Introduction
Elbow arthroscopy is a technically demanding procedure that may be used to evaluate and treat a variety of elbow disorders. Appropriate patient selection and knowledge of elbow anatomy, especially neurovascular anatomy, is critical to a good outcome.
Elbow arthroscopy was first described in the early 1930s, but did not become a viable operative technique until the 1980s, when arthroscopic equipment improved in quality and operative techniques became more refined. Since that time, elbow arthroscopy has evolved from a diagnostic tool to a treatment modality for multiple disorders of the elbow and its indications continue to expand.
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Indications
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Limited elbow range of motion (ROM)
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Mechanical symptoms of locking, popping, or catching
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Mild-moderate osteoarthritis
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Mayo grade 1 or 2 rheumatoid arthritis (RA)
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Early post-traumatic arthritis with minimal deformity
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Refractory lateral epicondylitis is a newer indication
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Potential arthroscopic candidates should all have attempted and failed conservative measures such as therapy, NSAIDs, medical management of RA, activity modification and/or corticosteroid injections before proceeding to surgery.
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Common procedures performed include:
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Diagnostic arthroscopy
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Removal of loose bodies
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Synovectomy
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Osteophyte débridement
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Capsular release
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Ulnohumeral arthroplasty
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Radial head resection
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Lateral epicondyle débridement
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Arthroscopically assisted fracture reduction and fixation of certain simple fracture patterns
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Contraindications to elbow arthroscopy include:
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The presence of significant heterotopic ossification
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Local skin infection
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The potential for noncompliance with postoperative therapy
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Special consideration and relative contraindications include:
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Severe joint contractures
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Previous open elbow procedure or severe trauma resulting in distortion of the normal anatomic landmarks and joint surfaces
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Previous ulnar nerve transposition
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Displaced radial head or distal humerus fracture
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Preoperative Considerations
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Preoperative workup
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A thorough history and physical examination is essential. Document history of previous elbow injury, previous surgeries, presence of locking or instability, and the patient’s current activity level and expectations.
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Physical examination should include evaluation of elbow range of motion in all planes including supination and pronation and stress testing of the collateral ligaments. A thorough neurovascular examination should include evaluation of the ulnar nerve for the presence of cubital tunnel syndrome or subluxation of the nerve over the medial epicondyle with elbow flexion.
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Appropriate elbow imaging may include radiographs with AP, lateral, and oblique views, MRI with or without arthrogram, CT scan, or diagnostic injections as indicated. If compressive neuropathy is suspected, EMG and nerve conduction studies are indicated.
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Discuss realistic expectations of the surgical procedure and the anticipated recovery time.Therapy is usually indicated postoperatively to regain elbow ROM and this should be discussed with the patient in the preoperative setting.
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Anesthesia
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General anesthesia is usually preferred. A regional intrascalene block is also an option but many surgeons opt for a postoperative block after the patient has had a thorough postoperative neurovascular examination.
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Patient positioning ( Fig. 6-1 )
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The patient may be placed supine, prone, or lateral decubitus depending on surgeon preference. This chapter will describe the lateral decubitus position. The patient is positioned on his or her side supported by a bean bag. The operative arm is placed on a padded arm holder with the shoulder at 90 degrees of forward flexion and the elbow is allowed to fall to gravity at 90 degrees. A nonsterile tourniquet (sterile may be used as well) is placed high on the brachium in the area supported by the arm holder to allow for maximal elbow ROM and access to the anterior elbow if necessary. The arm is then prepped and the patient is draped in a typical sterile manner. The monitor should be placed at the patient’s back facing the arthroscopist. Gravity inflow should be used and pump inflow should be avoided because of the risks of compartment syndrome.
Figure 6-1
Patient position. Lateral decubitus position.
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Equipment
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Padded arm holder
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Sterile or nonsterile tourniquet
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Arthroscope
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Blunt trochar with cannula
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11 blade
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Retractors
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Shaver
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Probe
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Graspers
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18-gauge needle
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Lactated Ringer solution or Normal Saline suspended from IV pole
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Monitor and printer to document findings
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Relevant Anatomy ( Fig. 6-2A-C )
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Distal humerus
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Capitellum
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Trochlea
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Coronoid fossa
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Olecranon fossa
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Lateral epicondyle
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Medial epicondyle
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Groove for ulnar nerve
Figure 6-2
A. Elbow and forearm bony anatomy: volar view ( left ), dorsal view ( right ). B. Joint and ligament anatomy of the elbow and forearm. C. Peripheral nerves at level of the elbow and volar forearm ( left ) and dorsal forearm ( right ). APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EIP, extensor indicis profundus; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus.
(From Chhabra AB. Elbow and forearm. In Miller MD, Chhabra AB, Hurwitz S, et al. [eds]. Orthopaedic Surgical Approaches. Philadelphia, Elsevier, 2008, pp 63, 64, 67, 74, 75.)
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Proximal radius
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Radial head
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Radial neck
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Proximal ulna
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Olecranon
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Coronoid process
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Trochlear notch
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Radial notch for radial head at proximal radial-ulnar joint
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Ulnar collateral ligament
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Anterior UCL
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Posterior UCL
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Transverse UCL
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Lateral collateral ligament complex
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Lateral ulnar collateral ligament
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Annular ligament
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Radial collateral ligament
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Joint capsule
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Median nerve
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Generally well protected because it crosses the elbow superficial to the large muscle belly of the brachialis
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Ulnar nerve
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Crosses the elbow in the cubital tunnel, which lies directly superficial to the joint capsule in the medial gutter.
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Radial nerve and posterior interosseous nerve (PIN)
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The radial nerve branches into a superficial sensory branch and a deep motor branch (PIN) just anterior to the lateral epicondyle.
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The PIN crosses the elbow anterolaterally before piercing the supinator muscle and lies in close proximity to the anterolateral joint capsule.
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Cutaneous nerves
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Medial antebrachial cutaneous
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Posterior antebrachial cutaneous
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Lateral antebrachial cutaneous
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Brachial artery
Portal Placement ( Fig. 6-3 )
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Anterior compartment
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Anteromedial portal
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May be one of the first portals established for introduction of the arthroscope.
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Located 2 cm distal and 2 cm anterior to the medial epicondyle
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Avoid injury to the anterior branch of the medial antebrachial cutaneous nerve during skin incision.
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Used to visualize the capitellum, radial head, and anterior surface of the humerus
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Proximal medial portal
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Located 2 cm proximal to the medial epicondyle and just anterior to the medial intramuscular septum
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Used to view the anterior compartment of the elbow and the lateral gutter. Many find it superior to the anteromedial portal.
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This portal is in close proximity to the ulnar nerve, approximately 12 mm away, and is contraindicated in the setting of a subluxating ulnar nerve or a previous ulnar nerve transposition.
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Avoid injury to the ulnar nerve during portal placement by aiming the trochar toward the radiocapitellar joint and sliding the trochar along the anterior aspect of the humerus.
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If a patient has a subluxating ulnar nerve, this portal should be made with extreme caution. When the ulnar nerve anatomy or location is variable, a mini-incision can be used to visualize the nerve and a retractor placed to protect the nerve before the portal is created.
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The medial antebrachial cutaneous nerve is at risk for injury because it lies approximately 2 mm from the portal.
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Anterolateral portal
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Located 3 cm distal and 1 cm anterior to the lateral epicondyle
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Establish this portal with a spinal needle under direct visualization from the anteromedial portal.
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Avoid injury to the anterior branch of the posterior antebrachial cutaneous nerve and the radial nerve, which should lie 2 to 10 mm anterior to the portal with the elbow in flexion.
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Proximal lateral portal
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Located 2 cm proximal and 1 cm anterior to the lateral epicondyle
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Provides access to the anterior compartment. It may be preferred to the anterolateral portal because it is farther from the radial nerve (9 mm) and provides better visualization.
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Avoid injury to the posterior branch of the lateral antebrachial cutaneous nerve located approximately 6 mm from the portal.
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