THE STIFF ELBOW

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:

Intra-articular pathology, such as intra-articular fibrosis, causing elbow stiffness may be amenable to arthroscopic treatment, but the prognosis may be limited.

Capsular contracture is the pathology most easily treated with arthroscopy, and it therefore carries the best prognosis.

Extra-articular causes of elbow stiffness, such as heterotopic ossification, are not amenable to arthroscopic management. The prognosis is mixed.

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.

FIGURE 15-1 Our preferred setup for elbow arthroscopy.

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

FIGURE 15-2 Cadaveric dissection shows the superficial cutaneous nerves in the deep subcutaneous fat layers about the elbow.

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:

A capsulotomy is performed superiorly from medial to lateral. It is performed proximally to minimize the chance of radial nerve injury, and it is usually performed with cautery or a hook knife.

In a linear capsulectomy, a strip of the proximal capsule is excised with a basket forceps or a resector.⁸

In a radical capsulectomy, the entire anterior capsule is excised. To perform this safely, the radial nerve requires exploration.⁹

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.

FIGURE 15-3 In this cadaveric specimen, the radial nerve has been exposed by an open technique. The course of the nerve where it is in direct contact with the elbow joint capsule has been identified by the two needles that are seen in the arthroscopic view.

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.

Postoperative Management and Rehabilitation

The range of motion achieved intraoperatively should be accurately recorded. The aim is to achieve this range as early as possible postoperatively. Good postoperative analgesia is essential, and the use of nerve blocks can be useful. Range-of-motion exercises should be active whenever possible. Continuous passive motion (CPM) or night splinting is advocated by some surgeons, but it is not used in our practice. Although CPM has been shown to mildly improve active flexion in open capsulectomy, mean active extension is unaffected, and it is often poorly tolerated.¹⁰

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