Thank you very much. Thank you to Anna for the opportunity. Thank you for your brave souls for staying put, and I've just sort of combined the two talks to save some boredom. There are no disclosures. So elbow arthroscopy is well established. It's one of the more challenging joints, and of course, neurovascular complications, one of the things we all worry about medially when we're working on the capsule or medial pathologies or laterally when we're working on lateral pathologies such as tennis elbow or capsulectomies, we're worried about the median nerve medially and radial nerve laterally. So there are some literature that talks about the anterior capsule being breached by the pathology itself, i.e., synovitis and rheumatoid, but when you talk about some literature, it talks about 0 to 14% neurovascular injury. But can we really blame the pathology for the neurovascular injury? So there are a multitude of case reports, small series of neurovascular injury. For instance, this report talks about radiofrequency probe that transiently gives a radial nerve palsy, and there's a whole host of other case reports, case series, literature talking about either partial, temporary, or permanent loss to a neurovascular structure, and these can sometimes be very devastating injuries. So what's to blame? So we are traditionally taught anatomy in this forum, and it's becoming less and less hands-on, so now we've got even less hands-on with all these virtual reality modes of education, and when you start taking off the muscles, this is exactly why the elbow is such a popular joint for arthroscopy. So you have a multitude of nerves, vessels, and lymphatics, and when you look at the lateral side, we're now looking at the lateral side of the joint with the extensor mass still there, the radial nerve is not that far from what you can see to be the capsule. So this is what we know, the radial nerve is close to the capsule, and when you go on to the medial side and you remove, these are my animations, by the way, I've spent hours, I'm quite proud of them, they're not very good, but they're okay, but on the medial side, you take away the brachialis and biceps, you can see the medial nerve brachial artery, and then when you take away the capsule, then you really start to understand the intra-articular relationship of some of these nerves, so there's the medial nerve and the radial nerve in their sort of different trajectories. So really, arthroscopists have not been well-educated in terms of where is the nerve in relation to an intra-arthroscopic view. We have studies that talk about where the nerves are in relation to the portals that we place and the risks that the portals place. So we're traditionally taught that, so the question really then becomes, our anatomical understanding within the joint is not as it should be. So this is why we think the rate, so why does the neurovascular injury risk profile in elbow scope so high? So when you're inside a joint, this is what you see. You see a capitellum at 11 o'clock, you see a lateral trochlear ridge at roundabout 10 o'clock, you see a radial head, you see a PRUJ, and you see a coronoid. You don't see any nerves at this point, but you're going to start working on structures without seeing the nerves, which is the bastion of open surgery. And so we're working on, so this is a capsulectomy, for instance, and we're working on a procedure, not knowing where the nerves are, and it's not surprising that nerves get injured. So when you then start seeing a duckbill with muscle, that means you've breached the plane of the structure you're trying to remove for a stiff elbow, for instance, i.e. the capsule has been taken off, as well as muscle. So that's the danger. So our aim of the study was to identify a better way to describe where the radial nerve and median nerve are in the front of the elbow, relevant to an arthroscopy. We took 70 elbows, bilateral 35 elbows. We kept them in an arthroscopic position, testing them in pronation and supination. We did almost no dissection, and in fact, they were whole arms to prevent a traction issue with where the nerves are. We actually measured a multitude of parameters, such as the coronoid fossa, the intertrochlear distances, the lateral trochlear ridge, the radiohead fossa, the capitellum, and the radial head. And we took lots and lots of measurements over several years and been using these parameters in our own clinical practice. And I'm not going to bore you with these results because, in fact, they are not what we're talking about. So when we talk about the neurovascular bundle width, we thought there's going to be a relevance, and there isn't. We talked about, where is the median nerve in relation to all these parameters? And we had all these data in terms of 1.6 millimeters from the coronoid fossa base, 2.2 millimeters from the tip of the coronoid, and you can see the median nerve even does translate inside that intertrochlear distance. The radial nerve is the same. We had lots and lots of measurements of the radial nerve, both in pronation and supination, in relation to all of these. But what we actually found, and I apologize, the median nerve data is not here, but for the radial nerve, the radial nerve never transgressed the lateral rim of the radiohead. It never transgressed medial to the PRUJ. The median nerve equally did not transgress the medial trochlear ridge, nor did it transgress the lateral trochlear ridge. So what we decided to do was, instead of giving arthroscopists data with millimeters, we decided that it would be more relevant to talk about a normalized parameter. Normalized parametric measures are those that are available to you at the site of surgery, i.e. all these fossa landmarks. We've been using normalization for many studies in the past. For instance, on the left, we used it for open surgeries for bicipital tuberosity in relation to where the radial nerve is. The middle study is where the radial nerve crosses from the posterior to the anterior compartment using the transepicondylar distance. And the third study was where the radial nerve is distal to the elbow in forearm rotational positions, again using the transepicondylar distance. So why do we need to know where these nerves are? Well, if you don't know, you can inadvertently damage the nerve. You can do an incomplete procedure because you're scared of where the nerve is. So by using a paranormalized method, you are inside a joint using a safety margin. So what we tried to do was to highlight safety windows, or actually danger windows and safety margins. So you can see the two measures for the median neurovascular bundle is the medial trochlear ridge and the lateral trochlear ridge. And these are then put into an arthroscopic view. So you have a red danger zone in that window. But you've got safety margins on either side. So if you're going to do a capsulectomy and you need to be there, this is where you see the medial nerve on the right. And the same with the radial nerve. So the radial nerve, again, if you stick with breaching the capsule on either the PRUJ or on the lateral radial rim, you can see the radial nerve right there on the medial margin of the brachialis right there. So this is a submission by David Rusch who presented this. Nerve injuries are probably underreported. And this is a problem because we as an orthopedic body need to know how many radial nerves and median nerves and nerve injuries are happening. So we need some form of anonymized reporting because, you know, we don't want to damage people's reputations. But we need to understand the problem. So I think this, if anyone from Anna is listening, we need an anonymized platform for getting these reported. But there you have the take-home message. Stick with those three parameters. Lateral radial rim, PRUJ, or medial to the medial trochlear rim. Thank you very much.

elbow arthroscopy

neurovascular complications

intra-articular location

nerve injuries

anonymized reporting platform