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textarea name="textfield222" cols="100" rows="50" class="bodycopy"> Equipement: br/>
- 30 deg, 4 mm arthroscope; br/>
- arthroscopic pump; br/>
br/>
b>- Positioning: /b>br/>
- patient is usually prone with sandbag placed under
antecubital fossa; br/>
- TV monitor is positioned opposite of the patient; br/>
- instill fluid into the joint thru the a href="http://www.wheelessonline.com/o6/88.htm">aconeus
triangle /a>; br/>
br/>
b>- Portal Placement: /b>br/>
- b>posterolateral portal: /b>br/>
- portal
is located thru the center of the a href="http://www.wheelessonline.com/o6/88.htm">aconeus
triangle /a>; br/>
- when
the anterior aspect of the joint is being visualized, the posterolateral
portal can be used as an outflow portal; br/>
- posterolateral
portal can be used to visualize the posterior elbow structures including
the olecranon fossa; br/>
-
use of a 70 deg arthroscope facilitates visualization of the radiocapitellar
joint; br/>
- this
portal allows debridement of the capitellum (in the case of a href="http://www.wheelessonline.com/o2/1700.HTM">osteochondritis
dissecans /a>); br/>
- b>anterosuperior lateral: /b>br/>
- considered
safer than anterolateral portal; br/>
- portal
allows visualization of the ulnohumeral articulation, anteromedial aspect
of elbow, coronoid fossa and process, and anterior aspect of radiocapitellar
joint; br/>
- portal
is placed 2 cm superior to the anterior aspect of lateral epicondyle; br/>
- blunt
dissection into the joint capsule helps to avoid injury. br/>
- b>cautions: /b>br/>
-
PIN is most at risk, (less than the anterolateral portal) and lateral antebrachial
cutaneous nerves are at risk; br/>
- b>anterolateral portal: /b>br/>
- this
portal can be used for instrumentation as well as visualization of the lateral
aspect of the radial head; br/>
- this
portal is often established first; br/>
- w/
elbow flexed 90 deg, the portal is located 3 cm distal and 1-2 cm anterior
to the lateral epicondyle, which should bring br/>
portal
just anterior and proximal to the radial-capitellar articulation w/ the portal
driven toward the center of the trochlea; br/>
-
elbow is kept flexed during trochar insertion since extension brings the
radial nerve closer to the joint (3 to 7 mm); br/>
- b>hazards: /b>br/>
-
the portal pass thru the ECRB and supinator; br/>
- a href="http://www.wheelessonline.com/05/37.htm">posterior
interosseous nerve /a> is at risk w/ this portal, as it runs about 0.5 cm to
1 cm anterior and medial to the portal; br/>
-
inorder to protect the PIN, this portal is made from inside outward under
visualization from the proximal-medial portal; br/>
-
the scope is advanced anterolaterally arcross the radial head w/ care not
to deviate too anteriorly; br/>
-
the light of the arthroscope will be visible thru the skin which will facilitate
proper skin incision; br/>
- b>proximal anterolateral portal: /b>br/>
- located
2 cm proximal and 1 cm anterior to the lateral epicondyle; br/>
- this
portal is significantly farther (on average 13.7 mm) from the radial nerve
than other anterolateral portal sites; br/>
- this
portal allows for an excellent view of the anterior radiohumeral and ulnohumeral
joints as well as the anterior capsular margin. br/>
- b>proximal antero-medial portal: /b>br/>
- allows
visualization of the following: br/>
-
anterior elbow including the anterior joint capsule, medial condyle, coronoid
process, trochlea, capitellum, and the radial head; br/>
-
radial head is best visualized from the proximal anteromedial portal br/>
- joint
should already be distened w/ fluid; br/>
- location
is 2 cm proximal to medial epicondyle, and immediately anterior to the inter-muscular
septum, using a longitudinal skin stab incision; br/>
- ensure
that the position of the intermusuclar septum is clearly demarcated; br/>
- make
1/2 cm incision and spread w/ hemostat; br/>
- trochar
is inserted over the anterior surface of the humerus aiming for the radial
head; br/>
- maintain
contact w/ anterior humerus at all times to reduce risk to N/V structures
is minimized. br/>
- trocar
w/ it (arthroscopic sheath) is then inserted, followed by the scope; br/>
- hazards: br/>
-
nerves at risk w/ this portal include the a href="http://www.wheelessonline.com/05/47.htm">ulnar
nerve /a>, medial brachial cutaneous, a href="http://www.wheelessonline.com/05/51.htm">medial
antebrachial cutaneous /a>, median nerve, and brachial artery; br/>
-
ulnar nerve lies 4 mm from this portal site; br/>
-
median nerve lies 7-20 mm away from portal with the elbow in flexion; br/>
- b>anteromedial portal: /b>br/>
- some
surgeons prefer to establish this portal first; br/>
- elbow
should be flexed 90 deg as the portal is established; br/>
- placed
2 cm anterior and 2 cm distal to the medial epicondyle, placed under direct
vision; br/>
- the a href="http://www.wheelessonline.com/05/38.htm">median
nerve /a> lies 1 to 2 cm anterior and lateral to this portal; br/>
br/>
br/>
b>- Complications: /b>br/>
- nerve damage: br/>
- be particularly
careful in elbow that have altered anatomy or scarring (as from intra-articular
fracture); br/>
-
this situation may distort normal landmarks, decrease arthroscopic distension,
and cause nerves to remain adherent to capsule; br/>
- 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; br/>
- of the 473 cases,
414 were followed for more than six weeks; br/>
- most common final
diagnoses were osteoarthritis (150 cases), loose bodies (112), and RA or
inflammatory arthritis (seventy-five); br/>
- arthroscopic procedures
included synovectomy (184), débridement of joint surfaces or adhesions
(180), excision of osteophytes (164), br/>
diagnostic
arthroscopy (154), loose-body removal (144), and capsular procedures such
as capsular release, capsulotomy, and capsulectomy (73). br/>
- a serious complication
(a joint space infection) occurred after four (0.8%) of the arthroscopic
procedures; br/>
- minor complications
occurred after fifty (11%) of the arthroscopic procedures; br/>
-
these complications included prolonged drainage from or superficial infection
at a portal site after br/>
33
procedures, persistent minor contracture of 20° or less after seven,
and twelve transient br/>
nerve
palsies (five ulnar palsies, four superficial radial palsies, one posterior
interosseous br/>
palsy,
one medial antebrachial cutaneous palsy, and one anterior interosseous palsy)
in ten patients; br/>
-
most significant risk factors for the development of a temporary nerve palsy
were an underlying diagnosis of br/>
rheumatoid
arthritis (p < 0.001) and a contracture (p < 0.05). There were no permanent
neurovascular injuries, br/>
hematomas,
or compartment syndromes in our series, and all of the minor complications,
except for the minor br/>
contractures,
resolved without sequelae. br/>
- references: br/>
- Complications of Elbow
Arthroscopy. EW. Kelly MD et al. J Bone Joint Surg [Am] 83-A:
25-34, 2001 br/>
- 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 br/>
br/>
a href="http://www.wheelessonline.com/j7/14.htm">Avoiding nerve damage during
elbow arthroscopy. /a>br/>
br/>
a href="http://www.wheelessonline.com/j2/190.htm">Medial approach in elbow arthroscopy. /a>br/>
br/>
a href="http://www.wheelessonline.com/l7/382.htm">Arthroscopy of the elbow.
Diagnostic and therapeutic benefits and hazards. /a>br/>
br/>
Neurovascular anatomy and elbow arthroscopy: Inherent risks. GJ Lynch et
al. Arthroscopy. Vol 2. 1986. p 190-197. br/>
br/>
a href="http://www.wheelessonline.com/t4/142.htm">Arthroscopic surgery of the
elbow. Therapeutic benefits and hazards. /a>br/>
br/>
Arthroscopy of the elbow. SW O'Driscoll and BF Morrey. JBJS 74-A.
1992. p 84-94. br/>
br/>
Arthroscopy of the elbow. Poehling et al. JBJS. Vol 76-A. No 8. Aug.
1994. p 1265-1271. /textarea>
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