ELBOW ARTHROSCOPYWHERE ARE WE NOW?

Christian Veillette M.D., M.Sc., FRCSCAssistant Professor, University of TorontoShoulder & Elbow Reconstructive Surgery

Toronto Western Hospital @ University Health NetworkUTOSM @ Women’s College Hospital

Email: orthonet@gmail.com

Objectives

1. Understand the indications and contraindications for elbow arthroscopy

2. Learn portal placement and basic surgical technique

3. Understand the safety measures for elbow arthroscopy

4. Review different elbow pathologies that can be addressed arthroscopically

Elbow Arthroscopy

• Advances in arthroscopic technique and equipment

– Safety – Effectiveness

• Elbow arthroscopy becoming more common

• To maximize success rate and improve clinical outcome requires knowledge of:

– Neurovascular anatomy– Preferred arthroscopic portals and techniques– Indications for definitive arthroscopic procedures

Question 1

• What are 4 advantages of elbow arthroscopy compared to open elbow procedures?

Role of Arthroscopic Management

• Advantages:1. Small incisions avoid postoperative scarring/contracture2. Allows more aggressive, earlier rehabilitation3. More thorough inspection of joint4. Decreased risks of infection/wound problems

• Complications – 10-30% open release

Question 2

• What are 3 disadvantages of elbow arthroscopy compared to open elbow procedures?

Role of Arthroscopic Management

• Disadvantages:1. Risk of neurovascular injury2. Increased operative times3. Highly technically demanding

Question 3

• What structure is at greatest risk when the anteromedial portal is used during elbow arthroscopy?

1. Brachial artery2. Ulnar nerve3. Median nerve4. Posterior interosseous nerve5. Biceps tendon insertion

Proximity of Arthroscope Sheath from Neurovascular Structures

Nerve/Artery Pre Post

Radial nerve 4 mm 11 mm

Median nerve 4mm 14 mm

Brachial artery 9 mm 17 mm

Ulnar nerve 25 mm 25 mm

Question 4

• What are 10 indications for elbow arthroscopy?

Indications for Elbow Arthroscopy

1. Diagnostic arthroscopy2. Loose body removal3. Plica4. Lateral epicondylitis5. Olecranon bursitis6. Septic arthritis7. Lysis and debridement of post-traumatic

adhesions8. Treatment of osteochondritis lesions9. Synovectomy10. Arthritis/Excision olecranon osteophytes11. Fracture evaluation and treatment

– radial head, coronoid

Question 5A 47-year-old man who works as a carpenter reports a 12-month history of painful mechanical locking of his dominant elbow in the mid range of movement. He also has progressive pain at terminal extension that has not responded to medication, rest, and intra-articular cortisone injection. Active range of movement is from 35 degrees to 130 degrees, and he has full pronation and supination. The ulnar nerve is stable, and he has no subjective or objective neurologic dysfunction in the hand. Radiographs are shown in Figures 22a and 22b. What is the most appropriate treatment?

1. Oral corticosteroid medication and changes in job activities

2. Soft-tissue interposition arthroplasty 3. Arthroscopic capsular release, loose body

removal, and osteophyte decompression 4. Radial head arthroplasty 5. Total elbow arthroplasty

Etiology of Elbow OA

• Primary OA (<2% of gen pop)– Assoc. with strenuous manual labor

(Stanley)– Lateral medial progression (Murato)– Multifactorial

• Secondary causes• Post traumatic/dislocations• Osteochondritis dissecans• Synovial chondromatosis• Developmental radial head disloc.• Valgus extension overload

Question 5

• Which of the following is NOT a typical characteristic of elbow osteoarthritis?

a) Painful terminal extensionb) Mechanical symptomsc) Loss of joint spaced) Hypertrophic osteophytes

Clinical Presentation

• Average age – 50 yrs (20 – 70 yr)• Males:Females – 4:1• Loss of motion – terminal ext > flex• Painful terminal extension/flexion

– “Impingement pain”• Painful catching or locking – loose bodies• Ulnar nerve symptoms (26 – 55%)• Night pain - rare

Physical Examination

• Skin inspection• Alignment• Range of motion

– Flexion/Extension– Pronation/Supination – Crepitus?

• Mid-arc pain vs Terminal pain• Neurovascular

– Ulnar nerve

Typical patterns of osteophytes

Question 6

A sedentary 60-year-old woman has had good elbow function and pain relief after undergoing an open ulnohumeral arthroplasty 10 years ago. However, she currently reports pain and stiffness for the past 6 months, and nonsurgical management has failed to provide relief. Examination reveals range of motion of 40 to 110 degrees of flexion with pain during the entire range. Radiographs are shown in Figures 43a and 43b. What is the next most appropriate step in management?

1. Unconstrained total elbow arthroplasty 2. Revision ulnohumeral arthroplasty with allograft

interposition3. Arthroscopic osteocapsular arthroplasty 4. Outerbridge-Kashiwagi procedure 5. Semiconstrained total elbow arthroplasty

Question 7

A 67-year-old woman with rheumatoid arthritis has had a 3-year history of gradually progressive right elbow pain and limited function despite intra-articular injections and medical management. She previously underwent a rheumatoid hand reconstruction, and has no pain or dysfunction of the ipsilateral shoulder. Radiographs are shown in Figures 93a and 93b. What is the most appropriate treatment?

1. Soft-tissue interposition arthroplasty with radial head resection

2. Arthroscopic synovectomy with radial head resection

3. Elbow arthrodesis 4. Total elbow arthroplasty 5. Resection arthroplasty

Question 8

• What are 3 contraindications for elbow arthroscopy?

Contraindications

• Distortion of normal bony or soft-tissue anatomy making safe portal placement difficult– Extensive heterotopic ossification– Deformity

• Previous ulnar nerve transposition– Relative contraindication– Identify ulnar nerve before establish medial

portal

Question 9

Which of the following is considered a contraindication to elbow arthroscopy?

1. Osteonecrosis of the elbow (Panner disease) 2. Loose body in the ulnohumeral joint 3. Status post open reduction and internal

fixation of a radial head fracture 4. Ulnar neuropathy with prior submuscular ulnar

nerve transposition 5. Elbow stiffness

Question 10 - Name Landmark

2

1

34

5

Question 11 – Name that posterior portal?

1

2

3 4

Question 12 – Name that structure/portal?

4

2

3

1 7

6

5

Question 13 – Name that structure/portal?

1

2

3

4

5

6

Anterolateral Portal

Anterolateral Portal

Anterolateral Portal

Do Not Put Your Anterolateral Portal Here!

• This portal location places the radial nerve at significant risk for iatrogenic injury

Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197.

Question 14

• During an arthroscopic release for lateral epicondyliis, care must be taken not to release what posterior structure lying under the anconeus that may be inadvertently injured during this common arthroscopic procedure of the elbow?

1. Ulnar nerve 2. Annular ligament 3. Anterior band of the medial collateral ligament 4. Lateral ulnar collateral ligament 5. Arcade of Struthers

Question 15

• What are the rates of major and minor complications in the published literature on elbow arthroscopy?

Complications

• Mayo Clinic• 473 consecutive elbow arthroscopies

(1980-1998)• Major complications: <1%

(4 deep infections)• Minor complications: 11%

– Prolonged drainage/superfical infection – 33– Persistent minor contracture <20o – 7– Transient nerve palsies – 10 patients

Kelly EW, Morrey BF, O'Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am. 2001

Complications

• Nerve palsies– Ulnar – 5– Superficial radial – 4– Posterior interosseous – 1– MABC – 1– Anterior interosseous – 1

• Only 2/10 attributed to direct trauma• Risk factors

– RA (7/10 patients)– Capsule release

Nerve injury and capsulectomy

• Kim – Median nerve palsies(Arthroscopy. 11: 680-3., 1995.)

• Jones and Savoie – PIN transection(Arthroscopy. 9: 277-283, 1993.)

• Haapaniemi – Median, radial nerve transection(Arthroscopy. 15: 784-7, 1999.)

• Ruch and Poehling - Nerve transecionin RA(Arthroscopy. 13: 756-8., 1997.)

Question 16

• What are 3 key measures to increasing the safety of elbow arthroscopy?

Safety Measures for Elbow Arthroscopy

• Safety– Retractors– No pressure for distension– No suction

• Knowledge of where nerves are in 3D space (and/or actually visualizing and protecting them)

• Know your curve and stay below– Recognize limits of surgical expertise and operate within them

Case

• 42 yo male, RHD, athlete• Right elbow decreased ROM, pain• No history trauma• 45-110 degrees• Locking symptoms• Terminal pain, no mid arc pain

Synovial Chondromatosis

Questions?