Elbow Arthroscopy

Elbow arthroscopy gives diagnostic and therapeutic access to all three compartments of the elbow through a handful of portals, and its indications have expanded considerably since Andrews and Carson first described the technique in 1985. Its strength is low morbidity, multi-compartment visualisation and the ability to combine procedures — its singular danger is the dense neurovascular envelope around the joint, which makes portal technique the whole game.

Consent specifically for transient nerve palsy (the PIN and ulnar nerve most commonly), the small risk of permanent nerve injury, fluid extravasation and compartment syndrome, infection, and — after contracture release — recurrence of stiffness and heterotopic ossification. Counsel the rheumatoid or contracted-elbow patient that nerve-palsy risk is higher (Kelly 2001). Setup. General anaesthesia with a high upper-arm tourniquet; regional supplementation optional. The standard position is lateral decubitus with the arm over a bolster and the elbow flexed to 90°, which gives free anterior and posterior access without a traction device. Before draping, mark the medial and lateral epicondyles, the radial head (palpated with forearm rotation), the olecranon tip — and palpate and mark the ulnar nerve in the cubital tunnel at 90° flexion.

The goal is to enter the joint safely, inspect every compartment systematically, and complete the therapeutic task — loose-body removal, OCD fixation, capsular release or synovectomy — without injuring a nerve. The elbow's tiny working volume of only 3–5 mL is the reason every portal is preceded by distension: 20–30 mL of saline confirms intra-articular placement, tenses the capsule away from the neurovascular structures, and creates working space. Getting the portals right — the exposure — is the dominant skill and the dominant examination topic.

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Rehabilitation is procedure-specific. The general principles are early range of motion (the first 4–6 weeks determine long-term outcome), active-assisted rather than forced passive stretching (forced stretching fuels heterotopic ossification), and strengthening in a pain-free arc as motion returns.

Contracture release — special protocol. Postoperative motion is the single most important determinant of outcome, so physiotherapy starts within 24–48 hours: therapist-guided active and passive ROM three times daily, dynamic extension splinting at night (turnbuckle or Dynasplint), serial static splinting for persistent deficits at 6 weeks, and a target of full terminal extension and 130° flexion by week 6. Return to throwing (OCD). Grades 1–2 begin an interval throwing programme at 3 months; Grades 3–4 after fixation begin at 6 months with full overhead competition at 9–12 months. Better outcomes are predicted by an open capitellar physis, a shorter symptom duration, and loose-body removal or advanced lesions (Bexkens 2017: 62% same-level return to sport; Lu 2018 meta-analysis: 91.4% return to sport in arthroscopically treated patients). Complications. Elbow arthroscopy carries a higher complication rate than shoulder or knee arthroscopy because of the neurovascular density — reported overall rates range from 0.8 to 14% across series.

Surgical anatomy. The elbow shares a single joint cavity across three articulations — the ulnohumeral hinge (flexion-extension), the radiocapitellar joint (rotation and valgus load) and the proximal radioulnar joint. For arthroscopy it is divided into anterior and posterior compartments with no true medial/lateral division as in the knee. The anterior compartment holds the capitellum (the site of OCD in young athletes), the trochlea, the coronoid process, the radial head and the anterior capsule (the target in contracture release); the posterior compartment holds the olecranon tip and fossa (where loose bodies collect), the posterior trochlea, the gutters and a thicker, more fibrous posterior capsule. Why the elbow is dangerous. The joint's tiny working volume of only 3–5 mL sits within the densest neurovascular envelope of any major joint — the radial and median nerves, the PIN, the ulnar nerve, the brachial artery and the medial and lateral antebrachial cutaneous nerves all pass within millimetres of the working portals. This is why distension, portal order and elbow position — not the procedure itself — determine nerve safety (Lynch 1986), and why overall complication rates of 0.8–14% are reported across series, higher than shoulder or knee arthroscopy. Epidemiology of the indications. Capitellar OCD presents in adolescent overhead or throwing athletes (open physis) with lateral elbow pain and locking; post-traumatic contracture follows elbow trauma in young adults, for whom a functional 30°–130° arc is the benchmark; loose bodies arise from synovial osteochondromatosis, OCD or trauma; and refractory lateral epicondylitis brings the middle-aged patient after at least 6 months of failed conservative care.

The consistent evidence message is that elbow arthroscopy is effective and mostly safe when portal discipline is meticulous: loose-body removal remains its most reliable indication (Andrews 1985), arthroscopic contracture release matches open release with lower morbidity (Ball 2002; Cohen & Hastings 1998), and arthroscopic OCD management gives good function with a majority return to sport (Bexkens 2017; Lu 2018) — but nerve-palsy risk rises sharply in rheumatoid and contracted elbows (Kelly 2001), who warrant extra caution and counselling.

1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy. 1985;1(2):97–107. PMID: 4091924. DOI: 10.1016/s0749-8063(85)80038-4. — First systematic description of elbow arthroscopy portals and technique; loose-body removal gave the best results. 2. Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular anatomy and elbow arthroscopy: inherent risks. Arthroscopy. 1986;2(3):190–197. PMID: 3768116. DOI: 10.1016/s0749-8063(86)80067-6. — Landmark cadaveric study mapping neurovascular structures to portals; injury driven by portal placement, entry direction and elbow position. 3. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: a new technique. Arthroscopy. 1989;5(3):222–224. PMID: 2775398. DOI: 10.1016/0749-8063(89)90176-x. — Prone position with a proximal medial portal improving scope mobility and visualisation. 4. Stothers K, Day B, Regan WR. Arthroscopy of the elbow: anatomy, portal sites, and a description of the proximal lateral portal. Arthroscopy. 1995;11(4):449–457. PMID: 7575879. DOI: 10.1016/0749-8063(95)90200-7. — Proximal medial and proximal lateral portals safer than anteromedial/anterolateral; recommended as standard anterior portals. 5. Cohen MS, Hastings H 2nd. Post-traumatic contracture of the elbow. Operative release using a lateral collateral ligament sparing approach. J Bone Joint Surg Br. 1998;80(5):805–812. PMID: 9768890. DOI: 10.1302/0301-620x.80b5.8528. — Open LCL-sparing release improved total ulnohumeral movement from 74° to 129°. 6. Ball CM, Meunier M, Galatz LM, Calfee R, Yamaguchi K. Arthroscopic treatment of post-traumatic elbow contracture. J Shoulder Elbow Surg. 2002;11(6):624–629. PMID: 12469091. DOI: 10.1067/mse.2002.126770. — Arthroscopic release: arc under 100° improved from 69° to 119°; no neurovascular complications. 7. Lindenhovius ALC, Linzel DS, Doornberg JN, Ring DC, Jupiter JB. Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion. J Shoulder Elbow Surg. 2007;16(5):621–625. PMID: 17644008. DOI: 10.1016/j.jse.2007.01.005. — Motion gains greater when motion-blocking HO is removed than with capsular contracture alone. 8. Bexkens R, van den Ende KIM, Ogink PT, van Bergen CJA, van den Bekerom MPJ, Eygendaal D. Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum. Am J Sports Med. 2017;45(10):2312–2318. PMID: 28520461. DOI: 10.1177/0363546517704842. — 75 elbows; 62% return to sport; open physis predicts better outcome. 9. Lu Y, Li YJ, Guo SY, Zhang HL. Is there any difference between open and arthroscopic treatment for osteochondritis dissecans (OCD) of the humeral capitellum: a systematic review and meta-analysis. Int Orthop. 2018;42(3):601–607. PMID: 29349503. DOI: 10.1007/s00264-018-3768-3. — 91.4% return to sport arthroscopic vs 86.4% open; no complications in arthroscopic group. 10. Kelly EW, Morrey BF, O'Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am. 2001;83(1):25–34. PMID: 11205854. DOI: 10.2106/00004623-200101000-00004. — 473 cases: 0.8% serious (infection), 11% minor; transient nerve palsy linked to rheumatoid arthritis and contracture. 11. Safran MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment. Clin Sports Med. 2004;23(4):643–663. PMID: 15474227. DOI: 10.1016/j.csm.2004.05.002. — Overhead-athlete elbow pathology relevant to the throwing population presenting with OCD and loose bodies. 12. Johnson JA, Beingessner DM, Gordon KD, Dunning CE, Stacpoole RA, King GJW. Kinematics and stability of the fractured and implant-reconstructed radial head. J Shoulder Elbow Surg. 2005;14(1 Suppl S):195S–201S. PMID: 15726082. DOI: 10.1016/j.jse.2004.09.034. — Radial head excision markedly alters elbow kinematics and stability — relevant when considering arthroscopic radial head excision.