Osteocapsular Arthroplasty of the Elbow

Journal of Bone and Joint Surgery Essential Surgical Techniques April 2014,vol3 Shawn W. O’Driscoll and Davide Blonna Mayo Clinic, Rochester

Level of evidence III

PRESENTER : Dr SAUMYA AGARWAL

Junior resident Dept of Orthopaedics J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum

INTRODUCTION

• Arthroscopic osteocapsular arthroplasty of elbow is a procedure involving 3D reshaping of bones, removal of loose bodies and capsulectomy to restore motion and function and to reduce or eliminate pain.

• It allows better visualization of intra-articular lesions, quick recovery and better cosmetic results.

• This procedure is technically challenging and there is often risk of nerve injury.

• Consequently, a safety-driven technique for arthroscopic osteocapsular arthroplasty was developed for prevention of neurologic injuries without compromising surgical efficacy.

Preoperative Planning

• 2D and 3D CT Scans with sagittal and coronal reconstruction to reveal any loose bodies, broken osteophytes.

• Osteophytes in the posteromedial corner are paid much attention due to closeness to ulnar nerve.

• Surgeon must be thorough with the location of radial and median nerve as well.

Patient Position

• Lateral decubitus position with arm resting on arm holder

• Tourniquet should be tied

• Shoulder flexed between 90⁰ and 100⁰ and elbow at 90⁰

• Keep elbow higher than shoulder

• Adequate access to coronoid fossa should be there

Limited Open Ulnar Nerve Decompression

• Through a small posteromedial skin incision a limited open ulnar nerve decompression is performed to prevent delayed onset ulnar neuritis.

• Decompression should be about 3 to 4 cm proximal and distal to cubital tunnel.

• Through this incision, posteromedial aspect of the capsule can also be released and osteophytes can be removed medially.

Portals and Fluid Management

• First in posterior compartment with arthroscope in posterolateral portal and working instrument in posterior portal.

• Retractor is placed in proximal posterolateral portal.

• Portals are switched on and work is completed posteriorly.

• Access can be made to lateral gutter by midlateral portal

• 3 anterior portals are used

• Anterolateral and proximal anteromedial portals for arthroscope and working instruments

and proximal anterolateral portal for retractor.

• For fluid management, a standard 3-L jet lavage system is used and attached to intravenous tubing for inflow.

• Shaver outflow left open

• Visualization is enhanced with capsular and soft tissue retraction

Step 1 : Get in and Establish a View

• Pointed switching stick should be used to enter the joint

• Sheath is inserted into joint over switching stick and then arthroscope is inserted.

• A 4.8mm shaver is inserted through the posterior portal into the olecranon fossa

• Articular structures are visualized and anatomic orientation is confirmed.

Step 2 : Create a Space in Which to Work

• A radiofrequency device is used with brief pulsations and pause

• Retractor can be used

• Capsule is stripped off the humerus proximally and along the medial and lateral supracondylar ridges.

Step 3 : Bone Removal

• Osteophytes are removed from the floor of the fossa and margins and olecranon is restored to its normal shape

• Shaver blade is used to prevent injury to ulnar nerve and soft tissue

Step 4 : Capsulectomy

• Capsule is released along the supracondylar ridges and also posteromedially and posterolaterally.

• If loss of flexion is severe, capsule is released through posterior bundle of medial collateral ligament on medial side and upto radial head on lateral side.

Medial Gutter

• Arthroscope in the posterolateral portal and shaver in posterior portal

• Posteromedial aspect of capsule is released

to restore lost flexion

• Medial osteophytes are removed from trochlea and olecranon.

Lateral Gutter

• Arthroscope in posterior portal and shaver in posterolateral portal

• Osteophytes are removed from posterior aspect of capitellum and lateral ridges of trochlea and olecranon

• All the loose bodies should be removed

Anterior joint Compartment

• Step 1 : Get in and establish a view :• Entry is made through proximal

anteromedial portal with a pointed switching stick• Sheath is inserted into joint and then

arthroscope• Articular structures are visualized and

anatomic orientation is confirmed

Step 2 : Create a Space in Which to Work

• This step includes : removal of the debris scar tissue loose bodies Stripping the capsule off the humerus• Capsular attachments are released along the

medial and lateral supracondylar ridges • Retractor is placed in proximal anterolateral

portal

Step 3 : Bone Removal

• Osteophytes are removed from coronoid and radial fossa

• Coronoid and coronoid fossa are reshaped

Step 4 : Capsulectomy

• Anterior capsulotomy : 1) detachment 2) preparation 3) incision 4) excision

• Capsule is detached from humerus proximally and along the medial and lateral supracondylar ridges

• Synovectomy

• removal of loose tissues from surface of capsule

• Capsule is incised from medial to lateral with a wide duck billed punch.

• Capsulotomy is now performed by extending it from medial side of ulnohumeral joint to common flexor pronator tendon.

• Using bite and peel technique capsule is incised upto lateral edge of brachialis.

• It is extended distally till the interval between brachioradialis and extensor carpi radialis longus is easily identifiable

• Capsule is excised off the lateral edge of brachialis and surrounding tissue.

Closure

• Close the wounds after drains have been placed anteriorly and posteriorly.

Postoperative Regimen

• An indwelling axillary catheter is put for a continous brachial plexus block

• Continous passive motion is started

• Catheter is removed 12 hours prior to discharge

Results

• Out of 464 patients , 24 cases revealed transient nerve injury

• Reasons being: Prolonged tourniquet time Simultaneous ulnar nerve transposition Cutaneous dysesthesia• All nerve palsies got resolved.

INDICATIONS

• Ideally indicated for symptomatic osteoarthritis of elbow with contracture.

CONTRAINDICATIONS

• Anterior capsulectomy may be contraindicated in patients with prior submuscular transposition of ulnar nerve.

• Substantial distortion of anatomic landmarks.

Pitfalls and Challenges

• Keep a margin of safety• Thorough knowledge about nerves• Use of retractors• Suction tubing to be detached from shaver• Burr should not be used near ulnar nerve• A stepwise approach

Clinical Comments

• Even in expert hands risk of nerve injury is there• But with safety driven strategy it

reduces to maximum