Elbow arthroscopy is a valuable tool for managing both simple and complex elbow conditions when conservative treatments have not provided relief. It does not replace the need for a thorough patient history, physical examination, diagnostic imaging, or appropriate non-surgical care.
Arthroscopic elbow surgery is indicated for the following conditions:
Supine Position (on the operating table): This is the traditional position.
Prone Position: The patient lies face down with large chest rolls placed under the torso. An arm board is positioned on the operative side of the table, parallel to it. To improve intraoperative mobility of the upper extremity, a sandbag, foam block, or rolled towel is placed under the shoulder to lift the arm further away from the table. The forearm is then allowed to hang in a dependent position at a 90-degree angle over the arm board.
Benefits of the prone position for elbow arthroscopy include:
Some surgeons prefer the lateral decubitus position. They believe it offers improved stability of the extremity, is more comfortable for the anesthesiologist, and provides access to the posterior elbow joint without compromising airway access. The patient is placed on their side with the affected arm facing up. The arm is then supported on a well-padded bolster, allowing the forearm to hang freely with the elbow bent at 90 degrees. In this position, the elbow is presented to the surgeon, who then has access to the various portal sites.
Proximal Anteromedial Portal: This portal, first described by Poehling, is established first. It is located approximately 2 cm proximal to the medial epicondyle and directly in front of the intermuscular septum. Before creating this portal, the location and stability of the ulnar nerve should be assessed. The prevalence rate of ulnar nerve subluxation in front of the cubital tunnel is approximately 17%.
A blunt dissection is performed until the anterior aspect of the humerus is palpated, staying anterior to the intermuscular septum. The arthroscopic sheath is then inserted in front of the intermuscular septum, maintaining contact with the anterior humerus, with the trocar directed toward the radial head.
Using the anterior surface of the humerus as a constant guide helps prevent injury to the median nerve and brachial artery, which lie in front of the capsule. The ulnar nerve is located about 3 to 4 mm from this portal, behind the intermuscular septum. By palpating the septum and ensuring the portal is anterior to it, the risk of nerve injury is minimized while still providing excellent visualization.
This portal provides excellent views of the anterior elbow, particularly the radiocapitellar joint, the humeroulnar joint, the coronoid fossa, and the superior joint capsule.
Special attention should be given to the medial side of the elbow, and the ulnar nerve should be carefully examined to ensure it is not subluxated. If there is any doubt, the ulnar nerve should be dissected out and identified, and the trocar carefully placed around it. Alternatively, two lateral portals or a trans-fossa portal with a 70-degree scope for viewing the anterior compartment can be used.
Anteromedial Portal: As described by Lynch and colleagues, this portal is located 2 cm distal and 2 cm anterior to the medial epicondyle, at or near the distal extent of the elbow capsule. Due to its location, the cannula can only enter the joint when advanced directly laterally towards the median nerve. For this reason, the proximal anteromedial portal is recommended; it is safer because its more proximal position allows the arthroscope to be directed distally, running nearly parallel to the median nerve in the anteroposterior plane.
Anterolateral Portal: Originally described by Carson and Andrews as 3 cm distal and 2 cm anterior to the lateral epicondyle, this portal position carries a significant risk of iatrogenic injury to the radial nerve. Lindenfeld showed that the radial nerve can be as close as 3 mm from this portal. To reduce this risk, several researchers have emphasized the importance of avoiding the distal placement of this portal in favor of a more proximal anterolateral portal.
Field and colleagues compared three lateral portals: a proximal anterolateral portal (2 cm proximal and 1 cm anterior to the lateral epicondyle), a distal anterolateral portal (as described by Carson and Andrews), and a mid-anterolateral portal (1 cm directly anterior to the lateral epicondyle). The researchers found that the proximal anterolateral portal was the safest and that visualization of the radiohumeral joint was most complete and technically easiest through this most proximal portal.
Proximal Anterolateral Portal: This portal is created 2 cm proximal and 1 cm anterior to the lateral epicondyle, as described by Field and colleagues. The exact entry point depends on the pathology being treated. From the proximal anteromedial portal, the lateral capsule is visualized, and palpation of the skin helps locate the exact position for a spinal needle to facilitate portal placement. It is crucial to direct the cannula toward the humerus when entering the capsule to avoid placing the portal too far anteriorly and medially. From the proximal anterolateral portal, the radiocapitellar joint is well visualized, along with the trochlea and coronoid process.
The proximal anterolateral portal is often used as a working portal. It is ideal for arthroscopic lateral epicondyle release and debridement of the radiocapitellar joint. The view from this portal allows visualization of the anterior compartment and is particularly useful for assessing medial structures such as the trochlea, coronoid tip, and medial capsule.
Straight Posterior Portal: Located 3 cm proximal to the olecranon tip, this portal can be used as either a viewing or a working portal. When first established, a cannula with a blunt trocar is inserted. The cannula pierces the triceps muscle directly above the musculotendinous junction and is manipulated in a blunt, circular motion to clear the soft tissues of the olecranon fossa for better visualization.
When used as a working portal, it is helpful for removing impinging olecranon osteophytes and loose bodies from the posterior elbow joint. It is also required for a complete elbow synovectomy. The straight posterior portal passes within 25 mm of the ulnar nerve and within 23 mm of the posterior antebrachial cutaneous nerve.
Posterolateral Portal: This portal is located 2 to 3 cm proximal to the olecranon tip on the lateral border of the triceps tendon. It is created by visualizing from the straight posterior portal and using a spinal needle directed toward the olecranon fossa. Initial visualization is often difficult due to scarring, fat pad hypertrophy, and synovitis. A trocar is then directed toward the olecranon fossa, passing through the triceps muscle to the capsule. A shaver is introduced to improve visualization of the posterior compartment. This portal allows visualization of the olecranon tip, the olecranon fossa, and the posterior trochlea, and can be used as a working portal to remove osteophytes and loose bodies from the posterior compartment.
However, the posterior capitellum is not well seen from this portal. The two most at-risk neurovascular structures are the medial and posterior antebrachial cutaneous nerves. They are, on average, 25 mm from this portal. The ulnar nerve is also approximately 25 mm away, but as long as the cannula is kept lateral to the posterior midline, there is no risk of injury to the nerve.
The posterolateral anatomy of the elbow allows for portal placement anywhere from the proximal posterolateral portal to the lateral soft spot. Changing the portal position along the line between the posterolateral portal and the lateral soft spot alters the portal's orientation relative to the joint. These portals are particularly useful for gaining access to the posterolateral recess.
Direct Lateral Portal: This portal is located at the soft spot, the triangle formed by the radial head, the lateral epicondyle, and the olecranon. It is developed under direct visualization using a spinal needle. It is suitable as a viewing portal for work in the posterior compartment and for viewing the radiocapitellar joint, as well as a working portal for radial head resection. The arthroscope is introduced into the posterior compartment through a straight posterior portal 3 cm proximal to the tip of the olecranon. A spinal needle is introduced lateral to the triceps tendon, directed toward the olecranon fossa, for the posterolateral portal.
Many complications associated with elbow arthroscopy are attributed to:
