New Techniques in Elbow Arthroscopy

CHAPTER 15 New Techniques in Elbow Arthroscopy

Elbow arthroscopy was pioneered during the early 1980s, but it came to increased prominence after Andrews and Carson’s 1985 paper,1 which described the anatomy of the elbow joint as seen through the arthroscope and demonstrated the feasibility of arthroscopic diagnosis and treatment of disorders of the elbow. Further works by Morrey,2 Lynch and colleagues,3 Poehling and coworkers,4 and O’Driscoll and Morrey5 secured the procedure as an accepted orthopedic practice. Initial concerns about the potential for neurologic injury remain the primary concern of elbow arthroscopists today, and thorough knowledge of the neurovascular anatomy of the elbow is essential for performing elbow arthroscopy safely.

Improvements and innovations in instrumentation, patient positioning, and arthroscopic techniques have led to a greatly expanded role of the arthroscope in the management of disorders of the elbow. A broad spectrum of indications for elbow surgery can be considered as indications for elbow arthroscopy or arthroscopically assisted management. This list is limited by the experience of the operating surgeon and includes the classic indications of diagnostic arthroscopy, treatment of osteochondritis dissecans, removal of loose bodies, and irrigation or débridement of septic joints. Widely accepted additional indications include capsular release, débridement, and osteophyte removal for osteoarthritis; synovectomy for rheumatoid arthritis or other inflammatory arthropathies; extensor carpi radialis brevis (ECRB) débridement for lateral epicondylitis; excision of symptomatic synovial plicae; and arthroscope-assisted repair of radial head fractures.

Further indications include a repair of other intra-articular fractures; assessment and arthroscope assisted repair of biceps tendon tears; management of posterolateral rotatory instability and the sequelae of thrower’s elbow; débridement of olecranon bursa in olecranon bursitis; and cubital tunnel release in cubital tunnel syndrome. Evidence for these procedures is limited to early reports from centers with an interest in elbow arthroscopy, and indications remain largely at the discretion of the expert arthroscopist based on individual experience and a limited number of case series.

In this chapter, we discuss newer surgical techniques that we employ for elbow arthroscopy and published procedures not covered in other chapters.


Familiarity with the classic open techniques of capsular release is essential before arthroscopic surgery can be considered. These procedures and approaches are necessary fallbacks and are still considered to set the standards by which arthroscopic surgical outcomes are measured. The procedures of arthroscopic capsular release remain the domain of experienced arthroscopic surgeons, who are thoroughly familiar with the regional anatomy and elbow arthroscopy. Before surgical intervention, the cause of the elbow stiffness must be determined. It may be classified according to the anatomic location of the tissue causing contracture:

We prefer to position the patient in a lateral position with the arm flexed at the elbow 90 degrees over a fixed bolster (Fig. 15-1). A 30-degree, 4.0-mm arthroscope without side-venting cannulas is most often used, but a 2.7-mm arthroscope can make visualization of the lateral gutter easier, and a 70-degree scope may add perspective in tight joints.

Capsule distention is performed easily and safely through the lateral soft spot. The normal joint can accommodate about 30 mL of fluid at 70 degrees of flexion, but in patients with joint contracture, this amount is significantly decreased and averages only 6 mL at 85 degrees. The capsule is also about 15% less compliant in these cases, and it is often thickened.6 Although capsule distention can increase the safety of portal placement by increasing the distance from the articulation to related neurovascular structures, the distance from the capsule to these structures remains unchanged and does not protect the neurovasculature during capsulectomy or capsular release.

We think the safest method of making portals is to incise sharply through the epidermis and dermis and bluntly dissect through the depths of the subcutaneous fat layers. This minimizes damage to cutaneous nerves that are found in the very depth of the subcutaneous fat (Fig. 15-2).7

Advanced therapeutic arthroscopy requires the ability to view the anatomy from multiple portals. Switching the arthroscope and other instruments between portals is necessary so the joint can be perceived in three dimensions. The joint is like a three-dimensional box. The use of retractors to increase arthroscopic exposure is a major advance in therapeutic arthroscopy of the elbow, but cutting instruments should only be used with direct visualization of the instruments and adjacent structures. Suction should be avoided near nervous tissue, and shaver blades should always point away from nerves. Patients with contracture greater than 90 degrees of flexion require open ulnar nerve release before any capsular release to prevent neurologic deficit.

Three types of anterior capsular releases have been reported:

We strongly recommend that these procedures be considered only by an experienced arthroscopist. Surgeons should first perform the procedure on a cadaveric model.

We prefer to perform a capsulectomy rather than a simple release to reduce the risk of recurrence. If the surgeon wishes to identify the radial nerve before excising the adjacent capsule, we recommend the use of two medial portals and a lateral retractor to protect nervous tissue (Fig. 15-3). Our preferred technique is to excise the medial one half of the capsule first. A mini-Hohmann retractor is then introduced through the medial portal. An arthroscope is placed in the medial superior portal with the retractor in the medial inferior portal. The capsule can then be teased off the brachialis muscle using blunt dissection. The blunt-ended retractor can be rotated to identify this natural interval. The radial nerve can be safely retracted anteriorly by advancing the retractor toward the lateral side. After this interval is developed, a second retractor is passed through the anterolateral portal and passed between the capsule and the first retractor, which can be removed. At this point, the capsulectomy can be safely completed. The capsulectomy should not proceed unless the nerve can be clearly visualized and protected with the Hohmann retractor.

A common cause of limited elbow flexion in an elbow with degenerative change is a coronoid osteophyte. Adequate excision of this osteophyte with a chondrotome can be challenging, and it may be associated with chondral damage to the trochlea. We prefer to introduce a narrow osteotome from an anteromedial working portal, with the arthroscope in the anterolateral portal. The osteotome can be placed at the chosen level of resection, and under arthroscopic vision, it is advanced into the bone with a mallet. This is most easily performed with the elbow flexed to 120 degrees. The osteotome can be rotated to complete the osteotomy of the coronoid (a wrench applied to the handle of the osteotome may be necessary to perform this maneuver). The resected bone is removed from the joint using an arthroscopic clamp or pituitary rongeur. We do not use a motorized resector because the shape of the blade prevents adequate excision.

Jun 19, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on New Techniques in Elbow Arthroscopy

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