I'm going to speak about elbow stiffness and arthritis, arthroscopic management and limitations. My professional relationships can be found on the AAOS website. First, I want to speak about elbow contractures. They're relatively uncommon, but can be difficult to manage. They're identified as having limited range of motion of the elbow, but often are painful, causing difficulties with activities of daily living. Release of these contractures has historically been an open procedure, but perioperative morbidity, including bleeding, wound complications, even further stiffness and pain has been attributed to open procedures, as well as nerve injury. Arthroscopic capsular release indications include patients with range of motion loss beyond the functional arc. Contraindications include significant heterotopic ossification, extensive muscular contractures, or prior older nerve transposition in which the nerve cannot be identified. Other contraindications include severe joint incongruity. Arthroscopic capsular release can be accomplished using standard arthroscopic instruments and camera. Low pump pressures are valuable because they minimize or reduce swelling. And handheld graspers, biters, and osteotomes are also valuable instruments. Patients can be positioned either supine, lateral, or prone for arthroscopic capsular release. I prefer the lateral position for this procedure. For anterior capsular release, proximal detachment of the capsule can be accomplished often using a metal trocar. Shavers and biters can be helpful. And it's important to avoid the capsule adjacent to the radial head. Note in this patient's anterior compartment, looking from a lateral toward medial, we can bring in a metal trocar and separate the anterior capsule from its insertion on the anterior humeral shaft, as shown here. Then we can resect the capsule as necessary medially, as shown here, using a variety of shavers and biters. Note here the exposed brachialis muscle after capsular resection has been accomplished. Now, if we move the camera to medial, we can look over the anterior humeral shaft. If we move to medial, we can look over and see the radiocapitellar joint in this same patient. Note the debris reaction in capsule that will need to be debrided away. In a similar fashion, the lateral capsule is excised anteriorly. Note that I've left a very small sliver of capsule adjacent to the radial head. Posteriorly, the capsule can be released and resected in a similar fashion. In this example, a metal trocar can be brought up along the posterior humeral shaft, and the posterior capsule can be separated and elevated, as shown here. Utilization of this metal trocar does not always allow for release of the posterior capsule, but it's a very valuable tool that's often effective. After the capsule is released, it can be resected, as shown here, using a similar technique. The posterior medial and posterior lateral gutters will need to be debrided and capsule excised, as this contracted capsule often contributes to motion loss. When arthroscopic capsule release is carried out for the elbow, the ulnar nerve should be decompressed when it's symptomatic preoperatively or when severe contracture is present. Typically, a limited incision can be established at the initiation of the case. The posterior medial ulnar collateral ligament bundle can be incised with preservation of the anterior bundle. When the literature on arthroscopic capsule release for the elbow is reviewed, we can see a number of articles that demonstrate consistently good outcomes and high success rates. Pearls for arthroscopic capsule release of the elbow include the importance of tracing the ulnar nerve on the skin with a marking pen to identify its location, to insufflate the joint when the anterior capsule is to be resected first. Precise portal placement is important because there's limited room and access to the interticular structures. Remember to consider sweeping the capsule from the humerus using a metal trocar, as shown. Avoid the capsule adjacent to the radial head because of the proximity of the radial nerve and its branches. And remember to decompress the ulnar nerve when indicated. I'd like to switch gears slightly here to talk more specifically about degenerative elbow arthritis in an arthroscopic approach to management. Degenerative elbow arthritis is relatively common. It usually occurs in middle-aged males, and it's often associated with manual occupations. Symptoms typically include pain, motion loss, and symptomatic loose bodies. Arthroscopic techniques for management of degenerative elbow arthritis have developed over the last 20 years. This technique allows for thorough assessment of both the anterior and posterior compartments while minimizing iatrogenic insult. The arthroscopic technique includes debridement and spur excision, along with loose body removal. Also, ulna humeral recontouring and resection of the radial head arthroscopically when indicated. Also, capsule release may be indicated as well in some patients. A 3D CT scan can be very helpful in preoperatively planning the amount of resection that's going to be required intraoperatively. Similar to the literature that we see for arthroscopic capsule release for contracture, the literature for arthroscopic elbow debridement of arthritis shows good results. In this study from Savoy et al., 24 patients had significant improvements in range of motion and symptoms postoperatively. Likewise, in a study published by Adams et al. in 41 patients, similar improvements in range of motion and functional outcomes was accomplished with arthroscopic debridement of arthritis. In another study, Blana et al. reviewed over 500 patients, 388 of which had an osteocapsular arthroplasty performed arthroscopically. And they saw no permanent nerve injuries with only 5% of patients having temporary nerve problems postoperatively. In this example of arthroscopic debridement of elbow arthritis, note the large prominent coronoid process impinging on bone on the anterior humerus. Arthroscopic instruments can be used to resect this bone. You can see here on the anterior humerus. And often, small handheld osteotomes that can be delivered through standard arthroscopic portals can be very helpful in resecting these osteophytes from this very congruent joint. Note that the coronoid process osteophytes have been resected, and a portion of the anterior capsule has been released as well. In this same patient, if we look in the posterior compartment, note the osteophytes in the posterior medial gutter, the osteophytes on the olecranon process, loose bodies, and significant bone within the olecranon fossa itself. It's important to resect all of this bone to recontour the elbow joint. The olecranon fossa and process osteophytes can be removed. And again, the osteotome is used here to resect these posterior medial gutter osteophytes while protecting the ulnar nerve. Note recontouring has been accomplished in the posterior elbow compartment. In a different example shown here in the posterior compartment, we can see the 3D CT scan demonstrating the so-called Mickey Mouse ears of large osteophytes on the olecranon process. Again, the handheld osteotome can be placed percutaneously and used to help remove these prominent osteophytes from the olecranon process. One can see here a large posterior lateral osteophyte being resected. Likewise, the posterior medial osteophyte in this same example is removed. Note the recontouring of the olecranon process in this example. In summary, arthroscopic management of both elbow contracture and elbow arthritis is effective for most cases requiring surgery. It allows the surgeon to thoroughly address the intrinsic and extrinsic components with minimal soft tissue disruption. An arthroscopic approach is technically demanding, though. Tips that can help with the arthroscopic management include mechanical capsule release using the metal trocar as shown in the videos. Also, these small handheld osteotomes can be helpful for removal of osteophytes as well. Thank you very much.

elbow stiffness

arthroscopic management

elbow contractures

degenerative arthritis

capsular release