Research Title
49 cases elbow arthroscopy: Results in neurovascular complication
Introduction
An elbow arthroscopic surgery has been used over the past 20 years for both diagnosis and
treatment. It has been widely accepted as the newer operative techniques and performed worldwide. The
indications for an elbow arthroscopic surgery include pathologic plica, septic arthritis, remove loose body,
osteoarthritis of the elbow or tennis elbow etc.
The benefits of elbow arthroscopic surgery include intra-articular pathology identification and the
minimal invasive surgery. Nevertheless, the complication in elbow arthroscopy is still the concern, due to the
close of major of neurovascular and the results in complication which are higher compared to others joint in
arthroscopy. Mostly, the concern is neurovascular complication such as nerve damage both temporarily and
permanently, compartment syndrome and vascular injury. All these complications have been reported in
international studies but neither in Thailand nor in South East Asia. Hence, this study has been developed.
Research Methodology
We collected data from patients who received elbow arthroscopic surgery performed by senior
author (C.C.) from April 2011 to April 2014. The number of patients was 44 whereas the number of elbows
was 49 cases. We aimed to investigate the complications of elbow arthroscopic surgery.
The complications of elbow arthroscopic surgeries can be classified as major complications such as
permanent nerve damage, elbow joint infection, compartment syndrome, and vascular damage. Minor
complications include temporary nerve damage, superficial skin infection that can control with oral antibiotic.
The data collection was done immediately after the surgery and the postoperative follow up. All
patients had appointments at least six weeks after the surgery depending on the problem, diagnosis and
patient clinical. The final report of the complications of elbow arthroscopic surgeries was done in the 6th week
following the surgery.
Surgical technique
We performed the operation under general anesthesia with no regional block or combined regional
pain control, because after the operation we could evaluate the status of nerve immediately. The patient was
placed in lateral decubitus position. The affected arm was laid on arm support and let the forearm move freely
for full flexion and extension. We applied pneumatic tourniquet at level of arm as high as possible. We didn’t
use fluid injection before arthroscopic surgery. The portals that we used for anterior space in elbow were
proximal antero-medial portal (starting portal) follow with antero-lateral portal by outside in technique this
portal was used for the instrument, then the proximal antero-lateral portal was created for place the retractor.
In the posterior space of the elbow, we started with postero-lateral or direct posterior portal for the
scope and instrument that also can switch them together. The direct lateral or soft spot portal we used in the
case that need the instrument in the lateral gutter (e.g. posterolateral plica etc.) The arthroscopic procedure
started at anterior if the main pathology stayed in anterior such as tennis elbow or started at posterior if the
diagnosis of the main pathology was stayed in the posterior (e.g. posteromedial bony impingement).
Radiofrequency cautery (Arthrocare) was used in the routine with the aggressive style shaver diameter 3.5
mm (Linvatec: ergo). The plier was use as the soft tissue retractor for increase the space and retracts the
nerve away from the shaver or RF cautery.
Results
All the 49 elbow surgeries performed by a single surgeon. There were 44 patients, 27 females (61%)
and 17 males (39%). The mean age of patients was 42 years old. There were 24 right elbows (48%) and 25
left elbows (52%) as shown in Table 1.
Topic
1. Total patient
- female
- male
2. Mean age (years)
3. Total elbow
- Right elbow
- Left elbow
Table 1 Demographic data of patients
Number
44
14(73%)
5(39%)
42(14-72)
49
24(48%)
25(52%)
The definite diagnosis after elbow arthroscopy was diagnosed as: tennis elbow 9 cases (18%), plica
10 cases (21%), osteoarthritis 4 cases (8%), combine tennis elbow and plica 6 cases (12%), septic arthritis 2
cases (4%), trauma 4 cases (8%) and miscellaneous 14 cases (29%).
DIAGNOSIS ELBOW ARTHROSCOPE
plica
21%
miscellaneous
29%
tennis elbow
18%
septic arthritis
4%
trauma
8%
OA elbow
8%
combine
plica+tennis elbow
12%
Figure 1 Definite diagnosis after elbow arthroscopic surgery
The 49 surgeries, there were 2 patients (4.1%) who were found to have complications of elbow
arthroscopic surgeries. The complications were: temporary nerve damage in one patient that experienced
numbness in lateral side of elbow and forearm following surgery (lateral cutaneous nerve of forearm injury)
and one patient that experience surgical site skin infection that can control with the short course of oral
antibiotic. The patient who developed the numbness takes around six weeks to recover. For the other types
of complication, major or minor, there was not found in our report.
Discussion
There have been studies on the complications of elbow arthroscopic surgery which reported
incidences and types of complication. E.W.Kelly (2001) found that there were 11% of his patients developing
minor complications and 2% for nerve damage. Elfeddali R (2013) reported that there were 7 percent of the
patients developing minor complications from arthroscopic surgery. Also, in Savoie’s study, from his
experience, the number of patients who developed complications following surgery was 9%. These studies
reported fairly similar results.
In this study, there were 2 cases who developed minor complications and there was no major
complication. In terms of percentage, out of 49 cases, it is 4% which is similar to previous studies in Europeon
and American series. As for the patient both of them were minor complication and were treat by simple
protocol in treatment. There was no serious complication in our study, because we performed the operation
based on the understanding basic of the elbow arthroscopic steps( ) and used a nerve retractor to protect
nerve injury.( ) Elbow arthroscopic surgery is a high risk procedure to injure nerves because low volume of
joint space and there are many nerves surround elbow joint. But in our experience the fluid injection to
distend the joint capsule before insert switching stick was not necessary for prevent the nerve injury. We do
the basic steps in the elbow arthroscopic surgery technique that describe by O’Driscoll. First step was
identified yourself where you are then the space around was create or increase that can be the debridement
the soft tissue or shave the bone. The next was bony procedure as cheilectomy, loose body removal then
follow by the soft tissue debridement or remove (e.g. Capsulectomy).
Figure 2 Pictures from elbow arthroscopic surgery; A. synovitis elbow, B. shrinkage capsule with nerve
retractor
Conclusion
From our experience, an elbow arthroscopic surgery has been considered as a safe operation since
few minor complications were similar to prior international studies.
Reference
1. Edward W. Kelly, et al. Complication of elbow arthroscopy. J Bone Joint Surg Am. 2001 January,
volume 83a number1
2. Shawn W. O’Driscoll, Bernard F. Morrey. Arthroscopy of elbow diagnostic and therapeutic benefit
and hazards. J Bone Joint Surg Am. 1992 January, volume 71a number1
3. Thomas Schubert, et al. A review of 24 cases of elbow arthroscopy using the DASH
questionnaire. Acta Orthop Belg., 2007, 73, 700-703
4. Savoie FH 3d. Complications. In: Savoie FH 3d, Field LD, editors. Arthroscopy of the elbow. New
York: Churchill Livingstone; 1996. 151-6.
5. Elfeddali R, et al. Arthroscopic elbow surgery, is it safe. J Shoulder Elbow Surg. 2013
May;22(5):647-52
6. Marti D. et al. The first 100 elbow arthroscopies of one surgeon: analysis of complications. J
Shoulder Elbow Surg. 2013 Apr;22(4):567-73
7. Reddy AS, et al. Arthroscopy of the elbow: a long-term clinical review. J arthroscopy. 2000
Sep;16(6):588-94
8. Christopher C. Dodson, MD, et al. Elbow Arthroscopy. J Am Acad Orthop Surg. 2008;16:574-585
Abstract
49 cases elbow arthroscopy: Results in neurovascular complication
An elbow arthroscopic surgery is a minimal invasive surgery. There are several international
publication reports about complications of elbow arthroscopic surgery. But there is no study which is
conducted in Thailand. Thus, our colleague has collected the data of the patients who underwent elbow
arthroscopic surgery from April 2011 to May 2014, there are 49 elbows from 44 patients was included. The
data was collected immediately after surgery until 6-week after procedure. We found total complication in 2
cases (4%), which were minor complication, one was transient cutaneous nerve injury and another was
cellulitis. No serious or permanent complication was detected in this study. In conclusion, in our series an
elbow arthroscopic surgery has been considered as a safe surgery since the complications were similar to
prior standard studies.
ผลข้ างเคียงจากการผ่าตัดแบบส่ องกล้ องข้ อศอก 49 ราย
การผ่าตัดแบบส่องกล้องข้อศอกเป็ นการรักษาที่มีการบาดเจ็บของเนื้อเยือ่ น้อย
และได้รับความนิยมมากขึ้นในปัจจุบนั โดยผลลัพธ์จากการผ่าตัดมีการรายงานในต่างประเทศเท่านั้น
ยังไม่พบรายงานในประเทศไทยมาก่อน
ทางผูศ้ ึกษาจึงได้ดาเนินการเก็บข้อมูลกลุ่มผูป้ ่ วยที่เข้ารับการผ่าตัดส่องกล้องข้อศอกตั้งแต่เดือนเมษายน พ.ศ.2554 จนถึง
พฤษภาคม พ.ศ.2557 ทั้งหมด 49 ข้อศอก จากผูป้ ่ วย 44 ราย โดยเก็บข้อมูลตั้งแต่หลังผ่าตัดทันที จนถึง 6
สัปดาห์หลังการผ่าตัด พบผลข้างเคียงจากการผ่าตัดชนิดรุ นแรงน้อย 2 ราย (4%) ได้แก่
การได้รับบาดเจ็บของเส้นประสาทรับความรู ้สึกบริ เวณผิวหนังแบบชัว่ คราว 1 ราย
และการติดเชื้อของผิวหนังบริ เวณแผลผ่าตัด 1 ราย โดยที่ไม่พบผลข้างเคียงชนิดรุ นแรงมากเลย
การศึกษานี้เป็ นตัวบ่งบอกได้ในระดับนึงว่าการผ่าตัดส่องกล้องข้อศอกในประเทศไทยสามารถทาได้อย่างปลอดภัย
และมีผลข้างเคียงจากการผ่าตัดเทียบเคียงกับนานาประเทศ