Safety of Anteromedial Portals in Elbow Arthroscopy: A Systematic Review of Cadaveric Studies

Cushing, Tucker; Finley, Zachary J.; O’Brien, Michael J.; Savoie, Felix H.; Myers, Leann; Medvedev, Gleb

doi:10.1016/j.arthro.2019.02.046

Cited by 12 publications

(19 citation statements)

References 22 publications

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“…This position, which is slightly more anterior than usually described positioning, allows better visualization of the joint and has been shown in cadaveric studies to put fewer structures at risk. 17 This more anterior portal also is extremely effective in arthritic elbows in allowing correct access into the joint. Tip #2: In arthritic elbows move both medial and lateral portals 0.5 mm more anterior to prevent the osteophytes from mis-directing the cannula out of the joint On the lateral side a modified anterolateral portal is used, which is established 2 cm proximal and 2 cm anterior to the lateral epicondyle.…”

Section: Portal Placementmentioning

confidence: 99%

Advanced elbow arthroscopy: Tips and tricks

Finley

Savoie

2021

Journal of Clinical Orthopaedics and Trauma

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Elbow arthroscopy can be a challenge, however, indications and benefits compared to open elbow surgery are rapidly evolving. The elbow has seemed to lag behind other joints including the knee, shoulder, ankle and the hip, both in number of cases and in widespread acceptance, as a joint amenable to arthroscopic management. This has occurred despite literature demonstrating successful utilization of arthroscopy in the management of a variety of injuries. The purpose of this review is to clarify and expand the indications for arthroscopy of the elbow in 2021. We will also offer tips and tricks to help make elbow arthroscopy more successful. Since originally publishing these guidelines in 2007, elbow arthroscopy has evolved, although the principles and progressions remain the same.

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Section: Portal Placementmentioning

confidence: 99%

Advanced elbow arthroscopy: Tips and tricks

Finley

Savoie

2021

Journal of Clinical Orthopaedics and Trauma

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“…Hackl et al demonstrated that the distance of the median nerve to the anterior tip of the coronoid and to the anterior border of the trochlea significantly increases from extension to 90° flexion [25]. These findings were supported by a recent review of cadaveric studies, which concluded that the distended elbow in a 90° flexed position minimizes the risk for neurovascular injury with the arthroscope [26].…”

Section: Discussionmentioning

confidence: 92%

“…For the median nerve, reliable landmarks have scarcely been reported, mostly by studies performed in arthroscopic settings and focused on defining anatomical relations at the level of the joint line, without investigating more distal regions. [13,17,18,[25][26][27][28][29]. Nevertheless, knowledge of median nerve position and behavior is essential in complex open surgery and revision cases and constitutes a precious help for all surgeons dealing with medial approaches, especially if lacking in a dedicated subspecialistic training on elbow surgery.…”

Section: Introductionmentioning

confidence: 99%

Anatomic relations of the median nerve to the ulnar insertion of the brachialis muscle: safety issues and implications for medial approaches to the elbow joint

Cucchi

Luceri

Menon

et al. 2021

Arch Orthop Trauma Surg

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Introduction Preventing nerve injury is critical in elbow surgery. Distal extension of medial approaches, required for coronoid fracture fixation and graft-replacement, may endanger the median nerve. This study aims to describe an easily identifiable and reproducible anatomical landmark to localize the median nerve distal to the joint line and to delineate how its relative position changes with elbow flexion and forearm rotation. Materials and methods The median nerve and the ulnar insertion of the brachialis muscle were identified in eleven fresh-frozen cadaveric specimens after dissection over an extended medial approach. The elbow was brought first in full extension and then in 90° flexion, and the shortest distance between the two structures was measured while rotating the forearm in full pronation, neutral position and full supination. Results The distance between the median nerve and the brachialis insertion was highest with the elbow flexed and the forearm in neutral position. All distances measured in flexion were larger than those in extension, and all distances measured from the most proximal point of the brachialis insertion were larger than those from the most distal point. Distances in pronation and in supination were smaller than to those in neutral forearm position. Conclusions The ulnar insertion of the brachialis is a reliable landmark to localize and protect the median nerve at the level of the coronoid base. Elbow flexion and neutral forearm position increase significantly the safety margins between the two structures; this information suggests some modifications to the previously described medial elbow approaches. Level of evidence Basic Science Study.

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“…A distalization of the AM portal can be conducted rather safely, with only a moderate risk of endangering the brachial artery and the median nerve, which lie more superficially, between the muscle bellies of the biceps brachii and the brachialis, and follow the medial border of the biceps brachii in an anterolateral direction. Nevertheless, elbow flexion and fluid joint distension are recommended to increase the distance of the median nerve to the anterior tip of the coronoid and to the anterior border of the trochlea, reducing the risk for neurovascular injuries during placement of medial portals [5,9,10]. Regarding the role of forearm rotation, conflicting results have been published, and no clear evidence exists to recommend a specific position (Fig.…”

Section: Medial Portalsmentioning

confidence: 99%