Lake Taho Knee and Shoulder Update 2002 Elbow Arthroscopy: Basic Technique, Portals and Anatomy
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1 Lake Taho Knee and Shoulder Update 2002 Elbow Arthroscopy: Basic Technique, Portals and Anatomy Jeffrey Halbrecht MD
2 Elbow Arthroscopy Experience Uncommonly scoped joint Based on AAOS Survey: Only 7.6% of Orthopaedic Surgeons perform elbow arthroscopy Elbow arthroscopy constitutes only 2% of all orthopedic procedures
3 Elbow Arthroscopy The most hazardous joint in terms of risk to intimately associated neurovascular structures Poses greater technical challenges/neurologic risks than knee/shoulder scope
4 Indications Removal of Loose body(ies) Olecranon Impingement Overload OCD Capitellum Debridement Degenerative Arthritis Synovectomy Diagnostic Evaluation Capsular Release Fx evaluation/tx Debridement Lateral Epicondylitis
5 Positioning Supine
6 Positioning Prone
7 Positioning Lateral Decubitus
8 Portals Anatomy Familiarity more critical than w/ any other arthroscopic procedure Anterior Posterior
9 Anterior Portals Assoc w/ greatest potential risk to nv structures Thorough exam of anterior compartment important in all cases Lateral Medial
10 Lateral Portals
11 Anterolateral Portal Initially described by Andrews and Carson (Arthroscopy, 1:97-107, 107, 1985) 3cm distal and 1-2cm 1 anterior to lateral epicondyle Penetrates Extensor Carpi Radialis Muscle
12 Anterolateral Portal Visualization Trochlea Distal Humerus Coronoid Process and Fossa Medial and Superior Capsule
13 Anterolateral Portal Risk LABCN ave.. 7.6mm (0-20mm), in contact 43% Radial nerve is at extreme risk ave.. 4.9mm (2-10mm) Recommended placement 3cm from LE results in entry point that is distal I most pts, below jt in some pts PIN Arcade of Froshe) poorly protected, even in flexion, close to distal capsular attachment (little chance of displacement w/ jt distension) No longer used by some, if used, established from inside-out, proximal to radial head
14 Proximal Lateral Portal Described by Strothers, Day and Regan (Arthroscopy, Vol. 11, No4, , 457, Aug 1995) 1-2cm proximal to the lateral epicondyle,, pierces Brachioradialis and distal Brachialis to reach lateral elbow capsule, lying directly on anterior surface of the humerus Improved margin of safety, supplants earlier AL portal
15 Proximal Lateral Portal Visualization Anterior/Lateral aspect of Radial head and capitellum Medial aspect of elbow including: Coronoid Process/Fossa Distal Humerus Trochlea Medial Capsule 0449F09_.95
16 Proximal Lateral Portal Risk LABCN branch ave 6.1mm (0-14mm), in contact 29% Radial nerve 2x distance vs AL portal (ave( 9.9mm in flexion)
17 Medial Portals
18 Anteromedial Portal 2cm distal, 2cm ant to medial epicondyle Passes through common flexor origin, then beneath or penetrates brachialis to enter capsule
19 Anteromedial Portal Visualization Affords excellent view of both radiocapitellar and ulnohumeral joints, coronoid fossa, capitellum and superior capsule Radial Head Coronoid Process Capitellum Trochlea
20 Anteromedial Portal Risk MABCN Branch ave 1mm (0-5mm), in contact 71% Median Nerve ave 7mm (5-13mm) w/ flexion Brachial Artery ave 15mm (8-20mm)
21 Proximal Medial Portal Described by Poehling (Arthroscopy, 5: , 224, 1989) 2cm proximal to medial epicondyle,, directly anterior to intermuscular septum Contact maintained w/ distal humerus to avoid med nerve risk scope lies deep to brachialis muscle
22 Proximal Medial Portal Visualization Similar to AM portal Excellent view, esp distal part of jt Radiocapitellar jt Ulnohumeral jt 70 Deg scope proximal capsule visualization prn
23 Proximal Medial Portal Risk MABCN very close, ave. 2.3mm (0-9mm), in contact 56% Median Nerve ave mm (7-20mm) Brachial Artery ave.. 18mm Ulnar Nerve av4e 12mm (7-18mm) Important to confirm location, stability of Ulnar nerve before establishing any medial portals
24 Proximal Medial Portal Recommended that proximal medial portal be first portal used in most cases of elbow arthroscopy Safer than anteromedial portal Excellent view AM PM
25 Posterior Portals All are relatively safe w/ distance to closest cutaneous or major nerve 15-20mm Mid or Direct Lateral ( Soft( spot ) Central Posterior Posterolateral
26 Mid-Lateral Portal AKA Soft spot portal Located within triangle formed by olecranon, lateral epicondyle and radial head Pierces Anconeus muscle Initial joint insufflation Only portal to provide easy access to posterior capitellum and radioulnar joint
27 Mid-Lateral Portal Visualization Posterolateral radial head Capitellum Trochlea notch Olecranon
28 Mid-Lateral Portal Risk Articular Cartilage
29 Central Posterior Portal 3cm proximal to Olecranon tip Passes through triceps tendon at its medial margin
30 Central Posterior Portal Visualization Olecranon Tip Olecranon Tip Olecranon Fossa Posteromedi Olecranon Fossa al Gutter
31 Central Posterior Portal Risk Ulnar Nerve ave 19.1mm (15-25mm)
32 Posterolateral Portal 3 cm proximal to olecranon tip, adjacent to lateral edge of triceps tendon Passes through triceps muscle
33 Posterolateral Portal Visualization Olecranon Fossa,, Tip Posterior trochlea
34 Posterolateral Portal Risk PABCN branch
35 Technique - Video
36 Complications Relatively higher incidence compared to other scope procedures (3-14%) Most significant is nerve injury (0-14%) Radial/PIN most common (Median/Ulnar Ulnar/AIN/MABC) (Rodeo etal JBJS A 1993;75:917-26) Other reported complications include: Compartment syndrome Septic Arthritis Superficial infection Persistent Drainage
37 Complications
38 Complications 473 cases 11.8% complication rate 0.8% (N=4) serious Infection 11% (N=50) minor Prolonged drainage/superficial portal site (N=33) Persistent minor contracture <20 deg (N=7) Transient nerve palsies (N=12) (extravasation of local anesthetic, direct blunt trauma, compression by tourniquet/forearm wrapping, use of indwelling catheter)
39 Avoiding Complications Most serious complications are reported assoc. w/ advanced procedures, which ought to be performed only by experienced surgeons Most minor complications however, are probably avoidable by Familiarity w/ normal anatomy/portals Attention to technique: Incise skin only w/ #11 blade Blunt dissection to/through capsule Maintain portal sites (avoid repeated re-entry) entry) Beware use of pump Limit procedure duration
40 THANK YOU
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