Mid-radial portal for operative arthroscopy of the elbow: cadaveric and clinical description of a new portal

Exclusive Posterolateral Arthroscopic and Endoscopic Approaches Used in the Treatment of Lateral Epicondylitis

Complications following arthroscopy of the elbow for the treatment of lateral epicondylitis are essentially related to the anterior arthroscopic approach. The principal aims of this study were to describe and evaluate the mixed arthroscopic and endoscopic surgical technique using posterolateral approaches exclusively. This was a retrospective study of consecutive patients operated on between 2005 and 2014 for lateral epicondylitis following more than 6 months of ineffective medical treatment. The exploration was arthroscopic via a distal posterolateral portal. The extensor carpi radialis brevis was disinserted via a proximal extra-articular posterolateral endoscopic portal. The postoperative clinical follow-up included subjective (visual analog scale, Nirschl) and objective (Mayo Clinic Elbow Performance Score) evaluations of pain, the time to return to work, the level of satisfaction, complications, and failures. Thirty-seven patients underwent the procedure, including 3 lost to follow-up. Mean±SD follow-up was 32.8±24.7 months. Mean±SD visual analog scale scores were 0.8±0.8 at rest, 2.4±1.3 during everyday activities, and 3.1±1.5 during effort. Mean±SD Mayo Clinic Elbow Evaluation Score was 10.1±1.0 of 12 and mean±SD Mayo Clinic Elbow Performance Score was 91.9±12.5 of 100. Mean±SD Nirschl score was 67.5±9.6 of 80. Mean±SD time to return to work was 2.0±2.6 months. The level of satisfaction was 94.1%. The failure rate was 2.9%, with no neurological lesions. With equivalent or even better results than those already published, this surgical procedure enables the treatment of lateral epicondylitis via posterolateral portals alone, thus avoiding the complications inherent to anterior and medial arthroscopic approaches. [Orthopedics. 2019; 42(6):e521-e527.].

An Anatomic Evaluation of Arthroscopic Access to the Radial Head

PURPOSE

To determine the area of the radial head accessible for visualization and screw placement from the standard anteromedial and anterolateral portals used in elbow arthroscopy.

METHODS

Five cadaveric elbows were arthroscopically evaluated using standard anteromedial and anterolateral portals. Markers (pins) were placed into the accessible portions of the radial head at maximal pronation and supination. Specimens were then evaluated by computed tomography, and the arc of the radial head accessible from each portal was determined.

RESULTS

A continuous 220.04° ± 37.58° arc of the radial head was accessible from the combination of the anterolateral and anteromedial portals. From the anteromedial portal, the arc obtained measured 147.96° ± 21.81°, and from the anterolateral portal, the arc obtained measured 156.02° ± 33.32°. Using the radial styloid as a marker for 0°, the mean total arc ranged from 92.3° ± 34.06° dorsal to 127.74° ± 23.65° volar relative to the radial styloid.

CONCLUSIONS

Standard anteromedial and anterolateral portals used for elbow arthroscopy allow access to an average 220° area of the radial head.

CLINICAL RELEVANCE

This study defines the area of the radial head that can be contacted using commonly used, safe, and simple portals.

Anatomic relations between the lateral collateral ligament and the radial head: implications for arthroscopic resection of the synovial fold of the elbow

PURPOSE

The purpose of this study was to determine the anatomic relationship between the radial head and the lateral collateral ligament (LCL) and when the LCL would be at risk of iatrogenic injury during arthroscopic resection of the synovial fold.

METHODS

Thirty-four formalin-fixed upper extremities were dissected. A projection of the LCL onto the radial head was marked with a needle. The percentage of the posterior border of the radial head overlaid by the LCL was digitally measured. A portion of the projection of the LCL was statistically correlated with the overall diameter of the radial head.

RESULTS

The overall diameter of the radial head was 21.2 mm ± 2.3. The proportionate projection of the medial border of the LCL onto the radial head was 5.3 ± 1.6 mm on average. The lateral 25 % of the radial head was overlaid by the LCL with a maximum value of 40 % on average. The inter- and intraobserver reliability showed very good accordance with the digital measurements (r > 0.8).

CONCLUSION

Care must be taken when performing a resection in the lateral 40 % of the radial head, whereas resection in the medial 60 % of the radial head appears to be safe. The LCL is an important stabiliser of the elbow joint, a lesion of which by undeliberate arthroscopic dissection may lead to joint instability. Iatrogenic injury to the LCL presumably can be prevented when respecting the given data.

LEVEL OF EVIDENCE

Experimental study.