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Elbow Arthroscopy

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Topic updated on 10/26/14 8:11am
Introduction
  • Indications
    • loose body removal post
    • osteophyte debridement
    • synovectomy
    • capsular releases for stiffness
    • osteochondritis dissecans of capitellum
    • lateral epicondylitis
  • Contraindications
    • prior trauma
    • surgical scarring
    • previous ulnar nerve transposition
      • ulnar nerve subluxation is not a contraindication, but it should be identified prior to surgery
  • Advantages
    • improved articular visualization
    • decreased postoperative pain
    • faster postoperative recovery
  • Disadvantages
    • technically demanding
    • high risk of damage to neurovascular structures due to proximity to the joint
Positioning
  • Patient position may be
    • supine  
    • prone  
    • lateral decubitus 
  • Anesthesia
    • general anesthesia (allows muscle relaxation and placement of patient in prone or lateral decubitus position)
    • regional anesthesia may be used but it does not allow for immediate evaluation of nerve function after surgery and patients may not tolerate uncomfortable position
Portals
  • Portal placement technique
    • fully distend joint through lateral soft spot before placing portals
      • capsule distension moves NV structures away from the joint when trocar is introduced
    • careful "nick and spread" technique using hemostat 
    • posterior medial portal usually avoided due to proximity to ulnar nerve  
  • Elbow position
    • establish anterior portals with elbow flexed 90deg
    • establish posterior portals in some extension
  • Summary of portals 
Portal
Location
Use
Nerve at Risk
Proximal anterolateral   2cm proximal, 1cm anterior to lateral epicondyle   Radial n.

 

Distal anterolateral  

1 cm anterior and 1-3cm distal to lateral epicondyle

1st portal for supine position

See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa

Radial and
lateral antebrachial cutaneous
Direct lateral (or midlateral)   

"soft spot" portal (in triangle formed by olecranon, radial head, epicondyle)

Initial site for joint distension before scope is inserted, viewing posterior compartment (capitellum, radial head, radioulnar articulation) relatively safe, lateral antebrachial cutaneous nerve 
Anteromedial   2 cm anterior and 2cm distal to medial epicondyle.  Place under direct visualization. medial antebrachial cutaneous and
median 
Proximal medial (or superomedial)    2cm proximal to medial epicondyle, anterior to intermuscular septum viewing entire anterior compartment, radial head, capitellum, coronoid, trochlea

ulnar and median 

Straight posterior (transtriceps)   3cm proximal to olecranon, triceps midline (musculotend. junction) Elbow partially extended, good for removing impinging olecranon osteophytes and loose bodies from posteromedial compartment

posterior antebrachial cutaneous 

ulnar nerve

Posterolateral  

2-3 cm proximal to olecranon and just lateral to triceps

center of anconeus triangle

Elbow 20-30deg flexion (to relax triceps)

Best access to posterior compartment, radiocapitellar joint (debridement of OCD capitellum), olecranon fossa and posterior structures

posterior antebrachial cutaneous  

medial brachial cutaneous  

ulnar 


Complications
  • Nerve palsy (1-5%)
    • greatest risks for nerve palsy
      • underlying rheumatoid arthritis
      • elbow contracture
    • nerves
      • transient ulnar nerve palsy (most common)  
      • radial nerve palsy (second most common)
    • mechanism
      • direct injury
        • trocars and instrumentation
        • failure to use blunt dissection (neuromas)
      • indirect injury
        • compartment syndrome (aggressive distension, fluid extravasation)
        • local anesthesia extravasation (transient)
  • Joint ankylosis/ heterotopic ossification
    • less than open surgery
    • minimize bleeding
  • Infection
    • sinus tract formation (posterolateral portal)

 

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Qbank (1 Questions)

TAG
(OBQ08.271) Which of the following portals is generally not used during elbow arthroscopy? Topic Review Topic

1. Antero-lateral
2. Antero-medial
3. Postero-lateral
4. Postero-medial
5. Direct posterior

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