Posterior interosseous nerve laceration following elbow arthroscopy

Radial neuropathy

Radial neuropathy is the third most common upper limb mononeuropathy after median and ulnar neuropathies. Muscle weakness, particularly wrist drop, is the main clinical feature of most cases of radial neuropathy, and an understanding of the radial nerve's anatomy generally makes localizing the lesion straightforward. Electrodiagnosis can help confirm a diagnosis of radial neuropathy and may help with more precise localization of the lesion. Nerve imaging with ultrasound or magnetic resonance neurography is increasingly used in diagnosis and is important in patients lacking a history of major arm or shoulder trauma. Radial neuropathy most often occurs in the setting of trauma, although many other uncommon causes have been described. With traumatic lesions, the prognosis for recovery is generally good, and for patients with persistent deficits, rehabilitation and surgical techniques may allow substantial functional improvement.

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.

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.

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.

The Needle-and-Knife Technique: A Safe Technique for Anterolateral Portal Placement in Elbow Arthroscopy

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.

Peripheral Nerve Injury After Elbow Arthroscopy: An Analysis of Risk Factors

PURPOSE

To identify risk factors associated with peripheral nerve injury after elbow arthroscopy and provide an updated incidence of those complications.

METHODS

The elbow arthroscopies that were performed at our institution between 2006 and 2016 were identified. Over a 10-year period, 253 elbow arthroscopies were performed at our institution. Two hundred twenty-seven cases had a minimum follow-up of 4 weeks, and were included in our analysis. Minor and major nerve-related complications were recorded. The surgeon's experience and training, body max index of the patients, surgical tourniquet time, type of anesthesia or surgery, radiographic appearance of the elbow, diagnosis at the time of surgery, and presence of diabetes were analyzed.

RESULTS

There were 12 reported peripheral nerve injuries, 10 minor (4.4%) and 2 major complications (0.9%). The risk factors examined in this study were not correlated with a higher rate of complications.

CONCLUSIONS

The minor nerve-related complication rate was 4.4%, with a 0.9% incidence of major peripheral nerve injury. Based on these findings, we conclude that elbow arthroscopy is a relatively safe procedure. The risk factors examined in this study had no association with the rate of complications. This finding could be potentially related to type II or beta error in the analysis of risk factors for nerve injury. The exact reasons for nerve injury are not known from this study.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Distance of the Posterior Interosseous Nerve from the Radial Head during Elbow Arthroscopy: An Anatomical Study

Purpose  The aims of this study were to measure the distance of the posterior interosseous nerve (PIN) from the radial head (RH) and its variations with forearm movements.

Methods  Five fresh frozen cadaver specimens were dissected under arthroscopy. An anterior capsulectomy extended to the entire lateral compartment was performed. The need of soft tissue dissection to isolate the nerve in the extracapsular space was recorded. The distance between the nerve and the anterior part of the RH was then measured with a graduated caliper inserted via the midlateral portal with the forearm in neutral position, full pronation, and full supination.

Results  The PIN was identifiable in all the specimens. In four cases, it was surrounded by a thick layer of adipose tissue, and further dissection was necessary to isolate it. Damage of the PIN during dissection occurred in one case, in which the proximal part of the nerve was accidentally cut. In three of the remaining cases, an increased distance was measured with the forearm in supination, as compared with neutral and full pronation position.

Conclusion  This anatomical study suggests that in most of the cases, the PIN does not lay just extracapular at the level of the radiocapitellar joint, but is surrounded by a thick layer of adipose tissue. Furthermore, its distance from the RH appears to increase with forearm supination. This position could increase the safe working space between RH and PIN.

Clinical Relevance  Knowledge of PIN position in relation to the anterior elbow capsule and its changes with forearm movements can help reduce the iatrogenic injuries during elbow arthroscopy.

Arthroscopic Management of Elbow Osteoarthritis

The incidence of osteoarthritis in the general population is low, but it can be seen in manual laborers, throwing athletes, and people dependent on crutches and wheelchairs. Patients often complain of pain at the terminal extents of motion, and imaging shows osteophyte formation at the tips of the coronoid and olecranon processes as well as thickening of the bone between the coronoid and the olecranon fossae. Recent advances in arthroscopic instrumentation and techniques have led to a growing interest in the arthroscopic treatment of elbow osteoarthritis. This article provides a review of basic arthroscopic elbow anatomy and the most common procedures, including diagnostic arthroscopy, loose body removal, and arthroscopic osteocapsular and ulnohumeral arthroplasty. As techniques advance, there might be interest in further procedures including arthroscopic-assisted interpositional arthroplasty. Although complications such as persistent drainage and nerve injury are frequently mentioned with elbow arthroscopy, the actual incidence of such complications remains low.

Intra-articular capacity of the elbow joint

The intra-articular capacity of the elbow joint is reported to be 23 ± 4 ml on cadaveric elbows. During years, this value was the standard. The aim of this observational study was to reanalyze the volume of the elbow joint on live patients. Measurement of the intra-articular capacity and pressure of the elbow joint was performed on 30 patients (mean age: 43.8 years) undergoing elbow arthroscopy. Intra-articular capacity was recorded when the elbow moved to the maximum lose packed position and/or when there was a sudden drop in pressure, indicating a capsular rupture (maximum capacity). Indications for arthroscopy were loose bodies, osteoarthritis, synovitis, radial head resection, and lateral collateral ligament repair. Mean intra-articular capacity and pressure were 35.8 ml and 557.5 mm Hg, respectively. Mean maximal capacity was 40.5 ml. We conclude that the intra-articular capacity of the elbow joint is substantially greater than reported in previous studies. Clin. Anat. 30:795-798, 2017. © 2017Wiley Periodicals, Inc.