Advanced and Future Trends in Elbow Arthroscopy

Introduction

As with many joint advances in technology and skills, collaborations have fueled major advancements in elbow arthroscopy indications and techniques. These advances have been noted in multiple case reports and by anecdotal evidence. However, the evidence via randomized control trials of the effectiveness of elbow arthroscopy has been lacking, with most reports detailing level 4 or 5 evidence. Minimally invasive techniques are permeating orthopedics, including treatment for the elbow. The key to developing advanced elbow arthroscopic techniques as we move into the future is to maintain a margin of safety for all surgeons. This is achieved by better delineation of accurate three-dimensional anatomy, which keeps the surgeon within the safety curve described by O'Driscoll in the third edition of this textbook. Advanced surgical skill training is essential in the elbow, as with no other joint do the neurovascular structures lie in such close proximity to the surgical fields.

Elbow arthroscopy has made great advances since the Andrews and Carson article in 1985. Early limited indications of diagnostic arthroscopy and removal of loose bodies have expanded to include debridement of conditions such as arthritis, synovitis, and epicondylitis; fracture reduction and fixation; reconstruction of instability; and resurfacing. Some procedures listed as advanced in prior editions of this textbook have now become commonplace (e.g., arthroscopic management of lateral epicondylitis). Experience gained during residency programs and fellowships is providing earlier training in arthroscopic procedures, and surgeons are emerging from training programs as experienced arthroscopists. Procedures once reserved for open cases, such as repairs of fractures and ligamentous injuries, are now being performed arthroscopically with increasing frequency.

This chapter aims to highlight current advanced arthroscopic techniques in the elbow, as well as possible future procedures on the horizon. As with most orthopedic conditions, the indications for surgery are pain and functional impairment despite appropriate nonoperative treatment. Certain acute injuries will require acute repair. The arthroscopic techniques and postoperative rehabilitation will be presented in each section.

Arthroscopic Triceps Tendon Repair

Triceps tendon ruptures ( Fig. 24.1 ) are increasingly more common as our aging patient population attempts to maintain an active lifestyle. Once a rare injury seen mostly in bodybuilders, it is now seen in older age groups with increasing frequency. The triceps takes its name from the three heads that originate from the humerus and infraglenoid tubercle of the scapula. It inserts in a fan like fashion on the posterior aspect of the olecranon and proximal ulna. Injuries of the triceps may take the form of partial or complete avulsion from the bone, intra­substance muscle tears, or tears at the muscle-tendon junction.

Most patients with this injury will experience pain or a “pop” with press-type activities. This may occur during push-ups, chest presses, or most commonly during the bench press when the weight lifter loses control of the bar. Partial tears may begin with these activities, as well as during dips or overhead triceps extensions. Physical examination begins with observation for swelling and ecchymosis posterior in the elbow. A palpable gap in the extensor mechanism can often be detected in both partial and complete tears. Patients with complete tears may have a complete loss of the ability to extend the elbow against gravity, whereas those with partial or degenerative tears may retain elbow extension in a weakened, painful state. In patients with subtle tears, trying to extend the elbow from a fully flexed position reproduces pain directly over the site of the injury (i.e., during the triceps stress test).

Radiographs may show a small avulsion fracture off the tip of the olecranon. Diagnosis can be confirmed with magnetic resonance imaging (MRI), which may be helpful in cases of partial tears.

An arthroscopic triceps repair has previously been described by Savoie et al. The patient is placed in the prone or lateral decubitus position. Care is taken to palpate the ulnar nerve and to ensure that it does not subluxate out of its groove. The initial portal is a proximal anterior medial or proximal anterior lateral portal for diagnostic arthroscopy of the anterior compartment. Many patients with this injury are very active and may be avid weight lifters. Pathology in the anterior compartment may include loose bodies or small osteophytes on the tip of the coronoid. This can be addressed before proceeding to the posterior compartment.

The initial posterior portal is a posterior central portal, located approximately 3 cm proximal to the tip of the olecranon. Care must be taken not to stray medial to midline for all posterior portals for risk of damage to the ulnar nerve. Normally a transtendon portal, in most triceps avulsions this portal actually goes through the tear. Next, a posterior lateral portal is established along the lateral border of the triceps tendon. The torn triceps tendon is visualized. The arthroscope is moved to the posterior lateral portal and the shaver is placed in the posterior central portal. The tip of the olecranon is debrided through this portal, as is the torn edge of the tendon. A central olecranon bursa portal is then established and a double-loaded suture anchor is inserted into the tip of the olecranon. The anchor is angled toward the coronoid to avoid inadvertent penetration of the articular surface.

A retrograde suture retriever is placed percutaneously though the medial and lateral aspects of the proximal triceps tendon, retrieving the sutures from the anchor. Two mattress sutures are usually required to capture the tendon and complete the proximal part of the repair. After subcutaneous retrieval, they are tied with a sliding knot. This secures the proximal part of the tendon to the tip of the olecranon and seals the joint. The arthroscope is then placed directly into the olecranon bursa portal. The previous sutures can be left long and retrieved through the bursa portal. Crossing the sutures and incorporating them into a second knotless suture anchor more distal down the ulna creates a suture bridge construct that compresses the tendon down to the bone. In a similar fashion, the first sutures can be cut, a second anchor placed more distally in the ulna, and the distal end of the triceps tendon can be tied down with simple sutures through the second anchor.

Postoperatively, the patient is placed into an anterior splint with the elbow in full extension. At the first postoperative visit, the patient goes into a hinged elbow brace, locked from full extension to 30 degrees of flexion. The flexion is increased 10 degrees per week until a full range of motion is obtained at 6 to 8 weeks postoperative, at which time the elbow brace is discontinued. Resistive exercises are initiated at 12 weeks postoperative, with return to lifting and sports activities at 4 to 6 months.

Arthroscopic Fracture Repair

Fractures about the elbow ( Fig. 24.2 ) remain a very common injury. Fractures can be very daunting, as comminution can distort the normal anatomy, major neurovascular structures are in close proximity to the joint, and postoperative stiffness is common. Arthroscopy can aid with fracture management and reduction, as it affords the surgeon a direct intraarticular view of the joint without disrupting the static and dynamic constraints about the elbow. This facilitates the reduction, limits the amount of intraarticular step-off, and avoids iatrogenic instability. Simple fracture patterns with one or two fracture fragments are very amenable to arthroscopic fixation. For complex fractures with severe comminution, open reduction and internal fixation may be more appropriate.

As with most fractures, the history will often include a traumatic injury such as a fall, sporting injury, or motor vehicle accident. The examination begins with close inspection of the involved extremity, looking for open wounds or punctate bleeding. Gentle palpation can localize pain, and crepitus of fracture fragments may be present. Gentle range of motion may reveal a block to forearm rotation or elbow flexion and extension. Pain and apprehension will likely limit the exam. Care must be taken to perform a careful neurologic examination in the case of any fracture or dislocation. The shoulder and wrist should routinely be examined. Routine radiographs of the elbow will diagnose most fractures. A computed tomography (CT) scan may be helpful to identify fracture fragments, to measure the size of the fragments, and to view the residual intact bone in order to predetermine screw size ( Box 24.1 ).

Simple fractures such as condylar fractures with one fracture line, capitellar shear fractures, radial head fractures with one or two fragments, and large coronoid fractures can be managed very well arthroscopically. Initially the arthroscope is usually placed in a proximal anterior medial portal to allow visualization of the lateral structures. Upon entrance into the elbow joint, abundant hematoma is encountered. A shaver placed in a proximal anterior lateral portal can be used to evacuate this hematoma and visualize the fracture line. During the initial debridement, limited use of suction is advised as tearing in the capsule and overlying brachialis may place the radial nerve in close proximity. The tip of the shaver may be used like a probe to manipulate the fracture fragments.

For radial head fractures (see Fig. 24.2A–C ) and capitellar shear fractures (see Fig. 24.2D–F ), a Freer elevator introduced through an anterior lateral portal at the level of the radiocapitellar joint can manipulate fracture fragments. Using arthroscopic instruments, the fracture is reduced, and provisional fixation with Kirschner wires can hold the reduction. Fluoroscopic images confirm reduction and pin placement. Headless cannulated screws can be placed over the pins for definitive fixation, from lateral to medial for radial head fractures and from posterior to anterior for capitellum fractures. The headless screws avoid articular cartilage erosion or impingement during elbow range of motion.

Rolla et al. reported preliminary results for six patients who underwent arthroscopic reduction and internal fixation for radial head fractures. All patients returned to their preinjury level of function within 6 months. Michels et al. presented 5-year follow-up data on 14 patients treated with an arthroscopic technique for Mason Type 2 radial head fractures. The Mayo Elbow Performance (MEP) scores were excellent in 11 and good in 3. A potential advantage of this arthroscopic technique was the observation that a single screw was usually sufficient to obtain stability.

In the case of condylar fractures of the distal humerus (see Fig. 24.2F,G ), the fracture line can be manipulated with the tip of the shaver or a Freer elevator. A large bone reduction clamp can be placed on the medial and lateral epicondyles to reduce the fracture and hold compression across the fracture site. Direct visualization with the scope in the anterior compartment can minimize step-off of the articular cartilage. Guide pins can be placed under fluoroscopic guidance from lateral to medial, and internal fixation performed with cannulated screws for definitive fixation. The reduction clamp should be left in place during drilling and screw placement; removing the clamp during either step could result in loss of reduction and fracture displacement.

There are no available series of unicondylar fractures managed arthroscopically. In our very limited series, all five patients healed the fracture within 4 weeks and recovered full motion and resumed normal activity within 12 weeks. None has required screw removal.

Operative intervention for coronoid process fractures is recommended for Regan and Morrey Type III fractures and any fracture that interferes with joint motion. When comminution precludes fixation, loose debris can be removed arthroscopically. Larger coronoid fractures can be treated effectively with arthroscopic techniques (see Fig. 24.2H,I ). The arthroscope is placed in the proximal anterior lateral portal to view the medial side of the elbow. The fracture fragments are reduced and held with a tibial anterior cruciate ligament drill guide. A guide pin can then be drilled from the posterior cortex of the ulna to engage the fracture fragment. If the fragment is of sufficient size, a single cannulated screw can be placed from posterior to anterior in the ulna to engage the fragment and maintain reduction. If the fragment is small or comminuted, two drill holes can be placed on either side of the fracture, and the fragments can be lassoed with a free suture and tied over a bone bridge on the posterior cortex of the ulna.

Adams et al. reported their experience with arthroscopically assisted reduction and fixation with four Type II and three Type III coronoid fractures. Cannulated screw fixation was achieved antegrade over pins placed with the use of an anterior cruciate ligament guide. All five of the patients available for follow-up at an average of 2 years and 8 months had MEP scores of 100%.