WASHINGTON — Elbow contractures can be treated arthroscopically with better efficacy and faster patient recovery than traditional open surgical techniques, Shawn W. O'Driscoll, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.
It's no longer a given that complicated procedures must be converted to open surgery, said Dr. O'Driscoll, professor of orthopedics at the Mayo Clinic in Rochester, Minn. Instead, the deciding factor should be the surgeon's level of experience.
Published data on efficacy are limited, and indications for the arthroscopic approach “are still evolving,” he said during a session on elbow stiffness and arthritis. But “it's pretty clear that [arthroscopic contracture release] is effective.”
An analysis of results from 10 reports of open procedures and 6 small reports of arthroscopic procedures shows that more significant improvements are gained in extension, flexion, and total arc of elbow motion with the arthroscopic approach, compared with the open surgical approach.
Average flexion, for instance, increased from 107 degrees preoperatively to 123 degrees postoperatively when contractures were treated with open surgery.
In comparison, with the arthroscopic approach, flexion increased from 114 degrees before the operation to 133 degrees after the operation, Dr. O'Driscoll said.
The main consideration—and the “one factor that creates anxiety and limits the indications for this operation”—is the risk of ulnar nerve injury, he said.
The arthroscopy procedure involves a straightforward, predictable sequence of steps, but it is “more complex … the difficulty in learning it is higher [than with open surgery], and the risk is higher when you're learning it,” Dr. O'Driscoll noted.
“There was a time when I thought this would never be a safe operation in anyone's hands,” he said. “Now, I think it's an unsafe operation” in the hands of surgeons who do not have the necessary skills and experience.
“I've done over 300 cases now, and my complication rate is lower than it is with open surgery. Patient recovery is faster, and efficacy is better, from my experience,” he said.
Dr. O'Driscoll uses an anterior approach to arthroscopic release that involves synovectomy before osteectomy, and then capsulectomy. He recommended using a scope in the anterolateral or proximal anteromedial portal and a retractor in the proximal anterolateral portal. A second retractor can be used in the anteromedial portal if necessary.
“It's necessary for safety and predictability reasons to use a retractor,” he said. Although some say otherwise, “you need to retract the tissues and create a space within which to work.
“And we don't rely on capsular distension, because in the stiff elbow, it's not possible to distend the capsule by very much,” he noted. “If you try to do it, you get a big fat swollen elbow. You want to avoid that; the elbow should be soft until near the end of the operation.”
A study reported more than 10 years ago showed that the capsular volume capacity is about 25 mL in the normal elbow but only about 6 mL in the contracted elbow, he said.
Dr. O'Driscoll strips the capsule off the proximal humerus and immediately releases tissue along the lateral supracondylar ridge, which “gives you some space to work, to move the scope back farther and get a bigger, better perspective.”
He removes loose bodies as they are encountered and debrides the capsule, defining it as a structure, before cutting it. He incises the capsule starting medially and progresses across laterally.
A distal lateral capsulectomy is the final and most risky step. “You need to be able to see the nerve … or know with absolute certainty where the nerve is and isn't,” Dr. O'Driscoll said. “If you have that degree of confidence, then you're safe to do it.”
A capsulotomy is performed from medial to lateral. The final strip of capsule over the radial nerve is released with a reverse cutting punch biopsy, as shown above. Courtesy Dr. Shawn W. O'Driscoll