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Updated: Mar 6 2024

Elbow Arthroscopy: Indications & Approach

Images portal.jpg arthroscopy.jpg
  • Introduction
    • Indications
      • loose body removal
      • osteophyte debridement
      • synovectomy
      • capsular releases for stiffness
      • osteochondritis dissecans of capitellum
      • lateral epicondylitis
      • debridement for septic arthritis
    • Contraindications
      • prior trauma
      • surgical scarring
      • previous ulnar nerve transposition
        • ulnar nerve subluxation is not an absolute contraindication, but it should be identified prior to surgery, especially with prior submuscular or intramuscular transposition
    • Advantages
      • improved articular visualization
      • decreased postoperative pain
      • faster postoperative recovery
    • Disadvantages
      • technically demanding
      • high risk of damage to neurovascular structures due to proximity to the joint
  • Positioning
    • Patient position may be
      • supine
      • prone
      • lateral decubitus
    • Anesthesia
      • general anesthesia (allows muscle relaxation and placement of patient in prone or lateral decubitus position)
      • regional anesthesia may be used; it does not allow for immediate evaluation of nerve function after surgery and patients may not tolerate the uncomfortable position for a prolonged period
  • Technique and Portals
    • Portal placement technique
      • fully distend joint through lateral soft spot before placing portals
        • capsule distension moves NV structures away from the joint when trocar is introduced
      • careful "nick and spread" technique using hemostat
      • posterior medial portal usually avoided due to proximity to ulnar nerve
    • Elbow position
      • establish anterior portals with elbow flexed 90deg
      • establish posterior portals in some extension
    • Standard 30deg arthroscope
    • Tourniquet
    • Solid cannulas are helpful to maintain fluid distension and avoid fluid extravasation into soft tissue (versus trephinated)
    • Landmarks: olecranon, lateral and medial epicondyles, radiocapitellar joint, ulnar nerve
      • mark out before insufflating joint as distension can alter position
    • Summary of portals
      • portal selection depends on the underlying pathology
      • after joint insufflation, establish either medially- or laterally-based viewing portal, then establish working portal under direct visualization via needle localization.
        • establishing a medially-based portal first, prior to joint/soft-tissue swelling, may be advantageous to avoid neurovascular injury
      • Elbow arthroscopy portals
      • Portal
      • Location
      • Use
      • Nerves at risk
      • Proximal anterolateral
      • 1-2cm proximal, 1cm anterior to lateral epicondyle
      •  Radial (risk decreases as portal moved more proximally)
      • Distal anterolateral 
      • 1-3 cm distal,1 cm anterior to lateral epicondyle
      • 1st portal for supine position
      • See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa
      •  PIN
      • Lateral antebrachial cutaneous
      • Direct lateral (or mid lateral)
      • "soft spot" portal (in triangle formed by olecranon, radial head, epicondyle)
      • Initial site for joint distension before scope is inserted
      • For viewing posterior compartment (capitellum, radial head, radioulnar articulation)
      • Relatively safe
      • Lateral antebrachial cutaneous nerve
      • Anteromedial 
      • 2 cm anterior and 2cm distal to medial epicondyle.
      • Used most often to augment the proximal anteromedial portal to access medial recess.
      • Place under direct visualization.
      •  Medial antebrachial cutaneous
      • Median
      • Proximal anteromedial (superomedial)
      • 2cm proximal to medial epicondyle, anterior to intermuscular septum
      • Viewing entire anterior compartment, radial head, capitellum, coronoid, trochlea
      •  Medial antebrachial cutaneous
      • Ulnar (7 mm away)
      • Median
      • Straight posterior (transtriceps)
      • 3cm proximal to olecranon, triceps midline (musculotend. junction)
      • Elbow partially extended
      • Good for removing impinging olecranon osteophytes and loose bodies from posteromedial compartment
      • Posterior antebrachial cutaneous
      • Ulnar nerve
      • Posterolateral
      • 2-3 cm proximal to olecranon and just lateral to tricepscenter of anconeus triangle
      • Elbow 20-30 deg flexion (to relax triceps)
      • Best access to posterior compartment, radiocapitellar joint (debridement of OCD capitellum), olecranon fossa and posterior structures
      • Posterior antebrachial cutaneous
      • Medial brachial cutaneous
      • Ulnar
  • Complications
    • Nerve palsy (1-5%)
      • greatest risks for nerve palsy
        • underlying rheumatoid arthritis
        • elbow contracture
      • nerves
        • transient ulnar nerve palsy (most common)
        • radial nerve palsy (second most common) - at risk from standard anterolateral portal
          • brachialis provides protective layer between anterior capsule and radial nerve proximal to the radial neck
        • medial antebrachial cutaneous and median nerves - at risk from anteromedial portal
        • PIN palsy - at risk from anterolateral portal
      • mechanism
        • direct injury
          • trocars and instrumentation
          • failure to use blunt dissection (neuromas)
        • indirect injury
          • compartment syndrome (aggressive distension, fluid extravasation)
          • local anesthesia extravasation (transient)
    • Joint ankylosis/ heterotopic ossification
      • less than open surgery
      • minimize bleeding
    • Infection
      • sinus tract formation (posterolateral portal)
      • higher risk with intra-articular steroid injection at the time of arthroscopy 
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