New Techniques in Elbow Arthroscopy

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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.

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.

PEARLS& PITFALLS

• Commence the capsulectomy from the medial side with a second medial viewing portal, and use a mini-Hohmann retractor interposed between the capsule and brachialis muscle.

• Use an osteotome to resect the tip of the coronoid.

• The radial nerve lies on the anterior capsule laterally and may be injured if not visualized when performing the capsulectomy.

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 We implement a 14-day course of nonsteroidal anti-inflammatory medication to minimize the risk of heterotopic bone formation and to reduce pain and swelling. We have used turnbuckle splints in more severe cases and for patients for whom rehabilitation has been slow.

ASSESSMENT OF ELBOW INSTABILITY

In our practice, elbow arthroscopy has an important role in the assessment of elbow instability. At the outset of any reconstructive procedure, the elbow is examined clinically through a range of movement, varus-valgus loading, and a pivot shift test. Fluoroscopic examination is performed to look for widening of the ulnohumeral joint on valgus loading. With the forearm held in supination, a lateral view is obtained to look for the tilt sign, which suggests lateral ligament instability.

Elbow arthroscopy is performed in all patients. The elbow is assessed with the arthroscope in the anteromedial portal. A rent may be seen of the lateral ligament complex from the humerus, which often tears off as a sleave.¹¹ This rent is the best sign of posterolateral rotatory instability (PLRI) when viewing from the anterior compartment. The capsule sits on the capitellum and therefore does not heal back to the lateral epicondyle. Scuffing of the radial head or capitellum humeri may be seen.

The arthroscope is then moved to the anterolateral portal to visualize the coronoid-trochlea articulation. Abnormal widening of this joint may be seen with varus or valgus loading in the unstable elbow. Widening of the joint of more than 1 mm is abnormal on the medial and lateral sides. This varus-valgus instability is best assessed anteriorly. PLRI is difficult to assess in the anterior compartment because the radial head is seen to slide of the capitellum. It can be impossible to determine whether this is normal or pathologic, because the radiocapitellar joint appears to close.

Another portal is created posteriorly to inspect the ulnohumeral articulation. With lateral instability, the joint may be seen to open laterally with forearm supination, and with medial instability, forearm pronation may cause the joint to open medially. The rotatory instability is best assessed from the posterior compartment. In the normal elbow, the olecranon-trochlea articulation may open and admit the probe medially and laterally. In patients with PLRI, the arthroscope can be introduced between the trochlea and trochlea notch. The bare area of the olecranon can often be seen, as can the radial head and a rent in the lateral capsule.

We use arthroscopy to classify patients with PLRI in three groups. Those with isolated PLRI are managed with a lateral reconstruction. Those with associated medial joint space opening are managed with a circumferential graft to reconstruct the medial and lateral collateral ligaments.¹² The third group of patients has degenerative changes, and their management is governed by the degree of instability and osteoarthrosis.

PEARLS& PITFALLS

• Rotational instability is most reliably assessed form the posterior compartment of the elbow.

SOFT TISSUE LESIONS OF THE ELBOW

Ulnar Neuritis

Ulnar neuritis is the second most common entrapment neuropathy of the upper limb. Various techniques have been described for performing endoscopic ulnar nerve decompression at the elbow. We prefer to use the Agee Micro-Aire device (LMT, Taringa, Queensland, Australia). A cadaveric study demonstrated the safety and efficacy of this technique.¹³

With the patient under general anesthesia and placed in the lateral position with the elbow flexed over a padded bar and an upper arm tourniquet inflated, a 3-cm incision is made between the olecranon and medial epicondyle. Blunt dissection is per formed to the cubital retinaculum. A small fenestration is performed to allow insertion of the Agee device adjacent to the nerve under direct vision. The device is used proximally and distally to divide the cubital retinaculum. The device is gently manipulated until the retinaculum is clearly visible and inspection shows that the nerve and its branches are not threatened. Activating the trigger mechanism advances the blade, and the entire device is carefully withdrawn to incise the retinaculum. The blade can be rapidly retracted by release of the trigger if any important structures come into view. The endoscope is then reintroduced to assess the adequacy of the decompression.

We performed a prospective study that compared the outcomes of this technique with open, in situ decompression and found no differences in the patient-reported outcomes at 12 months after surgery. The rate of complications was lower in the endoscopic group than in the open group. Complications included elbow pain, numbness, and scar tenderness. No patients had injury to the ulnar nerve, and there were no infections.

Biceps Tendon Bursoscopy

Distal biceps tendon bursoscopy may be indicated for patients presenting with symptoms of biceps bursitis or those with a suspected partial-thickness tear of the distal biceps tendon. The bicipitoradial bursa surrounds the distal biceps tendon. It is adherent to the radial aspect of the biceps tendon and drapes around the tendon before attaching circumferentially to the radius at the tendon-bone interface.¹⁴

The procedure is performed under general anesthesia with an inflated upper arm tourniquet. The arm is positioned in extension and supination. A 2.5-cm longitudinal incision commencing 2 cm distal to the anterior elbow crease is performed over the palpable biceps tendon. Care is taken to protect the lateral cutaneous nerve of the forearm. The bursa is identified surrounding the distal biceps tendon. The bursa can be inflated with 7 to 10 mL of saline. The trocar and cannula of the arthroscope are inserted into the apex of the bursa on its radial side, and the arthroscope is inserted. Inflation is maintained with saline by gravity feed.¹⁵

The bursa can be visualized to confirm the diagnosis of bursitis (Fig. 15-4). The biceps tendon insertion is examined for partial tears. Bursectomy or débridement of partial-thickness tears can be performed using a toothless, full-radius oscillating chondrotome. This should be performed without suction to avoid injury to neurovascular structures.

FIGURE 15-4 Olecranon bursectomy.

(Photograph courtesy of Adam C. Watts, MD, Adelaide, Australia.)

With this approach, care must be taken to avoid the median nerve and brachial artery. These structures lie on the ulnar side of the tendon and can be avoided by entering the bursa on its radial side. The chondrotome should not be used unless a clear field is visible, and suction should not be used. The lateral cutaneous nerve is at risk because it lies radial to the tendon. Neurapraxia has been witnessed with retraction, and care is required to protect it.

Olecranon Bursoscopy

Olecranon bursoscopy is discussed in detail in Chapter 5. We have modified our technique to protect the overlying skin when resecting the inflamed or infected bursa.

With the patient placed in the lateral position under general anesthesia and an upper arm tourniquet inflated, two 1.5-cm longitudinal incisions are made in the midline 3 cm proximal and distal to the margins of the bursa (Fig. 15-5). Blunt dissection is performed in the subcutaneous plane using Metzenbaum scissors to connect the two incisions, separating the cutaneous tissue from the bursa. Bursectomy can be safely performed using a toothed, oscillating chondrotome, which should be used with the jaws facing the bursa, away from the skin. The bursectomy is performed from the subcutaneous plane and directed toward the olecranon. The procedure is complete when the fibers of the triceps tendon are visible. Care must be taken not to weaken this insertion. Distention of the subcutaneous field can be facilitated by passing a tape or suture through from one portal to the other and applying traction or with the use of disposable arthroscopy portals placed in the dependent (distal) incision.

FIGURE 15-5 A, Biceps bursoscopy intraoperative setup. B, Endoscopic view of the bursa.

(From Eames MH, Bain GI. Distal biceps tendon endoscopy and anterior elbow arthroscopy portal. Tech Shoulder Elbow Surg. 2006;7:139-142.)

Ganglia

Synovial cysts (i.e., ganglia) of the elbow joint can rarely be found in patients with osteoarthrosis or rheumatoid arthritis (Fig. 15-6). Most can be managed nonoperatively. For patients with persistent symptoms, surgery may be advised. Other indications include compression of neurologic structures of the elbow by the mass affect of the ganglion.¹⁶ Feldman reported the first case of a ganglion cyst of the elbow treated with arthroscopic excision.¹⁷

FIGURE 15-6 Sagittal, T2-weighted magnetic resonance image shows a multilocular ganglion cyst arising from the elbow joint.

(From Kirpalani PA, Lee HK, Han CW. Transarticular arthroscopic excision of an elbow cyst. Acta Orthop Belg. 2005;71:477-480.)

The procedure is performed through standard arthroscopy portals. Excision can be facilitated by the addition of another portal anterior and distal to the anterolateral portal, through which a transfixing Wissinger rod can be inserted to distract the anterior neurovascular bundle away from the operating field.¹⁶^,¹⁸ The transfixing rod can protect neurologic structures, improve the arthroscopic view, and facilitate excision. We emphasize the importance of complete excision of the cyst lining to prevent recurrence (Fig. 15-7).

FIGURE 15-7 Diagrammatic view of the Wissinger rod inserted anterior and distal to the anterolateral portal.

(Modified from Kirpalani PA, Lee HK, Han CW. Transarticular arthroscopic excision of an elbow cyst. Acta Orthop Belg. 2005;71:477-480.)

BENIGN INTRA-ARTICULAR LESIONS

Osteoid Osteoma

Arthroscopic techniques can be used for the treatment of intra-articular osteoid osteoma of the elbow. Although this diagnosis is rare, the location of the lesions can render them entirely suitable for arthroscopic excision (Fig. 15-8).

FIGURE 15-8 Computed tomography of the elbow shows an osteoid osteoma of the posterior aspect of the capitellum in a 20-year-old man.

(From Nourissat G, Kakuda C, Dumontier C. Arthroscopic excision of osteoid osteoma of the elbow. Arthroscopy. 2007;23:799e1-799e4.)

Osteoid osteoma is a benign neoplasm that typically affects the diaphysis of long bones. Patients typically present with nocturnal symptoms of elbow pain that may be relieved by nonsteroidal anti-inflammatory analgesia. The elbow may be stiff because of pain or synovitis. Computed tomography showing a lesion less than 1 cm in diameter with a dense central nidus is diagnostic. The lesion may be visible on plain radiographs. Medical treatment of osteoid osteoma with nonsteroidal anti-inflammatory analgesia is possible, but it may take several years for the symptoms to resolve, and the location of the lesion may be associated with elbow stiffness that may not be tolerated.

Nourissat and colleagues ¹⁹ reported two cases of osteoid osteoma, one on the capitellum and the other on the trochlea in patients 20 and 27 years old, respectively. The procedure was performed with the patient under general anesthesia and in the lateral decubitus position. The lesion was removed with a curette (Fig. 15-9), producing complete resolution of symptoms by 2 weeks. One patient had an early, symptomatic recurrence of the lesion. This was attributed to the surgical technique. The surgeons thought that use of the chondrotome shaver for excision led to incomplete excision.

FIGURE 15-9 The arthroscopic view demonstrates the use of a curette for en bloc excision.

(From Nourissat G, Kakuda C, Dumontier C. Arthroscopic excision of osteoid osteoma of the elbow. Arthroscopy. 2007;23: 799e1-799e4.)

Patients with osteoid osteoma in the elbow joint can be offered arthroscopic excision, but the surgeon must ensure that incomplete excision does not occur. Complete excision may be aided with the use of fluoroscopy. A shaver should not be used for excision but may be used to expose the lesion. Excision biopsy should be performed with a curette, and the specimen should be sent for histologic evaluation. The surrounding hyperemic bone should be removed with a burr. The appropriate arthroscopic portals for safe excision should be tailored to the site of the lesion and can be planned from preoperative radiologic imaging.

The surgeon also should consider image-guided percutaneous radiofrequency ablation. It is an established technique for the treatment of osteoid osteoma when accessible.²⁰

Synovial Chondromatosis

Synovial chondromatosis is a rare condition that can be a primary condition or result from an underlying pathology, such as osteoarthrosis or osteochondritis dissecans. It is caused by metaplasia of synoviocytes. Histologically, the condition is characterized by synovitis with foci of newly formed cartilage. The patient presents with pain and swelling of the elbow. Epi sodes of locking occur because of cartilage bodies that develop within the joint.

Standard care involves removal of chondral bodies (often described as loose, although most remain bound to the synovium) and partial synovectomy, which may be performed as an open or an arthroscopic procedure. Arthroscopy is advocated because synovectomy can be performed with less trauma to the surrounding tissues,²¹ but it does require advanced arthroscopic skills to perform safely and adequately.

The procedure is performed through standard arthroscopy portals. Removal of sizeable chondral lesions that cause mechanical symptoms is mandatory (Fig. 15-10). The synovectomy should be as extensive as is safe to perform, but affected tissue often remains in the medial and lateral gutters.²¹^,²²

FIGURE 15-10 Computed tomography scans and arthroscopic views of primary chondromatosis. (From Flury MP, Goldhahn J, Drerup S, Simmen BR. Arthroscopic and open options for surgical treatment of chondromatosis of the elbow. Arthroscopy. 2008;24:520-525e1.)

Flury and colleagues ²³ reported the largest series of arthroscopic treatment of synovial chondromatosis. Fourteen adult patients with a mixture of primary and secondary chondromatosis of the elbow were reviewed retrospectively at an average of 39 months (range, 11 to 70 months) after arthroscopic synovectomy. This group was compared with five patients treated at the same center using open techniques. No differences in outcome were reported using validated outcome measures, although the investigators acknowledged the power limitations of the study. None of the patients had recurrence of chondral lesions on radiographic review. Two patients had some recurrence of symptoms that were attributed to underlying osteoarthrosis. The study authors suggest that the rehabilitation time was shorter for the arthroscopic group.