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Osteocapsular Arthroplasty of the Elbow
Journal of Bone and Joint Surgery Essential Surgical Techniques April 2014,vol3 Shawn W. O’Driscoll and Davide Blonna Mayo Clinic, Rochester
Level of evidence III
PRESENTER : Dr SAUMYA AGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum
INTRODUCTION
• Arthroscopic osteocapsular arthroplasty of elbow is a procedure involving 3D reshaping of bones, removal of loose bodies and capsulectomy to restore motion and function and to reduce or eliminate pain.
• It allows better visualization of intra-articular lesions, quick recovery and better cosmetic results.
• This procedure is technically challenging and there is often risk of nerve injury.
• Consequently, a safety-driven technique for arthroscopic osteocapsular arthroplasty was developed for prevention of neurologic injuries without compromising surgical efficacy.
Preoperative Planning
• 2D and 3D CT Scans with sagittal and coronal reconstruction to reveal any loose bodies, broken osteophytes.
• Osteophytes in the posteromedial corner are paid much attention due to closeness to ulnar nerve.
Patient Position
• Lateral decubitus position with arm resting on arm holder
• Tourniquet should be tied
• Shoulder flexed between 90⁰ and 100⁰ and elbow at 90⁰
Limited Open Ulnar Nerve Decompression
• Through a small posteromedial skin incision a limited open ulnar nerve decompression is performed to prevent delayed onset ulnar neuritis.
• Decompression should be about 3 to 4 cm proximal and distal to cubital tunnel.
• Through this incision, posteromedial aspect of the capsule can also be released and osteophytes can be removed medially.
Portals and Fluid Management
• First in posterior compartment with arthroscope in posterolateral portal and working instrument in posterior portal.
• Retractor is placed in proximal posterolateral portal.
• Portals are switched on and work is completed posteriorly.
• Access can be made to lateral gutter by midlateral portal
• 3 anterior portals are used
• Anterolateral and proximal anteromedial portals for arthroscope and working instruments
and proximal anterolateral portal for retractor.
• For fluid management, a standard 3-L jet lavage system is used and attached to intravenous tubing for inflow.
• Shaver outflow left open
• Visualization is enhanced with capsular and soft tissue retraction
Step 1 : Get in and Establish a View
• Pointed switching stick should be used to enter the joint
• Sheath is inserted into joint over switching stick and then arthroscope is inserted.
• A 4.8mm shaver is inserted through the posterior portal into the olecranon fossa
• Articular structures are visualized and anatomic orientation is confirmed.
Step 2 : Create a Space in Which to Work
• A radiofrequency device is used with brief pulsations and pause
• Retractor can be used
• Capsule is stripped off the humerus proximally and along the medial and lateral supracondylar ridges.
Step 3 : Bone Removal
• Osteophytes are removed from the floor of the fossa and margins and olecranon is restored to its normal shape
• Shaver blade is used to prevent injury to ulnar nerve and soft tissue
Step 4 : Capsulectomy
• Capsule is released along the supracondylar ridges and also posteromedially and posterolaterally.
• If loss of flexion is severe, capsule is released through posterior bundle of medial collateral ligament on medial side and upto radial head on lateral side.
Medial Gutter
• Arthroscope in the posterolateral portal and shaver in posterior portal
• Posteromedial aspect of capsule is released
to restore lost flexion
• Medial osteophytes are removed from trochlea and olecranon.
Lateral Gutter
• Arthroscope in posterior portal and shaver in posterolateral portal
• Osteophytes are removed from posterior aspect of capitellum and lateral ridges of trochlea and olecranon
• All the loose bodies should be removed
Anterior joint Compartment
• Step 1 : Get in and establish a view :• Entry is made through proximal
anteromedial portal with a pointed switching stick• Sheath is inserted into joint and then
arthroscope• Articular structures are visualized and
anatomic orientation is confirmed
Step 2 : Create a Space in Which to Work
• This step includes : removal of the debris scar tissue loose bodies Stripping the capsule off the humerus• Capsular attachments are released along the
medial and lateral supracondylar ridges • Retractor is placed in proximal anterolateral
portal
Step 3 : Bone Removal
• Osteophytes are removed from coronoid and radial fossa
• Coronoid and coronoid fossa are reshaped
• Capsule is detached from humerus proximally and along the medial and lateral supracondylar ridges
• Synovectomy
• removal of loose tissues from surface of capsule
• Capsule is incised from medial to lateral with a wide duck billed punch.
• Capsulotomy is now performed by extending it from medial side of ulnohumeral joint to common flexor pronator tendon.
• Using bite and peel technique capsule is incised upto lateral edge of brachialis.
• It is extended distally till the interval between brachioradialis and extensor carpi radialis longus is easily identifiable
• Capsule is excised off the lateral edge of brachialis and surrounding tissue.
Postoperative Regimen
• An indwelling axillary catheter is put for a continous brachial plexus block
• Continous passive motion is started
• Catheter is removed 12 hours prior to discharge
Results
• Out of 464 patients , 24 cases revealed transient nerve injury
• Reasons being: Prolonged tourniquet time Simultaneous ulnar nerve transposition Cutaneous dysesthesia• All nerve palsies got resolved.
CONTRAINDICATIONS
• Anterior capsulectomy may be contraindicated in patients with prior submuscular transposition of ulnar nerve.
• Substantial distortion of anatomic landmarks.
Pitfalls and Challenges
• Keep a margin of safety• Thorough knowledge about nerves• Use of retractors• Suction tubing to be detached from shaver• Burr should not be used near ulnar nerve• A stepwise approach
Clinical Comments
• Even in expert hands risk of nerve injury is there• But with safety driven strategy it
reduces to maximum