History

Posttraumatic arthritis, osteoarthritis, hemophilic arthritis, and inflammatory arthritis may affect the elbow joint. Pain is a common complaint; however, patients may also report stiffness, weakness, instability, mechanical symptoms, or cosmetic deformity.³ A description of the degree and direction of motion loss and presence and occurrence of pain is an important part of the history.

A history of trauma may be elicited from patients. The most common injury that may cause posttraumatic arthritis is a comminuted intra-articular fracture resulting in articular incongruity.³ Posttraumatic contractures caused solely by capsular fibrosis may be secondary to hemarthrosis from various traumatic causes. The patient should be asked whether he or she had physical therapy, whether it was painful or relatively benign, and whether splints had been used for short- or long-term sessions.

Osteoarthritis involving the elbow is most commonly seen in the dominant arm of men with a history of heavy labor, weightlifters, and throwing athletes.³ Crutch ambulators may also be more prone to this condition. These patients are commonly in the third to eighth decades. Patients typically report pain at extremes of motion with loss of terminal extension more than loss of flexion. Patients with osteoarthritis who may benefit from arthroscopic debridement typically lack significant pain in the mid-arc of motion; rather, pain will be noted more at the end arc of flexion and/or extension owing to impinging terminal osteophytes. The presence of mid-arc of motion discomfort or pain throughout the arc of motion may be indicative of more widespread joint changes that may not respond as well to arthroscopic debridement.

Symptomatic rheumatoid arthritis of the elbow fortunately is becoming less common with the advent of disease-modifying agents but can be quite debilitating when it does occur. Both elbows are commonly involved, and patients initially have pain and swelling from synovitis and effusion. More severe involvement with loss of bone and failure of the soft tissues around the elbow joint may cause instability, which may accelerate articular destruction as a result of subluxation or malalignment.4,5

Patients with hemophilia commonly develop arthropathy of the elbow. This appears to be related to some threshold of clinical or subclinical intra-articular bleeding, which seems to result in potentiation of an inflammatory cascade leading to worsening synovial proliferation and hemarthroses, with subsequent arthritis. Patients may report recurrent intra-articular bleeds caused by proliferative synovitis, or the secondary arthritic changes that ensue.⁶

Physical Examination

On examination, patients with osteoarthritis will commonly have pain at the endpoints of motion and/or mechanical symptoms. Lack of terminal extension is common, along with loss of terminal flexion. Likewise, patients with inflammatory or hemophilic arthritis will commonly have synovitis about the joint. In all types of arthritis, crepitus may also be present. It is important to record the passive and active ranges of motion. This aids in quantifying the functional deficits while determining the success of treatment. Although difficult, it may be useful to differentiate between a “soft” and “hard” endpoint, as this may lead the examiner to determine the cause of stiffness. A complete neurovascular examination should always be performed. The physical examination findings are then correlated with the radiographic findings.

Imaging

Anteroposterior, lateral, and oblique plain film views of the elbow are obtained. On radiographic examination of the typical osteoarthritic or posttraumatic elbow, osteophytes may be seen on the olecranon and coronoid processes and also in the olecranon and coronoid fossae. Many patients have loose bodies, and presence of a loose body on an elbow radiograph is in most instances a sign of an underlying and more substantial degenerative process.

Computed tomography with three-dimensional reformatting may be especially helpful for visualizing osseous anatomy and aiding in the development of the preoperative plan.

Indications

Surgery on an arthritic elbow may be indicated for patients with functional loss of motion, mechanical symptoms caused by loose bodies, and/or pain. Those with synovitis or hemophilic bleeds recalcitrant to medical management may also be candidates for surgical management.

Anesthesia and Positioning

We prefer to use general anesthesia. This permits the patient to be placed in either a prone or a lateral decubitus position, which might not be tolerated by an awake patient managed with a regional block. In addition, lack of paralysis allows the nerve to respond if dissection is too close; furthermore, the status of the major peripheral nerves may be established immediately after surgery.

Placement of the patient in the lateral decubitus position allows excellent access to the elbow joint (Fig. 44-1). The arm is placed in a padded arm holder that is attached to the side of the table. A low-profile elbow arm holder specifically designed for this purpose may be used.

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 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 360-degree exposure of the elbow joint, eliminating the potential for impingement of the arthroscope or other instruments against the side of the body (Fig. 44-2).

Surgical Landmarks, Incisions, and Portals

All portal sites are marked before surgery or insufflation of the joint, when the elbow is not distended or edematous and palpation of osseous landmarks is more precise (Fig. 44-3). Surface landmarks that should be marked include the lateral epicondyle, medial epicondyle, radial head, capitellum, ulnar nerve, and olecranon. The ulnar nerve is palpated to determine its location and to ensure that it does not subluxate from the cubital tunnel.

An 18-gauge needle is placed through the planned anterolateral portal. The elbow is then distended with 20 to 30 mL of saline. When the joint is distended, entry into the joint is easier and potentially safer. Attempting to enter a nondistended elbow joint accurately with a trocar is considerably difficult.

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 are made with a knife 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 commonly used to reduce the risk of injury to that nerve. One option is to establish an anterolateral portal as soon as the joint is distended, before fluid extravasation makes it difficult to see and to feel the anatomic landmarks. The anterolateral portal is established just anterior to the sulcus between the capitellum and the radial head. A second option is to establish an anteromedial portal first, and then make the anterolateral portal with an inside-out approach under direct visualization. The anteromedial portal is a safe distance away from the median and ulnar nerves; once it is established, 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 (4-mm, 30-degree) has been placed into the joint, visualization is maintained by pressure distention of the capsule or mechanical retraction. Both methods work, but excessively high fluid pressures may lead to fluid extravasation during the course of a long arthroscopic procedure. The retractors can be simple lever retractors such as a Howarth elevator or large 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.

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