Introduction

The primary function of the elbow joint is to enable free positioning of the hand in space. Good function of any extremity requires stable joints with normal pain-free motion of sufficient power to allow activities of daily living to be performed. Satisfactory hand function is dependent on the ability to position the hand in space and this ability is more dependent on elbow flexion, extension and forearm rotation than on any other single joint. In terms of overall upper extremity function it is very difficult to compensate for lost elbow motion.

Limitations in elbow motion restricts the extent of hand reach and, depending on the degree of loss of motion, can cause major functional limitations. Most activities of daily living and work can be accomplished with 100° of flexion–extension motion and 100° of rotation.¹ More severe restrictions of elbow motion are usually associated with significant loss of function.

Loss of elbow motion can be caused by a number of osseous or soft-tissue abnormalities located within or around the joint. Intra-articular causes include joint incongruity after fractures, articular adhesions and posttraumatic or degenerative arthritis. Diseases affecting the synovium such as rheumatoid arthritis and synovial chondromatosis (Fig. 39.1) may also result in limitation of motion. Posttraumatic capsular thickening and soft tissue contractures or heterotopic bone formation are typical extra-articular causes of loss of motion. Trauma is by far the most common cause of restriction of elbow motion.

Figure 39.1 Synovial chondromatosis.

Pain may or may not be a prominent feature of elbow stiffness. This may be related to the fact that patients may be less likely to seek advice for their elbow problem if the elbow is not painful. In patients with slight or moderate stiffness, pain is usually the main problem. In very stiff or ankylotic elbows it is the lack motion that causes the functional limitations. Very stiff elbows may actually be pain-free, but often have secondary pain related to the shoulder or neck region. Non-operative management consists of gentle, active physical therapy and dynamic or static progressive splinting, which is particularly useful in posttraumatic cases.^2,3 Surgical treatment may be indicated in patients with major functional limitations who have failed non-surgical management.

Advances in both open and in particular arthroscopic surgical approaches have led to a higher rate of clinically successful treatment of elbow stiffness and osteoarthritis of the elbow. In an recent state-of-the-art article, Bernhard Morrey stated that ‘without question, one of the greatest recent advances has been the application of techniques of elbow arthroscopy to the treatment of the stiff elbow’.⁴ The aim of this chapter is to discuss the role of arthroscopic release and debridement for elbow stiffness.

Background/aetiology

The most common cause of elbow stiffness is trauma. Posttraumatic contractures are related to the force of injury, the extent of soft tissue damage and severity of fractures. Contractures may be seen after simple soft tissue trauma or dislocations or the contracture may be secondary to severely comminuted fractures.

Intra-articular adhesions (Fig. 39.2), heterotopic ossification, scarring and contracture of the capsule all contribute to the stiffness. Scarring and shortening of the anterior capsule is usually the primary cause of the extension deficit and stiffness and shortening of the posterior oblique ligament medially and the posterior capsule result in flexion deficits.⁵ The degree of contracture is related to the severity of the initial trauma but other factors contribute including: non-anatomical reduction resulting in joint incongruency or inadequate fixation of the fractures not allowing early range of motion exercises. Prolonged immobilization can lead to capsular contracture and early active mobilization after injury is considered a significant factor in limiting residual stiffness.^6–8

Figure 39.2 Adhesions in the anterior compartment.

Heterotopic ossification may be caused by any type of trauma, including surgery, and is particularly common following elbow injuries when associated with head trauma. Heterotopic ossifications usually form in the flexor compartment of the elbow and can cause significant contractures. Resection should not be done until the ectopic bone exhibits a mature appearance on radiographs with trabeculations and well-defined cortical margins.⁷

Primary elbow osteoarthritis is relatively rare in comparison with osteoarthritis of the shoulder and the joints of the lower extremities (Fig. 39.3). Approximately 2% of the population is affected. Men are much more frequently affected than women and usually the dominant arm is involved. Because of the low prevalence, studies on larger number of patients are not possible, and our knowledge on factors associated with initiation of and progression of the condition is limited, as is the interplay and relative importance of risk factors. A multifactorial aetiology of elbow osteoarthritis is presumed. A number of factors, predisposing to or influencing the development and course of elbow osteoarthritis have been suggested: genetic predisposition, malalignment, ageing, joint loading and repetitive micro-trauma.⁹

Figure 39.3 Three-dimensional computed tomography (CT). Osteoarthrosis, lateral view.

Several reports have described an association between heavy manual labour and the development of elbow osteoarthritis. Two early reports noted a high incidence of elbow osteoarthritis in coal miners using pneumatic tools. In a study that examined 774 coal miners who used pneumatic tools Rostock found that 32.8% had degenerative arthritis of the elbow.¹⁰ Lawrence found a prevalence of osteoarthritis of 31% in miners who used pneumatic drills compared with only 16% in miners not using pneumatic tools.¹¹ In a more recent study Stanley found an association between strenuous manual work and the development of elbow osteoarthritis.¹² In most of the published series dealing with the management of elbow osteoarthritis there is an overrepresentation of patients engaged in strenuous manual labour or sports activities that induce comparative high loads or forces across the elbow. Even though the elbow is not a weight-bearing joint, forces across the joint are significant during normal activities of living. Using various simulation and mathematical models it has been estimated that resultant forces across the humeroulnar joint may reach one-half times body weight during normal daily activities and up to two to three times body weight during occupational activities such as lifting and moving heavy objects.¹³ Throwing or heavy pounding produce even higher forces of up to an estimated six times body weight.

Degenerative arthritis begins primarily at the radiocapitellar joint and at all stages changes tends to be more advanced radially than in the humeroulnar articulation.¹⁴ The early changes found are posteromedial defects on the radial head with a corresponding defect on the posterior part of the crest separating the trochlea from the capitellar area.

Contrary to osteoarthritis in most other joints, elbow osteoarthritis is characterized primarily by osteophyte formation, whereas loss of joint space occurs somewhat later. Osteophytes predispose to loose body formation as the osteophytes may break off during activity.

Loose bodies may remain loose, causing locking and pain, or they may become impacted in the coronoid or olecranon fossa increasing the thickness of the membrane. Some degree of capsular contracture is usually present and synovitis may or may not be a prominent feature.

Presentation, investigation and treatment options

Clinical presentation

Loss of elbow motion impairs hand reach and function and may cause significant functional impairment and pain. Motion loss after trauma depends on the type of injury and its treatment. After simple radial head fractures or dislocations without fracture the lost motion is usually in extension and caused by a combination of anterior capsular contracture and intra-articular adhesions. Prolonged immobilization is an important causative factor. Even though the extension deficit may be moderate, the patients often have high functional demands related to work or sport. Pain with activities involving extension is usually more the problem than the restriction of motion in itself.

Limitation of motion may also be related to a more severe trauma with joint incongruity, severe stiffness and pain causing significant impairment of function. A typical patient with elbow osteoarthritis is a manual worker in his mid-fifties, complaining of pain in the dominant arm on terminal elbow extension, flexion and forearm rotation. Usually the pain is elicited by more strenuous activities. Painful catching or locking sensations are common. The loss of motion is usually moderate with 20–30° of motion loss in both the flexion–extension and rotation arch.¹⁵ Between 25% and 50% of patients also have intermittent symptoms of ulnar neuropathy.^16–18

In primary osteoarthritis elbow motion may be compromised for several reasons. Flexion may be limited by osteophyte formation on the tip and on the medial facet of the coronoid (Fig. 39.4). In addition loose bodies or impacted loose bodies in the coronoid fossa may hinder flexion. Extension deficits or flexion contractures are usually caused by a combination of osteophytes along the olecranon process, loose bodies in the olecranon fossa and anterior capsular contracture (Figs 39.5, 39.6).

Figure 39.4 Three-dimensional CT. Osteoarthrosis, medial view. Prominent coronoid process. Osteophytes and loose bodies.

Figure 39.5 CT scan. Osteoarthritis. Loose bodies posteriorly.

Figure 39.6 Loose bodies and osteophytes in the posterior fossa.

Assessment (investigations)

To help determine the aetiology of elbow stiffness, a thorough history should be obtained. In posttraumatic contractures a detailed description of the initial injury is very important as well as the type of fracture and any associated soft tissue or neurovascular injuries. Any previous non-operative or surgical treatment, together with any complications, such as infection or nerve lesions, should be noted. In an osteoarthritic patient, details of workload and former elbow trauma should be clarified. Patients younger than 50 often have a history of a traumatic event. The degree of pain is variable and functional impairment depends largely on the individual requirements of each patient and is influenced by handedness as well as occupational and recreational demands. Future demands and expectations from the treatment should also be discussed.

At physical examination the elbow region is inspected, noting previous incisions, burns, scars and skin quality. Function of the radial, median and, in particular, the ulnar nerve is carefully evaluated and recorded. Position and mobility of the ulnar nerve is noted. A subluxating or transposed ulnar nerve should be identified. If nerve transposition or dislocation is suspected, preoperative ultrasonography may help determine the exact location if it is not readily located by palpation. Occasionally, minor or moderate elbow stiffness may be caused by an underlying instability. If this is suspected the elbow should be examined for instability under anaesthesia.

A goniometer is used to document active and passive motion in the extension–flexion plane (Fig. 39.7) as well as on rotation so that the response to treatment modalities can be documented. The presence of crepitus or pain in the motion arc is also noted. Standard anteroposterior and lateral radiographs are usually sufficient, but oblique and special projections may be helpful in evaluating possible intrinsic or extra-articular causes of restriction of motion: fracture deformity, joint incongruity, osteoarthritis, osteophytes, loose bodies, heterotopic ossifications and position of hardware. Computed tomography (CT) scans with three-dimensional reconstructions are very helpful in determining the extent and exact location of heterotopic ossification (Fig. 39.8), impinging osteophytes and the location of loose bodies in osteoarthritic elbows.¹⁹ CT scans are also routinely used if fracture deformity or joint incongruency is suspected.

Figure 39.7 Flexion deficit.

Figure 39.8 Heterotopic ossification anteriorly (CT scan).

Treatment options (indications)

Posttraumatic elbow stiffness

Trauma is by far the commonest cause of elbow contracture and prevention of stiffness is a primary goal in the rehabilitation after elbow trauma. Usually the main problem is an extension deficit as a result of a contracture of the anterior joint capsule. Less commonly, there is also heterotopic ossification present. Fracture deformity or joint incongruency can also cause flexion deficit. Finally, rotational deficit may be present after radial head fractures or in osteoarthritic elbows. In posttraumatic cases, physiotherapy, splinting, static or dynamic braces and other conservative treatment modalities should be tried to help improve range of motion. Some contractures, however, persist and do not improve over time in spite of therapy. A minimum of 6 months of non-operative treatment is recommended, but after 6 months there is usually only minimal additional gain in motion. There seems to be considerable individual clinical variation demonstrated by patients to similar degrees of trauma.²⁰

Osteoarthritis

Osteoarthritis is the second most common cause of elbow stiffness. Patients usually present with both pain and restriction of motion and often also locking or catching. Pain is often at the extremes of motion but there may also be mid-range pain with activity. Non-operative treatment options are: rest, activity modification and antiinflammatory medication.¹⁵ Temporary relief may also be achieved using intra-articular injections of steroid and local anaesthetics; however, they rarely provide pain relief of longer duration. Long-term activity modification is the most important component of conservative management. In patients engaged in strenuous work activities this may necessitate a job change. Physiotherapy with strengthening or range of motion exercises is rarely indicated and may actually increase pain.

Indications

Indications for surgical intervention in elbow stiffness should be based on the individual patient’s needs and the competence of the surgeon to fulfil these needs without undue risks for the patient.^1,21,22 If there is considerable loss of motion or even ankylosis the potential benefits from surgery are of course very significant. Functional demands in occupation, personal needs, sports and other activities, however, differ considerably. Restriction of motion, even if moderate, will not necessarily be tolerated by all. Surgical benefits and risks should always be carefully explained and discussed with each patient.

Open surgical releases using various techniques are well established and successful in the treatment of posttraumatic elbow stiffness. Depending on the type and localization of the pathology, limited anterior, lateral, medial or extensile posterior exposures may be used.^6,23–26 (The tendency over the last two decades has been to use less invasive techniques in an attempt to minimize soft tissue trauma, reduce pain to allow early aggressive rehabilitation and minimize the risk of recurrence because of scarring. The complication rate with open techniques has also been a concern. Limiting the exposure and extent of surgery has not negatively influenced the functional outcomes.

More recently arthroscopic techniques have evolved, further reducing soft tissue trauma. With only small arthroscopic scars and reduced pain postoperatively, rehabilitation can be accelerated and hospital stays shortened. Indeed, it can now be undertaken as an outpatient procedure. Clinical outcomes after arthroscopic release have been encouraging.^27–29 Arthroscopic elbow release is challenging because of the close proximity of neurovascular structures to portals and capsule, a limited working space within a stiff and non-compliant capsule and possibly joint incongruency. In addition it still is an uncommon procedure and only few surgeons perform a sufficient number of procedures to gain experience. Therefore, the indication for an arthroscopic procedure depends to a large extent on the surgeon’s ability and experience. Simple release of a moderate anterior capsular contracture in an otherwise intact joint with normal bony anatomy is not a technically demanding procedure, and an ideal case for an arthroscopic release. Very stiff joints with fracture sequelae or severely osteoarthritic joints with extensive osteophyte formation are more challenging and should be attempted only by the most experienced surgeons. Radial head resection is sometimes necessary as a part of the release procedure and again it may be performed arthroscopically. In patients with healed radial head fractures with deformity and radiocapitellar osteoarthritis with pain on forearm rotation and radiohumeral compression, resection is indicated. However, in osteoarthritis, there is still some controversy as to in which cases the procedure should be undertaken.^30–32

Relative contraindications for an arthroscopic approach include extremely stiff or ankylotic joints, some cases of heterotopic ossifications, and joint incongruity where joint surface correctional surgery is anticipated (Fig. 39.9). Unless the ulnar nerve can be clearly identified by palpation after a previous ulnar nerve transposition, localization may require either establishing the anteromedial portal through a mini-incision or identifying the ulnar nerve through a mini open approach before creating the portal.³³ Ultrasonography is usually very helpful in determining the exact location of nerves relative to ossification or the exact location of an anteposed ulnar nerve in different degrees of flexion. Heterotopic ossification is extracapsular and may be closely related to neurological structures.

Figure 39.9 Joint incongruency with severe restriction of range of motion following a distal humeral fracture. Not suited for an arthroscopic release.

Ulnar nerve intraneural pressure rises with increasing elbow flexion. Beyond 90° of flexion the intraneural pressure exceeds extraneural pressure and as a consequence it has been suggested that traction may be as important as compression in causing a cubital tunnel syndrome.³⁴ It has been suggested that in patients with flexion of less than 90–100° as well as undertaking a release, ulnar nerve decompression with resection of the posterior band of the medial collateral ligament should be undertaken.^1,33 Arthroscopic release is not an effective procedure for patients with restriction of forearm motion. Only rotation loss caused by adhesions, fracture deformity or osteophytes around the radial head may be dealt with this way. Open release is usually indicated if there is a need for articular reconstruction, as after malunited intraarticular fractures.

Clinical Pearl 39.1

Indications for surgical intervention in elbow stiffness should be based on the individual patient’s needs and the competence of the surgeon to fulfil these needs without undue risks for the patient.

Summary Box 39.2 Relative contraindications to arthroscopic release

• Extremely stiff or ankylotic elbow

• Several heterotopic ossifications

• Significant joint incongruity

Surgical techniques and rehabilitation

Personal technique

General anaesthesia is routinely preferred for arthroscopic procedures because it affords comfort and provides full muscle relaxation. Occasionally regional blocks are used as a supplement, usually in very stiff elbows where immediate postoperative CPM therapy may be indicated. Antibiotics are always administered before inflation of the tourniquet and repeated after 2 hours.

The patient is in the supine position lying with the side of the chest flush with the side of the operating table so that the arm is free. The hand and forearm are placed in a prefabricated forearm and wrist gauntlet connected to an overhead suspension device (Fig. 39.10). The upper arm is parallel to the floor at a right angle to the body and the elbow is flexed to 90°. It is a balanced suspension so that the elbow can be freely flexed, extended and rotated during surgery. The surgeon sits on the lateral side facing the elbow. The tourniquet is placed high on the upper arm. After exsanguination of the arm, the tourniquet is inflated to 250 mmHg.

Figure 39.10 Elbow arthroscopy in the supine position, with the arm in balanced suspension.

Surface landmarks and standard portals are marked at the initiation of the procedure: the medial and lateral epicondyles, the lateral and medial intermuscular septum, olecranon, radial head and capitellum. The course of the ulnar and radial nerves are marked. Elbow distension with either saline or local anaesthetics will displace the neurovascular structures away from the arthroscopic portals. The fluid may be injected in the ‘lateral soft spot’ or in midlateral portal in the centre of the triangle formed by the radial head, the lateral epicondyle and the lateral margin of the olecranon process. An alternative injection site is the posterior fossa; however, in stiff elbows the fossa may be completely obliterated by soft tissue or scar tissue. Injection into soft tissue should be avoided if possible because soft tissue swelling may further compromise identification of intra- and extra-articular landmarks. In a normal elbow, adequate distension can be accomplished by injection of saline or local anaesthetic. Easy injection and good backflow indicate that the needle tip is correctly positioned in the joint. In a stiff elbow, both the total joint volume and the compliance may be considerably decreased. Because of joint stiffness, capsular contracture and fibrosis, it is less likely that the neurovascular structures can be displaced anteriorly by fluid injection into the joint and hence great care should be taken entering a stiff elbow joint. Anterior portals should always be established in flexion.

Standard arthroscopic equipment is used: arthroscopes, instruments and portals. Standard portals for evaluating the anterior compartment are the anterolateral and anteromedial portals. Usually the anterolateral is the primary portal. This portal is located approximately 2 cm proximal and 1–2 cm anterior to the lateral epicondyle; depending on the size of the arm, the portal must be placed anteriorly enough for instruments to reach the bottom of the coronoid fossa. Because of the somewhat variable course of the radial cutaneous nerve branch, only the skin is incised and the joint is then entered careful by blunt dissection using a forceps (Fig. 39.11) followed by a blunt trochar.

Figure 39.11 Anatomical landmarks are marked. Skin incision only. Blunt dissection into the joint cavity.

Once the joint has been entered, the proximal anteromedial portal may be developed using either the inside-out or outside-in techniques. At this stage it is important to know that the ulnar nerve is not subluxed or has been transposed previously. There are also on the medial side cutaneous branches that may be injured. As a consequence only the skin should be incised and the portal established using blunt dissection. Care must also be taken that the portal is placed sufficiently anteriorly for instruments to be able to reach the bottom of the coronoid fossa. A 6 mm cannula is routinely used to ease switching of instruments and arthroscope. With the arthroscope in the anterolateral portal the anterior compartment and joint space is evaluated starting anteromedially and centrally (Fig. 39.12).

Figure 39.12 Patient in the supine position. Arthroscope in the proximal anterolateral portal.

The radiocapitellar joint is best evaluated with the arthroscope in the medial portal. To minimize swelling, fluid pressure is kept as low as possible at the beginning of the procedure, although it may be necessary to increase it later. Using a shaver, the anterior compartment is gradually cleared of adhesions, fibrotic capsule and synovial irritation. The resection is started proximally and continued distally. Only non-aggressive shavers are used and the tip of the shaver should be fully visible at all times so that blind shaving is avoided. Suction is used intermittently and in a controlled fashion, both to avoid uncontrolled suction of tissue into the shaver and joint collapse because of loss of fluid pressure. To maximize control of how much tissue is being resected, the cutting edge of the shaver should be kept at a right angle to the capsule or tissue that is being removed. Pointing the cutting edge of the shaver directly towards the capsule should be avoided or done only in a very controlled fashion and under direct vision. Capsule and tissue resection is usually started medially proximally along the humeral shaft, which is the safest place in terms of distance to neurovascular structures. Usually after resection of adhesions and capsular tissue proximally, the fat pad will appear and it is then possible to lift the remaining capsule away from the anterior and anteromedial part of the humerus using a blunt trochar so that a reasonable working space is then created. If necessary the plane between the deep surface of the brachialis muscle and the anterior capsule can be developed using a low profile basket forceps. The capsule can then be resected under full vision. Repeatedly cutting the edge of the often very thick and stiff capsule with a forceps may facilitate resection with the shaver. Occasionally in extremely stiff elbows with almost no joint volume, it may be difficult to start resection from within the joint capsule, in which case resection must start from the outside after developing the plane between capsule and brachialis muscle.⁵¹ It is safest to start the resection proximally and the joint should be entered as soon as possible. Retractors can be used to maintain visualization without resorting to a high-pressure irrigation.

Clinical Pearl 39.2

The position of the ulnar nerve must always be established prior to the development of the proximal anteromedial portal.

In osteoarthritic elbows there may be some synovitis but the capsule is usually not very thick and is easily resected (Fig. 39.13). Loose bodies in the fossa or attached to capsule are common and can either be removed using arthroscopic grabbing tools or, if large trimmed or divided, using an acromionizer pinning the loose body against the anterior humerus or fossa. There may also be impacted loose bodies at the bottom or the sides of the fossa necessitating a deepening of the fossa. Usually it is also necessary to trim osteophytes that have formed along the anteromedial and anterolateral facets of the coronoid process. The anteromedial osteophytes should be trimmed as far down on the medial side as possible. The tip of the coronoid is almost invariably prominent and will impinge on or sometimes block full flexion. Resection of the tip of the coronoid can be done in as much flexion as possible, thereby protecting the cartilage on the humeral side. Ossifications may also have formed just proximal to the joint surface of the capitellum, and should also be resected to ensure full flexion. In the posterior compartment there may also be loose bodies or impacted loose bodies filling up the olecranon fossa and hindering full extension. Re-creation of the depth and width of the fossa with trimming of osteophytes along the tip as well as the lateral and medial margins of the olecranon can be quite time consuming. Great care must be taken working in the medial recess as the ulnar nerve is very close; osteophytes can be trimmed with the acromionizer on reverse, soft tissue resection medially should be avoided or undertake with minimal or no suction, and the cutting edge of the shaver pointing away from the capsule and ulnar nerve. The posterolateral recess should be carefully evaluated; often there are loose bodies embedded in the synovial tissue (Fig. 39.2).

Figure 39.13 Anterior compartment. Radial head to the left, coronoid process in the centre. Synovitis.

Heterotopic ossification is most commonly located anteriorly and can usually be removed working from within the joint after careful dissection of the soft tissues covering the deep surface of the ossification (Figs 39.14, 39.15). Standard fine dissectors may be used. The heterotopic bone is usually fairly soft and can easily be removed using an acromionizer on reverse setting to minimize the risk of soft tissue damage. If the ossifications are attached to the humerus, the safest approach is often to resect the base, grab the bone fragment with a forceps and dissect of the soft tissues from the anterior surface, thereafter removing the fragment as a loose body. If it is suspected that the radial or median nerves are in contact with or run close to the ossifications, a preoperative ultrasonographic examination may help clarify the anatomical relationship.

Figure 39.14 Heterotopic ossifications. Preoperative flexion to 95°, extension deficit 70°, free rotation.

Figure 39.15 Following arthroscopic removal of heterotopic ossifications: flexion 140°, 15° of extension deficit, full rotation; pain-free motion.

Radiofrequency devices should generally not be used on the anterior capsular structures or only with great care. Radiofrequency devices are preferably used on bony surfaces to help clear the fossa, which is often obliterated by scarified soft tissue. However, the settings should be kept lower than normal because of the proximity of nerves.

Once the medial part of the joint is cleared the arthroscope can be switched to the proximal anteromedial portal and the cannula to the anterolateral portal using a switching stick. After completion of the capsular release and resection the status of radiocapitellar joint can be evaluated. Both cartilage status and rotation of the radial head should be examined. Capsular resection distally on the radial side of the joint must be performed with great care because of the close proximity of the deep branch of the radial nerve. Usually the capsule is trimmed down to the edge of the annular ligament. The distal 1 cm capsule, however, should be left to prevent nerve injury. Unfortunately there are no studies clarifying how much of the capsule should be resected. In several open techniques the capsule is only divided and not resected and based on these studies there does not seem to be any significant disadvantage by way of range of motion.

The posterior compartment is entered with the elbow in approximately 30° of flexion using two portals. A posterolateral portal is created 2 cm proximal to the tip of the olecranon at the lateral border of the thick part of the triceps aponeurosis and in line with the posterolateral recess. A posteromedial portal is placed 1 cm more proximally midway between the midline and the palpated ulnar nerve position. If the ulnar nerve is not freely moveable because of previous surgery or trauma, a more central position is preferred so as not to endanger the nerve. Placing the two portals too close together, however, will make triangulation difficult. If the olecranon fossa and posterior joint space is completely or nearly completely obliterated, a working space can be created by debriding the fossa blindly (Fig. 39.16) with a blunt forceps. Once a space is created the resection can be continued under direct arthroscopic vision. Dissection and resection medially under or along the course of the ulnar nerve must of course be done with great care, particularly in situations where the ulnar nerve does not have its normal mobility. Usually it is possible using fine dissectors to release the tissue of the posteromedial aspect of the humerus. Following posterior debridement the posterior capsule can gradually be lifted off the posterior part of the humerus. Finally both the medial and lateral recesses are inspected for synovitis and loose bodies (Fig. 39.17). If necessary an additional portal in the lateral soft spot is created.

Figure 39.16 Shaver in the posterior compartment. The ulnar nerve is marked.

Figure 39.17 Posterolateral recess.

With all instruments removed, gentle manipulation can be performed. There may, however, be considerable swelling of the soft tissues around the elbow at the end of the procedure. In severely stiff elbows the operating time may be extended up to 2 hours. Skin incisions are closed with sutures; if there is significant swelling staples are preferred. Epidural morphine (5 mL or 2 mg) and 10 mL of bupivacaine (Marcain) 0.5% with adrenaline is injected into the joint to help minimize pain, bleeding and inflammation postoperatively. A sterile dressing is followed by a compression wrap. A plaster keeping the elbow in extension or an extension splint may be helpful in controlling joint swelling and maintaining regained extension. Arthroscopic elbow release is routinely performed as an outpatient procedure. Preoperative antibiotics are always administered and postoperatively indometacin 25 mg thrice daily for 3 weeks is recommended.

Other pathology specific procedures include the following:

• Arthroscopic radial head resection is rarely performed and usually only if there are clear-cut radiohumeral symptoms and pain on forearm rotation and compression.

• Occasionally restriction of elbow motion and pain may be caused by inflammatory diseases or septic arthritis and arthroscopic synovectomy is indicated. There is often considerable synovitis under the annular ligament and resection in this area should be done with care, again because of the proximity of radial nerve branches.

• In elbows with a significant flexion deficit (<100° of flexion) a mini open ulnar nerve release with excision of the posterior medial capsule is usually performed prior to the arthroscopic release.

Outcome including literature review

The effectiveness of open surgical elbow release in restoring motion has been demonstrated by a number of authors.^{6,8,20,23–26,28,29,47,48,52–54} These surgical interventions have gradually developed into more limited exposures using sequential steps to address the specific causes of stiffness and limiting surgical exposure.^1,22 The less invasive techniques minimize soft tissue trauma, reduce pain and allow early and more aggressive rehabilitation. The introduction of arthroscopic techniques has followed the same trend of attempting to reduce soft tissue trauma. More extensive approaches are now primarily reserved for ankylotic or nearly ankylotic joints, usually post-fracture cases with a need for articular reconstruction because of joint incongruency.

The number of reports on results after arthroscopic elbow release is still fairly limited compared with open techniques, but the results using arthroscopic techniques have been good and seem to match open surgery in all aspects.27–29,31^,45,46,55,56 In most studies the results are reported for a mixture of pathologies resulting in elbow stiffness. Tables 39.1 and 39.2 give details from some of the series that have reported results for posttraumatic and osteoarthritic cases separately. Overall there seems to be only minor differences in results obtained, although the results in our series were slightly better for the posttraumatic cases. In most series the focus has been on improvements in arc of motion; however, the reported results in terms of pain relief, and functional improvements are also good.^28,45,48 In an open series Ring et al found that final motion influenced physician-based rating scales but not patient-specific health status, which was dominated by pain and persistent ulnar neuropathy.⁴⁸ In our series the results in terms of pain relief were slightly better for posttraumatic than for osteoarthritic cases. For patients with primarily soft tissue contractures the results were also good at 2–3-year follow-up, with close to 90% in the good or excellent category. Among patients with degenerative arthritis a slight tendency for the stiffness and pain to recur was observed and only 67% were satisfied at the 2–3-year follow-up.

Elbow arthroscopy has always been considered a demanding and potentially dangerous procedure because of the limited joint space and the close proximity of neurovascular structures. However, complications in the reported arthroscopic series are relatively few and usually minor. Complications after open contracture release include neuropathies, infection and recurrence of stiffness or heterotopic ossifications.^{6,7,21,23,25,47,49} Comparing complication rates after arthroscopic and open releases is difficult as there are no comparative studies, although complications after open procedures are not rare with reported rates up to 21%. A definite advantage of the arthroscopic techniques is that it can routinely be carried out as an outpatient procedure.

Many factors influence the functional outcome: patient age, type of pathology, degree of stiffness, presence or absence of arthrosis, joint incongruity, activity level, occupational demands and timing of surgery. With regard to the long-term prognosis it is likely that the most important factor is the presence of osteoarthritis. Short-term results after arthroscopic debridement in osteoarthrosis are almost as good as after arthroscopic release for soft tissue related contractures. However, over time there does seem to be higher incidence of recurrence of a contracture in the osteoarthritic group. Joint incongruity is also an important prognostic factor as it predisposes to secondary osteoarthrosis. Activity modifications, either recommended by the surgeon or physiotherapist, or activity modifications that patients impose on themselves to reduce or prevent pain, are also important factors in relation to outcome, although seldom accounted for.

The timing of surgery may also influence the outcome, although the optimal time remains unclear. Most clinicians, however, recommend surgery between 6 and 12 months after injury.

Complications of treatment

Over the past two decades there has been considerable evolution of arthroscopic elbow techniques. The number of procedures has increased, as has the complexity. In the beginning, elbow arthroscopy was primarily a diagnostic procedure with occasional removal of a loose body or partial synovectomy. Currently, much more extensive procedures are routinely performed: total synovectomy, arthroscopic arthrolysis, debridement with osteophytes resection and resection of heterotopic bone formation. Kelly et al,⁵² in a study on complications in elbow arthroscopies over an 18-year period, noted an increasing trend related to increasing complexity of procedures undertaken.

Very few studies have reported complication rates after arthroscopy in a systematic fashion.⁵² Most publications are case reports dealing with isolated and rare complications.^58–61 Complications after elbow arthroscopy include prolonged drainage, superficial and deep infection, neurovascular injury, heterotopic ossification and compartment syndrome. In an analysis of 473 consecutive elbow arthroscopies the overall complication rate was about 10%.⁵² The majority of complications was minor and temporary: prolonged drainage (5%) and superficial infection (2%). There were four cases of deep infection (0.8%). In a consecutive series of 374 arthroscopic elbow procedures performed at our institution, we had four cases of deep infection and two patients with prolonged drainage (unpublished data). Prophylactic antibiotics were administered to all of our patients. In this series, six patients developed significant heterotopic ossification after arthroscopic release (1.6%). None of these patients had taken the prescribed indometacin for the recommended 3 weeks; most had taken indometacin for only a few days or not at all.

The most feared complication in elbow arthroscopy is neurovascular injury. In most textbooks on elbow arthroplasty the risk of neurovascular injury is repeatedly stressed. The posterior interosseous and ulnar nerves are closest to the portals.^52,58,60,62 There have also been rare reports of anterior interosseous and median nerve injuries, and even a complete trans-section of both the median and radial nerves during an arthroscopic elbow release.^59,61 Kelly et al found transient nerve palsies in 2% (four superficial radial, one medial superficial, five ulnar and one anterior interosseous). There were no permanent injuries. In our series there were three transient nerve palsies (one radial, two superficial radial) but no permanent. Many of the nerve injuries reported in the literature have been partial and transient. That reports of nerve injuries are so rare, in spite of the documented close proximity of routinely used portals to the nerves, may be because not all cases of nerve injury are reported. Another possible reason could be that surgeons performing elbow arthroscopies, in particular the more advanced high-risk procedures, are very experienced and take all necessary precautions to avoid injury.

Even though most complications are minor, serious complications do occur and the risks and benefits of the procedure should always be discussed with the patient.

Conclusions/personal view

Loss of motion is a common complication following fractures, dislocations, and other trauma to the elbow. Restriction of motion may also be a prominent feature of primary degenerative arthritis or synovial diseases such as rheumatoid arthritis. Elbow stiffness impairs hand function and is often associated with pain. Surgery is indicated for patients not responding to conservative treatment.

Loss of motion may be due primarily to soft tissue contracture or secondary to both articular and soft tissue involvement as in degenerative arthritis or following intra-articular fractures. Careful selection of patients and appropriate procedures as well as an aggressive postoperative treatment programme are all essential requirements for a successful outcome. The approach to surgical management of the stiff elbow includes both arthroscopic and open procedures. The main advantage of an arthroscopic release is the decreased postoperative morbidity.

The main indications for an arthroscopic procedure are functional limitations because of pain, locking and restriction of motion in both soft tissue contractures and degenerative arthritis. Arthroscopic release is generally not recommended in very severe contractures or ankylotic elbows, if there is significant joint incongruity secondary to fractures, or if the restriction of motion is secondary to severe heterotopic bone formation. In degenerative arthritis an arthroscopic release and debridement is considered the arthroscopic equivalent to an open Outerbridge–Kashiwagi procedure.

For patients with primarily soft tissue contractures arthroscopic release is an efficient treatment with a low postoperative morbidity. The majority of patients with osteoarthritis also benefit from arthroscopic debridement both in terms of improvement of range of motion and pain relief, but less than patients with purely soft tissue contractures. Long-term follow-up of this group of patients is currently unavailable and as such it is not clear how long the benefits are maintained. However, there are few other surgical treatment options for these patients, the majority of whom are of a working age and often engaged in heavy manual activities.

Although neurovascular complications are rare it must be stressed that arthroscopic release is technically demanding and potentially hazardous because of the close proximity of neurovascular structures. A detailed knowledge of local gross and arthroscopic anatomy and strict adherence to proper surgical technique is strongly recommended.