Elbow arthroscopy has evolved over the past several years. Initially used
for simple removal of loose bodies or examination of a painful joint, it is
now being employed with greater frequency for arthritis and
contractures1-4.
As the indications for elbow arthroscopy increase, the potential for injury to
neurovascular structures remains a
concern5-8.
Elbow arthroscopy is technically demanding and requires experience in
advanced arthroscopic techniques. Potential advantages of arthroscopic
treatment include improved articular visualization and decreased postoperative
pain. There also may be decreased morbidity and faster postoperative
recovery.
Presently, elbow arthroscopy can be performed for removal of loose bodies,
resection of symptomatic plicae, release of the capsule in patients with
contracture, removal of osteophytes, synovectomy in patients with inflammatory
arthritis, treatment of osteochondritis dissecans, débridement for
treatment of lateral epicondylitis, and treatment of selected elbow
fractures1-4,9-11.
Elbow arthroscopy remains challenging because of the small working space in
the elbow joint and the unique articular anatomy of this joint. The close
proximity of major neurovascular structures is perhaps the greatest concern of
most orthopaedic surgeons.
Osteoarthritis, inflammatory arthritis, and posttraumatic conditions have
all been treated arthroscopically. Each of these arthritic conditions has
unique aspects that require specialized care.
We prefer to use general anesthesia. This allows full muscle relaxation and
permits the patient to be positioned in either a prone or a lateral decubitus
position, which might not be tolerated by an awake patient. Regional
anesthetic blocks can be used for elbow arthroscopy, but, when these blocks
are used, the patient should be in the supine position for comfort.
Positioning the patient in the lateral decubitus position allows excellent
access to the elbow joint (Fig.
1). The arm is placed in a padded-arm holder that is attached to
the side to the table. A low-profile elbow arm-holder specifically designed
for this purpose usually functions best.
A nonsterile tourniquet is then placed on the arm at the level of the
arm-holder, and the arm is firmly secured to the arm-holder. This facilitates
the arthroscopy by keeping the arm stable, just as a knee-holder maintains
stability during knee arthroscopy. The elbow should be positioned slightly
higher than the shoulder. This allows a 360° exposure of the elbow joint,
eliminating the potential for impingement of the arthroscope or other
instruments against the side of the body
(Fig. 2).
All portal sites should be marked before surgery, when the elbow is not
distended or edematous and palpation of osseous landmarks is more precise
(Fig. 3). Surface landmarks
that should be marked with a pen on all patients include the lateral
epicondyle, medial epicondyle, radial head, capitellum, and olecranon. The
ulnar nerve is then palpated to be sure of its location and to check that it
does not subluxate from the cubital tunnel. The location of the ulnar nerve is
then marked.
An 18-gauge needle is placed through the soft spot of the elbow, which is
the center of the triangle bounded by the lateral epicondyle, the radial head,
and the olecranon process or is directly posterior just proximal to the tip of
the olecranon. The elbow is then distended with 20 to 30 mL of saline
solution. When the joint is distended, the major neurovascular structures are
positioned farther away from the starting portal site and entry into the joint
is easier and potentially safer. Attempting to enter a nondistended elbow
joint accurately with a trocar is considerably more difficult.
Portal Placement
Initial portal entry can be performed safely from either the medial or the
lateral side, depending on the preference of the operating surgeon. All
portals should be made with a number-11 blade, which is drawn across the skin
to ensure that only the skin, and not the underlying soft tissue, is divided.
The neurovascular structure that is at greatest risk of injury from a lateral
portal is the radial nerve. There are two techniques to reduce the risk of
injury to that nerve. The first is to establish an anterolateral portal as
soon as the joint is distended, before fluid extravasation makes it difficult
to see and feel the anatomical landmarks. The anterolateral portal should be
established just anterior to the sulcus between the capitellum and the radial
head (Fig. 3). The other
technique is to establish an anteromedial portal first. This portal is a safe
distance away from the median and ulnar nerves. Then, under direct
visualization with the arthroscope inside the joint, an anterolateral portal
is established by placing a spinal needle into the joint and next placing a
trocar and cannula. This can be a safe technique in experienced hands, but
simply observing from inside of the joint, as is done with this technique,
does not guarantee that the spinal needle and trocar are not being passed
through the radial nerve.
Once the arthroscope has been placed into the joint, visualization is
maintained by pressure distention of the capsule or by mechanical retraction.
Both methods work, but pressure distention leads to fluid extravasation during
the course of a long arthroscopic procedure. The retractors can be simple
lever retractors such as Howarth elevator or large blunt Steinmann pins. They
are placed into the elbow joint through an accessory portal, which is
typically 2 to 3 cm proximal to the arthroscopic viewing portal. With the
capsule and overlying soft tissue held away from the bone with the retractors,
adequate visualization can be achieved with a high-flow, low-pressure
system.
Direct Lateral or Midlateral Portal
The direct lateral or midlateral portal is located at the center of the
triangle bounded by the olecranon, lateral epicondyle, and radial head. It is
difficult to visualize the anterior aspect of the joint from this portal;
however, it provides the best view of the posterior aspect of the capitellum,
radial head, and radioulnar articulation. This is helpful, especially when one
is examining a patient with osteochondritis dissecans of the capitellum.
Because of the shallow nature of this portal and the limited space in which to
work, it is probably best to use a 2.7-mm arthroscope.
Anteromedial Portal
The anteromedial portal is placed 2 cm distal and 2 cm anterior to the
medial epicondyle9.
Instruments placed through this portal tend to penetrate the common flexor
origin and the brachialis before entering the joint. Before any medial portals
are placed, the ulnar nerve should be palpated and checked for any tendency to
subluxate from the cubital tunnel. The medial antebrachial cutaneous nerve is
most at risk with this
portal12. The
median nerve is farther away: an average of 7 mm from the
portal12.
Posterior Portals
Two portals are necessary to visualize the posterior aspect of the elbow
joint. The fat pad normally occupies a large portion of the potential space. A
second portal is usually established simultaneously with the first since
débridement with an arthroscopic shaver will be needed immediately in
order to obtain a visible working space. The location of the ulnar nerve is
confirmed before the first portal is established. Unlike the anterior portals,
where palpation of the median or radial nerve is not possible, posterior
portals can be established safely, once the ulnar nerve is identified.
The posterolateral portal is excellent for initial viewing of the posterior
aspect of the elbow. It is made level with the tip of the olecranon, with the
elbow flexed 90°, at the lateral joint line. The trocar should be aimed at
the center of the olecranon fossa. The direct posterior portal is established
2 to 3 cm proximal to the tip of the olecranon, at the proximal margin of the
olecranon fossa. The triceps is quite thick at this point, and a knife blade
will be needed to penetrate directly into the elbow joint. After this portal
is created, a shaver or radiofrequency probe can be placed into the joint and
débridement can be performed. Loose bodies and osteophytes on the
entire olecranon fossa can be removed through this portal while the surgeon
views through the posterolateral portal. The arthroscope and the shaver can be
switched back and forth to complete the débridement. Because of the
frequent switching between portals, and the relative safety of the portal
location, it is not necessary to use a cannula in the posterior aspect of the
elbow joint. However, an outflow cannula should be maintained in the anterior
aspect of the elbow joint to limit fluid extravasation.
A posterior retractor portal can be created at a safe distance away from
the ulnar nerve to enhance the arthroscopic view. However, the retractor
should not interfere with the arthroscope, shaver, or other instruments. A
good location for an initial retractor portal is 2 cm proximal to the directly
posterior portal. This would be approximately in the midportion of the
triceps, several centimeters distal from the radial nerve. From this location,
a Howarth elevator or similar type of retractor can be used to elevate the
joint capsule out of view, yet not impinge on the working instruments. The
posterior retractor portal is not needed for every elbow arthroscopy, but it
is very helpful for retracting the capsule to visualize the medial and lateral
gutters. Use of a retractor makes it somewhat easier to visualize the release
of a tight posterior aspect of the capsule in a stiff elbow.
Primary Degenerative Arthritis
Degenerative arthritis is usually accompanied by osteophyte formation,
loose bodies, and capsular contraction. Patients have a loss of motion and
pain with forced flexion and extension. They typically do not have pain in the
mid-arc of motion. In addition to removing all loose bodies, the operating
surgeon should remove all impinging osteophytes and release the typically
tight, thickened capsule.
Arthroscopic débridement of an osteoarthritic elbow begins in the
posterior aspect of the joint when the patient predominantly lacks flexion and
in the anterior aspect of the joint when the patient predominantly lacks
extension. In order to achieve greater flexion at surgery, the posterior
aspect of the capsule needs to be released. This is safest and easiest to
perform early in the procedure, before any swelling or fluid extravasation has
occurred. In particular, release of the posteromedial aspect of the capsule
requires identification of the ulnar nerve so that the nerve will not be
injured. If the greatest lack of motion is in extension, then the procedure
should begin in the anterior compartment.
The posterior compartment is visualized well from the posterolateral
portal, and the directly posterior portal can be used as a working portal.
Osteophytes develop both on the tip of the olecranon and along the medial and
lateral sides of the ulna. It is important to check for osteophytes on the
sides of the olecranon, as often they are overlooked and only the one on the
tip of the olecranon is addressed. Additionally, the olecranon fossa should be
checked for osteophytes along the rim on the posterior aspect of the humerus.
These osteophytes often match arthritic osseous formation on the olecranon,
and both sites of bone formation need to be excised to restore normal joint
motion.
After initial joint inspection from an anterior portal and removal of
obvious loose bodies, all work on bone should be performed (Figs.
4-A and
4-B). A shaver or burr can be
used to remove osteophytes from the radial and coronoid fossae of the humerus.
Often, these osteophytes are neglected and only the tip of the coronoid is
excised. The medial aspect of the coronoid should also be examined for
osteophytes, which may be missed if they are not specifically sought. Using
motorized instruments without a suction device attached allows adequate tissue
removal and reduces the risk of inadvertent neurovascular injury.
Once all osteophytes have been excised, the anterior aspect of the capsule
can be removed. It helps to initially take the capsule off of the humerus.
This tends to also increase the working space in the anterior compartment.
While viewing from the lateral side, the surgeon excises the anterior aspect
of the capsule with a shaver or punch. The median nerve is the closest
important structure, but it is located behind the brachialis muscle. After the
capsule is excise to the midline of the joint, the viewing portal is changed
to the medial side and the shaver is placed through the lateral portal. Care
should be taken when the capsule is excised just anterior to the radial head
and the capitellum. The radial nerve is at great risk for injury at this
location. Often, a small fat pad can be visualized in this area. The radial
nerve lies just anterior to this fat pad.
At the end of the procedure, the elbow should be placed in an extended
position with a circumferential compressive dressing. The extended position
limits the amount of swelling and accumulation of intra-articular fluid. The
elbow should not be placed in flexion since this position allows the maximal
amount of fluid to collect in the elbow joint. Patients should be examined
immediately after the surgical procedure, when they are awake in the recovery
room, to confirm that the neurovascular status is stable postoperatively.
Elevating the extended arm into a "Statue of Liberty" position
overnight also helps to limit postoperative swelling. Motion can be delayed
for twenty-four hours to allow edema to resolve. Continuous passive motion or
splinting can then be started to help maintain the arc of motion achieved in
the operating room. Continuous passive motion is often used for patients who
had the most restricted motion preoperatively. It is often not needed for
those with a minimal loss of motion. It should be recognized, however, that
there is little evidence to confirm that continuous passive motion restores
motion better than splints alone or physical therapy. If continuous passive
motion is used, it is typically applied for twenty-three hours a day, with
breaks for cleaning and eating. The motion setting is started at the same
maximum motion achieved in the operating room. We do not start with a gentle
range of motion and "work up" to the range of motion restored in
the operating room. Continuous passive motion can be used with an indwelling
axillary block for paralysis and pain control for the first twenty-four hours
or intravenous narcotics can be used for pain control. We are not aware of any
reports on the use of intra-articular catheters to deliver lidocaine or
narcotics. Continuous passive motion is often used for the first three to four
weeks after surgery.
Splinting is also an effective option, and it typically involves
alternating periods of extension and flexion. Splinting is almost always used
for patients who had the least amount of motion loss preoperatively. A static
splint is thought to be the best type of splint. The patient is taught to
alternate periods of flexion and extension, typically for an hour at each end
of the range of motion achieved at surgery. While the patient is being treated
with either continuous passive motion or splinting, the neurovascular status
should be checked regularly; in particular, the condition of the ulnar nerve
should be assessed. An ulnar neuropathy has been noted following arthroscopic
or open release in some patients who had 90° of flexion preoperatively and
in whom surgery restored substantially greater
flexion5,13,14.
Because of this potential complication, ulnar nerve transposition may be
considered during surgery in a patient who is undergoing a substantial
restoration of the flexion arc.
Reports on arthroscopic débridement for treatment of osteoarthritis
of the elbow have tended to show satisfactory results. Cohen et
al.10 reported
excellent pain relief with no major complications in twenty-six patients
treated with an arthroscopic modification of the Outerbridge-Kashiwagi
procedure (removal of osteophytes and fenestration of the olecranon fossa to
allow greater excursion of the coronoid and olecranon). Savoie et
al.2 reviewed the
results of an arthroscopic version of the Outerbridge-Kashiwagi procedure in
twenty-four patients, eighteen of whom had excision of the radial head. All
patients had a decrease in pain and an improvement in the arc of motion of
81°. Phillips and
Strasburger15
reported satisfactory results, with an average 41° increase in the total
arc of motion, in twenty-five patients. In a study of thirty patients with
degenerative arthritis of the elbow, Kim and
Shin11 reported
that 92% had an improvement in the range of motion, from a mean of 81°
preoperatively to a mean of 121° postoperatively.
Posttraumatic Contracture
Posttraumatic contractures of the elbow represent a global capsular problem
that may stem from different etiologies. Contractures solely due to capsular
fibrosis are secondary to hemarthrosis from fractures, dislocations, or other
trauma about the elbow. Loss of motion may also be caused by articular
incongruity, adhesions, loose bodies, or degenerative osteophytes.
Initial evaluation of a contracted elbow begins with the recording of a
thorough history regarding the original injury as well as its initial
management. The patient should be asked whether he or she had had physical
therapy and whether it was painful or relatively benign, and whether splints
had been used for short or long-term sessions. Physical examination should be
performed to evaluate loss of motion, whether there is a hard or soft end
point, and whether there is any instability. Radiographs and computed
tomography reconstructions are valuable for detecting articular incongruity
and malalignment. Three-dimensional computed tomography scans are particularly
helpful for visualizing impinging osteophytes and malunions.
Indications for surgery in an elbow with a posttraumatic contracture
include functional loss of motion, a cooperative patient, and a failure of all
forms of nonoperative management. Nonoperative management includes physical
therapy, static splinting, and perhaps anesthetic injections followed by
manipulation and splinting in either flexion or extension depending on the
type of contracture. Relative contraindications to surgery include an age of
less than fourteen years, a lack of available physical therapy, and a patient
incapable or unwilling to cooperate with extensive postoperative physical
therapy.
The operative procedure usually begins with the anterior compartment.
Anteromedial and anterolateral portals are established. The contracted
anterior aspect of the capsule is readily visualized and should be released
and resected. It is important to protect the neurovascular structures, and the
brachialis muscle should serve as a barrier between the capsule and the
neurovascular structures. Once the capsule has been resected and the anterior
aspect of the elbow joint can be further evaluated, the coronoid fossa and
radial head fossa should be assessed and, if necessary, deepened to allow full
flexion. The radiocapitellar joint as well as the proximal radioulnar joint
should be evaluated from anteriorly. Damage to either of these articulations
may require radial head excision. Once the entire anterior part of the
procedure has been completed, attention should be directed to the posterior
compartment.
The evaluation of the posterior compartment begins with débridement
of the olecranon fossa. In an elbow with a posttraumatic contracture, the
fossa is often full of scar tissue and adhesions that need to be removed to
obtain visualization. In most elbows with a post-traumatic contracture, the
triceps is attached to the posterior aspect of the humerus by scar tissue and
needs to be elevated to allow complete flexion to occur. Once this has been
done, attention can be directed more distally to the tip of the olecranon,
which may require resection. The medial and lateral gutters should be
débrided of all soft tissue. When the medial gutter is débrided,
care should be taken to protect the ulnar nerve. If resection of the medial
aspect of the capsule is required in this area, the ulnar nerve should be
visualized and carefully protected during the procedure
(Fig. 5).
After surgery, therapy with a continuous-passive-motion machine is begun
and is continued for three weeks. Alternatively, a splinting regimen can be
instituted as described above. The patient is instructed to use the arm for
all activities of daily living, beginning on the day after the surgery. If
loss of motion recurs during the first three weeks postoperatively, it is
often possible to sedate the patient and gently manipulate the elbow to break
up the early accumulation of adhesions.
Rheumatoid Arthritis
Rheumatoid arthritis affects 1% of the population, and the elbow is
involved in >50% of patients with polyarticular disease. Both elbows are
commonly involved, and the dominant elbow is typically more severely
affected16.
Patients initially present with pain and swelling due to synovitis and an
effusion. Cartilage destruction, ligament attenuation, osseous erosions, and
deformity progress as the disease becomes more severe. Secondary capsular
contractures develop, resulting in increasing stiffness.
The medical management of rheumatoid arthritis has improved in recent years
with the development and more aggressive utilization of disease-modifying
agents such as methotrexate, infliximab, and etanercept, and intraarticular
steroid injections can provide short-term relief of acute exacerbations.
Medical management should be optimized before surgical treatment is considered
for persistent synovitis and/or stiffness.
Numerous studies have documented the beneficial effects of open radial head
excision and synovectomy in patients with rheumatoid
arthritis17-24.
With the improvement of instruments and techniques, there has been an
increasing interest in arthroscopic approaches to surgical synovectomy.
Arthroscopic synovectomy is less invasive than traditional open approaches and
it allows more of the elbow to be seen. The indication for arthroscopic
synovectomy is persistent elbow synovitis that cannot be controlled by medical
management and that is associated with pain, stiffness, and loss of function.
Elbows with less advanced articular destruction should be considered for
synovectomy, whereas those with complete loss of articular cartilage and
osseous deformities are best managed with total elbow
arthroplasty25. In
general, the results of arthroscopic surgery are best in patients with some
preserved articular cartilage and only mild bone deformity (Mayo grade-1 or 2
radiographic
changes)4,26.
An arthroscopic approach should also be considered for patients with more
advanced articular and osseous destruction (Mayo grade 3A) when they are
younger or have pauciarticular disease.
The location and function of the ulnar nerve should be assessed.
Preoperative ulnar nerve dysfunction is an indication for transposition of the
nerve at the time of the arthroscopy. A previous ulnar transposition makes
percutaneous placement of the medial portal risky. In this setting, open
placement of the portal is required to prevent iatrogenic nerve injury.
The range of motion of the elbow and forearm should be documented with use
of a goniometer. Motion can be lost as a result of a tense effusion with
synovitis, capsular contracture, or osseous deformity. A soft end point
suggests a soft-tissue cause, whereas a firm, painful end point suggests
osseous impingement. Varus and valgus loading to stress the collateral
ligaments should also be performed to evaluate elbow stability. Joint laxity
is common secondary to loss of articular cartilage and to ligament attenuation
resulting from the chronic inflammation. When a patient has lost forearm
rotation, the distal radioulnar joint should also be examined clinically and
with radiographs to determine the contribution of the proximal and distal
articulations to the forearm stiffness. Radial head excision should be
considered for patients with articular deformity impeding rotation in the
presence of a competent medial collateral ligament. The radial head can be
excised arthroscopically at the time of synovectomy. Osteophyte removal and
capsulectomy can also be performed arthroscopically concomitant with the
synovectomy to improve motion, if
needed3,5,27.
Postoperative management depends on the extent of the arthroscopic surgery.
If only a synovectomy is being performed
(Fig. 6), it is usually done as
an outpatient procedure followed by postoperative management with a sling and
with an early active range of motion. Patients undergoing a more extensive
débridement with a capsulectomy are candidates for continuous passive
motion or a splinting regimen.
With regard to elbow procedures in patients with rheumatoid arthritis, open
synovectomy and radial head excision is the operation for which the longest
follow-up data are
available17-24.
While it is successful in the majority of patients, its beneficial effect
deteriorates with time, and it seems to fail more quickly in patients with
valgus instability following the radial head excision. Retention of the radial
head should be considered for most patients unless there is severe deformity
interfering with rotation.
There is little information on the results of arthroscopic
synovectomy4,26.
The outcomes and complications may depend on the arthroscopic experience of
the surgeon. Patients with greater stiffness and deformity may be better
managed with open techniques because of the increased risk of nerve injury.
Extra-articular pannus is best dealt with through open surgery. We are not
aware of any published comparative clinical trials demonstrating the relative
efficacy and risk of open compared with arthroscopic synovectomy.
Reports in the literature demonstrate that the outcome of arthroscopic
synovectomy depends on the severity of the arthritis. The best results have
been reported in elbows that do not have substantial osseous deformity and
have some preserved articular cartilage (Mayo grade 1 or
2)4,16.
Patients treated with concomitant disease-modifying agents have a lower
prevalence of recurrent synovitis and a better long-term outcome. In 1997, Lee
and Morrey reported a 93% rate of good to excellent results at the initial
assessment, but the rate had deteriorated to 57% by forty-two months
postoperatively26.
In 2002, Horiuchi et al. reported a 71% rate of good to excellent results at
two years, which deteriorated to 43% by eight
years4. However, if
only Mayo grade-1 and 2 elbows were included, 100% and 71% of the results were
good or excellent at two and eight years, respectively.
With the advent of improved medications to control rheumatoid arthritis,
the prevalence of uncontrolled synovitis of the elbow seems to have
diminished. The judicious use of arthroscopic synovectomy of the elbow has
been very effective for decreasing pain and improving function in the majority
of patients with otherwise well-controlled disease.