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de Klerk HH, Verweij LPE, Sierevelt IN, Priester-Vink S, Hilgersom NFJ, Eygendaal D, van den Bekerom MPJ. Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review. Arthroscopy 2023; 39:2363-2387. [PMID: 37146664 DOI: 10.1016/j.arthro.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE To perform a systematic review of complications associated with elbow arthroscopy in adults and children. METHODS A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool. RESULT A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication. CONCLUSIONS Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates. LEVEL OF EVIDENCE Level IV; systematic review of Level I-IV studies.
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Affiliation(s)
- Huub H de Klerk
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.; Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, the Netherlands.
| | - Lukas P E Verweij
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam UMC, Amsterdam, the Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - Inger N Sierevelt
- Specialized Centre for Orthopedic Research and Education (SCORE), Xpert Clinics, Orthopedic Department, Amsterdam, the Netherlands; Department of Orthopaedics, Spaarne Gasthuis Academie, Hoofddorp, the Netherlands
| | - Simone Priester-Vink
- Medical Library, Department of Research and Epidemiology, OLVG, Amsterdam, the Netherlands
| | - Nick F J Hilgersom
- Department of Orthopaedic Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
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2
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Ge X, Ge X, Wang C, Liu Q, Wang B, Chen L, Cheng K, Qin M. Application of ultrasound in avoiding radial nerve injury during elbow arthroscopy: a retrospective follow-up study. BMC Musculoskelet Disord 2022; 23:1126. [PMID: 36566206 PMCID: PMC9789568 DOI: 10.1186/s12891-022-06109-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/21/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A safe and effective technique for anterolateral portal placement in elbow arthroscopy is significant. We compared the outcomes of patients who underwent elbow arthroscopy using different ultrasound-assisted techniques. METHODS From May 2016 to June 2021 a retrospective analysis on all patients who underwent elbow arthroscopy in our department was performed. Patients were separated into three groups: non-ultrasound; preoperative ultrasound; and intraoperative ultrasound. The minimum follow-up period was 1 year. Nerve injuries, visual analog scale (VAS), Mayo elbow-performance score (MEPS), Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), and range of motion (ROM) of the elbow were evaluated for comparison among the three groups pre- and post-operatively. RESULTS All 55 patients completed a 1-year follow-up: non-ultrasound (n = 20); preoperative ultrasound (n = 17); and intraoperative ultrasound (n = 18). There were 3 cases (15.0%) of transient radial nerve palsy in the non-ultrasound group. No nerve complications occurred in preoperative ultrasound and intraoperative ultrasound groups. The probability of postoperative radial nerve injury in the three groups was statistically different (P < 0.05). There was no significant difference in the VAS score, MEPS, DASH score, and ROM among the three groups at the follow-up evaluation (P > 0.05). CONCLUSION Performing anterolateral portal placement during elbow arthroscopy with ultrasound-assisted techniques successfully avoided radial nerve injury.
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Affiliation(s)
- Xingtao Ge
- grid.452710.5Department of Orthopedics, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Xinghua Ge
- grid.452710.5Department of Neurosurgery, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Chen Wang
- grid.452710.5Department of Orthopedics, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Qinghua Liu
- grid.452710.5Department of Ultrasonography, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Bin Wang
- grid.452710.5Department of Orthopedics, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Longgang Chen
- grid.452710.5Department of Orthopedics, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Kai Cheng
- grid.452710.5Department of Orthopedics, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
| | - Ming Qin
- grid.452710.5Department of Orthopedics, Rizhao People’s Hospital, 276800 Rizhao, Shandong P.R. China
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Papen A, Schöttker-Königer T, Schäfer A, Morrison F, Hollinger B, Burkhart KJ, Nietschke R, Zimmerer A, Maffulli N, Migliorini F, Schneider MM. Reliability, validity and critical appraisal of the cross-cultural adapted German version of the Mayo Elbow Performance Score (MEPS-G). J Orthop Surg Res 2022; 17:328. [PMID: 35752835 PMCID: PMC9233775 DOI: 10.1186/s13018-022-03210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background The Mayo Elbow Performance Score (MEPS) is a rating system consisting of four dimensions to evaluate elbow performance. It is a common tool for assessment of elbow impairments worldwide. We determined the validity and reliability of its German version (MEPS-G) after cross-cultural adaptation.
Methods Six investigators examined 57 patients with elbow pathologies. The MEPS-G was compared to validated elbow scores such as the German versions of DASH, the Oxford Elbow Score, pain level and subjective elbow performance on a VAS. Inter-rater reliability (IRR) and validity of the score and its dimensions were also reviewed. Verification was performed using the intraclass correlation coefficient (ICC), the prevalence and bias with adjusted Kappa (PABAK) and the Spearman correlation.
Results The IRR of the MEPS-G score was moderate (ICC (2.1) = 0.65). The IRR of the four individual dimensions was moderate to high (KPABAK = 0.55 -0.81). Validity for the sum score (r = 0.52–0.65) and the dimensions pain (r = 0.53–0.62), range of motion (r = 0.7) and stability (r = − 0.61) was verified. The function subscale reached insufficient validity (r = 0.15–0.39). Conclusion The MEPS-G is not sufficiently valid, which is consistent with its English version. The patient-based dimensions were a weakness, demonstrating high risk of bias. There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies.
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Affiliation(s)
- A Papen
- Faculty of Social Work and Health, University of Applied Science and Art (HAWK), Hildesheim, Germany
| | - T Schöttker-Königer
- Faculty of Social Work and Health, University of Applied Science and Art (HAWK), Hildesheim, Germany
| | - A Schäfer
- Faculty of Social Work and Health, University of Applied Science and Art (HAWK), Hildesheim, Germany
| | - F Morrison
- German Association for Manual Therapy (DVMT e.V.), Dresden, Germany
| | - B Hollinger
- Centre for Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - K J Burkhart
- Arcus Sportklinik, Pforzheim, Germany.,University of Cologne, Cologne, Germany
| | | | | | - N Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, UK.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - F Migliorini
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Marco M Schneider
- Arcus Sportklinik, Pforzheim, Germany. .,University of Witten/Herdecke, Witten, Germany.
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McCluskey LC, Cushing TJ, Weldy JM, Kale NN, Savoie FH, Medvedev G. Far Anterior Medial Portals in Complicated Elbow Arthroscopic Procedures: Safety Profile in a Cadaveric Model. Arthrosc Sports Med Rehabil 2022; 4:e503-e510. [PMID: 35494259 PMCID: PMC9042752 DOI: 10.1016/j.asmr.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/11/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose The 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. Methods 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. Results 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. Conclusions 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. Clinical Relevance 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.
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Tsenkov T, Dimitrov N. A systematic review of elbow arthroscopy complications : Complications, risk factors, and safety tips. INTERNATIONAL ORTHOPAEDICS 2022; 46:1073-1083. [PMID: 35106672 DOI: 10.1007/s00264-022-05320-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/23/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the complications from elbow arthroscopy for the past 16 years, and to summarize the most reported safety techniques and risk factors. METHODS Eligibility criteria included level I to IV evidence articles that were published after 2005 in the English language. Excluded were vet, paediatric, and cadaver studies. Open and arthroscopic-assisted elbow procedures were not included. Two online databases were comprehensively searched (PubMed and PMC) in April 2021. Relevant paper selection was conducted by two independent reviewers. MINORS score, demographic properties, indications, procedure type, complication rates, reoperation rates, reported risk factors, and safety techniques were recorded. RESULTS Fifty-two articles met the criteria and were included. No relevant level I to II evidence studies were discovered. The mean age ranged from 31 to 65 years. The average body mass indexes were between 26 and over 40 kg/m2. There was a prevalence of male sex (from 50.2 to 79.2%). Most of the studies reported a minimum follow-up (range, 4 weeks-12 months). The most common arthroscopic procedure was debridement (up to 73% in Leong et al.'s study). The average MINORS score was 12 (range, 10-16). The total complications rate ranged from 1.5 to 11%, with a few studies reporting over 25%. Nerve injury rate was 1.26-7.5%. Re-operation rate ranged from none (100 procedures) to 11.8%. CONCLUSIONS Elbow arthroscopy is a successful procedure with a low overall complications rate (from 1.5 to 11%), and a low nerve injury rate (from 1.26 to 7.5%). Risk factors include patient-related factors (obesity, female sex, age over 65 years, elevated blood sugar levels, hypercoagulable disorder, tobacco and alcohol use), preoperative elbow impairment/previous surgery, and periprocedural steroid injections. Our review discovered a re-operation rate of 2 to 18%.
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Affiliation(s)
- Tsvetan Tsenkov
- University Hospital of Orthopaedics "Prof. B. Boichev", Medical University of Sofia, 56 Nikola Petkov Blvd., Sofia, 1614, Bulgaria.
| | - Nikolay Dimitrov
- University Hospital of Orthopaedics "Prof. B. Boichev", Medical University of Sofia, 56 Nikola Petkov Blvd., Sofia, 1614, Bulgaria
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6
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Hilgersom NFJ, Viveen J, Tuijthof GJM, Bleys RLAW, van den Bekerom MPJ, Eygendaal D. Arthroscopic localization of the ulnar nerve behind the medial capsule is unreliable. JSES Int 2020; 4:1031-1036. [PMID: 33345253 PMCID: PMC7738441 DOI: 10.1016/j.jseint.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose Ulnar nerve injury is the most common neurologic complication of elbow arthroscopy. The purpose of this cadaveric study was to quantify the ability of surgeons to locate the ulnar nerve behind the posteromedial capsule during elbow arthroscopy using sole arthroscopic vision. Methods Twenty-one surgeons were asked to pin the ulnar nerve at the medial gutter and the posteromedial compartment using arthroscopic visualization of the medial capsule only. Pinning of the ulnar nerve was performed from extra-articular. Then, the cadaveric specimens were dissected and the shortest distances between the pins and ulnar nerve measured. Results Median pin-to-nerve distances at the medial gutter and posteromedial compartment were 0 mm (interquartile range [IQR], 0-3 mm) and 2 mm (IQR, 0-6 mm), respectively. The ulnar nerve was pinned by 11/21 surgeons (52%) at the medial gutter, and 7/21 surgeons (33%) at the posteromedial compartment. Three of 21 surgeons (14%) pinned the ulnar nerve at both the medial gutter and the posteromedial compartment. Surgeon's experience and operation volume did not affect these outcomes (P > .05). Conclusions Surgeons' ability to locate the ulnar nerve behind the posteromedial capsule using sole arthroscopic visualization, without external palpation, is poor. We recommend to proceed carefully when performing arthroscopic procedures in the posteromedial elbow, and identify and mobilize the ulnar nerve prior to any posteromedial capsular procedures.
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Affiliation(s)
- Nick F J Hilgersom
- Department of Orthopaedic Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - Jetske Viveen
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gabriëlle J M Tuijthof
- Department of Orthopaedic Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands.,Department of Instrument Development, Engineering and Evaluation, Maastricht University, Maastricht, the Netherlands
| | - Ronald L A W Bleys
- Department of Anatomy, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Denise Eygendaal
- Department of Orthopaedic Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands.,Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
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Complications of Elbow Arthroscopy in a Community-Based Practice. Arthroscopy 2020; 36:1283-1290. [PMID: 31785392 DOI: 10.1016/j.arthro.2019.11.108] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 10/31/2019] [Accepted: 11/16/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to report the complications of elbow arthroscopy in a large community practice with multiple surgeons and to analyze potential risk factors for these complications. METHODS Patient demographic information, surgical variables, surgeon variables, and complications were retrospectively reviewed for all elbow arthroscopies performed within the health network from 2006 to 2014. Inclusion criteria included patients of any age undergoing a primary and revision elbow arthroscopy, which may have been performed in conjunction with other procedures. Exclusion criteria included incorrectly coded procedures where arthroscopy was not performed and no postoperative follow-up. Statistical calculations were performed using a binary logistic regression analysis to fit a logistic regression model. RESULTS 560 consecutive elbow arthroscopies in 528 patients performed between 2006 and 2014, by 42 surgeons at 14 facilities, were reviewed. 113 procedures were performed in pediatric patients under the age of 18. The average age was 38.6 years (range: 5-88). There were 444 males. The average length of follow-up was 375.8 days (2 to 2,739 days). Overall, heterotopic ossification occurred in 14 of 560 cases (2.5%) (all males), and 20 of 560 (3.5%) cases developed transient nerve palsies (8 ulnar, 8 radial, 1 median, 3 medial antebrachial cutaneous). There were 3 (0.5%) deep and 11 (2%) superficial infections. There were no vascular injuries, compartment syndrome, deep vein thrombosis, or pulmonary embolism. Elevated blood sugar was a significantly higher risk for infection (odds ratio [OR] 4.11, 95% confidence interval [CI] 1.337 to 12.645; P = .0136). Previous elbow surgery (OR 3.57, 95% CI 1.440 to 8.938; P = .006) and female sex (OR 4.05; 95% CI 1.642 to 9.970; P = .002) had a significantly higher risk for nerve injury. Relative to pediatric patients, there were higher odds in adults for nerve injury, infection, and heterotopic ossification, but none reached significance. CONCLUSIONS Elbow arthroscopy is a safe procedure with low complication rates. Diabetes is a risk factor for infection. Prior surgery and female sex are risk factors for nerve injury. LEVEL OF EVIDENCE Case series, level 4.
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Cushing T, Finley Z, O’Brien MJ, Savoie FH, Myers L, Medvedev G. Safety of Anteromedial Portals in Elbow Arthroscopy: A Systematic Review of Cadaveric Studies. Arthroscopy 2019; 35:2164-2172. [PMID: 31272638 PMCID: PMC6774249 DOI: 10.1016/j.arthro.2019.02.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 02/20/2019] [Accepted: 02/24/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review available literature comparing location and safety of 2 common anteromedial portals with nearby neurovascular structures in cadaveric models and to determine the correct positioning and preparation of the joint before elbow arthroscopy. METHODS The review was devised in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of original, cadaveric studies performed by experienced surgeons on male or female elbows evaluating anteromedial portal placement with regard to proximity of the arthroscope to neurovascular structures. Exclusion criteria consisted of case reports, clinical series, non-English language studies, and noncadaveric studies. Statistical analysis was done to measure reviewer reliability after scoring of each study. RESULTS During screening, 2,596 studies were identified, and 10 studies met final inclusion as original, cadaveric investigations of anteromedial portal proximity to neurovascular structures. The difference in distance between proximal and distal portals was <1 mm for the brachial artery and <1.5 mm for the medial antebrachial cutaneous nerve, whereas the ulnar nerve was 4.17 mm further from the distal portal and the median nerve was 5.07 mm further from the proximal portal. Joint distension increased the distances of neurovascular structures to portal sites, with the exception of the ulnar nerve in distal portals. Elbow flexion to 90° increased distances of all neurovascular structures to portal sites. CONCLUSION The results show that the proximal anteromedial portal puts fewer structures at risk compared with the distal portal. Elbows in 90° flexion with joint distension carry a lower risk for neurovascular injury during portal placement. These findings suggest the proximal anteromedial portal to be the safer technique in anteromedial arthroscopy of the elbow. CLINICAL RELEVANCE Discrepancies in placement of portals have existed in the literature, indicating differing safety margins regarding surrounding neurovascular anatomy. The present study aims to link together the literature-based evidence to describe the safest anteromedial portal variation.
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Affiliation(s)
- Tucker Cushing
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Zachary Finley
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Michael J. O’Brien
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Felix H. Savoie
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Leann Myers
- Dept. Global Biostatistics and Data Science, Tulane School of Public Health & Tropical Medicine, New Orleans, LA, 70112
| | - Gleb Medvedev
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
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Arrigoni P, Cucchi D, Menon A, Guerra E, Nicoletti S, Colozza A, Luceri F, Pederzini LA, Randelli PS. The posterior interosseous nerve crosses the radial head midline and increases its distance from bony structures with supination of the forearm. J Shoulder Elbow Surg 2019; 28:365-370. [PMID: 30392934 DOI: 10.1016/j.jse.2018.08.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study investigated whether forearm movements change the relative position of the posterior interosseous nerve (PIN) with respect to the midline of the radial head (Rh) under direct arthroscopic observation. METHODS The PIN was identified in 10 fresh frozen cadaveric specimens dissected under arthroscopy. The forearm was moved first in full pronation and then in full supination, and the displacement of the PIN from medial to lateral with respect to the midline of the Rh was recorded. The shortest linear distance between the nerve and the most anterior part of the Rh was measured with a graduated calliper inserted via the midlateral portal with the forearm in neutral position, full pronation, and full supination. RESULTS The PIN was identifiable in all specimens. In all cases the PIN crossed the Rh midline with forearm movements, moving from medial in full pronation to lateral in full supination. The distance between the PIN and Rh is significantly greater in supination than in the neutral position and pronation (P = .0001). CONCLUSIONS This study confirms that the PIN movement described in open surgery (medialization with pronation) also occurs during arthroscopy. The role of pronation in protecting the PIN in extra-articularprocedures is therefore confirmed. Supination, however, increases the linear distance between the PIN and Rh and should therefore be considered to increase the safe working volume whenever intra-articular procedures are performed on the anterolateral aspect of the elbow.
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Affiliation(s)
- Paolo Arrigoni
- U.O. Clinica Ortopedica e Traumatologica Universitaria CTO, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy; Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Davide Cucchi
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy; Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Bonn, Germany.
| | - Alessandra Menon
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy; I Clinica Ortopedica, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Enrico Guerra
- Shoulder and Elbow Unit, Ortopedico Rizzoli, Bologna, Italy
| | - Simone Nicoletti
- S.O.C. Ortopedia e Traumatologia, Ospedale San Jacopo, Pistoia, Italy
| | - Alessandra Colozza
- Unità Operativa Ortopedia e Traumatologia, Ospedale Civile di Faenza, Faenza, Italy
| | - Francesco Luceri
- U.O. Clinica Ortopedica e Traumatologica Universitaria CTO, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy; Università degli Studi di Milano, Milan, Italy
| | | | - Pietro Simone Randelli
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy; I Clinica Ortopedica, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
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10
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Thaveepunsan S, Shields MN, O'Driscoll SW. The Needle-and-Knife Technique: A Safe Technique for Anterolateral Portal Placement in Elbow Arthroscopy. Orthop J Sports Med 2019; 7:2325967118817232. [PMID: 30729140 PMCID: PMC6350134 DOI: 10.1177/2325967118817232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Safe and effective portal placement is crucial for successful elbow
arthroscopy. Various techniques for anterolateral portal placement in elbow
arthroscopy have been described, yet radial nerve injuries are commonly
reported. Purpose: To report on the technique and safety of anterolateral portal placement by
the needle-and-knife method and its clinical applications. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was completed of patients who underwent an
arthroscopic procedure in the anterior compartment of the elbow and
anterolateral portal placement. Patients were evaluated immediately
postoperatively and at subsequent visits and were monitored for signs of
radial nerve injury. Results: A total of 460 patients met the inclusion criteria, of which 309 (67%)
underwent the needle-and-knife technique. There was 1 case (0.3%) of
temporary radial nerve palsy. For the remaining 151 patients who underwent
anterolateral portal placement by other techniques, there were 2 cases of
temporary radial nerve palsy (1.3%). There were no cases of the
needle-and-knife technique being unsuccessful or abandoned in lieu of a
different technique. Use of the needle-and-knife technique increased over
time with experience and practice. Initially, contraindications to this
technique included impaired view of the lateral side of the anterior
compartment of the elbow caused by severe intra-articular scar (65%),
extensive synovitis (10%), or large osteophytes or loose bodies (10%). For
the remaining patients (15%) who did not have portals placed via the
needle-and-knife technique, alternate techniques were used for teaching
purposes. Conclusion: The needle-and-knife technique is reproducible and easy to perform by a
clinician instructed in its use and trained in elbow arthroscopy. Its main
advantage is that it permits the surgeon to safely slide the knife along the
lateral supracondylar ridge, releasing the scarred capsule and thereby
increasing the available space in which to work. Enlarging the working space
inside scarred and contracted elbows cannot be accomplished by distending
the capsule.
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Affiliation(s)
- Sutee Thaveepunsan
- Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Maegan N Shields
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shawn W O'Driscoll
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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11
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Hilgersom NFJ, Cucchi D, Luceri F, van den Bekerom MPJ, Oh LS, Arrigoni P, Eygendaal D. Locating the ulnar nerve during elbow arthroscopy using palpation is only accurate proximal to the medial epicondyle. Knee Surg Sports Traumatol Arthrosc 2019; 27:3254-3260. [PMID: 30141147 PMCID: PMC6754351 DOI: 10.1007/s00167-018-5108-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/13/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Knowledge of ulnar nerve position is of utmost importance to avoid iatrogenic injury in elbow arthroscopy. The aim of this study was to determine how accurate surgeons are in locating the ulnar nerve after fluid extravasation has already occurred, and basing their localization solely on palpation of anatomical landmarks. METHODS Seven cadaveric elbows were used and seven experienced surgeons in elbow arthroscopy participated. An arthroscopic setting was simulated and fluids were pumped into the joint from the posterior compartment for 15 min. For each cadaveric elbow, one surgeon was asked to locate the ulnar nerve solely by palpation of the anatomical landmarks, and subsequently pin the ulnar nerve at two positions: within 5 cm proximal and another within 5 cm distal of a line connecting the medial epicondyle and the tip of the olecranon. Subsequently, the elbows were dissected using a standard medial elbow approach and the distances between the pins and ulnar nerve were measured. RESULTS The median distance between the ulnar nerve and the proximal pins was 0 mm (range 0-0 mm), and between the ulnar nerve and the distal pins was 2 mm (range 0-10 mm), showing a statistically significant difference (p = 0.009). All seven proximally placed pins (100%) transfixed the ulnar nerve versus two out of seven distally placed pins (29%) (p = 0.021). CONCLUSIONS In a setting simulating an already initiated arthroscopic procedure, the sole palpation of the anatomical landmarks allows experienced elbow surgeons to accurately locate the ulnar nerve only in its course proximal to the medial epicondyle (7/7, 100%), whereas a significantly reduced accuracy is documented when the same surgeons attempt to locate the nerve distal to the medial epicondyle (2/7, 29%; p = 0.021). Current findings support the establishment of a proximal anteromedial portal over a distal anteromedial portal to access the anterior compartment after tissue extravasation has occurred with regard to ulnar nerve safety.
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Affiliation(s)
- Nick F J Hilgersom
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, 1105 AZ, Amsterdam, The Netherlands.
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA.
| | - Davide Cucchi
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Sigmund-Freud Str. 125, 53127, Bonn, Germany
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Francesco Luceri
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Sigmund-Freud Str. 125, 53127, Bonn, Germany
- Clinica Ortopedica CTO, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
| | | | - Luke S Oh
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA
| | - Paolo Arrigoni
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Sigmund-Freud Str. 125, 53127, Bonn, Germany
- Clinica Ortopedica CTO, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, 1105 AZ, Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, Amphia Hospital, 4819 EV, Breda, the Netherlands
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