Principles of Elbow Arthroscopy

Michael D. Chiu

Jason L. Koh

Indications for Elbow Arthroscopy

• Evaluation of painful elbow

• Capsular release for contractures and stiffness¹

• Removal of loose bodies²

• Treatment of early degenerative changes²

• Osteophyte debridement of olecranon and coronoid fossae

▪ Valgus extension overload

• Treatment of osteochondral lesions of the radial head

• Treatment of osteochondritis dissecans of the capitellum

• Lateral epicondylitis debridement and release or repair

• Fractures of the radial head

• Partial synovectomy

Contraindications

• Altered anatomy—congenital or prior surgical procedures³

• Ulnar nerve transposition

• Bony ankylosis or extensive fibrous ankylosis¹

• Precludes safe introduction of arthroscope by impeding joint distension

• Local active soft tissue infection³

Advantages of Elbow Arthroscopy

• Minimally invasive⁴—decreased postoperative pain and faster return to activity

• Superior articular cartilage visualization

Disadvantages

• Risk of neurovascular (NV) injury³,⁵ and technically more challenging

Anesthesia, Positioning, and Setup

• Anesthesia

• General: minimal risks; complete muscle relaxation; allows postoperative neurologic examination⁶

• Regional: more risk involved; limited patient tolerance to positioning; decreased postoperative nausea⁶

• Patient positioning: supine, prone, or lateral decubitus

• Supine position

▪ Adequate access to anterior and posterior compartments

▪ Easier anesthesia airway management and open surgery conversion

• Prone or lateral decubitus position (Fig. 20-1)

Figure 20-1 | Lateral decubitus patient positioning with noted airway accessibility. Operative shoulder is abducted, with elbow flexed and upper arm supported by a padded bolster placed proximally. Surgical landmarks, ulnar nerve, and portals are drawn out for illustration purposes.

▪ Prone position: superior access to the posterior compartment; facilitates elbow manipulation, relaxes anterior NV structures

▪ Lateral decubitus position: similar advantages with improved airway access by anesthesia team

• Setup

• Shoulder abducted, elbow flexed (Fig. 20-1)

• Padded bolster placed high on arm along with tourniquet

▪ Allows anterior soft tissue relaxation

▪ Accommodates more elbow flexion for visualization

• Bony landmarks marked on skin

▪ Done before joint distension

▪ Ulnar nerve is evaluated for subluxation

• Sterile limb positioner may be beneficial (Fig. 20-2)