Elbow Arthroscopy - Shoulder & Elbow

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

Portal	Location	Use	Nerve at Risk
Proximal anterolateral	1-2cm proximal, 1cm anterior to lateral epicondyle		Radial (risk decreases as portal moved more proximally)
Distal anterolateral	1 cm anterior and 1-3cm distal to lateral epicondyle	1st portal for supine position See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa	Radial and lateral antebrachial cutaneous
Direct lateral (or midlateral)	"soft spot" portal (in triangle formed by olecranon, radial head, epicondyle)	Initial site for joint distension before scope is inserted, 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 and 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 (3-4mm away) and 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 triceps center of anconeus triangle	Elbow 20-30deg 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 proximal anterolateral portal
  - medial antebrachial cutaneous - at risk from proximal anteromedial portal
  - PIN palsy - at risk from proximal 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)