Fig. 3.1 Positioning and draping. The arm is in a traction device with a 3-kg counterweight on each side.Fig. 3.2 Anterolateral approach: 2 cm distal and 1.5–2 cm anterior to the lateral epicondyle. 1, Radial nerve. 2, Lateral cutaneous nerve of forearm.Fig. 3.3 The joint is punctured anterolateral to the radial head and synovial fluid is withdrawn for analysis. The joint is insufflated with fluid.Fig. 3.4 Following insertion of the trocar and insufflation of the joint, the second portal is placed on the contralateral side under direct vision.Fig. 3.5 Anteromedial approach: 2 cm distal and 2 cm anterior to the medial epicondyle. 1, Brachial artery. 2, Median nerve. 3, Medial cutaneous nerve of forearm. 4, Ulnar nerve.Fig. 3.6 Severe intra-articular elbow joint synovitis. Synovectomy is performed using a shaver and vaporizer.
3.1.2 Open Synovectomy of the Elbow Joint
Indication
Therapy-resistant Larsen 0–II/III synovitis after optimization of medication therapy, cortisone injections, and, if indicated, arthroscopic synovectomy. Ultrasound evidence of loculated synovitis or extra-articular bursae/rheumatic nodules.
Significant clinical symptoms and loss of mobility, particularly a functional loss such as an extension deficit, are indications for an open procedure. Painful pronation/supination and radial head destruction are indications for radial head excision. Late synovectomy is also indicated for more advanced stages of destruction.
Specific disclosures for patient consent
Recurrence. Infection. Loss of mobility with scarring.
Instruments
Standard surgical pans.
Position
Supine. Arm extended outward. Use an arm or hand table if necessary.
Fig. 3.7 A lateral incision is made starting approximately 3 cm proximal to the radial head and continued distally along the posterolateral side of the radial head.Fig. 3.8 The extensor digitorum muscle fascia is opened anteriorly. A strip of capsule approximately 1 cm wide is left on the humerus. A posterior opening is made in the fascia between the extensor carpi ulnaris muscle and the anconeus muscle. Musculature should not be detached from the humerus.Fig. 3.9 Schematic drawing of the approach. An incision between the extensor carpi ulnaris and anconeus muscles exposes the posterior compartment. An incision between the extensor digitorum and the radial extensor muscles exposes the anterior compartment. 1, Extensor carpi radialis longus muscle. 2, Extensor digitorum muscle. 3, Extensor carpi ulnaris muscle. 4, Anconeus muscle. 5, Triceps brachii muscle tendon.Fig. 3.10 Following posterior capsulotomy, bulging synovitis is readily apparent. View of the radial head. Synovectomy of the anterior compartment is performed with the elbow in flexion. The posterior compartment behind the retained muscle strip is more easily accessed with the elbow in extension. A posterior synovectomy is performed in the olecranon fossa. Caveat: the ulnar nerve lies relatively unprotected on the medial side.Fig. 3.11 Surgical site after open synovectomy. In case of a severe extension deficit, arthrolysis of the entire joint is also performed. The joint is easily accessible with the elbow in flexion. The capsule is released proximally from the humeral head and stripped off proximally approximately one hand’s width from the joint. This is a safe distance from the radial nerve. If there is residual extensor deficit, the capsule is carefully incised on the coronoid process under direct vision. This incision is made from the top of the coronoid process, perpendicular to the axis of the ulna, and directed toward the midline. The capsule is stripped off with a rasp.
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