Shoulder and Elbow

Elbow Arthroscopy

Anatomy

The elbow is a complex joint that allows bending and straightening (flexion and extension), and forearm rotation (pronation, palm down; and supination, palm up). The elbow is formed by the joining of three bones: the upper arm (humerus), the forearm on the pinky finger side (ulna), and the forearm on the thumb side (radius). The surfaces of these bones, where they meet to form the joint, are covered with articular cartilage, a smooth substance that protects the bones and acts as a natural cushion to absorb forces across the joint. A thin, smooth tissue, called synovial membrane, covers all remaining surfaces inside the elbow joint. In a healthy elbow, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction as you bend and rotate your arm.

Description

Arthroscopy is a minimally invasive surgical procedure used by orthopaedic surgeons to visualize, diagnose and treat problems inside the joint. Injury, overuse, and age-related wear and tear are responsible for most elbow problems. Your doctor may recommend elbow arthroscopy if you have a painful condition that does not respond to nonsurgical treatments such as rest, physical therapy and medications or injections to reduce inflammation. Elbow arthroscopy may relieve the painful symptoms of many problems that damage the cartilage surfaces and other soft tissues surrounding the joint.

Common arthroscopic procedures for the elbow include: osteoarthritis, rheumatoid arthritis, and osteochondritis dissecans (activity-related damage to the capitellum portion of the humerus, as seen in throwers or gymnasts); removal of loose bodies (loose cartilage and bone fragments); and release of scar tissue to improve range of motion.

Preparation

Once the decision to have surgery is made, your orthopaedic surgeon may ask you to see your primary care physician to be sure you do not have any medical problems that need to be addressed before surgery. Additional tests may be needed, such as blood and urine samples, electrocardiogram (EKG), or chest X-ray. If you have certain health risks, a more extensive evaluation may be required. Be sure to inform your othopaedic surgeon of any medications or supplements you take, as these may need to be stopped prior to surgery.

If your general health is good, your arthroscopy is likely to be performed on an outpatient basis, which means you will not be required to stay overnight in the hospital. It is very important that you follow all instructions regarding when to stop eating or drinking prior to surgery, and when to arrive at the hospital.

Surgery

Before the operation, you will be evaluated by a member of the anesthesia team. Elbow arthroscopy is usually performed using general anesthesia (you are put to sleep). Regional nerve block injections (you are awake but the elbow area is numb) are rarely used in elbow arthroscopy because the numbing effect can continue for hours after surgery is finished. Although this can help with pain management, it prevents your surgeon from performing a careful nerve examination in the recovery room to be sure that the nerves traveling down your arm are functioning properly. Your surgeon will see you before the surgery and sign your elbow to verify the surgical site.

In the operating room, you will receive general anesthesia and possibly intravenous antibiotics to lessen the risk of infection after surgery. Your surgeon may draw lines on your elbow to indicate specific structures (such as the ulnar nerve and olecranon bone), incision placements and portals for the arthroscope.

During surgery, your surgeon will make several small incisions to introduce the arthroscope and other small instruments. Filling your elbow with fluid will allow a clearer view inside the joint, and lessen risk of injury to surrounding blood vessels and nerves. Your surgeon will review projected images from the arthroscope to evaluate the inside of your joint before any specific treatments are begun. Once the problem is identified, your surgeon will insert specialized instruments for tasks such as shaving, cutting, grasping, suture passing and knot tying, as well as a special device often used to anchor stitches into bone. Incisions may be stitched or covered with skin tapes, followed by application of an absorbent dressing. Depending on the procedure, your surgeon will then apply an additional soft dressing that allows movement, or a plaster splint that restricts movement and offers more protection.

You will remain in the recovery room for 1 or 2 hours after surgery. During that time, nurses will monitor your responsiveness and recovery from the anesthesia, and provide pain medication, if needed. You may be given a regional anesthetic for pain control—after your orthopaedic surgeon has completed a nerve examination. When you are ready to go home, you will be given discharge instructions covering medications, need for ice and elevation, and dressing care. You will need someone to drive you home and stay with you, at least during the first night.

Recovery

Although recovery from arthroscopy is often faster than recovery from open surgery, your elbow joint may need weeks to recover completely. You can expect some pain and discomfort for at least 2 weeks after surgery. If your surgery was extensive, it may be several weeks before the pain subsides. Your doctor will likely prescribe pain medicine to be taken regularly for the first few days after surgery, as well as other medications such as stool softeners or anti-inflammatory drugs.

It is important to apply ice and elevate your elbow regularly for 48 hours after surgery to reduce the risk of severe swelling and to help relieve pain. To elevate, place your elbow in a resting position that is higher than your heart, with your hand placed higher than the elbow. Depending on the type of surgery performed, your doctor may give you specific instructions for longer periods of ice and elevation.

You will probably be encouraged to move your fingers and wrist frequently to help stimulate circulation and minimize swelling. Early range-of-motion exercises may also be recommended to prevent joint stiffness. Your orthopaedic surgeon will let you know when you can begin these gentle exercises and return to daily activities.

Dressing care will depend on the type of surgery performed and the preferences of your physician. In most cases, the operative dressing and/or splint is removed 2 to 3 days after surgery. During this time, your dressing must be left intact and kept dry. In some instances, you may be instructed to keep the dressing in place until your first postoperative clinic visit.

Rehabilitation

Rehabilitation plays an important role in getting you back to your daily activities. Your surgeon will develop an exercise program to help you facilitate motion, strength, and return of function of the elbow. This may include basic exercises to begin at home, or for more advanced surgeries, physical therapy may be prescribed after the first postoperative visit. The physical therapy prescribed will depend on the type and severity of your problem and the surgery required. Your surgeon will tell you when you can return to work, driving and normal daily activities.

Complications

Although most patients experience no complications after elbow arthroscopy, as with any surgery, there are some risks. These are typically minor, treatable and unlikely to affect your final outcome. Potential problems include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves. Most studies report a slightly higher risk of infection and nerve irritation/injury following elbow arthroscopy as compared to arthroscopy of the shoulder and knee joints. Discuss the potential risks and benefits with your orthopaedic surgeon prior to surgery.

Outcomes

The time needed for complete recovery varies according to the patient, the condition of the joint, and the extent of damage and repairs required. If your repair was minor, you may not need a splint, your range of motion and function may return after a short period of rehabilitation, and you may be able to return to work or school within a few days of the surgery. More complicated procedures may require as long as several months for a full recovery. Although the process may seem slow, following your surgeon's guidelines and rehabilitation plan is vital to a successful outcome.