CHAPTER SYNOPSIS:

Arthroscopy is a minimally invasive technique that has been shown to be an effective treatment for mild to moderate primary osteoarthritis, Mayo Grade I or II rheumatoid arthritis, and certain forms of early posttraumatic arthritis of the elbow. Arthroscopic osteophyte debridement, loose body excision, capsular release, or synovectomy can be effective surgical procedures to improve motion and reduce pain. Successful arthroscopy is dependent on patient selection, expected outcome, and surgical skill. The most common major complication is neurovascular injury. The purpose of this chapter is to outline appropriate patient selection and to discuss operative techniques and surgical outcomes.

IMPORTANT POINTS:

Indications:

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  Failure of conservative measures including therapy, NSAIDs, splinting, activity modification, and intra-articular steroid injections; persistent synovitis in an otherwise medically-controlled patient with rheumatoid arthritis.

  
  
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  Mild to moderate primary osteoarthritis with pain, impingement, or loose bodies may be treated with capsular release, osteophyte debridement, loose body excision, or ulnohumeral arthroplasty.

  
  
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  Mayo Grade I or II rheumatoid arthritis may be treated with arthroscopic synovectomy with or without radial head excision.

  
  
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  Early post-traumatic elbow arthritis may be treated with arthroscopic debridement, loose body excision, and capsular release, but patient selection should be limited to those with minimal deformity and minimal or no previous open elbow procedures.

Contraindications:

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  No previous conservative management

  
  
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  Significant heterotopic ossification

  
  
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  Local skin infection

  
  
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  Patient’s potential for non-compliance with post-op therapy regimen

  
  
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  Relative contraindications include: previous open elbow procedure, joint deformity or previous trauma causing distortion of the joint surface or normal anatomic landmarks, previous ulnar nerve transposition, or a displaced radial head fracture or a distal humerus fracture.

CLINICAL/SURGICAL PEARLS:

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  Extensive arthroscopic experience and advanced knowledge of elbow anatomy a must.

  
  
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  Positioning may be in lateral decubitus position using an arm holder or supine depending on surgeon preference. Prone technique is less commonly used.

  
  
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  Draw anatomic landmarks prior to joint distension.

  
  
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  Portal incisions should be through skin only, followed by blunt instrumentation into the joint to avoid injury to the cutaneous nerves.

  
  
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  Perform an ulnar nerve decompression and transposition if a flexion contracture of ≤100 degrees is present.

  
  
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  Examine anterior and posterior portions of the joint and radial and ulnar gutters.

  
  
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  Perform anterior capsular release for extension deficit and posterior capsular release for flexion deficit.

  
  
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  For more extensive ulnohumeral arthritic disease, consider ulnohumeral arthroplasty with trephination of the olecranon fossa.

  
  
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  For severe radiocapitellar disease, consider arthroscopic radial head resection.

  
  
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  Use of arthroscopic retractors greatly enhances visualization.

  
  
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  Postoperative treatment may include the use of flexion or extension splinting, static progressive splints, compression and elevation, and continuous passive motion machines to optimize postoperative motion.

  
  
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  Postoperative therapy should begin early in postoperative week 1; some advocate for immediate motion.

CLINICAL/SURGICAL PITFALLS:

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  Major complications of elbow arthroscopy include permanent nerve injury, compartment syndrome, septic arthritis, and joint contractures.

  
  
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  Minor complications include transient neurapraxia, hematoma, superficial infection, portal fistula formation, minor decrease in motion (<30 degrees), and (rarely) heterotopic ossification formation.

  
  
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  Injury to the antebrachial cutaneous nerves can occur during portal placement. This can be avoided with sharp incision of the skin only, followed by blunt dissection to the joint.

  
  
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  Injury to the radial nerve and posterior interosseous nerve (PIN) are most common and occur while working near the anterolateral joint capsule. The ulnar nerve is also subject to injury, usually as a transient neurapraxia, and can occur while working in the medial gutter.

  
  
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  A postoperative neurologic examination with documentation is absolutely necessary.

INTRODUCTION

Arthroscopy of the elbow is a relatively new technique in the field of arthroscopic surgery. Although elbow arthroscopy was described as early as the 1930s, it did not gain a reputation as a useful technique for treatment of elbow disorders until the late 1980s. Since then there have been great advances in our understanding of elbow anatomy, improvements in the arthroscope itself, and refinement in surgical techniques, which have led to an increasing number of surgical indications. Arthroscopy is now used as a diagnostic aide and a treatment modality for arthritis, synovitis, osteochondral lesions, ulnohumeral arthroplasty, and more recently lateral epicondyle debridement and assistance in fracture reduction. Most important to successful arthroscopy is correct patient selection, prior experience with arthroscopy, and familiarity with elbow anatomy. In particular, knowledge of neurovascular anatomy is paramount. Nerve injury is the most common and most serious complication of elbow arthroscopy and can be prevented with good surgical technique.

PRIMARY OSTEOARTHRITIS

Primary degenerative arthritis of the elbow is an uncommon problem. It is most commonly found in middle-aged men who repetitively use their arm for high load activities such as manual labor, weightlifting, or overhead throwing. Typical presentation for primary osteoarthritis of the elbow is pain at terminal extension and flexion ( Fig. 17-1 ). There is often a loss of range of motion that is classically an extension loss. Patients also present with mechanical symptoms such as catching and locking. Primary osteoarthritis typically begins with cartilage thinning and joint space narrowing at the ulnohumeral articulation resulting in osteophyte and loose body formation around the olecranon process, olecranon fossa, and coronoid. Small osteophytes may also be present on the radial head. More severe arthritis will involve the radiocapitellar joint and proximal radioulnar joint. ⁵ Indications for treatment of early primary degenerative arthritis of the elbow include removal of loose bodies, debridement of osteophytes, and release of contractures that have not resolved with 3 to 6 months of conservative therapy. More advanced arthritis involving the ulnohumeral joint may require ulnohumeral arthroplasty. Nonoperative therapy includes bracing, oral antiinflammatory medications, and judicious use of intraarticular steroid injections.

Primary osteoarthritis involving the radiocapitellar and ulnohumeral joints.

POSTTRAUMATIC ELBOW ARTHRITIS

Posttraumatic arthritis can be a painful and debilitating consequence of a previous elbow injury ( Fig. 17-2 ). Arthritis with or without joint contracture can be precipitated by a bony or strictly soft tissue injury. Patients present with similar complaints as in primary osteoarthritis but the demographic is nondiscriminatory. Also, patients with posttraumatic arthritis are more likely to have gross deformity, capsular contracture, and ligamentous instability, so a thorough examination is essential. It is important to obtain a thorough history of the previous injury and ensuing treatments. In many cases, obtaining previous office and postoperative notes is imperative to ascertain which structures were injured, whether an ulnar nerve transposition was performed, and if there were postoperative complications such as infection. Arthroscopy is a useful tool in the treatment of posttraumatic arthritis assuming that minimal or no previous surgeries have been performed. Previous surgical violation of the joint could distort the anatomic landmarks and cause significant scarring, making arthroscopy not only difficult, but also dangerous. Arthroscopy is indicated for posttraumatic arthritis if symptoms are related to pain, mechanical locking, or catching, or impinging osteophytes and if there is minimal distortion of the articular surface from the previous injury. Also, the patient needs to have access to and be compliant with a postoperative therapy regimen.

Posttraumatic osteoarthritis.

RHEUMATOID ARTHRITIS OF THE ELBOW

Rheumatoid arthritis of the elbow is present in 20% to 50% of patient with symptomatic polyarticular rheumatoid disease ( Fig. 17-3 ). The disease frequently affects the bilateral elbows. Early disease presentation includes elbow joint pain, edema, and decreased motion. More progressive arthritis will result in significant disability as a result of loss of motion, joint instability, or both. Symptoms may be related to synovitis alone or synovitis with articular erosive lesions, joint deformity, and ligament attenuation. A thorough physical examination is essential, and diagnostic imaging such as x-rays and magnetic resonance imaging (MRI) can be helpful. This disease process generally does not create the osteophytes seen in osteoarthritis; instead, it creates large articular or periarticular osseous erosions. Surgical intervention for the treatment of symptomatic rheumatoid arthritis of the elbow is thought to be decreasing as a result of better medical management with more effective disease-modifying agents. Therefore, medical management of the disease process and nonsurgical treatment of the elbow including therapy and intraarticular steroid injections should be maximized before pursuing more invasive measures.

Rheumatoid arthritis. Articular erosions. Patient has had a radial head resection.

Rheumatoid arthritis of the elbow has been classified into Mayo Stages 1–4 ( Table 17-1 ).

Arthroscopic treatment options include synovectomy, debridement, capsulotomy, and removal of loose bodies with or without arthroscopic radial head resection. Indications for arthroscopic synovectomy include the presence of pain for more than 6 months in a patient who has maximized medical management of their disease and conservative management of their joint symptoms. Additionally, synovectomy is only recommended in Mayo Grade I or II disease with a preoperative arc of motion ≥90 degrees because the long-term benefits of the procedure in more advanced disease states are not as reliable. If the arc of motion is restricted to <90 degrees, arthroscopic treatment may still be indicated because it provides an earlier return to motion and has been shown to have better functional outcome than an open procedure. Contraindications to arthroscopic synovectomy include patients with severe disease (Mayo Grade IIIa–IV), fibrous ankylosis, ligamentous instability, or presence of significant deformity or previous elbow procedure that results in distortion of normal anatomic landmarks. These patients are better candidates for open synovectomy, open ulnohumeral arthroplasty, or total elbow arthroplasty.

Another option in the arthroscopic treatment of rheumatoid arthritis is synovectomy with arthroscopic radial head excision. This procedure was more widely used in the 1980s and now seems to be falling out of favor with development of better radial head implants and total elbow prosthesis. Although recent literature on the subject of radial head resection in the setting of rheumatologic disease is limited, it is suggested that arthroscopic radial head excision should be considered in patients with Mayo Grade I or II arthritis with pain and limited forearm rotation or mechanical symptoms resonating from the radiocapitellar joint. Much controversy still exists over the timing of surgery and more specific indications. One main advantage of arthroscopic radial head excision is the ability to examine the radiocapitellar joint through minimal incision, faster return to motion, and lower surgical morbidity (in the hands of an experienced arthroscopist). Disadvantages are the potential for injury to the annular ligament resulting in elbow instability, inherent risk of neurovascular injury specifically to the posterior interosseous nerve (PIN), and the potential to cause progression of arthritis at the ulnohumeral joint.

PREOPERATIVE EVALUATION

A thorough history and physical examination are necessary prior to surgery. The patient’s age and treatments to date including previous surgeries, current activity level, and future physical demands should be assessed. In patients with rheumatoid arthritis, there should be documentation of all involved joints and the extent to which medical management with disease-modifying agents have been used. It is important to consider treatment of more proximal joints first if there is polyarticular involvement. The patient’s symptoms should be determined to be related to pain, decreased motion, or both and whether the pain occurs at terminal motion or during their arc of motion. Symptoms of locking, clicking, or catching should also be documented.