Artroscopia de codo

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Elbow arthroscopy is not without complications and morbidity despite being a minimally invasive procedure and advances made in surgical technique [1].
• The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used [2].
• Patients treated arthroscopically benefit from additional diagnostic techniques, improved visualization of the elbow joint, the ability to address coexisting intra-articular pathologic conditions, and minimal soft tissue injury with no clinical consequences in outcomes [3].
• Elbow arthroscopy has become a safer and more effective treatment modality for several elbow pathologies due to advances in equipment and surgical technique [6].
• Elbow arthroscopy has evolved from a diagnostic tool to a therapeutic procedure with expanded indications, though it requires careful attention to surgical anatomy and patient selection to avoid neurovascular complications [7].
• Elbow arthroscopy has expanded indications for diagnosing and treating acute trauma, including radial head fractures and instability, provided patients are carefully selected and neurovascular risks are managed with proper technique [12].
• Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy [5].
• Elbow arthroscopic surgery is a relatively safe procedure with low complication rates [15].
• Elbow arthroscopic debridement for primary degenerative osteoarthritis results in statistically significant and clinically relevant improvement in elbow range of motion and clinical outcomes with low complication and reoperation rates [14].
• Pediatric elbow arthroscopy performed by an experienced surgeon using a standardized technique for a wide variety of elbow conditions has an acceptable complication rate that is similar to rates in the previously published literature on elbow arthroscopy in the pediatric and adult populations [17].
• A significant proportion of pediatric patients who underwent elbow arthroscopy needed subsequent surgery in the following years [17].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [39].
• The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [39].
• The ulnohumeral articulation provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area on the greater sigmoid notch devoid of cartilage [39].
• The coronoid process has medial and lateral facets that buttress the trochlea anteriorly [39].
• The sublime tubercle is located just distal and medial to the coronoid and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [39].
• The radiocapitellar joint is formed by the articulation of the capitellum and radial head [39].
• The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [39].
• The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [39].
• The area of the ulna that articulates with the margin of the radial head at the proximal radioulnar joint is known as the lesser sigmoid notch [39].
• The distal humeral articulation is angled 30° from the longitudinal axis [39].
• The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [39].
• The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [39].
• The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [39].
• The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [42, 43].
• The trochlea has a 300-degree arc of cartilage [44].
• The medial column diverges from the humeral shaft at a 45-degree angle [44].
• The lateral column diverges from the humeral shaft at a 20-degree angle [44].
• The olecranon fossa is an oval structure that is wider in the medial to lateral dimension [34].

Ligamentous Anatomy¶

• Elbow stability is determined by primary and secondary stabilizers [20].
• The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [20].
• Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [20].
• The medial ulnar collateral ligament complex is comprised of the anterior bundle, posterior bundle, and transverse ligament [38].
• The anterior bundle of the medial ulnar collateral ligament is the strongest component and the primary restraint to valgus stress [38].
• The anterior bundle of the medial ulnar collateral ligament is further subdivided into anterior and posterior bands that provide reciprocal function, with the anterior band tight in extension and the posterior band tight in flexion [38].
• The medial collateral ligament originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [42, 43].
• The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [42, 43].
• Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [42, 43].
• The lateral ulnar collateral ligament origin center is located 10.7 mm from the lateral epicondyle [38].
• The lateral ulnar collateral ligament insertion is located 3.3 mm from the apex of the supinator crest [38].

Range of Motion & Biomechanics¶

• The normal elbow has a range of motion from 0° to 140° from extension to flexion [20].
• The normal elbow has a range of motion of 75° in pronation and 85° in supination [20].
• A functional arc of motion for the elbow is 100° for flexion and extension [20].
• A functional arc of motion for forearm rotation is 100° [20].
• The normal range of elbow flexion/extension is 0 to 150 degrees [42, 43].
• The normal forearm pronosupination is 80 to 85 degrees in each direction [42, 43].
• The functional range of motion for elbow flexion/extension is 30 to 130 degrees [42, 43].
• The functional range of motion for forearm pronosupination is 50 degrees [42, 43].
• The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [42, 43].
• In full extension, 60% of axial load is transmitted through the radiocapitellar joint [42, 43].

Pathophysiology¶

• Valgus extension overload syndrome is caused by the olecranon being repeatedly and forcefully driven into the olecranon fossa during throwing, exerting shear forces on the medial aspect of the olecranon tip and the olecranon fossa [21].
• The pathoanatomy of valgus extension overload syndrome includes chondrosis, osteophyte development on the posteromedial olecranon and humerus, and loose bodies [21].
• Medial ligamentous laxity commonly exacerbates valgus extension overload syndrome [21].
• Osteoarthritis of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [34].
• Periarticular hypertrophic osteophytes in elbow osteoarthritis act as a mechanical block at the end ranges of flexion and extension [34].
• Elbow osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [34].
• Stiffness of the elbow may be due to intrinsic (intra-articular) or extrinsic (extra-articular) causes [54].
• Intrinsic causes of elbow stiffness include articular damage or malunion, intraarticular hardware, and loose bodies [54].
• Extrinsic causes of elbow stiffness include a contracted joint capsule and ligaments, heterotopic ossification, prominent hardware, and skin contracture [54].
• Posttraumatic or postsurgical elbow contractures often involve a damaged, abnormally thickened joint capsule and potential for altered anatomy [54].
• In posttraumatic or postsurgical elbow contractures, the joint space is usually contracted and the capsule is scarred down to the bones [54].
• In posttraumatic or postsurgical elbow contractures, the locations of the median and radial nerves may be altered due to contracted anterior soft tissues [54].
• Lateral epicondylitis is an angiofibroblastic hyperplasia of the extensor carpi radialis brevis tendon, a noninflammatory, dysvascular degenerative process caused by repetitive microtrauma [56].
• Osteochondritis dissecans (OCD) of the elbow is caused by repetitive microtrauma to the vulnerable epiphysis, which has a tenuous blood supply [56].
• Repetitive loading of the lateral compartment of the elbow results in subchondral bone degeneration causing cartilage fragmentation in OCD [56].
• During arthroscopic surgery, joint distention moves the capsule away from bone, but the distance between the neurovascular structures and the capsule remains unchanged [34].
• The brachialis muscle protects the median nerve and brachial artery during capsular procedures [34].

Classification¶

• The Kwak classification categorizes primary elbow osteoarthritis into Stage I, Stage II, and Stage III [71].
• In a retrospective cohort study of 43 patients undergoing arthroscopic osteocapsular arthroplasty, 14 patients were classified as Kwak Stage I, 18 as Stage II, and 11 as Stage III [71].
• Radiologically severe osteoarthritis is associated with worse clinical outcomes after arthroscopic osteocapsular arthroplasty in primary elbow osteoarthritis at medium-term follow-up [71].
• The Mayo Elbow Performance Score (MEPS) classification defines excellent outcomes as a score greater than 89 [72].
• The Mayo Elbow Performance Score (MEPS) classification defines good outcomes as a score between 75 and 89 [72].
• The Mayo Elbow Performance Score (MEPS) classification defines fair outcomes as a score between 60 and 74 [72].
• The Mayo Elbow Performance Score (MEPS) classification defines poor outcomes as a score less than 60 [72].

Clinical Presentation¶

General Evaluation Principles¶

• The evaluation of the elbow requires an intimate understanding of anatomy, biomechanics, and diagnostic tests to understand functional biomechanics, perform physical examination maneuvers, and order appropriate imaging studies [20].
• A thorough history and physical examination are invaluable for understanding the type of disease process and the degree to which the condition affects the patient [57].
• Understanding whether a patient has pain throughout the arc of motion or only at terminal limits, as well as any associated mechanical symptoms or instability, is of paramount importance [57].
• Associated conditions such as cubital tunnel syndrome must be considered and evaluated to provide optimal recommendations on management [57].
• The physical examination is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [20].
• The location, quality or type, context, duration, and severity of elbow pain are important for understanding pathology and focusing the physical examination [65].
• Determining the symptom trajectory—whether pain is getting better, worse, or remaining constant over a period of time—is extremely helpful when considering intervention [65].
• A working knowledge of pathologic conditions affecting different locations around the elbow is paramount to making a correct diagnosis [65].

Range of Motion and Stability¶

• The normal elbow has 75° of pronation and 85° of supination [20].
• A functional arc in each plane is 100° for flexion and extension and forearm rotation [20].
• Elbow stability is determined by primary and secondary stabilizers, and injury to these structures causes elbow instability [20].

Imaging¶

• Plain radiographs remain the hallmark and the best screening test for elbow evaluation [20].
• Plain radiographs should be obtained during the initial workup to evaluate the articular surface and bony anatomy [57].
• CT scans with 3D reconstructions may be useful for evaluating the extent and location of disease and for surgical planning [57].
• MRI may be useful to evaluate the status of soft tissues, including the medial and lateral collateral ligamentous complexes [57].
• Electromyography and nerve conduction studies (EMG/NCS) may be useful to evaluate the degree of nerve compression and its contribution to elbow pain or dysfunction [57].

Osteoarthritis¶

• Patients with primary osteoarthritis of the elbow typically present with loss of terminal extension and flexion and painful catching, clicking, or locking of the elbow [34].
• Pain in primary osteoarthritis is typically noted at the end ranges of motion and not through the midrange [34].
• Night pain is not typical for primary osteoarthritis; if present, an inflammatory cause of the arthritis should be considered [34].
• On physical examination for osteoarthritis, pain is usually felt at the end ranges of flexion and extension rather than throughout the arc [34].
• Forearm rotation is relatively preserved until later in the disease process of osteoarthritis [34].
• Ulnar neuropathy is present in up to 50% of patients with osteoarthritis of the elbow [34].
• Radiographs for osteoarthritis typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [34].
• Radiographs typically underestimate the number of loose bodies present in osteoarthritis [34].

Valgus Extension Overload Syndrome¶

• Patients with valgus extension overload syndrome report posteromedial elbow pain that occurs during the deceleration phase of throwing as the elbow reaches terminal extension [21].
• Pain in valgus extension overload syndrome may also occur during the acceleration phase of throwing [21].
• Loss of terminal elbow extension may occur in patients with valgus extension overload syndrome [21].
• Crepitus and tenderness over the posteromedial olecranon may be noted on physical examination for valgus extension overload syndrome [21].
• Pain in valgus extension overload syndrome is reproduced when the elbow is forced into extension [21].
• Elbow flexion contracture may be seen in patients with valgus extension overload syndrome [21].
• CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [21].
• MRI may be most helpful in evaluating associated injuries, including partial or complete tears of the medial collateral ligament (MCL), in valgus extension overload syndrome [21].

Medial Collateral Ligament Injuries¶

• Patients with medial collateral ligament (MCL) injuries report medial elbow pain during the acceleration phase of throwing [62].
• Pain in MCL injuries may occur only when throwing at more than 50% to 75% of maximal effort [62].
• Acute MCL injuries may present suddenly with a pop, sharp pain, and inability to continue throwing [62].
• Point tenderness can be noted at the MCL or toward its insertion sites during physical examination [62].
• Valgus instability is tested with the patient’s elbow flexed between 20° and 30° to unlock the olecranon from its fossa as valgus stress is applied [62].
• The milking maneuver is performed by pulling on the patient’s thumb to create valgus stress while the forearm is supinated and the elbow is flexed beyond 90° [62].
• A subjective feeling of apprehension, instability, or localized pain at the MCL during the milking maneuver indicates injury [62].
• The moving valgus stress test involves applying valgus stress while the elbow is moved through an arc of flexion or extension [62].
• A subjective feeling of apprehension, instability, or localized pain at the MCL during the moving valgus stress test indicates injury [62].
• Valgus stress radiographs with the elbow in 20° to 30° of flexion and the forearm in full supination may be used to measure medial joint line opening [62].
• Medial joint line opening greater than 3 mm on valgus stress radiographs has been considered diagnostic for valgus instability [62].
• Conventional MRI can help identify thickening within the MCL from chronic injury or more obvious full-thickness tears [62].
• Magnetic resonance arthrography enhanced with intra-articular gadolinium improves the diagnosis of partial undersurface tears of the MCL [62].
• Dynamic ultrasonography can help detect increased laxity with valgus stress, though diagnostic quality is operator dependent [62].

Lateral Elbow Pathology¶

• Patients with lateral elbow tendinopathy report pain when lifting things from a bag with a pronated hand, turning doorknobs, taking milk from the fridge, shaking hands, taking a laptop out of a bag, or bumping the lateral elbow [65].
• Direct palpation of the extensor carpi radialis brevis (ECRB) origin is a physical examination maneuver for lateral elbow tendinopathy [65].
• The tennis elbow shear test is a physical examination maneuver for lateral elbow tendinopathy [65].
• Pain along with resisted wrist or long finger extension is a physical examination finding for lateral elbow tendinopathy [65].
• The laptop test is a physical examination maneuver for lateral elbow tendinopathy [65].
• Patients with radial tunnel syndrome report extensor musculature "forearm aching" [65].
• Wrist flexion and forearm pronation are physical examination maneuvers to elicit radial tunnel syndrome [65].
• The rule of nines test is a physical examination maneuver for radial tunnel syndrome [65].
• Weakness and pain with resisted long finger extension are physical examination findings for radial tunnel syndrome [65].
• Patients with cutaneous neuritis (posterior antebrachial cutaneous nerve or lateral antebrachial cutaneous nerve) report burning or radiating pain, often described as "I want to cut my arm off" [65].
• Direct palpation or percussion, such as the Tinel test, are physical examination maneuvers for cutaneous neuritis [65].
• Patients with posterolateral rotatory instability report not trusting the elbow or feeling of giving way or instability when pushing out of a chair with arms [65].
• The posterolateral rotatory (PLR) drawer test is a physical examination maneuver for posterolateral rotatory instability [65].
• The PLR pivot shift test is a physical examination maneuver for posterolateral rotatory instability [65].
• The supinated push-up test is a physical examination maneuver for posterolateral rotatory instability [65].
• Patients with plica report a pop with associated pain that then "feels better" [65].
• Direct palpation of a "click" with flexion and pronation (anterior) or extension and supination (posterior) are physical examination maneuvers for plica [65].
• Patients with radiocapitellar arthrosis report distant trauma or surgery [65].
• The radiocapitellar (RC) load test, characterized by pain with pronation and resisted extension, is a physical examination maneuver for radiocapitellar arthrosis [65].
• Patients with osteochondritis dissecans (OCD) or osteonecrosis report gradual loss of motion with or without pain, and catching and locking if loose bodies are present [65].
• The RC load test is a physical examination maneuver for OCD or osteonecrosis [65].
• Patients with partial biceps tendon tear report pain in the lateral arm with resisted supination [65].
• Direct palpation of the radial tuberosity with the arm in pronation elicits crepitus and pain in partial biceps tendon tear [65].

Medial Elbow Pathology¶

• Patients with medial elbow tendiopathy or tendon tear report pain when washing the face or carrying objects with the arm in a supinated position [65].
• Direct palpation of the flexor or pronator tendon origin is a physical examination maneuver for medial elbow tendiopathy [65].
• The face press examination is a physical examination maneuver for medial elbow tendiopathy [65].
• The server tray examination is a physical examination maneuver for medial elbow tendiopathy [65].
• Resisted flexion test is a physical examination maneuver for medial elbow tendiopathy [65].
• The moving valgus test, characterized by pain between 30° and 60° flexion, is a physical examination maneuver for medial elbow tendiopathy [65].
• Patients with snapping triceps report pain with flexion accompanied by a pop or snap and often tingling into the fingers if the ulnar nerve is involved [65].
• Palpation with flexion is a physical examination maneuver for snapping triceps [65].
• Patients with ulnar neuritis or neuropathy report that the ring and small finger go to sleep when the elbow is flexed, such as while reading in bed or waking them up at night [65].
• Direct palpation or Tinel test are physical examination maneuvers for ulnar neuritis or neuropathy [65].
• Patients with medial ulnar collateral ligament (MUCL) strain, tear, or instability report decreased control and velocity while pitching or a history of trauma and dislocation [65].
• The milking maneuver is a physical examination maneuver for MUCL strain, tear, or instability [65].
• The moving valgus stress test is a physical examination maneuver for MUCL strain, tear, or instability [65].
• Patients with valgus extension overload report decreased range of motion and pain with deceleration and follow-through [65].
• The valgus extension overload examination is a physical examination maneuver for valgus extension overload [65].
• The arm bar examination is a physical examination maneuver for valgus extension overload [65].
• Patients with varus posteromedial rotatory instability report decreased range of motion after traumatic dislocation with continued varus deformity and pain with activities with the arm away from the body [65].
• The gravity-assisted varus grind test is a physical examination maneuver for varus posteromedial rotatory instability [65].
• Patients with ulnohumeral arthritis report a history of inflammatory conditions or trauma [65].
• Painful range of motion through the midarc with or without a load is a physical examination finding for ulnohumeral arthritis [65].
• Patients with medial epicondyle or condyle fracture report a history of trauma [65].
• Direct palpation, valgus stress, and moving valgus stress test are physical examination maneuvers for medial epicondyle or condyle fracture [65].
• Patients with medial antebrachial cutaneous nerve (MABCN) neuroma or neuritis report localized pain or burning with an area of hypersensitivity over an area of injury or prior surgery [65].
• Palpation or Tinel test are physical examination maneuvers for MABCN neuroma or neuritis [65].
• Patients with median nerve compression report vague forearm pain that may radiate from hand to forearm [65].
• Palpation or Tinel test are physical examination maneuvers for median nerve compression [65].

Investigations¶

Physical Examination¶

• The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [20].
• Pathologic entities associated with specific compartments aid the examiner in detecting pathologic conditions [20].
• Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [45].
• The contralateral elbow should be examined for comparison during range of motion assessment [45].
• If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [45].
• Pain during the mid-arc of motion is more common with intrinsic disease and may not improve with contracture release alone [45].
• The ulnar nerve is of utmost importance in the neurovascular examination due to its anatomic proximity to the elbow [45].
• The posterior bundle of the medial collateral ligament forms the floor of the cubital tunnel along the course of the ulnar nerve [45].
• Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [45].
• An assessment for ulnar nerve subluxation should be performed [45].
• Ulnar nerve subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [45].
• The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [45].
• Crepitus and tenderness over the posteromedial olecranon may be noted in valgus extension overload syndrome [21].
• Pain is reproduced when the elbow is forced into extension in valgus extension overload syndrome [21].
• Elbow flexion contracture may be seen in valgus extension overload syndrome [21].
• Neurovascular status should be documented both before and after elbow reduction in acute dislocation [48].
• Open injuries and compartment syndrome should be ruled out during the physical examination of acute elbow dislocation [48].

Imaging¶

• AP, lateral, and oblique radiographs are standard for evaluating elbow stiffness [45].
• Serial radiography is used as follow-up when heterotopic ossification is present [45].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [45].
• Three-dimensional CT is used to check for heterotopic ossification [45].
• CT is not necessary when elbow stiffness is entirely soft-tissue related [45].
• CT is beneficial if any joint incongruity or abnormal bony anatomy is present [45].
• MRI can be used to evaluate ligaments and tendons but is rarely indicated for elbow stiffness [45].
• AP and lateral radiographs of the elbow are necessary to document congruent reduction in acute dislocation [48].
• Oblique views may be useful to identify periarticular fractures in acute dislocation [48].
• CT is useful to identify associated osseous injury in acute dislocation [48].
• CT or MRI should be considered to identify potential incarcerated osteocartilaginous fragments if the reduction is incongruous [48].
• AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [21].
• MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [21].
• Radiographs, CT, ultrasonography, and MRI each have a role in elbow imaging [46].
• CT can be helpful in identifying mineralized intra-articular loose bodies or delineating the anatomy of a complex intra-articular fracture [46].
• Ultrasonographic soft-tissue evaluation in the elbow is most useful in evaluating the distal biceps and the common flexor and extensor tendons [46].
• Ultrasonography allows dynamic imaging, which may be useful in evaluating for ulnar nerve subluxation or a snapping triceps [46].
• MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow including ligaments, tendons, cartilage, and nerves [46].
• Conventional MRI sequences should be obtained in all three planes using T1-weighted and fluid-sensitive sequences [46].
• Magnetic resonance arthrography is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament injury in a throwing athlete [46].
• Coronal MRI studies should be obtained along a line connecting the medial and lateral epicondyles [46].
• Sagittal MRI studies should be perpendicular to the coronal studies [46].
• MRI units with a 3-Tesla magnetic field strength can generate high signal-to-noise ratios and are more able to show normal anatomy than a 1.5-Tesla unit [46].
• 3-Tesla imaging can show mild signal alterations of tendons, ligaments, and nerves of the elbow that may not be symptomatic [46].
• Ligaments and tendons appear anechoic on all MRI imaging sequences [46].
• Tears are diagnosed on MRI by identifying signal in the tissue that brightens to the level of simple fluid, representing focal discontinuity of tendon or ligament fibers [46].

Treatment¶

General Indications and Safety¶

• Arthroscopy offers advantages such as less scarring, decreased risk of infection, and less postoperative pain [23].
• The majority of the top 50 cited articles in elbow arthroscopy comprised case series exhibiting Level IV or V evidence [10].

Specific Pathologies¶

• Patients treated arthroscopically for chronic elbow instability benefit from additional diagnostic techniques, improved visualization of the elbow joint, the ability to address coexisting intra-articular pathologic conditions, and minimal soft tissue injury with no clinical consequences in outcomes [3].
• Arthroscopic capsular release of the elbow is effective for restoring a functional arc of motion in the short term in most patients with extrinsic contractures [19].
• Patients with stiff elbows who underwent arthroscopic arthrolysis achieved satisfactory clinical outcomes very early postoperatively [11].
• Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release [13].
• Recent advances in arthroscopic instrumentation and techniques have led to growing interest in arthroscopic treatment of elbow osteoarthritis [16].

Pediatric Population¶

• Pediatric patients who underwent elbow arthroscopy had an 86% return-to-sport rate, a 12% reoperation rate, and a 3.7% complication rate [17].

Postoperative Care and Complications¶

• A significant proportion of patients from a large cohort of elbow arthroscopy patients visited the emergency department at least once in the 90 days following surgery [8].
• Additional peripheral nerve block combined with a postoperative nerve block catheter in arthroscopic arthrolysis in cases of elbow stiffness may be an opportunity to enhance postoperative outcomes by achieving better functional ROM, perhaps through reduced postoperative pain [68].

Surgical Technique and Positioning¶

• Patient positioning for elbow arthroscopy is based primarily on surgeon preference [63].
• The modern concept of arm suspension from the supine position, keeping the arm in 90° of shoulder abduction and 90° of elbow flexion, was introduced in 1985 [63].
• The modified supine position suspends the arm over the chest with the elbow in 90° of flexion while the forearm, wrist, and hand are secured in a commercially available mechanical holder [63].
• The modified supine position decreases the risk of injury to the anterior neurovascular structures by allowing them to drop away from the anterior capsule [63].
• In the lateral decubitus position, the patient is positioned laterally on a beanbag with the surgical arm flexed to 90° and suspended over a well-padded post, with joint distraction provided by a weight attached to the hand [63].
• In the prone position, the arm is suspended off the table in an arm holder with the arm in 90° of shoulder abduction and the elbow in 90° of flexion [63].
• It is crucial to assess the elbow for access to each compartment and to portal sites before starting the procedure [63].
• Pressure on the antecubital fossa should be avoided to decrease the risk of injury to anterior neurovascular structures [63].
• A tourniquet is placed as proximal on the arm as possible and can be insufflated as needed [63].
• Arthroscopic elbow arthrolysis via posterior and posterolateral approaches with humeral fenestration according to the Outerbridge-Kashiwagi method was performed for patients with elbow stiffness [69].
• The posterolateral portal for arthroscopic arthrolysis is located 2 cm proximal to the tip of the olecranon, adjacent to the lateral border of the triceps tendon [69].
• The posterior portal for arthroscopic arthrolysis is midway between the epicondyles, between 2 and 4 cm from the tip of the olecranon to the middle of the triceps [69].
• The olecranon fossa is hollowed out with radiofrequency energy until bone contact, avoiding damage to the cartilage border of the trochlea [69].
• The perforation and fenestration of the bottom of the olecranon fossa uses a 5.5-mm oval bur until the olecranon fossa is in communication with the coronoid fossa [69].
• The diameter of the humeral fenestration averaged 10 mm, allowing adequate visualization to perform anterior capsulectomy [69].

Complications¶

Overall Safety and Rates¶

• Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) after elbow arthroscopy [5].
• Predominantly low-level evidence studies demonstrate varying reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy [5].
• Elbow arthroscopy has historically been associated with complication rates as high as 20% [61].
• Overall rates of complication were lower following arthroscopic approaches in a cohort of surgeons undergoing arthroscopic versus open elbow debridements [37].
• Elbow arthroscopy is mostly safe and effective, but life-changing complications such as deep infection and permanent nerve injury do occur [77].

Neurovascular and Nerve Injuries¶

• The most common complication of elbow arthroscopy is neurovascular injury resulting from surgeon inexperience, poor technique, and lack of knowledge of elbow anatomy [61].
• Compression from cannulas, fluid extravasation into surrounding soft tissues, local anesthesia, and laceration with the scalpel or cannula are the most commonly cited insults for neurovascular injury [61].
• Most neurovascular injuries from elbow arthroscopy are transient and resolve without residual deficit [61].
• Nerve injuries are exceedingly rare, with reported transient nerve injury rates ranging from 1.7% to 2.0% [61].

Infection and Risk Factors¶

• An increased risk of postoperative infection was noted in patients receiving an intra-articular steroid injection at the end of the procedure [61].
• Intra-articular steroid injection at the end of the procedure is not recommended due to increased infection risk [61].
• Significant increases in postoperative infection risk in patients who underwent elbow arthroscopy were noted with intraoperative intra-articular corticosteroid injection administration or preoperative corticosteroid injection administration within 4 weeks of surgery [78].
• Significant increases in postoperative infection risk in patients who underwent elbow arthroscopy were noted with BMI >30 [78].
• Significant increases in postoperative infection risk in patients who underwent elbow arthroscopy were noted with diabetes [78].
• Significant increases in postoperative infection risk in patients who underwent elbow arthroscopy were noted with smoking tobacco [78].
• The average mention rate for risk factors across studies reporting complication rates after elbow arthroscopy was 31% [67].
• Non-modifiable risk factors were mentioned more often than modifiable ones in studies reporting complication rates after elbow arthroscopy [67].

Other Specific Complications¶

• Other known complications of elbow arthroscopy include articular cartilage injury, synovial fistula formation, instrument breakage, and tissue injury secondary to use of a tourniquet [61].
• Heterotopic ossification was a minor complication of elbow arthroscopy with a prevalence rate of 6.3% among 205 patients [36].
• Heterotopic ossification after elbow arthroscopy was usually located on the medial compartment of the elbow [36].
• Pediatric elbow arthroscopy has an acceptable complication rate that is similar to rates in the previously published literature on elbow arthroscopy in the pediatric and adult populations [17].
• Elbow arthroscopic debridement for primary degenerative osteoarthritis results in low complication and reoperation rates [14].

Recovery¶

• Elbow arthroscopy is associated with complications and morbidity despite being a minimally invasive procedure [1].
• A significant proportion of patients visited the emergency department at least once in the 90 days following elbow arthroscopy [8].
• Predominantly low-level evidence studies demonstrate varying complication rates with a median of 3% and a range of 0%-71% after elbow arthroscopy [5].
• Predominantly low-level evidence studies demonstrate varying reoperation rates with a median of 2% and a range of 0%-59% after elbow arthroscopy [5].
• Overall rates of complication were lower following arthroscopic approaches compared to open approaches in a cohort of surgeons [37].
• Patients saw improvement in elbow range of motion after arthroscopic elbow capsular release, but many still had residual symptoms from their underlying disease [13].
• Arthroscopic elbow contracture release can improve function and range of motion, though outcomes may vary based on preoperative patient characteristics [26].
• Elbow arthroscopic debridement for primary degenerative osteoarthritis results in statistically significant and clinically relevant improvement in elbow range of motion and clinical outcomes [14].
• Elbow arthroscopic debridement for primary degenerative osteoarthritis is associated with low complication and reoperation rates [14].
• Clinical outcomes for patients with primary elbow osteoarthritis who underwent arthroscopic osteocapsular arthroplasty improved from preoperative assessment to short- and medium-term follow-up [66].
• Range of motion decreased between short- and medium-term follow-up in patients with primary elbow osteoarthritis who underwent arthroscopic osteocapsular arthroplasty [66].
• Professional baseball players saw an improvement in several performance metrics after elbow arthroscopy [76].

Key Evidence¶

• [L3] Elbow arthroscopy is not without complications and morbidity despite being a minimally invasive procedure and advances made in surgical technique. [1] (10.1177/17585732241249393)
• [L4] The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used. [2] (10.1016/j.arthro.2011.10.007)
• [L4] Patients treated arthroscopically benefit from additional diagnostic techniques, improved visualization of the elbow joint, the ability to address coexisting intra-articular pathologic conditions, and minimal soft tissue injury with no clinical consequences in outcomes. [3] (10.1016/j.arthro.2013.08.016)
• [L4] Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. [5] (10.1016/j.arthro.2023.04.015)
• [L5] Elbow arthroscopy has become a safer and more effective treatment modality for several elbow pathologies due to advances in equipment and surgical technique. [6] (10.5435/00124635-200810000-00003)
• [L5] Elbow arthroscopy has evolved from a diagnostic tool to a therapeutic procedure with expanded indications, though it requires careful attention to surgical anatomy and patient selection to avoid neurovascular complications. [7] (10.1177/03635465990270022401)
• [L3] A significant proportion of patients from a large cohort of elbow arthroscopy patients visited the ED at least once in the 90 days following surgery. [8] (10.1016/j.jseint.2024.03.015)
• [L4] The majority of the top 50 cited articles in elbow arthroscopy comprised case series exhibiting Level IV or V evidence. [10] (10.1016/j.jisako.2024.04.011)
• [L1] Patients with stiff elbows who underwent arthroscopic arthrolysis achieved satisfactory clinical outcomes very early postoperatively. [11] (10.1016/j.jse.2024.06.009)
• [L5] Elbow arthroscopy has expanded indications for diagnosing and treating acute trauma, including radial head fractures and instability, provided patients are carefully selected and neurovascular risks are managed with proper technique. [12] (10.1016/j.hcl.2004.07.003)
• [L4] Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release. [13] (10.1177/23259671231190381)
• [L1] Elbow arthroscopic debridement for primary degenerative osteoarthritis results in statistically significant and clinically relevant improvement in elbow range of motion and clinical outcomes with low complication and reoperation rates. [14] (10.1016/j.arthro.2017.08.247)
• [L1] The results of this study showed that elbow arthroscopic surgery is a relatively safe procedure with low complication rates. [15] (10.1177/23259671221137863)
• [L5] Recent advances in arthroscopic instrumentation and techniques have led to growing interest in arthroscopic treatment of elbow osteoarthritis. [16] (10.1016/j.jhsa.2017.05.023)
• [L4] Pediatric elbow arthroscopy performed by an experienced surgeon using a standardized technique for a wide variety of elbow conditions has an acceptable complication rate that is similar to rates in the previously published literature on elbow arthroscopy in the pediatric and adult populations; however, a significant proportion of patients needed subsequent surgery in the following years. [17] (10.1016/j.asmr.2024.100952)
• [L5] Arthroscopic capsular release of the elbow is effective for restoring a functional arc of motion in the short term in most patients with extrinsic contractures. [19] (10.5435/00124635-201105000-00004)
• [L5] Arthroscopy is emerging as an invaluable tool for diagnosing and treating elbow pathology, offering advantages such as less scarring, decreased risk of infection, and less postoperative pain. [23] (10.1016/j.hcl.2009.05.009)
• [L4] Arthroscopic elbow contracture release can improve function and range of motion; however, outcomes may vary based on preoperative patient characteristics. [26] (10.1016/j.jseint.2026.101621)
• [L4] Among 205 patients who underwent elbow arthroscopy, HO was a minor complication of elbow arthroscopy, with a prevalence rate of 6.3%, and was usually located on the medial compartment of the elbow. [36] (10.1177/03635465231198862)
• [L3] Overall rates of complication were lower following arthroscopic approaches in this cohort of surgeons. [37] (10.1177/23259671261425647)
• [L4] Serial assessment of patients with primary elbow OA who underwent arthroscopic OCA showed that the clinical outcomes improved from preoperative assessment to short- and medium-term follow-up, although ROM decreased between short- and medium-term follow-up. [66] (10.1177/23259671231162398)
• [L2] The average mention rate for risk factors across studies reporting complication rates after elbow arthroscopy was 31%, with non-modifiable risk factors mentioned more often than modifiable ones. [67] (10.1016/j.arthro.2024.02.004)
• [L3] Additional peripheral nerve block combined with a postoperative nerve block catheter in arthroscopic arthrolysis in cases of elbow stiffness may be an opportunity to enhance postoperative outcomes by achieving better functional ROM, perhaps through reduced postoperative pain. [68] (10.1016/j.jseint.2024.10.009)
• [L4] [69] (10.1016/j.asmr.2024.101029)
• [L3] [71] (10.1016/j.jse.2023.05.041)
• [L4] [72] (10.1177/23259671251365973)
• [L3] After elbow arthroscopy, professional baseball players saw an improvement in several performance metrics. [76] (10.1177/03635465261424876)
• [L5] Elbow arthroscopy is mostly safe and effective, but life-changing complications such as deep infection and permanent nerve injury do occur; surgeons must strive to minimize patient exposure to these events by mastering indications, anatomy, and technique. [77] (10.1016/j.arthro.2023.06.011)
• [L3] Significant increases in postoperative infection risk in patients who underwent arthroscopy of the ankle, knee, hip, shoulder, and elbow were noted with intraoperative intra-articular CSI administration or preoperative CSI administration within 4 weeks of surgery, BMI >30, diabetes, and smoking tobacco. [78] (10.1177/03635465261429468)

References¶

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