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Elbow arthroscopy
Elbow arthroscopy is a procedure used to diagnose and treat conditions of the elbow joint. It provides improved visualization of the joint while allowing for less invasive treatment options compared to open surgery. Key advantages include decreased postoperative pain and faster recovery times. However, elbow arthroscopy also carries risks due to the complex anatomy and proximity of major neurovascular structures. Careful portal placement and consideration of patient positioning are important to minimize these risks as the surgeon gains experience performing this technically demanding procedure.
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Elbow arthroscopy
- 1. Elbow Arthroscopy Zahid Askar FCPS(Ortho), FRCS(Ortho) Prof & Chair Deptt of Orthopaedics & Trauma Khyber Medical College, Peshawer
- 2. Introduction • 1931 Burman •Initial Description in 1980s • Confined space, complex articulation, proximity of major neurovascular structures • Initially used primarily as a diagnostic tool, now routinely used to treat
- 3. • Advantages • Improvedarticular visualization • Decreased postoperative pain • Faster postoperative recovery • Disadvantages • Technically demanding • High risk of damage to neurovascular structures due to proximity to the joint
- 4. Elbow Arthroscopy • Anatomy •Indications • Patient setup • Portal placement • Procedures • Complications
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- 6. Indications •Loose body removal •Osteophytedebridement •Synovectomy •Capsular releases for stiffness •OCD capitellum •Lateral epicondylitis •Debridement for septic arthritis
- 7. Preparation • GA • EUA •Tourniquet
- 8. Instruments 4 mm, 30°angled arthroscope in the anterior compartment, and use a 2.7 mm, 30° scope in the posterolateral and posterior compartments.
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- 10. Prone Elbow Arthroscopy Advantages •Best access to posterior portal • No arm support necessary Disadvantages • More difficult anesthesia • Difficult to convert to open • Image reversal Lateral decubitus elbow arthroscopy • Same advantages with the prone position • It does not compromise the airway Supine Elbow Arthroscopy Advantages • Best anterior access • Easier anesthesia • Easy conversion to open Disadvantages • Difficult posterior access and orientation
- 11. Portal Placement Technique • Portalplacement technique • fully distend joint through lateral soft spot placing portal • capsule distension moves NV structures away from the joint when trocar is introduced • careful "nick and spread" technique using hemostat • Needle technique for the rest
- 12. Portals • Lateral DALP MALP PALP • Medial •Posterior DP PL DL DAMP MAMP PAMP
- 13. Lateral Portals Standard orDALP MALP PALP
- 14. . , Portals Situation UseNeurovascular Straucuture MALP directly anterior to the radiocapitellar joint workhorse of the lateral portals. 9.8 mm from the radial nerve PALP 1-2cm proximal, 1cm anterior to lateral epicondyle See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa Radial nerve with an average distance ranging from 9.9 to 13.7 mm and 6 mm from the LABCN DALP 3 cm distal and 1 cm anterior to the LE See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa radial nerve 4.0 to 7.2 mm.LABCN is approximately 7.6 to 12.6 mm away
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- 16. Portal Location UseNeurovascular Structures Anteromedial Portal 2 cm anterior and 2 cm distal to the ME. Used most often to augment the proximal anteromedial portal to access medial recess. Place under direct visualization. Median nerve 5.0 to 7.0 mm MABCN 1.0 to 8.9 mm away, Brachial artery 15.2 to 16.6 mm Mid- anteromedial Portal 1 cm proximal and 1 cm anterior to the ME. Given its close proximity to the anteromedial portal and proximal anteromedial portal (PAMP), it is rarely used 13.8 mm from the median nerve, 17.6 mm from the brachial artery, and 7.0 mm from the MABCN Proximal Anteromedial Portal 2 cm proximal to the ME and immediately anterior to the intermuscular septum viewing entire anterior compartment, radial head, capitellum, coronoid, trochlea Most commonly used medial portal median nerve and brachial artery are approximately 12.4 and 18.0 mm away ulnar nerve (3-4mm away)
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- 18. Portal Location UseNeurovascular Structures Straight posterior (transtriceps) 3cm proximal to olecranon, triceps midline (musculotend. junction Elbow partially extended, good for removing impinging olecranon osteophytes and loose bodies from posteromedial compartment NONE Posterolateral 2-3 cm proximal to olecranon and just lateral to triceps Elbow 20-30deg flexion (to relax triceps) NIL Direct lateral (or midlateral) "soft spot" portal (in triangle formed by olecranon, radial head, epicondyle) Initial site for joint distension before scope is inserted, viewing posterior compartment relatively safe, lateral antebrachial cutaneous nerve
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- 20. PALP provides goodvisualization of the anterior ulnohumeral and radiocapitellar joint Soft Spot Portal Best Visualization • Posterior Surface of Radial Head • Posterior Capitellum • Radial Surface of Olecranon
- 21. Proximal Medial PortalBest Visualization for: • Radiocapitellar joint • Coronoid • Trochlea • Radio-ulnar joint • Anterior capsule Posterolateral Portal Best Visualization for: • Olecranon Process • Olecranon Fossa • Posterior Ulnar Gutter
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- 25. Most experienced only •Capsulectomy •Osteocapsular arthroplasty • Fracture fixation Low Diagnostic arthroscopy, Loose body removal , Plicae excision Debridement of OCD Advanced • Synovectomy • Capsulotomy • Radial head excision • Lateral epicondylitis release Level of experience
- 26. Pearls • PROPER POSITIONINGOF THE PATIENT • Identification and labelling of all landmarks • Consideration of the intra- articular pathology • Fewest number of portals required • Beware of the location of Radial , Ulnar and Median Nerve
- 27. Pitfalls • Beware ofthe prior surgical interventions • Excessive swelling and fluid extravasation • Each additional portal increase the risk of complications • Inadvertent distal placement of anterior portals decrease the safe working distance from critical neurovascular distances • Because of the location of the Ulnar nerve , here is no true safe zone on the medial side
- 28. • Elbow arthroscopyis a difficult procedure with a steep learning curve • As experience is gained indications are expanding • Start with easier procedures and stay in the safe side
- 29. Thanks for yourattention !!!