Elbow Arthroscopy for Treatment of Valgus Extension Overload

Abstract

Valgus extension overload syndrome (VEO) is the result of supraphysiologic stresses placed across the posterior elbow during pitching. Following failure of nonoperative measures, surgical options consist of arthroscopic or limited incision posteromedial decompression. Although technically challenging, arthroscopic treatment offers many advantages over open treatment, including improved joint visualization, decreased soft-tissue dissection, decreased postoperative pain, and quicker rehabilitation. Arthroscopic treatment of VEO consists of soft tissue and bony debridement, loose body removal, and osteophyte resection. This technique report details the steps of arthroscopic treatment of VEO in a patient with a subluxating ulnar nerve.

Fig 1

The patient is placed in the lateral decubitus position with the right arm draped over an elbow arm holder such that the forearm is perpendicular to the floor. Although not visualized below the drapes in this figure, the nonoperative upper extremity is forward flexed, externally rotated, and placed on a padded arm board with a padded roll placed under the axilla. In addition, the contralateral lower extremity rests on the operating table, flexed slightly at the knee with all bony prominences padded and the peroneal nerve around the fibular neck unencumbered. Prior to prepping and draping, the surgeon must verify that adequate space is available to range the elbow as needed and to pass instruments. In addition, an exam under anesthesia is performed to confirm passive range of motion of the elbow.

Fig 2

(A) The bony and soft-tissue landmarks as well as potential portals to be used are marked after positioning in a lateral decubitus position and draping with the right arm bent over an arm holder. The view in the image is of the posteromedial elbow. Based on review of the preoperative imaging and palpation of anatomical landmarks, the location of the ulnar nerve with respect to the medial epicondyle (ME), the olecranon tip (OTip), and the associated fractured olecranon osteophyte (FX) are marked. Portals marked are the direct posterior (dP) portal 2 cm proximal to the olecranon tip, in the midline of the triceps tendon. The top of the photo is toward the shoulder, and the bottom edge of the photo is toward the hand, medial is to the left, and lateral is toward the right. (B) In a similar manner, on the posterolateral side of the right elbow, the relevant bony landmarks and potential portals are marked including the olecranon tip (OTip), lateral epicondyle (LE), and radial head (Rad). Potential portals to be used are the direct lateral (L) portal, which is the “soft spot” formed between the LE, Rad, and olecranon, the posterolateral (PL) portal approximately 1.5 cm from the proximal edge of the olecranon just lateral to the triceps tendon, and the accessory posterolateral (aPL) portal approximately 1.5 cm proximal to the LE and 1 cm anterior to the lateral intermuscular septum. This image is taken from the viewpoint of the surgeon looking down onto the posterior aspect of the elbow with the patient in the lateral decubitus position; the top of the photo is toward the shoulder, and the bottom of the photo is toward the hand, with lateral facing right and medial facing left.

Fig 3

(A) After completion of a diagnostic arthroscopy of the posterior compartment, the direct posterior (dP) portal is established in the right upper extremity under direct visualization following placement of an 18-gauge spinal needle and triangulation. To enhance visualization, the fibrous tissue in the olecranon fossa is debrided with an arthroscopic shaver by using the posterolateral (PL) portal for viewing and the dP portal for instrument passage. In the image, the contour of the olecranon fossa and the demarcation of the olecranon osteophyte are obscured by excessive overlying fibrous tissue. The image orientation is that proximal (i.e., humeral side) is toward the top of the image, distal (i.e., olecranon side) to the bottom, medial to the left, and lateral to the right. (B) For further debridement, an arthroscopic ablation device is used to debride soft tissue to expose the posterior surface of the olecranon by using the PL portal for viewing and the dP portal for instrument passage. The goal is to expose irregularities in the surface contour of the olecranon suggestive of an osteophyte, encased loose body, and/or fractured olecranon tip. The image orientation is that proximal (i.e., humeral side) is toward the top of the image, distal (i.e., olecranon side) is toward the bottom, medial is toward the left, and lateral is toward the right.

Fig 4

(A) Using the posterolateral (PL) portal in the right upper extremity for viewing and the direct posterior (dP) portal for instrument passage, a Freer elevator is used to probe for the plane between the fractured olecranon osteophyte and the native olecranon. The Freer elevator is used to separate the fractured osteophyte from the native olecranon but not necessarily completely detach the osteophyte. Some fibrous attachments between the osteophyte and native olecranon should be left in place to assist in stabilization for further debridement. The image orientation is that proximal (i.e., toward the humeral side) is toward the top of the image, distal (i.e., toward the olecranon side) to the bottom, medial to the left, lateral to the right, and the Freer elevator is separating osteophyte on the left side from native olecranon on the right side. (B) Using the PL portal for viewing and the dP portal for instrument passage, an electrocautery ablation device can be used for further debridement of the soft tissue encasing and attaching the fractured osteophyte. Again, the image orientation is that proximal (i.e., toward the humeral side) is toward the top of the image, distal (i.e., toward the olecranon side) toward the bottom, medial toward the left, lateral toward the right, and the ablation device is separating osteophyte on the left side from native olecranon on the right side. (C) Using the PL portal for viewing and the dP portal for instrument passage, an arthroscopic motorized shaver can be used to debride surrounding soft tissue as well as debride the margins of the osteophyte to reduce its size. Reducing the size of the fractured osteophyte will assist in its eventual extraction. The image orientation is that proximal (i.e., toward the humeral side) is toward the top of the image, distal (i.e., toward the olecranon side) to the bottom, medial to the left (with the posterior aspect of the medial gutter being visualized toward the far left), lateral to the right, and the motorized shaver is separating osteophyte on the left side from native olecranon on the right side. (D) Using the PL portal for viewing and the dP portal for instrument passage, the osteophyte has been adequately freed of its attachments and is now ready for extraction from the elbow. A few fibrous attachments between the osteophyte and native olecranon are intentionally maintained to prevent escape of the osteophyte and transformation into a loose body. The image orientation is that proximal (i.e., toward the humeral side) is toward the top of the image, distal (i.e., toward olecranon side) to the bottom, medial to the left, lateral to the right, and the Freer elevator is separating osteophyte on the left side from native olecranon on the right side.

Fig 5

(A) To facilitate delivery of the osteophyte from the elbow joint, the arthroscope should be inserted into the dP portal and an 11-blade should be used to extend the length of the PL portal incision. This image is taken from the viewpoint of the surgeon looking down onto the posterolateral aspect of the right elbow with the patient in the lateral decubitus position; the top of the photo is perpendicular to the posterior elbow, and the bottom of the photo is perpendicular to the longitudinal axis of the forearm/hand, with the right side of the photo toward the patient's head, and the left side of the photo toward the patient's torso. (B) To retrieve the osteophyte, the dP portal is used for visualization and an arthroscopic grasper is placed in the PL portal to retrieve the bony fragment. Delivering bony fragments through the PL portal is easier than through the dP portal because there are fewer layers of soft tissue to traverse between the elbow joint and skin (lateral epicondyle [LE], and radial head [Rad], direct lateral portal [L], posterolateral portal [PL], and accessory posterolateral portal [aPL]). As before, this image is taken from the viewpoint of the surgeon looking down onto the posterolateral aspect of the elbow with the patient in the lateral decubitus position; the top of the photo is perpendicular to the posterior elbow, the bottom is perpendicular to the longitudinal axis of the forearm, the right side is toward the patient's head, and the left side is toward the patient's torso.