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