Arthroscopic Surgery of the Elbow; Indications, Contra-Indications, Complications and Operative Technique

doi:10.4236/ss.2011.25049

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Surgical Science, 2011, 2, 219-223

doi:10.4236/ss.2011.25049 Published Online July 2011 (http://www.SciRP.org/journal/ss)

Arthroscopic Surgery of the Elbow; Indications,

Contra-Indications, Complications and

Operative Technique

Frank Theodoor Gabriel Rahusen1, Denise Eygendaal2

1St. Jansgasthuis Weert, Weert, Netherlands

2Amphia Ziekenhuis Breda, Breda, Netherlands

E-mail: [email protected], [email protected]

Received February 8, 2011; revised April 7, 2011; accepted June 2, 2011

Abstract

Arthroscopy of the elbow was first described by Burman in 1931. In this first article about arthroscopy of the

elbow in the journal of bone and joint surgery, he concluded that the elbow joint was not suitable for arthro-

scopy; the joint was too small and the neurovascular structures in the anterior compartment of the elbow

were close. In 1932 he revised his original article with some technical modifications and slowly arthroscopy

of the elbow was performed more often. In the late 1980’s arthroscopic surgery of the elbow became more

and more popular. In this article an overview is given of the indications for elbow arthroscopy, the surgical

technique is described in detail and the possible complications are highlighted.

Keywords: Elbow, Arthroscopy, Surgical Technique, Overview

1. Introduction

Since the eighties, arthroscopy of the elbow joint is per-

formed more often as the under standing of the arthrosco -

pic anatomy and its disorders have become clearer.

Small performed an epidemiologic survey and in the

late 1980’s; only 0.77% of all arthroscopies in those days

performed were arthroscopies of the elbow [1].

Currently common indications for arthroscopy of the

elbow are symptomatic loose bodies, posterior impinge-

ment, osteochondritis dissecans (OCD), long standing

lateral epicondylitis, persistent synovitis which require

debridement or diagnostic biopsy, and stiff elbow due to

arthritic changes or due to posttraumatic deformity [2].

Peri-articular, endoscopic, techniques as a bursectomy, a

tenoscopy of the biceps tendon or decompression of the

ulnar nerve will not be discussed in this overview.

Since the popularity of sports, especially the overhead

throwing and racket sports, is growing, the incidence of

elbow pathology is increasing.

The technique of arthroscopic surgery has been im-

proved dramatically last ten years; the incidence of com-

plication as neurovascular damage is acceptable.

In this overview the indications for elbow arthroscopy

are listed, the surgical technique is described in detail

and the possible complications are highlighted.

The most common complication in elbow arthroscopy

is neurologic deficit post-operatively. Also post-operative

elbow stiffness, persistent portal drainage and infection

have been mentioned. O’Driscoll and Morrey showed an

overall 10% risk in their review of 70 patients [3]. Other

papers show complication rates between 0% and 15%.

There are several techniques to perform an elbow arthros-

copy. Mainly there are 3 different patient positions; su-

pine, prone and lateral decubitus [4]. All have their own

benefits in different indications.

2. Indications for Elbow Arthroscopy

2.1. Diagnostic Elbow Arthroscopy

Diagnostic elbow arthroscopy is not advocated, but may

be helpful when the clinical diagnosis is unclear. Also

undetected elbow instability in overhead athletes can be

seen during diagnostic elbow arthroscopy. Timmermans,

et al. described an arthroscopic valgus instability test, in

which a valgus load is applied to the elbo w in 70 degrees

of flexion during the arthroscopy. The medial comart-

ment opens up and can be inspected. If the medial com-

partment open up for more than 2 - 3 mm, Field and

F. T. G. Rahusen ET AL.

220

Altchek concluded that the ulnar collateral ligament can

be torn [5].

2.2. Loose Bodies

Symptomatic loose bodies are the most common indica-

tion for arthroscopy of the elbow. Loose bodies are often

a symptom of an underlying disorder which has to be

assessed and treated. Often, loose bodies are the result of

a trauma, resulting in osteochondral fractures or fracture

of (asymptomatic) osteofytes. Loose bodies are also

formed in longstanding OCD or in synovial chondro-

matosis as described by Flury, et al.; in both diseases

additional arthroscopic treatment is indicated [6].

Loose bodies may hide in any part of the elbow joint.

Most commonly they are hided posteriorly in the olec-

ranon fossa, at the posterior aspect of the radial capitellar

articulation or anteriorly in the coronoid fossa. In case of

loose bodies the surgeon therefore should assess all

compartments of the elbow joint during the arthroscopic

procedure. Preoperative radiographs and computer

tomography is indicated and delineate in most cases the

location of loose bodies.

2.3. Posterior Impingement

Posterior impingement of the elbow is an uncommon

disorder in the general young population; it is usually

seen in patients that overuse their elbow during specific

sporting activities as overhead throwing or tennis. During

the throwing motion, in baseball, for example, the elbow

moves during late cocking and acceleration phases from

110˚ to 20˚ of flexion with velocities up to 3000 deg/sec.

This combination of valgus forces and rapid extension

results in tensile forces along the medial side, com-

pression on the lateral portion of the elbow, and shear

forces in the posterior compartment. This combination is

called valgus extension overload syn dr ome and forms the

basic pathologic model behind posterior impingement of

the elbow as formation of bony or soft tissue in the

posterior compartment results in mechanical abutment

leading to complaints of the posterior compartment dur-

ing extension. The exact fit of the olecranon in the olec-

ranon fossa of the humerus is critical for a maximal

extension and, therefore, for the function of the elbow. In

particular the maximal extension needed in most over-

head sports is reduced, lead ing to complaints of the post-

erior compartment of the elbow. The athlete complains

of pain posteriorly at the elbow, joint effusion, locking,

crepitus, and a decrease in range of motion, most notably

an extension deficit. X-rays, especially an axial view,

may be helpful to detect osteophytes on the olecranon or

on the borders of the posterior fossa. More sensitive is an

MRI with intra-articular contrast; sensitivity for posterior

soft tissue or loose bodies is nearly 90%. If conservative

treatment of posterior impingement is not successful;

arthroscopy of the elbow can be successfully used in

these patients as described in an earlier review of

Rahusen, et al. [7].

2.4. Osteochondritis Dissecans

Osteochondritis dissecans is a localized condition in-

volveing the articular surface that results in the se-

paration of a segment of articular cartilage and sub-

chondral bone. The most common site of osteochondritis

dissecans of the elbow is the capitellum although lesions

have been reported in the trochlea, radial head, as well as

the olecranon and olecranon fossa. Osteochondritis dis-

secans generally occurs in athlete’s ages 11 to 21 years

who report a histo ry of overuse. The osteonecrotic lesion

involves only a segment of capitellum, located primarily

at a central or anterolateral position. Appropriate treat-

ment of this disorder remains controversial.

Often treated with benign neglect, this condition is a

potentially sport-ending injury for anathlete, with long-

term sequelae of degenerative arthritis. The surgical option

is fragment excision with debridement of the necrotic

lesion.

2.5. Longstanding Lateral Epicondylitis

Lateral epicondylitis or tennis elbow is a common disor-

der in primary care. It is rath er related to manually in ten-

sive work, requiring forceful and repetitive rotation of

the forearm, wrist extension or flexion (e.g. in mechanics,

butchers, construction workers)The incidence of lateral

humeral epicondylitis in general practice is estimated at

4 - 7 per 1000 patients per year, with a peak between 35

and 54 years of age. Lateral epicondylitis is generally a

self-limiting cond ition. The average duration of a typical

episode varies from six months to two years, but most

patients (90%) respond to conservative treatments and

recover within one year. Surgical treatment is recom-

mended for those patients who are not responding to

conservative treatment after at least six months to a year.

Surgical techniques are various, including open, percu-

taneous and arthroscopic treatment. Research investi-

gating which approach is superior, reveals that the less

invasive approaches (percutaneous or arthroscopic) allow

faster return to work, than the open procedure. Arthro-

scopic release is potential beneficiary because an arthro-

scopic evaluation of the whole joint can be done during

the procedure. Also other in tra-articular problems, which

have been described in up to 50% of all cases, can be

addressed simultaneously. Baker, et al. showed a return

F. T. G. Rahusen ET AL.221

to work a t an aver age of 2.2 weeks and a grip strength of

96% compared to the unaffected limb [8].

2.6. Persistent Synovitis

Persistent synovitis of the elbow, due to rheumatoid

arthritis or other inflammatory pathology, which is not

responding to conservative treatment, can be indication

for debridement or diagnostic biopsy in cases the cause

of the synovitis is unknown. De boer, et al. showed this

in their studies [9].

Septic arthritis of the elbow can be treated with arth ro-

scopy as well.

2.7. Stiff Elbow

Loss of motion is a common complication in degenera-

tion or after elbow trauma. Restoration of joint motion

especially in the posttraumatic stiff elbow can be a dif-

ficult, time-consuming, and a costly challenging [10].

Elbow contractures can be the result of intrinsic (intra-

articular) or extrinsic (extra-articular) causes [11-13]. In

most posttraumatic contractures both intrinsic and ex-

trinsic causes play a role. Established contractu res should

be treated initially with physical therapy and static-

progressive splinting. Patients who have failed a minimum

of 6 to 12 months of non-surgical management and who

are motivated to comply with a strict postoperative re-

habilitation program are candidates for surgical release

[14].

Arthroscopic arthrolysis of stiff elbows has been intro-

duced as a safe, but technical demanding technique [15].

The indications for surgery dep end on the patient’ s func-

tional needs. Morrey, et al. stated that an elbow needs a

minimal range of motion (ROM) of 100 degrees flexion

/extension and 100 degrees of pronation/supination to

function adequately in daily life [16]. However in speci-

fic groups of patients, as professional athletes, even a

slight extension deficit of 20 degrees can result in a dys-

function of t he e l bo w.

Disadvantages of elbow arthroscopy include the in-

ability to deal with ulnar nerve disease or heterotopic

ossification and the leng th of the procedure.

2.8. Surgical Technique

Arthroscopy of the elbow is routinely done under general

anesthesia without additional regional anesthesia, to

allow postoperative evaluation of the integrity of the

nerves. With the patient still in supine position, the

elbow is examined for range of motion and for instability.

Then the patient is placed in supine or prone position.

We generally perform the arthroscopy with the patient in

a lateral decubitus position with the upper arm in a

support with tourniquet. In this position all compart-

ments are easily accessible. Alternatively the patient is

positioned in prone, with the arm hanging down, or

supine with the arm suspended and the elbow passively

flexed in 90˚.

It is very important to identify and mark the bony

landmarks and the ulnar nerve before insufflating the

joint with saline. After this the joint is filled with 30 ml

of saline, before making the first portal. Backflow of

fluid verifies proper placement. Cadaveric studies have

demonstrated that joint insufflation significantly increases

the distance between the join t surfaces and neurovascular

structures, thus helping to protect them from injury

during joint entry and during the use of intraarticular

instrumentation.

When the arthroscopic sheath is inserted only blunt

trocarts should be used. When creating portals, the sur-

geon should avoid penetrating the subcutaneous tissue,

thereby helping to prevent injury to the superficial cu-

taneous nerves. A mosquito clamp can be used to spread

tissues down to the capsule.

A high pump pressure during the arthroscopy can re

sult in loss of fluid in the soft tissues, resulting in com-

partment syndrome of the fore-arm. Insufflation of the

joint above a pressure of more than 50 mmHg should be

avoided.

Portal placement is at the surgeon’s distinction. Many

portals have been described and specific portals have

their own benefits. Usually the direct-lateral, anterome-

dial, anterolateral and the proximal-medial portals are

used for the anterior, lateral and medial co mpartment. The

straight-posterior and posterolateral portals are used for

the arthroscopy of the posterior compartment.

The initial survey of the anterior aspect of the elbow is

performed using the proximal medial portal: This allows

localization of the loose fragments, their approximate

position, and it allows the assessment of the medial and

lateral gutters. The loo se body is noted, and the proximal

anterolateral portal is established by using the spinal

needle to ensure adequate access with the pending entry.

This portal is established, and the loose body is located,

grasped, and removed. In many cases, it may be useful to

“pin” the loose fragment with a spinal needle to provide

resistance for grasping the loose piece of bone. Addi-

tionally, the portal may need to be enlarged to allow full

excision of the fragment, or alternatively, it may be

removed piece by piece. Using the antero-lateral portal

the tip of the coronoid can be debrided, as well as the

coronoid fossa.

Most OCD are not visible from anterior. Lateral

epicondylitis is debrided in the manner as well. With a

standard arthroscopy of the posterior compartment of the

F. T. G. Rahusen ET AL.

222

elbow the olecranon fossa is cleared of soft tissue.

Osteofytes at the posteromedial site of the proximal ulna

or distal humerus can be debrided. Using a mid posterior

portal and a postero-lateral portal the posterior com-

partment can be debrided using a 5.5 MM oscillating

shaver an d a 4 MM cyl in d r ic s haver burr.

In case of arthrocopic artrholysis all osteofytes, loose

bodies and fibrotic tissue are removed. The anterior com-

partment is examined using an antero-medial portal after

a careful palpation of the ulnar nerve and intramuscular

septum; a second portal antero lateral is created outside-

in as described previously. With a 5.5 MM oscillating

shaver a synovectomie is performed. With a 4 MM

cylindric shaver burr, the coronoid process and the

coronoid fossa are debrided. In the end the anterior cap-

sule is released using a punch from medial to lateral.

After treatment consists of Continuous Passive Motion

device (CPM) for the first 24 hours, continuously, followed

by a standardized program under supervision of a phy-

siotherapist. The results of arthroscopic treatment com-

pare favourably with those of open techniques with low

rate of complications in both techniques. Elbow arthro-

scopy offers improved joint visualisation, reduced pain,

smaller scars, accelerated rehabilitation and shorter hos-

pital stay, potentially making arthro scopic release an out-

patient procedure.

2.9. Complications in Arthroscopy of the Elbow

Most often complication s of arthro scop y of the elbow ar e

of neurologic origin. Usually the neurologic complica-

tions are transient but several authors describe total tran-

section of the nerve, in particular the ulnar nerve. Tran-

sient radial nerve en median nerve problems have been

reported, but the incidence is very low. Transient nerve

deficiencies can be due to neuropraxia by compression of

the nerve by instruments or by positioning of the patient

on the table. Transection of the nerve mostly occurs by

introduction of the scope or by capsulectomy anterolate-

ral (radial nerve) or posteromedial (ulnar nerve) [17].

Excessive drainage from the portal sites has been

described however the imported infection rate is low

[8,18]. Temporary loss of motion is seen in most cases,

but usually resol ves wit hin 6 - 8 weeks [8]

3. Conclusions

Indications for arthroscop y of th e elbow are sy mpto matic

loose bodies, posterior impingement, osteochondritis dis-

secans (OCD), long standing lateral epicondylitis, per-

sistent synovitis which require d ebridement or diagnostic

biopsy, and stiff elbow due to arthritic chang es or due to

posttraumatic deformity

The technique of arthroscopic surgery has been im-

proved dramatically last ten years; the incidence of com-

plication as neurovascular damage is acceptable.

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