Surgical Science, 2011, 2, 219-223
doi:10.4236/ss.2011.25049 Published Online July 2011 (
Copyright © 2011 SciRes. SS
Arthroscopic Surgery of the Elbow; Indications,
Contra-Indications, Complications and
Operative Technique
Frank Theodoor Gabriel Rahusen1, Denise Eygendaal2
1St. Jansgasthuis Weert, Weert, Netherlands
2Amphia Ziekenhuis Breda, Breda, Netherlands
Received February 8, 2011; revised April 7, 2011; accepted June 2, 2011
Arthroscopy of the elbow was first described by Burman in 1931. In this first article about arthroscopy of the
elbow in the journal of bone and joint surgery, he concluded that the elbow joint was not suitable for arthro-
scopy; the joint was too small and the neurovascular structures in the anterior compartment of the elbow
were close. In 1932 he revised his original article with some technical modifications and slowly arthroscopy
of the elbow was performed more often. In the late 1980’s arthroscopic surgery of the elbow became more
and more popular. In this article an overview is given of the indications for elbow arthroscopy, the surgical
technique is described in detail and the possible complications are highlighted.
Keywords: Elbow, Arthroscopy, Surgical Technique, Overview
1. Introduction
Since the eighties, arthroscopy of the elbow joint is per-
formed more often as the under standing of the arthrosco -
pic anatomy and its disorders have become clearer.
Small performed an epidemiologic survey and in the
late 1980’s; only 0.77% of all arthroscopies in those days
performed were arthroscopies of the elbow [1].
Currently common indications for arthroscopy of the
elbow are symptomatic loose bodies, posterior impinge-
ment, osteochondritis dissecans (OCD), long standing
lateral epicondylitis, persistent synovitis which require
debridement or diagnostic biopsy, and stiff elbow due to
arthritic changes or due to posttraumatic deformity [2].
Peri-articular, endoscopic, techniques as a bursectomy, a
tenoscopy of the biceps tendon or decompression of the
ulnar nerve will not be discussed in this overview.
Since the popularity of sports, especially the overhead
throwing and racket sports, is growing, the incidence of
elbow pathology is increasing.
The technique of arthroscopic surgery has been im-
proved dramatically last ten years; the incidence of com-
plication as neurovascular damage is acceptable.
In this overview the indications for elbow arthroscopy
are listed, the surgical technique is described in detail
and the possible complications are highlighted.
The most common complication in elbow arthroscopy
is neurologic deficit post-operatively. Also post-operative
elbow stiffness, persistent portal drainage and infection
have been mentioned. O’Driscoll and Morrey showed an
overall 10% risk in their review of 70 patients [3]. Other
papers show complication rates between 0% and 15%.
There are several techniques to perform an elbow arthros-
copy. Mainly there are 3 different patient positions; su-
pine, prone and lateral decubitus [4]. All have their own
benefits in different indications.
2. Indications for Elbow Arthroscopy
2.1. Diagnostic Elbow Arthroscopy
Diagnostic elbow arthroscopy is not advocated, but may
be helpful when the clinical diagnosis is unclear. Also
undetected elbow instability in overhead athletes can be
seen during diagnostic elbow arthroscopy. Timmermans,
et al. described an arthroscopic valgus instability test, in
which a valgus load is applied to the elbo w in 70 degrees
of flexion during the arthroscopy. The medial comart-
ment opens up and can be inspected. If the medial com-
partment open up for more than 2 - 3 mm, Field and
F. T. G. Rahusen ET AL.
Altchek concluded that the ulnar collateral ligament can
be torn [5].
2.2. Loose Bodies
Symptomatic loose bodies are the most common indica-
tion for arthroscopy of the elbow. Loose bodies are often
a symptom of an underlying disorder which has to be
assessed and treated. Often, loose bodies are the result of
a trauma, resulting in osteochondral fractures or fracture
of (asymptomatic) osteofytes. Loose bodies are also
formed in longstanding OCD or in synovial chondro-
matosis as described by Flury, et al.; in both diseases
additional arthroscopic treatment is indicated [6].
Loose bodies may hide in any part of the elbow joint.
Most commonly they are hided posteriorly in the olec-
ranon fossa, at the posterior aspect of the radial capitellar
articulation or anteriorly in the coronoid fossa. In case of
loose bodies the surgeon therefore should assess all
compartments of the elbow joint during the arthroscopic
procedure. Preoperative radiographs and computer
tomography is indicated and delineate in most cases the
location of loose bodies.
2.3. Posterior Impingement
Posterior impingement of the elbow is an uncommon
disorder in the general young population; it is usually
seen in patients that overuse their elbow during specific
sporting activities as overhead throwing or tennis. During
the throwing motion, in baseball, for example, the elbow
moves during late cocking and acceleration phases from
110˚ to 20˚ of flexion with velocities up to 3000 deg/sec.
This combination of valgus forces and rapid extension
results in tensile forces along the medial side, com-
pression on the lateral portion of the elbow, and shear
forces in the posterior compartment. This combination is
called valgus extension overload syn dr ome and forms the
basic pathologic model behind posterior impingement of
the elbow as formation of bony or soft tissue in the
posterior compartment results in mechanical abutment
leading to complaints of the posterior compartment dur-
ing extension. The exact fit of the olecranon in the olec-
ranon fossa of the humerus is critical for a maximal
extension and, therefore, for the function of the elbow. In
particular the maximal extension needed in most over-
head sports is reduced, lead ing to complaints of the post-
erior compartment of the elbow. The athlete complains
of pain posteriorly at the elbow, joint effusion, locking,
crepitus, and a decrease in range of motion, most notably
an extension deficit. X-rays, especially an axial view,
may be helpful to detect osteophytes on the olecranon or
on the borders of the posterior fossa. More sensitive is an
MRI with intra-articular contrast; sensitivity for posterior
soft tissue or loose bodies is nearly 90%. If conservative
treatment of posterior impingement is not successful;
arthroscopy of the elbow can be successfully used in
these patients as described in an earlier review of
Rahusen, et al. [7].
2.4. Osteochondritis Dissecans
Osteochondritis dissecans is a localized condition in-
volveing the articular surface that results in the se-
paration of a segment of articular cartilage and sub-
chondral bone. The most common site of osteochondritis
dissecans of the elbow is the capitellum although lesions
have been reported in the trochlea, radial head, as well as
the olecranon and olecranon fossa. Osteochondritis dis-
secans generally occurs in athlete’s ages 11 to 21 years
who report a histo ry of overuse. The osteonecrotic lesion
involves only a segment of capitellum, located primarily
at a central or anterolateral position. Appropriate treat-
ment of this disorder remains controversial.
Often treated with benign neglect, this condition is a
potentially sport-ending injury for anathlete, with long-
term sequelae of degenerative arthritis. The surgical option
is fragment excision with debridement of the necrotic
2.5. Longstanding Lateral Epicondylitis
Lateral epicondylitis or tennis elbow is a common disor-
der in primary care. It is rath er related to manually in ten-
sive work, requiring forceful and repetitive rotation of
the forearm, wrist extension or flexion (e.g. in mechanics,
butchers, construction workers)The incidence of lateral
humeral epicondylitis in general practice is estimated at
4 - 7 per 1000 patients per year, with a peak between 35
and 54 years of age. Lateral epicondylitis is generally a
self-limiting cond ition. The average duration of a typical
episode varies from six months to two years, but most
patients (90%) respond to conservative treatments and
recover within one year. Surgical treatment is recom-
mended for those patients who are not responding to
conservative treatment after at least six months to a year.
Surgical techniques are various, including open, percu-
taneous and arthroscopic treatment. Research investi-
gating which approach is superior, reveals that the less
invasive approaches (percutaneous or arthroscopic) allow
faster return to work, than the open procedure. Arthro-
scopic release is potential beneficiary because an arthro-
scopic evaluation of the whole joint can be done during
the procedure. Also other in tra-articular problems, which
have been described in up to 50% of all cases, can be
addressed simultaneously. Baker, et al. showed a return
Copyright © 2011 SciRes. SS
F. T. G. Rahusen ET AL.221
to work a t an aver age of 2.2 weeks and a grip strength of
96% compared to the unaffected limb [8].
2.6. Persistent Synovitis
Persistent synovitis of the elbow, due to rheumatoid
arthritis or other inflammatory pathology, which is not
responding to conservative treatment, can be indication
for debridement or diagnostic biopsy in cases the cause
of the synovitis is unknown. De boer, et al. showed this
in their studies [9].
Septic arthritis of the elbow can be treated with arth ro-
scopy as well.
2.7. Stiff Elbow
Loss of motion is a common complication in degenera-
tion or after elbow trauma. Restoration of joint motion
especially in the posttraumatic stiff elbow can be a dif-
ficult, time-consuming, and a costly challenging [10].
Elbow contractures can be the result of intrinsic (intra-
articular) or extrinsic (extra-articular) causes [11-13]. In
most posttraumatic contractures both intrinsic and ex-
trinsic causes play a role. Established contractu res should
be treated initially with physical therapy and static-
progressive splinting. Patients who have failed a minimum
of 6 to 12 months of non-surgical management and who
are motivated to comply with a strict postoperative re-
habilitation program are candidates for surgical release
Arthroscopic arthrolysis of stiff elbows has been intro-
duced as a safe, but technical demanding technique [15].
The indications for surgery dep end on the patient’ s func-
tional needs. Morrey, et al. stated that an elbow needs a
minimal range of motion (ROM) of 100 degrees flexion
/extension and 100 degrees of pronation/supination to
function adequately in daily life [16]. However in speci-
fic groups of patients, as professional athletes, even a
slight extension deficit of 20 degrees can result in a dys-
function of t he e l bo w.
Disadvantages of elbow arthroscopy include the in-
ability to deal with ulnar nerve disease or heterotopic
ossification and the leng th of the procedure.
2.8. Surgical Technique
Arthroscopy of the elbow is routinely done under general
anesthesia without additional regional anesthesia, to
allow postoperative evaluation of the integrity of the
nerves. With the patient still in supine position, the
elbow is examined for range of motion and for instability.
Then the patient is placed in supine or prone position.
We generally perform the arthroscopy with the patient in
a lateral decubitus position with the upper arm in a
support with tourniquet. In this position all compart-
ments are easily accessible. Alternatively the patient is
positioned in prone, with the arm hanging down, or
supine with the arm suspended and the elbow passively
flexed in 90˚.
It is very important to identify and mark the bony
landmarks and the ulnar nerve before insufflating the
joint with saline. After this the joint is filled with 30 ml
of saline, before making the first portal. Backflow of
fluid verifies proper placement. Cadaveric studies have
demonstrated that joint insufflation significantly increases
the distance between the join t surfaces and neurovascular
structures, thus helping to protect them from injury
during joint entry and during the use of intraarticular
When the arthroscopic sheath is inserted only blunt
trocarts should be used. When creating portals, the sur-
geon should avoid penetrating the subcutaneous tissue,
thereby helping to prevent injury to the superficial cu-
taneous nerves. A mosquito clamp can be used to spread
tissues down to the capsule.
A high pump pressure during the arthroscopy can re
sult in loss of fluid in the soft tissues, resulting in com-
partment syndrome of the fore-arm. Insufflation of the
joint above a pressure of more than 50 mmHg should be
Portal placement is at the surgeon’s distinction. Many
portals have been described and specific portals have
their own benefits. Usually the direct-lateral, anterome-
dial, anterolateral and the proximal-medial portals are
used for the anterior, lateral and medial co mpartment. The
straight-posterior and posterolateral portals are used for
the arthroscopy of the posterior compartment.
The initial survey of the anterior aspect of the elbow is
performed using the proximal medial portal: This allows
localization of the loose fragments, their approximate
position, and it allows the assessment of the medial and
lateral gutters. The loo se body is noted, and the proximal
anterolateral portal is established by using the spinal
needle to ensure adequate access with the pending entry.
This portal is established, and the loose body is located,
grasped, and removed. In many cases, it may be useful to
“pin” the loose fragment with a spinal needle to provide
resistance for grasping the loose piece of bone. Addi-
tionally, the portal may need to be enlarged to allow full
excision of the fragment, or alternatively, it may be
removed piece by piece. Using the antero-lateral portal
the tip of the coronoid can be debrided, as well as the
coronoid fossa.
Most OCD are not visible from anterior. Lateral
epicondylitis is debrided in the manner as well. With a
standard arthroscopy of the posterior compartment of the
Copyright © 2011 SciRes. SS
F. T. G. Rahusen ET AL.
elbow the olecranon fossa is cleared of soft tissue.
Osteofytes at the posteromedial site of the proximal ulna
or distal humerus can be debrided. Using a mid posterior
portal and a postero-lateral portal the posterior com-
partment can be debrided using a 5.5 MM oscillating
shaver an d a 4 MM cyl in d r ic s haver burr.
In case of arthrocopic artrholysis all osteofytes, loose
bodies and fibrotic tissue are removed. The anterior com-
partment is examined using an antero-medial portal after
a careful palpation of the ulnar nerve and intramuscular
septum; a second portal antero lateral is created outside-
in as described previously. With a 5.5 MM oscillating
shaver a synovectomie is performed. With a 4 MM
cylindric shaver burr, the coronoid process and the
coronoid fossa are debrided. In the end the anterior cap-
sule is released using a punch from medial to lateral.
After treatment consists of Continuous Passive Motion
device (CPM) for the first 24 hours, continuously, followed
by a standardized program under supervision of a phy-
siotherapist. The results of arthroscopic treatment com-
pare favourably with those of open techniques with low
rate of complications in both techniques. Elbow arthro-
scopy offers improved joint visualisation, reduced pain,
smaller scars, accelerated rehabilitation and shorter hos-
pital stay, potentially making arthro scopic release an out-
patient procedure.
2.9. Complications in Arthroscopy of the Elbow
Most often complication s of arthro scop y of the elbow ar e
of neurologic origin. Usually the neurologic complica-
tions are transient but several authors describe total tran-
section of the nerve, in particular the ulnar nerve. Tran-
sient radial nerve en median nerve problems have been
reported, but the incidence is very low. Transient nerve
deficiencies can be due to neuropraxia by compression of
the nerve by instruments or by positioning of the patient
on the table. Transection of the nerve mostly occurs by
introduction of the scope or by capsulectomy anterolate-
ral (radial nerve) or posteromedial (ulnar nerve) [17].
Excessive drainage from the portal sites has been
described however the imported infection rate is low
[8,18]. Temporary loss of motion is seen in most cases,
but usually resol ves wit hin 6 - 8 weeks [8]
3. Conclusions
Indications for arthroscop y of th e elbow are sy mpto matic
loose bodies, posterior impingement, osteochondritis dis-
secans (OCD), long standing lateral epicondylitis, per-
sistent synovitis which require d ebridement or diagnostic
biopsy, and stiff elbow due to arthritic chang es or due to
posttraumatic deformity
The technique of arthroscopic surgery has been im-
proved dramatically last ten years; the incidence of com-
plication as neurovascular damage is acceptable.
4. References
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