- Email: [email protected]
Arthroscopic capsular release of the elbow
J Shoulder Elbow Surg (2010) 19, 13-19
www.elsevier.com/locate/ymse
Arthroscopic capsular release of the elbow Nathan L. Van Zeeland, MD, Ken Yamaguchi, MD* Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO Loss of motion of the elbow joint has several etiologies, with trauma to the elbow being most common. Restricted elbow motion can lead directly to functional decline and interfere with activities of daily living. Most patients can regain a functional arc of motion with a combination of physical therapy and a splinting regimen. However, some patients will maintain persistent elbow stiffness. Traditionally, open techniques have been used successfully to release the elbow joint capsule and regain a functional arc of motion. Early results of arthroscopic elbow capsule release were concerning for peripheral nerve injury. Technical advances and modifications have allowed arthroscopic capsular release of the elbow to emerge as a safe and reliable, though technically demanding, and method to restore elbow motion Level of Evidence: Review Article. Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
Acquired elbow stiffness can result from several different etiologies, including burns, trauma, spasticity, osteoarthritis, and septic arthritis. Of these, trauma to the elbow is most common. The sequelae of elbow trauma often include loss of motion and, unlike other etiologies, this is due primarily to contracture of the anterior joint capsule. This decreased elbow motion can lead to corresponding functional deficits. Most activities of daily living require an arc of elbow flexion of 100 (from 30 to 130 ) as well as an arc of forearm rotation of 100 .13 Therefore, several treatment strategies have emerged to restore elbow motion following trauma. A primary goal following elbow trauma is prevention of contracture. To that end, the importance of physiciandirected physiotherapy following elbow trauma is paramount. However, the desire to maintain elbow motion, at the risk of hindering osseous and ligamentous healing, must be considered individually by the clinician, dictated by the *Reprint requests: Ken Yamaguchi, MD, Sam & Marilyn Fox Distinguished Professor of Orthopaedic Surgery, Washington University School of Medicine, Department of Orthopaedic Surgery, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address: [email protected] (K. Yamaguchi).
specific injury pattern. Once a post-traumatic elbow contracture is established, splinting and other therapeutic modalities can be employed. Near full-time use of a custom-fit static progressive (turnbuckle) orthotic has been shown to increase the overall arc of flexion by 43.1 .6 Some contractures are recalcitrant to static progressive splinting, and a subset of patients simply does not tolerate the splint. Open surgical release is an established surgical intervention for elbow contractures refractory to nonoperative modalities. 5,8,22,23 Early authors advocated a more extensile, comprehensive release, including anterior capsulectomy, release of anterior portion of collateral ligaments, biceps lengthening, brachialis myotomy, and dissection of the flexor-pronator origin.5,23 However, Urbaniak et al demonstrated 61% improvement in preoperative flexion contractures by performing a more limited, open anterior capsulotomy.22 Likewise, Husband and Hastings demonstrated a 46 improvement in arc of motion through a more limited lateral approach8 and anterior capsulotomy. Less invasive techniques for elbow contracture release have been developed in an effort to avoid excessive scarring and soft tissue trauma, which may contribute to contracture recurrence. More recently, arthroscopic release
1058-2746/2010/$36.00 - see front matter Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.01.003
14 of post-traumatic elbow contractures has gained acceptance.2,9,11,12,14,21 Arthroscopic release of the anterior elbow capsule has had encouraging clinical outcomes, but this is tempered by concerns for peripheral nerve injuries.7,9,12 The purpose of this report is to discuss the surgical technique and clinical outcomes for arthroscopic capsular release of the elbow. The use of arthroscopy to regain motion in the elbow is limited dependent upon the experience of the surgeon and the degree of intra or extra-articular derangement of the joint. Generally, excessive alteration of the normal joint architecture is a contraindication to an arthroscopic procedure. The patient should also have no mid arc pain. The pain, if present, should only be at the terminal limits of elbow motion. The presence of degenerative changes, such as osteophyte abutment, can be addressed arthroscopically with an osteocapsular arthroplasty, but is a difficult procedure that should be reserved for the most experienced of surgeons. Presence of significant heterotopic ossification is also a contraindication to an arthroscopic procedure. It cannot be addressed by arthroscopy alone. Finally, significant loss of flexion (100-110 ) requires an accessory open procedure to address the ulnar nerve and, generally, cannot be addressed with an arthroscopic procedure alone.
Patient evaluation Clinical evaluation should begin with inspection of the skin for evidence of burns, skin loss, or scars, which could represent a cutaneous contribution to the contracture. The clinician should use a goniometer to monitor active and passive motion of the elbow, thus accurately documenting response to various treatment protocols. Underlying ligamentous instability can present secondarily as joint stiffness. Therefore, lateral instability tests, such as the apprehension, lateral pivot shift, posterolateral rotatory drawer, and stand-up tests, may all be positive even in the context of apparent joint stiffness. Apparent joint stiffness in these cases can be acquired as the patient avoids instability positions, such as extension, in order to maintain greater stability. Over time, the extension motion is then lost.15,16 Medial elbow joint stability is assessed with the moving valgus stress test and milk test.17 A complete neurovascular examination should be included, with particular emphasis on ulnar nerve function and irritation. The presence of a subluxating or previously transposed ulnar nerve must be identified, as it may have surgical implications. Two-point discrimination and motor strength should be documented. Routine AP, oblique, and lateral radiographs of the affected elbow should be obtained to evaluate for any intrinsic sources of restricted motion: osteoarticular incongruity, osteophytes, arthrosis, loose bodies, heterotopic ossification, and prominent or loose hardware. The changes to elbow articular architecture or
N.L. Van Zeeland, K. Yamaguchi heterotopic ossification may often be difficult to assess by plain radiographs. In these cases, computer tomography (CT) scan can be very helpful. At this time, in most cases when a CT scan is required, a 3-dimensional (3-D) reconstruction is also obtained. Additionally, a magnetic resonance image (MRI) can be helpful in assessing the patient with suspected ligamentous injury or to evaluate for cartilaginous loose bodies. Nonoperative modalities should be attempted when possible, to include static progressive splinting. The ideal candidate for arthroscopic capsular release is a patient without cutaneous or osteoarticular sources of restricted motion, who has failed conservative therapies, and whose activities of daily living continue to be adversely affected.
Surgical technique Set-up While elbow arthroscopy is becoming increasingly popular, it remains technically demanding with potential for serious injury to peripheral nerves, blood vessels, and articular cartilage. Attention to detail is required to minimize risk of complications. Many authors perform elbow arthroscopy under regional anesthesia; though we prefer only general anesthesia for several reasons. The primary reason is that general anesthesia, without regional, allows for immediate and repeated postoperative neurovascular evaluation. This is particularly helpful if there are any concerns that a postoperative compartment syndrome may be occurring. Next, regional anesthesia alone does not allow for complete relaxation and easy positioning for surgeons who utilize the lateral decubitus/prone or the prone position for elbow arthroscopy. Finally, regional anesthesia alone may not be sufficient to prevent tourniquet pain during the arthroscopic procedure. A first generation cephalosporin is administered before tourniquet inflation. In case of allergy, vancomycin or clindamycin can be used as alternates. Serious deep joint infection following elbow arthroscopy has a reported incidence of 0.8%. Likewise, prolonged portal drainage and superficial infection are observed in nearly 7% of elbow arthroscopies.10 In addition to antibiotic administration, we close the portal sites with a locked horizontal mattress stitch to prevent persistent drainage and fistula formation. Elbow arthroscopy has been performed in the supine, prone, and lateral decubitus positions.1,18,19 Each position has unique advantages and disadvantages, mostly related to airway access and ability to get to the anterior and posterior compartments of the elbow. We prefer the lateral decubitus position, keeping the airway accessible to the anesthesiologist and providing ready access to the anterior and posterior compartments. After general anesthesia is obtained, the patient is positioned with the unaffected side down in the
Arthroscopic capsular release of the elbow
Figure 1 Basic set-up. The brachium should be abducted at least 90 from the thorax, with the elbow slightly high than the shoulder. This allows ample room for instruments.
lateral decubitus position on a beanbag. A nonsterile tourniquet is then applied to the affected brachium. The affected limb is then positioned in a stationary arm holder at roughly 90 of elbow flexion. To ensure that there is enough space for the instruments to fit between the elbow and the thorax/ abdomen, the arm should be abducted at least 90 from the body and the elbow positioned slightly higher than the level of the shoulder (Figure 1). The patient should be positioned so that the anterior portion of the trunk is at the edge of the bed, allowing the elbow to easily achieve full flexion and extension during the procedure.24
Surgical steps Once the patient has been prepped and draped in the padded arm holder, we first mark the surface landmarks and portal sites. This includes marking the medial and lateral epicondyles, medial intermuscular septum, lateral intermuscular septum, olecranon, radial head, and capitellum. We also like to palpate and mark the general course of the ulnar nerve. Once our landmarks are marked, the limb is exsanguinated and the tourniquet is elevated to 260 mm Hg. Next, the elbow joint must be distended with normal saline. While the neurovascular structures will maintain a constant distance from the joint capsule, by distending the joint the distance increases between the humerus and the neurovascular structures, thus increasing the working space. Using an 18-gauge needle, we inject normal saline in to the joint through the ‘‘soft spot’’ (site of midlateral portal), located at the center of a triangle formed by the lateral epicondyle, radial head, and olecranon process. While insufflating the joint, the fluid should flow unimpeded and good backflow should be obtained; slight extension of the elbow joint should be observed during joint distension. It is important to have the needle within the elbow joint, because injection of normal saline in to the adjacent soft
15 tissues can make identification of landmarks more difficult and will put the neurovascular structures at risk. In a typical elbow, 20-30 ml of normal saline will adequately distend the joint. However, capsular compliance in stiff elbows is only 15% of a normal elbow, significantly decreasing joint space volume and putting neurovascular structures at increased risk for injury.3 It should be stressed that as joint distention is decreased, the danger of the procedure increases. Thus, any lack of distention less than 10-15 cc of normal saline is an indication that the procedure should be performed by an appropriately experienced surgeon. Because of the large volume of arthroscopic releases having been performed at our institution, we do not have a contraindication for the procedure based on a lack of joint distention; however, it should be stressed that these can be difficult and dangerous procedures primarily at the initiation of the surgery. Once the joint is distended, we first establish a proximal anteromedial portal.24 This is typically 2 cm proximal to the medial epicondyle and 1-2 cm anterior to the medial intermuscular septum. Again, we stress the need to know if the patient has a subluxated or transposed ulnar nerve, as that could be a relative or absolute contraindication to establishing this portal. Considering the ulnar nerve is in the usual position, a scalpel blade is used to incise only the skin, as the medial antebrachial cutaneous nerve is typically within 2 mm from the portal. A blunt trochar and the cannula for the 4.0 mm, 30 arthroscope are passed 2-3 cm anterior to the intermuscular septum until contact with the anterior medial cortex of the humerus. Then, the cannula is pushed lateral while maintaining contact with the anterior humerus. The objective is to enter the joint at the most medial extent of the joint. By staying anterior to the intermuscular septum, the ulnar nerve stays posterior to the portal. With the trochar between the intermuscular septum and brachialis muscle, the median nerve is an average of 12 mm anterior. Once the proximal anteromedial portal is established, a good view of the anterior radiocapitellar joint is achieved. We generally set our pump to 35 mmHg (Arthrex, Naples, Florida). It should be noted that the pump pressures vary from manufacturer to manufacturer. As a general rule, our pump pressure is about 30% lower than used with the same pump for shoulder arthroscopy. Excessively contracted capsule may inhibit that view. At that point, we establish a proximal anterolateral portal, located roughly 2 cm proximal to the lateral epicondyle and just anterior to the supracondylar ridge.24 We first place a guidewire in to the joint and visualize the point of entry with the aid of the arthroscope. We then use a scalpel blade to incise the skin, and then use cannulated dilators to accurately create the portal. The radial nerve averages 5-10 mm from this portal. Once we have safely established the proximal anteromedial and proximal anterolateral portals, we then proceed to enlarge our working space. With the arthroscope in the proximal anteromedial portal, we use the blunt
16
N.L. Van Zeeland, K. Yamaguchi
Figure 2 A, Through the proximal anterolateral portal, a blunt trochar is introduced. B, It is used to elevate the contracted capsule from the anterior humerus.
trochar in the proximal anterolateral portal to release intraarticular adhesions, working proximally and lifting the anterior capsule off of the anterior humerus (Figure 2). After we have improved our working space, we then introduce the 4.0-mm oscillating shaver and debride synovium and adhesions. Care is taken to avoid directing the shaver toward the capsule. Anterior loose bodies can be removed and small anterior osteophytes can likewise be debrided (Figure 3). At that point, sharp anterior capsulotomy can be performed. Debridement of the capsule with an oscillating shaver may result in injuries to neurovascular structures. We use the 15 up-cutting basket resector and, under direct arthroscopic vision, develop a plane between the brachialis and the anterior capsule. Once that plane is developed, the capsule is incised, proceeding from lateral to medial. It is important to avoid any suction instruments at this point, as they cause the joint to collapse and bring the neurovascular structures closer to the sharp resector. Additionally, through a proximal anterolateral portal, a blunt trochar can be introduced to retract the capsule and maintain direct visualization.24 The arthroscope can be switched to the anterolateral portal via a switching stick. The anterior capsulotomy is then completed from the anteromedial working portal. The entire capsulotomy incises the viewable anterior capsule all the way from the anterolateral portal to the anteromedial portal. The deep surface of the brachialis is thus exposed, marking the completion of the anterior capsulotomy (Figure 4). We then proceed to the posterior compartment. A posterolateral viewing portal is established, 2 cm proximal to the olecranon and just lateral to the triceps tendon.24 A working posterior portal is created 3 cm proximal to the olecranon tip through the triceps tendon. The oscillating shaver can be used to debride synovium and small osteophytes. Then, a blunt trochar can be used to lift the posterior capsule off of the humerus. To protect the ulnar
Figure 3 The oscillating shaver is used to perform an initial debridement, taking care not to engage the capsule with the shaver.
nerve, we do not routinely release the capsule beyond the medial border of the olecranon fossa. Following capsular release, gentle manipulation of the elbow can be performed to release any residual contracture. The instruments are then removed and the portals are closed tightly with a locking nylon mattress suture. A sterile dressing is applied with an overlying ACE wrap. The tourniquet is then released. Over that dressing, we place an anterior plaster slab maintaining the elbow in extension, securing it in place with an additional ACE wrap.
Ulnar nerve Ulnar nerve intraneural pressure increases as the elbow proceeds from full extension to full flexion. Beyond 90 of
Arthroscopic capsular release of the elbow
17
Figure 4 A, B, Using a sharp biter, the anterior capsule is divided lateral to medial. C, The viewing and working portals are switched and the capsulotomy is completed through the proximal anteromedial portal. When the capsule is completely released, the fibers of the overlying brachialis are exposed (denoted by asterisk). D, The release is completed at this point.
flexion, the intraneural pressure raises in excess of the extraneural pressure, suggesting a traction component of cubital tunnel syndrome, not just extrinsic compression. In fact, at 130 of elbow flexion, the intraneural pressure is 45% greater than the extraneural pressure.4 Therefore, patients who have pre-operative elbow flexion 100 are at increased risk for developing ulnar nerve complications once they are able to flex beyond that. In these stiff elbows, some authors have advocated for concurrent in situ ulnar nerve decompression.20 We prefer to perform a formal ulnar nerve decompression when the passive preoperative elbow flexion is 100 or less. Ulnar nerve decompression is performed by an open, limited approach. A 3-cm incision is made over the proximal portion of the cubital tunnel. Blunt dissection is taken down to the ulnar nerve and the cubital tunnel retinaculum then released with tenotomy scissors. If there is 100 available flexion, the posterior bundle of the medial collateral ligament requires release. The ulnar nerve is gently retracted medially away from the floor of the cubital tunnel, and the floor of the cubital tunnel is thus exposed. The posterior bundle of the medial collateral ligament comprises the floor of the cubital tunnel. With the elbow maximally flexed, this posterior bundle of medial collateral
ligament undergoes tension and should readily be identifiable. It is released sharply with a knife under direct visualization. Immediate improvement in elbow flexion should occur. At this point, the ulnar nerve is allowed to relocate within the cubital tunnel; the skin incision is then closed in a layered fashion. No deep fascial sutures are applied. This portion of the operation is generally done last in order to be able to maintain intra-articular joint distention during the arthroscopic portion.
Postoperative care The patient is maintained in a plaster extension splint for 24 hours after arthroscopic release. The following day, the patient is allowed to take off the outer ACE wrap, remove the plaster slab, and maintain the underlying dressing. We then allow unrestricted active and passive motion. A 2week course of a first generation cephalosporin is prescribed postoperatively. The use of a 2-week course is relatively long and does not have literature support. We have instituted this protocol because of the high incidence of postoperative drainage previously reported with arthroscopy and also seen in our experience. Additionally, superficial infection has been observed in as many as 7% of
18 elbow arthroscopies and is related to prolonged portal drainage.17 For this reason, sutures are maintained in the portal sites for a full 2 weeks, at which point nearly all portal sites have closed sufficiently to obviate the concern of drainage. We have felt it prudent to maintain patients on antibiotics until such closure is seen. To our knowledge, since the institution of this protocol, we have not seen a single deep infection of an elbow arthroscopy. We have had 1 deep infection of an elbow arthroscopy prior to the institution of this protocol. The sutures are discontinued at 2 weeks. Some patients require supervised physical therapy, night-time extension splinting, or static progressive splints, but these are determined on an individual basis. In our experience, most patients following arthroscopic release of soft tissue contractures do not have significant pain following the procedure. Thus supplemental regional anesthesia is rarely required. Use of NSAID’s or oral pain medications is generally sufficient in the immediate postoperative period. Routine prophylaxis of heterotopic ossifications is also not generally necessary, as the presence of HO is a relative contra-indication. Of course, certain highrisk patients may require prophylaxis on an individual basis.
Clinical outcomes Several authors have demonstrated excellent restoration of elbow motion following arthroscopic capsule release of the elbow.9,11,12,14,21 In 2002, we reported a retrospective series of 14 consecutive patients with post-traumatic stiffness, who underwent elbow arthroscopy and sharp anterior capsulotomy with a minimum 1-year follow-up.2 Only 6 of 14 patients continued to have some pain at 1-year follow-up, with a mean maximal visual analog pain score of 4.6/10. Pre-operative range of motion was from 35.4 of extension to 117.5 of flexion, with a mean arc of 82 . At minimum 1year follow-up (range, 12-29 months) mean motion was from 9.3 of extension to 133 of flexion, with a mean arc of motion of 123.6 . This represented a mean improvement of 41.5 in arc of motion. The mean self-reported visual analog satisfaction score was 8.4/10. All patients stated that they would have the surgery again. Functionally, patients did remarkably well, with a mean score of 28.3/30 on the American Shoulder and Elbow Surgeons Functional Self-Evaluation Form. Complications were rare. One patient had a superficial portal site infection that resolved with drainage and oral antibiotic therapy. There were no neurovascular complications. Comparing complication rates between open and arthroscopic capsular release is difficult, as there are no direct comparative studies in the literature. Historically, the literature suggests a low complication rate following open elbow capsulotomy. Three transient nerve palsies (2 radial, 1 ulnar) were observed in 15 patients following an open,
N.L. Van Zeeland, K. Yamaguchi anterior capsulotomy. All resolved over a course of 3 weeks to 7 months. No infections were noted.22 Husband and Hastings noted transient paresthesias of the ulnar nerve in 1 of 7 patients following an open capsulotomy through a lateral approach. This spontaneously resolved. No infections or heterotopic ossification were observed.8 Arthroscopic elbow capsule release has had early reports of peripheral nerve injuries, but an improved safety profile over time. Haapaniemi et al provided a case report where both the radial and median nerves were transected during an arthroscopic release of a post-traumatic elbow contracture. 7 Jones et al reported 12 patients who had an arthroscopic capsule release. One patient required a subsequent manipulation under anesthesia and another had a permanent posterior interosseous nerve palsy, requiring additional surgery.9 Two transient median nerve palsies in 25 patients were reported by Kim et al, following arthroscopic elbow debridement and capsule release.11 In another series of 22 patients, 1 patient developed a transient ulnar neuropathy and another developed a permanent medial antebrachial cutaneous neuroma. Three patients had persistent, mild tenderness at the portals.14 In our aforementioned series, we had 1 infection and no neurovascular injuries following arthroscopic elbow capsule release.2 These historical data underscore the fact that arthroscopic release of the posttraumatic elbow contracture is technically challenging and requires ample surgeon experience.
Conclusion Post-traumatic elbow stiffness can restrict activities of daily living. In some patients, physiotherapy and splinting regimens can restore a functional arc of motion (100 ); however, other patients will continue to have residual elbow stiffness. Open elbow capsular release is a viable option, with an established track record. Arthroscopic elbow capsular release is a technically demanding procedure that requires detailed knowledge of 3-D elbow anatomy. Severe neurovascular complications have been reported in the literature. However, in properly selected candidates, arthroscopic elbow capsule release can reliably improve elbow arc of motion with minimal soft tissue trauma and a low incidence of neurologic complications.
Disclaimer Nathan L. Van Zeeland, MD, nor any family member, has received any financial remuneration related to the subject of this article. Ken Yamaguchi, MD, receives royalties from Tornier and Zimmer related to total elbow and shoulder products. IRB approval was not required for this technique article.
Arthroscopic capsular release of the elbow
References 1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 2. Ball CM, Meunier M, Galatz LM, Calfee R, Yamaguchi K. Arthroscopic treatment of post-traumatic elbow contracture. J Shoulder Elbow Surg 2002;11:624-9. 3. Gallay SH, Richards RR, O’Driscoll SW. Intraarticular capacity and compliance of stiff and normal elbows. Arthroscopy 1993;9:9-13. 4. Gelberman RH, Yamaguchi K, Hollstien SB, Winn SS, Heidenreich FP, Bindra RR, et al. Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera. J Shoulder Elbow Surg 1998:492-501. 5. Glynn JJ, Niebauer JJ. Flexion and extension contracture of the elbow: surgical management. Clin Orthop Relat Res 1976:289-91. 6. Green DP, McCoy H. Turnbuckle orthotic correction of elbow-flexion contractures after acute injuries. J Bone Joint Surg Am 1979;61:1092-5. 7. Haapaniemi T, Berggren M, Adolfsson L. Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture. Arthroscopy 1999;15:784-7. 8. Husband JB, Hastings H II. The lateral approach for operative release of post-traumatic contracture of the elbow. J Bone Joint Surg Am 1990;72:1353-8. 9. Jones GS, Savoie FH III. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 1993;9:277-83. 10. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am 2001:25-34. 83-A. 11. Kim SJ, Kim HK, Lee JW. Arthroscopy for limitation of motion of the elbow. Arthroscopy 1995;11:680-3.
19 12. Kim SJ, Shin SJ. Arthroscopic treatment for limitation of motion of the elbow. Clin Orthop Relat Res 2000:140-8. 13. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-7. 14. Nguyen D, Proper SI, MacDermid JC, King GJ, Faber KJ. Functional outcomes of arthroscopic capsular release of the elbow. Arthroscopy 2006;22:842-9. 15. O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res 2000:34-43. 16. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-6. 17. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect 2001;50:89-102. 18. O’Driscoll SW, Morrey BF. Arthroscopy of the elbow. Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg Am 1992;74: 84-94. 19. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: a new technique. Arthroscopy 1989;5:222-4. 20. Sahajpal D, Choi T, Wright TW. Arthroscopic release of the stiff elbow. J Hand Surg Am 2009;34:540-4. 21. Timmerman LA, Andrews JR. Arthroscopic treatment of posttraumatic elbow pain and stiffness. Am J Sports Med 1994;22:230-5. 22. Urbaniak JR, Hansen PE, Beissinger SF, Aitken MS. Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. J Bone Joint Surg Am 1985;67:1160-4. 23. Wilson P. Capsulectomy for the relief of flexion contractures of the elbow following fracture. J Bone Joint Surg 1944;26:71-86. 24. Yamaguchi K, Tashjian RZ. Setup and Portals. In: Yamaguchi K, King GJW, McKee MD, O’Driscoll SWM, editors. Advanced reconstruction elbow. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2007. p. 3-11.
www.elsevier.com/locate/ymse
Arthroscopic capsular release of the elbow Nathan L. Van Zeeland, MD, Ken Yamaguchi, MD* Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO Loss of motion of the elbow joint has several etiologies, with trauma to the elbow being most common. Restricted elbow motion can lead directly to functional decline and interfere with activities of daily living. Most patients can regain a functional arc of motion with a combination of physical therapy and a splinting regimen. However, some patients will maintain persistent elbow stiffness. Traditionally, open techniques have been used successfully to release the elbow joint capsule and regain a functional arc of motion. Early results of arthroscopic elbow capsule release were concerning for peripheral nerve injury. Technical advances and modifications have allowed arthroscopic capsular release of the elbow to emerge as a safe and reliable, though technically demanding, and method to restore elbow motion Level of Evidence: Review Article. Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
Acquired elbow stiffness can result from several different etiologies, including burns, trauma, spasticity, osteoarthritis, and septic arthritis. Of these, trauma to the elbow is most common. The sequelae of elbow trauma often include loss of motion and, unlike other etiologies, this is due primarily to contracture of the anterior joint capsule. This decreased elbow motion can lead to corresponding functional deficits. Most activities of daily living require an arc of elbow flexion of 100 (from 30 to 130 ) as well as an arc of forearm rotation of 100 .13 Therefore, several treatment strategies have emerged to restore elbow motion following trauma. A primary goal following elbow trauma is prevention of contracture. To that end, the importance of physiciandirected physiotherapy following elbow trauma is paramount. However, the desire to maintain elbow motion, at the risk of hindering osseous and ligamentous healing, must be considered individually by the clinician, dictated by the *Reprint requests: Ken Yamaguchi, MD, Sam & Marilyn Fox Distinguished Professor of Orthopaedic Surgery, Washington University School of Medicine, Department of Orthopaedic Surgery, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address: [email protected] (K. Yamaguchi).
specific injury pattern. Once a post-traumatic elbow contracture is established, splinting and other therapeutic modalities can be employed. Near full-time use of a custom-fit static progressive (turnbuckle) orthotic has been shown to increase the overall arc of flexion by 43.1 .6 Some contractures are recalcitrant to static progressive splinting, and a subset of patients simply does not tolerate the splint. Open surgical release is an established surgical intervention for elbow contractures refractory to nonoperative modalities. 5,8,22,23 Early authors advocated a more extensile, comprehensive release, including anterior capsulectomy, release of anterior portion of collateral ligaments, biceps lengthening, brachialis myotomy, and dissection of the flexor-pronator origin.5,23 However, Urbaniak et al demonstrated 61% improvement in preoperative flexion contractures by performing a more limited, open anterior capsulotomy.22 Likewise, Husband and Hastings demonstrated a 46 improvement in arc of motion through a more limited lateral approach8 and anterior capsulotomy. Less invasive techniques for elbow contracture release have been developed in an effort to avoid excessive scarring and soft tissue trauma, which may contribute to contracture recurrence. More recently, arthroscopic release
1058-2746/2010/$36.00 - see front matter Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.01.003
14 of post-traumatic elbow contractures has gained acceptance.2,9,11,12,14,21 Arthroscopic release of the anterior elbow capsule has had encouraging clinical outcomes, but this is tempered by concerns for peripheral nerve injuries.7,9,12 The purpose of this report is to discuss the surgical technique and clinical outcomes for arthroscopic capsular release of the elbow. The use of arthroscopy to regain motion in the elbow is limited dependent upon the experience of the surgeon and the degree of intra or extra-articular derangement of the joint. Generally, excessive alteration of the normal joint architecture is a contraindication to an arthroscopic procedure. The patient should also have no mid arc pain. The pain, if present, should only be at the terminal limits of elbow motion. The presence of degenerative changes, such as osteophyte abutment, can be addressed arthroscopically with an osteocapsular arthroplasty, but is a difficult procedure that should be reserved for the most experienced of surgeons. Presence of significant heterotopic ossification is also a contraindication to an arthroscopic procedure. It cannot be addressed by arthroscopy alone. Finally, significant loss of flexion (100-110 ) requires an accessory open procedure to address the ulnar nerve and, generally, cannot be addressed with an arthroscopic procedure alone.
Patient evaluation Clinical evaluation should begin with inspection of the skin for evidence of burns, skin loss, or scars, which could represent a cutaneous contribution to the contracture. The clinician should use a goniometer to monitor active and passive motion of the elbow, thus accurately documenting response to various treatment protocols. Underlying ligamentous instability can present secondarily as joint stiffness. Therefore, lateral instability tests, such as the apprehension, lateral pivot shift, posterolateral rotatory drawer, and stand-up tests, may all be positive even in the context of apparent joint stiffness. Apparent joint stiffness in these cases can be acquired as the patient avoids instability positions, such as extension, in order to maintain greater stability. Over time, the extension motion is then lost.15,16 Medial elbow joint stability is assessed with the moving valgus stress test and milk test.17 A complete neurovascular examination should be included, with particular emphasis on ulnar nerve function and irritation. The presence of a subluxating or previously transposed ulnar nerve must be identified, as it may have surgical implications. Two-point discrimination and motor strength should be documented. Routine AP, oblique, and lateral radiographs of the affected elbow should be obtained to evaluate for any intrinsic sources of restricted motion: osteoarticular incongruity, osteophytes, arthrosis, loose bodies, heterotopic ossification, and prominent or loose hardware. The changes to elbow articular architecture or
N.L. Van Zeeland, K. Yamaguchi heterotopic ossification may often be difficult to assess by plain radiographs. In these cases, computer tomography (CT) scan can be very helpful. At this time, in most cases when a CT scan is required, a 3-dimensional (3-D) reconstruction is also obtained. Additionally, a magnetic resonance image (MRI) can be helpful in assessing the patient with suspected ligamentous injury or to evaluate for cartilaginous loose bodies. Nonoperative modalities should be attempted when possible, to include static progressive splinting. The ideal candidate for arthroscopic capsular release is a patient without cutaneous or osteoarticular sources of restricted motion, who has failed conservative therapies, and whose activities of daily living continue to be adversely affected.
Surgical technique Set-up While elbow arthroscopy is becoming increasingly popular, it remains technically demanding with potential for serious injury to peripheral nerves, blood vessels, and articular cartilage. Attention to detail is required to minimize risk of complications. Many authors perform elbow arthroscopy under regional anesthesia; though we prefer only general anesthesia for several reasons. The primary reason is that general anesthesia, without regional, allows for immediate and repeated postoperative neurovascular evaluation. This is particularly helpful if there are any concerns that a postoperative compartment syndrome may be occurring. Next, regional anesthesia alone does not allow for complete relaxation and easy positioning for surgeons who utilize the lateral decubitus/prone or the prone position for elbow arthroscopy. Finally, regional anesthesia alone may not be sufficient to prevent tourniquet pain during the arthroscopic procedure. A first generation cephalosporin is administered before tourniquet inflation. In case of allergy, vancomycin or clindamycin can be used as alternates. Serious deep joint infection following elbow arthroscopy has a reported incidence of 0.8%. Likewise, prolonged portal drainage and superficial infection are observed in nearly 7% of elbow arthroscopies.10 In addition to antibiotic administration, we close the portal sites with a locked horizontal mattress stitch to prevent persistent drainage and fistula formation. Elbow arthroscopy has been performed in the supine, prone, and lateral decubitus positions.1,18,19 Each position has unique advantages and disadvantages, mostly related to airway access and ability to get to the anterior and posterior compartments of the elbow. We prefer the lateral decubitus position, keeping the airway accessible to the anesthesiologist and providing ready access to the anterior and posterior compartments. After general anesthesia is obtained, the patient is positioned with the unaffected side down in the
Arthroscopic capsular release of the elbow
Figure 1 Basic set-up. The brachium should be abducted at least 90 from the thorax, with the elbow slightly high than the shoulder. This allows ample room for instruments.
lateral decubitus position on a beanbag. A nonsterile tourniquet is then applied to the affected brachium. The affected limb is then positioned in a stationary arm holder at roughly 90 of elbow flexion. To ensure that there is enough space for the instruments to fit between the elbow and the thorax/ abdomen, the arm should be abducted at least 90 from the body and the elbow positioned slightly higher than the level of the shoulder (Figure 1). The patient should be positioned so that the anterior portion of the trunk is at the edge of the bed, allowing the elbow to easily achieve full flexion and extension during the procedure.24
Surgical steps Once the patient has been prepped and draped in the padded arm holder, we first mark the surface landmarks and portal sites. This includes marking the medial and lateral epicondyles, medial intermuscular septum, lateral intermuscular septum, olecranon, radial head, and capitellum. We also like to palpate and mark the general course of the ulnar nerve. Once our landmarks are marked, the limb is exsanguinated and the tourniquet is elevated to 260 mm Hg. Next, the elbow joint must be distended with normal saline. While the neurovascular structures will maintain a constant distance from the joint capsule, by distending the joint the distance increases between the humerus and the neurovascular structures, thus increasing the working space. Using an 18-gauge needle, we inject normal saline in to the joint through the ‘‘soft spot’’ (site of midlateral portal), located at the center of a triangle formed by the lateral epicondyle, radial head, and olecranon process. While insufflating the joint, the fluid should flow unimpeded and good backflow should be obtained; slight extension of the elbow joint should be observed during joint distension. It is important to have the needle within the elbow joint, because injection of normal saline in to the adjacent soft
15 tissues can make identification of landmarks more difficult and will put the neurovascular structures at risk. In a typical elbow, 20-30 ml of normal saline will adequately distend the joint. However, capsular compliance in stiff elbows is only 15% of a normal elbow, significantly decreasing joint space volume and putting neurovascular structures at increased risk for injury.3 It should be stressed that as joint distention is decreased, the danger of the procedure increases. Thus, any lack of distention less than 10-15 cc of normal saline is an indication that the procedure should be performed by an appropriately experienced surgeon. Because of the large volume of arthroscopic releases having been performed at our institution, we do not have a contraindication for the procedure based on a lack of joint distention; however, it should be stressed that these can be difficult and dangerous procedures primarily at the initiation of the surgery. Once the joint is distended, we first establish a proximal anteromedial portal.24 This is typically 2 cm proximal to the medial epicondyle and 1-2 cm anterior to the medial intermuscular septum. Again, we stress the need to know if the patient has a subluxated or transposed ulnar nerve, as that could be a relative or absolute contraindication to establishing this portal. Considering the ulnar nerve is in the usual position, a scalpel blade is used to incise only the skin, as the medial antebrachial cutaneous nerve is typically within 2 mm from the portal. A blunt trochar and the cannula for the 4.0 mm, 30 arthroscope are passed 2-3 cm anterior to the intermuscular septum until contact with the anterior medial cortex of the humerus. Then, the cannula is pushed lateral while maintaining contact with the anterior humerus. The objective is to enter the joint at the most medial extent of the joint. By staying anterior to the intermuscular septum, the ulnar nerve stays posterior to the portal. With the trochar between the intermuscular septum and brachialis muscle, the median nerve is an average of 12 mm anterior. Once the proximal anteromedial portal is established, a good view of the anterior radiocapitellar joint is achieved. We generally set our pump to 35 mmHg (Arthrex, Naples, Florida). It should be noted that the pump pressures vary from manufacturer to manufacturer. As a general rule, our pump pressure is about 30% lower than used with the same pump for shoulder arthroscopy. Excessively contracted capsule may inhibit that view. At that point, we establish a proximal anterolateral portal, located roughly 2 cm proximal to the lateral epicondyle and just anterior to the supracondylar ridge.24 We first place a guidewire in to the joint and visualize the point of entry with the aid of the arthroscope. We then use a scalpel blade to incise the skin, and then use cannulated dilators to accurately create the portal. The radial nerve averages 5-10 mm from this portal. Once we have safely established the proximal anteromedial and proximal anterolateral portals, we then proceed to enlarge our working space. With the arthroscope in the proximal anteromedial portal, we use the blunt
16
N.L. Van Zeeland, K. Yamaguchi
Figure 2 A, Through the proximal anterolateral portal, a blunt trochar is introduced. B, It is used to elevate the contracted capsule from the anterior humerus.
trochar in the proximal anterolateral portal to release intraarticular adhesions, working proximally and lifting the anterior capsule off of the anterior humerus (Figure 2). After we have improved our working space, we then introduce the 4.0-mm oscillating shaver and debride synovium and adhesions. Care is taken to avoid directing the shaver toward the capsule. Anterior loose bodies can be removed and small anterior osteophytes can likewise be debrided (Figure 3). At that point, sharp anterior capsulotomy can be performed. Debridement of the capsule with an oscillating shaver may result in injuries to neurovascular structures. We use the 15 up-cutting basket resector and, under direct arthroscopic vision, develop a plane between the brachialis and the anterior capsule. Once that plane is developed, the capsule is incised, proceeding from lateral to medial. It is important to avoid any suction instruments at this point, as they cause the joint to collapse and bring the neurovascular structures closer to the sharp resector. Additionally, through a proximal anterolateral portal, a blunt trochar can be introduced to retract the capsule and maintain direct visualization.24 The arthroscope can be switched to the anterolateral portal via a switching stick. The anterior capsulotomy is then completed from the anteromedial working portal. The entire capsulotomy incises the viewable anterior capsule all the way from the anterolateral portal to the anteromedial portal. The deep surface of the brachialis is thus exposed, marking the completion of the anterior capsulotomy (Figure 4). We then proceed to the posterior compartment. A posterolateral viewing portal is established, 2 cm proximal to the olecranon and just lateral to the triceps tendon.24 A working posterior portal is created 3 cm proximal to the olecranon tip through the triceps tendon. The oscillating shaver can be used to debride synovium and small osteophytes. Then, a blunt trochar can be used to lift the posterior capsule off of the humerus. To protect the ulnar
Figure 3 The oscillating shaver is used to perform an initial debridement, taking care not to engage the capsule with the shaver.
nerve, we do not routinely release the capsule beyond the medial border of the olecranon fossa. Following capsular release, gentle manipulation of the elbow can be performed to release any residual contracture. The instruments are then removed and the portals are closed tightly with a locking nylon mattress suture. A sterile dressing is applied with an overlying ACE wrap. The tourniquet is then released. Over that dressing, we place an anterior plaster slab maintaining the elbow in extension, securing it in place with an additional ACE wrap.
Ulnar nerve Ulnar nerve intraneural pressure increases as the elbow proceeds from full extension to full flexion. Beyond 90 of
Arthroscopic capsular release of the elbow
17
Figure 4 A, B, Using a sharp biter, the anterior capsule is divided lateral to medial. C, The viewing and working portals are switched and the capsulotomy is completed through the proximal anteromedial portal. When the capsule is completely released, the fibers of the overlying brachialis are exposed (denoted by asterisk). D, The release is completed at this point.
flexion, the intraneural pressure raises in excess of the extraneural pressure, suggesting a traction component of cubital tunnel syndrome, not just extrinsic compression. In fact, at 130 of elbow flexion, the intraneural pressure is 45% greater than the extraneural pressure.4 Therefore, patients who have pre-operative elbow flexion 100 are at increased risk for developing ulnar nerve complications once they are able to flex beyond that. In these stiff elbows, some authors have advocated for concurrent in situ ulnar nerve decompression.20 We prefer to perform a formal ulnar nerve decompression when the passive preoperative elbow flexion is 100 or less. Ulnar nerve decompression is performed by an open, limited approach. A 3-cm incision is made over the proximal portion of the cubital tunnel. Blunt dissection is taken down to the ulnar nerve and the cubital tunnel retinaculum then released with tenotomy scissors. If there is 100 available flexion, the posterior bundle of the medial collateral ligament requires release. The ulnar nerve is gently retracted medially away from the floor of the cubital tunnel, and the floor of the cubital tunnel is thus exposed. The posterior bundle of the medial collateral ligament comprises the floor of the cubital tunnel. With the elbow maximally flexed, this posterior bundle of medial collateral
ligament undergoes tension and should readily be identifiable. It is released sharply with a knife under direct visualization. Immediate improvement in elbow flexion should occur. At this point, the ulnar nerve is allowed to relocate within the cubital tunnel; the skin incision is then closed in a layered fashion. No deep fascial sutures are applied. This portion of the operation is generally done last in order to be able to maintain intra-articular joint distention during the arthroscopic portion.
Postoperative care The patient is maintained in a plaster extension splint for 24 hours after arthroscopic release. The following day, the patient is allowed to take off the outer ACE wrap, remove the plaster slab, and maintain the underlying dressing. We then allow unrestricted active and passive motion. A 2week course of a first generation cephalosporin is prescribed postoperatively. The use of a 2-week course is relatively long and does not have literature support. We have instituted this protocol because of the high incidence of postoperative drainage previously reported with arthroscopy and also seen in our experience. Additionally, superficial infection has been observed in as many as 7% of
18 elbow arthroscopies and is related to prolonged portal drainage.17 For this reason, sutures are maintained in the portal sites for a full 2 weeks, at which point nearly all portal sites have closed sufficiently to obviate the concern of drainage. We have felt it prudent to maintain patients on antibiotics until such closure is seen. To our knowledge, since the institution of this protocol, we have not seen a single deep infection of an elbow arthroscopy. We have had 1 deep infection of an elbow arthroscopy prior to the institution of this protocol. The sutures are discontinued at 2 weeks. Some patients require supervised physical therapy, night-time extension splinting, or static progressive splints, but these are determined on an individual basis. In our experience, most patients following arthroscopic release of soft tissue contractures do not have significant pain following the procedure. Thus supplemental regional anesthesia is rarely required. Use of NSAID’s or oral pain medications is generally sufficient in the immediate postoperative period. Routine prophylaxis of heterotopic ossifications is also not generally necessary, as the presence of HO is a relative contra-indication. Of course, certain highrisk patients may require prophylaxis on an individual basis.
Clinical outcomes Several authors have demonstrated excellent restoration of elbow motion following arthroscopic capsule release of the elbow.9,11,12,14,21 In 2002, we reported a retrospective series of 14 consecutive patients with post-traumatic stiffness, who underwent elbow arthroscopy and sharp anterior capsulotomy with a minimum 1-year follow-up.2 Only 6 of 14 patients continued to have some pain at 1-year follow-up, with a mean maximal visual analog pain score of 4.6/10. Pre-operative range of motion was from 35.4 of extension to 117.5 of flexion, with a mean arc of 82 . At minimum 1year follow-up (range, 12-29 months) mean motion was from 9.3 of extension to 133 of flexion, with a mean arc of motion of 123.6 . This represented a mean improvement of 41.5 in arc of motion. The mean self-reported visual analog satisfaction score was 8.4/10. All patients stated that they would have the surgery again. Functionally, patients did remarkably well, with a mean score of 28.3/30 on the American Shoulder and Elbow Surgeons Functional Self-Evaluation Form. Complications were rare. One patient had a superficial portal site infection that resolved with drainage and oral antibiotic therapy. There were no neurovascular complications. Comparing complication rates between open and arthroscopic capsular release is difficult, as there are no direct comparative studies in the literature. Historically, the literature suggests a low complication rate following open elbow capsulotomy. Three transient nerve palsies (2 radial, 1 ulnar) were observed in 15 patients following an open,
N.L. Van Zeeland, K. Yamaguchi anterior capsulotomy. All resolved over a course of 3 weeks to 7 months. No infections were noted.22 Husband and Hastings noted transient paresthesias of the ulnar nerve in 1 of 7 patients following an open capsulotomy through a lateral approach. This spontaneously resolved. No infections or heterotopic ossification were observed.8 Arthroscopic elbow capsule release has had early reports of peripheral nerve injuries, but an improved safety profile over time. Haapaniemi et al provided a case report where both the radial and median nerves were transected during an arthroscopic release of a post-traumatic elbow contracture. 7 Jones et al reported 12 patients who had an arthroscopic capsule release. One patient required a subsequent manipulation under anesthesia and another had a permanent posterior interosseous nerve palsy, requiring additional surgery.9 Two transient median nerve palsies in 25 patients were reported by Kim et al, following arthroscopic elbow debridement and capsule release.11 In another series of 22 patients, 1 patient developed a transient ulnar neuropathy and another developed a permanent medial antebrachial cutaneous neuroma. Three patients had persistent, mild tenderness at the portals.14 In our aforementioned series, we had 1 infection and no neurovascular injuries following arthroscopic elbow capsule release.2 These historical data underscore the fact that arthroscopic release of the posttraumatic elbow contracture is technically challenging and requires ample surgeon experience.
Conclusion Post-traumatic elbow stiffness can restrict activities of daily living. In some patients, physiotherapy and splinting regimens can restore a functional arc of motion (100 ); however, other patients will continue to have residual elbow stiffness. Open elbow capsular release is a viable option, with an established track record. Arthroscopic elbow capsular release is a technically demanding procedure that requires detailed knowledge of 3-D elbow anatomy. Severe neurovascular complications have been reported in the literature. However, in properly selected candidates, arthroscopic elbow capsule release can reliably improve elbow arc of motion with minimal soft tissue trauma and a low incidence of neurologic complications.
Disclaimer Nathan L. Van Zeeland, MD, nor any family member, has received any financial remuneration related to the subject of this article. Ken Yamaguchi, MD, receives royalties from Tornier and Zimmer related to total elbow and shoulder products. IRB approval was not required for this technique article.
Arthroscopic capsular release of the elbow
References 1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 2. Ball CM, Meunier M, Galatz LM, Calfee R, Yamaguchi K. Arthroscopic treatment of post-traumatic elbow contracture. J Shoulder Elbow Surg 2002;11:624-9. 3. Gallay SH, Richards RR, O’Driscoll SW. Intraarticular capacity and compliance of stiff and normal elbows. Arthroscopy 1993;9:9-13. 4. Gelberman RH, Yamaguchi K, Hollstien SB, Winn SS, Heidenreich FP, Bindra RR, et al. Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera. J Shoulder Elbow Surg 1998:492-501. 5. Glynn JJ, Niebauer JJ. Flexion and extension contracture of the elbow: surgical management. Clin Orthop Relat Res 1976:289-91. 6. Green DP, McCoy H. Turnbuckle orthotic correction of elbow-flexion contractures after acute injuries. J Bone Joint Surg Am 1979;61:1092-5. 7. Haapaniemi T, Berggren M, Adolfsson L. Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture. Arthroscopy 1999;15:784-7. 8. Husband JB, Hastings H II. The lateral approach for operative release of post-traumatic contracture of the elbow. J Bone Joint Surg Am 1990;72:1353-8. 9. Jones GS, Savoie FH III. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 1993;9:277-83. 10. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am 2001:25-34. 83-A. 11. Kim SJ, Kim HK, Lee JW. Arthroscopy for limitation of motion of the elbow. Arthroscopy 1995;11:680-3.
19 12. Kim SJ, Shin SJ. Arthroscopic treatment for limitation of motion of the elbow. Clin Orthop Relat Res 2000:140-8. 13. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-7. 14. Nguyen D, Proper SI, MacDermid JC, King GJ, Faber KJ. Functional outcomes of arthroscopic capsular release of the elbow. Arthroscopy 2006;22:842-9. 15. O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res 2000:34-43. 16. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-6. 17. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect 2001;50:89-102. 18. O’Driscoll SW, Morrey BF. Arthroscopy of the elbow. Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg Am 1992;74: 84-94. 19. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: a new technique. Arthroscopy 1989;5:222-4. 20. Sahajpal D, Choi T, Wright TW. Arthroscopic release of the stiff elbow. J Hand Surg Am 2009;34:540-4. 21. Timmerman LA, Andrews JR. Arthroscopic treatment of posttraumatic elbow pain and stiffness. Am J Sports Med 1994;22:230-5. 22. Urbaniak JR, Hansen PE, Beissinger SF, Aitken MS. Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. J Bone Joint Surg Am 1985;67:1160-4. 23. Wilson P. Capsulectomy for the relief of flexion contractures of the elbow following fracture. J Bone Joint Surg 1944;26:71-86. 24. Yamaguchi K, Tashjian RZ. Setup and Portals. In: Yamaguchi K, King GJW, McKee MD, O’Driscoll SWM, editors. Advanced reconstruction elbow. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2007. p. 3-11.