INTRODUCTION TO ARTHROSCOPIC BURSECTOMY

Olecranon bursitis is a common orthopedic condition characterized by inflammation, fluid accumulation, and synovial hypertrophy within the olecranon bursa. While conservative management—including compression, nonsteroidal anti-inflammatory drugs (NSAIDs), and aspiration—is successful in the majority of aseptic cases, recalcitrant or chronic symptomatic bursitis often necessitates surgical intervention. Historically, open bursectomy has been the gold standard; however, it is fraught with high rates of wound healing complications, skin necrosis, and secondary infections due to the tenuous vascularity of the posterior elbow skin.

Arthroscopic bursectomy has emerged as a superior, minimally invasive alternative. By utilizing small portal incisions, the arthroscopic approach preserves the delicate subcutaneous vascular plexus, significantly reducing postoperative wound morbidity. Furthermore, it allows for excellent visualization of the bursal cavity, precise resection of hypertrophic synovial tissue, and concurrent management of underlying osseous pathology, such as olecranon osteophytes.

This comprehensive guide details the arthroscopic olecranon bursectomy technique as described by Baker and Cummings, while also providing an exhaustive review of the complications associated with elbow arthroscopy and the strict protocols required to avoid them.

SURGICAL ANATOMY AND BIOMECHANICS

A profound understanding of the posterior elbow anatomy is mandatory before undertaking an arthroscopic bursectomy. The olecranon bursa is a subcutaneous, synovial-lined sac located directly over the posterior aspect of the olecranon process. Its primary biomechanical function is to facilitate the smooth gliding of the posterior skin over the olecranon during elbow flexion and extension.

The Triceps Footprint and Olecranon

The triceps tendon inserts into the posterior aspect of the olecranon. In chronic bursitis, traction osteophytes or "spurs" frequently develop at the triceps insertion. These spurs can act as a mechanical irritant, perpetuating bursal inflammation. Arthroscopic visualization allows for the identification of the triceps tendon fibers and the precise resection of these bony prominences without compromising the integrity of the extensor mechanism.

Neurovascular Proximity

While the olecranon bursa is a superficial structure, the portals required for access place several critical neurovascular structures at risk:
* Ulnar Nerve: Located in the cubital tunnel posteromedially, the ulnar nerve is highly vulnerable during posterior and medial portal placement.
* Radial Nerve and Posterior Interosseous Nerve (PIN): Located anterolaterally, these structures are at risk during lateral portal placement and anterior capsular work.
* Medial Antebrachial Cutaneous Nerve (MABC): Branches of the MABC arborize over the medial aspect of the elbow and can be injured by errant medial incisions.

Surgical Warning: The absolute contraindication to medial portal placement during an isolated arthroscopic olecranon bursectomy is the unacceptably high risk of iatrogenic injury to the ulnar nerve. All work must be conducted through lateral and central portals.

INDICATIONS AND PREOPERATIVE PLANNING

Indications

1. Chronic Aseptic Bursitis: Failure of conservative management (minimum of 3 to 6 months), characterized by recurrent swelling, pain, and mechanical symptoms.
2. Septic Bursitis: Recalcitrant to serial aspirations and intravenous antibiotic therapy.
3. Symptomatic Olecranon Spurs: Concomitant with bursitis, causing mechanical irritation or localized tenderness.
4. Inflammatory Arthropathies: Rheumatoid arthritis or gouty arthropathy presenting with severe bursal hypertrophy and loose bodies (e.g., tophi).

Preoperative Evaluation

A thorough neurovascular examination of the upper extremity must be documented preoperatively. Radiographs (AP and lateral views) are essential to evaluate for olecranon osteophytes, loose bodies, or underlying joint pathology. In cases of suspected septic bursitis, preoperative aspiration for cell count, Gram stain, and culture is mandatory.

SURGICAL TECHNIQUE: ARTHROSCOPIC BURSECTOMY (BAKER AND CUMMINGS)

The technique described by Baker and Cummings remains the foundational approach for arthroscopic olecranon bursectomy. It emphasizes safe portal placement, systematic tissue resection, and meticulous fluid management.

Patient Positioning and Setup

1. Anesthesia: General anesthesia is typically preferred. Regional anesthesia (e.g., supraclavicular or axillary block) is generally avoided or used with extreme caution, as it precludes the ability to perform an immediate postoperative neurological evaluation—a critical requirement following elbow arthroscopy.
2. Positioning: After intubation, the patient is placed in the prone position on the operating table. The operative arm is supported over a well-padded bolster or arm board, allowing the elbow to flex freely to 90 degrees.
3. Tourniquet: A high-arm pneumatic tourniquet is applied but should only be inflated if visualization is compromised, to minimize the risk of tourniquet-induced neuropraxia.

Portal Placement

Accurate portal placement is the cornerstone of a safe arthroscopic bursectomy. Three specific extra-articular portals are utilized:
1. Lateral Portal: Established first, serving as the initial viewing portal.
2. Proximal Central Portal: Located directly proximal to the olecranon tip, in line with the triceps tendon.
3. Distal Central Portal: Located distal to the olecranon tip, allowing access to the distal extent of the bursa.

Clinical Pearl: Use a standard No. 11 surgical blade to incise only the dermis. Subsequently, use a small hemostat to bluntly spread the subcutaneous soft tissue down to the bursal cavity. This blunt dissection technique pushes superficial cutaneous nerves out of the trajectory of the trocar, drastically reducing the risk of neuroma formation.

Fluid Management

Unlike intra-articular elbow arthroscopy, the olecranon bursa is a confined, superficial space. Do not use pressurized infusion. High-pressure fluid can rapidly extravasate into the subcutaneous tissues and fascial compartments of the forearm, leading to compartment syndrome or compression neuropraxia.
* Utilize a low-flow pump setting (40 to 45 mL/min) or rely entirely on gravity inflow.

The Bursectomy Procedure

1. Initial Evaluation: Introduce a 4.0-mm, 30-degree arthroscope through the lateral portal. Establish inflow through the arthroscope sheath.
2. Tissue Resection: Introduce a 4.0-mm or 4.5-mm full-radius shaver through the proximal or distal central portal. Begin a systematic, total bursectomy.
3. Portal Exchange: Frequently exchange the operative and viewing portals to ensure no loculations or hypertrophic synovial folds are missed.
4. Endpoint of Resection: The bursectomy is considered complete when two visual criteria are met:
   • Transillumination: An increase in light transmission can be seen clearly through the posterior skin.
   • Triceps Visualization: The distinct fibers of the triceps tendon and the underlying triceps muscle belly are clearly visible.
5. Fat Preservation: Exercise extreme caution to excise only minimal subcutaneous fat. Over-resection of the fat pad can lead to skin necrosis, adherence of the skin to the olecranon, and chronic posterior elbow pain.

Osteophyte Excision

If preoperative radiographs or intraoperative visualization reveal traction spurs on the olecranon tip, these must be addressed to prevent recurrence.
* Introduce an arthroscopic burr (e.g., 4.0-mm oval burr) through a central portal.
* Carefully decorticate the olecranon tip, removing the osteophyte until a smooth, flat surface is achieved. Ensure the triceps insertion is protected during this maneuver.

Closure

• Evacuate all fluid from the bursal space.
• Close the arthroscopic portals using simple interrupted 3-0 nylon sutures.
• Crucial Step: Do not inject postoperative local anesthetic into the portals or the bursal space. The presence of local anesthetic can mask iatrogenic nerve injuries, confusing the immediate postoperative neurological evaluation.

POSTOPERATIVE CARE AND REHABILITATION

The postoperative protocol is designed to prevent hematoma formation while rapidly restoring range of motion.
* Dressing: Apply a bulky, sterile compression dressing immediately in the operating room. This dressing provides mechanical compression to obliterate the dead space created by the bursectomy.
* Neurological Exam: Perform a comprehensive motor and sensory examination of the median, ulnar, and radial nerves in the Post-Anesthesia Care Unit (PACU) as soon as the patient is awake.
* Mobilization: Mobilization of the extremity should be started immediately. Early active and active-assisted range of motion (ROM) prevents capsular adhesions and stiffness.
* Follow-up: The compression dressing and nylon sutures are removed at 7 to 10 days postoperatively in the clinic.

COMPLICATIONS OF ELBOW ARTHROSCOPY

While arthroscopic bursectomy is an extra-articular procedure, surgeons performing it must be intimately familiar with the global complications of elbow arthroscopy. The proximity of the bursa to the joint capsule means that extra-articular fluid extravasation or errant instrument placement can rapidly lead to severe intra-articular or neurovascular complications.

Complications of elbow arthroscopy mirror those of other arthroscopic procedures, including infection, instrument breakage, iatrogenic scuffing of articular surfaces, tourniquet-induced ischemia, and neurovascular injuries.

Incidence of Complications

In a landmark report from the Mayo Clinic, Kelly et al. analyzed the safety profile of elbow arthroscopy. They noted a 1% incidence of true, major complications that adversely affected the final clinical outcome (e.g., permanent nerve damage, deep infection). However, they also reported a 10% incidence of lesser problems (e.g., transient neuropraxia, superficial portal infections, fluid extravasation) that increased postoperative morbidity without causing long-term sequelae.

Neurological Complications: The Primary Threat

Neurological problems are unequivocally the most commonly reported complications in elbow arthroscopy. The thinness of the elbow capsule and the intimate proximity of major nerve trunks make this joint particularly unforgiving. Savoie and Field reported approximately a 3% prevalence of neurological complications in a massive review of 465 arthroscopic procedures. Fortunately, the vast majority of these were transient injuries.

Radial Nerve and Posterior Interosseous Nerve (PIN)

The radial nerve and its deep branch, the PIN, are highly susceptible to injury during anterolateral portal placement and anterior capsulectomy.
* Jones and Savoie reported a case of severe posterior interosseous nerve injury resulting from an arthroscopic capsular release. To mitigate this risk, they strongly recommended utilizing a more proximal lateral portal, which significantly increases the anatomical distance from the radial nerve.
* Thomas et al. described direct radial nerve injury, while Guhl reported isolated injury to the superficial sensory branch of the radial nerve.
* Protection Strategy: Placing the forearm in pronation during anterolateral work drops the PIN further away from the joint line, offering a mechanical advantage and protecting the nerve.

Ulnar Nerve

The ulnar nerve is at extreme risk during posteromedial work.
* Casscells described a catastrophic, irreparable damage to the ulnar nerve during an abrasion arthroplasty of the elbow.
* Horiuchi et al., in a series of arthroscopic synovectomies in 29 elbows, noted that extreme caution must be exercised posteromedially. Due to the high risk, they explicitly avoided performing a full synovectomy or capsular release in the posteromedial gutter.

Median Nerve

Though protected by the brachialis muscle, the median nerve can be injured if instruments plunge too far anteriorly.
* Haapaniemi et al. reported a devastating complete transection of both the median and radial nerves during an arthroscopic release of a posttraumatic contracture.
* Andrews and Carson reported a transient median nerve palsy that was believed to result not from direct trauma, but from the leakage and extravasation of local anesthetic from the joint space into the anterior compartment.
* Lynch et al. reported transient low radial nerve and transient low median nerve palsies, as well as a neuroma of the medial antebrachial cutaneous nerve.

Non-Surgical Neurological Insults

Postoperative paresthesias and dysesthesias are not always the result of direct scalpel or trocar trauma. They are frequently caused by:
1. Tourniquet Ischemia: Prolonged inflation times exceeding 90-120 minutes.
2. Fluid Extravasation: High-pressure pumps forcing fluid into the fascial compartments, causing a localized compartment syndrome that compresses the nerves.
3. Blunt Trauma or Traction: Aggressive manipulation of the arm or heavy retraction.

STRATEGIES FOR COMPLICATION AVOIDANCE

To prevent serious complications from elbow arthroscopy and arthroscopic bursectomy, surgeons must possess a masterful understanding of three-dimensional anatomy and strictly perform procedures in accordance with their technical ability. As noted in the literature, the proximity of the nerves combined with the thinness of the capsule dictates that these procedures should be attempted only when high proficiency in elbow arthroscopy has been obtained.

Based on Morrey’s excellent review of elbow arthroscopy complications, the following evidence-based recommendations are mandatory for safe practice:

1. Anatomical Mapping: Carefully draw all anatomical landmarks, including the olecranon, epicondyles, and radial head, prior to tourniquet inflation and fluid distention.
2. Ulnar Nerve Palpation: Always palpate and mark the location of the ulnar nerve. Subluxating ulnar nerves require altered portal placement.
3. Capsular Distention: Obtain adequate capsular distention (typically 15-25 mL of fluid) before establishing intra-articular portals to push neurovascular structures away from the joint line.
4. Optimal Positioning: Place the elbow in exactly 90 degrees of flexion during portal establishment. This position relaxes the anterior capsule and maximizes the capacity of the joint.
5. Proximal Portal Utilization: Favor more proximal portals (e.g., proximal anterolateral) to increase the margin of safety from the radial and median nerves.
6. Strict Fluid Management: Do not use pressurized infusion. A low flow of 40 to 45 mL/min or simple gravity inflow can be used safely and effectively.
7. Dynamic Nerve Protection: Protect the posterior interosseous nerve by maintaining the forearm in pronation during lateral compartment work.
8. Mechanical Retraction: Use an arthroscopic retractor or the arthroscope sheath to physically lift the capsule away from aggressive débridement instruments (shavers/burrs).
9. Visual Control: Keep instrument tips in full view at all times. Never activate a shaver or burr blindly.
10. Suction Discipline: Avoid using suction when working in close proximity to nerves or the capsule to prevent drawing capsular tissue and adjacent nerves into the shaver blade.
11. Avoid Local Anesthesia: Do not inject local anesthetics at the conclusion of the case, as this will confound the mandatory immediate postoperative neurological evaluation.

CONCLUSION

Arthroscopic olecranon bursectomy is a highly effective, minimally invasive procedure that offers significant advantages over traditional open techniques, particularly regarding wound healing and postoperative morbidity. By utilizing a prone setup, specific central and lateral portals, and meticulous shaver technique, surgeons can achieve a complete bursectomy and osteophyte resection. However, the elbow remains an unforgiving anatomical region. Mastery of fluid management, strict adherence to safe portal zones, and a profound respect for the surrounding neurovascular anatomy are imperative to prevent the devastating complications associated with elbow arthroscopy.