Elbow arthroscopy is technically challenging; experience and a sound knowledge of anatomy keep complications to an acceptable rate.
Indications include diagnostic arthroscopy and loose body removal and have expanded to treatment of lateral epicondylitis, arthritis, contractures, and periarticular elbow fractures.
The proximity of critical neurovascular structures makes placement of the portals critically important.
Arthroscopic release should minimize wound and soft tissue complications and thus facilitate early exercise.
Following arthroscopic contracture release, an exercise approach that emphasizes achieving one repetition of a full range of elbow motion every 30 minutes may be more effective that high-repetition exercise in the “comfortable zone” of motion.
Communication between the therapist and surgeon about the expectations for elbow range of motion (ROM) following contracture release is essential.
Although arthroscopy was first described in 1932 and became widely employed in the 1970s, elbow arthroscopy is relatively new in orthopedics. With experience, the indications have dramatically expanded from diagnostic arthroscopy and loose body removal to treatment of lateral epicondylitis, arthritis, contractures, and even periarticular elbow fractures. Elbow arthroscopy remains technically challenging, but experience and a sound knowledge of the anatomy have kept complications at an acceptable rate.
Basic Anatomy and Portals
The proximity of critical neurovascular structures makes placement of the portals critically important. Prior to making an incision, the ulnar nerve is marked, along with the medial and lateral epicondyles, the olecranon, and the radial head ( Fig. 81-1 ).
Standard portals for visualizing the posterior elbow, include the posterocentral (transtriceps), posterolateral and accessory posterolateral, and posterior radiocapitellar portals. The medial and posterior antebrachial cutaneous nerves are the structures most at risk when placing the posterolateral portals. Anterior portals include the anterolateral, proximal anterolateral, anteromedial, and proximal anteromedial portals. The median nerve is at risk when placing the proximal anteromedial portal, the medial antebrachial cutaneous nerve is at risk when placing the anteromedial portal, and the radial nerve is at risk when placing the anterolateral portal.
The ulnar nerve rests in the cubital tunnel, just posterior to the medial epicondyle. The floor of the tunnel is the capsule of the medial ulnohumeral joint. When working in the medial gutter, the ulnar nerve is always at risk, so appropriate caution must be used.
Set-Up and Instrumentation
Elbow arthroscopy may be performed in the supine, lateral decubitus, or prone positions under general or regional anesthesia ( Fig. 81-2 ). For patients undergoing extensive releases that require aggressive therapy in the immediate postoperative period, an in-dwelling brachial plexus catheter allows the patient to continue working with the gains achieved in the operating room with less discomfort. The downside to using a catheter with local anesthetic is that it delays the postoperative neurologic exam. Alternatively, the block may be administered postoperatively, after the neurologic status is checked.
As the “last frontier” of major joint arthroscopy, most elbow arthroscopy instruments are “purloined” from the knee and shoulder surgeons. However, there are a few important differences. Special trocars and cannulae without fenestrations that would leak fluid into the subcutaneous tissues must be used. Another important difference is that because of its greater congruency and small joint volume, it is more difficult to see in the elbow than other joints. , This requires the use of retractors, rather than the fluid pressure used in knee and shoulder arthroscopy. Nonetheless, significant fluid extravasation and swelling may occur in the early postoperative period that can impede motion. This is usually resorbed within 24 to 36 hours.
Arthroscopic procedures may be classified, in order of increasing complexity and difficulty, as diagnostic; removal of loose bodies; simple; limited debridement (e.g., an operation for tennis elbow); fracture treatment; and complex, extensive debridement (for osteoarthritis, contracture release, or removal of heterotopic bone). In addition to the arthroscope, a variety of motorized cutting instruments (shavers) and burrs are used to resect soft tissue and remove extra bone or osteophytes. Fracture fixation is performed with cannulated screws or suture-passing instruments similar to those used for shoulder instability and rotator cuff repairs.
The first indications for elbow arthroscopy were for elbow pain and the removal of loose bodies. , Arthroscopy has become the preferred method for loose body removal and diagnostic evaluation. Even with the advent of higher-quality imaging studies, such as MRI and 3D reconstructions of CT scans, diagnostic arthroscopy remains a vital tool in the orthopedist’s arsenal. , The ability to dynamically examine the elbow under direct vision allows the surgeon to assess the elbow in a way in which all other modalities fail. A patient with pain and positive physical exam findings in the absence of an abnormal radiographic exam may be a candidate for arthroscopy. With the establishment of newer technology and with the standardization of portals and techniques, more and more surgeries became approachable with the use of an arthroscope. , This became especially important in the treatment of pathologies that resulted in contracted joint spaces, such as post-traumatic fibrosis and osteoarthritis.
Synovectomy for treatment of early rheumatoid arthritis has been controversial. However, multiple authors have indicated that in addition to the use of antirheumatologic medications, arthroscopic synovectomy is a vital tool in helping to increase function and decrease pain when the patient is operated on early (Larsen stage 0–2). Recently, Tanaka and colleagues noted that for the stiff rheumatoid elbow (total arc of motion <90 degrees), arthroscopic synovectomy has been shown to have a better outcome than open debridement ( Fig. 81-3 ). Synovectomy is also an established treatment for other proliferative synovial diseases, such as pigmented villonodular synovitis and synovial chondromatosis.
Although restoration of motion is rarely an issue in the “loose,” unstable rheumatoid elbow, synovectomy, either arthroscopic or open, does not, of itself, increase the ROM in a patient with a painful, stiff, arthritic elbow. Radial head excision, which can also be performed arthroscopically, may improve motion and alleviate pain, at least over the short term. However, resection of the radial head results in increased valgus instability and may accelerate degeneration of the ulnohumeral joint.
Even though lateral epicondylitis, or “tennis elbow,” is relatively common, a consensus among physicians and therapists is lacking about the cause and treatment of the condition. Although the vast majority of cases that present to the physician’s office resolve, 25% of patients presenting to a specialist’s office may be surgical candidates. Various surgical techniques have been advocated for refractory cases. Surgeons have recommended removing structures thought to be pathologic, including portions of the common extensor origin, the origin of the extensor carpi radialis brevis, the lateral epicondyle, and the capsule.
There is also disagreement as to which structures should be treated arthroscopically. In our opinion, patients who demonstrate a positive extension–compression test (reproducible pain over the lateral elbow with resisted wrist extension that is greater with elbow extension than elbow flexion) have pain caused by impingement of the radiocapitellar capsular complex, which has a variable morphology among the general population. In patients with a capsular complex that enfolds the radiocapitellar joint ( Fig. 81-4 ), resection of the pathologic portions of the complex, tendon and surrounding structures, as described by Baker and Jones, has provided excellent results that meet or exceed the results obtained via open surgical treatment. In a published study, 28/30 patients reported complete relief within 2 weeks, and 20/24 returned back to a competitive level of athletic activity. Similar results achieved with arthroscopic treatment have also been reported by other authors.
Perhaps the greatest benefit to treating recalcitrant lateral epicondylitis arthroscopically is the ability to decrease the length of time the elbow is immobilized and to speed the return to work and activities. The standard postoperative protocol for an open surgical procedure for lateral epicondylitis immobilizes the elbow for at least 10 days and restricts strenuous activities for 6 weeks. Arthroscopic treatment may permit early exercise within 1 to 2 days, and use, as tolerated, may be permitted. Therapy is employed if the patient has difficulty achieving full motion within 1 week.
Osteoarthritis and the Stiff Elbow
The most common pattern of osteoarthritis of the elbow is associated with overuse, such as throwing, and has a characteristic pattern of peripheral osteophytes around the joint that may impinge and cause pain and loss of motion. However, the central portions of the radiocapitellar and ulnohumeral joints are well preserved. In such cases, debridement of the peripheral osteophytes may restore motion and alleviate pain. The patient with moderate osteoarthritis of the elbow has pain at the ends of flexion or extension (or both), with loss of ROM. Most frequently, this patient is a young, active, male laborer or throwing athlete with complaints of pain and a loss of terminal extension of 10 to 30 degrees. The source of the pain and cause of the decreased ROM is osteophyte impingement along the periphery of the elbow, particularly in the coronoid fossae by medial and lateral olecranon osteophytes (the so-called “Mickey Mouse ears”) and in the supracapitellar zone of the distal humerus. Frequently, these osteophytes can break off and form loose bodies, which may be a further source of symptoms. Before considering an arthroscopy, appropriate imaging studies (preferably CT scans with 3D reconstruction) must be obtained to guide the resection of osteophytes and identify the presence of loose bodies ( Fig. 81-5 ).
Less common is advanced, primary osteoarthritis resulting in destruction of the entire joint surface. Such cases do not improve with debridement and should be managed by activity modification, medical therapy, and, if the pain is intractable, some form of elbow arthroplasty.
Even minor elbow injuries may result in loss of motion. This is particularly likely if the elbow is immobilized ( Fig. 81-6 ). This group of patients includes those with almost no articular surface derangement, but whose motion is restricted entirely due to capsular thickening, fibrosis, contracture, and consequent loss of joint volume. With a normal, total volume of only about 50 mL, the elbow is particularly sensitive to contracture. In the case of a patient with articular derangement, osteophytes, similar to those in the degenerative elbow, may also be seen.
Contracture release performed by open surgery, with one or more incisions and followed by a period of immobilization to allow for wound healing, has been shown to be a consistently successful procedure for restoring motion to the stiff elbow. Some of the advantages in performing this via arthroscopy include better visualization for more complete resection of scar tissue, decreased postoperative pain, the ability to begin therapy immediately, and perhaps a faster recovery, although this has yet to be documented.
Successful contracture release must address all components of the pathology, which vary according to the injury. For a moderate flexion contracture after a radial head fracture, the anterolateral capsule is usually affected and must be resected. More complex fracture dislocation extends the pathology and usually requires resection of the entire anterior and posterior capsules, as well as the posterior medial collateral ligament. The anterior band of the medial collateral ligament and the lateral ulnar collateral ligament must be preserved to avoid an elbow that is, paradoxically, stiff, but unstable. This is a most difficult problem to treat.
The therapist should inquire about the patient’s preoperative ROM. This not only helps to guide the therapy, but establishes the patient’s degree of flexion. Patients with extension contractures who cannot flex to approximately at least 100 degrees must have the ulnar nerve decompressed prior to even attempting to flex the elbow. Attempts to forcefully flex the elbow without decompressing the nerve results in tightening of Osborne’s ligament and is associated with a high probability of injury to the ulnar nerve. , The nerve need not be transposed, but must be decompressed in such circumstances.
The therapist must also know if the surgeon has resected a significant amount of excess bone. This can weaken the medial and lateral columns of the elbow, and a supracondylar fracture may result from postoperative manipulation ( Fig. 81-7 ). When manipulating the elbow and performing therapy, it is wise to push on the proximal or midforearm to decrease the amount of leverage and thus avoid inadvertent excessive force.