John E. Conway
DEFINITION
Elbow arthroscopy involves the use of an arthroscope to examine the interior of the elbow joint and provides the opportunity to perform minimally invasive diagnostic and therapeutic procedures.
Elbow arthroscopy has evolved to allow the definitive care of more than a dozen complex elbow conditions.
Despite an expanded understanding of the surrounding neurovascular anatomy, essential portal placement for access to the elbow joint continues to present a level of risk for injury that exceeds that seen in other joints.4,6,7,13
The safe application of this treatment modality requires that the surgeon have a solid grasp of the relative anatomy, fellowship or laboratory training in treatment techniques, experience as an arthroscopist, and an objective assessment of his or her own level of skill.
ANATOMY
Neurovascular injury risk is relatively high and a threedimensional grasp of elbow anatomy is essential for safe and successful elbow arthroscopy (FIG 1).1,3,5–8,10–12,14
Miller et al8 showed that the bone-to-nerve distances in the 90-degree-flexed elbow increased with joint insufflation an average of 12 mm for the median nerve, 6 mm for the radial nerve, and 1 mm for the ulnar nerve.
The capsule-to-nerve distance changes very little with insufflation, however, and the protective effect of insufflation is lost when the elbow is in extension.
Miller et al8 also showed that in the insufflated, 90-degreeflexed elbow, both the radial and median nerves passed within 6 mm of the joint capsule and that the radial nerve was on average 3 mm closer to the capsule than the median nerve. The ulnar nerve was essentially on the capsule.
Others have also shown the close proximity of the radial nerve to the joint capsule and stressed the greater risk to this nerve during both portal placement and capsular resection.2,3,6,8,12
Stothers et al11 emphasized the importance of elbow flexion during portal placement and showed that the portal-to-nerve distances decreased an average of 3.5 to 5.1 mm laterally and 1.4 to 5.6 mm medially when the elbow was in extension.
For the distal anterolateral portal, the distance from the sheath to the radial nerve averaged 1.4 mm (range 0 to 4 mm) in extension and 4.9 mm (2 to 10 mm) in flexion.
Field et al3 compared three anterolateral portals and reported a statistically significant difference in portal-to-radial nerve distance, with greater safety shown with the more proximal locations.
Anatomic studies suggest three guidelines for neurovascular safety:
Portal placement is safer when the elbow is flexed 90 degrees than when it is in extension.11
Maximal joint distention before portal placement increases the safety during placement by increasing the nerve-to-portal distance.3,5,6,11
FIG 1 • A. Relative anatomy of the medial elbow and the arthroscopic portal sites: 1, standard anteromedial; 2, midanteromedial; and 3, proximal anteromedial. B. Relative anatomy of the lateral and posterior elbow and the arthroscopic portal sites: 1, distal anterolateral; 2, mid-anterolateral; 3, proximal anterolateral; 4, direct posterolateral; 5, posterolateral; and 6, posterior central.
The nerve-to-portal distance is greater for the more proximal anterior portals than for the more distal anterior portals.
PATIENT HISTORY AND PHYSICAL FINDINGS
This chapter does not address a specific condition but instead offers a broad view of the basic considerations and setup issues for a surgical treatment that may be applied to many different elbow problems.
A complete review of the numerous clinical tests described for the diagnostic evaluation of the elbow would exceed the scope of this chapter.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Routine preoperative elbow radiographs should include a true lateral view, a standard anteroposterior (AP) view, and an AP view of both the distal humerus and proximal forearm when joint motion loss prevents full joint extension.
Additional radiographic views include the cubital tunnel view, the posterior impingement view, the capitellum view, and the radial head view.
The cubital tunnel view, an AP projection of the humerus with the elbow maximally flexed, provides a clear view of the medial epicondyle and cubital tunnel groove.
The posterior impingement view is also an AP projection of the humerus with the elbow maximally flexed, but the humerus is rotated into 45 degrees of external rotation. This image offers better assessment of the posteromedial edge of the olecranon tip and the medial epicondyle apophysis.
The capitellum view, an AP projection of the ulna with the elbow flexed 45 degrees, provides a tangential view of the capitellum for better evaluation of osteochondritis dissecans lesions.
The radial head view is an oblique view of the 90-degreeflexed elbow with the beam passing between the ulna and the radial head. It allows for clear imaging of both the radial head and the radial–ulna interval.
Although this point is sometimes argued, computed tomography is often useful when resection of intra-articular bone is considered as a part of contracture release arthroscopy.
Magnetic resonance (MR) imaging in a closed high-field magnet with thin-section, optimized, high-spatial-resolution sequences may provide exceptional detail of the structures surrounding the elbow joint; however, MR arthrography, with either saline or gadolinium, will improve the assessment of intra-articular structures such as loose bodies.
SURGICAL MANAGEMENT
The indications for elbow arthroscopy include the evaluation and treatment of septic arthritis, lateral synovial plica syndrome, systemic inflammatory arthritis, loose bodies, synovitis, osteochondritis dissecans (OCD), degenerative arthritis, posterior impingement, traumatic arthritis, trochlea chondromalacia, arthrofibrosis, lateral epicondylitis, joint contracture, posterolateral rotatory instability, and olecranon bursitis.
Treatment options for these conditions include diagnostic evaluation, loose body removal, synovial biopsy, partial or complete synovectomy, plica excision, extensor carpi radialis brevis tendon débridement, capsule release, capsulotomy, capsulectomy, exostosis excision, ulnohumeral arthroplasty, contracture release, chondroplasty, microfracture chondroplasty, percutaneous drilling or fixation of OCD lesions, capitellum osteochondral transplantation, radial head excision, internal fixation of fractures, lateral ulnar collateral ligament plication, ulnar nerve decompression, and finally olecranon bursoscopy and bursectomy.
The relative contraindications for elbow arthroscopy include recent joint or soft tissue infection, developmental changes, previous trauma or surgery that significantly alters the normal neurovascular, bony, or soft tissue anatomy of the elbow, extensive extracapsular heterotopic ossification, complex regional pain syndrome, and conditions that prevent distention of the elbow capsule.
Previous ulnar nerve transposition usually requires exposure of the ulnar nerve before the creation of an anteromedial portal.
Preoperative Planning
As with all medical conditions, the importance of the information gained from a careful and complete history and examination for establishing an accurate diagnosis cannot be overemphasized.
Plain radiographs are also essential, but some authors suggest that computed tomography and MRI offer little in the preoperative assessment.
In contrast, the exact location of intra-articular, capsular, and extra-articular bone, the thickness of the joint capsule, the integrity of the cartilage covering an OCD lesion, and the presence of stress fractures or loose bodies unseen on radiographs are a few examples of how additional imaging may direct or modify care.
The surgeon should consider how associated procedures to be performed in conjunction with the arthroscopy will affect patient positioning and the possible need to reposition during the case.
Fluoroscopy should be available when drilling, pinning, or internal fixation is considered.
In addition to standard arthroscopic instrumentation, the preoperative plan should also consider the need for specialized instruments such as retractors and special biters for contracture release surgery and small-fragment-fixation devices for OCD or fracture care.
Elbow arthroscopy may be done using either general or regional anesthesia.
General anesthesia is typically preferred as it allows for complete muscle relaxation. Regional blockade is reserved for contracture release procedures where repeated manipulation and continuous passive motion is planned during the hospitalization.
While regional anesthesia may be given before surgery, many surgeons prefer to wait until the status of the neurovascular structures is established in the recovery setting.
Indwelling catheter regional anesthesia is described and sometimes recommended for contracture release procedures, but not all centers are comfortable or experienced with these techniques, and repeated regional anesthesia during the hospitalization appears to be equally effective.
The use of ultrasound during injection may decrease the morbidity associated with regional anesthesia.
Positioning
The four patient positions for elbow arthroscopy are the supine cross-body position, the supine suspended position, the lateral decubitus position, and the prone position.
While the latter two positions are most popular today, experience with one of the supine positions still offers advantages. For example, a surgeon who prefers the prone position may elect to use the supine cross-body position when arthroscopic and open procedures are combined, preventing the need for repositioning.
Supine cross-body position.
Arthroscopy in this position may be done with one of several commercially available arm-holding devices but is performed equally well with an assistant acting as the arm holder (FIG 2A).
Because the elbow is not rigidly stabilized in this position, complex procedures may be more challenging and present a greater level of risk for injury.
The supine cross-body position is most useful when a less demanding arthroscopic procedure is performed along with an open surgery.
Supine suspended position.
This position requires the use of a traction device from which the arm is hung. Capture of the hand or wrist is necessary, and finger traps on the index and long fingers work well in this regard (FIG 2B).
The elbow is not stabilized against either a post or pad, which allows considerable movement of the elbow beneath the hand.
Two potential disadvantages of this position are the unexpected withdrawal of the arthroscope from the freely swinging joint and the almost vertical position of the arthroscope during arthroscopy of the posterior compartment.
Lateral decubitus position.
This position for elbow arthroscopy is typically set up the same as for shoulder surgery except that the arm is draped across a padded horizontal post attached to the table (FIG 2C).
The advantage of this position over the supine positions is that a stable platform is created on which the upper arm rests. There is equal access to the anterior and posterior compartments.
The advantage of this position over the prone position becomes apparent when management of the airway is at issue. If prone positioning is a concern, such as in patients with a high body mass index or compromised lung volume, the case is probably best done in the lateral decubitus position.
One disadvantage of this position is that small patients, such as gymnasts with OCD lesions, are difficult to position lateral and still maintain full access to the arm.
FIG 2 • Positioning. A. Left elbow draped in the supine cross-body position. An arthroscope is in the proximal anteromedial portal and a loose body is shown on the monitor. B. Left elbow draped in the supine suspended position. Sterile towels and elastic wrap are used to cover finger traps attached to the index and long fingers. C. Left elbow in the lateral decubitus position. D. Right elbow draped in the prone position. A roll of towels is placed between the upper arm and a shortened armboard aligned with the table. E. Right elbow draped over a shortened padded armboard.
Prone position.
Many surgeons, because of the stability and access provided, prefer the prone position. However, careful attention to positioning is essential to avoiding complications (FIG 2D).
The airway must be secure and the face should be well padded.
Chest rolls are used to lift the chest and abdomen from the table, decreasing the airway pressure required for ventilation.
The knees are padded and the feet are elevated.
The nonoperative arm is placed on a well-padded arm board, with attention to the ulnar nerve, and the operative arm is allowed to hang over a shortened, padded armboard positioned along the side of the table (FIG 2E).
Pulses in all four extremities are confirmed.
After draping, a small roll of towels is placed beneath the upper arm to align the humerus in the coronal plane of the body and to allow the elbow to flex to 90 degrees.
Approach
The first arthroscopic portal is anterior except when the entire procedure is accomplished through posterior portals. Occult conditions may exist in the anterior compartment, and a complete diagnostic assessment of the joint requires anterior portals.
Whether the initial anterior portal should be medial or lateral is debatable but usually determined by surgeon preference and patient diagnosis. Good arguments may be made for either approach.1,9,13
The second anterior portal may then be created with either outside-in or inside-out methods. We prefer to make the medial portal first and then create the lateral portal with an outside-in method.
Instrument.
A standard 4.0-mm, 30-degree offset arthroscope may be used for virtually all elbow arthroscopic procedures. On rare occasion, both a 4.0-mm, 70-degree offset arthroscope and a 2.7-mm arthroscope may be helpful. Because it is often necessary to maintain the tip of the arthroscope just a few millimeters through the capsule, an arthroscope sheath without side flow ports is preferred and minimizes fluid extravasation into soft tissues.
Essential instruments include an 18-gauge spinal needle, a hemostat, a Wissinger rod, switching rods, and both standard and small mechanical shavers (FIG 3A,B).
Specialized instruments have recently become available from several sources and include a series of curved and straight arthroscopic retractors, curettes, and osteotomes. Hand biters, designed to resect the anterior capsule more safely, are very useful during contracture release surgery (FIG 3C).
FIG 3 • A,B. Basic instruments used in elbow arthroscopy. A. A standard 4.0-mm, 30-degree offset arthroscope, an arthroscope sheath with sharp and dull trocars, an 18-gauge spinal needle, a 60-cc saline in large syringe with connector tubing, a hemostat, a Wissinger rod, and switching rods. B. A standard mechanical shaver, a mini mechanical shaver, an arthroscope camera, a light cord, inflow tubing, and suction tubing. C. Specialized instruments for elbow arthroscopy: a hand biter and curved and straight arthroscopic retractors, curettes, awls, and osteotomes.
TECHNIQUES
LIMB PREPARATION
Setup and portal positions are shown in the supine crossbody position.
After the administration of general anesthesia, the operative-arm shoulder is relocated to extend just over the edge of the surgical table, affording access to the whole extremity and limiting the reach required for the surgeon.
Both the shoulder and the entire arm are prepared and draped and a sterile tourniquet is applied as proximally as possible.
After limb exsanguination, the tourniquet is elevated and an elastic compression wrap is applied tightly to the forearm, extending from distal to proximal and ending just distal to the radial head.
The elastic wrap will limit fluid extravasation into the subcutaneous tissues and the muscle compartments of the forearm and potentially decrease the risk of compartment syndrome.
Landmarks about the elbow and the proposed arthroscopic portal sites are marked.
Before portal placement, the joint is distended with saline using an 18-gauge spinal needle passed through the posterolateral “soft spot” (TECH FIG 1).
The “soft spot” is located at the center of the triangle formed by the olecranon prominence, the lateral epicondyle prominence, and the lateral margin of the radial head.
Connector tubing attached to a 60-mL syringe allows an assistant to maintain joint distention during the creation of the initial portal without obstructing the surgeon's access.
Order of Portal Placement
Anterior or posterio.
Neurovascular risk is the most important factor to be considered when determining the order of portal placement.
Soft tissue swelling and loss of the capacity to distend the joint would be expected after the creation of the posterior portals and would place both the median and radial nerves closer to the path of the anterior portals.
Most surgeons choose to begin the arthroscopy with the anterior portals.
TECH FIG 1 • Left elbow joint in the supine cross-body position being inflated with saline through the posterolateral “soft spot” with an 18-gauge spinal needle. The “soft spot” is found at the center of a triangle formed by the olecranon tip, the lateral epicondyle prominence, and the lateral margin of the radial head.
Medial or latera.
The order is usually determined by surgeon preference and the nature of the conditions requiring treatment.
The sheath-to-nerve distance for the mid-anteromedial portal averages 23 mm,5 that for the distal anterolateral portal averages 3 mm,5 and that for the proximal anterolateral portal averages 14.2 mm.3
Because the nerve-to-sheath distance is greater for the anteromedial portals than for the anterolateral portals, it has been argued that the initial approach to the joint is safer when medial.
Once the medial portal is established, the lateral portal can be made with an outside-in technique and an 18-gauge spinal needle11,12 or with an inside-out technique and a Wissinger rod.5
Both methods are relatively safe techniques, but the outside-in method affords greater control of the angle into the joint and potentially greater access to the anterior humerus.
ANTEROMEDIAL PORTALS
There are three commonly described anteromedial portals: standard, mid, and proximal (TECH FIG 2A).
The nerve at greatest risk for injury is the medial antebrachial cutaneous nerve. This risk diminishes when the depth of the portal incision avoids cutting the subcutaneous tissues.6
Dissection to the flexor fascia with a blunt-tipped hemostat allows mobilization of the cutaneous nerves away from the portal for additional protection.
Up to six branches are described crossing the medial elbow, and on average at least one branch is within 1 mm (range 0 to 5 mm) of the portal (TECH FIG 2B).
Both the median nerve and the brachial artery are also at risk during medial portal placement.
Continuing the hemostat dissection to the medial joint capsule (TECH FIG 2C), introducing the arthroscope sheath with a blunt trocar, and finally penetrating the capsule with a sharp trocar will allow safe medial capsule penetration and avoid extracapsular arthroscope placement.
Some authors argue that sharp trocars have no role in elbow arthroscopy; however, blunt trocars are more inclined to penetrate the capsule laterally or, even less desirably, to remain extracapsular. Modifying a sharp trocar by blunting the tip provides a safe and effective compromise.
TECH FIG 2 • A. Medial surface of the left elbow in the supine cross-body position. Locations of the standard and proximal anteromedial portals are shown. B. Medial elbow showing multiple branches of the medial antebrachial cutaneous nerve (MABCN). C. Anteromedial portal being created with hemostat dissection through the skin, subcutaneous tissues, fascia, and muscle to the medial capsule. ME, medial epicondyle; MAMP, mid-anteromedial portal; UN, ulnar nerve.
Standard Anteromedial Portal
Andrews and Carson2 described the standard anteromedial portal as located 2 cm anterior and 2 cm distal to the prominence of the medial epicondyle. They reported that the median nerve-to-sheath distance was 6 mm.
The path of the portal penetrates the common flexor origin, as well as the flexor carpi radialis and the pronator muscles.
In some patients, the portal also penetrates the medial border of the brachialis muscle.
Lynch et al6 showed that with joint distention and 90-degree elbow flexion, this portal averaged 14 mm from the median nerve. However, Stothers et al11,12 showed that the median nerve-to-sheath distance averaged only 7 mm (range 5 to 13 mm) and that the brachial artery-to-sheath distance was just 15 mm (range 8 to 20 mm).
The standard anteromedial portal may be created with either medial (outside-in) or lateral (inside-out) methods. Some authors suggest that it is more safely created using the latter method with a rod exchange technique.
Although this portal offers excellent visualization of the anterolateral contents of the elbow joint, it is now most commonly recommended as an accessory portal for capsular retractors.
Proximal Anteromedial Portal
The proximal anteromedial portal, popularized by Poehling et al,10 is described as 2 cm proximal to the prominence of the medial epicondyle and just anterior to the medial intermuscular septum.
Others have subsequently described this portal as up to 2 cm anterior to the septum.9
The locations of both the septum and the ulnar nerve must be established before portal placement and the path of the portal must remain anterior to the septum.
Arthroscope sheath contact with the anterior humerus is advised to further protect the median nerve.10
In this location, at 90 degrees of flexion and with joint distention, the portal averages 12.4 mm (range 7 to 20 mm) from the median nerve, 18 mm from the brachial artery, 12 mm (range 7 to 18 mm) from the ulnar nerve, and 2.3 mm (0 to 9 mm) from the medial antebrachial cutaneous nerves.
This portal also provides visual access to the lateral elbow joint structures, but viewing the superior capsular structures, the lateral capitellum, and the radiocapitellar joint space is limited compared to the standard anteromedial portal.11,12
Mid-Anteromedial Portal
A modification of the proximal anteromedial portal was described by Lindenfeld5 as located 1 cm proximal and 1 cm anterior to the prominence to the medial epicondyle.
The portal is directed distally into the center of the joint to preserve the protection afforded by the proximal location and was shown to average 22 mm from the median nerve.
ANTEROLATERAL PORTALS
While at less risk for injury than the medial antebrachial cutaneous nerve, the anterior branch of the posterior antebrachial nerve crosses the lateral elbow and may be injured during portal placement. Limiting the depth of the skin incision and using the arthroscope to cast a silhouette of the nerve may provide reasonable protection.
There are three anterolateral portal locations: distal, mid, and proximal (TECH FIG 3).
Distal Anterolateral Portal
Andrews and Carson 2 were first to describe an anterolateral portal and recommended placement 3 cm distal and 1 cm anterior to the prominence of the lateral epicondyle. Their work documented that the radial nerve averaged 7 mm from the arthroscope sheath when the elbow was flexed 90 degrees.
TECH FIG 3 • Lateral surface of the left elbow in the supine cross-body position. Locations of the distal, mid, and proximal anterolateral portals are shown.
Others have reported that the nerve-to-sheath distance was less, averaging only 3 to 4.9 mm,5,11,12 and that in extension this distance was just 1.4 mm.
Field et al3 showed that Andrew and Carson's recommendation located the portal near or directly over the radial head in all specimens studied, and that for smaller patients these measurements would potentially place the portal distal to the radial head.
To lessen the risk of radial nerve injury, landmarks, rather than measurements, are used to determine that the portal is proximal to the radial head.3
Because of safety concerns, this portal is much less commonly used than the more proximal portals and is typically reserved for a blunt retractor.
An outside-in method is effective and probably safest.
With the elbow at 90 degrees, the forearm in slight pronation, and the joint maximally distended, an 18-gauge spinal needle is placed just anterior to the radial head and directed proximally toward the center of the radiocapitellar joint (TECH FIG 4).
A hemostat is then used to dissect through the capsule and a blunt-tipped retractor is introduced to mobilize the anterior capsule.
The arthroscope and working instruments are placed in more proximal portals.
Superficially, the anterior branch of the posterior antebrachial cutaneous nerve was shown to lie on average 7.6 mm (range 0 to 20 mm) from the portal entry and was in contact with the sheath in 43% of elbows studied.11
Mid-Anterolateral Portal
The mid-anterolateral portal is safer and used more commonly than the distal anterolateral portal.
TECH FIG 4 • Lateral surface of the left elbow with a midanterolateral portal being created using an outside-in method. The spinal needle defines the path of the portal.
Field et al3 compared distal, mid, and proximal anterolateral portals and found that the more proximal portals were statistically farther from the sheath than the distal portal. They described the location of the midanterolateral portal as 1 cm anterior to the prominence of the lateral epicondyle and just proximal to the anterior margin of the radiocapitellar joint space.
At 90 degrees of flexion, the radial nerve-to-sheath distance was reported to average 9.8 mm without joint distention and 10.9 mm with distention. This was more than twice the distance reported for the distal portal.
Both inside-out and outside-in methods are effective and safe means to establish this portal. This portal is most useful for visualization of the medial elbow and débridement of the anterior radiocapitellar joint surfaces.
Proximal Anterolateral Portal
Stothers et al11,12 described the location of the proximal anterolateral portal as 1 to 2 cm proximal to the prominence of the lateral epicondyle, with the path of the portal along the surface of the anterior humerus. The sheath is directed toward the center of the elbow joint, penetrating the brachioradialis, brachialis, and extensor carpi radialis muscles before passing through the joint capsule.
Several studies have shown that the radial nerve-to-sheath distance averaged 9.9 to 14.2 mm in the 90-degree-flexed and distended elbow.3,11 This represents a statistically significant increase in the distance from the nerve from the sheath compared to either the mid or the distal portal.
The anterior branch of the posterior antebrachial cutaneous nerve averaged 6.1 mm from the portal, with the trocar in contact with the nerve 29% of the time.11
The proximal anterolateral portal may be made before or after the anteromedial portal, and an outside-in method is most commonly recommended.
Although the view of the anteromedial structures was similar for all three anterolateral portals, the proximal anterolateral portal was consistently described as providing a more extensive evaluation of the joint, particularly when viewing the radiocapitellar joint.11,12,14
POSTERIOR PORTALS
Compared with the anterior portals, all posterior portals are relatively safe11 (TECH FIG 5).
Laterally, the posterior antebrachial cutaneous nerve is at risk, and there are anecdotal reports of injury to the radial nerve branch to the anconeus muscle.
The ulnar nerve is the closest major nerve to any posterior portal and has been described as no closer than 15 to 25 mm from the posterior central portal.11
This nerve is typically at risk only during posteromedial capsule resection for joint contracture release; however, even with safely performed perineural capsulectomy, recovery of flexion for patients with less than 110 degrees of preoperative elbow flexion still exposes the ulnar nerve to traction injury.
In this setting, nerve transposition is advised.
The posterior portals may be established with the elbow between 45 and 90 degrees of flexion.11,12
Less flexion is recommended and is thought to decrease the tension in the posterior tissues, expand the olecranon fossa, and provide greater access to the medial and lateral recesses.
Posterior Central Portal
The posterior central portal, also called the straight posterior portal, has been described by many authors and is usually located 2 to 4 cm proximal to the olecranon prominence and halfway between the medial and lateral condyles.
This is commonly the initial posterior portal and provides good visualization of the olecranon fossa, the olecranon tip, the posterior trochlea, and the medial recess. The lateral recess, the central trochlea, and the radiocapitellar joint are less well seen.
TECH FIG 5 • Posterior surface of the left elbow in the supine cross-body position. Locations of the posterior central, posterolateral, and direct posterolateral portals are shown.
Although the ulnar nerve-to-sheath distance is consistently described as 15 mm or more,11 the nerve should always be palpated and outlined before portal placement.
Sharp dissection and sharp trocars are often discouraged when establishing anterior portals; however, a no. 11 blade may be used safely to create the posterior central portal and probably limits triceps tendon trauma.
An 18-gauge needle is first used to confirm the location of the fossa, and the blade is then directed toward the center of the fossa and in line with the tendon fibers.
For patients with arthrofibrosis, the portal may be more easily created with a sharp trocar.
An intercondylar foramen is found in some patients, so caution is advised when establishing this portal.
Transhumeral access to the anterior compartment is possible through the foramen.
In patients without a foramen, a fenestration technique using a small-headed reamer is described for anterior access.
Use of the posterior central portal for anterior compartment visualization is recommended only for those well experienced in elbow arthroscopy, however.
Posterolateral Portal
Andrews and Carson2 described the posterolateral portal as 3 cm proximal to the olecranon and through the lateral border of the triceps tendon.
More distally, accessory portals may be safely placed anywhere between the proximal posterolateral portal and the soft spot.1,12 The location of the portal is determined by the intended purpose.
For procedures performed in the posteromedial region of the elbow, a more proximal portal will provide greater access and visualization.
In contrast, a more distal portal will facilitate procedures confined to the posterolateral recess.
An 18-gauge needle is used to confirm proper access to the olecranon fossa and the lateral gutter.
The scope is established in the olecranon fossa while remaining directly on the lateral column of the humerus to avoid capture of the posterior fat pad.
When properly placed, this portal provides a clear view of the olecranon fossa, the olecranon tip, the posterior and central trochlea, the medial recess, the lateral recess, and the posterior radiocapitellar joint.
Direct Posterolateral Portal
The direct posterolateral portal is typically the site used for joint inflation before anterior portal placement. The location is defined as the center of a triangle formed by the prominence of the lateral epicondyle, the prominence of the olecranon, and the radial head (see Tech Fig 1).
Also known as the mid-lateral portal, the dorsal lateral portal, and more commonly the “soft spot” portal, this portal penetrates the anconeus muscle and consistently provides the best view of the radiocapitellar joint.
Lateral Radiocapitellar Portal
O'Driscoll and Morrey9 described the standard mid-lateral portal, also called the lateral radiocapitellar portal, and noted that this portal is difficult to create because of limited space.
This portal is best used when a very small mechanical shaver blade may be employed in the management of OCD capitellum lesions and radiocapitellar chondral injury.
An 18-gauge needle is used to determine appropriate portal location (TECH FIG 6).
TECH FIG 6 • Posterolateral surface of the left elbow with the arthroscope in the direct posterolateral portal and an 18-gauge spinal needle being used to determine the appropriate location for the accessory direct radiocapitellar portal.
POSTOPERATIVE CARE
Wounds are routinely closed with simple sutures.
Synovial–subcutaneous and synovial–cutaneous fistulas have been described and most commonly occur in the posterolateral portals along the lateral margin of the triceps tendon.4
Deep absorbable sutures placed in the fascia of the lateral triceps along with locking mattress sutures in the skin will minimize the risk for this complication.
Unless contraindicated by the procedure performed, the elbow is splinted near full extension to minimize swelling.
The arm is elevated overnight and the splint is removed the following day.
Passive and active range-of-motion exercises are started as soon as the procedure performed will allow.
For patients undergoing contracture release surgery, an axillary regional block is performed early the next day.
The elbow is gently taken through a full arc of motion and then placed into continuous passive motion.
Based on the extent of the release, the amount of swelling, and the level of pain, the patient is hospitalized for 1 to 3 days.
Postoperative static progressive range-of-motion braces and physical therapy are also used to recover motion.
COMPLICATIONS
The incidence of neurologic complications after elbow arthroscopy has been reported to be 0% to 14%.4
Transient as well as incomplete and complete permanent nerve palsies, including iatrogenic nerve resection injuries, have also been described for the radial, ulnar, and median nerves.
Kelly et al4 retrospectively reviewed 473 consecutive arthroscopy procedures and found an overall complication rate of 7%.
Transient neuropraxia was the most common immediate minor complication and included radial nerve, ulnar nerve, posterior interosseous nerve, anterior interosseous nerve, and medial antebrachial cutaneous nerve palsies.
Risk factors include autoimmune disorder, contracture, capsulectomy, and possibly prolonged tourniquet time.
Prolonged clear or serous drainage from anterolateral and mid-lateral portal sites was the most common minor complication and was reported to occur in 5% of patients.
Deep infection occurred in 0.8% of patients; all the cases occurred in patients who had received intra-articular corticosteroids at the end of the procedure.
Mild postsurgical contracture occurred in 1.6% of patients.1,4
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