ARTHROSCOPIC APPROACHES TO THE ELBOW

Arthroscopic Approaches to the Elbow

Ethan R. Wiesler and Gary G. Poehling

Recent advances in the techniques and instrumentation in elbow arthroscopy have enabled the surgeon to expand the indications and treatment options available to safely perform this procedure. Thorough knowledge of elbow anatomy and surrounding neurovascular structures is paramount.

Indications

1. Loose bodies

2. Osteochondritis dessicans

3. Rheumatoid arthritis—synovectomy

4. Contracture/arthrofibrosis

5. Pigmented villinodular synovitis

6. Lateral epicondylitis

7. Radial head fractures

8. Radial head resection

9. Synovial chondromatosis

10. Infection/septic arthritis

11. Posterolateral instability

Contraindications

1. Advanced degenerative joint disease

2. Previously transposed ulnar nerve prevents any medial approaches

3. Excessive heterotopic bone

4. Reflex sympathetic dystrophy

5. Soft tissue compromise

Physical Examination

1. Range of motion assessment

2. History of mechanical symptoms

3. Neuromuscular examination

Diagnostic Tests

1. Plain radiographs (anteroposterior and lateral); contralateral radiographs for comparison

2. Magnetic resonance imaging for soft tissue problems

3. Computed tomography scans for loose bodies or bony defects

Special Considerations

Anatomy—Osseous

1. Ulnohumeral joint: Best visualized with the camera in straight lateral or adjacent lateral portal.

2. Radiocapitellar joint: Best seen with the camera in proximal medial portal and instruments placed in straight lateral or adjacent lateral portals (in the anatomic soft spot).

3. Proximal radioulnar joint: Technique aided with the use of a 2.7 mm arthroscope placed in the lateral or adjacent lateral portal.

Anatomy—Neurovascular

1. Median nerve: This is most at risk during contracture release of the anterior capsule. It is important to do the capsular release proximally, close to the distal anterior humerus.

2. Ulnar nerve: Injuries occur primarily with too posterior placement of the proximal medial portal, or an excessive capsular release of the medial joint.

3. Radial nerve (Figs. 39–1A,B): Posterior interosseous nerve and lateral antebrachial cutaneous nerve. This is the most commonly injured nerve at arthroscopy, especially with anterolateral portal placement, with either inside-out or outside-in techniques.