Débridement and capsular resection provides good outcomes
An evolving technique, presented during the Arthroscopy Association of North America’s annual meeting, addresses three main pathologic processes involved in primary degenerative arthritis of the elbow. According to first author Julie E. Adams, MD, “Loss and fragmentation of cartilage lead to loose body formation. Reactive bone and cartilage formation give rise to osteophytes. These two processes cause impingement and contribute to the third process, progressive joint contractures. Arthroscopic débridement and osteocapsular resection addresses these underlying pathologic processes, provides outcomes similar to open procedures, and is associated with minimal perioperative morbidity.”
The study presented a retrospective review of 41 patients (42 elbows) with symptomatic primary osteoarthritis of the elbow and at least two years of follow-up. All patients were treated with arthroscopic osteophyte débridement and capsulectomy, performed by Scott P. Steinmann, MD. At final follow-up, patients experienced significant improvements in extension lag, flexion, and supination, and two thirds reported minimal or no pain after the surgery.
As the researchers pointed out, osteoarthritis of the elbow can be treated conservatively as well as surgically. Conservative treatments include anti-inflammatory medications and activity modifications. Surgical procedures used to treat this condition include resection arthroplasty of the ulnohumeral joint, total elbow arthroplasty, elbow arthrodesis, and a variety of open débridement procedures, which have had good success.
“Arthroscopic osteophyte débridement and capsulectomy provides a minimally invasive technique to treat primary degenerative arthritis of the elbow joint,” said Dr. Adams. “The results in this series are similar to other reports of open surgical débridement and compare favorably to other series with minimal complications, establishing the safety and utility of arthroscopic interventions.”
The surgical technique involves work through the anterolateral and anteromedial portals. Care must be taken to avoid and protect the radial nerve. The anteromedial capsule is first stripped off the humerus, and loose bodies are removed. Osteophytes on the coronoid and radial head fossa are also removed with a shaver and burr. The anterior capsule is then completely resected, and the arthroscope is moved to the medial portal so that bony débridement and capsulectomy can be performed on the lateral side of the joint.
After completing the work on the anterior aspect of the joint, the surgeon establishes the posterolateral portals and removes osteophytes from the tip and sides of the olecranon and the rim of the olecranon fossa, taking care to identify and protect the ulnar nerve. Concomitant ulnar nerve procedures are performed on patients with preoperative symptoms of ulnar neuropathy.
Postoperative care includes overnight splinting in full extension, followed by a full active range of motion using either bracing or a continuous passive motion (CPM) device. No limitations are placed on use of the arm.
A summary of results is presented in Table I. The mean extension lag improved significantly (P < 0.0001)—from a preoperative mean of 21.4° to 8.4° postoperatively (range: 0° to 30°). Mean flexion also increased significantly—from 117.3° to 131.6° at final follow-up. Although there was no significant change in pronation, supination increased significantly—from 70.7° to 78.6°.
The surgery is also effective in reducing pain. Postoperatively, 78.6 percent of patients reported that they felt much better (42.9 percent) or better (35.7 percent); more than two thirds of patients reported minimal or no postoperative pain. Based on Mayo Elbow Performance (MEP) scores, 32 percent of the overall results were rated as excellent, 49 percent as good, 12 percent as fair, and 7 percent as poor.
The researchers also examined the use of CPM (12 patients) versus bracing protocols (29 patients). They found that there were no differences postoperatively between the groups with respect to motion, pain, or MEP scores.
Two patients experienced complications—heterotopic ossification formation developed in one patient, requiring open surgical excision, and ulnar nerve dysesthesias, which resolved spontaneously over three months, developed in the other.
“This minimally invasive approach provides excellent visualization and access to all areas of the joint and adequately addresses the causative pathological processes,” concluded the researchers. “An arthroscopic approach enables the surgeon to visualize all areas in the anterior and posterior aspects of the elbow joint and address any pathologies. However, it remains a technically demanding procedure that requires a high level of arthroscopic experience and training to perform safely.”
In addition to Drs. Adams and Steinmann, the research team included Luther H. Wolff III, MD and Sheri M. Merten, RN; all are affiliated with the Mayo Clinic in Rochester, Minn.