Editorial Commentary: Safety in Anteromedial Elbow Portal Placement? Go North!

Since iatrogenic injury to surrounding structures is more likely in the elbow than in the other major joints, many studies have examined the relationship of elbow arthroscopy portals to the at-risk anatomy. In accessing the anterior compartment of the elbow from the medial side, the brachial artery and median, ulnar, and medial antebrachial cutaneous nerves are at risk. Factors that improve the safety of this approach include the use of a proximal versus distal anteromedial portal, a distended versus and nondistended joint, and a flexed versus extended elbow position, all of which result in an approximate margin of safety of 2 cm from the deep at-risk structures.     

Arthroskopie des Ellenbogens

Indications for elbow arthroscopy include diagnostic arthroscopy, removal of loose bodies and osteophytes, synovectomy, treatment of osteochondrosis dissecans and capsular release in case of contracture. In particular, the anatomic vicinity of the neurovascular structures to the portals requires a thorough knowledge of elbow anatomy and some experience with the procedure. The exact positioning of the patient, identification of the landmarks and knowledge of the correct portal placement are necessary to perform a safe and effective operation and to avoid complications. The overall complication rate is higher as compared to knee- or shoulder arthroscopy with minor complications predominating. Nerve lesions are transient most of the time; however, being permanent they cause substantial problems for the patient. Overall, elbow arthroscopy has become a safe and reliable procedure for the diagnosis and therapy of elbow disorders.     

Arthroscopy of the elbow joint: A cadaveric study of portal placement

Sixteen fresh cadaver elbows were examined by arthroscopy and dissection to evaluate the usefulness and the anatomic relationships of seven previously described portals for elbow arthroscopy. Most of the examined portals were found to be relatively close to neurovascular structures. The nerves that were found to be located closest to the portals were the posterior antebrachial cutaneous nerve at the direct lateral and antero-lateral portals, the radial nerve at the antero-lateral portal, and the medial antebrachial cutaneous nerve at the high and low antero-medial portals. The degree of flexion and fluid distension of the joint were found to influence the position of nerves and vessels in relation to the arthroscopy portals. At least three different portals were found to be required for thorough examination of the elbow joint. The combination of the low postero-lateral, the direct lateral, and the high antero-medial portals provided the largest visualized area.     

Arthroscopy of the elbow: Anatomy,portal sites,and a description of the proximal lateral portal

Cadaveric studies were carried out to evaluate the safety and value of the standard portals used in elbow arthroscopy. The dissections were performed in 12 fresh cadaveric specimens. Each portal was assessed in terms of its safety with respect to nearby important structures. A proximal lateral portal was evaluated and has subsequently been used in 62 patients. A straight posterior (transhumeral) portal was also studied. We have found that in arthroscopy of the elbow joint, the proximal approaches (proximal medial and proximal lateral), are safer than the anteromedial and anterolateral approaches. All areas of the anterior compartment can be visualized using these two portals, and we recommend that they be the standard anterior portals used in elbow arthroscopy. All of the posterior approaches are safe.     

The distance between the sural nerve and ideal portal placements in lateral subtalar arthroscopy: a cadaveric study

BACKGROUND: There have been limited studies assessing the relative safety of lateral portals for subtalar arthroscopy in terms of their distance from the sural nerve and its branches. The aim of this cadaveric study was to assess and compare the distance of lateral subtalar arthroscopy portal sites to the sural nerve and its branches. MATERIALS AND METHODS: Twenty embalmed cadaveric lower limbs were dissected exposing the nerves and tendons and subtalar arthroscopy portals were replicated using pins. The anatomically important distances were measured with a digital caliper. Statistical analysis of the data was performed using SPSS for Windows 11.5 (SPSS Inc, Chicago, IL) using Friedman Tests and Wilcoxon Signed Ranks tests. RESULTS: The median distance of the anterior and middle subtalar portals to the nearest nerve was 21.3 mm and 20.9 mm, respectively, and 11.4 mm for the posterior portal. There was no statistically significant difference between anterior and middle portals (p=0.87) but there was statistically significant difference between anterior versus posterior and middle versus posterior portals (p=0.001 in each comparison). CONCLUSION: The anterior and middle subtalar portals were both less likely to damage important structures than the posterior subtalar portal. CLINICAL RELEVANCE: The results of this study can be of value to the surgeon when planning arthroscopic procedures to the subtalar joint from the lateral approach.     

Arthroscopic Approaches to the Ankle Joint

This chapter reviews anterior and posterior arthroscopic approaches to the ankle and subtalar joints. The specific anatomy relevant to arthroscopy is reviewed including the major tendon, vascular, nerve and ligament structures along with the bony anatomy of the joints. A step by step discussion of portal placement, portal establishment, and diagnostic arthroscopy of the joints is presented, first for anterior approaches and then for posterior approaches.     

Neurovascular anatomy and elbow arthroscopy: inherent risks

Five cadaver elbows were examined arthroscopically. Detailed dissections of superficial cutaneous nerves and of deeper neurovascular structures were carried out either before or after arthroscopic examination. Normal neurovascular anatomy and variants were defined in relation to standard portal placement. The danger of neurovascular injury is emphasized due to inappropriate portals, direction of entry, or elbow position. A safe, reliable, and reproducible technique is defined.     

Ankle Arthroscopy: Correct Portals and Noninvasive Distraction

Noninvasive ankle distraction technique is the standard of care for ankle arthroscopic surgery. Noninvasive distraction can be performed safely and with fewer complications when compared side-by-side with the nondistraction dorsiflexion technique. Moreover, distraction techniques allow a single surgeon to operate in the most convenient supine position and in a “hands-free” manner, with adequate space to avoid iatrogenic chondral damage. In addition, distraction allows for dedicated inflow and outflow portals to sufficiently irrigate the joint. Although the nondistraction technique allows excellent visualization of the anterior joint, it fails to provide appropriate visualization of the entire joint, using both anterior and posterior portals. Pathology that is best accessed from the posterior portal includes posterior osteochondral lesions, loose bodies, tears of the transverse ligament, acute ankle fractures, posterior tibial osteophytes, and occasionally an os trigonum. Fortunately, noninvasive distraction techniques plantarflex the ankle, also providing optimal access to the talus through the anterior approach. With the added use of posterolateral and occasionally posteromedial portals, near-universal access to lesions about the ankle can be obtained. In this infographic, the authors present the current indications for noninvasive ankle distraction arthroscopy and illustrate the importance of proper portal placement in obtaining the access and visualization necessary to easily and safely address pathology throughout the entire ankle and subtalar joint.     

Hip arthroscopy: An anatomic study of portal placement and relationship to the extra-articular structures

The purpose of this study is to accurately describe the relationship of the major neurovascular structures to standard portals used in hip arthroscopy Placement of three standard arthroscopic portals was simulated in eight fresh paired cadaveric hip specimens by placing Steinmann pins into the joint under fluoroscopic control. The specimens were then dissected and the relationship of the portals to the following structures was recorded: lateral femoral cutaneous nerve, femoral nerve, ascending branch of the lateral circumflex femoral artery, superior gluteal nerve, and sciatic nerve. The lateral femoral cutaneous nerve had divided into three or more branches at the level of the anterior portal. The anterior portal averaged only 0.3 cm from one of these branches. The average minimum distance from the anterior portal to the femoral nerve was 3.2 cm. The ascending branch of the lateral circumflex femoral artery averaged 3.7 cm from the anterior portal. A terminal branch of this vessel was present in three specimens 0.3 cm from the portal. The superior gluteal nerve averaged 4.4 cm superior to the anterolateral and posterolateral portals. The sciatic nerve averaged 2.9 cm from the posterolateral portal. From this study, these portal placements appear to be safe. Proper positioning depends on careful attention to the topographical anatomy about the hip. Avoidance of the important structures depends on proper positioning and proper technique in portal placement.     

不同体位下肘关节镜常用入路与周围神经的解剖关系

目的 比较不同体位下各种肘关节镜入路与毗邻神经血管的解剖关系,评价肘关节镜操作中各种标准入路的安全性及应用价值.方法 选用新鲜尸体肘关节10个进行解剖,测量9种标准肘关节镜入路与毗邻神经血管的最近距离,并根据各入路下关节镜检的镜下视野及操作灵活性评价其应用价值. 结果肘关节镜人路与毗邻神经距离受注水膨胀关节、肘关节伸直或屈曲及前臂旋前或旋后体位变化影响.肘关节屈曲90°前臂旋后、中立、旋前位,前外侧入路关节镜套管与桡神经距离分别为(2.9±1.1)mm、(4.5±1.5)mm、(5.8 ±1.7)mm,穿刺造成神经损伤风险大;肘关节伸直前臂旋后位2例肘关节中套管与桡神经直接接触.近端前内侧或近端前外侧人路观察肘关节前间室、后正中人路观察后间室视野良好且穿刺风险小.后方入路均安全. 结论近端前内侧或近端前外侧入路优于前内侧或前外侧人路,与后正中入路结合应用可基本满足多数肘关节镜手术的要求,是一组安全、有效的人路点.     

Anterior portals in shoulder arthroscopy

The anterior portal has been the major operative portal through which hand and motorized instrumentation have been introduced into the glenohumeral joint. This portal has been limited with respect to its access to structures in the anteroinferior aspect of the joint. Anatomical and clinical studies were undertaken to evaluate the safety and effectiveness of the use of an anterior inferior, as well as an anterior superior portal. Seventy-eight unembalmed cadaver specimens and 34 operative cases were used in the studies. Only an "inside out" technique using blunt instrumentation is recommended in creating the anterior inferior portal. The margin of safety with respect to the musculocutaneous nerve is increased with adduction. The use of these two anterior portals greatly enhanced our ability to visualize and work directly on lesions of the glenohumeral ligament labral complex. These anterior portals can be safely created if guidelines are carefully followed by surgeons with considerable experience in shoulder arthroscopy.     

Ankle anatomy for the arthroscopist. Part I: The portals

Proper portal placement is critical to performing good diagnostic and therapeutic arthroscopy. When the portals are positioned improperly, visualization can be impaired, making diagnosis and treatment more difficult. Three main anterior portals are available in arthroscopy of the ankle: anteromedial, anterolateral, and anterocentral. Posterior portals are also routinely used in ankle arthroscopy and can be established at a posterolateral or posteromedial position or directly through the Achilles tendon. Because of the potential for serious complications, the anterocentral and transAchilles portals are no longer used. Other portals have been described to obtain more complete access, particularly to the posterior compartment of the ankle joint. This work reviews the relationships that exist between the most important anatomic structures and arthroscopic portals of the ankle.     

Ankle arthroscopy: neurovascular and arthroscopic anatomy of standard and trans-achilles tendon portal placement

Ankle arthroscopy is an accepted method of evaluating ankle disorders. Accurate arthroscopic portal placement is essential because of the proximity of superficial and deep neurovascular and tendinous structures of the ankle. In order to define this anatomy as it pertains to safe portal placement, five fresh frozen cadaver ankles were dissected after standard arthroscopic portals were placed anteriorly and posteriorly. All structures were identified. The distances to these structures from the most lateral portals were recorded. Five other ankles were arthroscoped using standard portals and evaluated. In addition, a trans-achilles tendon (TAT) approach was evaluated for portal use. Ankle arthroscopy can be performed in a safe, reproducible manner when the following recommendations are followed: (a) outline tendinous structures, and remain parallel to them with the knife blade to avoid laceration of underlying structures; (b) penetrate only the skin with the knife to avoid laceration of superficial nerves in the subcutaneous tissue; (c) perform pre- and postneurovascular examination; and (d) understand that anterocentral and posteromedial portals are potentially hazardous to their respective neurovascular bundles. The TAT approach, based only on cadaver studies, appears anatomically safe and offers the potential advantage of an additional posterior portal.     

Arthroscopic resection of the radial head.

The authors describe arthroscopic radial head resection in patients with post-traumatic arthritis after fractures of the radial head or in patients with rheumatoid arthritis of the elbow joint, as an expanded indication for elbow arthroscopy. Arthroscopic radial head resection allows the surgeon to deal with the intrinsic joint pathology, as well as with accompanying symptoms such as synovitis, capsular contracture, or loose bodies. The portals used are the proximal medial, anterolateral, and the midlateral portal. The anterior three quarters of the radial head and 2 to 3 mm of the radial neck are resected with the stone-cutting abrader in the anterolateral portal and the arthroscope in the proximal medial portal. For resection of the posterior portion of the radial head, the abrader may be transferred to the midlateral portal. This permits resection of the remnants of the radial head posteriorly and also at the proximal radioulnar joint. Arthroscopic treatment allows the patient to begin and maintain an aggressive postoperative physical therapy program immediately after surgery, thus decreasing the risk of anterior scarring and reoccurring contracture of the capsule of the elbow joint.     

An aiming guide for anterior portal placement in hip arthroscopy

Hip arthroscopy has become a standard surgical procedure. Specific portals and portal placement techniques are well described and routinely used. The anterior portal placement relies on the ability of the surgeon to introduce a needle into the joint from the landmark located at the crossing of a vertical line from the anterior superior iliac spine and a horizontal line from the greater trochanter. Directing the needle at 30° medially and 45° proximally is recommended, but some adjustment is always necessary to access the joint. Multiple punctures are often needed to place the needle in the correct path into the hip. This increases the risk of injury by puncture of the structures adjacent to the site of the anterior portal and increases surgical time. This study reports the use of a guide device we developed to assist anterior portal placement. The device consists of an intra-articular probe attached to an extra-articular aiming guide that introduces the needle into the hip joint. The needle enters at the previously described landmark and is directed towards the tip of the probe inside the joint. Early clinical results are presented.     

肘关节镜"序贯五入路法"的有效性与安全性分析

目的 探讨肘关节镜"序贯五入路法"在肘关节损伤和疾病治疗中的有效性与安全性.方法 2004年4月至2007年5月期间收治53例肘关节镜手术患者,包括肘关节强直24例,骨折15例,肘关节游离体7例,桡骨小头脱位2例,关节结核8例,类风湿关节炎4例,骨化性肌炎5例,色素沉着绒毛结节性滑膜炎3例,滑膜软骨瘤1例.手术入路采用"序贯五入路法",由肘后"软点"建立第一入路后,关节镜监视下于前外侧建立第二入路,通过第二入路绕过冠突由内向外建立第三入路.再在肘后肱三头肌腱两侧建立后外侧人路和后内侧人路,作为第四、五入路.按顺序探查肘关节腔,并进行相应处理.其中3例转为切开手术.术后采取无痛性康复训练,对手术前、后肘关节Mayo功能评分进行比较.结果 46例患者术后获6～34个月(平均11.65个月)随访,Mayo评分:术前45～85分,平均(66.8±11.5)分,良14例,可21例,差11例;术后55～100分,平均(84.5～10.5)分,优16例,良21例,可8例,差1例.术后2例出现一过性神经麻痹症状,其中尺神经深支和桡神经深支各1例,3个月后恢复.结论 采用"序贯五入路法"肘关节镜下显露满意、视野清晰,手术效果好;手术入路安全,并发症少,值得在肘关节镜手术中推广使用.     

Medial and Lateral Malleolar Arteries in Ankle Arthroscopy: A Cadaver Study

Neurovascular injury may occur during ankle arthroscopy. The majority of complications are neurological injuries; however, vascular injuries do exist. Neurovascular structures are especially vulnerable during portal placement and debridement of anterior structures. Routine anteromedial and anterolateral portals are generally accepted to be safe; this is different from the anterocentral portal, which is associated with a higher risk of injury. However, injuries may occur in these relatively safe portals. The purpose of this cadaver study was to examine other relatively minor neurovascular structures such as medial and lateral malleolar arteries and to determine how these portals can be more safely placed. The distance between standard anteromedial, anterolateral portals and the medial and lateral malleolar arteries was measured in 18 ankles from 9 cadavers. These distances varied with the position of the ankle during portals placement, and measurements were obtained in both flexion and extension. The average distance in flexion and extension was 6.41 to 2.47 mm on the lateral side and 4.73 to 1.58 mm on the medial side. The distances significantly increased with ankle flexion and decreased with extension (P < .005). The current study demonstrated that there were other minor vascular structures at risk other than tibialis anterior artery and proper positioning of the ankle during portal placement, and that injury risk may be associated with ankle position. Ankle flexion may decrease the risk of damage to malleolar arteries and decrease minor vascular complications such as postoperative bleeding and hematoma.     

Understanding the medial ulnar collateral ligament of the elbow: Review of native ligament anatomy and function

The medial ulnar collateral ligament complex of the elbow, which is comprised of the anterior bundle [AB, more formally referred to as the medial ulnar collateral ligament (MUCL)], posterior (PB), and transverse ligament, is commonly injured in overhead throwing athletes. Attenuation or rupture of the ligament results in valgus instability with variable clinical presentations. The AB or MUCL is the strongest component of the ligamentous complex and the primary restraint to valgus stress. It is also composed of two separate bands (anterior and posterior) that provide reciprocal function with the anterior band tight in extension, and the posterior band tight in flexion. In individuals who fail comprehensive non-operative treatment, surgical repair or reconstruction of the MUCL is commonly required to restore elbow function and stability. A comprehensive understanding of the anatomy and biomechanical properties of the MUCL is imperative to optimize reconstructive efforts, and to enhance clinical and radiographic outcomes. Our understanding of the native anatomy and biomechanics of the MUCL has evolved over time. The precise locations of the origin and insertion footprint centers guide surgeons in proper graft placement with relation to bony anatomic landmarks. In recent studies, the ulnar insertion of the MUCL is described as larger than previously thought, with the center of the footprint at varying distances relative to the ulnar ridge, joint line, or sublime tubercle. The purpose of this review is to consolidate and summarize the existing literature regarding the native anatomy, biomechanical, and clinical significance of the entire medial ulnar collateral ligament complex, including the MUCL (AB), PB, and transverse ligament.