Introduction
Advancements in elbow arthroscopy have led to an increase in its use. As surgeons have become more familiar with the technique, and instrumentation has become more intuitive, indications for its use are ever expanding. Indications include aiding in diagnosis, debridement for osteoarthritis, loose body removal, synovectomy, irrigation and debridement for septic arthritis, chondroplasty, contracture release, osteochondral lesions, microfracture, lateral epicondylitis treatment, instability, and others.
Because elbow arthroscopy is a technically demanding operation and many neurovascular structures are in close proximity, it is important to have an understanding of the complications that may occur. Kelly et al. published the largest series of patients who underwent elbow arthroscopy and reported a complication rate of 11%. Others have reported complication rates ranging from 0% to 15%. , The incidence of complications may be underreported; most reports in the literature reflect the experiences of experienced elbow arthroscopy surgeons. In general, complications can be categorized into minor/transient problems or major/permanent complications.
In this chapter, we describe the complications associated with elbow arthroscopy and discuss strategies for avoiding or minimizing them. Furthermore, we offer recommendations regarding management when these complications occur.
Preoperative Planning to Avoid Complications
Preoperative Assessment and Patient-Related Factors
The first opportunity to avoid complications is knowing when and when not to perform elbow arthroscopy. Ideally, the surgeon should have had a certain degree of arthroscopic training. A thorough history should be elicited from the patient because prior injury or surgery involving the elbow may substantially distort the anatomy. Additionally, patients with diseases that cause joint destruction, such as rheumatoid arthritis, have been shown to be at increased risk of nerve injury. , This has been attributed to the inflammatory process which results in an attenuated joint capsule. Physical examination is important to identify anatomic variants and document any preoperative contractures. Obesity, particularly a body mass index greater than 30, has been reported to increase the rates of postoperative infection, stiffness, nerve injury, and medical complications. As with any other surgical procedure, it is vital to make sure the patient is medically optimized for surgery, as most arthroscopic elbow procedures, except in the setting of septic arthritis, are elective.
Anesthesia
General anesthesia is often preferred over preoperative regional anesthesia because many of the dreaded complications associated with elbow arthroscopy involve damage to the peripheral nerves. This allows for a thorough postoperative neurological assessment. Once a postoperative examination confirms intact nerve function, a postoperative regional block could be administered if indicated.
Patient Positioning and Portal Placement
Damage to the ulnar, radial, median/anterior interosseous, posterior interosseous, and medial antebrachial cutaneous nerves have been described in the literature. , Proper patient positioning and portal placement play a vital role in helping prevent iatrogenic nerve injury. The patient may be positioned prone, in the lateral decubitus position ( Fig. 39.1 ), or supine ( Fig. 39.2 ). If positioned laterally, an axillary roll should be placed, and pressure on or stretching of the brachial plexus should be avoided. An arm holder may be used, but should not impinge on the antecubital fossa. General consensus is that the elbow should rest in 80 to 90 degrees of flexion. This allows the anterior joint capsule to be maximally distended, which places the at-risk neurovascular structures furthest away from the joint and portals. If the elbow is moved into extension, the brachial artery and anterior nerves are brought closer to the joint. , Lateral portals should be established with the elbow in supination, as pronation brings the posterior interosseous nerve more anterior and places it in greater danger.
Camp et al. provide a very helpful review of the commonly used portals. They recommend marking out the elbow anatomy ( Fig. 39.3 ) before introducing fluid into the joint because this will distort the anatomy. As presented in the review, the most commonly used portals include proximal anterolateral, proximal anteromedial, posterolateral, and direct posterior portals. Accessory portals consist of the midanterolateral, midanteromedial, distal ulnar portal, and accessory retraction portals ( Fig. 39.4 ).
Intraoperative Complications and Management
There have been multiple case series published outlining elbow arthroscopy complications. , , The largest case series consists of 473 patients with an overall complication rate of 11%. In this series and others, the complications are classified into major and minor groups. Although many preventative measures can be taken preoperatively, additional measures can be taken intraoperatively.
Before beginning the arthroscopy, it is advisable to insufflate the joint with normal saline solution ( Fig. 39.5 ). This is typically performed through the soft spot in the triangle between the radial head, capitellum, and proximal ulna. Typically, between 20 and 30 mL of fluid is used. This technique has been studied extensively and has been shown to move the neurovascular structures away from the working field. This is particularly important when the arthroscopic procedure is beginning in the anterior compartment. This is done before portal placement and increases the distance from the neurovascular structures to the portal, but it does not affect the distance of the capsule to the neurovascular structures. Before performing an arthroscopic capsular procedure, it is critical to be aware of this point because joint insufflation does not cause the neurovascular structures to be moved further away from the working field. Along with proper patient positioning, remember how the position of the elbow impacts the relative location of the neurovascular structures. As discussed previously, the elbow should be kept in at least 80 to 90 degrees of flexion when operating in the anterior elbow. Hackl et al. demonstrated in a cadaveric model that the distance between arthroscopic portals and the median and radial nerves triples with the combination of joint insufflation and elbow flexion. As discussed in the preoperative section, proper portal placement is imperative.
