Tips to avoid nerve injury in elbow arthroscopy

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

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.

Arthroscopic-Assisted Fracture Fixation About the Elbow

Arthroscopic-assisted fracture fixation can be used for some adult elbow fractures. In particular, for articular fractures of the anterior elbow (coronoid/capitellum), elbow arthroscopy can provide excellent visualization of fracture fragments using a less invasive surgical exposure. Meticulous adherence to safe techniques and utilization of specialized equipment can help maximize safety and facilitate reproducible surgical results.

Management of the stiff elbow: a literature review

The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient's activities of daily living. Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness. In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended. Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications. Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months. This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.

Risk of nerve injury during elbow arthroscopy: ultrasonographic evaluation of preoperative patients

BACKGROUND

To clarify the real risk of nerve injury during elbow arthroscopy, the distances of the radial and median nerves to the elbow joint were investigated using ultrasonography in patients who underwent surgery.

METHODS

A total of 35 patients who underwent arthroscopic surgery of the elbow were investigated. The distances of the nerves to the capsule and bony landmarks were measured using ultrasonography. The radial nerve distances were measured at the capitellum, joint space, radial head, and radial neck levels. The median nerve distances were measured at the trochlear, joint space, and coronoid process levels. The patients were divided into 2 groups: nine patients in the hydrarthrosis (HA) group and 26 patients in the non-hydrarthrosis (non-HA) group. HA was defined as the intra-articular effusion on magnetic resonance imaging scans.

RESULTS

The radial nerve ran closer to the capsule at the radial neck level in the HA group than in the non-HA group (2.0 mm vs. 5.9 mm, P < .01). In the non-HA group, the radial nerve ran closer to the radial head than in the HA group (6.3 mm vs. 8.5 mm, P = .01). The median nerve ran closer to the capsule at the trochlear level in the HA group than in the non-HA group (5.2 mm vs. 8.8 mm, P < .01). Nerves at a distance of ≤2 mm from the capsule were found in 7 patients at the radial neck of the radial nerve and in 2 patients at the trochlear region of the median nerve in the HA group. In the non-HA group, they were found in 3 patients at the radial head and in 1 patient at the joint space of the radial nerve.

CONCLUSIONS

The dangerous locations for nerve injury during elbow arthroscopy vary according to hydrarthrosis, and this risk should be recognized during arthroscopic surgery.

Have Elbow Arthroscopy Hospitalizations Decreased over the Years? An Epidemiological Italian Study from 2001 to 2016

This study describes the trends of elbow arthroscopy in Italy and other countries in order to evaluate the yearly rates of EA. Its purpose is for future epidemiological studies to be able to compare their data between countries in order to understand the reasons for the increasing and decreasing trends. Data for this study were obtained from National Hospital Discharge records (SDO) at the Italian Ministry of Health (INHS). Data regarding sex, age, region of residence, region of surgery, length of hospitalization, and procedure codes were included. In total, 2414 elbow arthroscopies were performed in Italy from 2001 to 2016 in the adult population. The highest number of procedures was found in the 40-44 and 45-49 years age groups. Males represented the majority of patients undergoing EA both in total and over the years. An increase from 2001 to 2010 and a decrease from 2010 to 2016 were reported in the present analysis. According to other studies, males of 40-44 and 45-49 years age groups represent the most treated patients. Further epidemiological studies would provide data that could be compared between countries, reaching a general consensus on the best indications for this procedure.

Complications in Elbow Arthroscopy: Management and Prevention

With advances in the understanding of elbow anatomy, pathologies of the elbow, arthroscopic instrumentation, and surgical techniques over recent decades, elbow arthroscopy has become a valuable treatment modality for a variety of conditions. Elbow arthroscopy has gained utility for treating problems such as septic arthritis, osteoarthritis, synovitis, osteophyte and loose body excision, contracture release, osteochondral defects, select fractures, instability, and lateral epicondylitis. Accordingly, precise knowledge of the neurovascular anatomy, safe arthroscopic portal placement, indications, and potential complications are required to maximize patient outcomes and assist in educating patients. This comprehensive review provides the reader an understanding of the potential complications associated with arthroscopic procedures of the elbow and to describe strategies for prevention and management.

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.

Elbow arthroscopy - Indications and technique

Throughout the years, elbow arthroscopy has advanced tremendously due to improvements in technology and surgical techniques. It is now considered a safe and effective treatment for a variety of elbow disorders. Due to the small working space and nearby neurovascular structures, it is a technically challenging procedure. It can be used to successfully treat complaints caused by loose bodies, osteoarthritis, arthrofibrosis, OCD, lateral epicondylitis, VEOS and fractures. The most devastating complication of elbow arthroscopy is (permanent) nerve injury. Therefore, distortion of the anatomy of the elbow joint and transposition of the ulnar nerve can be a contra-indication for elbow arthroscopy due to the higher risk of postoperative complications. The results of the arthroscopy depend on the experience, knowledge, technique and expertise of the performing surgeon.

Diagnostic and Therapeutic Elbow Arthroscopy Using Small-Bore Needle Arthroscopy

Needle arthroscopy may provide several potential advantages over standard arthroscopy. The smaller camera size and weight allows for a minimally invasive and percutaneous approach with decreased fluid use. As resolution and image quality improve, the potential to expand clinical use for therapeutic applications becomes possible. One promising use is in elbow arthroscopy. Difference in the technology, such as a zero-degree optic and less-rigid instrumentation, necessitate a modified technique to accommodate thorough diagnostic arthroscopy and therapeutic procedures. This manuscript introduces the authors' approach to diagnostic needle arthroscopy of the anterior and posterior elbow compartments and placement of therapeutic instrumentation. This technique could theoretically decrease the risk of iatrogenic neurovascular injuries, reduce postoperative swelling and pain due to decreased fluid use, and potentially lead to faster recovery.

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.

Arthroscopic Arthrolysis of Stiff Elbow

Elbow stiffness is defined as an arc of flexion-extension motion of less than 100° and/or a contracture of more than 30° in flexion. Stiff elbow is common and can be very disabling, preventing individuals from carrying out the basic activities of daily living. The most common cause of stiff elbow is the sequela of an injury, but osteoarthritis can also produce limitations of mobility, which can benefit from surgical treatment The treatment of stiff elbow is initially orthopedic. If the patient still has functional limitations of the elbow after 6 months of suitable rehabilitation treatment , the option of surgical treatment must be considered. Surgical arthrolysis of the elbow can be performed with open surgery as well as with arthroscopic surgery. Good results can be obtained with both techniques achieving a functional arc of at least -30° extension to 130° of flexion. Arthroscopic surgery enables results comparable with those of open surgery but with a lower percentage of complications.

The posterior interosseous nerve crosses the radial head midline and increases its distance from bony structures with supination of the forearm

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.

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.

Force measurement metrics for simulated elbow arthroscopy training

Background

Elbow arthroscopy is a difficult surgical technique. Objective metrics can be used to improve safe and effective training in elbow arthroscopy. Force exerted on the elbow tissue during arthroscopy can be a measure of safe tissue manipulation. The purpose of this study was to determine the force magnitude and force direction used by experts during arthroscopic elbow navigation in cadaveric specimens and assess their applicability in elbow arthroscopy training.

Methods

Two cadaveric elbows were mounted on a Force Measurement Table (FMT) that allowed 3-dimensional measurements (x-, y-, and z-plane) of the forces exerted on the elbow. Five experts in elbow arthroscopy performed arthroscopic navigation once in each of two cadaveric elbows, navigating through the posterior, posterolateral and anterior compartment in a standardized fashion with visualization of three to four anatomic landmarks per compartment. The total absolute force (F_abs) and force direction exerted (α and β) on the elbow during arthroscopy were recorded. α being the angle in the horizontal plane and β being the angle in the vertical plane. The 10th–90th percentiles of the data were used to set threshold levels for training.

Results

The median F_abs was 24 N (19 N – 30 N), 27 N (20 N – 33 N) and 29 N (23 N – 32 N) for the posterior, posterolateral and anterior compartment, respectively. The median α was - 29° (- 55° – 5°), - 23° (- 56° – -1°) and 4° (- 22° – -18°) for the posterior, posterolateral and anterior compartment, respectively. The median β was - 71° (- 80° – -65°), - 76° (- 86° – -69°) and - 75° (- 81° – -71°) for the posterior, posterolateral and anterior compartment, respectively.

Conclusion

Expert data on force magnitude and force direction exerted on the elbow during arthroscopic navigation in cadaveric specimens were collected. The proposed maximum allowable force of 30 N (smallest 90th percentile of F_abs) exerted on the elbow tissue, and the 10th–90th percentile range of the force directions (α and β) for each compartment may be used to provide objective feedback during arthroscopic skills training.

Elbow Injuries: Common Problems and Solutions

The elbow is one of the more difficult joints in which to obtain good results. Common issues include placement of correct portals, neuropraxia, ankylosis, heterotopic bone formation, and simple failure of the procedure. Common solutions include portal placement safeguards, nerve protection, early motion and cryocompression, oral or injectable steroids, radiation therapy, secure stabilization, and postoperative protection and rehabilitation based on available evidence and imaging.

Nerve injuries do occur in elbow arthroscopy

PURPOSE

The purpose is to create more awareness as well as emphasize the risk of permanent nerve injury as a complication of elbow arthroscopy.

METHODS

Patients who underwent elbow arthroscopy complicated by permanent nerve injury were retrospectively collected. Patients were collected using two strategies: (1) by word-of-mouth throughout the Dutch Society of Shoulder and Elbow Surgery, and the Leiden University Nerve Centre, and (2) approaching two medical liability insurance companies. Medical records were reviewed to determine patient characteristics, disease history and postoperative course. Surgical records were reviewed to determine surgical details.

RESULTS

A total of eight patients were collected, four men and four women, ageing 21-54 years. In five out of eight patients (62.5%), the ulnar nerve was affected; in the remaining three patients (37.5%), the radial nerve was involved. Possible causes for nerve injury varied among patients, such as portal placement and the use of motorized instruments.

CONCLUSIONS

A case series on permanent nerve injury as a complication of elbow arthroscopy is presented. Reporting on this sequel in the literature is little, however, its risk is not to be underestimated. This study emphasizes that permanent nerve injury is a complication of elbow arthroscopy, concurrently increasing awareness and thereby possibly aiding to prevention.

LEVEL OF EVIDENCE

IV, case series.