If the ulnar nerve is found to be unstable, an endoscopic anterior transposition can be performed [29]. A standard ulnar nerve release is performed. The MIMS is excised. Care is required to ensure any adjacent vessels are identified and cauterised if required. The ulnar nerve is then mobilised and transposed anterior to the medial epicondyle (Fig. 18.2). Once the nerve is checked proximally and distally to ensure no kinking, the subcutaneous fat is sutured to the soft tissue over the medial epicondyle. Rehabilitation involves placing the elbow into a sling in flexion for 1 week to allow for soft tissue healing and stabilisation of the nerve in its new bed.

Surgery traditionally involves open bursectomy, with incision over the point of the olecranon. However, wound healing can be a problem owing to the area of bridging skin. Endoscopic techniques allow for faster healing with improved outcome.

Utilising the wet technique, two separate 1.5 cm longitudinal portals are made 2 cm proximal and distal to the margins of the bursa, in the midline. Distension is maintained via saline inflow and arthroscopic cannula to prevent fluid draining away. The scope can then be placed into the bursa, resecting the bursa from inside-out until normal tissue planes are visualised. Care should be taken to protect the overlying skin and to prevent any perforations that may develop into sinuses.

The senior author’s preferred technique is the dry endoscopic procedure, specifically for treatment of sterile olecranon bursitis [36], utilising the Storz endoscopic equipment described above (Fig. 18.3). A 2 cm incision distal to the bursa is made to allow the introduction of the hooded scope, and the subcutaneous tissues are elevated off the bursa and olecranon. A separate proximal portal is made, and a pituitary rongeur is used to resect the bursa and cautery to control bleeding and fluid accumulation postoperatively (Fig. 18.4). To prevent recurrence in the dead space, the elbow should be placed in a sling at 90° of flexion.

Once the position of the spur is identified using fluoroscopy, dry endoscopy can be used to resect the spur by introduction of high-speed burr. Fluoroscopy can then be used to ensure complete resection (Fig. 18.5).

Dry arthroscopy has been utilised in elbow, providing greater appreciation of the anatomy of the elbow joint, reducing the risk of fluid extravasation and compartment syndrome. When the joint is distended with air, the synovial and articular surfaces are able to reflect light, allowing superior clarity and better understanding of subtle findings of the soft tissues and articular cartilage (Fig. 18.6). This technique has been shown to be particularly useful in synovitis, as fluid distension in wet arthroscopy may compress the soft tissues, change the shape of the synovium and reduce its vascularity [30, 34].

However, there are relative contraindications to using dry arthroscopic techniques. When radiofrequency ablation is required, wet arthroscopy should be used to provide cooling effect to the joint and prevent risk of chondrocyte damage. Furthermore, there is a theoretical risk of air embolus when arthroscopy is performed under air pump pressure and when a tourniquet is not inflated. Therefore, this technique should not be used with an air pump until further research is available [34].

It can also be used for any of the therapeutic procedures, such as synovectomy, resection of osteophytes and capsulectomy (Fig. 18.7).

Arthroscopic management of elbow arthroplasty has been utilised as a valuable adjunct in the diagnosis of painful or swollen arthroplasty. Arthroscopy in this setting allows for targeted biopsies for microbiological diagnosis and for assessment of mechanical factors before an informed decision regarding definitive management is made [34]. Mechanical diagnosis can be made, and sometimes running repairs can be performed (Fig. 18.8).

The senior author has performed deep suturing endoscopically using barbed sutures (Fig. 18.9). These are ideal for endoscopic repairs, as they do not require knot tying. The sutures can be inserted in the same way as we perform microsurgery. They can be used to repair deep fascia and other soft tissues [36].

Soft tissue endoscopy has grown to encompass a range of pathologies (Table 18.1). In the elbow, endoscopy has been successfully utilised in biceps bursoscopy and distal biceps tendon repairs [9, 15, 37]. which is described in more detail in another chapter in this series. In the forearm, endoscopic techniques have been used for decompression of the anterior interosseous nerve [22, 25], pronator syndrome [27], and performing fasciotomy in cases of chronic exertional compartment syndromes [10, 32].