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Risk of nerve injury during arthroscopy portal placement in the elbow joint: A cadaveric study.

Chaware PN, Santoshi JA, Pakhare AP, Rathinam BA - Indian J Orthop (2016 Jan-Feb)

Bottom Line: No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow.In practice, the actual incidence of nerve injury may still be lower.We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

View Article: PubMed Central - PubMed

Affiliation: Department of Anatomy, AIIMS, Bhopal, Madhya Pradesh, India.

ABSTRACT

Background: Elbow arthroscopy has become a routine procedure now. However, placing portals is fraught with dangers of injuring the neurovascular structures around elbow. There are not enough data documenting the same amongst the Indians. We aimed to determine the relative distances of nerves around the elbow to the arthroscopy portals and risk of injury in different positions of the elbow.

Materials and methods: Six standard elbow arthroscopy portals were established in 12 cadaveric upper limbs after joint distension. Then using standard dissection techniques all the nerves around the elbow were exposed, and their distances from relevant portals were measured using digital vernier caliper in 90° elbow flexion and 0° extension. Descriptive statistical analysis was used for describing distance of the nerves from relevant portal. Wilcoxon-signed rank test and Friedman's test were used for comparison.

Results: There was no major nerve injury at all the portals studied in both positions of the elbow. The total incidence of cutaneous nerve injury was 8.3% (12/144); medial cutaneous nerve of forearm 10/48 and posterior cutaneous nerve of forearm 2/24. No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow.

Conclusion: This study demonstrates the risk of injury to different nerves at the standard portals of elbow arthroscopy. In practice, the actual incidence of nerve injury may still be lower. We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

No MeSH data available.


Related in: MedlinePlus

A cadaveric left elbow showing placement of all the standard elbow arthroscopy portals. Antero-medial (AM), supero-medial (SM), direct-lateral (DL), antero-lateral (AL), postero-lateral (PL), straight-posterior (SP)
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Figure 1: A cadaveric left elbow showing placement of all the standard elbow arthroscopy portals. Antero-medial (AM), supero-medial (SM), direct-lateral (DL), antero-lateral (AL), postero-lateral (PL), straight-posterior (SP)

Mentions: After the portals were established, the pins were left in place [Figure 1]. Then using standard dissection tools, skin, and subcutaneous fat were removed around the elbow region. Dissection was done carefully preserving the original position of the nerves by avoiding disruption of the soft tissue under these structures and therefore maintaining the support of each nerve at its original position. The nerves studied were median nerve, ulnar nerve, radial nerve, lateral cutaneous nerve of forearm (LCNF), medial cutaneous nerve of forearm (MCNF) and posterior cutaneous nerve of forearm (PCNF). The distances from each nerve to the relevant portals were measured using digital vernier caliper with a measuring range of 0–150 mm, resolution of 0.01 mm, accuracy ± 0.02 mm of linear capacitive measuring system. For example, for ulnar nerve, its distance from SP, SM, and AM portals were recorded, as it is obviously at a safe distance from the lateral portals (PL, DL and AL). However, it may still get injured by instruments through any portal.15161718 Similar data for other nerves was recorded. All measurements were carried out by two observers to avoid intra observer error. Measurements were taken from the edge of the portal to the closest border of the nerve “at risk.” In the case of actual impalement or displacement of a nerve with any pin, it was deemed to be injured, and the distance was recorded as zero (0.00 mm).


Risk of nerve injury during arthroscopy portal placement in the elbow joint: A cadaveric study.

Chaware PN, Santoshi JA, Pakhare AP, Rathinam BA - Indian J Orthop (2016 Jan-Feb)

A cadaveric left elbow showing placement of all the standard elbow arthroscopy portals. Antero-medial (AM), supero-medial (SM), direct-lateral (DL), antero-lateral (AL), postero-lateral (PL), straight-posterior (SP)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4759879&req=5

Figure 1: A cadaveric left elbow showing placement of all the standard elbow arthroscopy portals. Antero-medial (AM), supero-medial (SM), direct-lateral (DL), antero-lateral (AL), postero-lateral (PL), straight-posterior (SP)
Mentions: After the portals were established, the pins were left in place [Figure 1]. Then using standard dissection tools, skin, and subcutaneous fat were removed around the elbow region. Dissection was done carefully preserving the original position of the nerves by avoiding disruption of the soft tissue under these structures and therefore maintaining the support of each nerve at its original position. The nerves studied were median nerve, ulnar nerve, radial nerve, lateral cutaneous nerve of forearm (LCNF), medial cutaneous nerve of forearm (MCNF) and posterior cutaneous nerve of forearm (PCNF). The distances from each nerve to the relevant portals were measured using digital vernier caliper with a measuring range of 0–150 mm, resolution of 0.01 mm, accuracy ± 0.02 mm of linear capacitive measuring system. For example, for ulnar nerve, its distance from SP, SM, and AM portals were recorded, as it is obviously at a safe distance from the lateral portals (PL, DL and AL). However, it may still get injured by instruments through any portal.15161718 Similar data for other nerves was recorded. All measurements were carried out by two observers to avoid intra observer error. Measurements were taken from the edge of the portal to the closest border of the nerve “at risk.” In the case of actual impalement or displacement of a nerve with any pin, it was deemed to be injured, and the distance was recorded as zero (0.00 mm).

Bottom Line: No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow.In practice, the actual incidence of nerve injury may still be lower.We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

View Article: PubMed Central - PubMed

Affiliation: Department of Anatomy, AIIMS, Bhopal, Madhya Pradesh, India.

ABSTRACT

Background: Elbow arthroscopy has become a routine procedure now. However, placing portals is fraught with dangers of injuring the neurovascular structures around elbow. There are not enough data documenting the same amongst the Indians. We aimed to determine the relative distances of nerves around the elbow to the arthroscopy portals and risk of injury in different positions of the elbow.

Materials and methods: Six standard elbow arthroscopy portals were established in 12 cadaveric upper limbs after joint distension. Then using standard dissection techniques all the nerves around the elbow were exposed, and their distances from relevant portals were measured using digital vernier caliper in 90° elbow flexion and 0° extension. Descriptive statistical analysis was used for describing distance of the nerves from relevant portal. Wilcoxon-signed rank test and Friedman's test were used for comparison.

Results: There was no major nerve injury at all the portals studied in both positions of the elbow. The total incidence of cutaneous nerve injury was 8.3% (12/144); medial cutaneous nerve of forearm 10/48 and posterior cutaneous nerve of forearm 2/24. No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow.

Conclusion: This study demonstrates the risk of injury to different nerves at the standard portals of elbow arthroscopy. In practice, the actual incidence of nerve injury may still be lower. We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

No MeSH data available.


Related in: MedlinePlus