proximal MCL consistently exhibited dense blood supply, while the distal MCL was hypovascular. The authors also found a possible contribution to the proximal MCL from the medial epicondyle. An artery from the flexor/pronator musculature also consistently provided blood to the proximal MCL. The average length of vascular penetration was 49% for the entire MCL. The study concluded there is a difference in vascular supply between the proximal and distal MCL. They suggested that the hypovascularity of the distal MCL may result in a lack of appropriate healing capacity, and MCL injuries may differ in a progression based on the location of the injury (proximal vs. distal). [9] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics. Specifically, the blood supply to the medial collateral ligament is unknown. A descriptive laboratory study utilizing 18 fresh-frozen male cadaveric elbows injected 60 mL of India ink into the brachial artery of each elbow. The proximal MCL consistently exhibited dense blood supply, while the distal MCL was hypovascular. The authors also found a possible contribution to the proximal MCL from the medial epicondyle. An artery from the flexor/pronator musculature also consistently provided blood to the proximal MCL. The average length of vascular penetration was 49% for the entire MCL. The study concluded there is a difference in vascular supply between the proximal and distal MCL. They suggested that the hypovascularity of the distal MCL may result in a lack of appropriate healing capacity, and MCL injuries may differ in a progression based on the location of the injury (proximal vs. distal). [9] |
statpearls_NBK430685\article-101404_13 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics | Superficial cubital lymph nodes and deep cubital lymph nodes are located above the medial epicondyle at the elbow. The superficial cubital nodes receive lymph from the medial side of the hand and forearm, while the deep cubital nodes drain the elbow joint itself. The lymph from these nodes eventually reaches the axillary lymph nodes bilaterally. The lymph from the left will enter the thoracic duct and lymph from the right will enter the right lymphatic duct. [7] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics. Superficial cubital lymph nodes and deep cubital lymph nodes are located above the medial epicondyle at the elbow. The superficial cubital nodes receive lymph from the medial side of the hand and forearm, while the deep cubital nodes drain the elbow joint itself. The lymph from these nodes eventually reaches the axillary lymph nodes bilaterally. The lymph from the left will enter the thoracic duct and lymph from the right will enter the right lymphatic duct. [7] |
statpearls_NBK430685\article-101404_14 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Nerves | The elbow joint receives branches of the median, radial, and musculocutaneous nerves anteriorly. Posteriorly the elbow joint is supplied by the ulnar nerve. [7] The median nerve branches into small sections that innervate the anteromedial epicondyle, where the MCL originates. The ulnar nerve supplies the posteromedial part of the elbow capsules, also in the neighborhood of the medial epicondyle and the olecranon. Branches from the radial nerve supply the posterolateral region of the elbow capsule, which is the location of the LCL. [10] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Nerves. The elbow joint receives branches of the median, radial, and musculocutaneous nerves anteriorly. Posteriorly the elbow joint is supplied by the ulnar nerve. [7] The median nerve branches into small sections that innervate the anteromedial epicondyle, where the MCL originates. The ulnar nerve supplies the posteromedial part of the elbow capsules, also in the neighborhood of the medial epicondyle and the olecranon. Branches from the radial nerve supply the posterolateral region of the elbow capsule, which is the location of the LCL. [10] |
statpearls_NBK430685\article-101404_15 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Muscles | The MCL works with the medial flexor musculature to resist valgus stress. Medial flexor musculature includes the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres. The LCL works with the extensor forearm musculature to resist varus forces. The extensor muscles include the extensor carpi ulnaris, extensor digitorum communis, extensor carpi radialis brevis and longus, and the anconeus. The anconeus is of significant importance because it provides major dynamic constraint to posterolateral rotatory instability and varus stresses, two functions that are also provided by the LCL. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Muscles. The MCL works with the medial flexor musculature to resist valgus stress. Medial flexor musculature includes the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres. The LCL works with the extensor forearm musculature to resist varus forces. The extensor muscles include the extensor carpi ulnaris, extensor digitorum communis, extensor carpi radialis brevis and longus, and the anconeus. The anconeus is of significant importance because it provides major dynamic constraint to posterolateral rotatory instability and varus stresses, two functions that are also provided by the LCL. [1] |
statpearls_NBK430685\article-101404_16 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants | A study examining cadaveric specimens looked at specific ligaments of the MCL (anterior bundle, posterior bundle, and transverse ligament). Specifically, they focused on the transverse ligament and its relationship with the anterior ligament. The majority of the transverse ligament continues to the distal half of the anterior ligament, and less common variants included transverse ligaments that traveled the entire anterior ligament. [3] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants. A study examining cadaveric specimens looked at specific ligaments of the MCL (anterior bundle, posterior bundle, and transverse ligament). Specifically, they focused on the transverse ligament and its relationship with the anterior ligament. The majority of the transverse ligament continues to the distal half of the anterior ligament, and less common variants included transverse ligaments that traveled the entire anterior ligament. [3] |
statpearls_NBK430685\article-101404_17 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants | There is minimal variation with the anterior and posterior bundles. Of note, while the most common insertion site for the anterior bundle of the MCL is the sublime tubercle, variations have been found. Studies have found anterior bundle insertion only 1 mm away from the joint line. Other studies have found the insertion of the anterior bundle to be 3 mm more distal. This distal insertion has clinical relevance because it creates a small recess on arthrograms, which simulates a partial undersurface tear of the anterior bundle. [11] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants. There is minimal variation with the anterior and posterior bundles. Of note, while the most common insertion site for the anterior bundle of the MCL is the sublime tubercle, variations have been found. Studies have found anterior bundle insertion only 1 mm away from the joint line. Other studies have found the insertion of the anterior bundle to be 3 mm more distal. This distal insertion has clinical relevance because it creates a small recess on arthrograms, which simulates a partial undersurface tear of the anterior bundle. [11] |
statpearls_NBK430685\article-101404_18 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants | An accessory or "extra bundle" ligament belonging to the MCL was also present in a quarter of examined specimens found in one study. The addition of this ligament creates an MCL comprised of four ligaments. The extra-bundle ligament originates from the posteromedial aspect of the capsule and inserts on the transverse bundle. The transverse bundle itself has a variation of a fanlike distribution with insertions onto the anterior bundle and coronoid; this creates a strong oblique pattern on imaging. [11] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants. An accessory or "extra bundle" ligament belonging to the MCL was also present in a quarter of examined specimens found in one study. The addition of this ligament creates an MCL comprised of four ligaments. The extra-bundle ligament originates from the posteromedial aspect of the capsule and inserts on the transverse bundle. The transverse bundle itself has a variation of a fanlike distribution with insertions onto the anterior bundle and coronoid; this creates a strong oblique pattern on imaging. [11] |
statpearls_NBK430685\article-101404_19 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations | Posterolateral rotatory instability (PLRI) occurs secondary to a traumatic or iatrogenic injury to the LCL, which is the most common recurrent instability of the elbow. The radial head frequently subluxes, which creates lateral elbow pain and mechanical issues while the elbow is in flexion and supination, and a load is applied. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Posterolateral rotatory instability (PLRI) occurs secondary to a traumatic or iatrogenic injury to the LCL, which is the most common recurrent instability of the elbow. The radial head frequently subluxes, which creates lateral elbow pain and mechanical issues while the elbow is in flexion and supination, and a load is applied. [1] |
statpearls_NBK430685\article-101404_20 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations | While conservative treatment such as physical therapy and activity modification should be trialed, nonoperative management of PLRI is typically ineffective. Surgical treatment is necessary to restabilize the joint in patients with persistent and symptomatic instability that causes pain or functional impairment. In acute, simple dislocation, closed reduction under general anesthesia is suggested. If the lateral elbow is stable past 30 degrees of extension, the patient wears a dynamic brace for six weeks. However, if after the closed reduction, the lateral elbow is still unstable before 30 degrees extension, ligament repair is necessary. | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. While conservative treatment such as physical therapy and activity modification should be trialed, nonoperative management of PLRI is typically ineffective. Surgical treatment is necessary to restabilize the joint in patients with persistent and symptomatic instability that causes pain or functional impairment. In acute, simple dislocation, closed reduction under general anesthesia is suggested. If the lateral elbow is stable past 30 degrees of extension, the patient wears a dynamic brace for six weeks. However, if after the closed reduction, the lateral elbow is still unstable before 30 degrees extension, ligament repair is necessary. |
statpearls_NBK430685\article-101404_21 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations | Chronic and symptomatic PLRI requires surgical intervention, as mentioned. The pivot shift test is performed on a supine patient, with the forearm hypersupinated. Valgus stress, along with an axial load, is then applied to the elbow while moving the elbow form extension to flexion. A positive-shift test on a conscious patient is with patient apprehension. In a sedated patient (under general anesthesia), this test is positive with subluxation or dislocation of the elbow, typically occurring between 30 to 45 degrees of flexion. | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Chronic and symptomatic PLRI requires surgical intervention, as mentioned. The pivot shift test is performed on a supine patient, with the forearm hypersupinated. Valgus stress, along with an axial load, is then applied to the elbow while moving the elbow form extension to flexion. A positive-shift test on a conscious patient is with patient apprehension. In a sedated patient (under general anesthesia), this test is positive with subluxation or dislocation of the elbow, typically occurring between 30 to 45 degrees of flexion. |
statpearls_NBK430685\article-101404_22 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations | Low-grade PLRI (subluxation) is treated with LCL imbrication via arthroscopic or open technique. Severe PLRI (dislocation) requires LCL reconstruction with graft use. Results after reconstruction show good to excellent results in 85% of patients. Recurrent instability has been seen even after surgical intervention, in up to as many of 25% of patients after medium to long-term follow-up. [12] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Low-grade PLRI (subluxation) is treated with LCL imbrication via arthroscopic or open technique. Severe PLRI (dislocation) requires LCL reconstruction with graft use. Results after reconstruction show good to excellent results in 85% of patients. Recurrent instability has been seen even after surgical intervention, in up to as many of 25% of patients after medium to long-term follow-up. [12] |
statpearls_NBK430685\article-101404_23 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations | MCL injury is more common, and especially seen in overhead throwers such as pitchers. For painful, symptomatic MCL injuries, reconstruction is a reliable treatment method for correction. Surgery is indicated after nonoperative treatment has been exhausted. Surgical treatment for the MCL is one of the most well known in the sports world and is dubbed "Tommy John surgery" after pitcher Tommy John was successfully treated using the following technique. The docking technique is most commonly performed. Advantages include minimizing injury to the flexor/pronator musculature, avoidance of the ulnar nerve, providing an optimal location for graft tensioning, and minimizing the amount of bone removed from the medial epicondyle. [13] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. MCL injury is more common, and especially seen in overhead throwers such as pitchers. For painful, symptomatic MCL injuries, reconstruction is a reliable treatment method for correction. Surgery is indicated after nonoperative treatment has been exhausted. Surgical treatment for the MCL is one of the most well known in the sports world and is dubbed "Tommy John surgery" after pitcher Tommy John was successfully treated using the following technique. The docking technique is most commonly performed. Advantages include minimizing injury to the flexor/pronator musculature, avoidance of the ulnar nerve, providing an optimal location for graft tensioning, and minimizing the amount of bone removed from the medial epicondyle. [13] |
statpearls_NBK430685\article-101404_24 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations | Surgical treatment utilizes autograft, most commonly from the palmaris longus. Other graft options include gracilis, semitendinosus, toe extensor, plantaris, patellar tendon, and Achilles autografts. This injury that was once deemed a career-ending injury for major league baseball pitchers now shows an astounding 83% return to sport after UCL reconstruction. [14] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Surgical treatment utilizes autograft, most commonly from the palmaris longus. Other graft options include gracilis, semitendinosus, toe extensor, plantaris, patellar tendon, and Achilles autografts. This injury that was once deemed a career-ending injury for major league baseball pitchers now shows an astounding 83% return to sport after UCL reconstruction. [14] |
statpearls_NBK430685\article-101404_25 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance | The collateral ligaments and their significant responsibility in maintaining elbow function make it pivotal for physicians to diagnose injuries properly. Whether the MCL or LCL injury at the elbow, a history, physical exam, imaging, and exhausted conservative treatments prior to surgery is the generalized outline of patient care. | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. The collateral ligaments and their significant responsibility in maintaining elbow function make it pivotal for physicians to diagnose injuries properly. Whether the MCL or LCL injury at the elbow, a history, physical exam, imaging, and exhausted conservative treatments prior to surgery is the generalized outline of patient care. |
statpearls_NBK430685\article-101404_26 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance | Medial elbow injuries are amongst the most common in sports. Elbow injuries are the most common cause of time loss (over ten days) in collegiate pitchers, Upper extremity injuries account for 45% of all injuries in the NCAA, and 7-8% of these injuries belong to the elbow. Specifically pertaining to baseball, 97% of pitchers elbow pain is on the medial side of the elbow [14] . | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. Medial elbow injuries are amongst the most common in sports. Elbow injuries are the most common cause of time loss (over ten days) in collegiate pitchers, Upper extremity injuries account for 45% of all injuries in the NCAA, and 7-8% of these injuries belong to the elbow. Specifically pertaining to baseball, 97% of pitchers elbow pain is on the medial side of the elbow [14] . |
statpearls_NBK430685\article-101404_27 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance | A patient history determining the location of the pain, how long the pain has been present, the exact point in motion where the patient experiences the injury is imperative in diagnosing MCL injury. If present in an athlete, they may complain of decreased performance, such as throwing velocity or stamina. Patients might also site issues of numbness and tingling in the ulnar distribution pattern since the chronic UCL injuries are associated with ulnar neuropathy. Physical exam should check for the palmaris longus muscle if surgery is required; this requires the patient to flex the wrist with opposing the first and fifth digits. | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. A patient history determining the location of the pain, how long the pain has been present, the exact point in motion where the patient experiences the injury is imperative in diagnosing MCL injury. If present in an athlete, they may complain of decreased performance, such as throwing velocity or stamina. Patients might also site issues of numbness and tingling in the ulnar distribution pattern since the chronic UCL injuries are associated with ulnar neuropathy. Physical exam should check for the palmaris longus muscle if surgery is required; this requires the patient to flex the wrist with opposing the first and fifth digits. |
statpearls_NBK430685\article-101404_28 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance | Special tests, including the valgus stress test, milking maneuver, and moving valgus stress test, can be performed to facilitate the diagnosis of UCL injury. Imaging such as MRI, MRA, and US provide the best visualization for the UCL. The MRA has the highest sensitivity and specificity, along with superior interobserver reliability. Imaging can also provide prognostic factors. One study demonstrated that MRI of UCL with a higher T2 signal intensity is less likely to benefit from conservative treatment. [14] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. Special tests, including the valgus stress test, milking maneuver, and moving valgus stress test, can be performed to facilitate the diagnosis of UCL injury. Imaging such as MRI, MRA, and US provide the best visualization for the UCL. The MRA has the highest sensitivity and specificity, along with superior interobserver reliability. Imaging can also provide prognostic factors. One study demonstrated that MRI of UCL with a higher T2 signal intensity is less likely to benefit from conservative treatment. [14] |
statpearls_NBK430685\article-101404_29 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance | While not as common as MCL injuries, PLRI due to LCL damage can occur. Similar to that of MCL, history is a critical portion in evaluation, although injury to the LCL may not be as apparent as is with the MCL. The physical exam can include special tests, such as the pivot-shift test (mentioned above), posterolateral rotatory drawer test, chair push-up test, prone push-up test, and table-top relocation test. All of these are examining for radial head subluxation or apprehension in conscious patients. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. While not as common as MCL injuries, PLRI due to LCL damage can occur. Similar to that of MCL, history is a critical portion in evaluation, although injury to the LCL may not be as apparent as is with the MCL. The physical exam can include special tests, such as the pivot-shift test (mentioned above), posterolateral rotatory drawer test, chair push-up test, prone push-up test, and table-top relocation test. All of these are examining for radial head subluxation or apprehension in conscious patients. [1] |
statpearls_NBK430685\article-101404_30 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance | Varus posteromedial rotatory instability occurs when axial and valgus stress is applied to the forearm, which is in a pronated position. This stress results in a fracture to the anteromedial facet of the coronoid, and LCL rupture. This injury typically occurs in an acute, traumatic setting. In a subacute setting, the gravity-assisted varus stress test is an option, where the patient flexes and extends their elbow at 90 degrees of shoulder abduction, allowing gravity to apply the varus stress. This technique has shown to be the most sensitive and specific in diagnosing varus posteromedial rotatory instability. [1] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. Varus posteromedial rotatory instability occurs when axial and valgus stress is applied to the forearm, which is in a pronated position. This stress results in a fracture to the anteromedial facet of the coronoid, and LCL rupture. This injury typically occurs in an acute, traumatic setting. In a subacute setting, the gravity-assisted varus stress test is an option, where the patient flexes and extends their elbow at 90 degrees of shoulder abduction, allowing gravity to apply the varus stress. This technique has shown to be the most sensitive and specific in diagnosing varus posteromedial rotatory instability. [1] |
statpearls_NBK430685\article-101404_31 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Other Issues | While UCL surgical intervention has progressed over the years, the tracking of patient outcomes in a quantitative manner is lacking relative to other musculoskeletal injuries such as ACL tears and its reconstruction. The function of the UCL and the stresses put on this ligament need to be analyzed in various settings, especially the athletic setting such as baseball. Functional screening and quantitative measures regarding injury progression, proper postsurgical therapy, and the timeline for return to sport still need to be accounted for in the literature regarding UCL injuries. [15] | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Other Issues. While UCL surgical intervention has progressed over the years, the tracking of patient outcomes in a quantitative manner is lacking relative to other musculoskeletal injuries such as ACL tears and its reconstruction. The function of the UCL and the stresses put on this ligament need to be analyzed in various settings, especially the athletic setting such as baseball. Functional screening and quantitative measures regarding injury progression, proper postsurgical therapy, and the timeline for return to sport still need to be accounted for in the literature regarding UCL injuries. [15] |
statpearls_NBK430685\article-101404_32 | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Review Questions | Access free multiple choice questions on this topic. Comment on this article. | Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Review Questions. Access free multiple choice questions on this topic. Comment on this article. |
statpearls_NBK430685\article-101481_0 | Spirometry -- Continuing Education Activity | Spirometry is one of the most commonly used approaches to test pulmonary function. It measures the volume of exhaled air vs. time. This activity highlights its role in the evaluation of pulmonary disease by the interprofessional team. Objectives: Identify the indications of spirometry. Describe the technique of spirometry. Outline the clinical significance of spirometry. Access free multiple choice questions on this topic. | Spirometry -- Continuing Education Activity. Spirometry is one of the most commonly used approaches to test pulmonary function. It measures the volume of exhaled air vs. time. This activity highlights its role in the evaluation of pulmonary disease by the interprofessional team. Objectives: Identify the indications of spirometry. Describe the technique of spirometry. Outline the clinical significance of spirometry. Access free multiple choice questions on this topic. |
statpearls_NBK430685\article-101481_1 | Spirometry -- Introduction | Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation. | Spirometry -- Introduction. Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation. |
Subsets and Splits