Many surgical procedures done within the elbow joint can be performed with arthroscopy (keyhole surgery). This involves the insertion of a fibreoptic scope through a small thin metal tube into the elbow joint. This is done through incisions of between 0.5 and 1 cm in length. The number of incisions used depends on the type of surgery being performed. This is less invasive surgery and while it may decrease the risks involved with wound healing in larger incisions, the same operation is being performed inside the joint. This means that the recovery can still take some time. The advantage of this approach is that the entire elbow joint can be examined through the camera. Areas that might not be visible to open surgery are visible and unexpected problems may be identified and dealt with at the same time.
Indications for elbow arthroscopy
Tennis elbow release: a tennis elbow release may be done either through open surgery or through arthroscopic surgery. The advantage of the arthroscopic procedure is that it allows better visualisation of the entire elbow and may identify other pathology. There is a slightly higher risk of nerve injury with the arthroscopic procedure. There are also reports of a slightly higher failure rate with arthroscopic tennis elbow releases compared to open tennis elbow releases. For this reason, the majority of uncomplicated tennis elbow surgery is performed open. In cases where there is a doubt in the diagnosis or dual pathology your surgeon may suggest doing the procedure arthroscopically in order to deal with the other pathology at the same time.
Removal of loose bodies: some patients may develop loose bodies of cartilage or bone within the elbow joint. This can be as a result of previous injury, arthritis or other less common rheumatological conditions. This frequently results in “locking” or “catching” of the elbow. It can also be accompanied by significant pain and stiffness. Arthroscopic surgery is an excellent way of assessing the elbow joint and removing these loose bodies which cause the mechanical symptoms. This often results in a dramatic improvement in symptoms which is noticeable even within the first few days.
Elbow joint arthritis: arthritis of the elbow is relatively uncommon compared to arthritis seen in other joints, for example hips and knees. Rheumatoid arthritis, osteoarthritis and arthritis following an injury (post traumatic arthritis) do however occur in the elbow. These conditions can often be dealt with very effectively through arthroscopic procedures. While the procedure may not undo the arthritic damage and the cartilage damage within the joint it can improve the range of motion and can improve the pain through removal of inflammatory tissue. During the arthroscopic procedure the entire elbow joint can be assessed and extra spurs of bone (which grow as a result of the arthritis) can be removed. The lining of the joint which may become very inflamed, generate pain and block movement can also be removed (synovectomy). This may slow the progress of the arthritis and in some cases delay the need for more major surgery such as elbow replacements.
Elbow stiffness: the elbow joint may become stiff for a number of reasons. This most commonly occurs after injury or surgery for fractures or dislocations. In severe cases extra bone may grow across the elbow joint (heterotopic ossification) preventing or movement. While each of these cases needs to be judged on its own merit, many of them can be managed with arthroscopic surgery. During these procedures the extra bone that blocks the movement can be respected and the scar tissue and thickened capsule (joint lining) can be excised. In severe cases open surgery may be better able to access the heterotopic ossification. The pros and cons of both arthroscopic and open surgery will be discussed with you by your surgeon prior to any procedure.
Osteochondral defects: an osteochondral defect is a discrete area of damage to the cartilage and underlying bone in the elbow. This most commonly occurs in adolescent patients and may be as a result of overuse of the elbow. In some cases there is no clearly defined cause for this. Not all osteochondral defects require surgery but if the fragment becomes loose or there are mechanical symptoms (“locking”, “catching” or stiffness) then arthroscopic surgery is a good way to remove the loose body and debride the joint. A joint debridement involves removal of any rough areas of cartilage, excess bone or inflammatory tissue which may limit movement will cause pain.
During and elbow arthroscopy the patient usually lies on the unaffected side. The elbow being operated on is rested on a padded bolster to support the arm and allow easy access during the surgery. The procedure is done under a general anaesthetic and this may be accompanied by a regional block. A regional block is when local anaesthetic is injected around the nerves in the neck that supply the elbow. This is done under ultrasound guidance to minimise the risk of nerve injury during this part of the procedure. The block allows the anaesthetist to use a lighter general anaesthetic and allows the patient to wake up pain free. It sometimes lasts as long as 24 hours and during this time the arm may be completely dead (this is normal) which can be a disconcerting feeling.
With the patient asleep an inflatable tourniquet is applied to the upper arm. This is inflated during the procedure to a controlled pressure which prevents blood from flowing into the surgical field. This allows better visualisation and more precise surgery. The pressure is carefully controlled but there are reports of neurological injury as a result of uncontrolled pressure. This is an extremely uncommon complication.
For elbow arthroscopy patients come in on the morning of the surgery and depending on the extent of the procedure may either stay overnight or potentially go home on the same day.