CHAPTER 18 Complications of Elbow Arthroscopy

Richard J. Thomas, Felix H. Savoie, III, Larry D. Field

Arthroscopic surgery is increasingly used in the treatment of elbow pathology, including loose bodies, synovitis, degenerative joint disease, osteochondritis dissecans, arthrofibrosis, lateral epicondylitis, olecranon bursitis, fractures, and plica.¹^,² Advantages of elbow arthroscopy over open surgery include decreased scarring, decreased risk of infection, less postoperative pain, and better visualization of the joint.² Elbow arthroscopy is considered one of the most challenging types of arthroscopic surgery, most likely because of the high congruence of the joint and the proximity of neurovascular structures.²

Little research has been done in regard to complications in elbow arthroscopy. Most studies in the literature are case reports or case series that do not specifically look at the incidence of complications of arthroscopic surgery of the elbow. Few large series studies have looked at complications in elbow arthroscopy. In a review of the literature, Savoie ³ found 16 reported complications in 465 elbow arthroscopic surgeries, or a 3% incidence. Micheli and colleagues⁴ described elbow arthroscopy performed on an athletically active pediatric population and found no complications for 47 patients. The members of the Arthroscopy Association of North America were surveyed about the complications of arthroscopic surgery. For the 1569 elbow arthroscopies in the survey, only three complications were reported.⁵

Kelly and coworkers ² looked at 473 elbow arthroscopies over an 18-year period done by 12 different surgeons and reported an 11% minor complication rate and a 0.8% major complication rate. Savoie and associates⁶ found an overall complication rate of 7% in a series of 269 consecutive elbow arthroscopies over a 3-year period. In this chapter, we discuss the complications associated with elbow arthroscopy, their possible causes, and tips on how to prevent them.

COMPLICATIONS

The anatomy of the elbow makes arthroscopy a technically difficult procedure that is predisposed to complications.⁷ The reported complications of elbow arthroscopy include infection, heterotopic ossification, complex regional pain syndrome, nerve injury, fistula, and olecranon bursitis.²^,⁶^–¹⁰

Infection

One of the most common complications of elbow arthroscopy is infection. The anatomy of the elbow makes it more vulnerable than other joints to infection. The soft tissue envelope around the elbow is extremely thin, and the capsule is separated from the skin by a thin layer of subcutaneous tissue, predisposing the site to prolonged drainage,⁷ which may precede cellulitis, abscesses, intraarticular infections, or portal fistulas.

Superficial infections and persistent drainage after elbow arthroscopy are much more common than deep infections.²^,¹⁰^,¹¹ Superficial infections of the elbow after arthroscopy typically manifest as prolonged serous drainage or erythema around a portal site. Patients may have low-grade fevers and tenderness around portal sites. The erythema and drainage usually resolve with 2 weeks of oral antibiotics. Immobilization may be beneficial in the setting of prolonged drainage.

Kelly and colleagues ² reported a 5% incidence of prolonged drainage from portal sites and a 2% incidence of superficial infection in their series of 473 procedures. These minor infections resolved with a short course of oral antibiotics. Reddy and associates¹² reported a 1% incidence of persistent drainage from arthroscopic portals. Drainage was treated successfully with 7 days of oral antibiotics. Thomas and coworkers⁶ found a 2.2% incidence of superficial infections, which resolved within 7 to 14 days with oral antibiotics. Several reports ²^,⁶^,⁷ indicate that the lateral portals, including the soft spot portal and the anterolateral portal, are more susceptible to infection and prolonged drainage than the medial portals. This finding is probably reflects the fact that the skin is thinner on the lateral side of the elbow.²^,⁷ Suture closure of the portal sites has been recommended to decrease the incidence of prolonged drainage and infection.²^,¹³

Extreme pain with minimal elbow motion, high fevers, and purulent drainage after elbow arthroscopy should alert the clinician to the possibility of a septic joint. Because of the catastrophic results of a missed septic joint, the clinician should be ready to aspirate the elbow to rule out an intra-articular infection.. A septic joint should be treated with emergent irrigation and débridement of the joint, drain placement, and a course of intravenous antibiotics.

Deep infections are rare after elbow arthroscopy. Micheli and colleagues,⁴ Reddy and associates,¹² and Lynch and coworkers¹⁴ reported no deep infections in their series of 47, 187, and 21 respective elbow arthroscopies. Thomas and colleagues⁶ reported one deep infection in their series of 269 patients (0.4% incidence) that resolved with arthroscopic irrigation and débridement, drain placement, and 6 weeks of intravenous antibiotics. Kelly and associates² reported a 0.8% incidence of intra-articular infections after elbow arthroscopy. They theorized that immediate postoperative steroid injections might increase the risk of joint infections.

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