Elbow synovitis, loose bodies, and posteromedial impingement

Overview

Chapter synopsis

Overhead-throwing athletes place a tremendous amount of force on their elbows during activity. Over time, this may lead to inflammatory conditions, posteromedial impingement, osteophytes, and loose bodies. Elbow arthroscopy has become the treatment of choice for these conditions when nonoperative treatment has failed. A thorough history and physical examination are necessary to guide the surgeon to the proper diagnosis and subsequent use of elbow arthroscopy. An understanding of the anatomy around the elbow is imperative to performing a thorough debridement while avoiding serious complications. Overall, most athletes are able to return to the same level of their sport after arthroscopic elbow surgery.

Important points

Indications: loose bodies and synovial conditions leading to pain and mechanical symptoms. Failed conservative management.
Contraindications: overlying cellulitis.
Relative Contraindication: altered elbow anatomy secondary to surgical or traumatic causes.
Symptoms: catching or locking of the elbow, limitations in range of motion, valgus instability, pain, and/or an effusion.
Surgical technique: Begin with an examination under anesthesia to evaluate the patient for instability and range of motion. Typically, two anterior portals and two or three posterior portals are employed based on surgeon preference, followed by debridement of osteophytes and removal of loose bodies.

Clinical and surgical pearls

Perform a preoperative upper extremity exam to document instability and subluxation of the ulnar nerve and its resting position.
Simulate elbow movements and instrument passage required during surgery prior to prepping and draping to minimize positioning issues during the case.
Keep the elbow flexed at 90 degrees and distend with saline before initial portal placement to help protect neurovascular structures.
A spinal needle can help stabilize loose fragments and prevent migration during removal.
Loose bodies can be brought toward the cannula by allowing fluid outflow from a cannula side port.
Use a freer or osteotome to develop a plane to dislodge osteophytes and loose bodies.

Clinical and surgical pitfalls

Maintain low or no suction on the shaver while working in the proximity of the capsule.
Consider the use of arthroscopic retractors for protection and visualization.
Be cognizant of the posterior band of the ulnar collateral ligament when debriding the posteromedial olecranon.
When debriding a posteromedial osteophyte from the olecranon, minimize resection of native bone.
In the anterior compartment, check the coronoid fossa and anteromedial and lateral gutters for loose bodies. In the posterior compartment, check the olecranon fossa as well as the medial and lateral gutters for loose bodies or bony pieces trapped in the synovium.
Persistent posteromedial impingement following olecranon osteophyte resection should prompt further exploration of osteophytes on the humeral side or loose bodies in the posterior radiocapitellar joint.

Overhead-throwing athletes place a tremendous amount of force on their elbows during the throwing cycle. Stability provided by static and dynamic stabilizers, including bony articulations, ligaments, and muscles surrounding the elbow, help resist these large forces. Over time, these stresses may lead to inflammation, synovitis, joint degeneration, and formation of osteophytes and loose bodies. In fact, loose body removal represents the most common indication for elbow arthroscopy in this population, while debridement and release are the most common indications for elbow arthroscopy in general. Acutely, even relatively small losses in range of motion (ROM) or throwing speed can have devastating consequences on a high-level elite athlete. Athletes with chronic motion loss may be able to adapt with greater ease. The necessary ROM varies with each sport, position, and the individual mechanics required to remain competitive.

Posteromedial impingement occurs during the deceleration or follow-through phase of throwing as throwers reach full extension. During the late cocking and early acceleration phases of throwing, valgus torque can reach 65 Nm. This valgus torque and rapid extension leads to 3 major forces at the elbow: a tensile force medially, compressive force laterally, and shearing stress posteriorly. The medial tensile force may compromise the integrity of the ulnar collateral ligament (UCL), which has been shown to lead to valgus instability and posterior and lateral pathology. Lateral compressive forces may lead to radiocapitellar overload, plica formation, and chondral wear or fracture, resulting in intra-articular loose bodies. The shear stress on the tip and fossa of the medial olecranon leads to the development of osteophytes, chondral lesions, and possibly loose bodies. Clinically, the athlete has posteromedial pain, decreased ROM, and altered throwing mechanics.

Underlying synovial disorders may secondarily result in pain and mechanical symptoms that can hinder an athlete’s performance. Diseases such as synovial chondromatosis, pigmented villonodular synovitis (PVNS), and inflamed synovial plica can produce mechanical symptoms and alter anatomical structures that limit normal elbow motion. A broad differential diagnosis is important in accurately elucidating the primary cause of an athlete’s symptoms.

As our understanding of elbow anatomy, biomechanics, and pathophysiology has increased and our techniques improved, elbow arthroscopy has become a safe and effective tool for addressing these disorders. Regardless of cause, the procedure aims to resolve the clinical presentation with the goal of returning an athlete to their previous level of competition.

Preoperative considerations

History

A thorough history and physical exam are critical to elucidating the cause of the patient’s chief complaint. Patients will typically have a history of repetitive throwing or overhead activity. Patients may describe pain, mechanical symptoms (catching, locking, and popping), or throwing-specific symptoms. The specific activity or timing within the activity can be important in determining the type of pathologic changes present. A history of prior surgeries (e.g., ulnar nerve transposition) is also important, as it may affect future treatment options.

Signs and symptoms

Insidious onset of pain primarily located in the posteromedial aspect of the olecranon. Acute onset of pain likely secondary to traumatic ligamentous injury.
Intermittent swelling post-activity. Early morning stiffness more indicative of arthrosis. Persistent swelling and stiffness may be indicative of an underlying synovial disease.
Typically asymptomatic at rest. Exacerbated with activity.
Phase of throwing: pain during extension (deceleration and follow-through). Flexion contracture with a tendency to throw high from an early release point.
Limited ROM, particularly with full extension from impinging posterior osteophytes
Mechanical symptoms: painful clicking, catching, popping, or locking as a result of loose bodies, osteophytes, or plica.
Paresthesia: irritation from activity or compression of ulnar nerve from osteophytes, loose bodies, or synovial disease.

Physical examination

Physical examination starts with inspection. Observe the skin for prior incisions, skin breakdown, erythema, and edema or effusion; muscle mass for atrophy; and the resting position of the joint. Palpation is carried out among the medial, lateral, anterior, and posterior aspects of the joint to pinpoint the location of tenderness. Take the patient through their ROM to evaluate for any stiffness, mechanical blocks, or contractures. UCL insufficiency is a known cause of posteromedial impingement, and as such, ligamentous assessment is necessary. Neurovascular status should be documented.

Brief examination of the kinetic chain of the athlete is important prior to a focused exam of the elbow. The cervical spine, scapulothoracic joint, ipsilateral shoulder, wrist, and contralateral elbow are important to evaluate in addition to the affected elbow, as they may be a cause of or provide insights into the elbow pain.

ROM, loss of extension: posterior olecranon spur, posterior compartment loose bodies, bridging osteophyte across olecranon fossa, anterior capsule contracture, collateral ligament contracture with or without ossification.
ROM, loss of flexion: coronoid spur, anterior compartment loose bodies, coronoid fossa spur, posterior capsule contracture or triceps adhesions, collateral ligament contracture.
A soft end point suggests synovitis or capsular contracture. A firm endpoint indicates osseous impingement. Limitation in rotation may be the result of radial head deformity or distal radioulnar joint disease.
Palpation, with or without joint effusion, warmth, or crepitation. Posteromedial tenderness along the proximal ulna and olecranon process is used to assess impingement. Posterolateral (PL) tenderness is present with lateral synovial plicae.
Boggy PL swelling is typically the result of synovitis and effusion.
Ligamentous stability: UCL assessed at 50 to 70 degrees of flexion. Specific tests include the milking maneuver and O’Driscoll’s moving valgus stress test (see chapters on UCL Reconstruction for more detail).
Extension Impingement Test: elbow is snapped into terminal extension. Elicits pain in the posterior compartment in a patient with posteromedial impingement.
Arm Bar Test: Position patient’s shoulder at 90 degrees of forward flexion, full internal rotation, with the patient’s hand placed on the examiner’s shoulder. Examiner pulls down on the olecranon, simulating forced extension. Pain indicates a positive test.
Valgus extension overload test: combined valgus and gentle terminal extension with simultaneous palpation of the posteromedial tip of the olecranon.
Neurovascular: Palpate ulnar nerve through flexion/extension to evaluate for subluxation. Check Tinel’s sign. Perform distal motor and sensory examination.
Intra-articular injections of a local anesthetic may be helpful in assessing an intra-articular versus extra-articular pathologic process.

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