- See
Elbow
Arthritis
- Equipement:
- 30 deg, 4 mm arthroscope;
- arthroscopic pump;
- Positioning:
- patient is usually prone with sandbag placed under antecubital fossa;
- TV monitor is positioned opposite of the patient;
- ulnar nerve is palpated
to pinpoint its location and to ensure
that it does not subluxate
with elbow flexion
- instill fluid into the joint thru the
aconeus
triangle;
- through the lateral soft spot,
which is bound by the
radial head, lateral epicondyle, and olecranon
- when the elbow is distended, the major neurovascular structures
are positioned farther away from the
portal sites
- Portal Placement:
-
posterolateral portal:
- portal is located thru the center of the
aconeus
triangle;
- when the anterior aspect of the joint is being visualized, the
posterolateral portal can be used as an
outflow portal;
- posterolateral portal can be used to visualize the posterior elbow
structures including the olecranon fossa;
- use of a 70 deg arthroscope facilitates visualization of
the radiocapitellar joint;
- this portal allows debridement of the capitellum (in the case of
osteochondritis dissecans);
-
anterosuperior lateral:
- considered safer than anterolateral portal;
- portal allows visualization of the ulnohumeral articulation,
anteromedial aspect of elbow, coronoid fossa
and
process, and anterior aspect of radiocapitellar joint;
- portal is placed 2 cm superior to the anterior aspect of lateral
epicondyle;
- blunt dissection into the joint capsule helps to avoid injury.
-
cautions:
- PIN is most at risk, (less than the anterolateral portal)
and lateral antebrachial cutaneous nerves are
at risk;
-
anterolateral portal:
- this portal can be used for instrumentation as well as
visualization of the lateral aspect of the radial head;
- this portal is often established first;
- w/ elbow flexed 90 deg, the portal is located 3 cm distal and 1-2
cm anterior to the lateral epicondyle,
which
should bring portal just anterior and proximal to the radial-capitellar
articulation w/ the portal
driven toward the center of the trochlea;
- elbow is kept flexed during trochar insertion since
extension brings the radial nerve closer to the
joint (3 to 7 mm);
-
hazards:
- the portal pass thru the ECRB and supinator;
-
posterior interosseous nerve is at risk w/ this portal, as it runs about 0.5
cm to 1 cm anterior and
medial to the portal;
- inorder to protect the PIN, this portal is made from
inside outward under visualization from the
proximal-medial portal;
- the scope is advanced anterolaterally arcross the radial
head w/ care not to deviate too anteriorly;
- the light of the arthroscope will be visible thru the skin
which will facilitate proper skin incision;
-
proximal anterolateral portal:
- located 2 cm proximal and 1 cm anterior to the lateral epicondyle;
- this portal is significantly farther (on average 13.7 mm) from the
radial nerve than other anterolateral
portal sites;
- this portal allows for an excellent view of the anterior
radiohumeral and ulnohumeral joints as well as
the anterior capsular margin.
-
proximal antero-medial portal:
- allows visualization of the following:
- anterior elbow including the anterior joint capsule,
medial condyle, coronoid process,
trochlea, capitellum, and the radial head;
- radial head is best visualized from the proximal
anteromedial portal
- joint should already be distened w/ fluid;
- location is 2 cm proximal to medial epicondyle, and immediately
anterior to the inter-muscular septum,
using
a longitudinal skin stab incision;
- ensure that the position of the intermusuclar septum is clearly
demarcated;
- make 1/2 cm incision and spread w/ hemostat;
- trochar is inserted over the anterior surface of the humerus
aiming for the radial head;
- maintain contact w/ anterior humerus at all times to reduce risk
to N/V structures is minimized.
- trocar w/ it (arthroscopic sheath) is then inserted, followed by
the scope;
- hazards:
- nerves at risk w/ this portal include the
ulnar nerve,
medial brachial cutaneous,
medial antebrachial cutaneous, median nerve, and brachial artery;
- ulnar nerve lies 4 mm from this portal site;
- median nerve lies 7-20 mm away from portal with the elbow
in flexion;
-
anteromedial portal:
- some surgeons prefer to establish this portal first;
- elbow should be flexed 90 deg as the portal is established;
- placed 2 cm anterior and 2 cm distal to the medial epicondyle,
placed under direct vision;
- the
median nerve lies 1 to 2 cm anterior and lateral to this portal;
- Complications:
- nerve damage:
- be particularly careful in elbow that have altered anatomy or
scarring (as from intra-articular fracture);
- this situation may distort normal landmarks, decrease
arthroscopic distension, and cause nerves to
remain adherent to capsule;
- in the report by EW. Kelly MD et al, the authors retrospective review of
473 consecutive elbow
arthroscopies performed in 449 patients over an 18
year period was conducted;
- of the 473 cases, 414 were followed for more than six weeks;
- most common final diagnoses were osteoarthritis (150 cases), loose
bodies (112), and RA or
inflammatory
arthritis (seventy-five);
- arthroscopic procedures included synovectomy (184), débridement of
joint surfaces or
adhesions (180),
excision of osteophytes (164),
diagnostic arthroscopy (154), loose-body removal (144), and
capsular procedures such as
capsular release, capsulotomy, and capsulectomy (73).
- a serious complication (a joint space infection) occurred after four
(0.8%) of the arthroscopic procedures;
- minor complications occurred after fifty (11%) of the arthroscopic
procedures;
- these complications included prolonged drainage from or
superficial infection at a portal site after
33 procedures, persistent minor contracture of 20° or
less after seven, and twelve transient
nerve palsies (five ulnar palsies, four superficial
radial palsies, one posterior interosseous
palsy, one medial antebrachial cutaneous palsy, and
one anterior interosseous palsy) in ten patients;
- most significant risk factors for the development of a
temporary nerve palsy were an underlying
diagnosis of rheumatoid arthritis (p < 0.001) and a contracture (p < 0.05).
There were no
permanent neurovascular injuries, hematomas, or compartment syndromes in our
series, and all
of the minor complications, except for the minor contractures, resolved without
sequelae.
- references:
- Complications of Elbow Arthroscopy. EW. Kelly MD et al. J Bone
Joint Surg [Am] 83-A: 25-34, 2001
- Case Report. Complete Transection of the Median and Radial Nerves
During Arthroscopic Release of
Post-traumatic
Elbow Contracture. Tomas Haapaniemi, M.D. et al. Arthroscopy: The Journal of
Arthroscopic and
Related Surgery, Vol 15, No 7 (October), 1999: pp 784-787
