Arthroscopy of the elbow joint

Recently, arthroscopy of the elbow joint has become widespread and introduced into clinical practice. In addition to purely diagnostic purposes (revision of intraarticular structures, biopsy of synovial membrane and articular cartilage), various surgical procedures are performed: removal of intraarticular bodies, sanation of chondromalization foci, arthrolysis, etc.

[1], [2]

Method of arthroscopy of the elbow joint

Preliminary marking of the elbow joint when bending it to 90 °: marking the lateral and medial epicondyle of the humerus, the head of the radius and all used arthroscopic approaches.

Position of the patient

The supine position. The position of the patient is on the back, the arm in the shoulder joint is withdrawn to 90 °. The distal forearm and hand are fixed in such a way that, if necessary, it is possible to pull through a special suspension device attached to the operating table with a block and counterweight. At the same time, bending at the elbow joint is maintained at an angle of about 90 °.

Pronational position. The position of the patient is on the stomach. The test arm freely hangs from the edge of the operating table. In this version, the suspension system is not needed, the shoulder is withdrawn to 90 °, the angle of 90 ° bending is spontaneously set in the elbow joint. Under the shoulder joint and the upper third of the shoulder, a short stand with a roller is installed.

In the upper third of the shoulder, a pneumatic tourniquet is applied. The maximum pressure is 250 mm Hg.

At the first stage, the maximum filling of the elbow joint cavity with physiological saline is performed, which allows to displace the nervous and vascular structures anteriorly and excludes the possibility of their damage. Filling of the joint is made through a direct lateral access, in it a permanent cannula is installed for outflow. Topographically, this access is located in the center of the so-called Smith triangle, formed by the middle of the head of the radius, the tip of the elbow and the lateral epicondyle of the shoulder. The needle is inserted perpendicular to the skin surface through the muscles and the joint capsule. Usually the volume of the joint cavity is 15-25 ml. An indication that the joint is maximally filled is the flow of fluid from the needle under pressure. The recommended pressure in the joint cavity is up to 30 mm Hg. At a higher pressure, the capsules and the overgrowth of the radial nerve can occur along with overgrowth.

Most often, with arthroscopy of the elbow joint, three main accesses are used: anterolateral, anterolateral and posterolateral. The remaining accesses are considered additional and used as needed. It is unacceptable to "blindly manipulate" instruments in the joint cavity: this can lead to damage to the neurovascular bundle and / or articular cartilage, even with the maximum filling of the joint cavity.

Diagnostic arthroscopy of the elbow joint starts from the anterior part. This is due to the fact that the maximum expansion of the joint cavity is possible only if the joint capsule retains its tightness, and this condition is no longer met during the back access - accordingly, there is no maximum filling and movement of the neurovascular structures anteriorly.

Anterolateral access. According to JR Andrews (1985), this access is located 3 cm distal and 1 cm anterior to the lateral epicondyle. In this case, when introduced, the trocar passes ventral to the radial head through a short radius extensor of the hand, just 1 cm from the radial nerve located anteriorly. WG Carson (1991) defines the point for this access 3 cm distally and 2 cm anterior to the lateral epicondyle, resulting in even closer to the radial nerve. In the experiment on cadaveric drugs, we worked out the optimal, in our opinion, point for this access: it is located 1 cm distal and 1 cm anterior to the lateral epicondyle. In the longitudinal direction, a skin incision of 0.5 cm is made. The shell of the arthroscope with a blunt trocar is inserted strictly in the direction of the coronoid process. The trajectory runs straight, in front of the radial head, through a short radius of the extensor and 1 cm from the radial nerve. The arthroscope is injected with pronation of the forearm, which reduces the risk of damage to the deep branch of the radial nerve.

First of all, examine the medial section of the joint capsule.

In some cases, it can be noted wrinkling and scarring of the medial part of the joint capsule. With hypertrophy of synovial villi, which makes it difficult to examine the joint, the synovial membrane is shaved.

Then the arthroscope is moved from the medial to the middle and then to the lateral joint. Consistently inspect the block of the humerus, the coronoid process, the head of the condyle of the shoulder and the head of the radius. When examining these structures, attention is drawn to the state of the cartilaginous cover, the presence of chondromalization foci, their prevalence, the depth of the cartilage plate lesion, the presence of osteophytes of the coronoid process, its deformation and its compliance with the humerus block when flexing and expanding. The head of the arm is viewed from the front, the head of the radius - with rotational movements of the forearm, which makes it possible to inspect about three quarters of its surface.

At the next stage, the anterior medial approach is determined, located 2 cm distal and 2 cm anterior to the medial epicondyle. The path of the trocar is very close to the main vascular-neural bundle. Research Lynch et al. (1996), and our observations showed that with a joint that is not filled with saline, the arthroscope passes only 6 mm from the median nerve and the nearby brachial artery, the place of division of which is approximately at the level of the neck of the radius. When the joint is filled, the main vascular-neural bundle is displaced by 8-10 mm anteriorly. In addition, when passing the trocar, it is necessary to unfold the patient's arm to 110-120 °. This is due to the fact that there is a so-called mobile ulnar nerve, which when bending the elbow joint can move to the inner condyle of the humerus and, accordingly, may be in the area of passage of the trocar or other arthroscopic instruments. This access is considered instrumental.

There is a second way of setting anteromedial access. In this arthroscope, introduced through the anterolateral access, is advanced to the lower medial joint. Then the arthroscope is replaced by a long trocar that rests against the medial wall of the joint, and an incision is made from the outside in the region of the protruding end of the trocar. In our opinion, the second method has advantages, since there is no risk of damage to the articular cartilage upon introduction of the trocar. In addition, the point selected in the joint cavity under vision control is maximally removed from the anterior surface of the joint and, hence, from the neurovascular bundle.

During arthroscopy, an inversion is possible, i.e. Permutation of the arthroscope and instruments, as the best visualization of the synovial membrane of the lateral part of the joint, the head and the arm of the arm and the head of the radius are made from anterior medial access.

The main diagnostic access for the posterior part of the joint is considered posterolateral access, localized 3 cm proximal to the tip of the ulnar process, immediately behind the lateral edge of the tendon of the triceps. In the access zone pass the branches of the posterior cutaneous nerve of the forearm and lateral cutaneous nerve of the shoulder. To prevent their damage, it is necessary to exclude the use of an acute trocar when access is made.

The second way of installation of posterolateral access is along the articular gap between the posterior posterior and mid-lateral access. In this case, the arthroscope passes into the pit of the elbow process from the bottom up, which has its advantages for the review. Instrumental access will then be a straight back. By the posterolateral approach, one can visualize the fossa of the ulnar process, the apex of the ulnar process, the posterolateral side of the humerus articulation. When examining, it is necessary to perform flexion-extensor movements in the joint, which allows more complete examination of this zone.

Direct posterior access is slightly lateral to the median line passing through the ulnar process. Troakar is carried directly through the tendon of the triceps muscle towards the center of the ulnar fossa. This access is used to install the arthroscope, while the instruments are carried through the posterolateral access.

After the arthroscopy, sutures are applied to skin wounds. Immobilization of a limb is shown on a bandage bandage. The next day, active movements begin in the elbow joint.

Contraindications to arthroscopy of the elbow joint

Contraindications to arthroscopy in the following cases:

• presence of general and local infection;
• deforming arthrosis of III - IV degree with a significant narrowing of the joint gap and deformation of the articular ends;
• Severe contractures of the elbow joint with a decrease in the volume of the joint cavity.

[3], [4], [5], [6], [7]

Errors and complications in arthroscopy of the elbow joint

According to the literature, the most serious complications in carrying out arthroscopy of the elbow joint are neurovascular. GJ Linch et al. (1986) reported the results of 21 elbow joint arthroscopy. One patient had a short-term paresis of the radial nerve, which, in the author's opinion, was associated with overgrowth of the joint cavity, the other had a short-term paresis of the median nerve, caused by the action of the local anesthetic, and the formed neuroma of the medial cutaneous nerve of the forearm. JR Andrews and WG Carson (1985) also reported temporal paresis of the median nerve. At sharp and rough manipulations with artroskopicheskimi tools in a cavity of a joint damage of an articulate cartilage is possible.

In conclusion, it should be noted that arthroscopy of the elbow joint is a promising method of examination and treatment. Malotraumatism, the maximum diagnostic value, as well as the possibility of combining arthroscopy with open surgical interventions, makes it possible to significantly improve the effectiveness of treatment of a very complicated intraarticular pathology of the elbow joint.

[8], [9], [10], [11]