Arthroscopic Management of Posterior Elbow Impingement

Abstract

Background:

Posterior elbow impingement is often seen in athletes who engage in overhead sports that involve repetitive elbow extension; for these patients with persistent symptoms, arthroscopic debridement is often recommended. While traditionally performed in the supine or prone position, arthroscopic elbow debridement performed in the lateral decubitus position has distinct advantages that make it our preferred method.

Indications:

Arthroscopic debridement in the context of posterior elbow impingement is utilized when conservative management with rest, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs) does not provide improvement in pain or range of motion.

Technique Description:

After induction of general anesthesia and placement of an interscalene block, the patient is placed on the operating table in the lateral decubitus position utilizing the arm holder of choice. The bony landmarks of the operative elbow are identified, and the joint capsule is insufflated with 25 mL of saline before placement of the arthroscopic portals. A diagnostic arthroscopy of the anterior and posterior compartments of the elbow is first performed. Debridement of loose bodies, inflammatory synovium, and capsular tissue is conducted as needed. Attention is then turned to the direct posterior working portal where the olecranon tip is identified. The posterior olecranon and olecranon fossa are thoroughly smoothed with a shaver to create a flush surface. Scope instrumentation is withdrawn, and the elbow is manipulated to ensure full range of motion.

Results:

It is the senior author’s belief that management of posterior elbow impingement with arthroscopic debridement in the lateral decubitus approach provides enhanced visualization and allows free manipulation of the joint throughout the procedure. This facilitates direct treatment of the olecranon and olecranon fossa while permitting comprehensive evaluation of the joint for concomitant loose bodies and inflammatory synovium. Additionally, the risk of iatrogenic injury to nearby neurovascular structures while instrumenting the joint is diminished.

Discussion/Conclusion:

Arthroscopic debridement for posterior elbow impingement in the lateral decubitus position with the operative extremity supported proximally in an arm holder has been shown to optimize arthroscopic viewing of the joint. This technique also provides ease of access to the posterior compartment, thereby substantially and immediately increasing patient range of motion.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video will demonstrate the senior author’s (N.N.V.) preferred surgical approach to arthroscopic management of posterior elbow impingement in the lateral decubitus position.

Author disclosures are as listed.

Background

Posterior elbow impingement is often associated with valgus extension overload syndrome, which involves repetitive valgus stress and terminal elbow extension and can lead to mechanical obstruction that requires surgical intervention with arthroscopic debridement. To distinguish posterior elbow impingement from other possible causes of elbow pain in a thrower, a thorough clinical evaluation is essential. Patients typically have pain at the posteromedial aspect of the elbow during the late cocking and early acceleration phases of throwing. ¹ On examination, maneuvers, including the elbow extension impingement test and the arm bar test, may be positive. Additionally, imaging studies often reveal subtle bony changes, such as joint space narrowing, subchondral sclerosis, and osteophytes, which are characteristic of posterior elbow impingement. ⁴ Although this procedure has traditionally been approached with the patient prone or supine, ² the lateral decubitus position has the potential to provide superior visualization. Moreover, optimization of portal placement described in this technical note minimizes risk to neurovascular structures.

Indications

Our patient is a 25-year-old male baseball player with no history of elbow dysfunction. He had persistent left posteromedial elbow pain and decreased elbow extension for 4 months despite an adequate trial of conservative treatments. On examination, he lacked approximately 12° of terminal extension with a firm end point and a positive elbow extension impingement test. The patient also had mild medial tenderness. There was no evidence of ulnar nerve subluxation, and he had a negative Tinel’s sign and was neurovascularly intact. Standard 3-view radiographs showed posterior osteophyte formation. Magnetic resonance imaging revealed an intact ulnar collateral ligament (UCL) and a small effusion in the anterior compartment.

Technique Description

After induction of anesthesia, the patient was placed into the lateral decubitus position with the operative extremity up and supported with an arm holder at 90°. The arm holder should support the arm proximally to allow intraoperative elbow flexion and to improve visualization. The left side was then prepped and draped sterilely.

Anatomic landmarks were then mapped out, ³ and the joint capsule was insufflated with 25 mL of saline. A thorough understanding of local anatomy and nearby neurovascular structures is essential to avoid complications. The ulnar nerve was stabilized externally while an incision was made for the superomedial viewing portal, 2 cm proximal to the medial epicondyle. This portal was then used to create an anterolateral portal, 1 cm proximal and 1 cm anterior to the lateral epicondyle under direct visualization with a spinal needle. A cannula was placed at the location of the anterolateral portal for ease of instrument manipulation. Upon cannula placement, a 2-portal diagnostic arthroscopy was performed, revealing inflammatory synovitis.

Using the anterolateral portal as a working portal, an arthroscopic shaver was utilized to gently and thoroughly debride the synovitis in the anterior compartment. The arthroscope was then switched to the anterolateral portal to complete the synovectomy. This is critical, as proper visualization within the joint is needed to avoid iatrogenic nerve injuries. The elbow may be flexed and extended to aid in this visualization. After completion of debridement, the remainder of the articular surface was visualized to assess for concomitant pathologies, including the presence of loose bodies that may contribute to mechanical obstruction.

Attention was then turned to the posterior compartment. A posterolateral portal, 2 cm proximal to the olecranon and just lateral to the triceps center of the anconeus triangle, was established to permit visualization of the olecranon and olecranon fossa. Then, a direct posterior working portal, directly proximal to the olecranon, was established under direct visualization, and an arthroscopic shaver was used to debride additional inflammatory synovium noted in the posterior compartment. A radiofrequency probe was then used to ablate any soft tissue overlying the tip of the olecranon. Impinging osteophytes were then removed with a combination of shaver and burr. It is important to flash the suction judiciously, as loss of insufflation can lead to iatrogenic nerve injury if the capsule is inadvertently drawn into the shaver or burr. Meticulous care should be taken to ensure a flush surface is established and that there is no impingement into the posterior aspect of the fossa. Once restoration of full elbow extension was achieved, a shaver was again used to clean up residual debris.

Scope instrumentation was withdrawn and the elbow manipulated for identification of full range of motion. Portal sites were closed, and sterile dressing was applied before completion of the procedure. Although our technique describes a safe, reproducible approach to arthroscopic management of posterior elbow impingement, there is still a risk of neurovascular injury as well as persistent postoperative pain and stiffness. Postoperatively, the patient was discharged in a sling and is expected to achieve full range of motion by 6 weeks. Return to full activity as tolerated is anticipated at approximately 16 weeks.

Results

For throwing athletes, an additional throwing program is implemented beginning 12 weeks postoperatively. The purpose of the interval throwing program is to progressively load the tissues of the throwing arm and build strength to safely and effectively return to sport. Baseline requirements to begin the program include pain-free range of motion, appropriate elbow and shoulder strength, and endurance of the affected site, as well as the entire body. It is highly recommended that graded progression plyometrics be performed before starting this program. The complete throwing program is 147 days and should provide athletes with the strength and endurance to fully return to sport by 6 months.

Discussion/Conclusion

Investigations have shown that arthroscopic treatment of posterior impingement of the elbow consistently improves patient comfort and function.^5,7,8,10 Studies have also shown that a high percentage of athletes return to their previous level of play. Specifically, Koh et al ⁵ found that 97% of athletes, including all professional athletes, returned to their previous level of activity following arthroscopic debridement. Improvements in range of motion are commonly observed. In fact, another recent study found that patient extension deficit improved from 8° to 2° postoperatively. However, a history of posterior elbow impingement can lead to increased valgus stress on the medial elbow structures, including the UCL. Studies have shown that procedures addressing posterior elbow impingement further increase strain on the UCL. ⁶ This suggests that while posterior elbow impingement itself may not directly cause UCL injury, the associated valgus stress and surgical interventions to address impingement can increase the risk of future UCL strain and injury. Of note, in a recent study, Paul et al ⁹ reported an 18% risk of subsequent UCL reconstruction in baseball pitchers following arthroscopic posteromedial osteophyte resection. Nonetheless, there is a paucity of literature describing the outcomes and complications of the presented technique in the lateral decubitus position in comparison to treatment in the prone or supine position.