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Elbow Arthroscopy

(see also: Elbow Arthritis)

Equipement

  • 30 deg, 4 mm arthroscope;
  • arthroscopic pump;

Positioning

  • patient is usually prone with sandbag placed under antecubital fossa;
  • TV monitor is positioned opposite of the patient;
  • ulnar nerve is palpated to pinpoint its location and to ensure that it does not subluxate with elbow flexion
  • instill fluid into the joint thru the aconeus triangle;
    • through the lateral soft spot, which is bound by the radial head, lateral epicondyle, and olecranon
    • when the elbow is distended, the major neurovascular structures are positioned farther away from the portal sites

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 through 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;
  • in order to protect the PIN, this portal is made from inside outward under visualization from the proximal-medial portal;
  • the scope is advanced anterolaterally across 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

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References