This document summarizes the technique for arthroscopic osteocapsular arthroplasty of the elbow. The procedure involves reshaping bones, removing loose bodies, and performing a capsulectomy to restore motion, function, and reduce pain. Key steps include preoperative planning with imaging, positioning the patient laterally, limited open ulnar nerve decompression, establishing portals while managing fluid, removing osteophytes and reshaping bones, performing a complete capsulectomy, and closing wounds. The procedure aims to improve visualization and outcomes while minimizing risks like nerve injury through careful technique.

1. Osteocapsular Arthroplasty of the
Elbow
Journal of Bone and Joint Surgery
Essential Surgical Techniques
April 2014,vol3
Shawn W. O’Driscoll and Davide Blonna
Mayo Clinic, Rochester
Level of evidence III
PRESENTER : Dr SAUMYAAGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and
Dr. Prabhakar Kore Hospital and MRC, Belgaum

2. INTRODUCTION
• Arthroscopic osteocapsular arthroplasty
of elbow is a procedure involving 3D
reshaping of bones, removal of loose
bodies and capsulectomy to restore
motion and function and to reduce or
eliminate pain.

3. • It allows better visualization of intra-
articular lesions, quick recovery and
better cosmetic results.

4. • This procedure is technically challenging and
there is often risk of nerve injury.
• Consequently, a safety-driven technique for
arthroscopic osteocapsular arthroplasty was
developed for prevention of neurologic
injuries without compromising surgical
efficacy.

5. Preoperative Planning
• 2D and 3D CT Scans with sagittal and
coronal reconstruction to reveal any loose
bodies, broken osteophytes.
• Osteophytes in the posteromedial corner
are paid much attention due to closeness
to ulnar nerve.

6. • Surgeon must be thorough with the
location of radial and median nerve
as well.

8. Patient Position
• Lateral decubitus position with arm resting
on arm holder
• Tourniquet should be tied
• Shoulder flexed between 90⁰ and 100⁰ and
elbow at 90⁰

9. • Keep elbow higher than shoulder
• Adequate access to coronoid fossa
should be there

11. Limited Open Ulnar Nerve Decompression
• Through a small posteromedial skin incision
a limited open ulnar nerve decompression
is performed to prevent delayed onset
ulnar neuritis.
• Decompression should be about 3 to 4 cm
proximal and distal to cubital tunnel.

12. • Through this incision, posteromedial
aspect of the capsule can also be
released and osteophytes can be
removed medially.

13. Portals and Fluid Management
• First in posterior compartment with
arthroscope in posterolateral portal and
working instrument in posterior portal.
• Retractor is placed in proximal
posterolateral portal.

14. • Portals are switched on and work is
completed posteriorly.
• Access can be made to lateral gutter by
midlateral portal
• 3 anterior portals are used

15. • Anterolateral and proximal anteromedial portals
for arthroscope and working instruments
and proximal anterolateral portal for retractor.
• For fluid management, a standard 3-L jet lavage
system is used and attached to intravenous tubing
for inflow.
• Shaver outflow left open
• Visualization is enhanced with capsular and soft
tissue retraction

16. Step 1 : Get in and Establish a View
• Pointed switching stick should be used to enter
the joint
• Sheath is inserted into joint over switching stick
and then arthroscope is inserted.
• A 4.8mm shaver is inserted through the
posterior portal into the olecranon fossa
• Articular structures are visualized and anatomic
orientation is confirmed.

17. Step 2 : Create a Space in Which to Work
• A radiofrequency device is used with brief
pulsations and pause
• Retractor can be used
• Capsule is stripped off the humerus
proximally and along the medial and lateral
supracondylar ridges.

19. Step 3 : Bone Removal
• Osteophytes are removed from the floor
of the fossa and margins and olecranon is
restored to its normal shape
• Shaver blade is used to prevent injury to
ulnar nerve and soft tissue

21. Step 4 : Capsulectomy
• Capsule is released along the supracondylar
ridges and also posteromedially and
posterolaterally.
• If loss of flexion is severe, capsule is
released through posterior bundle of medial
collateral ligament on medial side and upto
radial head on lateral side.

22. Medial Gutter
• Arthroscope in the posterolateral portal and
shaver in posterior portal
• Posteromedial aspect of capsule is released
to restore lost flexion
• Medial osteophytes are removed from
trochlea and olecranon.

23. Lateral Gutter
• Arthroscope in posterior portal and shaver
in posterolateral portal
• Osteophytes are removed from posterior
aspect of capitellum and lateral ridges of
trochlea and olecranon
• All the loose bodies should be removed

25. Anterior joint Compartment
• Step 1 : Get in and establish a view :
• Entry is made through proximal
anteromedial portal with a pointed
switching stick
• Sheath is inserted into joint and then
arthroscope
• Articular structures are visualized and
anatomic orientation is confirmed

26. Step 2 : Create a Space in Which to Work
• This step includes :
removal of the debris
scar tissue
loose bodies
Stripping the capsule off the humerus
• Capsular attachments are released along the
medial and lateral supracondylar ridges
• Retractor is placed in proximal anterolateral
portal

28. Step 3 : Bone Removal
• Osteophytes are removed from
coronoid and radial fossa
• Coronoid and coronoid fossa are
reshaped

30. Step 4 : Capsulectomy
• Anterior capsulotomy :
1) detachment
2) preparation
3) incision
4) excision

31. • Capsule is detached from humerus proximally
and along the medial and lateral supracondylar
ridges
• Synovectomy
• removal of loose tissues from surface of
capsule
• Capsule is incised from medial to lateral with a
wide duck billed punch.

32. • Capsulotomy is now performed by
extending it from medial side of
ulnohumeral joint to common flexor
pronator tendon.
• Using bite and peel technique capsule is
incised upto lateral edge of brachialis.

33. • It is extended distally till the interval
between brachioradialis and extensor
carpi radialis longus is easily identifiable
• Capsule is excised off the lateral edge of
brachialis and surrounding tissue.

34. Closure
• Close the wounds after drains have
been placed anteriorly and
posteriorly.

35. Postoperative Regimen
• An indwelling axillary catheter is put for
a continous brachial plexus block
• Continous passive motion is started
• Catheter is removed 12 hours prior to
discharge

36. Results
• Out of 464 patients , 24 cases revealed
transient nerve injury
• Reasons being:
Prolonged tourniquet time
Simultaneous ulnar nerve transposition
Cutaneous dysesthesia
• All nerve palsies got resolved.

37. INDICATIONS
• Ideally indicated for symptomatic
osteoarthritis of elbow with
contracture.

38. CONTRAINDICATIONS
• Anterior capsulectomy may be
contraindicated in patients with prior
submuscular transposition of ulnar
nerve.
• Substantial distortion of anatomic
landmarks.

39. Pitfalls and Challenges
• Keep a margin of safety
• Thorough knowledge about nerves
• Use of retractors
• Suction tubing to be detached from shaver
• Burr should not be used near ulnar nerve
• A stepwise approach

40. Clinical Comments
• Even in expert hands risk of nerve
injury is there
• But with safety driven strategy it
reduces to maximum