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Handheld Osteotomes Facilitate Arthroscopic ElbowOsteophyte Removal

Wesley S. Greer, M.D., Adam C. Field, B.S., and Larry D. Field, M.D.

Abstract: Arthroscopic elbow surgery is a challenging procedure in part because of the limited intra-articular volume ofthe joint, the congruence of the elbow articulation, and the close proximity of the neurovascular structures. Arthriticconditions that result in the development of bony prominences and osteophytes are usually amenable to arthroscopicmanagement and include diagnoses such as osteoarthritis, rheumatoid arthritis, and valgus extension overload syndrome.Safe and efficient removal of these osteophytes can be problematic, however, because of technical difficulties oftenencountered while using arthroscopic burrs and shavers as well as the risks of inadvertent, iatrogenic injury to adjacentarticular cartilage and other structures. A valuable and effective technique using small handheld osteotomes to facilitatethe arthroscopic removal of intra-articular osteophytes and other bony prominences is described and shown.

rthroscopic surgery of the elbow was initially

Aindicated only for diagnostic evaluation andremoval of loose bodies. The indications, and thus thenumber and type of procedures available to thearthroscopic surgeon to manage a wide variety of elbowconditions, have significantly expanded over the years.Elbow arthroscopy, however, is a technicallydemanding exercise, and iatrogenic injury to the intra-articular and extra-articular structures, including thenerves and arteries that cross the elbow joint, remains asignificant concern.1 Because of significant potentialrisks of elbow arthroscopic intervention, it is importantto proceed in a stepwise and progressive manner thatallows for the development of elbow arthroscopic skillsand technical expertise while minimizing the risk foriatrogenic injury.2

Mississippi Sports Medicine and Orthopaedic Center, Jackson,.S.A.rs report the following potential conflicts of interest or sources of.F. receives institutional grants, travel support, and boardfees from the Arthroscopy Association of North America;fees from Smith & Nephew; and research and educational sup-threx, Mitek, and Smith & Nephew. Full ICMJE author disclo-re available for this article online, as supplementary material.ebruary 20, 2018; accepted June 19, 2018.rrespondence to Larry D. Field, M.D., Mississippi Sports Medicineedic Center, 1325 East Fortification Street, Jackson, MS 39202,il: lfield@msmoc.comy the Arthroscopy Association of North America. Published bys is an open access article under the CC BY-NC-ND license (http://ons.org/licenses/by-nc-nd/4.0/)./18254.org/10.1016/j.eats.2018.06.009

Arthroscopy Techniques, Vol 7, No 10

A wide variety of procedures is commonly performedusing elbow arthroscopic techniques. Many of theseelbow conditions result in the formation of hypertro-phic bony prominences and osteophytes. Osteoarthritisof the elbow is one of these conditions and differssomewhat from osteoarthritis in some other joints inthat the articular cartilage is generally relatively wellpreserved in elbow osteoarthritis. The symptomsattributable to elbow osteoarthritis are felt to resultfrom the presence of these hypertrophic osteophytes incombination with symptoms attributable to thecommonly associated contracture of the elbowcapsule.3 These characteristic intra-articular findingsseen in patients with elbow osteoarthritis are alsoroutinely identified in other common elbow conditionssuch as valgus extension overload. Posteromedialimpingement owing to spur formation in patients withvalgus extension overload significantly limits overheadperformance and generates these characteristic signsand symptoms.4

An integral component of arthroscopic surgicalmanagement for these type of elbow conditions centerson the removal of these osteophytes, and arthroscopictechniques have proven very effective.5,6 Although theuse of osteotomes is well described and commonlyemployed for open surgical procedures, the use ofsmall handheld osteotomes, inserted through standardportal cannulas and used arthroscopically to removeelbow osteophytes, has not been well described.Nevertheless, these small osteotomes have been usedroutinely by the senior author (L.D.F.) for cases inwhich elbow osteophytes are to be removed for over20 years. Furthermore, these same osteotomes used to

(October), 2018: pp e1031-e1035 e1031

Fig 1. From top to bottom: Arthroscopic suture grasper,straight ¼00 osteotome, curved ¼00 osteotome, and arthro-scopic grasper.

Fig 3. From top to bottom: Symmetry Surgical 1/800 curvedosteotome 28-4953, Symmetry Surgical ¼00 curved osteo-tome 28-4956, Symmetry Surgical 1/800 straight osteotome28-4903, and Zimmer ¼00 straight osteotome 852-00-04.

e1032 W. S. GREER ET AL.

remove elbow osteophytes can also be just as easily andeffectively used arthroscopically within other jointssuch as the knee and shoulder.These small osteotomes, variable in width and either

straight or slightly angled, offer significant potentialbenefits and advantages when compared with arthro-scopic shavers and burrs that are most commonly usedfor elbow osteophyte removal. The elbow joint is a verycongruent articulation. This “hinge” joint creates anintra-articular environment in which the highlycongruent articular surfaces are at significantlyincreased risk of iatrogenic injury at the time of osteo-phyte removal because of their immediate proximity toany devices used to remove these osteophytes. Thesesmall osteotomes are valuable because they can be very

Fig 2. From top to bottom: Enlarged view of the tips of thearthroscopic suture grasper, straight ¼00 osteotome, curved¼00 osteotome, and arthroscopic grasper.

precisely positioned directly onto the base of theosteophyte to be removed and then carefully advancedwith gentle mallet taps through the extent of theosteophyte until it is separated from its bony origin.Conversely, resection of osteophytes using an arthro-scopic burr or shaver may be more likely to inadver-tently make contact with the adjacent articular cartilageof the opposing joint surface. In addition, the intra-articular debris that an arthroscopic burr generatesreduces visualization and can significantly limit thesurgeon’s view, making osteophyte removal moredifficult and potentially increasing the risk of uninten-tional injury to the articular surfaces or other nearbystructures. Another potential advantage of the use of

Fig 4. Patient is prone with the left arm over post. Viewingfrom the anteromedial portal of the coronoid osteophyte, theosteotome is introduced from the anterolateral portal fordirect access to the coronoid osteophyte.

Fig 5. Patient is prone with the left arm over the post.Viewing from the posterolateral portal, the osteotome isworking through the central posterior portal, allowingremoval of all desired osteophytes of the olecranon.

Fig 6. Three-dimensional computed tomographic reconstruc-tion. Viewing from the posterior, showing posterior elbow andrevealing “Mickey Mouse ears” osteophytes of the olecranon.

HANDHELD OSTEOTOMES e1033

these osteotomes compared with arthroscopic burrsrelates to the risks of osteophyte removal within theposterior medial and posterior lateral elbow compart-ment gutters. Osteophytes occur very commonly inthese gutters in both post-traumatic and degenerativeosteoarthritis. These gutters, because of the very limitedspace available, can be difficult to access and visualize,making arthroscopic burr excision especially chal-lenging. The proximity of the ligamentous structureswithin the gutters (medial ulnar collateral ligament andlateral ulnar collateral ligament), as well as the ulnarnerve immediately adjacent to the posterior medialgutter, makes the use of very controllable and easilyvisualized osteotomes particularly appealing. Moreimportantly, because no suction is necessary and nospinning burrs or blades are used, there is less risk ofinadvertent damage to the ligaments or ulnar nerve.Once these spurs in the elbow are broken free using theosteotomes, they are then easily removed using stan-dard arthroscopic graspers.

Surgical TechniqueThe use of small handheld osteotomes can be easily

incorporated into elbow arthroscopic procedures inwhich osteophytes or other bony prominences are to beremoved. Following the induction of anesthesia, thepatient is positioned prone on the table with appro-priate padding of all bony prominences. The operativearm is draped over a post or placed in an arm holder.A nonsterile tourniquet is applied before prepping anddraping. After draping, landmarks are palpated andmarked to aid in portal placement. Likewise, the ulnarnerve is always palpated to confirm that it can be found

within the ulnar groove and that it is not subluxated orsubluxatable. Twenty to 30 mL of normal saline isinjected into the elbow joint via the soft spot using an18-gauge needle. Diagnostic arthroscopy is then per-formed after the establishment of standard proximalanteromedial and proximal anterolateral portal sitesusing standard arthroscopic cannulae. After identifica-tion of the osteophytes, sequential removal iscompleted under careful arthroscopic visualizationemploying osteotomes (Symmetry Surgical, Antioch,TN; Zimmer Biomet, Warsaw, IN) of various sizes asnecessary. Examples of these osteotomes are shown inFigures 1-3. A preoperative 3-dimensional computedtomography (3D CT) scan is particularly helpful inidentifying pathologic spur formation and forpreoperative planning of the bony resections. Not allosteophytes to be removed require the use of theseosteotomes, depending on the size, orientation, and

Table 1. Pearls and Pitfalls of the Handheld Osteotome Technique

Pearls Pitfalls

Osteotomes less than 4 mm are ideal because of their ability to fitthrough small metal cannulas.

Most facilities may not have small osteotomes, thus requiring newpurchase or removal of cannula from the portal.

Wider osteotomes are easily used through posterior portals without acannula.

Larger bone resections may still require expanding the portal size toremove the bone piece.

Curvedosteotomes can allowadditional resectionand improvedangles. Curved osteotomes do not readily fit through cannulas.

e1034 W. S. GREER ET AL.

density of the osteophytes, as some of these spurs arerelatively soft and easily resected using standardarthroscopic shavers or arthroscopic graspers.However, when the osteophytes are particularlydense, osteotomes can be especially useful. Removalof an anterior coronoid osteophyte is shown in thesecond case in Video 1 and in Figure 4. Finally, beforetransferring the arthroscope to the posterior elbowcompartment, any other indicated anterior elbowcompartment procedures such as capsular release, loosebody removal, and synovectomy are completed.Attention can then be turned to the posterior

compartment. Typically, a posterior lateral viewingportal and a posterior central working portal areestablished initially. The olecranon process and fossacan be visualized and bony overgrowths and osteo-phytes evaluated. Once a specific plan for osteophyteresection is made, the osteotome can be delivered intothe posterior compartment through the posterior cen-tral working portal percutaneously. This technique isshown in Video 1 in the first and third cases. Figure 5also shows this technique. Progressive removal ofosteophytes from the olecranon process, olecranonfossa, and posterior compartment gutters is continueduntil normal bony architecture is restored. Slightextension of the elbow increases the distance betweenthe olecranon process spurs and the articular surface ofthe distal humerus and may provide additional pro-tection for the articular cartilage. The fragments that areliberated using the osteotomes are then removed piece-meal using an arthroscopic grasper device (Figs 1-3).After the recontouring of the olecranon process, fossa,and gutters is completed, the elbow can be takenthrough a passive range of motion under directarthroscopic visualization to ensure that all residualbony impingement has been alleviated. Even whenvery significant degrees of hypertrophic olecranonprocess and fossa osteophytes are present, resectionand removal of these osteophytes can be efficiently

Table 2. Advantages and Disadvantages of the Handheld Osteoto

Advantages

Quickly remove large osteophyte piecesProtect the capsule and neurovascular structures during osteophyte

removalLimited amount of bony debris released during removal

accomplished using these osteotomes while protectingthe adjacent articular cartilage and other importantstructures (Fig 6).

DiscussionElbow arthroscopy is a valuable surgical technique for

the management of symptomatic elbow arthritis and forother etiologies that are characterized by the develop-ment of osteophytes, such as valgus overload and post-traumatic arthritis. Proper technique combined with athorough knowledge of elbow anatomy, including thelocations and pathways of the vital neurovascularstructures, helps ensure that the risk of complications isminimized. In concert with these considerations, theuse of small handheld osteotomes not only aids inachieving the goal of recontouring the intra-articularbony architecture of the elbow joint but also serves toeffectively and efficiently accomplish this procedurewhile minimizing the iatrogenic risks.The senior author (L.D.F.) has used small handheld

osteotomes during arthroscopic elbow debridementcases to resect osteophytes approximately 150 timesover the past 20 years. We have found that theseosteotomes greatly improve access to and efficientremoval of osteophytes from all areas of the elbow jointand also help protect the articular surfaces and otherimportant nearby structures from iatrogenic injury.These osteotomes, although very efficient, do lead tolarge bone pieces, which have to be removed throughthe portal. Larger pieces may even require the portal tobe enlarged. Although arthroscopic burrs are acceptableand used in many cases by the authors and others forosteophyte removal, there are inherent risks associatedwith these burrs that are obviated by the use of anosteotome. However, the advantage of the burr is thatthe bony pieces are removed through the shaver andtherefore do not require an additional step or length tothe portal incision (Tables 1 and 2). The authorsrecommend the use of these small osteotomes, when

me Technique

Disadvantages

Large pieces then have to be removed from the existing portalCurved and larger-width osteotomes may require removal of the

cannula to enable its useAdditional hand required during case than when using arthroscopic

shaver or burr

HANDHELD OSTEOTOMES e1035

possible, to aid in the removal of bony osteophytesduring arthroscopic surgery of the elbow.

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