ELBOW ARTHROSCOPY WHERE ARE WE NOW?

ELBOW ARTHROSCOPY WHERE ARE WE NOW? Christian Veillette M.D., M.Sc., FRCSC Assistant Professor, University of Toronto Shoulder & Elbow Reconstructive Surgery Toronto Western Hospital @ University Health Network UTOSM @ 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/contracture 2. Allows more aggressive, earlier rehabilitation 3. More thorough inspection of joint 4. 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 injury 2. Increased operative times 3. Highly technically demanding

Question 3 What structure is at greatest risk when the anteromedial portal is used during elbow arthroscopy? 1. Brachial artery 2. Ulnar nerve 3. Median nerve 4. Posterior interosseous nerve 5. 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 arthroscopy 2. Loose body removal 3. Plica 4. Lateral epicondylitis 5. Olecranon bursitis 6. Septic arthritis 7. Lysis and debridement of post-traumatic adhesions 8. Treatment of osteochondritis lesions 9. Synovectomy 10. Arthritis/Excision olecranon osteophytes 11. Fracture evaluation and treatment radial head, coronoid

Question 5 A 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 extension b) Mechanical symptoms c) Loss of joint space d) 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 interposition 3. 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 3 5 4

Question 11 Name that posterior portal? 1 2 3 4

Question 12 Name that structure/portal? 2 5 3 6 4 1 7

Question 13 Name that structure/portal? 2 5 1 4 3 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 transecion in 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?