1. Elbow Arthroscopy Indications and Technique Joel Gonzales, M.D. William R. Beach, M.D. Richard B. Caspari, M.D.

2. Indications Loose Bodies DJD - Debridement and Osteophyte Removal Capsular Contracture OCD Synovectomy Radial head excision Olecranon Bursectomy (Kerr)

3. Indications Septic Arthritis Internal Fixation Capsulorraphy Ligament Reconstruction ? Lateral Epicondyle Release (Champ Baker) ?

4. Contraindications Bony Ankylosis Coagulopathy History of nerve transposition or muscle/tendon transfer

5. Advantages Excellent Visualization Smaller Scars Rapid Return To Function

6. Disadvantages Technique Dependent Takes Longer Inability to Accomplish Procedure

7. Patient Positioning Prone Supine Modified Supine

8. Prone Advantages Best access to posterior portal No arm support necessary Disadvantages More difficult anesthesia Difficult to convert to open Image reversal

10. Supine Advantages Best anterior access Easier anesthesia Easy conversion to open Familiar arm support (shoulder holder) Disadvantages Difficult posterior access and orientation Posterior scope-under fogging

12. Modified Supine Advantages Easy anterior and posterior access Anesthetic options Familiar anatomic presentation Easy conversion to an open procedure Disadvantages Requires an arm holder Restricted motion in the present holder Compresses Anterior structures

14. Instruments 20 cc Syringe and Sterile I.V. Tubing 18 Gauge Angiocatheter Sterile Marking Pen #11 Scalpel Standard Arthroscopy Pump or gravity

15. Instruments Switching Sticks(smooth metal rods) 76mm Plastic Cannula with Membrane Motorized Shaver and Burr Hand Held Arthroscopic Instruments –Suction Punch –Basket Punch –Grasper

16. Portals Anterior –Proximal Medial (superomedial) –Anteromedial –Anterolateral Posterior –Soft Spot (direct lateral) –Posterolateral –Trans-Triceps Tendon (straight posterior)

17. Anteromedial Portal 3 cm. distal and 1 cm. anterior to the medial epicondyle Passes through common flexor origin (2 cm. distal, 2 cm anterior - Lynch, Whipple, Meyers)

18. Anteromedial

19. Anteromedial Portal Best Visualization for: Radiocapitellar Joint Coronoid Fossa Trochlea Radio-ulnar Joint Anterior Capsule

20. Anteromedial View

21. Anteromedial Portal At Risk MABC Nerve (6mm) Median (19mm distended, 12mm non-distended) –sheath lies in contact with nerve in 56% of extended elbows Brachial Artery

22. Anteromedial View

23. Anterolateral Portal 2 cm. anterior and 2 cm. distal to the lateral epicondyle Passes through ECRB and Supinator posterolateral to radial nerve (3cm distal and 2cm anterior Andrews and Carson)

24. Anterolateral

25. Anterolateral Portal Best Visualization for: Coronoid Trochlea Radioulnar articulation Anterior Capsule Valgus Instability test (70 degree flexion, full pronation, Ulnohumeral opening - Andrews and Timmerman)

26. Anterolateral View Ulnotrochlear Joint Anterior Capsule

27. Anterolateral Portal At Risk Radial Nerve (as close as 3 mm) PIN (1 to 13 mm increasing with pronation) Posterior Antebrachial Cutaneous Nerve (2mm)

28. Proximal Medial Portal Usually start medially 2-3 cm. Proximal to the Medial Humeral epicondyle Just Anterior to the Medial Intermuscular Septum

29. Proximal Medial Portal

30. Best Visualization for: Radiocapitellar joint Coronoid Trochlea Radio-ulnar joint Anterior capsule

31. Proximal Medial Portal At Risk Ulnar Nerve MABC Nerve Median Brachial Artery

32. Soft Spot Portal Center of triangle formed by the radial head, lateral epicondyle, and olecranon Passes through anconeus and triceps Posterior Antebrachial Cutaneous Nerve (7 mm average)

33. Soft Spot Portal

34. Best Visualization Posterior Surface of Radial Head Posterior Capitellum Radial Surface of Olecranon

35. Soft Spot Portal Trochlea (above) Radial Head (left) Olecranon Bare Spot Tip of Olecranon (right)

36. Posterolateral

37. Posterolateral Portal Best Visualization for: Olecranon Process Olecranon Fossa Posterior Ulnar Gutter 70 degree scope - Posterior portion of UCL

38. Posterolateral Portal Olecranon Fossa

39. Posterolateral Radiocapitellar Articulation

40. Trans-Triceps Tendon Portal 2 - 3 cm. proximal to the tip of the olecranon process

41. Structures Best Seen Olecranon Process Olecranon Fossa

42. Structures Best Seen Posterior Radial and Ulnar Gutters (Loose Bodies, Osteophytes, Synovectomy)

43. Caveats 1. Avoid Stab Wounds 2. 90° Flexion 3. Bony Landmarks

44. Caveats 4. Measure Precisely 5. Direction Critical 6. Post-Op Neurovascular Examination Mandatory

45. Thank You Orthopaedic Research of Virginia

46. Olecranon - R Fossa - L Soft Spot Portal