ANATOMY

Pathologic processes include the loss of cartilage and fragmentation with reactive bone formation in the form of osteophytes and loose bodies, which contribute to impingement and joint contracture as the capsule becomes abnormally thickened and fibrotic.³^,¹¹ Bony osteophytes commonly occur on the tip of the olecranon and coronoid process. Significant osteophytes also can occur along the medial aspect of the coronoid and may not be obvious on standard plain radiographs. Similarly, osteophytes may be found at the radial head fossa and the posterior aspect of the capitellum. The osteophytes in this area are difficult to visualize at time of surgery but can be seen while viewing from the posterolateral gutter when performing the posterior portion of the procedure, and they can be removed through a working portal at the soft spot. These bony spurs contribute to the loss of extension, and osteophytes at the radial head fossa contribute to a lack of flexion by impingement.

PATIENT EVALUATION

History and Physical Examination

Primary osteoarthritis of the elbow is uncommon, but when it occurs, it tends to manifest in manual laborers, athletes, or crutch and wheelchair ambulators.¹^–⁴^,¹⁰ Post-traumatic stiffness and arthrosis can be problematic after fractures or dislocations of the elbow.

Symptoms include loss of motion, mechanical catching and locking, and pain.⁴^,¹⁰ Pain often is felt at the end arc of motion, and it is more likely to be improved by arthroscopic means than pain experienced throughout the arc of motion, which typically indicates severe joint changes.

Patients frequently have signs and symptoms of ulnar nerve compression at the elbow, and they should be examined for and queried about dysesthesias or paresthesias and weakness in the ulnar nerve distribution.⁴^,¹² Electrical studies can document the severity of cubital tunnel compression, but they may not be necessary. Nerve compression occurs after progressive contracture of the elbow and scarring at the cubital tunnel. Postoperatively, if a large restoration of motion is achieved but the ulnar nerve is not addressed, symptomatic ulnar neuritis or neuropathy can occur as the nerve is stretched further.

Diagnostic Imaging

Plain radiographs should be obtained, and they typically demonstrate hypertrophic bony spurs and loose bodies (Fig. 8-1). The bone usually is sclerotic rather than osteopenic, as seen in rheumatoid arthritis. Computed tomography (CT) is useful, particularly with three-dimensional reconstructions, to map areas of interest that will require recontouring (Fig. 8-2). Using three-dimensional CT as a preoperative planning tool allows the surgeon to gain an increased appreciation of the osteophytic areas that require attention to improve range of motion. During the procedure, these areas may be overlooked without this three-dimensional map of normal and abnormal anatomy.

FIGURE 8-1 A and B, Typical radiographic appearance of a severely osteoarthritic elbow.

FIGURE 8-2 A–D, Computed tomography can provide a three-dimensional view of the pathology.

TREATMENT

Indications and Contraindications

Pain at the end arc of motion, symptomatic loose bodies with mechanical symptoms, and joint contracture that limits activity are indications for arthroscopic débridement or capsular release, or both. Pain in the middle arc range of motion may indicate severe joint changes and fail to respond to arthroscopic treatment. A subluxating ulnar nerve or a prior subcutaneous ulnar nerve transposition is not necessarily a contraindication to arthroscopy of the elbow; however, an intermuscular or submuscular transposition is often considered a relative contraindication unless the precise course of the nerve can be ascertained by visual inspection, palpation, or ultrasonography.

Conservative Management and Alternatives to Arthroscopy

Nonoperative treatment options such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and activity modifications should be exhausted before considering surgery.¹³

Alternatives to arthroscopic procedures include open procedures such as resection arthroplasty of the ulnohumeral joint and open débridement such as the Outerbridge-Kashiwagi procedure. The medial “over-the-top” contracture release and the lateral column procedures allow access to the joint for excision of the thickened and abnormal capsule, with débridement of bony osteophytes.¹⁴^,¹⁵ Total elbow arthroplasty reliably relieves pain and motion, but early aseptic loosening is an unsolved problem, especially in young and active patients. Joint fusion can relieve pain, but it has dramatic implications on function and is sometimes difficult to achieve.⁷

Multiple open débridement procedures have been used with success and an acceptable complication rate, but open procedures remain the gold standard by which arthroscopic procedures are assessed.^{3,4,10,12,15-21} Arthroscopic débridement and capsular release is an evolving technique that addresses underlying pathologic processes and provides outcomes similar to those of open procedures, and it is associated with an acceptable complication rate.^5,9,13,22-26

Arthroscopic Technique

The arthroscopic technique and setup have been described previously.¹^,¹⁹^,²⁰ General endotracheal anesthesia is induced, and the patient is placed in the lateral decubitus position. Various positions have been described for elbow arthroscopy, but we prefer the lateral decubitus position as described here.

A conforming bean bag is useful to position and secure the patient. The operative arm is secured in a dedicated arm holder with the elbow higher than the shoulder and the forearm hanging freely. This allows unrestricted access to the elbow. A nonsterile tourniquet may be applied, or a sterile one is used after the arm is prepared and draped in the usual fashion (Fig. 8-3).