Elbow arthroscopy can treat many pathologies, but is technically demanding

It is a powerful tool in the treatment of many elbow disorders, but requires a specialized set of skills.

Although elbow arthroscopy can allow surgeons to inspect articular surfaces, improve cosmesis and shorten patients’ recovery time, the learning curve is steep, according to an investigator from St. Louis.

Leesa M. Galatz, MD, described the experience level needed for performing different elbow arthroscopic procedures.

“With improved education, I think that a lot of procedures are possible in many hands,” she said. “But knowing your anatomy and being comfortable with basic arthroscopic techniques are critical for patient safety. As the application of arthroscopic techniques broadens, we need to consider what is a triumph of technology over reason. We must verify efficacy of advanced procedures as we go forward while maximizing generalized use of existing procedures to varying diagnoses.”

Indications

Arthroscopy can help allay concerns regarding contractures and heterotopic ossification associated with extensile approaches and can lead to lower morbidity following open procedures.

“However, arthroscopy of the elbow is technically demanding. Most would agree, that arthroscopy of the elbow has the steepest learning curve of all the joints, and extensive experience is required to perform the more complicated procedures,” Galatz said. “The elbow does not require surgery as often as other joints, so in many general practices, it is often difficult to gain this experience.”

Established indications for elbow arthroscopy include tennis elbow release and loose body removal, which she cited as a good starting place for those starting to scope elbows. Treating arthrofibrosis is an evolving indication.

“This is technically demanding, places neurovascular structures at risk, and really should only be done if you are familiar with elbow arthroscopic techniques,” Galatz said.

Some surgeons are exploring arthroscopy for the treatment of posterolateral instability, radial head fractures and unicondylar humerus fractures, she said.

Experienced surgeons

Arthroscopy can be used to treat elbow arthritis with capsular release and removal of osteophytes. Called an osteocapsular arthroplasty, this is equivalent to an Outerbridge procedure, according to Galatz.

“Elbow arthritis is different than arthritis in the other joints,” she told Orthopedics Today. “It is not necessarily a problem of cartilage loss, but rather osteophyte formation at the periphery of the joint. … Post-traumatic contractures can also be released. As educational opportunities increase, these procedures could be within reach of many surgeons.”

Elbow contractures in which the elbow lacks flexion often involve the ulnar nerve. When the contracture is released and flexion is restored, the ulnar nerve should be released or transposed, she said.

A posteromedial release and release of the ulnar nerve is an increasingly recognized technique. Surgeons comfortable with arthroscopic exposure of the ulnar nerve can release the posterior bundle of the medial collateral ligament, which forms the floor of the cubital tunnel. This bundle limits flexion in contracted elbows and must be released to restore flexion, Galatz said.

Although more surgeons are now releasing the posterior bundle of the medial collateral ligament, she noted that surgeons must exercise caution and take care to protect the nerve.

“What can you not do?” she asked. “Well, thus far, no one has done a medial collateral ligament reconstruction or ulnar nerve transposition or, of course, complex open reduction and internal fixation.”

For more information:
Leesa M. Galatz, MD, can be reached at Washington University Orthopedics, One Barnes-Jewish Hospital Plaza, Suite 11300, West Pavilion, St. Louis, MO 63110; 314-747-2813; e-mail: galatzl@wustl.edu. She has no financial disclosures related to this article.

Reference:
Galatz LM. Elbow arthroscopy: What I can do and what I shouldn't do. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.