- Positioning:
     - patient is usually prone with sandbag placed under
antecubital fossa;
     - TV monitor is positioned opposite of the patient;
     - instill fluid into the joint thru the aconeus
triangle ;

- Portal Placement:
     - posterolateral portal:
             - portal
is located thru the center of the aconeus
triangle ;
             - when
the anterior aspect of the joint is being visualized, the posterolateral portal
can be used as an outflow portal;
             - posterolateral
portal can be used to visualize the posterior elbow structures including the
olecranon fossa;
                     -
use of a 70 deg arthroscope facilitates visualization of the radiocapitellar
joint;
             - this
portal allows debridement of the capitellum (in the case of osteochondritis
dissecans );
     - anterosuperior lateral:
             - considered
safer than anterolateral portal;
             - portal
allows visualization of the ulnohumeral articulation, anteromedial aspect of
elbow, coronoid fossa and process, and anterior aspect of radiocapitellar joint;
             - portal
is placed 2 cm superior to the anterior aspect of lateral epicondyle;
             - blunt
dissection into the joint capsule helps to avoid injury.
             - cautions:
                     -
PIN is most at risk, (less than the anterolateral portal) and lateral antebrachial
cutaneous nerves are at risk;
     - anterolateral portal:
             - this
portal can be used for instrumentation as well as visualization of the lateral
aspect of the radial head;
             - this
portal is often established first;
             - w/
elbow flexed 90 deg, the portal is located 3 cm distal and 1-2 cm anterior to
the lateral epicondyle, which should bring
                     portal
just anterior and proximal to the radial-capitellar articulation w/ the portal
driven toward the center of the trochlea;
                     -
elbow is kept flexed during trochar insertion since extension brings the radial
nerve closer to the joint (3 to 7 mm);
             - hazards:
                     -
the portal pass thru the ECRB and supinator;
                     - posterior
interosseous nerve is at risk w/ this portal, as it runs about 0.5 cm to
1 cm anterior and medial to the portal;
                     -
inorder to protect the PIN, this portal is made from inside outward under visualization
from the proximal-medial portal;
                     -
the scope is advanced anterolaterally arcross the radial head w/ care not to
deviate too anteriorly;
                     -
the light of the arthroscope will be visible thru the skin which will facilitate
proper skin incision;
     - proximal anterolateral portal:
             - located
2 cm proximal and 1 cm anterior to the lateral epicondyle;
             - this
portal is significantly farther (on average 13.7 mm) from the radial nerve than
other anterolateral portal sites;
             - this
portal allows for an excellent view of the anterior radiohumeral and ulnohumeral
joints as well as the anterior capsular margin.
     - proximal antero-medial portal:
             - allows
visualization of the following:
                     -
anterior elbow including the anterior joint capsule, medial condyle, coronoid
process, trochlea, capitellum, and the radial head;
                     -
radial head is best visualized from the proximal anteromedial portal
             - joint
should already be distened w/ fluid;
             - location
is 2 cm proximal to medial epicondyle, and immediately anterior to the inter-muscular
septum, using a longitudinal skin stab incision;
             - ensure
that the position of the intermusuclar septum is clearly demarcated;
             - make
1/2 cm incision and spread w/ hemostat;
             - trochar
is inserted over the anterior surface of the humerus aiming for the radial head;
             - maintain
contact w/ anterior humerus at all times to reduce risk to N/V structures is
minimized.
             - trocar
w/ it (arthroscopic sheath) is then inserted, followed by the scope;
             - hazards:
                     -
nerves at risk w/ this portal include the ulnar
nerve , medial brachial cutaneous, medial
antebrachial cutaneous , median nerve, and brachial artery;
                     -
ulnar nerve lies 4 mm from this portal site;
                     -
median nerve lies 7-20 mm away from portal with the elbow in flexion;
     - anteromedial portal:
             - some
surgeons prefer to establish this portal first;
             - elbow
should be flexed 90 deg as the portal is established;
             - placed
2 cm anterior and 2 cm distal to the medial epicondyle, placed under direct vision;
             - the median
nerve lies 1 to 2 cm anterior and lateral to this portal;

- Complications:
     - nerve damage:
           - be particularly
careful in elbow that have altered anatomy or scarring (as from intra-articular
fracture);
                 -
this situation may distort normal landmarks, decrease arthroscopic distension,
and cause nerves to remain adherent to capsule;
     - in the report by EW. Kelly MD et al, the authors retrospective
review of 473 consecutive elbow arthroscopies performed in 449 patients over
an 18 year period was conducted;
           - of the 473 cases,
414 were followed for more than six weeks;
           - most common final
diagnoses were osteoarthritis (150 cases), loose bodies (112), and RA or inflammatory
arthritis (seventy-five);
           - arthroscopic procedures
included synovectomy (184), débridement of joint surfaces or adhesions
(180), excision of osteophytes (164),
                   diagnostic
arthroscopy (154), loose-body removal (144), and capsular procedures such as
capsular release, capsulotomy, and capsulectomy (73).
           - a serious complication
(a joint space infection) occurred after four (0.8%) of the arthroscopic procedures;
           - minor complications
occurred after fifty (11%) of the arthroscopic procedures;
                   -
these complications included prolonged drainage from or superficial infection
at a portal site after
                            33
procedures, persistent minor contracture of 20° or less after seven, and
twelve transient
                            nerve
palsies (five ulnar palsies, four superficial radial palsies, one posterior interosseous
                            palsy,
one medial antebrachial cutaneous palsy, and one anterior interosseous palsy)
in ten patients;
                   -
most significant risk factors for the development of a temporary nerve palsy
were an underlying diagnosis of
                            rheumatoid
arthritis (p < 0.001) and a contracture (p < 0.05). There were no permanent
neurovascular injuries,
                            hematomas,
or compartment syndromes in our series, and all of the minor complications, except
for the minor
                            contractures,
resolved without sequelae.
     - references:
          - Complications of Elbow
Arthroscopy.  EW. Kelly MD et al.  J Bone Joint Surg [Am] 83-A: 25-34,
2001
          - Case Report.  Complete
Transection of the Median and Radial Nerves During Arthroscopic Release of Post-traumatic
Elbow Contracture.  Tomas Haapaniemi, M.D. et al. Arthroscopy: The Journal
of Arthroscopic and Related Surgery, Vol 15, No 7 (October), 1999: pp 784-787

Avoiding nerve damage during
elbow arthroscopy.

Medial approach in elbow arthroscopy.

Arthroscopy of the elbow.
Diagnostic and therapeutic benefits and hazards.

Neurovascular anatomy and elbow arthroscopy: Inherent risks.  GJ Lynch et
al.  Arthroscopy. Vol 2. 1986. p 190-197.

Arthroscopic surgery of the
elbow. Therapeutic benefits and hazards.

Arthroscopy of the elbow.  SW O'Driscoll and BF Morrey.  JBJS 74-A.
1992. p 84-94.

Arthroscopy of the elbow.  Poehling et al. JBJS. Vol 76-A. No 8. Aug. 1994.
p 1265-1271.