Elbow Arthroscopy

Elbow arthroscopy is a useful tool in the treatment of simple and complex disorders of the elbow when conservative measures have failed. it does not replace a careful history, physical examination, diagnostic testing, or an adequate course of nonoperative treatment.

Elbow Arthroscopy Indications

Arthroscopic elbow surgery is indicated in these cases:

1. Treatment of tennis elbow (lateral epicondylitis).
2. Removal of loose bodies (loose cartilage and bone fragments).
3. Release of scar tissue to improve range of motion.
4. Treatment of osteoarthritis (wear and tear arthritis).
5. Treatment of rheumatoid arthritis (inflammatory arthritis).
6. Treatment of osteochondritis dissecans.
7. Treatment of fractures.

See Also: Elbow Anatomy

Patient Positioning

Supine on the operating table: Traditional position.

Prone Position: with large chest rolls under the torso. An arm board is placed on the operative side of the table and parallel to it. To increase the mobility of the upper extremity intraoperatively, a sandbag, block, or firm bump of towels is placed under the shoulder to further elevate the arm away from the table. The forearm is then allowed to hang in a dependent position over the arm board at 90 degrees.

The prone position in Elbow Arthroscopy:

1. improves the mobility of the arthroscope within the joint,
2. facilitates manipulation of the joint,
3. provides for a more complete intra-articular inspection (especially in the posterior aspect of the joint), and eliminates the need for an overhead suspension device to support the elbow.
4. The main disadvantage to this position is a more difficult access to the patient’s airway.

Some surgeons prefer the lateral decubitus position because they feel it provides improved stability of the extremity, is more convenient for the anesthesiologist, and allows posterior elbow joint access without compromising airway access. The patient is placed in the lateral decubitus position with the involved extremity facing upward. The arm is then supported on a well-padded bolster, with the forearm hanging free and the elbow flexed to 90 degrees. In this position, the elbow is supported in front of the surgeon, who then has access to the various portal sites.

Elbow Arthroscopy Portal Placement

Anterior Compartment

The proximal anteromedial portal is established first, and it was first described by Poehling. It is located approximately 2 cm proximal to the medial epicondyle and just anterior to the intermuscular septum. Before establishing this portal, the location and the stability of the ulnar nerve should be assessed. The prevalence rate of ulnar nerve subluxation anterior to the cubital tunnel is approximately 17%.

Blunt dissection is carried out until the anterior aspect of the humerus is palpated while staying anterior to the intermuscular septum. The arthroscopic sheath is then inserted anterior to the intermuscular septum while maintaining contact with the anterior aspect of the humerus and directing the trocar toward the radial head.

Use of the anterior surface of the humerus as a constant guide helps to prevent injury to the median nerve and the brachial artery, which are anterior to the capsule. The ulnar nerve is located approximately 3 to 4 mm from this portal and posterior to the intermuscular septum. Palpating the septum and making sure that the portal is established anterior to the septum minimizes the risk of injury to the nerve while providing excellent visualization.

This portal provides excellent visualization of the anterior compartment of the elbow, particularly the radiocapitellar joint, the humeroulnar joints, the coronoid fossa, and superior joint capsule.

Careful attention should be paid to the medial aspect of the elbow, and the ulnar nerve should be carefully examined to make sure the ulnar nerve does not subluxate. If there is any question, the ulnar nerve should be dissected out and identified, and the trocar should then be placed carefully around it. Another option is for two lateral portals to be used, or a transfossa portal with a 70-degree scope to view into the anterior compartment can be used.

The anteromedial portal as described by Lynch and associates is located 2 cm distal and 2 cm anterior to the medial epicondyle, and it is at or near the distal extent of the elbow capsule. Because of the location of this portal, the cannula can enter the joint only by being advanced straight laterally, toward the median nerve. Because of this, the proximal anteromedial portal is recommended; it is safer because the more proximal position allows the arthroscope to be directed distally, resulting in the arthroscope being almost parallel to the median nerve in the anteroposterior plane.

The anterolateral portal was originally described by Carson and Andrews as being located 3 cm distal and 2 cm anterior to the lateral epicondyle. However, this portal location places the radial nerve at significant risk for iatrogenic injury. Lindenfeld demonstrated the radial nerve could be as close as 3 mm to this portal. To decrease risk of injury to the radial nerve, several investigators have stressed the importance of avoiding the distal placement of this portal in favor of a more proximal placement of the anterolateral portal.

Field and colleaues compared three lateral portals: a proximal anterolateral portal (located 2 cm proximal and 1 cm anterior to the lateral epicondyle), a distal anterolateral portal (as described by Carson and Andrews), and a middle anterolateral portal (located 1 cm directly anterior to the lateral epicondyle). The investigators found that the proximal anterolateral portal was the safest and that the radiohumeral joint visualization was most complete and technically easiest using this most proximal portal.

The proximal anteromedial portal is created 2 cm proximal and 1 cm anterior to the lateral epicondyle, as described by Field and coworkers. The exact entry depends on the pathology to be addressed. From the proximal anteromedial portal, the lateral capsule is visualized, and palpation of the skin helps to localize the exact location of the spinal needle to aid in portal placement. It is important to direct the cannula toward the humerus while penetrating the capsule so that the portal placement is not too far anterior and medial. From the proximal anteromedial portal, the radiocapitellar joint is easily visualized. The trochlea and the coronoid process can be seen from the proximal anteromedial portal.

The proximal anterolateral portal is often a working portal and is ideal for arthroscopic lateral epicondyle release and for débridement of the radiocapitellar joint. Viewing from this portal permits visualization of the anterior compartment and is particularly good for evaluating medial structures, such as the trochlea, coronoid tip, and the medial capsule.

Posterior Compartment

The straight posterior portal is located 3 cm proximal to the tip of the olecranon and can be used as a viewing portal or as a working portal. When it is the first portal created, a cannula with a blunt trocar is inserted. The cannula pierces the triceps muscle just above the musculotendinous junction and is bluntly maneuvered in a circular motion, manipulating the soft tissues from the olecranon fossa for better visualization.

When used as a working portal, it is helpful for removal of impinging olecranon osteophytes and loose bodies from the posterior elbow joint. It is also needed for a complete synovectomy of the elbow. The straight posterior portal passes within 25 mm of the ulnar nerve and within 23 mm of the posterior antebrachial cutaneous nerve.

The posterolateral portal is located 2 to 3 cm proximal to the tip of olecranon at the lateral border of the triceps tendon. This is created while visualizing from the straight posterior portal and using a spinal needle directed toward the olecranon fossa. Initial visualization is often difficult due to scar, fat pad hypertrophy, and synovitis. A trocar is then directed toward the olecranon fossa, passing through the triceps muscle to reach the capsule. A shaver is introduced to improve visualization of the posterior compartment. This portal permits visualization of the olecranon tip, olecranon fossa, and the posterior trochlea, and it can be used as a working portal to remove osteophytes and loose bodies from the posterior compartment.

However, the posterior capitellum is not seen well from this portal. The medial and posterior antebrachial cutaneous nerves are the two neurovascular structures at most risk; they are an average of 25 mm from this portal. The ulnar nerve is approximately 25 mm from this portal, but as long as the cannula is kept lateral to the posterior midline, the nerve is not at risk for injury.

The posterolateral anatomy of the elbow allows for portal placement anywhere from the proximal posterolateral portal to the lateral soft spot. Altering the portal position along the line between the posterolateral portal and lateral soft spot changes the orientation of the portal relative to the joint. These portals are particularly useful for gaining access to the posterolateral recess.

The direct lateral portal is located at the soft spot, which is the triangle formed by the radial head, lateral epicondyle, and olecranon. It is developed under direct visualization using a spinal needle. It is useful as a viewing portal for working in the posterior compartment and viewing the radiocapitellar joint and as a working portal for radial head resection. The arthroscope is introduced into the posterior compartment using a straight posterior portal at 3 cm proximal from the tip of the olecranon. A spinal needle is introduced lateral to the triceps tendon toward the olecranon fossa for the posterolateral portal.

Elbow Arthroscopy Complications

1. Neurologic injury: One of the most common complications. Transient nerve palsies involving the radial nerve, posterior interosseous nerve, ulnar nerve.
2. infection.
3. prolonged drainage.
4. contracture.

Many of the complications associated with elbow arthroscopy are the result of:

1. inexperience,
2. poor technique,
3. lack of knowledge regarding elbow anatomy.

References

1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy. 1985;1(2):97-107. doi: 10.1016/s0749-8063(85)80038-4. PMID: 4091924.
2. Poehling GG, Ekman EF . Arthroscopy of the Elbow . J Bone Joint Surg Am. 1994 ; 76A : 1265 – 1271.
3. Baker CL, Grant LJ . Arthroscopy of the elbow . Am J Sports Med. 1999 ; 27 : 251 – 264 .
4. Poehling GG, Whipple TL, Sisco L, Goldman B . Elbow arthroscopy: a new technique . Arthroscopy. 1989 ; 5 : 220 – 224 .
5. Baker CL, Brooks AA . Arthroscopy of the elbow . Clin Sports Med. 1996 ; 15 : 261 – 281
6. O’Driscoll SW, Morrey BF. Arthroscopy of the elbow. Diagnostic and therapeutic benefi ts and hazards . J Bone Joint Surg Am. 1992 ; 74A : 84 – 94.
7. McLaughlin RE, Savoie FH, Field LF, Ramsey JR . Arthroscopic treatment of the arthritic elbow due to primary radiocapitellar arthritis. Arthroscopy. 2006 ; 22 : 63 – 69 .
8. Abboud JA, Ricchette ET, Tjoumakaris F, Ramsey ML . Elbow arthroscopy: basic set-up and portal placement . J Am Acad Orthop Surg. 2006 ; 14 : 312 – 318 ..
9. Field LD, Altchek DW, Warren RF , et al . Arthroscopy anatomy of the lateral elbow: a comparison of 3 portals . Arthroscopy. 1994 ; 10 : 602 – 607.
10. Andrews JR, St Pierre RK, Carson WG . Arthroscopy of the elbow . Clin Sports Med. 1986 ; 5 : 653 – 662 .
11. Lindenfeld TN . Medial approach in elbow arthroscopy . Am J Sports Med. 1990 ; 18 : 413 – 417 .
12. Lynch GJ, Meyers JF, Whipple TL, Caspari RB . Neurovascular anatomy and elbow arthroscopy: inherent risks . Arthroscopy. 1986 ; 2 : 190 – 197 .
13. Moskal MJ . Advanced arthroscopic management of common elbow disorders. Presented at the Arthroscopy Association of North America 24th Annual Meeting , May 2005 ; Vancouver, Canada.
14. Savoie FH, Nunley PD, Field LD . Arthroscopic management of the arthritic elbow: indications, technique and results . J Shoulder Elbow Surg. 1999 ; 8 : 214 – 219