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Arthroscopic management of arthritic elbow
1.
Arthroscopic Treatment of the Arthritic Elbow Aaron Venouziou, MD OrthopaedicHand and Upper Extremity Surgeon St. Luke’s Hospital Thessaloniki www.handsurgery.gr
2.
www.handsurgery.gr Introduction Arthroscopic ulnohumeral / osteocapsular arthroplasty •Removal of osteophytes •Removal of any loose bodies •Capsulectomy •Restoration of motion & function •Elimination / reduction pain
3.
www.handsurgery.gr Pathoanatomy Typical locations of osteophytes •Olecranon •Olecranon fossa •Coronoidprocess •Coronoidfossa •Radial head Anterior and posterior capsule contracture
4.
www.handsurgery.gr Indications •Primary osteoarthritis •Post-traumatic arthritis •Arthritis after OCD •Rheumatoid arthritis
5.
www.handsurgery.gr Contraindications •Inadequate experience on elbow scope •Prior ulnar nerve transposition •Severe post-traumatic arthritis •Severe joint surface irregularities
6.
www.handsurgery.gr Patient Evaluation •Laborers and athletes •Pain at the end of motion •Loss of full extension •Flexion contracture •Crepitus / locking •Ulnar neuritis symptoms History
7.
www.handsurgery.gr Patient Evaluation •Posterior Impingement Test •Arm Bar Test Clinical Examination
8.
www.handsurgery.gr Imaging X-rays CT scan 3D
9.
www.handsurgery.gr Arthroscopic Technique •Lateral decubitus •Arm holder •Shoulder forward flexed at 90o •Shoulder slightly abducted •Non-sterile tourniquet Positioning
10.
www.handsurgery.gr Arthroscopic Technique •4-mm, 30-degree scope •Arthroscopic retractors and graspers •Standard shaver and burr •Suction is placed to gravity only Equipment
11.
www.handsurgery.gr Arthroscopic Technique • Get in and establish a view •Create a space in which to work •Bone removal •Capsulectomy General Rules
12.
www.handsurgery.gr Arthroscopic Technique •Posterior Joint Compartment •Medial Gutter •Lateral Gutter •Anterior Joint Compartment Sequence of Elbow Scope
13.
www.handsurgery.gr Arthroscopic Technique •Olecranon •Lat. Epicondyle •Radial head •Med. Epicondyle •Ulnar nerve Landmarks
14.
www.handsurgery.gr Arthroscopic Technique 1. Get in: posterior, posterolateral, direct midlateral
portals 2. Create space: synovectomy, removal of debris, scar tissue, and loose bodies 3. Bone removal: osteophytesfrom olecranon tip & fossa 4. Capsulectomy:use large shaver Posterior Joint Compartment
15.
www.handsurgery.gr Arthroscopic Technique Medial Gutter 1. Get in: posterolateral viewing portal, posterior working portal 2.
Create space:synovectomy, stay away from the ulnar nerve 3. Bone removal:osteophytes from posteromedial olecranon w/ shaver 4. Posteromedial capsulectomy:⬆ flexion
16.
www.handsurgery.gr Arthroscopic Technique Lateral Gutter 1. Get in: posterior viewing portal, posterolateral working portal 2.
Create space:synovectomy, use of soft spot portal & RF device 3. Bone removal:posterior capitellum, lateral trochlea and olecranon, loose bodies 4. Posterolateral capsulectomy:⬆ flexion
17.
www.handsurgery.gr Arthroscopic Technique Anterior Joint Compartment 1. Get in: anterolateral & anteromedial portals, accessories portals for retractors 2.
Create space:synovectomy, scar tissue & loose bodies removal 3. Bone removal:osteophytes from the coronoid tip / fossa and radial fossa 4. Anterior capsulectomy:medial ➡ lateral
18.
www.handsurgery.gr Management of the Ulnar Nerve •Preoperative ulnar nerve symptoms •Large restoration of motion •Preoperative flexion < 100o When to perform a release:
19.
www.handsurgery.gr Postoperative Care • Posterior splint in full extension • On postop day 5 full active ROM with no limitations is permitted •
Static progressive (turnbuckle) splint for 4-6 weeks • PT for 2-3 months
20.
www.handsurgery.gr Conclusions • Overall, arthroscopic treatment of the arthritic elbow yields very good pain relief and significant improvement in joint range of motion • Indications still depend on surgeon’s arthroscopic skills •
Proceed cautiously and remember that WHEN IN DOUBT GET OUT
21.
www.handsurgery.gr
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