Arthroscopic Management of Elbow Plica and Loose Bodies

Introduction

Elbow arthroscopy has been utilized increasingly commonly since 1932, when Burman concluded in the Journal of Bone and Joint Surgery that the elbow joint was arthroscopically “unsuitable for examination.” In fact, it has proven to be a valuable tool in the treatment of many elbow conditions. The arthroscope has been demonstrated to be ideally suited for the removal of elbow loose bodies and is the most common indication for elbow arthroscopy. Other limited procedures such as debridement and synovectomy are also very amenable to arthroscopic management. The potential advantages of elbow arthroscopy in the identification and removal of loose bodies include reduced iatrogenic insult using limited portal site incisions, a more thorough and complete assessment of the anterior and posterior compartments of the elbow, and possibly reduced propensity for scarring postoperatively as a result of limited disruption of the elbow capsule. Disadvantages of elbow arthroscopy center squarely on the technical requirements to safely and effectively perform the procedure due to the close proximity of neurovascular structures. A thorough knowledge of the anatomy of the elbow, particularly from the arthroscopist's perspective, is critical in reducing the chances of neurovascular injury. Preinsufflation of the joint with fluid and maintaining the elbow at approximately 90 degrees of flexion during the procedure will increase the distance of the neurovascular structures from the articular surfaces and arthroscopic instruments, decreasing the chance of morbidity from portal placement. Also, drawing the anatomic landmarks, including marking the location of the ulnar nerve at the initiation of the procedure, probably serves to reduce the risk of injury to these structures as well.

Loose Bodies

Patients with loose bodies usually present with complaints of elbow pain and stiffness and often report catching, snapping, popping, or locking of the joint ( Fig. 20.1 ) (see Chapter 84 ). Loose bodies do not cause elbow contracture, but they are often present in patients with elbow contracture. These patients with elbow contractures develop loose bodies as a result of the underlying pathologic condition such as osteochondritis dissecans, posterior impingement, or degenerative arthritis with posterior osteophytes on the olecranon and in the olecranon fossa. On physical examination, patients with loose bodies generally have maintenance of elbow motion but may have mild degrees of flexion and/or extension loss. Also, a mild effusion best identified in the posterolateral gutter of the elbow may be present.

Although anteroposterior (AP) and lateral radiographs of the elbow often demonstrate loose bodies ( Fig. 20.2 ), as many as 30% of loose bodies are not detected on plain x-ray studies. Most often, when loose bodies are suspected but not identified on plain radiographs, they will be found in the posterior compartment of the elbow ( Fig. 20.3 ). In addition, loose bodies will often migrate within the elbow and even between compartments, making reliable identification more difficult.

Ultrasonography, computed tomographic arthrography, and magnetic resonance imaging may be helpful in diagnosing loose bodies. However, even if objective testing fails to demonstrate loose bodies in patients with classic loose body symptoms, elbow arthroscopy may still be indicated because it represents the best diagnostic modality.

Surgical Indications

Elbow arthroscopy performed for loose body removal is indicated in symptomatic patients who have failed to respond to nonoperative management. An important adjunct in the management of these patients, however, is a concerted attempt to determine the etiology of the loose bodies. Loose bodies often result from pathologic conditions such as osteochondritis dissecans, trauma, degenerative arthritis, or synovial osteochondromatosis. Determining the source of the loose bodies will allow the surgeon to more effectively treat the underlying cause of the elbow condition. In fact, effective arthroscopic management of the primary cause of the loose bodies may be more important than simple removal of the loose bodies themselves.