Hello, this is Scott Steinman, and I'll go through one way to do elbow arthroscopy. This is not the best way to do elbow arthroscopy, just one way that I prefer to do it. But again, this is not the only way and certainly not the best way. Disclosures. Elbow arthroscopy is becoming a more common procedure. Contracts release and treatment of arthritis. Unfortunately, the neuroanatomy can get in the way and every nerve has been reported injured about the elbow, even from good surgeons. Preoperative planning is very helpful. In addition to x-rays, I believe a 3D CT scan is very helpful to give you a roadmap of where you need to remove osteophytes. You can see here osteophytes anteriorly in the radial head fossa and at the coronoid tip and posteriorly we can see osteophytes here also. We can't forget that open exposure is still a good option. General anesthesia is preferred in my practice simply because if I do a block, I won't be able to discern the nerve status post-op until several hours or maybe the next day. The operative setup is, in my practice, the lateral decubitus position. We can see here the artist representation of that and I'll go through the steps. Here we can see positioning the patient. You want to have the opposite arm out of the way and anesthesia can help you with this. A low-profile arm holder is helpful in these cases, not a large knee holder, for example. Here we can see the positioning of the patient. You want to make sure you can flex the elbow up when needed. You can see we use a non-sterile tourniquet and then use a co-band to hold this in position. Here we can see the before draping and after giving exposure for the elbow. It's important to remember there is no wrong portal, just safe portals. It's fine to start medial, lateral, or even posterior. There's no limit on the number of portals, just safe portals. Having said that, I tend to start anterolateral, just over the rheocapitellar joint, and I mark out all potential portals. Here we can see medial portals and anterolateral injection. After marking out the portals, I typically insufflate the elbow with 20 cc's of saline and typically I do this at the anterolateral portal. Here we can see that established. A straight hemostat gets us into the joint. Then we are able to place the trocar. Here we can see the trocar being placed across the elbow joint, beginning the medial portal from an inside-out approach. We can simply incise the skin medially and then comb over the trocar with a cannula. I always maintain a constant outflow through the cannula and use retractors and use a switching stick once to switch from lateral to medial viewing. Here we can see doing that over a switching stick. Posterior portals are established also, and an articulating retractor can be helpful to lift up the fat pad for greater visualization. To summarize through the steps, I like to say the elbow is the highest thing in the room and again we tilt the patient toward the surgeon. Here we can see the anterolateral portal, which is essentially right over the radial capitella joint. This is the portal that's closest to a major nerve, the radial nerve. Do your bony work first, removing osteobites, particularly off of the humerus, removing loose bodies, and then stripping the capsule off of the humerus, followed by arthroscopic resection with a shaver. As you can see here, I do not remove the capsule that is near the radial nerve. I used to do a complete capsulectomy, but I do not do that anymore. I don't think you need to remove the capsule by the radial nerve, which can make for a dangerous procedure. Some arthroscopic anatomy. Here we can see the fat pad. This is in the anatomy lab and you can see the radial nerve is hiding just inside that fat pad. This is an older procedure that I did where I did a complete capsulectomy and you can see the radial nerve and you can see how close this really is to the joint and just above the area of the radial head. So I don't do this anymore. I leave a patch of capsule there to make it a safer procedure. The median nerve is a little shy, is protected by the brachialis, and you should never see the median nerve during an elbow arthroscopy. The ulnar nerve hides right behind the posterior medial capsule, so you have to remember if you're releasing that capsule, the ulnar nerve is very close. Range of spotting removal is important, but it's the osteophytes that usually affect range of motion. Minor complications include a heterotopic bone after an elbow scope. I've had two or three cases of heterotopic bone and this typically is a open procedure for me to remove the heterotopic bone. Here we can see the heterotopic bone being removed after an elbow scope. Recently, we wrote up an editorial in the Arthroscopy Journal about safe elbow arthroscopy, which I refer you to. Remember to start with small cases before moving on to bigger cases. Thank you very much.

elbow arthroscopy

neuroanatomy

operative setup

nerve safety

preoperative planning