As in any surgical procedure, the key to avoiding complications in elbow arthroscopy is to have a clear understanding of the relationship of the neurovascular structures to the topograph
Trang 1becoming more common, precise knowledge of the neurovascular anatomy, preferred arthroscopic por-tals, and considered indications for definitive arthroscopic procedures is required to maximize the success rate and improve the clinical out-come
Indications and Contraindications
Diagnostic indications include in-flammatory arthritis, loose bodies, degenerative and traumatic arthritis, and intra-articular fractures Thera-peutic indications include removal
of loose bodies, synovectomy, tennis elbow release, débridement of osteo-chondritis dissecans of the capitel-lum, radial head excision, and man-agement of arthritis of the elbow (osteophyte excision and contracture release).4-6 Evolving indications in-clude capsulectomy for arthrofibro-sis, instability management, and percutaneous pinning of fractures
Contraindications to elbow ar-throscopy include distortion of nor-mal bony or soft-tissue anatomy, making safe portal placement diffi-cult.5Extensive heterotopic ossifica-tion is a contraindicaossifica-tion to elbow arthroscopy because of the
frequent-ly extensive anatomic distortion and the usual necessity for open treat-ment of the associated extracapsular contractures of the elbow Previous submuscular or subcutaneous trans-position of the ulnar nerve is a
rela-Surgical Technique
Prior to surgery, a thorough preoper-ative evaluation is performed to de-termine the presence of elbow insta-bility, heterotopic bone in the olecranon fossa or anterior capsule, ligamentous laxity, and range of mo-tion As in any surgical procedure, the key to avoiding complications in elbow arthroscopy is to have a clear understanding of the relationship of the neurovascular structures to the topographic anatomy.7 Because the elbow is a subcutaneous joint, it is easy to palpate the bony landmarks before surgery—specifically, the me-dial epicondyle, lateral epicondyle, olecranon process, radial head, and location of the ulnar nerve (Figure 1)
Anesthesia
Most surgeons prefer to use gen-eral anesthesia for patients undergo-ing elbow arthroscopy because it pro-vides total muscle relaxation and is comfortable for the patient Some physicians avoid the use of regional anesthesia because the patient’s postoperative neurologic status can
be difficult to assess and may be compromised by an extended axil-lary or supraclavicular nerve block.8
We prefer regional blocks, such as axillary blocks, for postoperative pain control If there has been a pre-vious nerve injury or nerve transfer, general anesthesia alone is preferred Infrequently, we have observed com-plete but usually transient ulnar nerve palsy following elbow
arthros-Dr Abboud is Clinical Assistant
Profes-sor of Orthopaedic Surgery, Department
of Orthopaedic Surgery, Pennsylvania
Hospital, University of Pennsylvania
Health System, Philadelphia, PA Dr.
Ricchetti is Orthopaedic Surgery
Resi-dent, Department of Orthopaedic
Sur-gery, University of Pennsylvania School
of Medicine, Philadelphia Dr
Tjou-makaris is Orthopaedic Surgery
Resi-dent, Department of Orthopaedic
Sur-gery, University of Pennsylvania School
of Medicine Dr Ramsey is Associate
Professor of Orthopaedic Surgery and
Chief, Shoulder and Elbow Service,
De-partment of Orthopaedic Surgery,
Uni-versity of Pennsylvania School of
Medi-cine.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr Abboud, Dr Ricchetti, Dr.
Tjoumakaris, and Dr Ramsey.
Reprint requests: Dr Abboud,
Department of Orthopaedic Surgery, 3B
Orthopaedics, Pennsylvania Hospital,
University of Pennsylvania Health
System, 800 Spruce Street, 8th Floor
Preston, Philadelphia, PA 19107.
J Am Acad Orthop Surg
2006;14:312-318
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
Placement,” available on the
Orthopaedic Knowledge Online
Web-site, at http: //www5.aaos.org /oko/jaaos/
surgical.cfm
Trang 2copy In patients in whom we used
an axillary nerve block, nerve
activ-ity could not be accurately
deter-mined postoperatively
Instrumentation
A standard 4.0-mm, 30° offset
ar-throscope permits excellent
visual-ization of the elbow joint A smaller
2.7-mm arthroscope typically is not
necessary but can be useful for
view-ing small spaces, such as the lateral compartment from the direct lateral portal, and for arthroscopy in adoles-cent patients
Side-vented inflow cannulas should be avoided in elbow arthros-copy because the distance between the skin and the joint capsule is of-ten very slight With side-vented cannulas, the cannula can be intra-articular while the side vents remain
extra-articular, resulting in fluid ex-travasation into the surrounding soft tissues Inflow cannulas should be devoid of side vents, with fluid flow occurring directly at the end of the cannula9(Figure 2, A)
All trocars are conical and blunt-tipped to decrease the possibility of neurovascular and articular injury A variety of accessory handheld instru-ments (eg, probes, grasping forceps,
Figure 1
Surface landmarks of the elbow for arthroscopy Posterior view of the elbow hinged over a support padded bolster A, The medial epicondyle, ulnar nerve, and olecranon process are outlined in relation to the elbow joint B, The lateral epicondyle, radial
head, and olecranon process are outlined in relation to the elbow joint
Figure 2
A,Inflow cannulas Side vented inflow cannulas (right) should be avoided because the side vents may lie outside of the elbow joint, resulting in fluid extravasation into the surrounding soft tissues Fluid flow should occur from the end of the cannula (left)
B,Elbow arthroscopy instruments Clockwise from upper left: irrigation system; grasping forceps, and grasping and cutting punches; plastic and metal trocars and cannulas for portal dilation and exposure; and 20-mL irrigation syringe, triangulation probe, spinal needle (Panel A reproduced with permission from Ramsey ML, Naranja RJ: Diagnostic arthroscopy of the elbow,
in Baker CL Jr, Plancher KD [eds]: Operative Treatment of Elbow Injuries New York, NY: Springer-Verlag, 2002, p 165.)
Trang 3punches) and motorized instruments
(eg, arthroscopic radial-sided cutting
shavers, end-cutting burrs) are used
during elbow arthroscopy (Figure 2,
B)
Patient Position
Patients may be positioned in one
of four ways for elbow arthroscopy:
supine, supine-suspended, prone,
and lateral decubitus Each position
has its advantages and
disadvantag-es We prefer the lateral decubitus
position because it provides
im-proved stability of the extremity and
posterior elbow joint access without
compromising airway access.5,7
Arthroscopy Setup
After general anesthesia is
admin-istered, the patient is placed in the
lateral decubitus position with the
involved extremity facing upward
(Figure 3, A) The arm is supported
and stabilized on a padded bolster
with the shoulder abducted to 90°
and the elbow flexed to 90° A
tour-niquet is placed proximally on the
arm with the pressure set at 250 mm
Hg The extremity is sterilely
pre-pared and draped free to allow
intra-operative manipulation To
mini-mize fluid extravasation into the
forearm, the forearm is wrapped with an elastic bandage from the fin-gers to just below the elbow
The bony landmarks of the elbow and the portal sites are marked on the skin before joint distention
(Fig-ures 1 and 3) ( video step 1) An
18-gauge needle is inserted through the lateral “soft spot,” which is bounded by the lateral epicondyle, ra-dial head, and olecranon process (Fig-ure 3, B) Using this site, the elbow is then distended with 15 to 25 mL of sterile saline Joint insufflation in-creases the distance between the joint surfaces and neurovascular structures, helping to protect vessels and nerves from injury during joint entry10 ( video step 2)
Impor-tantly, joint distention does not in-crease the distance between the joint capsule and adjacent neurovascular structures and, therefore, does not protect the neurovascular structures from work performed against the joint capsule Distention of the joint can be confirmed by elevation of the elbow capsule anteriorly and poste-riorly Return of fluid from the nee-dle when the stylus is removed also confirms that the joint space has been entered and capsular distention obtained Distention of the joint with
more than 15 to 25 mL of fluid risks capsular rupture, resulting in poor ar-throscopic visualization and fluid ex-travasation during arthroscopy.11
Portal Placement
Neurovascular injury is a primary concern with elbow arthroscopy and can occur with any of the described portal sites Several surgeons have described creating various portals around the elbow with the intention
of decreasing the risk of neurovascu-lar injury while maintaining ade-quate intra-articular visualiza-tion.1,2,5,12
The initial portal for joint visual-ization is a matter of surgeon prefer-ence but is dictated to some extent
by the underlying pathology to be ad-dressed Some elbow surgeons de-scribe initial visualization of the pos-terolateral recess from the soft-spot portal, then progressing to the poste-rior compartment of the elbow before moving to the anterior compartment Most elbow surgeons, however, pre-fer to visualize the anterior compart-ment of the elbow first, then the pos-terior compartment, and finally the posterolateral recess to complete joint visualization We find that ini-tially observing the radiocapitellar
A,After the administration of general anesthesia, the patient is placed in the lateral decubitus position with the surgical elbow
supported and stabilized on a padded bolster (shoulder abducted to 90° and elbow flexed to 90°) B, Prior to beginning
arthroscopy, distention of the elbow joint is performed through the lateral soft spot, bounded by the lateral epicondyle, radial head, and olecranon process
Trang 4and ulnohumeral joints aids in
intra-articular orientation
Whether the anteromedial or
an-terolateral portal should be created
first has been an issue of some
de-bate Many surgeons create a lateral
portal initially and then establish a
medial portal with a spinal needle by
direct visualization from within the
joint Alternatively, an inside-out
technique may be employed in
which a switching stick is used to
es-tablish the medial portal from inside
the joint.13Other surgeons, using the same techniques, establish the me-dial portal first.14We create a medial portal first and then establish the lat-eral portal under direct visualization with the aid of a spinal needle We think that the medial approach is safer because the average distance between the medial portals and the median nerve is greater than the dis-tance between the lateral portals and the radial or posterior interosseous nerve.13,14
Proximal Anteromedial (Superomedial) Portal
The proximal anteromedial (or su-peromedial) portal popularized by Poehling et al2is located just anterior
to the intermuscular septum and
2 cm proximal to the medial epi-condyle (Figure 4, A) The ulnar nerve
is located approximately 3 to 4 mm from this portal, posterior to the in-termuscular septum Palpating the septum and making sure that the portal is established anterior to
Figure 4
A,The proximal anteromedial portal (or superomedial portal) is just anterior to the intramuscular septum and 2 cm proximal to
the medial epicondyle Care must be taken to avoid the ulnar nerve B, The anteromedial portal is approximately 2 cm anterior
and 2 cm distal to the medial epicondyle This portal augments the proximal anteromedial portal and is helpful for working in the medial recess of the elbow Care must be taken to avoid the medial antebrachial cutaneous nerve
Figure 5
A,The proximal anterolateral portal is 1 to 2 cm proximal to the lateral epicondyle, just anterior to the lateral supracondylar
column of the distal humerus This proximal position minimizes the risk of radial nerve injury B, The anterolateral portal also is
favored to decrease the risk of radial nerve injury Compared with the proximal anterolateral portal, this placement is more proximal and somewhat anterior Creating this portal under direct visualization, after establishment of a medial portal, helps avoid injury to lateral structures
Trang 5the septum minimizes the risk of
in-jury to the nerve while providing
ex-cellent visualization laterally of the
radiocapitellar joint The proximal
anteromedial portal is safer than the
anteromedial portal because the
more proximal position allows the
arthroscope to be directed distally,
re-sulting in the arthroscope’s being
al-most parallel to the median nerve in
the anteroposterior plane.14The
ar-throscope is inserted through this
portal, and systematic examination
of the anterior compartment is then
performed The capitellum and radial
head are inspected; the forearm is ro-tated to evaluate the medial and lat-eral surfaces of the radial head The anterior and lateral aspects of the capsule are viewed next by slowly withdrawing the arthroscope A tri-angulation probe can help evaluate the trochlea, coronoid fossa, and
coronoid process ( video step 3).
Anteromedial Portal
The anteromedial portal1is
locat-ed 2 cm anterior and 2 cm distal to the medial epicondyle (Figure 4, B)
The anteromedial portal is used
pri-imal to the lateral epicondyle, di-rectly on the anterior humerus (Fig-ure 5, A) This portal brings the arthroscope into the lateral aspect of the joint at an angle that allows visu-alization of the medial aspect of the joint, radiocapitellar joint, and
later-al recess ( video step 4) In
prac-tice, anterior portal placement from the lateral side of the elbow can oc-cur anywhere from the sulcus be-tween the radial head and capitel-lum to a point 2 cm proximal to the lateral epicondyle, along the
anteri-or aspect of the humerus, without placing the radial nerve at increased risk.12In fact, the risk of neurovascu-lar injury decreases as the portal is moved more proximally
Anterolateral Portal
The anterolateral portal was orig-inally described as being located
3 cm distal and 2 cm anterior to the lateral epicondyle.1 However, this portal location places the radial nerve at significant risk for
iatrogen-ic injury.15To decrease risk of injury
to the radial nerve, several investiga-tors have stressed the importance of avoiding the distal placement of this portal in favor of a more proximal placement of the anterolateral por-tal, at the sulcus between the capi-tellum and the radial head12(Figure
5, B)
Posterocentral Portal
The posterocentral portal is
locat-ed 3 cm proximal to the tip of the
cutaneous tissue to prevent injury to the superficial cutaneous nerves
• Use a hemostat or mosquito clamp to spread tissues down to the
capsule
• Keep the elbow flexed 90° to increase the distance between the
nerves and the capsule
• Do not use pressurized infusion systems They can cause capsular
rupture, extra-articular fluid extravasation, and obstruction of joint
visualization.18
• Always visualize your instrument tip
• Use a retractor introduced into the joint through a separate portal to
lift the capsule away from the débriding instrument
• Use of retractors for greater visualization and exposure is probably
most important in preventing nerve injury.16
• In some cases, safe surgery requires arthroscopic identification of
nerves This technique is reserved for the most experienced elbow
arthroscopists Novice arthroscopists attempting to arthroscopically
identify nerves or attempting to perform surgery that requires nerve
identification are more likely to injure the nerves they are
attempt-ing to protect This is particularly true with the ulnar nerve
• Avoid suction when working against the capsule This may cause
capsular collapse and inadvertent nerve injury
• Use of local anesthetics around the portals can produce local
neu-ral deficits that may confuse the postoperative neurologic status of
the patient
Trang 6olecranon in the midline (Figure 6,
A) It pierces the triceps muscle just
above the musculotendinous
junc-tion and provides excellent
visual-ization of the entire posterior
com-partment of the elbow, including the
medial and lateral gutters ( video
step 5) The straight posterior portal
passes within 23 mm of the
posteri-or antebrachial cutaneous nerve and
within 25 mm of the ulnar nerve
Posterolateral Portal (Proximal
Posterolateral Portal)
This portal is located 2 to 3 cm
proximal to the tip of the olecranon
at the lateral border of the triceps ten-don (Figure 6, B) The trocar is di-rected toward the olecranon fossa, passing through the triceps muscle to reach the capsule This portal permits visualization of the olecranon tip, olec-ranon fossa, and posterior trochlea, but the posterior capitellum is not well seen The medial and posterior antebrachial cutaneous nerves are the two neurovascular structures most at risk; they are, on average, approxi-mately 25 mm from this portal.15The ulnar nerve is approximately 25 mm
from this portal medially but is safe
as long as the cannula is kept lateral
to the posterior midline.3
Accessory Posterolateral Portals
The posterolateral anatomy of the elbow allows for portal placement anywherefromtheproximalpostero-lateral portal to the anywherefromtheproximalpostero-lateral soft spot (Figure 6, C) Altering the portal po-sition along the line between the proximal posterolateral portal and lateral soft spot changes the orienta-tion of the portal relative to the
Figure 6
A, The posterocentral portal, the safest portal, is placed in the midline 3 cm proximal to the tip of the olecranon process B, The
posterolateral portal (or proximal posterolateral portal) is 2 to 3 cm proximal to the tip of the olecranon process at the lateral
border of the triceps tendon The medial and posterior antebrachial cutaneous nerves are most at risk C, Accessory
posterolateral portals may be placed anywhere along a line from the site of the proximal posterolateral portal to the site of the
lateral soft spot distally D, The direct lateral portal (or soft-spot portal) is at the center of the triangle formed by the lateral
epicondyle, olecranon process, and radial head Care must be taken to avoid the posterior antebrachial cutaneous nerve
Trang 7neurovascular structure to the portal
is the posterior antebrachial
cutane-ous nerve, which passes
approxi-mately 7 mm from the portal The
soft-spot portal allows visualization
of the inferior aspect of the
capitel-lum and the inferior portion of the
radioulnar articulation Establishing
this portal is an essential component
to a complete arthroscopic
examina-tion of the elbow
Complications
Although rare and often transient,
nerve injuries are the most
com-monly reported complications of
el-bow arthroscopy.1,15,19These can be a
result of direct injury from the
tro-cars and instruments used, or they
can result from overly aggressive
joint distention/fluid extravasation,
compression caused by arthroscopic
sheaths, or use of local anesthesia.1,15
More specifically, the radial nerve
is at risk for injury during placement
of the anterolateral portal Injuries to
the radial nerve, the superficial
branch of the radial nerve, and the
posterior interosseous nerve have
been reported.15,20,21 The median
nerve is susceptible to injury during
placement of the anteromedial
por-tal; injuries to the median and
ante-rior interosseous nerves also have
been documented.1,15,22 Damage to
the ulnar nerve after the use of
mul-tiple medial portals has been
report-ed Finally, injury to superficial
cuta-neous nerves about the elbow (ie,
surgical procedure, careful preopera-tive planning, including a detailed history and physical examination, and careful portal placement are nec-essary to ensure a successful surgical outcome The surgeon’s experience, skill level, and knowledge of local anatomy should determine the com-plexity of elbow arthroscopy cases at-tempted Elbow arthroscopy cur-rently serves as an adjunct therapy to open surgical procedures in the treat-ment of a variety of elbow condi-tions.8New indications for elbow ar-throscopy are likely to emerge as surgical equipment and techniques are refined and as the clinical expe-rience of elbow surgeons increases
References Citation numbers printed in bold
type indicate references published
within the past 5 years
1 Andrews JR, Carson WG: Arthroscopy
of the elbow Arthroscopy
1985;1:97-107.
2 Poehling GG, Whipple TL, Sisco L, Goldman B: Elbow arthroscopy: A
new technique Arthroscopy 1989;5:
222-224.
3 Baker CL, Brooks AA: Arthroscopy of
the elbow Clin Sports Med 1996;15:
261-281.
4 Morrey BF: Arthroscopy of the elbow.
Instr Course Lect1986;35:102-107.
5 O’Driscoll SW, Morrey BF:
Arthrosco-py of the elbow: Diagnostic and
ther-apeutic benefits and hazards J Bone
Joint Surg Am1992;74:84-94.
6 Savoie FH III, Nunley PD, Field LD:
Arthroscopic management of the ar-thritic elbow: Indications, technique,
and results J Shoulder Elbow Surg
traarticular pressure and capacity of
the elbow Arthroscopy
1990;6:100-103.
12 Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL: Arthroscopic anatomy of the lat-eral elbow: A comparison of three
por-tals Arthroscopy 1994;10:602-607.
13 Andrews JR, St Pierre RK, Carson
WG Jr: Arthroscopy of the elbow.
Clin Sports Med1986;5:653-662.
14 Lindenfeld TN: Medial approach in
el-bow arthroscopy Am J Sports Med
1990;18:413-417.
15 Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent
risks Arthroscopy 1986;2:190-197.
16 Morrey BF: Complications of elbow
arthroscopy Instr Course Lect 2000;
49:255-258.
17 Stothers K, Day B, Regan WR: Ar-throscopy of the elbow: Anatomy, portal sites, and a description of the
proximal lateral portal Arthroscopy
1995;11:449-457.
18 Ogilvie-Harris DJ, Weisleder L: Fluid pump systems for arthroscopy: A comparison of pressure control versus
Arthroscopy1995;11:591-595.
19 Poehling GG, Ekman EF: Arthroscopy
of the elbow Instr Course Lect 1995;
44:217-223.
20 Papilion JD, Neff RS, Shall LM: Com-pression neuropathy of the radial nerve as a complication of elbow ar-throscopy: A case report and review of
the literature Arthroscopy 1988;4:
284-286.
21 Thomas MA, Fast A, Shapiro D:
Radi-al nerve damage as a complication of elbow arthroscopy. Clin Orthop Relat Res1987;215:130-131.
22 Ruch DS, Poehling GG: Anterior in-terosseus nerve injury following
el-bow arthroscopy Arthroscopy 1997;
13:756-758.