Elbow Arthroscopy 29830

Elbow Cross Sectional Anatomy picture

elbow arthroscopy medial portals

elbow arthroscopy lateral portals

synonyms: elbow arthroscopy, elbow scope, EATS

Elbow Scope CPT

Elbow Scope Indications

  • Elbow pain with abnormal PE or xray
  • Loose body (snapping, clicking, locking)
  • Synovial biopsy for persistent synovitis
  • Elbow arthritis (osteophyte removal)
  • Symptomatic plica
  • Elbow contracture (capsular release)
  • Lateral epicondylitis
  • Elbow fracture (radial head, coronoid, capitellum)
  • Evaluation of valgus instability in overhead athletes
  • Posteromedial Elbow Impingement(generally a result of chronic valgus instability in the overhead athlete)
  • Capitellar OCD

Elbow Scope Contraindications

  • Significant prior trauma
  • Active infection (arthroscopy may be of benefit in the treatment of a septic elbow)
  • Elbow pain with no other supporting clinical or radiographic abnormalities

Elbow Scope Alternatives

  • Open approach

Elbow Scope Pre-op Planning / Special Considerations

  • Instrumentation needs: 4.0mm scope (consider 2.7mm for small elbows), nonvented cannulas, shaver, positioner, pump, retractors

Elbow Scope Technique

  • Sign operative site
  • Pre-operative antibiotics, +/- regional block (regional block can complicate post-operative NV exams).
  • General endotracheal anesthesia
  • Examination under anesthesia. Examine ulna nerve to ensure it does not subluxate from the cubital fossa (occurs in @16% of general population; subluxation puts ulnar nerve at risk during anterior medial portal creation).
  • Lateral decubitus position with tourniquet, elbow flexed to 90° and supported with padded bulster. All bony prominences well padded, axillary role placed.
  • Tourniquet placed high on the arm.
  • Prep and drape in standard sterile fashion.
  • Arm exasguinated with eschmar bandage. and tourniquet inflated.
  • Forearm wraped with elastic bandage (Coban) to minimize extravasation.
  • Distend elbow joint with saline (Normal capacity of elbow joint=15-25ml) using spinal needle in mid-lateral portal. 6cc in stiff elbows. (Galley SH, Arthroscopy 1993;9:9).
  • Superomedial portal (proximal anteromedial portal): anterior to the intermuscular septum, 2cm proximal to the medial epicondyle. Must stay anterior to the medial intermuscular septum to avoid ulnar nere injury.
  • Inspect anterior compartment: capitellum, radial head, rotate forarm to fully evaluate radial head, anterior capsule, lateral capsule, trochlea, coronoid fossa, coronoid process.
  • Proximal anterolateral portal: 2cm proximal and 1cm anterior to the lateral epicondyle. Lowest risk or radial nerve injury. (MIller C, JSES 1995;4:168).
  • Anterolateral portal=access to anterior joint (trochlea, coronoid process, coronoid fossa, medial radial head), placed exactly in the sulcus felt between radial head and capitellum anteriorly, elbow flexed 90°, capsule fully distended to displace NV structures anteriorly. Risks radial nerve.
  • Mid-lateral portal: within soft spot in triangle formed by olecranon, lateral epicondyle, and radial head. Allows visualization of: inferior capitellum, inferior radioulnar joint. Risks:posterior antebrachial cutaneous nerve.
  • Posterolateral portal=anywhere posterior to the mid-lateral portal, used for loose body removal, instrument insertion. Generally 2-3cm proximal to the tip of the olcranon along the lateral border of the triceps. Allows visualization of: olecranon tip olecranon fossa, posterior trochlea. Risks: medial and posterior antebrachial cutaneous nerves.
  • Posterocentral portal=3cm proximal to the tip of the olecranon in the midline. Allows evaluation of the posterior compartment, medial gutter, lateral gutter. Risks: posterior antebrachial cutaneous nerve, ulnar nerve.
  • Anteromedial portal-generally used to augment superomedial portal. Ensure ulnar nerve is not subluxed before establishing anteromedial portal. Generally 2cm distal and 2 cm anterior to the medial epicondyle. Risks: ulnar nerve, medial antebrachiocutaneous nerve.
  • Posteromedial portal=no such thing, ulnar nerve is at to much risk.
  • Arthroscopic valgus instability test: apply valgus stress with elbow in 70° of flexion with visualizing the medial ulnohumeral joint. Any opening >1mm indicates valgus instability.
  • DJD technique: removal all loose bodies and impinging osteophytes. Consider removal of tip of the coronoid. May need capsular release.
  • Chronic Valgus instability technique: perfrom arthroscopic valgus instability test, posterior osteophyte debridement, olcranon tip excision, posteromedial gutter decompression, consider olecranon fossa fenestration / deepening.

Elbow Scope Complications

  • 11% minor complications, 0.8% major (Kelley EW, JBJS 2001;83A:25).
  • Overall approximately 10% complication rate
  • Compartment syndrome
  • Septic arthritis / infection: 0.8% (Kelley EW, JBJS 2001;83A:25).
  • Nerve injury (median, ulnar, radial, posterior interosseous): use of retractors effectively decreases risk.
  • Cutneous neuromas (associated with portal placement).
  • 4%transient radial-nerve palsy after intraarticular anesthetic injection
  • Vascular injury
  • Prolonged drainage (portal sites): 4% aseptic drainage
  • Stiffness / flexion contracture

Elbow Scope Follow-up care

  • Post-op: compressive dressing, elevation
  • 1 week: Start PT focused on ROM and strengthening. AAROM, PROM.  AROM, free weights start at 3 weeks.
  • 6 weeks: progressive sport specific activity.
  • 3 months: Return to sport / full activities.
  • Elbow Arthroscopy Rehab Protocol
  • Elbow Outcome Measures

Elbow Scope Outcomes

Elbow Scope Review References

  • O’Driscoll, JBJS 1992;74A:84
  • Abboud JA, JAAOS 2006;14:312