Julie E. Adams and Scott P. Steinmann
DEFINITION
Primary degenerative arthritis of the elbow joint is a relatively rare condition.9,18
Patients with primary osteoarthritis of the elbow are frequently manual laborers, athletes, and those who rely on wheelchairs or crutches for ambulation.4,15,18,21
Although total elbow arthroplasty provides pain relief and improved range of motion in patients with inflammatory arthritis and or low demands, use in young active patients has been associated with early loosening and is undesirable in this group. Likewise, elbow arthrodesis is undesirable to many patients who do not wish to sacrifice motion in favor of pain relief.8
Open débridement procedures have been described and used with good success.3,4,6,9,14,16,22,23
Arthroscopic procedures have gained acceptance with patients and surgeons for perceived benefits of a minimally invasive nature and better visualization of the joint.
More series are confirming results at least equivalent to open procedures, with similar complication rates.
Arthroscopic débridement and osteocapsular resection is a procedure that adequately addresses the underlying pathologic processes and is associated with early return to activities, a durable result that does not preclude future reconstructive procedures, and minimal perioperative morbidity.2,10,11,12,17,20
ANATOMY
At the elbow, the coronoid fossa anteriorly, the trochlea, and the olecranon fossa posteriorly articulate with the coronoid and olecranon. Bony osteophytes may develop, leading to impingement in flexion and extension in degenerative conditions.
PATHOGENESIS
Three main pathologic processes are involved in primary elbow arthritis. Loss and fragmentation of cartilage lead to loose body formation. Osteophytes arise from reactive bone formation.
These two processes cause impingement and contribute to the third process, progressive joint contractures.21,22 The capsule becomes abnormally thickened and contracted.
Symptoms include loss of extension, pain at the end points of motion, and mechanical symptoms such as catching or locking.4,9
Other commonly associated conditions include cubital tunnel syndrome with paresthesias and weakness in the ulnar distribution and decreased grip strength.4,13
NATURAL HISTORY
The natural history is one of slowly progressive joint contracture and discomfort. Ulnar neuritis may develop.
PATIENT HISTORY AND PHYSICAL FINDINGS
The typical patient is a middle-aged male laborer with a painful dominant elbow, worse with use.
Less frequently, patients who depend on wheelchairs or crutches for mobility, and who thus put increased forces across their elbow joints, may be afflicted.
Progressive loss of motion and pain at the extremes of motion due to impingement of osteophytes are noted.
Painful crepitus and catching or locking sensations may be noted with range of motion. Usually pain in the mid-arc of motion is absent.
Patients with contracture of the posterior capsule will lack flexion, whereas those with anterior contractures will lack extension.
Not infrequently, ulnar nerve irritation is noted. This should be documented and will contribute to decision making regarding the need for decompression or transposition.
FIG 1 • AP and lateral radiographs of the typical patient with degenerative arthritis of the elbow. Bony osteophytes are noted with loose body formation.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Usually plain film radiographs, clinical examination, and history are sufficient to make the diagnosis (FIG 1).
Radiographs may show joint space narrowing, hypertrophic bony osteophytes, loose bodies, and subchondral sclerosis typical of osteoarthritis.
DIFFERENTIAL DIAGNOSIS
Usually it is easy to exclude inflammatory arthropathies and posttraumatic arthritis, which may also be treated with this technique.
FIG 2 • A. The patient is positioned laterally with the arm secured in a dedicated armholder. B. Operative setup.
Physical examination will also exclude other painful elbow conditions, such as tendinitis, instability, or cubital tunnel syndrome.
NONOPERATIVE MANAGEMENT
Operative treatment should be considered only after exhausting conservative measures, which include activity modification and nonsteroidal anti-inflammatory medications.17
SURGICAL MANAGEMENT
Patients who have failed to respond to nonoperative management and desire improved range of motion and pain relief may be surgical candidates.
Preoperative Planning
Careful physical examination with attention to neurovascular status should be documented.
Routine radiographs are usually all that are necessary.
Positioning
General endotracheal anesthesia is induced and the patient is placed in the lateral decubitus position.
The arm is secured in a dedicated arm holder, ensuring free access to the elbow with instruments (FIG 2A).
Positioning the elbow just higher than the shoulder allows free access to the elbow.
A nonsterile tourniquet is applied and the arm is prepared and draped in the usual fashion (FIG 2B).
Approach
Patients with lack of flexion will need to have the posterior aspect of the joint addressed; patients with lack of extension will require release and débridement anteriorly. Either compartment may be addressed first, depending on the pathology present.
The standard arthroscopic setup and equipment includes the 4-mm 30-degree arthroscope.
A 2.7-mm arthroscope can be used, but in most cases the joint can accommodate a 4-mm arthroscope.
A 70-degree arthroscope may likewise be used but is usually not necessary and may be awkward unless the surgeon has experience using this arthroscope.
Only blunt, not sharp, trocars should be used.
Retractors such as a Howarth elevator or a large blunt Steinmann pin make the procedure easier and enhance visualization. Commercially available retractors are now available.
The standard arthroscopic shaver and burr are used.
Suction should be placed to gravity only to prevent accidently shaving objects that may be sucked into the shaver (FIG 3).
The portal sites and landmarks, including the radial head, medial and lateral epicondyles, capitellum, and olecranon, should be marked before insufflation of the joint, which may obscure landmarks.
The ulnar nerve should be examined and its location marked; the surgeon should watch for a subluxating ulnar nerve.
If prior surgery has been performed or there is any question of the nerve's location, a small incision may be made to identify and retract the nerve to protect it against inadvertent injury.
FIG 3 • Standard instruments used for elbow arthroscopy. A. From left: syringe for insufflation of the joint, spinal needle, knife, hemostat for spreading to establish portal site, blunt trocar and cannula, switching stick, and blunt trocar and cannula. B. Howarth elevators, retractors, and large Steinmann pins are useful for retraction.
TECHNIQUES
ANTERIOR PORTAL PLACEMENT
The surgical technique for arthroscopic elbow débridement and capsular release involves the standard arthroscopic technique and setup as previously described.1,19,20
The joint is distended with 20 to 30 mL of saline introduced via an 18-gauge needle through the “soft spot” (the center of a triangle formed by the olecranon process, the lateral epicondyle, and the radial head). This makes entry into the joint easier to achieve.
Portal sites are established according to the order preferred by the surgeon; the procedure described below is our preference.
Portal sites are made by incising the skin only with a no. 11 blade, and then blunt dissection with a hemostat proceeds to the joint.
Capsular entry and joint location is confirmed by sudden egress of fluid.
The blunt trocar and sleeve are then placed into the joint and exchanged for the arthroscope.
The anterolateral portal (TECH FIG 1A) is established first, with care taken to avoid and protect the radial nerve.
This portal is established just anterior to the sulcus between the capitellum and the radial head.
The anteromedial portal is established using an insideout technique with direct visualization.
The arthroscope is removed and replaced with the blunt trocar, which is pushed directly across the joint until it tents the skin overlying the medial side of the elbow.
The skin is incised over this region and the trocar pushed through the remaining soft tissue.
A cannula may be placed over the trocar on the medial side, and the trocar is pulled back into the joint and out the lateral side (TECH FIG 1B).
A proximal anterolateral retraction portal may be established about 2 cm proximal to the lateral epicondyle.
TECH FIG 1 • A. Drawing the portal sites and palpable landmarks as well as the ulnar nerve is useful before insufflation of the joint. The anterolateral portal is usually the first portal made. B. The anteromedial portal is usually established from inside out. The site of the ulnar nerve is marked.
ANTERIOR CAPSULECTOMY AND ARTHROSCOPIC DÉBRIDEMENT
A 4.8-mm arthroscopic shaver is introduced through the anteromedial portal with retraction via a proximal anterolateral portal.
Shaving proceeds to gain visualization.
The anteromedial capsule is then stripped off the humerus to expand space in the contracted joint.
Loose bodies are removed as they are identified. Osteophytes are removed with the shaver and burr from the coronoid and radial head fossae.
After completion of the bony débridement, the anterior capsule is completely resected under direct visualization with the arthroscope in the lateral portal site.
The biter is used to gain a free edge of the anterior capsule, proceeding from medial to laterally and halting when the fat pad anterior to the radial head is encountered.
The shaver is used to completely resect the anterior capsule.
The arthroscope is placed in the medial portal and bony débridement and capsulectomy is completed.
POSTERIOR PORTAL PLACEMENT
After completing the anterior joint débridement and capsulectomy, attention is turned to the posterior aspect of the joint.
Again, the location of the ulnar nerve is established and marked (see Tech Fig 1B).
The posterolateral portal is used for visualization.
It is made with the elbow in a 90-degree flexed position and is placed at the lateral joint line at a level with the tip of the olecranon.
The direct posterior portal is the working portal. It is made 2 to 3 cm proximal to the tip of the olecranon. It penetrates the thick triceps, and a knife should be used to establish this portal.
Optional posterior retractor portals include one placed 2 cm proximal to the direct posterior portal, situated either slightly medially or laterally.
POSTERIOR DÉBRIDEMENT AND CAPSULAR RELEASE
After a posterolateral viewing portal and a direct posterior working portal are created, the shaver is placed in the direct posterior portal and osteophytes are removed from the tip and sides of the olecranon and the rim of the olecranon fossa.
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.
In general, if a large restoration of motion is anticipated postprocedure, if preoperative ulnar nerve symptoms exist, or if preoperative flexion measures less than 90 degrees, the surgeon should consider ulnar nerve decompression or transposition.
This may be achieved via arthroscopic decompression if the surgeon has the requisite skill, or an open subcutaneous transposition is done.
POSTOPERATIVE CARE
After the procedure, motion is assessed (FIG 4), the portals are closed in the standard fashion with 3-0 nylon or Prolene sutures, and a sterile compressive dressing 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 postoperative day 1, 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 initiated. No limitations are placed on use of the arm.
Heterotopic ossification prophylaxis, consisting of indomethacin 75 mg three times daily for 6 weeks, is initiated.
Splinting protocols, such as splints that may be adjusted from full extension to full flexion, are useful in most cases. The patient usually alternates hourly between the extremes of motion achieved at the time of surgery.
Continuous passive motion may be initiated using a continuous passive motion device with or without a nerve block; however, in our experience it is not usually necessary.
In patients who cannot practice motion on their own or in those with severe contractures, it may be of benefit, although a consensus regarding the indications and need for continuous passive motion is lacking.
OUTCOMES
In our series,2 outcomes after the described procedure in 41 patients and 42 elbows were reviewed after an average follow-up of 176.3 weeks (minimum 2 years of follow-up).
Significant improvements in mean flexion (from 117.3 degrees preoperatively to 131.6 degrees, P <0.0001), extension (from 21.4 degrees to 8.4 degrees, P <0.0001), supination (from 70.7 degrees to 78.6 degrees, P = 0.0056), and Mayo Elbow Performance Index scores (P <0.0001) were noted, with 81% good to excellent results.
FIG 4 • Intraoperatively after release, the range of motion is assessed.
Pain decreased significantly (P <0.0001).
Complications were rare (n = 2; heterotopic ossification and transient ulnar dysthesias).
Cohen et al5 compared outcomes after arthroscopic débridement versus open débridement of the elbow for osteoarthritis, using the Outerbridge-Kashiwagi procedure and an arthroscopic modification.
Both groups showed improved range of elbow flexion, decrease in pain, and a high level of patient satisfaction.
Increases in elbow extension, although improved in both groups, were more modest.
Neither procedure included capsular release.
Comparison between the open and arthroscopic procedures showed that the open procedure might be more effective in improving flexion, whereas the arthroscopic procedure seemed to provide more pain relief.
No differences between overall effectiveness of the two procedures were noted.
From these series and others in the literature, it appears that arthroscopic débridement and capsular release have similar outcomes with respect to pain relief, improved range of motion, and complications. Although the use of arthroscopic procedures is attractive to decrease morbidity, benefits over open procedures have not been proved.
COMPLICATIONS
As with any arthroscopic or open procedure about the elbow, the risk of neurovascular injury is a real concern.
In a series from the Mayo Clinic,7 50 complications were observed after 473 elbow arthroscopies for a variety of interventions.
Most frequently, this included prolonged wound drainage; other complications included infection, nerve injury, and contractures.
No permanent nerve injuries were observed.
Nevertheless, injuries of each of the susceptible nerves about the elbow joint have been observed.
Careful attention intraoperatively, appropriate portal placement, and knowledge of anatomy will help prevent injury.
REFERENCES
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