So good morning. I guess this is what happens when everything else works. We end up with arthritic elbow. My conflicts are in the program. So we know that elbow arthritis affects about 5% of the population. In the last 35 years, we've seen a huge shift in what we do in terms of total elbow versus arthroscopy. It seems to be occurring at a younger and more active age. The pathology includes coronoid spurs, olecranon spurs, radiocapitular DJD, fossa thickening, and then synovitis primary or secondary. Presenting symptoms are usually stiffness in the morning. I mean, this is pretty straightforward. They come in. They start having pain with activities when they try to hyperextend or hyperflex. There's a subset of patients we wrote up with Rob McLaughlin, Larry and I did back in 2006 where it starts on the lateral side, and these tend to progress more rapidly. And they have a loss of motion, and it's interesting in the last 30 years, arthritis has moved because of the DMARs, because of the rheumatoid drugs. We've really gotten away from total elbow arthroplasty. I was talking with Scott at the Mayo elbow course, and basically most of the elbow replacements we're doing now are revisions because the arthroscopic procedures work so well. So how do we get there? Well, your exam's going to show decreased motion in both flex and extension. You'll see spurs on both the olecranon and the coronoid. You may see narrowing at the radiocapitular joint. In physical exam, you'll feel the crepitation, and there's always swelling posterolaterally where the posterolateral plica is. Imaging is helpful. CT scan is often very helpful, so you can actually see the spurs, and you can map out how much you're going to want to take. And if you do 3D imaging, and I think these are actually from Larry, Larry Field, and you can see the loose bodies. You can see the spurring here, and you can actually draw in and plan exactly how much bone you want to take out when you go in arthroscopically, and whether you do it with a shaver or a osteotome. We'll talk about that later. Initial management's always non-operative. Put a shot in. They already have some cartilage damage, so you're not going to affect the joint. I think a short course of oral steroids is often effective. Most of these people would love to take glucosamine, so give it to them and let them take it. PRP, HA injections are all off-label, but you can try. It's no harm. If you do PRP, this case would have to be leukocyte poor because you want to decrease the inflammation, and we've actually had some good results. Srinath Kamaneni has done some HA injections, but it takes multiple ones in the elbow for some reason. Surgery is indicated, as always, pain, functional impairment, and a failure of non-operative treatment. We actually sometimes will use a JAS brace, but these are bony impingements, so you're not going to get a lot of benefit until you take the spurs out. Precautions, watch the ulnar nerve. It's not so much as an ankylosed elbow where they're stiff and you have a loss of flexion, but in the arthritic elbow, you're going to have spurs along the medial column, and so if you have spurs on the medial joint line, they may be tenting the nerve, and if you're going to take those out arthroscopically, you need to be prepared to retract the nerve. We'll show you that, but the same token, if you don't want to do that, then you really need to make an incision and open the ulnar nerve, and we'll show you an extreme case of that in some of the pictures. The other thing is to be wary. If they've had a biceps rupture in the past or if they've had a procedure on the anterolateral aspect of the elbow, you may have scarring on the posterior osseous nerve, and so you may need to do a little radial tunnel release at the same time, so these are two precautions when you're treating these just to be aware of that there's a problem. Most of the time, it's not important. Open procedures, the old Outerbridge-Kashiwaga OK procedure where you drilled a cloud or drill bit and connected the two fossa actually worked really well because you knock out the spurs, and that's basically the premise of the arthroscopic procedure, but we can do spur resection and removal, and we started reporting on this in 1990, and it's progressed pretty well. The advantages of arthroscopy, improved visualization of the entire elbow. You can do anatomic, pathologic-specific surgery, take out what's harmful and leave what's not. Less associated scarring, very rapid rehabilitation. These guys can get back to work and play pretty much right away as soon as the portals heal, and we do think there's a decreased incidence of HO when you do it arthroscopically as opposed to open. So this is what I was telling you about, about combined procedures. This patient had had three ulnar nerve surgeries and was also arthritic and was referred in to have the arthritis taken care of since the nerve was well. I think if you look at this nerve, it's certainly not well and not in a good position, but we couldn't tell where it was, so the first thing we did was make an incision, dissect out the nerve, put some retractors around it, and then started our arthroscopic procedure. So anteriorly, it's a synovectomy, removal of loose bodies, coronoid spur removal, and then radial head excision if necessary. So these are the anterior pathologies, a giant coronoid spur as you see here. More spurring, it goes around the medial gutter. Here's another one here and here. You got to get all those out when you want to do this. Radiocapitella arthritis, there's no cartilage left here, and if they're symptomatic there, you want to take it out. If they're a power lifter, it doesn't matter how bad it looks, leave it alone because they'll start to shift a little bit, and then of course you want to get out the synovitis. So anterior setup, I use prone, but you can certainly do lateral decubitus. It's the same. Those people that do advanced elbow arthroscopy are moving away from supine elbow arthroscopy. We use a proximal-anterior medial portal. My portals are about three millimeters more anterior than most, especially in the arthritic elbow because you have to come around those anterior spurs to get into the elbow joint, which means your portals need to move more anterior. They're very safe. They're not at risk. We've done some very nice studies in arthroscopy on this. And so this is the view. So we're looking from lateral. This is the coronoid spur here. We're going to come in, and you can actually do this with a soft tissue shaver. You can do it with an osteotome. You can do it with a burr. Remember that your median nerve and everything is out over here along with the brachial arteries. So the brachialis is your friend. Always stay posterior to the brachialis. In the arthritic elbows, I rarely would do a capsular excision anteriorly first. I'll leave it alone while we take all that out rather than taking it down. If you have significant radiocapitellar problems or cysts, you may need to do something else. And so remember that the PIN becomes really adjacent to the bone about right here. And so you want to be a little bit careful about that. So we create an anterior resection on the radiohead first. It increases your safety margin. You can also decide how much you want to take. If it's radiocapitellar arthritis, you only really need to take about five or six millimeters. If it's proximal radial ulnar arthritis where they're having problems with pronation and supination, many of the rheumatoid patients are having that again now that we've gone, the insurance companies have demanded a course of methotrexate and prednisone before they go to the better medications. And so they're getting that proximal radial ulnar shifting again. And so create a margin here, resect this back as far as you can, and then move, coming in through your soft spot portal, move that portal a little bit distally. And then you can coplane and you can put a retractor here in the front or an inflow cannula because I don't use the pump, and really get it all the way down until you take out the entire radiohead. It's not a triumph of technology because you're preserving all of your lateral ligaments and most people, when they do it open, have to damage that just a little bit for exposure purposes. Posteriorly, posterior central, posterior lateral portals are your workhorses. If you need a posterior medial portal, remember that the ulnar nerve is here. We'll go back over that again. You can switch back and forth and do what you need to do. Once you're in the fossa, this is going to be pretty much impacted by both bone in the fossa itself, multiple loose bodies will be here, and then the olecranon tip will be distal and they'll be kind of bulging up against you. So the first thing is to clean out the fossa. You can see all the spurring across here. All that has to go. The olecranon tip is actually way down at the bottom. And then you want to trim these parts out, get rid of this so you can actually see the true olecranon fossa. So in these patients, it's not on one side, but it's actually on both. And once we get all of this down, then the other thing we like to do is elevate the triceps. So you're in the back of the elbow. The ulnar nerve is medially, the radial nerve is about eight centimeters proximal to where you are. So it's very simple to come up the back of the humerus, trim out these adhesions or the scarring where it's stuck down because they haven't been able to flex and extend all the way, and elevate that triceps. So you'll see as we go up the humerus, the triceps lifts up and actually creates a bigger window for you to see in the back of the elbow. So I think this is a very important part. And you can use an accessory portal to lift it up and keep it out of the way. It's nice to do that from the lateral side because it pulls your ulnar nerve back and lets you really slide down the rest of the elbow and see quite well. I like to do fossa fenestration, trained on this a little bit. I know many people have gotten away from it, but it increases your flow. I think it decreases your risk of increased stiffness later and decreases our risk of recurrence. As we looked at these over the past 35 years, usually about every 10 years or so, they come back for a tune-up to clean out some more spurs. It's not as big a deal. And if we make the fenestration, they seem to have less recurrence or less early recurrence. They can last a little bit longer. And this can be about two centimeters thick. The bone here is supposed to be one millimeter thick. So if your pre-op planning shows that it's about two centimeters thick, you really want to work on that a little bit. And you can use drill holes to do that and clean all the way out to the front. Lastly, the gutters, the lateral gutter is always a place where loose bodies hide. And so you want to come down here. Here's the ulna humeral articulation. This is all synovitis along the lateral side. The normal bare spot of the ulna will be here. So we have to get all this out and look for loose bodies because they like to stay in that posterior recess where the radial capitellar joint is right back here. So here's our radial head. Here's our ulna. This is the humerus above. You can see this proliferative synovitis, previous radial head excision here. And then we look for loose bodies in this area. This is the place they like to hide. And they'll go there even though you're doing the rest of the surgery. And lastly, we talked about the medial gutter. So if you want to take out medial spurs down here, the ulnar nerve is sitting here and coming closer. So if you haven't done it open like we did on the first slides, then you have to find it arthroscopically. And this is it right here. And so I sort of alternate. It's about half of the time we'll do this arthroscopically and half the time, depending on where the nerve is and how well I can feel it through the skin, sometimes the size of the arm and the patient. We may do this arthroscopically or open and you'll put a retractor on the nerve here. This is the ulnar nerve coming down and around. You cannot do, or I cannot do, let me rephrase that, an ulnar nerve release distal to the tip of that pecan. Now, you can go all the way down. You can completely excise the poster band of the UCL arthroscopically, but you can't get to the flexor pronator or fae, or I don't know how to do that yet, maybe one day. So that restructures anteriorly, your posterior osteus nerve, especially when you're working on the radial head and radial capitellar osteophytes. Poster medially is your ulnar nerve. Ulnar nerve, really on rheumatoids with anterior synovectomies, if the brachialis is very thin, you're at risk, but that's a distance to get there and you really got to kind of get lost a little bit to get to it. So if you simply use retractors, you'll protect all these structures. Our early results were quite good from motion improved. Patients were satisfied. As I said, when we got them back about 10 years, we re-debrided about 10 of these patients, but I really don't think that's a failure of the operation as much as it's a progression of the disease. There's been many reports, Rob McLaughlin, Ken Yamaguchi's group, Tanaka, all about arthroscopic debridement being satisfactory for arthritis, and then Scott and Graham and I did a really nice ICL that he was in charge of, and we thought that arthroscopic treatment was the procedure of choice for degenerative elbow, even more so today, because I don't think elbow replacement has progressed. So in conclusion, elbow arthroscopy for arthritis is very effective, safe, and I think it's the treatment of choice for most patients. Thank you. Awesome.

elbow arthritis

arthroscopy

surgical procedure

imaging

non-operative treatments