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.

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).

FIGURE 8-3 Operative setup.

The standard equipment used for elbow arthroscopy includes the 4-mm, 30-degree arthroscope; arthroscopic cannulas; retractors; and graspers. Retractors such a Howarth elevator and large, blunt Steinmann pins can improve the visual field. Special-use retractors have become available from various manufacturers. The standard arthroscopic shaver and burr are used. The suction tubing is placed to gravity only, because active suction by vacuum can injure structures that may be pulled inadvertently into the shaver.

Before insufflation, portal sites and landmarks should be marked, because after the operation proceeds, bony landmarks may become difficult to palpate because of soft tissue fluid extravasation. The radial head, medial and lateral epicondyles, capitellum, and olecranon are marked, as is the location of the ulnar nerve (Fig. 8-4).

FIGURE 8-4 Portals sites and landmarks are marked before starting the procedure. A, On the lateral side, the elevator marks the anterolateral portal. B, On the medial side, the elevator marks the anteromedial portal.

It is essential to determine the position of the ulnar nerve and to rule out a subluxating ulnar nerve before starting the procedure. If there is any question about the nerve’s location, ultrasonography in the operating room can confirm the location. Alternatively, a small incision may be made to identify and protect the nerve.

The joint is distended with 20 to 30 mL of saline introduced by means of an 18-gauge needle through the soft spot, which is the center of a triangle formed by the olecranon process, lateral epicondyle, and radial head. Fluid distention makes portal establishment easier and safer.

Portal sites are made by incising only the skin with the blade. Blunt dissection with a hemostat allows access to the capsule and joint. Capsular entry and joint location are confirmed by a sudden egress of fluid. The blunt trocar and sleeve are placed into the joint, and the arthroscope is then placed into the sleeve.

The order in which portal sites are established depends on surgeon’s preference and comfort level. We prefer the sequence as described subsequently. The technique and order of the procedure depend on the indications. If the patient lacks flexion, the posterior joint must be addressed. If extension is limited, the anterior joint must be released and débrided.

Anterior Capsulectomy and Débridement

A 4.8-mm arthroscopic shaver is introduced through the anteromedial portal. Retraction through a proximal anterolateral portal is useful as arthroscopy proceeds. The shaver is used initially to débride soft tissue and to improve visualization. Loose bodies may be removed as they are visualized (Fig. 8-5) with arthroscopic graspers or a narrow jaw needle driver through an enlarged portal. Alternatively, large loose bodies may be burred down to a size small enough to be extracted.

FIGURE 8-5 Loose bodies are removed as they are visualized.

After visualization is adequate, bony work can proceed. A burr can be used to recontour the joint and remove osteophytes from the coronoid and radial head fossae (Fig. 8-6). Bony work should be near complete before addressing soft tissue contracture with capsular release, because after the capsulotomy is performed, fluid extravasation limits the duration of arthroscopy that may be safely performed.

FIGURE 8-6 Osteophytes are removed from the radial head and coronoid tip (A) and the anterior humerus (B).

For capsular release, the anteromedial capsule is first stripped off the humerus with an elevator (Fig. 8-7). Large Steinmann pins or Howarth elevators may be used for retraction.

FIGURE 8-7 An elevator is used to lift the capsule off the anterior humerus.

The arthroscope is placed in the lateral portal, and an arthroscopic biter is used on the anterior capsule, working from medial to lateral aspects (Fig. 8-8). The appearance of the fat stripe anterior to the radial head marks the safe limit of resection. The shaver is then introduced to completely resect the anterior capsule (Fig. 8-9). The arthroscope is then placed in the medial portal site, and working from the lateral side, the capsulectomy and bony débridement are completed.

FIGURE 8-8 A biter is used to perform the capsulotomy anteriorly.

FIGURE 8-9 The shaver is brought in to resect the capsule.

Radial head excision is not needed in many patients with primary osteoarthritis of the elbow, because they often have preservation of much of the cartilage on the capitellum and radial head. In patients with complete loss of cartilage at the radiocapitellar articulation, significant crepitus, or loss of pronosupination, radial head excision may be beneficial. Many of these patients also have osteophytes on the posterior aspect of the capitellum and the radial head fossa, which should be resected. Occasionally, significant osteophytes limit pronosupination. They can be resected with a burr without excising the radial head itself. Radial head excision may be performed while viewing from the medial side. The anterolateral portal provides a good working portal for resection of the anterior aspect of the radial head with a burr and shaver. With progressive supination and pronation, resection of a large portion of the radial head can be achieved. Complete resection may be facilitated while viewing posterolaterally and bringing in the burr through the soft spot portal as a working portal. A detailed description of this procedure is provided in Chapter 11.

Posterior Capsular Débridement

After a posterolateral viewing portal and a direct posterior working portal are created, the shaver is placed in the direct posterior portal, and the view is improved by débridement of soft tissue. This is a potential space, and débridement is required to create a view. Subsequently, osteophytes are removed from the tip and sides of the olecranon and from the rim of the olecranon fossa (Fig. 8-10).

FIGURE 8-10 Posteriorly, osteophytes are seen at the olecranon fossa (A), and they are removed with the burr to improve motion (B).

An arthroscopic Outerbridge-Kashiwagi procedure can be performed using a burr or a large drill bit to remove the thickened bony bridge between the coronoid fossa and the olecranon fossa. The size of this fenestration should be limited to just the area of the olecranon fossa. In most individuals, this is a very thin portion of bone, measuring less than 3 to 4 mm. However, in throwing athletes with medial osteophytes, who may have instability, the osteophyte alone should be removed. Opposing osteophytes are often present on the medial aspect of the olecranon fossa. Resection should include only the osteophyte rather than additional native bone. If too much resection is performed in throwing athletes, additional strain will be placed upon the medial collateral ligament, potentially leading to instability.

Patients who lack flexion preoperatively should also undergo posterolateral and posteromedial capsular releases. When addressing the posteromedial capsule, care should be exercised to identify and protect the ulnar nerve (Fig. 8-11).

FIGURE 8-11 When performing a posteromedial capsulectomy (A), care is taken to identify and protect the ulnar nerve (B).

Management of the Ulnar Nerve

If a large restoration of motion is anticipated after the procedure, if preoperative ulnar nerve symptoms exist, or if preoperative flexion measures less than 90 degrees, ulnar nerve decompression or transposition should be considered. This may be done with arthroscopic decompression (see Fig. 8-11) if the surgeon possesses the requisite skill or with an open subcutaneous transposition or in situ decompression.

Postoperative Rehabilitation

After completion of the procedure, motion is assessed in the operating room to ensure adequate release. Portals are closed in the standard fashion with 3-0 nylon or Prolene sutures, and a sterile compressive dressing is applied. A posterior slab of plaster is used to splint the operative extremity in full extension, and the arm is elevated in the Statue of Liberty position overnight.

On the first postoperative day, the splint is removed, and the neurovascular status is evaluated with particular attention to the radial, median, and ulnar nerves. Full active range of motion is then initiated. No limitations are placed on use of the arm.

Heterotopic ossification prophylaxis, consisting of 75 mg of indomethacin three times daily for 6 weeks, is initiated. In selected patients who have had documented significant heterotopic ossification after an elbow procedure, radiation therapy is an option. A single dose of 700 cGy can be initiated within 72 hours of the procedure. We have found that this is rarely indicated for patients undergoing arthroscopic débridement of an arthritic elbow.

Splinting protocols, such as splints that may be adjusted from full extension to full flexion, are useful in many cases. The patient usually alternates hourly between the extremes of motion achieved at the time of surgery. In our experience, patients respond best to static progressive (turnbuckle) splints.

Continuous passive motion may be initiated using a continuous passive motion device with or without a nerve block, but in our experience, it is usually not necessary. In patients who are unable to move the elbow on their own or in those with severe contractures, it may beneficial, although a consensus regarding the indications and need for continuous passive motion is lacking.