• Nonsterile tourniquet

• Articulating arm holder (if supine)

• Lateral elbow positioner (if lateral position)

• Beanbag (for lateral position)

• 4.0-mm 30-degree arthroscope

• 2.7-mm arthroscope as needed

• 3.5- and 4.5-mm mechanical shavers

• Electrocautery device

• Switching stick(s)

• Fully threaded and partially threaded graspers

• Blunt-tipped elevator

• Osteotomes (one-fourth in both straight and curved)

• Articulating retractor

• 60-cc syringe with normal saline and 18-G needle

• 10-cc syringe containing lidocaine with epinephrine

• For an isolated arthroscopy case (no ligament reconstruction), the following positioning is preferred (Fig. 22-4).

• Lateral decubitus position with a beanbag.

• All bony prominences, such as the femoral condyles and fibular head, are padded.

• An axillary roll is placed underneath the contralateral axilla.

• The shoulder is at 90 degrees of forward elevation and in slight abduction.

• The ipsilateral humerus is supported with a lateral elbow positioner as high as possible.

• The elbow positioner is secured on the table in such a way to avoid interference with elbow range of motion. This can be achieved by securing the positioner to the table at the level of the nipple and angling it slightly proximally. Maximal flexion and extension of the elbow is ensured with positioning (Figs. 22-3 and 22-4).

• The contralateral elbow is in 90 degrees of flexion on an arm rest positioned as high as possible.

• A nonsterile tourniquet is placed on the ipsilateral arm.

• Positioning of the beanbag and any instruments anterior to the chest of the patient is minimized to avoid obstructing the arthroscopic instrumentation to the elbow.

• After the patient is positioned, instruments entering the elbow from the various portals and at various elbow flexion angles should be simulated to verify optimal setup and unobstructed path of instruments.

• For arthroscopy in conjunction with a procedure requiring a supine position (such as an ulnar collateral ligament [UCL] reconstruction, ulnar nerve transposition, or other open procedure), the following positioning is recommended (Fig. 22-5).

• The patient is placed supine with an articulating arm holder on the contralateral side, secured to the table at the level of the patient’s contralateral knees.

• If associated open procedures are warranted, arthroscopy is done first followed by the open procedure.

• Once arthroscopy is complete, the arm is disengaged from the articulating arm holder and is placed on a hand table on the ipsilateral side of the operating table.

• The remainder of this technique is presented from the perspective of lateral positioning, but similar principles apply to supine positioning regarding planning, instrumentation, and strategy.

• Before surgery, history, physical examination, and imaging confirm the diagnosis.

• The history should be consistent with a story of posterior elbow pain.

• Physical examination findings consistent with valgus extension overload (VEO) include pain with provocative maneuvers, tenderness at the posteromedial olecranon, and pain with forced elbow extension.

• Imaging should confirm an osteophyte at the posteromedial olecranon.

• It is important to determine the location of the ulnar nerve and whether it subluxes on dynamic examination. This can influence whether it is safe to use a standard anteromedial portal and also may affect any potential vulnerability of the nerve when working in the posteromedial aspect of the elbow. Knowledge of the location of the ulnar nerve is especially important after previous elbow surgery, such as UCL reconstruction, in which the nerve may have been transposed anteriorly. This information should be obtained from previous operative reports.

• Preoperative CT scanning with 2-D and 3-D reconstructions helps identify the precise location of the osteophytes (Fig. 22-6A-C). During arthroscopy, some osteophytes may be encased in soft tissue and not easily identified.

• An essential component of good surgical planning is appropriate patient counseling. Many patients with VEO have concomitant insufficiency or will later develop insufficiency of the UCL. Patients should be made aware that they can experience UCL dysfunction and may eventually require UCL reconstruction.

• Before marking the portals, the following structures are outlined (Figs. 22-7 and 22-8).

• Olecranon

• Lateral epicondyle

• Radial head

• Medial epicondyle

• Path of the ulnar nerve

• Next, the various portals are outlined.

• Anteromedial (AM) portal: 2 cm proximal to the medial epicondyle and 1 cm anterior to intermuscular septum. This portal can be 1-13 mm from the medial antebrachial cutaneous nerve (MABCN).¹

• Anterolateral (AL) portal: 1 cm anterior and proximal to the lateral epicondyle. This portal is established with needle localization.

• Posterolateral (PL) portal: 1 cm proximal to the olecranon tip and adjacent to the lateral border of the triceps.

• Accessory proximal posterolateral portals (PPL): proximal to the PL portal for retractor insertion, typically 3 cm proximal to the olecranon tip and along the lateral border of the triceps tendon.

• Direct posterior portal (DPP): located 2-3 cm proximal to the tip of the olecranon in the midline of the triceps. This portal can be established under direct vision with a spinal needle to ensure a good angle and access to the olecranon tip.

• Soft spot (SS) portal: also known as the direct lateral portal, placed in the recess formed between the olecranon tip, radial head, and lateral epicondyle.