Arthroscopic Treatment of Elbow Loss of Motion

DEFINITION Loss of motion is a common sequela of elbow trauma or the natural progression of nontraumatic conditions of the elbow, significantly impairing function of the upper extremity and hindering performance of activities of daily living (ADLs). A functional arc of 100 degrees (30 to 130 degrees) in flexion and extension, along with 100 degrees in pronation and supination (50 degrees each), is required for most ADLs.19 Neighboring joints offer little compensatory function, making elbow stiffness poorly tolerated. Stiffness may be due to intrinsic (intra-articular) or extrinsic (extra-articular) causes (Table 1) or a combination of both.6,14 Posttraumatic stiffness is most common, but osteoarthritis, inflammatory conditions, systemic injuries (head trauma), and neurologic disorders may also cause elbow joint contractures. Loss of extension is most common, although loss of flexion is more poorly tolerated due to an inability to reach the face for eating or grooming.18 The key to treatment is identifying and correcting the functional and occupational impairment; decisions should not be based solely on the absolute loss of motion of the elbow.11 Arthroscopic treatment of elbow stiffness is intended to restore motion, function, and relieve pain when present.23
	Table 1 Classification of Elbow Stiffness Based on Location of Structure in Relation to the Elbow Joint     Type Location Description     Intrinsic Within the Articular incongruity after fracture, degenerative changes and elbow joint loss of cartilage, intraarticular adhesions, loose bodies, synovitis, infection     Extrinsic Tissues Soft tissue and capsular contracture, muscle fibrosis (brachialis immediately especially), collateral ligament stiffness, to the elbow joint adjacent heterotopic ossification, skin contractures     Peripheral Factors Stroke, neurologic problems, peripheral nerve disorder, head anatomically injury, cerebral palsy

From Jupiter JB, O’Driscoll SW, Cohen MS. The assessment and management of the stiff elbow.

AAOS Instr Course Lect 2003;52:93-111.

Arthroscopic treatments may range from capsular release alone to osteocapsular arthroplasty, including the

removal of loose bodies, osteophytes, and capsulectomy.22

separate from

the elbow

 

 

ANATOMY

 

The elbow is anatomically predisposed to stiffness by virtue of the close relationship of the capsule to the surrounding ligaments and muscles, along with the presence of three joints within a synovial-lined joint cavity—

(a hinge ginglymus) ulnohumeral articulation and rotatory (trochoid) radiocapitellar and radioulnar joints.11

 

The anterior elbow capsule attaches proximally above the coronoid fossa and distally extends to the coronoid medially and annular ligament laterally. The posterior capsule starts proximally just above the olecranon fossa and inserts at the articular margin of the sigmoid notch and annular ligament (FIG 1).

 

The anterior capsule is taut in extension and lax in flexion, with strength derived from the cruciate orientation of its fibers.

 

The greatest capsular capacity is at 80 degrees flexion.9,24 The normal capacity of 25 mL can be reduced to as little as 6 mL in a contracted state.9,24

 

The joint capsule is innervated by branches from all the major nerves crossing the joint along with the musculocutaneous nerve.16

 

The cubital tunnel, which houses the ulnar nerve at the elbow, becomes compressed in flexion (due to stretching of the retinaculum between the olecranon and medial epicondyle) and loosens in extension.

 

Flexion contractures may adversely compress the ulnar nerve, leading to ulnar neuropathy (FIG 2).

 

PATHOGENESIS

 

O’Driscoll23 describes four stages of posttraumatic elbow stiffness:

 

 

Bleeding: minutes to hours

 

Edema: hours to days. Both bleeding and edema cause swelling within the joint and surrounding tissues, and the capsule become biomechanically less compliant. Early elbow range of motion through an entire range during stages 1 and 2 can help prevent stiffness.

 

Granulation tissue: days to weeks. Splints can be used to regain range of motion.

 

Fibrosis: Maturation of the granulation tissue further decreases compliance. More aggressive splinting is necessary, along with possible surgical management.

 

 

 

 

 

 

FIG 1 • Anatomic drawing of elbow capsular structures. The anterior (A) and posterior capsular areas (B) are highlighted. The anterior capsule distally extends to the coronoid medially and annular ligament laterally. C. Lateral diagram of the elbow shows the capsular size and fat pad.

 

 

The posttraumatic joint capsule is sensitive to contracture, secondary to an increase in disorganized collagen fiber deposition at the cellular level, resulting in thickening that translates into loss of flexibility and joint volume.9,16,23

 

The reasons for altered capsular properties are multifactorial and not completely known.

 

 

Myofibroblasts, cells that enhance collagen production and tissue contraction, increase in number in the posttraumatic anterior capsule.10

 

Collagen formation, cross-linking, and hypertrophy increase while water and proteoglycan content decrease in the contracted elbow tissue.1

 

Increased matrix metalloproteinase activity and collagen disorganization have also been described in the contracted capsular tissue.10

 

Growth factors and other cellular mechanisms may be involved. This is highly variable among individuals.17

 

Heterotopic ossification may also occur in conjunction with capsular thickening and act as a bony block to motion. Patients most at risk are those with combined head and elbow trauma, burn patients, and those who have undergone surgical approaches to the elbow, all of which are believed to incite a complex inflammatory

NATURAL HISTORY

 

The onset and progression of elbow stiffness is closely related to its inciting causes (see Table 1); most contractures have mixed elements.14

 

Posttraumatic contracture is most common and is associated with a failure to regain motion after a direct traumatic injury to the elbow joint rather than progressive elbow motion loss. A posttraumatic contracture will typically remain stable over the long-term unless intra-articular degenerative changes ensue that would worsen motion further.

 

Contractures associated with degenerative or inflammatory arthritis may slowly progress with time due to capsular contraction and impingement on osteophytes or hypertrophic synovium. Such cases will often have episodic flares of swelling and stiffness in combination with steady baseline progression.

 

 

Morrey17 has also characterized elbow stiffness as static or dynamic based on tissue involvement (Table 2).

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

 

It is critical to determine the degree of functional impairment and duration of symptoms for each patient. Management decisions should be based on subjective

 

impairment and demands, not necessarily the amount of motion loss.11

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FIG 2 • Anatomic location of the ulnar nerve at the elbow (A), which is contained in the cubital tunnel (B).

 

 

Associated disorders should be identified, as peripheral or central neurologic pathology may influence management decisions.

 

 

Hand dominance, the patient’s occupation, and the extent of prior therapy should be noted.

 

Physical examination

 

 

 

The cranial nerves and cervical spine should be examined to assess for neurologic pathology. Shoulder motion and strength is assessed.

 

Careful assessment of the ulnar nerve

 

 

The physical examination is critical, as the patients will often not even recognize the presence of ulnar neuropathy in the setting of their adjacent elbow pathology. The elbow flexion and ulnar nerve

compression test is the most sensitive for detection of ulnar nerve entrapment at the elbow.21

 

Classification

Relative Occurrence

Location

Description

 

Table 2 Characterization of Elbow Stiffness by Tissue Involvement

Static

Most

common

Tissues in and

around the elbow joint

Capsule, ligaments, heterotopic

ossification, articular and cartilaginous components

Dynamic

Less

common

Involves Poor muscle tone, nerve injuries, and poor

muscles around excursion of the muscles that cross the the joint elbow joint

From Morrey BF. The stiff elbow with articular involvement. In: Jupiter JB, ed. The Stiff Elbow.

Rosemont, IL: American Academy of Orthopaedic Surgeons, 2006:21-30.

 

 

Two-point discrimination: Although less than 6 mm is considered normal, careful comparison to the ipsilateral median nerve and contralateral ulnar nerve is necessary to detect subtle signs of nerve damage.

 

Froment sign and intrinsic hand muscle function: Weakness of the adductor pollicis or interossei may also signify ulnar neuropathy.

 

The cubital tunnel is palpated to assess for tenderness or a positive Tinel sign.

 

Elbow range of motion: Flexion and extension are tested with the shoulder flexed to 90 degrees, whereas pronation and supination are evaluated with the elbow held in flexion at the side of the body.

 

 

Measure the flat surface of the forearm just proximal to the wrist in comparison to the axis of the humerus. Measurements in supination can be erroneous if tested through the palm because patients can often compensate with significant intercarpal supination.

 

 

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Measurements can also be erroneous in obese patients who cannot fully adduct the arm to the side, as they will appear to have a deficit in supination if the measurement is compared to the trunk axis and not the abducted humerus, which stresses the importance of using the humerus and not the trunk as the reference point.

 

Elbow instability: The surgeon should check the ligamentous restraints to varus and valgus stress, as concomitant elbow instability and stiffness may occur after elbow dislocation or subluxation.

 

Ligaments are assessed with varus and valgus stress at 0 and 30 degrees of flexion as allowed by the patient’s range of motion.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Plain radiographs (anteroposterior [AP] and lateral) are usually adequate.

 

 

The AP provides joint line and subchondral bone visualization.

 

 

If an elbow is contracted more than 45 degrees, the AP view of the joint line is usually distorted.17

 

The lateral view may show osteophytes on the olecranon or coronoid processes or within their respective fossae (FIG 3A,B).

 

Radiographs can be used to follow the maturation process of heterotopic ossification, which usually signifies multiple extrinsic causes of elbow contracture that preclude arthroscopic treatment (FIG 3C).

 

Computed tomography (CT) is useful to better characterize impinging osteophytes, loose bodies, and intraarticular non- or malunions. These studies are often more for preoperative planning than for diagnostic purposes

 

Magnetic resonance imaging (MRI) has a limited role in the management of elbow stiffness but is the favored imaging study for staging and diagnosis of osteochondritis dissecans lesions and ulnar collateral ligament insufficiency, both of which not uncommonly will be accompanied by loss of motion. Fortunately, the age and history in these patients are quite specific, which helps narrow the differential diagnosis.

 

 

 

FIG 3 • A. Preoperative lateral radiograph of an elbow before arthroscopic resection of osteophytes at the olecranon and coronoid, with associated anterior capsular contracture. Heterotopic ossification is absent. B. Postoperative radiograph after resection of osteophytes. C. Lateral radiograph of an elbow with heterotopic ossification. Arthroscopic resection is not recommended in this type of patient.

 

DIFFERENTIAL DIAGNOSIS

 

 

 

 

Elbow fracture-dislocation Osteoarthritis/posttraumatic arthritis Inflammatory arthropathy Osteochondritis dissecans

 

Ulnar collateral ligament insufficiency with posteromedial impingement

 

 

 

Heterotopic ossification Closed head injury Burns

 

 

Dysplastic radial head (congenital) Neuromuscular disease

 

Stroke

 

NONOPERATIVE MANAGEMENT

 

Nonoperative management should be considered up to 6 months after contracture onset.14

 

Response is better if there is a soft “spongy” end point during range of motion14,23; bony blocks to motion such as heterotopic ossification or osteophytes are unlikely to respond to stretching protocols.

 

The goal is to gain motion gradually without causing additional trauma to the capsule and, subsequently, development of additional capsular contracture (more pain, inflammation, and swelling leads to more contracture).

 

Edema control is critical, and therapy should focus on this, not exercises that induce inflammation around the elbow.

 

Static-progressive splinting is indicated as a first-line treatment for capsular contracture and should be used

three times daily in between therapy sessions.11,18 Dynamic splints yield results comparable to static progressive but are often less well tolerated as they provide a constant tension over time rather than allowing

stress relaxation of soft tissues.16,20 Care should be taken not to be overly aggressive in stretching as this may incite an inflammatory process leading to further capsular contracture. Regardless of whether static or dynamic splinting is chosen, this type of splinting can be beneficial for up to 1 year in treating posttraumatic elbow

stiffness.16

 

 

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Nonoperative improvements in range of motion vary widely. A systematic review by Müller20 found an average improvement of 40 degrees with static-progressive splinting, but results of 10 to 50 degrees or more have been reported.14,17,23

SURGICAL MANAGEMENT

 

The key is to identify the functional disability of the patient— pain, loss of motion, or both—and what would be most beneficial to correct.

 

The indications include a loss of function precluding the patient from performing ADLs and occupational or vocational activities.

 

Arthroscopic treatment of elbow stiffness should be undertaken only if the offending structures can be treated from an arthroscopic approach. Capsular contractures and intraarticular osteophytes are ideally suited for arthroscopic treatment, whereas articular malunion, heterotopic ossification, or skin and muscle contractures are not amenable to arthroscopic release.

 

Appropriate counseling with the patient should cover realistic expectations of range of motion and functional recovery. Will patients be able to get their hand to their mouth, comb their hair, or reach behind their back, or are more extensive demands required?

 

There are several contraindications to arthroscopic release:

 

 

Prior surgery that has altered the neurovascular anatomy, especially of the radial nerve from previous surgery in the area of the radial head

 

Joint deformity that would compromise arthroscopic viewing, such as with severe posttraumatic malunion or inflammatory arthritis

 

Arthroscopy is also less favored for pathology best treated through an open approach such as heterotopic ossification or a fracture malunion that requires osteotomy.3,26,27

Preoperative Planning

 

An examination under anesthesia helps to distinguish static versus dynamic elbow stiffness and should confirm the preoperative clinical diagnosis.

 

 

 

FIG 4 • A,B. Setup of patient for elbow arthroscopy in lateral (A) and prone (B) positioning. C. Landmarks of the elbow drawn for operative incisions and to identify at-risk structures, including the ulnar nerve, in the prone position.

 

 

A thorough understanding of the pathoanatomy will allow the surgeon to plan the surgical order of events to maximize surgical efficiency and optimize patient safety.

 

 

In the presence of osteophytes or loose bodies, a CT scan with two-dimensional coronal and sagittal reconstructions as well as three-dimensional surface renderings may be helpful to provide a “road map” for the osteocapsular arthroplasty.

 

If the posterior compartment medial and lateral gutters require extensive work, it may be technically easier to

perform this first before significant soft tissue swelling evolves. Visualization of the anterior compartment in the presence of soft tissue swelling can be better accommodated by the use of arthroscopic retractors.

 

If the preoperative examination documented ulnar nerve irritation or neuropathy or if the patient has a subluxating ulnar nerve,3 it should be exposed and an in situ release across the elbow joint be performed.

 

We recommend that the ulnar nerve be released before arthroscopy for ease of soft tissue dissection before fluid distention.

 

In patients with elbow flexion of less than 100 degrees, the nerve should be prophylactically released to prevent compression once flexion is restored postsurgically.17

 

Exploration and identification of the nerve prior to arthroscopy is also mandatory for patients who have undergone a prior ulnar nerve transposition. Open release may be preferable for these patients.

 

Following release, the nerve must be protected during placement of the anteromedial portal to prevent iatrogenic injury.

 

Positioning

 

Either the lateral decubitus or prone position can be used, with the operative extremity supported by either an arm cradle or rolled sheets (FIG 4A,B).

 

 

A well-padded sterile tourniquet is used to optimize viewing by limiting intra-articular bleeding. The remainder of the arthroscopic setup has been described elsewhere.

 

The surgeon should clearly mark the course of the ulnar nerve, portal sites, and bony landmarks with surgical marker (FIG 4C).

 

 

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Approach

 

Arthroscopic elbow osteocapsular arthroplasty should proceed in a stepwise fashion.

 

 

 

Establish a view—get into the joint and confirm your anatomic orientation. Create a working space—synovectomy and removal of debris

 

Bone removal—retractor is used to hold soft tissue away from burr or shaver blade.

 

Capsulectomy—using a large shaver can optimize fluid outflow and act as a periosteal elevator to strip soft tissue off bone before resection.

 

Capsular contraction and loss of volume complicates arthroscopic visualization of the stiff elbow but can be greatly facilitated through the use of arthroscopic retractors placed through proximal medial and proximal lateral portals 1 to 2 cm above the standard medial and lateral portals.22,23

 

Avoiding nerve injury during the approach and during capsular treatment is critical.

 

If required, the ulnar nerve is decompressed and protected prior to arthroscopy in order to avoid soft tissue distortion due to fluid extravasation (FIG 5).

 

 

 

FIG 5 • If the ulnar nerve is thought to be involved, it may be released before starting the arthroscopy to facilitate dissection without the soft tissue changes that occur after fluid extravasation from the elbow joint. The ulnar nerve is marked with a vessel loop.

 

TECHNIQUES

• Ulnar Nerve Release and Transposition

  Subcutaneous transposition or in situ decompression of the ulnar nerve can be performed; these techniques are described elsewhere within this text.

  The ulnar nerve is exposed before performing the arthroscopic release to allow gentle fluid extravasation from the soft tissue posteromedially.23

  Gentle retraction on the nerve with a Penrose drain can help protect it while performing arthroscopic releases in this area, especially posteromedial osteophytes.

• Portal Establishment in the Contracted Elbow

The joint is distended with saline through the “soft spot” portal (up to 40 mL, as allowed by contracture). Portals are established.

The proximal anteromedial portal is established first (2 cm proximal to the medial epicondyle and 1 cm

 

anterior to the intermuscular septum). A 4.5-mm, 30-degree scope is used for visualization (TECH FIG 1A,B).2

 

 

 

TECH FIG 1 • A. Arthroscopic view of a right elbow joint after first obtaining scope entry into the proximal anteromedial portal, looking laterally. There is synovitis in the joint. B. After the synovitis is gently débrided with an arthroscopic shaver, the bony overgrowth of the coronoid and radial fossa is revealed. There is a lack of concavity in the trochlea and capitellum area. C. Arthroscopic view of elbow joint viewed from the medial portal, showing the increased visualization of the elbow joint that is obtained with the use of intra-articular retractors. C, capitellum; RH, radial head; T, trochlea.

 

 

The proximal anterolateral portal (1.5 to 2 cm proximal to lateral epicondyle) is useful as a retractor portal to improve distention and visualization. The portal is established with either a blunt-tipped Wissinger rod as an inside-out technique or a spinal needle under direct visualization using an outside-in technique. (TECH FIG 1C).

 

Blunt elevation with the Wissinger rod, a freer elevator, or specially designed retractors will help create a working space by lifting the capsule away from the joint and anterior humerus.

 

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Avoid excessive inflow and high-pump pressures (>35 mm Hg), which will lead to increased fluid extravasation and extra-articular soft tissue distention that will impair visualization.

 

A 4.5-mm shaver (oscillate function) débrides intra-articular synovitis or loose flaps of articular cartilage.

 

A small radiofrequency device can also be used to ablate scar tissue within the joint. Inflow should be increased during the use of thermal energy to prevent cartilage injury.

 

Impinging osteophytes of the coronoid tip and coronoid or trochlear fossae can be resected with a burr or shaver, if necessary.

 

Direct the burr away from the capsule to prevent accidental injury to the anterior neurovascular structures.

 

The capsule is débrided superficially to define it as a structure and clear any synovitis; however, it is not removed until all intraarticular débridement, both bony and soft tissue, has already been carried out so as to limit fluid extravasation.

• Anterior Capsular Release

   

  Capsulotomy of the anterior capsule is performed with an arthroscopic basket cutter or radiofrequency ablation, from lateral to medial, along the nonarticular distal humerus.

   

  The radial nerve rests on the anterior capsule at the level of the radial head. To prevent injury to it, the capsulotomy should be performed as close to the humerus as possible.

   

  The posterior interosseous nerve (PIN) is adjacent to the anterolateral capsule at the level of the radial neck.26

   

  The capsulotomy can be continued to the level of the collateral ligaments on each side, but the ligaments are not incised.

   

  The brachialis muscle can be visualized and the plane between the capsule and brachialis developed from the lateral working portal (TECH FIG 2A).

   

   

   

  TECH FIG 2 • A. Arthroscopic view of the elbow joint after capsulectomy and deepening of the coronoid and radial fossae. The dissection is carried down to the fibers of the brachialis muscle but does not violate the brachialis (retracted structure). B. View from the lateral portal shows the partially completed release.

  Bony work and resection are completed before capsulectomy. The concavity of the coronoid and trochlear fossae areas is restored, but anterior capsulectomy is not yet completed. AC, anterior capsule; C, capitellum; RH, radial head; T, trochlea.

   

   

  The brachialis protects the median nerve, so the surgeon should avoid penetrating this muscle. The fibers of the brachialis serve as the marker that the capsule has been released to an appropriate depth.

   

  The arthroscope is then moved to the anterolateral portal and the same steps of capsular release performed to ensure adequate medial release (TECH FIG 2B).

   

  Check passive extension after excision of posterior osteophytes and anterior capsulotomy alone, and if sufficient extension is restored, then complete capsulectomy can be avoided.

   

  A wide capsulotomy fully from medial to lateral off the humerus is often sufficient for the anterior release without endangering the neurovascular structures that are more at risk with a complete capsulectomy.

• Posterior Capsular Release

 

Portals are established:

 

The posterocentral viewing portal (3 to 4 cm proximal to the olecranon tip, through the triceps) is established first; it must be placed sufficiently proximal to clear the olecranon tip and enter the olecranon fossa.

 

A proximal posterolateral working portal (2 cm proximal to the olecranon tip and lateral to the triceps) is also established using an outside-in technique.

 

A shaver is used to débride the posterior fat pad and open the posterior working space, avoiding shaving medial to the midline and certainly in and along the medial gutter until full visualization is obtained.

 

The capsule is elevated from the distal humerus using blunt dissection or an elevator.

 

Visualization and débridement of the posterior radiocapitellar joint can be facilitated using a midlateral (soft

spot) working portal.

 

Viewing through the posterolateral portal, the midlateral portal is made under direct visualization using a spinal needle placed through the soft spot toward the posterior radiocapitellar joint.

 

An arthroscopic shaver is in used in this portal to débride the posterior capsule and arthrofibrosis. Suction is avoided in and along the medial gutter.

 

Loose bodies and impinging osteophytes are removed before capsular resection to optimize visualization.

 

 

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Osteophytes are resected from the olecranon fossa, posterior capitellum, and olecranon tip using an arthroscopic burr or shaver.

 

When necessary, osteophytes involving the medial gutter should be removed with care. Using a burr or serrated shaver may inadvertently draw the ulnar nerve into harm’s way. For this reason, it is recommended to use a shaver blade instead.

 

 

Up to 14 mm of the olecranon tip can be resected without injury to the triceps tendon.12 A small open arthrotomy may be required at times for removal of larger loose bodies.

 

The posterior capsule is released with a basket cutter or arthroscopic elevator on the medial and lateral sides; care should be taken to avoid capsular release medial to the olecranon fossa to avoid injury to the ulnar nerve.

 

The posteromedial capsule (posterior band of the medial collateral ligament) should be resected in the setting of significant flexion loss. Release of this tissue does not risk medial-sided elbow instability.25

 

 

 

TECH FIG 3 • A. View from the lateral portal after medial release showing completed capsulectomy and bony débridement in the coronoid fossa area. B. Loose bodies are removed during this procedure via a 5-mm smooth cannula. CF, coronoid fossa; T, trochlea.

 

 

Care should be taken to protect the ulnar nerve, as this tissue represents the floor of the cubital tunnel. If a posteromedial release is planned, a limited open ulnar nerve decompression or full transposition should be performed prior to arthroscopy.

 

Release is performed along the olecranon, rather than the humerus, as this portion of the capsule is furthest from the ulnar nerve.

 

Use of radiofrequency ablation or suction medially should also be avoided to protect the nerve.

An open arthrotomy through the ulnar nerve incision carries minimal morbidity and can be very useful to access the posteromedial capsule for release and the olecranon tip for excision in cases where the arthroscopic visualization is limited.

Final inspection from both portals is done to ensure adequate release (TECH FIG 3).

• Wound Closure and Intraoperative Splinting

A drain is placed through the proximal anterolateral portal because accumulation of fluid and postoperative bleeding will compromise range of motion.

Our postoperative dressing is a soft bulky dressing with Webril, Kerlix, and Ace bandages from wrist to shoulder. Material is cut out from the antecubital fossa in order to facilitate flexion (TECH FIG 4).

Continuous passive motion (CPM) can be initiated on postoperative day 0 at the surgeon’s discretion.

 

TECH FIG 4 • A. Postoperative dressing is applied to the patient after capsular release in the operating room with a drain. B. Flexion obtained after removing splint material from the antecubital fossa. C. Immediate continuous passive motion is instituted.

 

Alternatively, an anterior plaster slab is placed to keep the elbow near full extension and alternating resting flexion and extension splints are used.

Indwelling catheters, a long-acting regional block, or cryotherapy may be used to facilitate CPM (from full flexion to extension).

 

 

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PEARLS AND PITFALLS
	Managing the ▪ Prophylactic release before arthroscopy if flexion contracture is significant or if ulnar nerve examination consistent with neuropathy or neuritis.   Optimizing ▪ Use arthroscopic retractors to aid visualization in anterior and posterior visualization compartments.   Avoiding ▪ The surgeon should avoid motorized burrs. No suction should be used on the neurovascular shaver in at-risk areas. Use of arthroscopic retractors is recommended. injury   Anterior ▪ Using a basket and retractor, develop the plane between capsule and brachialis osteocapsular until the defined fat stripe over the midportion of radiocapitellar joint, which release represents the radial nerve. Watch for PIN adjacent to anterolateral capsule

 

 

 

distally.

 

Posterior osteocapsular release

• Consider performing first if working in medial and lateral gutters. Retract the ulnar nerve and use a shaver blade to avoid iatrogenic nerve injury.

 

POSTOPERATIVE CARE

 

CPM can be continued at home up to 4 weeks and should be used in full range of motion (0 to 145 degrees) with a bolster behind the elbow.26

 

Daily physiotherapy is instituted immediately postoperatively, with home static- (preferred) or dynamic-progressive splinting.

 

The surgeon should consider prophylaxis of heterotopic ossification with indomethacin. Single-dose external beam irradiation is only considered in the most severe cases of heterotopic ossification, in which case, the release is typically performed open.

 

OUTCOMES

Patients usually regain about 50% of lost motion.11,23

About 80% of patients obtain a functional arc of motion greater than 100 degrees.11

A systematic review by Kodde et al15 found a mean gain in arc of motion of 40 degrees (from 84 to 124 degrees) with arthroscopic elbow release, although gains of up to 80 degrees have been reported.26

Ball et al3 reported high patient satisfaction and recovery of function after surgery, with all patients in the series stating they wound undergo surgery again.

In high-level athletes undergoing arthroscopic release for loss of terminal extension (<35 degrees), the average loss of flexion improved from 27 degrees to 6 degrees, and 23 of 26 athletes returned to the

previous level of performance.4

It is difficult to compare arthroscopic versus open capsular releases as arthroscopic surgery is typically performed for less severe disease, whereas open release is preferred for more complex cases.15

 

 

COMPLICATIONS

The overall complication rate for arthroscopic release is low (5% vs. 23% for open surgery).15

Blona et al5 reported no permanent neurologic injuries in a series of over 500 elbow arthroscopic releases for stiffness. In less experienced hands, a neurologic injury is more likely and the learning curve should be appreciated.

Persistent stiffness requiring a second surgical release is the most common complication.15 Ulnar nerve

Although the overall rate of ulnar nerve injury with elbow arthroscopy is low (1%), the preoperative diagnosis of elbow contracture and performance of a capsulectomy are both risk factors for transient

 

 

ulnar nerve palsy.13

In the medial aspect of joint, the surgeon should use retractors to move the capsule medially and avoid resection along the humerus, or identify and protect the ulnar nerve through a small open incision prior to any work in the posteromedial gutter.

Ulnar neuritis

If present preoperatively, or there will be a significant increase in flexion after surgery, the ulnar nerve should be released.

Postoperatively, it may be transient; there is a much lower incidence if it is transposed during the initial surgery.

Radial or PIN

 

The overall rate of radial or PIN nerve palsy with elbow arthroscopy is 1%.13

Iatrogenic injury can be avoided by refraining from use of suction when working near the capsule anterior to the midline of the radiocapitellar articulation.

Retractors of soft tissue are used to improve visualization and distention.

Median or anterior interosseous nerve

Iatrogenic injury is avoided by not penetrating the brachialis muscle.

The surgeon should place portals carefully, avoiding moving more anterior than necessary.

Excessive bony resection leading to iatrogenic fracture or inadvertently aggressive resection of soft tissues surrounding the radial head leading to violation of the collateral ligament and elbow instability

When working in the anterolateral joint, avoid débriding further posterior than the equator of the radiocapitellar joint, as this corresponds to the superior margin of the lateral collateral ligament.8

 

REFERENCES

1. Akai M, Shirasaki Y, Tateishi T. Viscoelastic properties of stiff joints: a new approach in analyzing joint contracture. Biomed Mater Eng 1993;3:67-73.

    

    

2. An K, Morrey BF. Biomechanics of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. Philadelphia: WB Saunders, 2000: 43-74.

    

    

3. Ball CM, Meunier M, Galatz LM, et al. Arthroscopic treatment of posttraumatic elbow contracture. J Should Elbow Surg 2002;11:624-629.

    

    

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4. Blonna D, Lee G, O’Driscoll SW. Arthroscopic restoration of terminal elbow extension in high-level athletes. Am J Sports Med 2010;38:2509.

    

    

5. Blonna D, Wolf JM, Fitzsimmons J, et al. Prevention of nerve injury during arthroscopic capsulectomy of the elbow utilizing a safetydriven strategy. J Bone and Joint Surg Am 2013;95:1373-1381.

    

    

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