Arthroscopy: The Journal of Arthroscopic & Related Surgery
Neurovascular anatomy and elbow arthroscopy: Inherent risks*
Abstract
Five cadaver elbows were examined arthroscopically. Detailed dissections of superficial cutaneous nerves and of deeper neurovascular structures were carried out either before or after arthroscopic examination. Normal neurovascular anatomy and variants were defined in relation to standard portal placement. The danger of neurovascular injury is emphasized due to inappropriate portals, direction of entry, or elbow position. A safe, reliable, and reproducible technique is defined.
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Cited by (149)
Arthroscopic treatment of diffuse pigmented villonodular synovitis of the elbow
2023, Orthopaedics and Traumatology: Surgery and ResearchPigmented villonodular synovitis (PVNS) is a rare pathology of the elbow, but presents a risk of progression with cartilage destruction. Surgical treatment consists in synovectomy, as complete as possible. Arthroscopy is an excellent tool for the exploration and treatment of intra-articular lesions in the elbow, but the results in PVNS of the elbow have never been evaluated. The aim of this study was to assess the recurrence rate of PVNS of the elbow after arthroscopic synovectomy, and secondarily to assess pain, joint range of motion, functional scores and complication rate.
We performed a retrospective study of a continuous series of 8 patients operated on between February 2012 and February 2019, with a mean age of 43.7 years. The operated side was the dominant side in 75% of cases. Surgery consisted in the most complete synovectomy possible, performed arthroscopically. Recurrence, clinical evaluation, with pain at rest and on mpvement on visual analogue scale (VAS) and joint range of motion, functional MEPS and DASH scores, and any complications were collected.
At a mean 66.4 months’ follow-up, 2 patients required revision surgery for recurrence. At the last follow-up, VAS for pain at rest was 0.9 and 1.9 for pain on movement. MEPS score was 85.6 and DASH score 82.2. No neurological, vascular or infectious complications of arthroscopic synovectomy were found in our series.
Arthroscopic synovectomy in the treatment of PVNS of the elbow was a reliable and safe therapeutic alternative, with a low complications rate and 2 cases of recurrence (25%) in our study. This was the first study to report the results of arthroscopic surgical treatment of elbow PVNS.
IV Retrospective study without control group.
Arthroscopic treatment of diffuse pigmented villonodular synovitis of the elbow
2023, Revue de Chirurgie Orthopedique et TraumatologiqueLa synovite villo-nodulaire pigmentée (SVNP) est une pathologie rare du coude mais présente un risque évolutif avec destruction cartilagineuse. Le traitement chirurgical consiste à réaliser une synovectomie la plus complète possible. L’arthroscopie est un excellent outil pour l’exploration et le traitement des lésions intra-articulaires du coude mais les résultats dans la SVNP du coude n’ont jamais été évalués. Le but de cette étude était d’évaluer le taux de récidive des SVNP du coude après synovectomie arthroscopique puis d’évaluer la douleur, les mobilités articulaires, les scores fonctionnels et le taux de complication.
Nous avons réalisé une étude rétrospective d’une série continue de 8 patients opérés entre février 2012 et février 2019 de 43,7 ans d’âge moyen. Le côté opéré était le côté dominant dans 75 % des cas. La chirurgie comprenait la réalisation d’une synovectomie la plus complète possible réalisée sous arthroscopie. La survenue d’une récidive, l’évaluation clinique avec l’échelle visuelle analogique (EVA) de douleur au repos et à l’effort, la mobilité articulaire et fonctionnelle avec le score de MEPS et de DASH ainsi que la recherche de complications ont été recueillies.
À 66,4 mois de suivi moyen, 2 patients ont nécessité une reprise chirurgicale pour une récidive. Au dernier recul, l’EVA au repos était de 0,9 et à l’effort de 1,9. Le score de MEPS était de 85,6 et le score DASH de 82,2. Aucune complication neurologique, vasculaire ou infectieuse du geste d’arthrolyse arthroscopique n’a été retrouvée dans notre série.
La synovectomie arthroscopique dans le traitement des SVNP du coude est une alternative thérapeutique fiable et sûre, avec un taux de complication faible et 2 cas de récidive (25 %) dans notre étude. Notre étude est la première à rapporter les résultats du traitement chirurgical arthroscopique de la SVNP du coude.
IV. Étude rétrospective sans groupe contrôle.
Needle arthroscopy of the elbow through an anterior transbrachial portal
2023, JSES InternationalCurrent innovation in needle arthroscopy is improving the safety of anterior portals around the elbow. This study evaluated the proximity to the radial nerve, median nerve, and brachial artery on cadaveric specimens of an anterior portal used for elbow arthroscopy.
Ten fresh-frozen adult cadaveric extremities were used. After marking the cutaneous references, the NanoScope cannula was introduced just lateral to the biceps tendon, through the brachialis muscle and the anterior capsule. Elbow arthroscopy was performed. Dissection was then carefully performed on all specimens with the NanoScope cannula in place. The shortest distance from the cannula to the median nerve, radial nerve, and brachial artery was measured with a handheld sliding digital caliper.
The cannula was an average of 12.92 mm away from the radial nerve, 22.27 mm from the median nerve, and 16.8 mm from the brachial artery. Needle arthroscopy performed through this portal allows complete visualization of the anterior compartment of the elbow, as well as direct visualization of the posterolateral compartment.
Needle arthroscopy of the elbow through an anterior transbrachialis portal is safe for the main neurovascular structures. In addition, this technique allows complete visualization of the anterior and posterolateral compartments of the elbow through the humerus-radius-ulna space.
Risk of nerve injury during elbow arthroscopy: ultrasonographic evaluation of preoperative patients
2023, Journal of Shoulder and Elbow SurgeryTo clarify the real risk of nerve injury during elbow arthroscopy, the distances of the radial and median nerves to the elbow joint were investigated using ultrasonography in patients who underwent surgery.
A total of 35 patients who underwent arthroscopic surgery of the elbow were investigated. The distances of the nerves to the capsule and bony landmarks were measured using ultrasonography. The radial nerve distances were measured at the capitellum, joint space, radial head, and radial neck levels. The median nerve distances were measured at the trochlear, joint space, and coronoid process levels. The patients were divided into 2 groups: nine patients in the hydrarthrosis (HA) group and 26 patients in the non-hydrarthrosis (non-HA) group. HA was defined as the intra-articular effusion on magnetic resonance imaging scans.
The radial nerve ran closer to the capsule at the radial neck level in the HA group than in the non-HA group (2.0 mm vs. 5.9 mm, P < .01). In the non-HA group, the radial nerve ran closer to the radial head than in the HA group (6.3 mm vs. 8.5 mm, P = .01). The median nerve ran closer to the capsule at the trochlear level in the HA group than in the non-HA group (5.2 mm vs. 8.8 mm, P < .01). Nerves at a distance of ≤2 mm from the capsule were found in 7 patients at the radial neck of the radial nerve and in 2 patients at the trochlear region of the median nerve in the HA group. In the non-HA group, they were found in 3 patients at the radial head and in 1 patient at the joint space of the radial nerve.
The dangerous locations for nerve injury during elbow arthroscopy vary according to hydrarthrosis, and this risk should be recognized during arthroscopic surgery.
Far Anterior Medial Portals in Complicated Elbow Arthroscopic Procedures: Safety Profile in a Cadaveric Model
2022, Arthroscopy, Sports Medicine, and RehabilitationThe purpose of this study is to describe the placement and evaluate the safety of the far anterior proximal and distal anteromedial portals by comparing them to previously defined portal techniques in a cadaveric model of the elbow.
Six paired (left and right) fresh, frozen cadaveric elbow joints were dissected. .62-mm Kirschner wires were placed at the literature-defined distal and proximal portal sites on right elbows. The proposed “far anterior” distal and proximal portals were established on the matched left elbows. The elbows were dissected to display the median and ulnar nerves. Digital calipers were used to measure distances from wires to nerves.
For the distal portal, the literature-defined portals were a significantly greater distance (P = .014) from the ulnar nerve (31.22 mm) compared to the far anterior portals (24.65 mm). For the proximal portal, the far anterior portals were a significantly greater distance (P = .026) from the ulnar nerve (26.98 mm) than the literature-defined portals (13.75 mm). There was no significant difference between the far anterior and literature-defined proximal and distal portal techniques in relation to the median nerve.
Analysis of elbow arthroscopy anteromedial portal technique shows the far, anterior, proximal, and distal portals are a safe distance from the ulnar and median nerves. A portal modification that may address complicated elbow conditions is a more anterior placement of the medial portals to allow for better visualization and access.
The elbow is a difficult joint in which to perform arthroscopic surgery. One option our institution has used for safe portal modification to address complicated elbow conditions is a further anterior placement of the medial portals to allow better visualization and access.
Patient positioning and portal placement
2022, Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine, Third EditionElbow arthroscopy can be utilized to safely address a variety of pathologic conditions involving the elbow; however, it can be a technically demanding procedure. In order to optimize patient safety and intraoperative execution, careful attention should be paid toward patient positioning and portal placement.
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This study was supported by resources from Orthopaedic Research of Virginia and the Humana Center for Orthopaedics, Richmond, Virginia.