Loose Bodies of the Elbow Joint
Intra-articular loose bodies are one of the most common indications for surgery of the elbow. Rather than open arthrotomy of the joint, arthroscopic removal of the loose bodies has gained significant popularity as it significantly reduces surgical morbidity and allows for a more rapid return to function. Although most procedures can predictably lead to improvement in symptoms, varied clinical response should be expected depending on the source of the loose body and underlying disease process.
The most common complaint for patients with intra-articular loose bodies of the elbow is pain. Depending on the size and location of the loose body, the condition may cause mechanical symptoms such as locking, catching, clicking, and crepitus. In addition, if the loose bodies are located within the coronoid or the olecranon fossa, motion will be affected.
In addition to these symptoms, other complaints that suggest the possible source of the loose body should be elicited. Prior history of trauma such as fractures, falls, or dislocation that could have led to osteochondral damage should be identified. Overuse-type injuries in athletes who engage in repetitive overhead throwing are associated with osteochondritis dissecans of the capitellum and loose body formation. Possibly the most common disease process that produces intra-articular loose bodies of the elbow, however, is osteoarthritis. Although gradual in onset, damaged cartilage fragments dissociate and enlarge within the joint fluid to become a loose body.
Physical exam should first include inspection of the upper extremity. In most instances, this will demonstrate a normal appearing elbow. However, evidence of mild effusion about the elbow joint can be noted. Palpation typically reveals pain in the area of interest, and palpation while taking the elbow through a range of motion can reveal crepitus. Range of motion should be assessed and compared to the contralateral elbow. Elbow motion may also be associated with pain. If so, it should be carefully determined whether the pain is associated throughout motion, or only at the extremes of elbow motion.
Initial radiographic evaluation requires both anterioposterior (AP) and lateral view x-rays (Figure 1). Additionally, an axial “Jones” view could be obtained to further evaluate the bony anatomy. The sensitivity in detecting loose bodies with standard radiographs has been reported to vary from 38-75%. Small loose bodies, especially if they are mostly cartilaginous, will not be evident on plain radiographs. However, radiographs should be inspected for other pathologic changes associated with loose bodies such as post-traumatic changes, osteophytes, and joint space narrowing.
If clinical suspicion for intra-articular loose bodies exists, advanced imaging should be considered to confirm or establish the diagnosis. However, its added value in detecting loose bodies in the elbow has been questioned. While CT scan and MRI demonstrated high sensitivity, the specificity for detecting loose bodies, especially in the anterior compartment, may be quite low. More recently, MR arthrogram and ultrasound have been proposed for detection of loose bodies, but their efficacy has yet to be validated.
Without mechanical symptoms, patients may benefit from possible activity modifications and non-steroidal anti-inflammatory drugs (NSAIDS) to improve their pain. In addition, therapy exercises with or without supervision, may provide more motion and strength. If, however, there are mechanical symptoms of clicking, locking, and catching, immediate surgical management must be considered as prolonged presence of loose bodies within the joint can lead to further articular damage.
Indications for Surgery
Confirmation of intra-articular loose bodies, along with mechanical symptoms, is indicative for surgical removal of the loose bodies. In addition, even without mechanical symptoms, if patients fail to respond to non-operative treatments, surgical management should be considered.
Rather than open arthrotomy, arthroscopic removal of the loose bodies has gained significant popularity due to low morbidity. The loose bodies can be removed through established portals whole or in pieces. If needed, accessory portals may need to be utilized. Regardless of the specific technique, it is imperative that all possible space within the joint is visualized and that all loose bodies are removed.
Depending on the other possible associated pathologies about the elbow, arthroscopic removal of the loose bodies may be performed concomitantly with other procedures such as contracture release or synovectomy. These portions of the surgery may be performed arthroscopically or open, pending surgeon preference and expertise.
For most cases, a standard 4.0 mm arthroscope, with 30 degree viewing angle, should be sufficient. In some patients, especially for adolescents, a 2.7 mm arthroscope may be necessary. Again, standard arthroscopy equipment, including a 3.5 mm shaver should be sufficient for loose body removal. If, however, other concomitant procedures are anticipated, more specialized equipment such as arthroscopic burrs and ablation devices may be necessary. Elbow arthroscopy typically utilizes low water flow under low pressure. This can be accomplished by hanging bags of saline at approximately 2 m or by setting the arthroscopy pump to 30 mmHg.
After anesthesia, patients can be positioned either supine or lateral. Supine position is superior for airway management, familiar anatomical orientation for the surgeon, and ability to convert to open procedures without re-positioning. Supine position, however, is inferior in accessing the posterior compartment of the elbow and requiring the use of a traction device to suspend the arm. In the lateral position, the arm is placed over a simple post such that the elbow is flexed to 70-80 degrees and the forearm is hanging down. In this fashion, gravity should allow the neurovascular structures to drift away from the anterior capsule and the weight of the forearm provides traction with easier access to the posterior compartment. It should be noted that the upper arm must be placed over the post and that the post does not encroach the antecubital fossa as this will compress the anterior soft tissues against the joint.
After skin preparation and sterile draping, bony landmarks including the epicondyles and the path of the ulnar nerve are noted (Figure 2). Most surgeons prefer the use of a tourniquet during the procedure. In order to minimize interference with the surgical site, a sterile tourniquet placed on the upper arm may be preferable. Prior to establishing arthroscopy portals, the capsule is distended by injecting 30-40 cc of normal saline into the joint. Either the anterior or the posterior compartment of the elbow can be first approached based on surgeon preference.
For the anterior compartment, most surgeons utilize anterior medial and anterior lateral portals. Care must be taken to identify and avoid the ulnar nerve when establishing the anterior medial portal. If the ulnar nerve subluxes anteriorly with elbow flexion, it may be possible to still establish the anterior medial portal by manually stabilizing the ulnar nerve posterior to the medial epicondyle while the cannula is inserted. If the ulnar nerve cannot be protected, however, anterior medial portal must be avoided as permanent injury to the nerve may occur.
For anterior lateral portal, the posterior interosseous branch of the radial nerve can be injured as it traverses the radiocapitellar joint anterior to the capsule. Care must be taken to ensure that the cannula penetrates through the lateral joint capsule rather than sliding anteriorly along the joint capsule. Using these portals interchangeably, the entire anterior compartment can be visualized to locate, isolate, and remove the loose body (Figure 3). The capsule should be preserved to maintain visualization and to protect the nearby neurovascular structures. If visualization is limited, an accessory portal can be created proximally to insert a switching stick that can push the capsule anteriorly and act as a retractor.
For the posterior compartment, posterior central and posterior lateral portals are generally utilized. The posterior lateral portal must be inserted into the joint space deep to the capsule. Often, the cannula can slide into the interval between the triceps and the capsule, rather than into the joint. Using these portals interchangeably, the posterior compartment, including the olecranon, the olecranon fossa, and the ulnar gutter can be inspected. The ulnar nerve is just superficial to the capsule on the medial aspect of the joint. Therefore, significant care must be taken to protect the joint capsule in this area. Through the posterior lateral portal, the arthroscope can be placed lateral to the olecranon to also inspect the radial gutter and the posterior aspect of the radiocapitellar joint. Typically, however, an accessory straight lateral portal must be established for instruments.
For both compartments, the diagnostic arthroscopy must be completed and the entire joint must be inspected. Often the loose body is tethered to the joint with fibrous tissue. Therefore, these tissues should be first resected to mobilize the loose body. Then, the loose body can be grasped and removed from the joint. Prior to removing the instruments, the joint should be re-inspected and even moved under arthroscopic visualization to ensure that no other loose bodies remain.
After completion of the procedure, the wounds are closed and covered in a bulky dressing. Post-operative neurological examination must be completed and documented. The bulky dressing may become saturated overnight. Therefore, the patients should be counseled regarding this possibility and to change the dressing as necessary
Pearls and Pitfalls of Technique
The patient must be positioned to allow full access to the joint. This includes avoiding placing the post over the antecubital fossa or placing the tourniquet close to the joint.
Regardless of pre-operative imaging, all areas of the elbow must be inspected to identify and remove the loose bodies. Even after removing the loose bodies, the joint must be re-inspected to ensure that other loose bodies do not remain.
If the loose body is not immediately visible, it may be helpful to run the arthroscopic shaver in the middle of the compartment with intermittent suction to create turbulence in water flow and allow movement of the loose body. The loose body may also become visible by moving the elbow under arthroscopic visualization.
Accessory portals can be used to place blunt instruments as retractors to improve visualization.
Large loose bodies should be sectioned and removed in piecemeal.
Ensure a firm grasp of the loose body prior to extraction from the joint. Otherwise, the loose body can be lost outside the joint within the subcutaneous or intramuscular tissue.
Nerve palsies (superficial radial, ulnar, posterior interosseous, medial antebrachial cutaneous, and anterior interosseous nerves) are the most common immediate complication from elbow arthroscopic removal of loose bodies. However, most resolve within 6 weeks. The most frequent delayed complication is prolonged drainage (greater than 5 days) from the portal sites which can be associated with superficial infection. Deep joint infection can also occur but is much less common.
Unless other concomitant reconstructive procedures were performed, the patients are instructed to perform motion exercises as soon as possible. Therefore, pain permitting, most patients are able to start motion exercises immediately after the surgery. Although these exercises can be performed as a home-based regimen, immediate supervised therapy should also be considered for patients at high risk for developing joint contracture. Although immediate weight-bearing can be allowed, most patients are instructed to modify their activities to allow adequate soft tissue healing. Typically, strengthening exercises can be instituted within 4-6 weeks and resumption of full activities should be possible in about 8-12 weeks.
Outcomes/Evidence in the Literature
Most patients treated with arthroscopic removal of elbow loose bodies report good to excellent outcomes. In fact, Andrews and Carson reported that, among all conditions treated with elbow arthroscopy, those patients with isolated loose body removal demonstrated best objective and subjective scores. Similarly, O’Driscoll and Morrey reported on 24 elbow arthroscopic procedures in 23 patients, 18 of which had loose body removal. They reported marked improvement in outcomes in patients with isolated loose bodies in the joint without other significant elbow pathology. They also cautioned, however, that in patients with underlying arthritis, isolated removal of loose bodies did not provide significant benefit.
Others, however, have reported that arthroscopic removal of elbow loose bodies can produce good outcomes even in the presence of underlying joint arthritis. Claspers and Carr, for example, reported that 81% of their patients had some improvement in symptoms (pain, mechanical locking, etc.) following the procedure. They also noted that most patients noted improvement after elbow arthroscopy even if pre-operatively diagnosed loose bodies could not be located. However, rate of recurrence in their symptoms was much higher in this subgroup.
As stated previously, with elbow arthroscopy, serious complications are rare but minor complications are not infrequent. Kelly et al. performed a retrospective review of their previous 473 elbow arthroscopies, specifically examining complication rates. They found that serious complications, such as deep joint infections, occurred 0.8% of the time and minor complications 11%. Minor complications included prolonged portal drainage, persistent minor contracture less than 20 degrees, and transient nerve palsies. Risk factors for developing nerve palsies were underlying diagnosis of rheumatoid arthritis and contracture.
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Intra-articular loose bodies of the elbow joint can often be difficult to identify. Once the diagnosis is established and the mechanical symptoms are confirmed, arthroscopic removal provides a reliable treatment option. This approach offers several advantages over an open procedure, including opportunity for a thorough joint evaluation, reduced morbidity, and earlier rehabilitation. Although elbow arthroscopy can be technically demanding, it has been demonstrated to be a safe and effective procedure.
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