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Duke Orthopaedics

Wheeless' Textbook of Orthopaedics

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Joint Menu:
- 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;
     - instill fluid into the joint thru the aconeus

- Portal Placement:
     - posterolateral portal:
             - portal
is located thru the center of the aconeus
             - 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
             - this
portal allows debridement of the capitellum (in the case of osteochondritis
     - 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
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
             - trocar
w/ it (arthroscopic sheath) is then inserted, followed by the scope;
             - hazards:
nerves at risk w/ this portal include the ulnar
, 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
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
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),
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
procedures, persistent minor contracture of 20° or less after seven, and
twelve transient
palsies (five ulnar palsies, four superficial radial palsies, one posterior interosseous
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
arthritis (p < 0.001) and a contracture (p < 0.05). There were no permanent
neurovascular injuries,
or compartment syndromes in our series, and all of the minor complications, except
for the minor
resolved without sequelae.
     - references:
          - Complications of Elbow
Arthroscopy.  EW. Kelly MD et al.  J Bone Joint Surg [Am] 83-A: 25-34,
          - 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

Avoiding nerve damage during
elbow arthroscopy.

Medial approach in elbow arthroscopy.

Arthroscopy of the elbow.
Diagnostic and therapeutic benefits and hazards.

Neurovascular anatomy and elbow arthroscopy: Inherent risks.  GJ Lynch et
al.  Arthroscopy. Vol 2. 1986. p 190-197.

Arthroscopic surgery of the
elbow. Therapeutic benefits and hazards.

Arthroscopy of the elbow.  SW O'Driscoll and BF Morrey.  JBJS 74-A.
1992. p 84-94.

Arthroscopy of the elbow.  Poehling et al. JBJS. Vol 76-A. No 8. Aug. 1994.
p 1265-1271.

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Original Text by Clifford R. Wheeless, III, MD.