Need a Refresher on Elbow Arthroscopy?

Dr. J. Michael Bennett from Texas Orthopedic Hospital in Houston has written a short but very complete review of elbow arthroscopy. This surgical technique is used routinely now for the evaluation and treatment of many elbow problems. So, a refresher update is a helpful way to keep patients and physicians informed.

Dr. Bennett begins by reviewing indications (when to use this technique) and contraindications (when NOT to use elbow arthroscopy) then moves through the actual surgical technique. Using words to describe the process along with photos, the reader gains a clear understanding of the procedure. The final section is a presentation of complications the patient might develop.

First, who is best served by having an arthroscopic examination or procedure? Since the first arthroscopic elbow treatment became available, the ways and reasons to use this tool have expanded. Now surgeons use it to clean the joint out from any infection, remove any loose bodies (fragments of bone, soft tissue, cartilage), and repair defects (holes or other lesions) in the bone.

Next, who shouldn't be treated with arthroscopy but rather treated with open incision surgery? Anyone with abnormal or distorted anatomy and anyone with severe heterotopic ossification (bone formation in the soft tissues). Patients with burns or who have skin grafts are not good candidates for this type of procedure because of the danger of damage to the nerves and blood vessels.

The procedure itself is usually done with the patient under general anesthesia. The patient will be relaxed and comfortable. If there is concern for postoperative nausea from the anesthesia, then a regional anesthesia (just the arm is numbed) can be used. Using a nerve block like this has one major disadvantage. The surgical staff cannot assess the patient's neurologic status for quite some time after surgery (until the nerve block wears off).

Dr. Bennett makes his recommendations for size of scope and type of cannula and trocars he uses for elbow arthroscopy. Careful patient positioning is important to give the surgeon the best view inside and around the joint. Depending on the procedure, the patient may be supine (on his or her back) with the arm suspended by traction or prone (face down) with the arm hanging off the table in a special arm holder. Advantages and disadvantages of each position are discussed.

A detailed description of portal placements is provided with particular concern for reducing the risk of damage to the neurovascular structures (nerves and blood vessels). Photos of patients are provided with the skin marked-up to demonstrate where the portal sites should be. Direction of scope placement is also reviewed; once again, in an effort to help the surgeon avoid damaging vital structures.

Though elbow arthroscopy is a well-used procedure now, it still takes expertise and experience on the part of the surgeon to be successful. There are many factors to take into consideration including knowledge of the elbow anatomy and correct patient positioning. Inserting the scope into the joint also requires careful selection of placement to avoid complications.

As you might guess from what has been said already, the most commonly reported complication is nerve injury. Damage to the nerve usually results in a temporary neurologic injury but sometimes the nerve gets cut completely. This is more likely to cause permanent damage. Infection and damage to the soft tissues are the other most common problems surgeons must try and avoid. Good surgical technique and proper portal placement go a long way in preventing complications.

In summary, this short but very complete review of elbow arthroscopy is packed with detailed information about this particular surgical procedure. Anyone who would like to understand the basics of elbow arthroscopy will find this article of interest.

References: J. Michael Bennett, MD. Elbow Arthroscopy: The Basics. In The Journal of Hand Surgery. January 2013. Vol. 38A. No. 1. Pp. 164-167.