The Safety of Using Proximal Anteromedial Portals in Elbow Arthroscopy With Prior Ulnar Nerve Transposition

Far Anterior Medial Portals in Complicated Elbow Arthroscopic Procedures: Safety Profile in a Cadaveric Model

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.

Arthroscopic management of elbow stiffness

The elbow is particularly prone to stiffness. Loss of elbow motion is very limiting, and can be the result of trauma, primary osteoarthritis, heterotopic ossification and other conditions. Several exposures have been described for open elbow contracture release. Although a few decades ago elbow arthroscopy was considered only for diagnosis and removal of loose bodies, contemporary arthroscopic techniques allow successful management of the majority of conditions leading to elbow stiffness. Careful patient evaluation, use of advanced imaging studies, and acquisition of appropriate surgical skills are essential for the successful arthroscopic management of the stiff elbow. This expert opinion reviews some fundamentals of elbow stiffness as well as principles for the evaluation and arthroscopic management of the stiff elbow.

Preoperative sonographic ulnar nerve mapping in the postoperative elbow

OBJECTIVE

To describe the technique of sonographic ulnar nerve mapping in the postoperative elbow for surgical planning.

MATERIALS AND METHODS

A retrospective review of a surgical databank identified 24 patients, all aged 18 years and older with a history of orthopedic elbow surgery, who were referred for preoperative sonographic mapping of the ulnar nerve prior to subsequent surgery. All cases were reviewed for patient demographics, clinical presentation, prior surgical interventions, and ultrasound technique. Charts were reviewed for intraoperative and postoperative outcomes, including nerve injury.

RESULTS

The cohort included 12 males and 12 females with a mean age of 51 years (range 22-68 years) and a mean BMI of 29 (range 20-48). Preoperative sonographic ulnar nerve mapping occurred following various elbow surgeries including ulnar nerve transposition to assess nerve location prior to subsequent elbow surgery. Of the 24 patients with preoperative sonographic ulnar nerve mapping, subsequent surgery was performed arthroscopically in 14 and open in 10 cases. In 11 of the 24 cases, there was specific mention of a modified approach to joint access which was guided by the ulnar nerve map. There were no perioperative ulnar nerve-related complications, such as nerve transection.

CONCLUSION

Preoperative mapping can facilitate planning of surgical access and ulnar nerve dissection. Sonographic mapping of the ulnar nerve reduces the potential uncertainty of nerve palpation in a complex postoperative elbow following ulnar nerve transposition. This technique may mitigate the risk of ulnar nerve injury.

Arthroscopic localization of the ulnar nerve behind the medial capsule is unreliable

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.

Safety of Arthroscopic Versus Open or Combined Heterotopic Ossification Removal Around the Elbow

PURPOSE

To analyze the complications of arthroscopic heterotopic ossification (HO) excision and compare them with those of open removal of HO or a combined open-arthroscopic approach.

METHODS

We performed a retrospective review of elbow HO removal cases performed by a single surgeon from 1997 to 2014. In all cases studied, the intention was to restore range of motion owing to the presence of HO causing functional impairment. The arthroscopic, open, and combined treatment groups were compared.

RESULTS

The study cohort consisted of 223 surgical procedures performed on 213 elbows in 211 patients. Fifty major complications occurred in 46 cases (21%): 17 hematomas (8%) treated by irrigation and debridement, 8 cases of HO requiring reoperation (4%), 7 deep infections (3%), 4 contractures (2%), 3 cases of delayed-onset ulnar neuritis (1%), 2 cases of distal humeral avascular necrosis (1%), 2 tendon ruptures (1%), 2 cases of instability requiring reconstruction (1%), 2 postoperative fractures (1%), 1 intraoperative fracture (<0.5%), 1 case of worsening of pre-existing neuropathic pain (<0.5%), and 1 permanent partial posterior interosseous nerve injury (<0.5%). Of these 46 cases, the major complications occurred in 6 of the 41 (15%) performed arthroscopically, in 36 of the 158 (23%) performed open and in 4 of the 21 (17%) with combined (i.e. open + arthroscopic) HO removal. Preventive strategies, introduced to prevent hematomas and delayed-onset ulnar neuritis, reduced the rate of major complications from 35% during the period from 1997 to 2005 to 10% during the period from 2006 to 2014 (P < .0001). Moreover, the rate of reoperations was reduced from 34% to 10% in the same periods (P < .0001). Minor complications occurred in 36 cases (16%), including 17 cases of transient nerve palsy, 9 cases of superficial infection or delayed wound healing, 6 cases of mild instability, and 4 cases of hematoma resolved by aspiration.

CONCLUSIONS

The use of arthroscopy-or a combination of arthroscopic and open techniques-to remove HO around the elbow by a surgeon skilled in both arthroscopic and open elbow surgery does not increase the risk of major complications or need for reoperation compared with traditional open surgery. Preventive strategies, such as avoiding raising skin flaps by using multiple separate incisions for open and prophylactic ulnar nerve decompression in arthroscopic cases, were developed during the study period. These strategies were monitored prospectively and found to be effective in preventing two-thirds of the major complications needing reoperation with both open and arthroscopic HO removal.

LEVEL OF EVIDENCE

Level III, retrospective comparative study of prospectively collected data.

Safety of Anteromedial Portals in Elbow Arthroscopy: A Systematic Review of Cadaveric Studies

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.

Locating the ulnar nerve during elbow arthroscopy using palpation is only accurate proximal to the medial epicondyle

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.

Arthroscopic Anterior Elbow Capsular Release Initiated Using Metal Trocar

Elbow stiffness occurs as a consequence of multifactorial etiologies and can be broadly classified into either extra-articular or intra-articular contracture. Although nonoperative treatment regimens may prove successful, recalcitrant cases may require operative management. Both open and arthroscopic procedures to address these contractures have been described. Open techniques have historically been the mainstay of surgical management prior to the advent and advancement of arthroscopy. Although often successful, open elbow contracture release introduces added iatrogenic insult to the soft tissue envelope and has the potential to compromise the intraoperatively obtained gains in motion. Arthroscopic contracture release, although not without its own inherent risks, has been shown to be an effective intervention for the release of elbow capsular contractures. Arthroscopic release of the elbow capsule can be challenging, however, because of its thickness and proximity to vital neurovascular structures. The authors describe an adjunctive technique for effectively and efficiently releasing the anterior and posterior capsule under arthroscopic visualization using a 4.5-mm large metal trocar.