Chapter 30 Treatment by Arthroscopy

Introduction

With the advances in techniques and tools for elbow arthroscopy, treatment of the stiff elbow by arthroscopic methods has become increasingly popular. Arthroscopy offers improved joint visualization, reduced pain, smaller scars, accelerated rehabilitation and shorter hospital stay, potentially making arthroscopic release a day-case procedure.

However, the management of elbow stiffness arthroscopically does demand complete confidence and skill in arthroscopic elbow surgery. The stiff joint has a poor capsular compliance and is more difficult to access.¹ All standard and often many accessory portals are required to deal with all the restrictive lesions. Additional ‘technical tricks’ may be required to access and treat these lesions. Normal anatomy may be distorted by deformity and/or previous surgery. Nonetheless, once mastered the arthroscopic treatment of stiff elbows can be a rewarding and beneficial procedure for the patient and surgeon.

Background

In 1931 Burman ^2,³ performed a cadaveric elbow arthroscopy and concluded that the elbow was ‘unsuitable for examination’. One year later however after performing 10 arthroscopic procedures he changed his mind and described the elbow as a joint that could be visualized with the arthroscope.³ It took another 50 years before Carson⁴ demonstrated in a clinical study the utility and safety of elbow arthroscopy.

During its infancy, elbow arthroscopy was used primarily for loose body removal and synovectomy.⁴^–¹⁰ As experience has grown, techniques and results have been published on using arthroscopy for the excision of osteophytes in arthritis¹¹^–¹⁴ capsular releases¹⁵^–¹⁸ resection of symptomatic plicae¹⁹^–²¹ and the excision of the radial head.²² This expansion in elbow arthroscopic procedures has only occurred since the early 1990s, and is still developing. The improved understanding of the relevant anatomy, and technological advances in instruments and hardware have made elbow arthroscopy significantly safer and have resulted in an expansion of treatment options.

Presentation and investigations

Patients present with disabling stiffness and pain or discomfort. Loss of elbow motion can be significantly disabling. Although Morrey ²³ described a functional arc of motion as 30 to 130° of flexion, this 100° arc of motion is the arc in which most activities of daily living (ADLs) can be performed. Many activities may require more motion than this, including tying shoes, eating, personal hygiene and sporting activities.

Clinical examination involves assessing the active and passive sagittal arc motion of the elbow and comparing it to the opposite side. This can be best appreciated by having the patient stand with arms outstretched to the side and asking them to bend and straighten their elbows. A measurement should be taken with a large goniometer. The flexion and extension blocks should be gently tested for any ‘give’ to ascertain whether the block is a ‘springy’ soft-tissue block or ‘rigid’ bony block. Forearm rotation should similarly be comparatively assessed and measured. Muscle function is assessed and a thorough neurovascular examination performed. Particular attention is paid to the ulnar nerve and its position in the cubital tunnel. It should be examined for subluxation through range of motion, as the position of the nerve must be known when the medial arthroscopic portals are created.

Plain radiographs are required for all patients and should include true lateral and anteroposterior views of the elbow joint. In cases of extreme stiffness it may be difficult to obtain an adequate anteroposterior radiograph. In these cases a computed tomography (CT) scan is required to assess the bony architecture of the elbow and identify calcified loose bodies (Fig. 30.1). In patients with normal X-rays we prefer a CT arthrogram or magnetic resonance (MR) arthrogram. These scans will help identify any cartilaginous or soft tissue blocks and synovial swellings. Often loose bodies, previously undetected can be seen²⁴ (Fig. 30.2).

Figure 30.1 (A) Radiograph and (B) three-dimensional (3D) computed tomography (CT) scan showing arthritis and loose bodies.

Figure 30.2 MR arthrogram showing a spur/osteophytes of the olecranon limiting extension (arrow).

Preoperative functional assessment scoring is useful to objectively quantify and compare the level of elbow disability, pain and motion. We prefer the elbow functional assessment (EFA) tool and the Mayo performance indicator ²⁵ (Table 30.1).

Table 30.1 Elbow functional assessment tool ²⁵

I. Pain (max = 30 points)
Pain sensation at rest (10 cm VAS, no pain is 10 points)
Pain sensation on motion (10 cm VAS _ 2, no pain is 20 points)
II. ADL^a (max = 35 points)
Cup to mouth
Eating with a spoon
Lifting a kettle filled with 1 L
Pouring water from a kettle to a glass
Telephone receiver to ipsilateral ear
Cutting with a knife
Pulling an object over the table
III. Motion (max = 35 points)
Active range of motion (max = 25 points)
Active flexion	≥125° = 15
	100–125° = 10
	75–100° = 5
	<75° = 0
Flexion contracture	≤20° = 10
	20–40° = 5
	≥40° = 0
Combined movement (max = 10 points)
Grasping ear lobe of contralateral side with arm in front of the body	Without difficulty = 10
	With difficulty = 5
	Impossible = 0

^a On a self-reported questionnaire for the ipsilateral arm. Without difficulty = 5; with little difficulty = 3; with much difficulty = 2; with aid = 1; impossible = 0.

Indications and contraindications

The main indication for surgical intervention for the stiff elbow is pain disabling and stiffness. An arthroscopic approach is best suited to intra-articular causes of elbow stiffness, which include capsular contractures, synovial swelling, arthritic lesions (osteophytes and articular irregularities) and loose bodies. It does not adequately address pathologies outside the joint, such as muscle or skin contractures, heterotopic ossification, etc.

The commonest indication is primary osteoarthritis of the elbow, where the causative factors can all be addressed arthroscopically.²⁶ These include osteophytes, capsular contracture, loose bodies, synovitis, joint incongruities and intra-articular adhesions. Pain and stiffness due to posttraumatic arthritis, rheumatoid arthritis, septic arthritis and osteochondritis dissecans can also be treated arthroscopically with excellent results.^10,²⁷^–³¹

Each pathology has lesions in common, which need to be treated in all cases together with lesions specific to that disease. The common lesions are capsular contracture and adhesions, articular incongruities, synovitis (of varying degrees) and loose bodies. Osteophytes are more prominent in primary and posttraumatic osteoarthritis. These are predominantly on the coronoid, anterior humerus, olecranon process and olecranon fossa. The rheumatoid elbow may have more synovitis and articular irregularities. Osteochondritis dissecans primarily affects the radiocapitellar joint and the lesion may be difficult to visualize from the anterior and posterior compartments. Therefore the lateral (radiocapitellar) portal may be best to see the lesion, associated synovitis and loose bodies.

Jupiter et al described six features of the ‘simple’ stiff elbow.³² This was described for open surgery and elbows that may do well with soft tissue release alone. We have found this guide also useful and applicable for intrinsic stiffness and have modified it to define our indications for arthroscopic treatment of a stiff elbow (Table 30.2).

Table 30.2 Six features of the ‘simple’ stiff elbow (data from Jupiter et al)³²

1	Mild to moderate contracture (<80°)
2	No or minimal prior surgery
3	No prior ulnar nerve transposition
4	No or minimal internal fixation/hardware in place
5	No or minimal heterotopic ossification
6	Normal bony anatomy has been preserved

Elbow arthroscopy is not recommended in patients who have undergone previous elbows procedures with changes to the normal anatomy.³³ It is also contraindicated in the presence of infection or a non-distensile joint. Gallay et al³¹ demonstrated that the capsular compliance of stiff elbows is reduced to 15% of normal elbow joints. Therefore, the stiff elbow is already more difficult to access arthroscopically.

Elbow arthroscopy after ulnar nerve transposition remains a relative contraindication. Steinmann et al ³⁴ recommend extending the incision for the medial portal to identify and protect the nerve before inserting the arthroscope or instruments. An absolute contraindication for arthroscopic treatment of stiff elbows is a lack of experience with elbow arthroscopy. This procedure can be extremely difficult with a higher risk of nerve injury than other arthroscopic elbow procedures.

Surgical techniques and rehabilitation

Position

The patient setup is an essential part of elbow arthroscopy. Poor positioning can make access and instrumentation difficult. The position of the patient, on the operative, table may depend on surgeon preference. Supine, prone and lateral positions have been described.

The supine position was originally described by Andrews and Carson.⁴ The shoulder is positioned in 90° abduction with the elbow flexed in suspension and held by a traction device. In this position, the anaesthetist has easy access to the patient’s airway. Arthroscopic access to the anterior compartment of the elbow is easy, but the forearm is difficult to mobilize during the procedure due to the traction.

Poehling et al ³⁵ described the prone position with the shoulder abducted 90° and the elbow flexed 90°. The advantages of this position are that the elbow is free to move in a sagittal arc range of 0 to about 120° and access to the posterior compartment is easier. The disadvantages are the need to roll the patient and the difficulty to access the airway.

The lateral position (Fig. 30.3) was originally described by O’Driscoll and Morrey.³⁶ It was originally described as an alternative, offering the advantages of the prone position, without the disadvantages. The upper arm, is positioned on a short arm support. We recommend a support designed for elbow arthroscopy, such as the Weston arm holder (Fig. 30.4). This will prevent obstruction of the camera and instruments by the arm holder during the procedure.

Figure 30.3 Lateral position for elbow arthroscopy, allowing full sagittal arc motion and high tourniquet.

(Courtesy of Orthoteers.com.)

Figure 30.4 Lateral position with Weston arm holder (Smith & Nephew).

Tourniquet

We prefer to use a tourniquet for more extensive procedures, but it is not essential and a good bloodless view can be obtained without a tourniquet. If it is used it must be positioned high on the upper arm. Exsanguination and inflation of the tourniquet should be done just before skin preparation to avoid any wasted tourniquet time. We advise a maximum tourniquet inflation time of 1 hour.

Fluid management

Many options exist for fluid management in elbow arthroscopy. Most shoulder surgeons use a fluid management system, while most hand surgeons use manual fluid pressure management via a 50 mL syringe. For the extensive procedures required for stiff elbow surgery we recommend a fluid management system, with the lowest inflow pressure and flow to allow for good visualization. This is usually lower (20–30%) than that required for shoulder arthroscopic procedures.

Instruments

We prefer to use a 2.9 mm arthroscope with 30° angled lens (Conmed Linvatec) which provides the same wide field of view as a 4.0 mm arthroscope. An end-flow cannula sheath is preferential to a side-flow sheath, particularly for smaller spaces such as the elbow. If a 4.0 mm arthroscope is used, we recommend using a 2.7 mm arthroscope (wrist scope) for the posterior compartment and the radiocapitellar compartment, as these spaces will be narrower than usual in the stiff and arthritic joint (Fig. 30.5)

Figure 30.5 Arthroscopes used for elbow arthroscopy. A 2.4 mm scope (Smith & Nephew) (above) for the posterior compartment and a 2.9 mm scope (Conmed Linvatec) (below) for the anterior compartment.

Cannulae can be used for instruments, with 5 or 6 mm cannulae being the most useful. These can be inserted using an inside-out approach with switching sticks or an outside-in approach under direct arthroscopic vision. We prefer an outside-in approach, as we can then position portals in the most appropriate place to access the pathology. However, generally we do not use cannulae, as they may restrict access around the joint and are easily displaced when removing instruments.

Both a large and small shaver can be useful and we would recommend having both available for an extensive anterior and posterior debridement and release. Curved shaver blades are extremely useful, but more difficult to triangulate in small spaces. A MacDonald’s retractor, broad trocar or Howarth elevator are useful as capsular retractors as they enable a better view to be obtained during the release procedure (Fig. 30.6).

Figure 30.6 Using an elevator (left) to retract the capsule and allow access to the joint for instrumentation.

Portals

The elbow joint is initially inflated with saline to increase the joint volume and aid placement of the arthroscope into the joint. The soft spot is located on the postero-lateral surface of the elbow and is at the centre of a triangle formed by the lateral epicondyle, the radial head and the olecranon. An 18-gauge needle is inserted and the joint distended with 20–40 mL of saline. With distension of the joint the neurovascular structure are displaced anteriorly allowing safer positioning of the instruments (Fig. 30.7).

Figure 30.7 Pre-insufflation of the joint via the lateral soft spot with saline.

An accurate knowledge of neurovascular anatomy is fundamental to creating safe portals. Prior to proceeding it is essential to palpate the ulnar nerve in the cubital tunnel and ensure it is not subluxing on elbow flexion or has not previously been transposed. If this is the case then the nerve will need to be identified and protected with a larger incision. The relevant surface anatomy should be marked on the skin, these being the olecranon, radial head, medial and lateral epicondyles, and ulnar nerve. We also mark the course of the radial nerve on the lateral side (Fig. 30.8).

Figure 30.8 (A) Lateral skin surface markings (O = olecranon; LE = lateral epicondyle; RH = radial head). The dashed line indicates the approximate surface marking of the radial nerve. (B) Medial skin surface markings (O = olecranon; ME = medial epicondyle; UN = ulnar nerve)

Numerous portals have been described for elbow arthroscopy, of these the most common used are the anterolateral, direct lateral, superomedial, anteromedial, direct posterior and posterolateral ³⁷ (Fig. 30.9). Either the medial or lateral portal can be used as the initial portal for the arthroscope. The choice depends on the surgeon’s preference and experience. For arthroscopic debridement and capsular release procedures we prefer the lateral portal for the initial viewing portal. This provides a good view of the coronoid and coronoid fossa, which are two key areas for debridement of elbows with a flexion block.