This video presentation will provide an introduction to elbow arthroscopic osteocapsular arthroplasty for the treatment of osteoarthritis of the elbow. Arthroscopic osteocapsular arthroplasty has been utilized as a surgical technique for mild to moderate osteoarthritis of the elbow in a young active patient. In this video, pertinent history physical exam findings will be noted. The surgical procedure will be highlighted and short-term post-operative clinical examination will be shown to form a cohesive treatment plan for elbow osteoarthritis. Indications include mild to moderate osteoarthritis of the elbow, loose bodies, and elbow contractions. Contraindications include severe osteoarthritis of the elbow, elderly low-demand patients, or situations with prior severe trauma which may alter the anatomic location of the owner. In this video, the patient's a 67-year-old male retiree. He has pain with strenuous activities and activities of daily living. His elbow range of motion is from 40 to 125 degrees. His preoperative visual analog scale is 3.6, his dash score is 23, and male elbow performance from 60. The patient's interoperative motion is demonstrated here where he has flexion to 125 degrees and extension to 40 degrees short full extension. In the next image, you will see he has full pronation and supination. The APU view of the right elbow demonstrates mild olohumeral and radiocapitellar joint space narrow. This lateral radiograph demonstrates loose bodies in the anterior aspect of the joint, as well as osteophyte formation at the tip of the coronoid and olecranon. There are matching osteophytes in the olecranon, coronoid, and radial adipocytes. The patient can be positioned in supine, lateral, or prone. I prefer prone positioning as no specialized equipment is required to support the arm, and the arm can be freely moved from maximum flexion and extension during kicks. The disadvantages of prone positioning are the effort required to roll the patient into the correct position, and a patient with respiratory disorders or significant shoulder pathology may not tolerate it. The equipment that is used is similar to that which is used in standard knee arthroscopy. The arthroscope is a 4.0 millimeter 30 degree scope, and it's used in most cases, but one should have a 2.7 millimeter scope available for use in smaller spaces within the joint. Standard arthroscopic handheld instruments should be available, and I like to use a shaver such as a 4.0 millimeter one for synovectomy and capsulotomy. I also like to have a 4.0 hooded burr available for spur removal. Arthroscopic osteotomes, curettes, and cobs may also be useful throughout these cases. My first step is to mark out the surface landmarks including the medial epicondyle, lateral epicondyle, radial head, capitellum, and olepranon. The ulnar nerve should be palpated and marked as well. Distention of the joint is critical for a successful elbow arthroscopy. Fluid insufflation helps distend the joint capsule, remove the neurovascular structures away from the site of portal insertion. An 18 gauge spinal needle is placed into the joint through the posterior soft spot. A normal joint makes up up to 25 milliliters of fluid. I prefer to perform these surgeries under tourniquet control, but I start with the first portal, the proximal anteromedial portal, by making a small incision with an 11 blade scalpel, localized two centimeters proximal to the medial epicondyle, and one centimeter anterior to the intermuscular septum. I use a hemostat to spread through the soft tissues, feel the intermuscular septum with the tip of the hemostat, and then I direct the trocar towards the humerus angled towards the radial head. The blunt hemostat or trocar is used to penetrate the joint and avoid any damage to the cartilage. Backflow of fluid is seen once the joint is penetrated. The median nerve is about 19 millimeters from this portal and the ulnar nerve 21 millimeters. The medial anabrachial cutaneous nerve is six millimeters away. The proximal medial portal is good for viewing the entire joint anteriorly. This joint is full of loose bodies and synovitis. The radial head is identified by pronating and supinating the forearm. The annular ligament is identified as well and the coronoid process and its articulation with the trochlea is visualized. A switching stick is then introduced through the proximal medial portal to create the anterolateral portal which is typically two centimeters distal and one centimeter anterior to the lateral fecondyle. The scope was directed to a location anterior to the radial head and cavitellum. The switching stick is then used to penetrate the soft tissues bluntly and separate incisions made and dilators used to create a channel to accept the cannula. The radial nerve is approximately three millimeters from this portal. Synovitis debris and loose bodies are removed with a motorized shaver to gain better visualization. Here you can see a view of the joint with the coronoid on the bottom right and radial head towards the top of the screen. Once again the radial head is seen best with rotation of the forearm. An arthroscopic grasper is introduced through the proximal anterolateral portal to remove loose bodies. Now that the joint has been debrided anteriorly with flexion and extension you can easily see the radial head, cavitellar articulation, and the coronoid articulation with the trochlea. Here there's a large anterior humeral osteophyte as well that can be seen. Use of an arthroscopic ablator probe can be useful to remove soft tissue from the anterior osteophyte on the humerus allowing better visualization prior to removal with a 4.0 hooded bur. The 4.0 millimeter hooded bur removes osteophytes very easily. One must be careful as the bur can easily pass through the coronoid osteophyte and damage the trochlea articular surface. The goal is to remove the bone with the bur leaving a small rim of subchondral bone cartilage which is then removed with a curette. In this case overzealous use of the bur on my part resulted in damage to the trochlea. This is an uncommon complication and will not likely affect the outcome of surgery but I feel that it's important to point out. Further debridement was required to remove a very large loose body from the joint. An arthroscopic curette is introduced through the lateral portal and is utilized to remove the subchondral bone cartilage from the tip of the cornoid. With flexion and extension of the joint you can see that the tip of the cornoid has been removed and no longer will impinge with the cornoid fossa. The small defect in the trochlear cartilage is evident but doesn't appear to be causing any impingement with the cornoid. The view that we see here is from the lateral portal and a shaver has been introduced into the joint in order to remove a very large loose body which is attached to the anterior capsule. The shaver can be utilized to break apart adhesions between the loose body and the capsule. Once it's been loosened up a grasper can then be introduced through the medial portal in order to remove the loose body. Now we're visualizing the joint again from the medial side looking laterally. The biter is introduced through the lateral portal and is used to form a capsulotomy. In my earlier experience with this technique I used a four millimeter shaver without suction to form the capsulotomy and over the last few years I've performed the capsulotomy entirely with the arthroscopic biter. In this view you can see that the capsule has been completely released and the brachialis is visualized towards the right of the screen. The straight posterior portal is created through a small incision through the skin localized two centimeters proximal to the tip of the lacrinon. The posterior lateral portal is three centimeters lateral to the straight posterior portal. It's also created with a small incision. A blunt dissection is performed with a curved hemostat down to the level of the lacrinal fossa. The scope is introduced through the direct posterior portal and the shaver through the posterior lateral portal. These portals allow for full visualization of the lacrinon fossa which gives you the opportunity to perform synovectomy, juice body removal, as well as osteophyte incision. In order to gain better visualization the fat pad has been partially removed by the shaver. The grasper can be introduced into the posterior aspect of the joint to remove loose bodies. Here you can see that I'm using again a cautery probe to elevate capsular tissue off of the posterior aspect of the humerus. Again more loose bodies are removed. The tip of the lacrinon impinges against osteophytes which are formed in the lacrinon fossa. These osteophytes will be removed with a 4.0 burr as well as osetones. The direct posterior portal can then be used to visualize the medial gutter. Here you can see that there's an osteophyte in the posterior aspect of the lacrinon. Another view of the lacrinon fossa of the osteophyte. Here the burr is being brought in to remove the osteophyte from the lacrinon fossa. Some surgeons advocate complete fenestration of the lacrinon fossa with the burr similar to an outer bridge Kashiwagi type procedure. I have not found that it is needed in these cases and I've been able to achieve good extension without complete fenestration. Now we're visualizing the joint from the posterior lateral view. Flexion extending the elbow you can see that I've missed a portion of the osteophyte at the tip of the lacrinon fossa. Here you can see that I've missed the osteophyte at the tip of the lacrinon. In order to get full extension we're going to have to remove some of that osteophyte with the burr again. The burr is now being introduced into the joint through the direct posterior portal and is being brought over laterally to the remaining osteophyte. Here I've introduced an osteotome through the direct posterior portal where I'll remove more of the osteophyte at the tip of the lacrinon. An arthroscopic curette can then be introduced to remove the remaining subcontinent bone and cartilage without damaging the posterior aspect of the trochlea. Here we're looking again through the direct posterior portal to check for any remaining impingement. The resected bed of the lacrinon is seen and on the far right of the screen you can see that there's remaining osteophyte that I have not removed and there's still some impingement and full extension. At this point I'll reintroduce the burr from the posterior lateral portal to remove remaining osteophyte from the tip of the lacrinon. The tourniquet has now been released and intraoperative range of motion is checked. Here we're able to achieve full extension with a little bit of pressure and he was able to flex to approximately 135 degrees. There are several surgical pearls that are important to remember. Patient selection is important. Patients that have pain throughout the elbow range of motion most likely have more advanced elbow arthritis and are not well suited to this type of procedure. Patients with impingement type pain at the end or extremes of flexion extension typically do better with a elbow arthroscopic osteopathic project. Maintaining adequate visualization throughout the procedure is important for safety and avoiding injury to the nerves. Accessing the joint through standard arthroscopic portals which are reproducible is also important. Maintaining space while you're doing the procedure perhaps even adding in retractors to maintain visualizations. It's important to perform the bony work first and then form capsulotomy after that. If capsulotomy is performed too early in the procedure then you get more extravasation of fluids into the soft tissues making your visualization more difficult and increasing the risk of injury to vital structures. It's important to know when to convert to an open procedure. Sometimes there can be excessive swelling and also there are times when you're having trouble progressing through the steps of the procedure. If any of these problems occur it's probably best to go ahead and open and perform an open capsulotomy or open osteophyte excision. Preoperatively we should always be assessing these patients for ulnar neuropathy or cubital tunnel syndrome. Any patient who has symptoms consistent with cubital tunnel syndrome should undergo decompression of the ulnar nerve at the time of surgery or even perhaps anterior transposition. Those patients who lack more than 95 degrees of elbow flexion should always undergo a cubital tunnel release and anterior ulnar nerve transposition during the arthroscopic procedure. Here the patient is at six weeks post op where he has almost no pain and his elbow range of motion was from 13 degrees of extension to 130 degrees of flexion. After surgery the patient was placed in a soft dressing and allowed to begin immediate range of motion. I typically have patients follow up with our therapists at one week to be in formal therapy. At that point they're allowed to do active active assistive passive motion. At six weeks if motion isn't progressing as expected a static progressive splinting program is started. We've reviewed 31 of the patients where I've performed this surgery on at three and a half year follow-up and what we found was that flexion extension improvement was modest with 13 degrees improvement of extension and 10 degrees of improvement in flexion. The pain relief though was much more significant with improvement in pain visual analog scale levels from 6.35 preoperatively to 1.57 postoperatively.

elbow arthroscopic osteocapsular arthroplasty

osteoarthritis of the elbow

surgical technique

young active patients

post-operative care