We retrospectively evaluated the results of open and arthroscopic surgical release for symptomatic elbow OA in a comparative case series of patients who were managed at two institutions. In this study, the surgical procedures were performed by two doctors at two institutions; one doctor performed open surgery at one institution while another doctor performed arthroscopic surgery at the other institution. Of the 51 patients who underwent surgery for OA between 2007 and 2017, 36 patients who were observed for more than 6 months were included in the study.
Under general anesthesia or brachial plexus block combined with intravenous sedation, the patients were positioned in the spine and lateral decubitus position for open and arthroscopic surgery, respectively. Additionally, a tourniquet was applied during surgery.
Open surgery was performed from the medial side and ulnar nerve release was performed regardless of the symptoms. Growing osteophytes and synovia in the anterior and posterior capsules were excised. The range of motion of the joint was confirmed intraoperatively; in four cases, the surgery was performed inside the joint using the lateral approach.
Arthroscopic surgery was performed by first creating a proximal anteromedial portal and then a mid-anterolateral portal using the inside-out technique. The assistant supported the joint capsule with a blunt tip. We mainly used a 2.9-mm 30° arthroscope, a 3.5-mm full radius resector, and a 4.0-mm motorized burr to perform arthroscopic debridement of the anterior side of the elbow joint and excision of the growing synovium and osteophyte. Following debridement of the anterior side, we added a posterolateral portal to begin debridement of the posterior side; the direct posterior portal and direct lateral portal (soft spot) were used to perform arthroscopic debridement on the posterior side of the elbow. For concomitant cubital tunnel syndrome, nerve release and anterior subcutaneous transfer with internal synovial and osteophyte resection on the medial side were performed in 11 patients.
Following surgery, we checked the passive motion arc and confirmed that there was no remnant mechanical impingement. Soft compressive dressings were applied in both groups, and a suction drain was inserted in patients in the open surgery group for 1–2 days. At 2–4 days after surgery, patients were instructed to start active-assisted motion exercises. Neither braces nor continuous passive motion were employed and assisted mobilization by a physiotherapist twice per week was recommended.
The primary outcome was the range of motion, while the secondary outcome was the Hand20 score (10). We examined and compared the ulnar nerve symptoms, operation time, range of motion, postoperative pain, Hand20 score, and OA levels using both the Broberg and Morrey (BM) and the Hastings and Rettig classifications for OA levels (11,12).
The BM classification of elbow OA (11) was used to stage the severity of OA using the following criteria: Grade 1 – slight joint space narrowing with minimal osteophyte formation; Grade 2 – moderate joint space narrowing with moderate osteophyte formation; and Grade 3 – severe degenerative change with gross destruction of the joint.
Furthermore, the Hasting and Rettig classification (HR) of elbow OA (12) was used to stage the severity of OA using the following criteria: Class I – degeneration in the margins of the ulnotrochlear joint with the presence of coronoid and olecranon spurring and absence of degenerative changes within the radiocapitellar joint; Class II – class I with mild joint space narrowing within the radiocapitellar joint, without subluxation of the radial head; and Class III – class II with radiocapitellar subluxation.
Two independent observers were asked to evaluate both classifications from plain films without instruction using the standard computerized measurement caliper with references (11,12). After 2 weeks, the same observers repeated evaluation of the films.
All data analyses were performed using SPSS software version 26 (IBM, Chicago, IL). We used the chi-square test to compare categorical variables and analyzed differences in two independent samples of pre- and postoperative measurements using the Mann-Whitney U-test. Values of p < 0.05 were considered statistically significant. Intra- and interobserver reliability was calculated using the intraclass correlation coefficient (ICC) (13). The degree of agreement of the two evaluations made by the observers was interpreted as follows: poor ICC, < 0.20; fair ICC, 0.21–0.40; moderate ICC, 0.41–0.60; good ICC, 0.61–0.80; and very good ICC, > 0.80 (14).