Dr. Zaba, my charge is to discuss the basics of elbow arthroscopy, setting up for success. I have nothing to disclose pertaining to this specific talk. As you can see in this cartoon schematic here, there's a lot of nervous tissues surrounding the elbow. We're gonna discuss today about the indications, contraindications, considerations, setup, anatomy, and pearls, while being thoughtful of the adjacent neurovascular structures. Well, it's important to incorporate elbow arthroscopy because it can treat a myriad of pathologies, such as low occlinogen monopathy, arthritis, ankylosis, loose bodies, instability, chondral issues such as OCD of the capitellum, fractures, intraarticular joint sepsis, and synovial disorders. However, we must be aware of the patient's anatomy, whether they've had previous surgery, have peritopic ossification, previous malunited fracture, or a congenital radial head dislocation, may be a contraindication to proceed with arthroscopic techniques over open techniques. We also have to be aware that 16% of the population has ulnar nerve subluxation, and that may interfere with the creation of portals and put that structure at risk. For people who have already had ulnar nerve surgery, there are three possible scenarios that you can encounter prior to doing arthroscopy. One would be that the nerve is palpable. This is an easy circumstance because you palpate it, identify it, and make your portal accordingly. Two, the nerve is equivocal. In that circumstance, usually a subcutaneous transposition. You make a small incision, identify the nerve, then around the nerve, you make your medial-sided portal. The third is typically with a submuscular transposition where the location is truly unknown. In that circumstance, a medial portal may be contraindicated, and you may want to adopt two lateral portals or just go to an open technique. The setup is crucial. How you start the procedure must be consistent in the position of the patient. You must visualize the landmarks and have a home to prevent from getting lost. You always need a backup plan to prepare for open surgery, and it's important to make perfect portals. If you don't make perfect portals, you can struggle and also put the adjacent neurovascular structures at unnecessary risk. So I urge you to take your time, whether it be a cadaver or a living human, be very methodical and conscientious about how these portals are made. There's two ways to really do elbow arthroscopy, either prone or lateral. In the prone position, anesthesia may be a consideration. As well, you have no access to the anterior knee. Laterally, in my patient population, you can have issues with the medial portal having a obese patient and a need for a commercial arm holder. This is how I proceed with arthroscopy in the prone position. This is looking down at the operative table. There are bolsters underneath the chest and hips. There's a towel pack in which the arm will rest on for surgery, and all bony prompts is retarded. This is how it looks like at the time of arthroscopy. Then if I want to do a combined open surgery, whether it's harvesting the palmaris longus or a nerve surgery or a UCL reconstruction, I can just internally rotate the shoulder and have nice access to medial elbow and forearm. Now, if I want to work laterally, I can do the same by axillary rotating the shoulder, and now I have access to the extensor tendon in the lateral ulnar collateral ligament complex. And if I want, for UCL reconstruction, I can do a posterior harvest technique to get one of the hamstring tendons of the knee at the same time. The setup is similar to neo-arthroscopy with a four millimeter 30 degree arthroscope. That may be helpful at times to use a seven degree scope, especially when dealing with intra-articular fractures. I utilize gravity inflow as opposed to a pump. I use a tourniquet. My solution is without open effort. I co-band the forearm to prevent extravasation and also prevent compartment syndrome because it's in the dependent position. I utilize a general anesthetic over regional. However, I do consider post-operatively a regional block only after the neurovascular examination has been confirmed to be intact. The portals I make in a very similar manner. I palpate the overlying skin of the ulnar nerve and I mark it as I do with the medial abdicondyle, lateral abdicondyle, the rare capillary articulation, and the tip of the olecranon. I want to distend the joint. This may bring away the neurovascular structures, but more importantly, it makes it easier to enter the joint itself. This video depicts in the cadaver, placing the spinal needle in the olecranon fossa, instilling saline, and you can see here lateral capsular distension and a passive extension of the elbow that occur to confirm the joint is being adequately distended prior to creating the portals. The portals, I skin-neck incision only in line with the at-risk structures. I make the portals with the elbow inflection, and once they're created, I maintain their position with metallic cannulas in which I can plug and play, moving interchangeably my cannula and my shaver back and forth without needing to traverse repetitively the adjacent neurovascular structures. I typically start viewing from the proximal intramedial portal. This is two centimeters proximal and one centimeter anterior to the medial abdicondyle in intermuscular septum, but this is a rough estimate and you can't hold true if you're operating on a six-foot, eight-patient or a five-foot patient. The at-risk structures of the ulnar nerve, therefore, you need to know if it's been transposed because it's clearly at risk in that circumstance. The antebrachial cutaneous nerve is also at risk, and if you veer more medially or centrally, the median nerve and brachial artery are also at risk. You have to understand that in the anterior compartment where you're gonna start visualization is like a rectangle. You wanna enter into the far end of the rectangle with your camera to afford the best visualization of the entirety of the joint. In this circumstance, this is the technique I utilize to make this portal and ensure it's in the appropriate position and to maximize my visualization. You can see skin-neck incision only. Now I'm gonna use a blunt trocar to enter into the skin. I'm gonna then take that tip and touch the anterohumeral cortex, and I'm gonna slide down to the joint. I'm gonna feel the joint capsule. Then I'm gonna drop my hand as I push it into the joint. You can see an egressive fluid to confirm intraarticular placement. When you look from the medial side, you'll see the lateral structures of the capsule, the rare capillary articulation, and then you can look back to see the tip of the coronoid, and you know that that's the appropriate position of this cannula that gives you the best visualization. Laterally, after I've established a healing portal, I always make it with an outside-in technique with a spinal needle. However, Dr. Field has done a nice anatomic description of the different portals you can utilize, and you may vary in their locations depending on the pathology in which you encounter. Over here, the radial nerve, the posterior branch of the lateral intraperitoneus nerve are at risk. So this is how close the radial nerve is. This is a cadaveric specimen, viewing immediately over to the lateral side. The shaver is doing a capsulectomy and opening up a window. Once that window's open, you're gonna see a stripe of fat pad above that. I'm gonna just turn my suction on, and I'm gonna bring the radial nerve down into the field. At this point, I'm gonna take a probe within here, and then I'm gonna bring that into the joint just to show how close it is to the radial capillary articulation. What this video really shows is how close this nerve is, and also that you must have a home and be aware at all times where you're operating within the elbow. Now, making a portal with a purpose is addressing the pathology with the best portal as possible. You can see here that there's a condyle issue at the capitellum in the anterior elbow. Therefore, the spinal needle is more mid-articulation. It's a little more distal than typical, but it allows my shaver to enter into that joint. Whereas on the right side, you can see a portal entering the more traditional proximal-interlateral position, and that's gonna be able to access the tip of the cornoid if you need to address pathology there or other structures. So I always understand the pathology and make the portals accordingly to address appropriately. Posteriorly, the posterior central portal is three centimeters from the tip of the olecranon through the triceps. You use the spinal nerve to feel the depth of the olecranon fossa to localize this. At risk is the owner move immediately, and it's very close in proximity, so with great care, especially when you're using a shaver, never use suction in this area. Posterior lateral portal is just lateral to the posterior central, and it's off of the edge of the triceps tendon with similar at-risk structures. In order to visualize the posterior compartment, there's a technique that can be utilized with your 30-degree obliquity. You're gonna start with the portal in the olecranon fossa. You're gonna put the obliquity downwards towards your belly button, and then if you wanna go to the medial or lateral gutter, you're gonna change your obliquity in this manner depicted on the outside of the view. Now, from the arthroscopic vantage point, this is what it looks like looking down the medial gutter. You can see here that the obliquity is pointing centrally. Now, you're gonna bring the obliquity and bring it down posteriorly to the tip of the olecranon fossa, which is here, and then you're gonna go centrally again with the obliquity, but now you're going in the lateral direction, and you're gonna drive forward with your camera, and this is the easiest and most effective way to examine the posterior aspect of the elbow arthroscopically. It's also important to understand the instability signs that we can encounter at the time of arthroscopy. Therefore, I included it in this talk specific so that you can look at every elbow you see and assess the ligamentous structures through arthroscopic techniques and make it more easy for you to identify what is normal and what is pathologic. The video on the left is demonstrating a lateral viewing portal medially, and a velga stress has been applied in the anterior compartment. You can see here that it's abnormal opening the oneum articulation, confirming an ulnar collateral ligament tear. The video on the right is now looking from posterior, and it's going medially, and that's a medial drive-through sign, and the oneum articulation abnormally opens, and this also confirms the diagnosis of an ulnar collateral ligament tear. Laterally, you can look at both the lateral ulnar collinear complex and the radial collinear complex through specific maneuvers. The video on the left is showing your posterior viewing portal, and you see an avulsion of the lateral ulnar collinear complex in the drive-through with the elbow hinging open in abnormal opening. You have to be very cautious and concerned because there can be some normal opening in an elbow, and understand what's pathologic and what's just laxity. The other test that can be helpful with radial collateral ligament is the SHEP test, and here we're in the anterior compartment looking at the radial collateral articulation, and with just longitudinal distraction, you can see the entirety of the radial head, which is an abnormal finding for injury to that ligament. So I would suggest trying all of these maneuvers each time you do arthroscopy to get a feel. Arthroscopic treatment is typically safe. Looking at a series of 227 scopes, there are only 10 minor, but transient complications, two major. In another series with 532 arthroscopic cases, there's a less than 2% adverse event occurrence. So in conclusion, it's important to know the anatomy. It's more important to know your own patient's anatomy. Consistent setup is crucial in making your portals through a systematic technique, marking the overlying skin landmarks, distending the joint, skin-neck incision only, then blunt entry, make your cannula and portals inflection, and maintain your cannulas for safety. I thank you, and I wish you all the success.

elbow arthroscopy

portal placements

neurovascular structures

arthroscopic techniques

instability assessments