Prevention of Nerve Injuries Using a Safety-Driven Step-Wise Technique for Arthroscopic Capsulectomy of the Elbow (SS-23)

Abstract

The risk of nerve injury is of concern in arthroscopic elbow release, but has not previously been described in a large series. We report a series of 502 arthroscopic capsular releases over 15 years by a single surgeon, using a standardized technique, with specific focus on neurological outcomes. There were no permanent nerve injuries, with 23 patients (4.6%) noted to have transient nerve palsies due to varied factors such as tourniquet time, retraction, or medial skin incisions. In this series, a standardized safety-driven approach and experience of the surgeon decreased the risk of nerve injury. Release of contracture is a common indication for elbow arthroscopy. The major factor limiting use of arthroscopy for contracture release is the concern about nerve injury, but the risk of nerve injury has not been documented in a large series. The purpose of this report is to document the risk of nerve injury in arthroscopic contracture release using a safety-driven step-wise technique. A retrospective review was performed of 502 consecutive cases of arthroscopic contracture release in 464 patients by one surgeon during a 15 year period. The safety-driven step-wise technique evolved during the first 100 cases from detaching to incising to completely excising the capsule. For the next 402 cases arthroscopic capsulectomy was performed in a standardized sequence: (1) Get In and Establish a View, (2) Create a Space in Which to Work, (3) Bone Removal, and (4) Capsulectomy. Retractors were used to maintain space and to protect the nerves. Suction was detached from the shavers and burrs. Cases included complex and revision contracture releases. Transient sensory motor nerve palsies that resolved within three days developed in three cases (0.6%), two from blunt retraction and one from local anesthetic injection. Two medial antebrachial cutaneous nerve injuries from portal sites occurred but resolved completely within 3 and 18 months respectively. Thus, 5 nerve palsies (1%) occurred as a direct result of the arthroscopy itself. Eleven patients (2.2%) experienced transient diffuse sensory motor nerve palsies involving 2 or 3 major nerves that were associated with prolonged tourniquet times; all resolved within 3 days. Two patients (0.4%) had a transient partial sensory motor after ulnar nerve transposition that resolved completely within 1-3 days. Seven patients experienced sensory dysesthesia of the skin innervated by the posterior branch of the medial antebrachial cutaneous nerve due to a posterior medial incision for decompression of the ulnar nerve. These involved the skin in the region of the olecranon and six of seven (1.4%) resolved completely within three months to two years. The final patient was lost to follow-up. Thus, a total of 19 cases (3.8%) experienced nerve palsies indirectly related to the arthroscopy (due to other factors such as prolonged tourniquet time, ulnar nerve transposition, or a posteromedial skin incision). Overall, 23 of the 502 cases (4.6%) experienced transient nerve palsies that resolved completely with 1 additional patient (0.2%) having a cutaneous nerve dysesthesia but was lost to follow-up. There were no permanent nerve injuries. Temporary nerve injuries are a definite risk with arthroscopic elbow contracture release. They occur due to tourniquet palsies, compression by instruments and retractors. However, under the conditions in this study, we found permanent nerve injuries to be a minimal risk, with a surgeon highly experienced in open and arthroscopic elbow surgery, the adherence to a safety-driven step-wise technique, the routine use of retractors and avoidance of suction on shavers. The risk of nerve injury is more related to the experience and expertise of the operating team and facility than to the severity of the contracture.