Arthroscopy is a medical procedure used in the diagnosis as well as in the therapy of various injuries or degenerative changes of joints. Arthroscopy is primarily used in orthopedics and trauma surgery. The arthroscope is a variant of the endoscope that is used exclusively in the therapy and diagnosis of pathological joint changes. Decisive for the function of any arthroscope is the basic principle of its construction. Regardless of where the device is used, every arthroscope consists of an optical system of special rod lenses and a small but powerful light source. Furthermore, flushing devices are often integrated into the arthroscope. Using arthroscopy, it was possible for the first time to perform minimally invasive surgical interventions in the joint area. Diagnostic arthroscopy is of particular importance in surgery and orthopedics because, on the one hand, it can be performed as a stand-alone examination and, on the other hand, it can be used directly as part of peri- and preoperative diagnostics (its use is possible during and before surgery). Arthroscopy of the elbow joint is performed far less frequently than comparable procedures on the knee and shoulder joint, both as a diagnostic and as a surgical therapeutic measure. As a result, surgeons have less experience in performing operations due to the rarer method. Despite this limitation, arthroscopy of the elbow joint represents an important option in the treatment and detection of pathological joint processes, so that under no circumstances should this procedure be dispensed with when therapy is indicated. In addition to the relatively infrequent performance, anatomical peculiarities of the elbow joint also complicate the procedure, which leads to a higher risk of complications. However, optimal surgical execution is almost always given, since surgeons who use this procedure have all the necessary knowledge and skills. Furthermore, it should be noted that the number of arthroscopic surgical options for the elbow joint is comparatively low.
Indications (areas of application)
- Osteophytes – surgical removal of osteophytes by arthroscopy is performed by using shavers and chisels, which are auxiliary instruments. Osteophytes are degenerative and structural changes of the bony spurs at the edge of the bone, which are non-physiological new bone formations. Osteophytes, which can form primarily on bony prominences at the edge of articular surfaces, vary in size and shape, making removal relatively complex.
- Free joint bodies – as already described, the so-called free joint bodies represent structures that can form as a result of joint folds and adhesions in the articular area of the elbow. The removal of these joint bodies by means of arthroscopy has led to a significant reduction in pain in the affected patient in various clinical studies. However, it should be noted that surgical planning must assess whether the existing free joint bodies can be removed in toto (in one piece) or after comminution has occurred in the elbow joint. Basically, a complete diagnostic walk-around is necessary to avoid overlooking any existing joint bodies.
- Osteoarthritis – the use of this procedure for degenerative phenomena at the elbow joint (joint wear) should be considered reasonable depending on the stage and duration of symptoms. However, the lesions on the cartilage are much rarer than on the knee or shoulder joint. Scattered cartilage must be removed using the shaver to avoid postoperative symptoms.
Contraindications
- Infection – if there is inflammation in the surgical area, arthroscopy cannot be performed under any circumstances.
- Reduced general condition
Before surgery
- Education – since arthroscopy of the elbow joint is a surgical procedure, it is imperative that each patient be educated about the benefits and risks of the procedure. The possible complications can occur both in the diagnostic and therapeutic application of the procedure.
- Planning the procedure – before using arthroscopy, precise consideration must be given to whether the potential therapeutic effect or diagnostic findings could not be achieved by a less invasive procedure with fewer complications. For this reason, a two-plane X-ray must be taken before any arthroscopic procedure. If there is a suspicion for the presence of so-called free joint bodies (structures that can arise due to joint folds and adhesions in the joint area), several X-ray images should be taken. As diagnostic procedures that can replace an arthroscopy of the elbow joint with given application possibilities are magnetic resonance imaging (MRI) and computed tomography (CT).
- Planning of anesthesia – furthermore, it is necessary to check whether the physical conditions for the implementation of a general anesthesia are given.
- Neurological examination – before the procedure, the surgeon or neurologist performs an examination for the function of the nerve cords running in the elbow area. The aim of this diagnostic measure is the preoperative (before surgery) exclusion of nerve damage.
- Examination under anesthesia – prior to arthroscopic examination or therapy, a check of both ligament stability and range of motion can be performed after the patient has been anesthetized. The anesthesia allows a passive review, which is completely painless for the affected patient.
The surgical procedure
For arthroscopy of the elbow joint, the patient can adopt different positions of positioning. A distinction should be made here between the prone, supine and lateral positions.
- Prone position – the most common position is the prone position, in which the forearm hangs down, providing the surgeon with good access on the one hand and offering improved working possibilities for both the anterior and posterior parts of the joint on the other. In the abdominal position, it is also necessary to cut off the blood flow to the upper arm by means of a special blood-emptying cuff. The advantage of this form of positioning is the fact that the operation can be performed completely under regional anesthesia (an anesthetic procedure aimed at eliminating pain in certain regions of the body). However, a disadvantage is that the abdominal positioning can become uncomfortable for the patient over time, and thus unconscious movements can complicate the procedure. Despite this disadvantage, this positioning has been used for years by the majority of surgeons.
- Lateral positioning – in contrast to the abdominal positioning, the arm to be operated on is positioned in front of the body, with the forearm hanging down. With the help of this positioning variant, the advantage of optimal accessibility to the surgical area is also ensured. However, in order to maintain a stable position, it is necessary to fix the patient and to wear a stirrup-like device in front of the chest over which the arm hangs, which results in an uncomfortable position for the patient. There is also a risk of patient slippage. Furthermore, there is a limited bending ability for the forearm due to the stop on the body.
- Supine positioning – the third positioning option is the supine positioning, in which the arm is laterally dislocated on an additional table, so that the surgical access to the anterior joint portion can be judged as good. However, a major disadvantage of this positioning option is that the posterior portion of the elbow joint can only be accessed by the surgeon by lifting the arm onto the patient’s abdomen. On the basis of this, most surgeons judge this form of positioning is not recommended.
For surgical preparation, it is necessary to determine the portals (surgical accesses) with the help of palpation (palpation) and diagnostic examinations. The following portals can be used for arthroscopy of the elbow joint:
- Anterolateral portal – the anterolateral portal, which describes the anterior route of access to the joint, represents the primary portal for arthroscopy at the elbow joint. To access the elbow joint via this route, a skin incision of approximately five millimeters must be made in which either blunt spreading of the subcutis (deep layer of skin) is performed or the arthroscopy shaft with a blunt obturator (surgical instrument) is inserted directly into the extended joint at 90° of flexion.With this portal, however, there is a risk that complications may arise from penetrating too far into the joint. In addition, the joint capsule can be affected and various nerve structures can be damaged.
- Anteromedial portal – in this portal, which describes the anteromedial access route to the elbow joint, two different options are possible in its application. The first option is the so-called inside-out method, in which the arthroscope is advanced under visualization to the mid-capsular portion. Following this, the optic can now be removed and the arthroscope can be advanced after the joint capsule has been transected. A relatively small skin incision over the tip of the rod follows. A disadvantage of the inside-out method is that the technique involves capsular perforation, which cannot be planned with complete precision. In contrast, the outside-in method allows for very precise capsular transection. Capsular puncture of this more commonly used method is performed under arthroscopic view from the anterolateral side. The precise definition of the perforation area is of great importance for the subsequent maneuverability of the surgical instruments. The spreading of the capsule proceeds analogously to the inside-out method.
- Dorsolateral portal – this access route, which leads from behind laterally to the elbow joint, is in principle rather rarely used, because the existing villous structure of the synovium makes the identification of tissue elements much more difficult. As with the anteromedial portal, a cannula puncture is used to specifically cut through the joint capsule at a defined and marked entry point. As a result of poor visibility, the use of a shaver (sharp knife) is usually necessary to ensure that the operation is performed correctly. In addition, in the absence of visibility, the cutaneus antebrachii posterior nerve, which is located in the surgical area, is also particularly at risk.
After surgery
After arthroscopy, it is important to note that full weight-bearing of the arm can not take place. Since swelling is possible, the elbow should be cooled for several days.
Possible complications
- Nerve lesions – in general, nerve damage is quite common, but almost all functional deficits are temporary (limited in time). Especially the ulnar nerve is affected excessively often.
- Empyema – furthermore, inflammatory processes also occur postoperatively, which can occasionally cause permanent damage. Empyema (accumulation of pus in a preformed (usually natural) body cavity or in a hollow organ) is a particularly serious inflammation, which is accompanied by necrosis (tissue destruction) and is usually only surgically treatable.
