Table of Contents
Elbow arthroscopy is a technically demanding procedure but it is very useful to evaluate the entire elbow joint for pathology with minimal surgical exposure and faster recovery than a traditional arthrotomy. The neurovascular structures of the elbow joint are in close proximity to the joint, thus there is a risk of injury to these structures, so care must be taken to fully understand elbow anatomy and to be prepared for aberrations. Elbow arthroscopy can be used diagnostically, as in this video article, or to surgically treat a variety of conditions including ligamentous tears, loose bodies, capsular stiffness, osteochondritis dissecans of the elbow, osteophyte debridement, and lateral epicondylitis. A patient with a previous ulnar nerve transposition is a relative contraindication to elbow arthroscopy, as there is a high risk of injury to the ulnar nerve during portal placement.
Questions to Ask while Conducting the History1:
- Is there a history of repeated elbow dislocations?
- Is there elbow instability? What is the timing?
- Is there pain with range of motion?
- Is there complete range of motion?
- What articulation is involved? It can be the hinge joint or the proximal radioulnar joint.
- Was there predisposing trauma?
- Has there been previous elbow trauma or surgery?
- Does the elbow displace? In what direction?
- Posterolateral rotatory displacement is the most common direction.
- Anterior displacement may be seen with olecranon fractures.
- Valgus instability may be seen with post-traumatic rupture of the MCL or radial head fractures, it may also be seen in athletes with repetitive stress and overload that diminishes or ruptures the anterior band of the MCL.
- Varus instability may be seen with LCL complex disruption.
- What is the degree of displacement?
- There can be posterolateral rotatory subluxation with pivot-shift testing (Stage 1)
- There can be incomplete dislocation with the coronoid perched under the trochlea (Stage 2)
- There can be complete dislocation with the coronoid behind the humerus (Stage 3)
- Is there recurrent, clicking, snapping, clunking, or locking of the elbow?
Tips for Conducting the Physical Exam1:
- Visually examine for gross deformity, skin lesions, erythema, or effusion.
- Palpate the humerus, elbow joint, radius, and ulna. Looking for tenderness indicative of occult fracture.
- Observe and document Elbow range of motion. Observe for any mechanical block to motion or painful range of motion. Assess instability at 0 and 30 degrees of flexion.
- At 30 degrees of flexion, medial collateral ligament (MCL) complex is primary stabilizer. Instability only at 30 degrees indicates MCL pathology.
- In full extension other bony and soft tissue restraints exist. Instability here indicates more extensive injury, with possible anterior and posterior capsule involvement.
- Observe Elbow supination and pronation.
- Special tests:
- Lateral pivot-shift apprehension test. Patient supine with arm overhead, forearm supinated, hold distal to elbow and near the wrist and apply valgus and compressive forces while flexing. This will recreate symptoms and cause sensation that elbow is about to dislocate. With flexion, the radius and ulna should reduce with a clunk onto the humerus.
Imaging should include AP and lateral views of the elbow to assess for fracture or visible loose bodies. A lateral stress view, preferably valgus and varus stress under fluoroscopy, should be taken to assess for displacement. Joint space widening >2 mm indicates instability. MRI of the elbow can provide good visualization of the MCL. CT arthrography can help to evaluate for tears on the undersurface of the MCL.2
Elbow stability is derived from the combination of static forces from bony articulations, capsule, and ligaments with dynamic forces from muscles and tendons. MCL complex is composed of anterior (AMCL) and posterior (PMCL) bundles of MCL and the transverse oblique bundle. The AMCL is taut throughout elbow range of motion and provides at least 70% of valgus stability. Lateral collateral ligament (LCL) complex is composed of annular ligament, radial collateral ligament (RCL), lateral ulnar collateral ligament (LUCL), and accessory lateral collateral ligament. The LUCL is the most important stabilizer against posterolateral instability. Chronic valgus instability is usually due to overuse by throwing athletes or those performing overhead activities. Repetitive stress due to frequent muscle use or extrinsic loading applies valgus force to the MCL over prolonged periods without time for adequate healing. This results in the valgus-extension overload syndrome defined by diminution of the MCL, compression of the radiocapitellar and posteromedial ulnohumeral joints. Subsequent olecranon impingement can lead to inflammation and osteophytes that can fracture and form loose bodies. Pain and flexion contracture may result. Acute MCL rupture may occur with elbow dislocation and, without repetitive stress, generally heals adequately and does not lead to valgus elbow instability. Loose bodies may also result from osteochondritis dissecans of the bony elbow structures.
Elbow arthroscopy may be used for diagnostic and therapeutic purposes as an alternative to the more invasive surgical arthrotomy. The technique may be used for diagnosis of inflammatory, degenerative, or traumatic arthritis, loose bodies, acute evaluation of elbow fractures, and evaluation of elbow pain of unclear etiology. The technique may be used for therapeutic extraction of loose bodies, debridement of capitellar osteochondritis dissecans, synovectomy for treatment of rheumatoid arthritis, tennis elbow release, radial head excision, and lysis of adhesions and osteophyte extraction in arthritic conditions, capsulectomy, elbow instability and elbow ligament reconstruction, and arthroscopic reduction of elbow fractures.
- Proximal Anterolateral Portal: useful for evaluation of medial elbow joint, radiocapitellar joint, and the lateral recess. Take care to avoid injury to the radial nerve.
- Anterolateral Portal: useful for evaluation of the distal humerus, trochlear ridges, and coronoid process. You may be able to evaluate the radial head by angling the arthroscope. Take care to avoid injury to the radial nerve.
- Proximal Anteromedial (Superomedial) Portal: useful for evaluation of the anterior compartment, the capitellum and radial head. May also be possible to evaluate the annular ligament as it courses over the radial neck. Trochlear, coronoid process, and coronoid fossa may also be observed via this portal. Take care to avoid injury to the ulnar nerve.
- Anteromedial Portal: useful for examination of lateral elbow joint and proximal capsular insertion. Take care to avoid injury to the medial antebrachial cutaneous nerve.
- Posterolateral Portal: useful for evaluation of the olecranon fossa, olecranon process, and posterior trochlea. Take care to avoid injury to the medial and posterior antebrachial cutaneous nerves.
- Accessory Posterolateral Portals: useful for evaluation of the posterolateral recess.
- Direct Lateral (Soft-Spot) Portal: useful for joint distention and evaluation of the inferior capitellum and radioulnar joint. Take care to avoid injury to the posterior antebrachial cutaneous nerve.
Diagnostic elbow arthroscopy is a way to fully evaluate the elbow joint with minimal surgical exposure. It is particular useful in evaluating trauma to the elbow that has resulted in ligamental tears, the joint capsule, the synovium, loose bodies, adhesions and cartilage lesion. Additionally, many therapeutic interventions can be conducted through arthroscopic portals as noted above.
Special Considerations and contraindications to elbow arthroscopy5
Contraindications include distorted anatomy that would make portal placement difficult or dangerous. Care should always be taken to avoid the ulnar nerve, medial nerve, radial nerve, medial and posterior antebrachial cutaneous nerves, and brachial artery during portal placement by thorough evaluation of bony landmarks prior to portal placement. Elbow structures can also be damaged by overly aggressive distention or instrument manipulation. Previous transposition of the ulnar nerve is not an absolute contraindication, but should be considered carefully before proceeding with elbow arthroscopy, as this can increase the risk of nerve injury during portal placement.
- O'Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2000;370:34-43. doi:10.1097/00003086-200001000-00005.
- Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography: evaluation in 25 baseball players with surgical confirmation. Am J Sports Med. 1994;22(1):26-32. doi:10.1177/036354659402200105.
- Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Clin North Am. 1999;30(1):81-89. doi:10.1016/S0030-5898(05)70062-6.
- Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy. 1985;1(2):97-107. doi:10.1016/S0749-8063(85)80038-4.
- Abboud JA, Rocchetti ET, Tjoumakaris F, Ramsey ML. Elbow arthroscopy: basic setup and portal placement. J Am Acad Orthop Surg. 2006;14(5):312-318. doi:10.5435/00124635-200605000-00007.
Diagnostic Elbow Arthroscopy Demonstration on a Cadaver Specimen
- Make Anatomic Landmarks, note Medial and Lateral
- Anteromedial (Starting Portal)
- Proximal Anterolateral Portal
- Soft Spot Portal
- Modified Posterolateral Portal
- Insufflate joint with 20-30cc saline
- Entering Anteromedial portal
- Entering Proximal anterolateral portal
- Enter Anterior Compartment and Evaluate:
- Lateral gutter
- Capsule evaluation
- Annular Ligament
- Enter Posterior compartment
- Enter Accessory Posterolateral Portal and Evaluate:
- Medial Gutter
- Tristate Area
- Posterior Capitellum
- Enter Accessory Posterolateral Portal and Evaluate:
- Enter Accessory Distal Ulna Portal
- Demonstrating the Use of Elevator
My name is Patrick Vavken. I'm a Sportsman's fellow at Boston Children's. I'm going to take you guys through portals and diagnostic elbow arthroscopy 101 basically. Starting out with the case, we do a lateral decubitus, which is, you know, how I learned it and how I like to do it for a number reasons. Anesthesia likes it. It's a quick set up, and if you use a pillow a similar device, you can do a straight lateral approach without changing the position of the patient.
In terms of marking, the things that I've found most interesting and most important is write down "lateral," write down "medial," on the elbow because throughout the case you might get lost, and it's going to be very helpful. Other than that, I do a very small lateral epicondyle and septum, a very small medial epicondyle and septum - make sure I get my olecranon going. I want to know where my radial head is, which will give me my soft-spot portal, and I want to palpate the ulnar nerve. Make sure it doesn't move all that much, and it doesn't sublux in FlexAngle - could be a potential contraindication for an elbow procedure.
Portals we're going to be using - based on the publications of Verhaar et al., I like to use the anteromedial portal as the starting portal because there's the lowest risk of neurovascular injury. It's about a centimeter up, and it's a centimeter anterior to the medial epicondyle - just in front of the septum, so you're away from the ulnar nerve.
Second port we're going to use is a proximal anterolateral portal as opposed to just anterolateral portal. Remember, all the proximal ones are safer than the distal.
We'll be using a soft-spot portal, and we're going to be using a modified posterolateral portal. This one - we like to be just shy off the tricep - triceps tendon because that's painful for the patient if you don't poke the tendon too many times.
Going into the joint, the most crucial part is sufficient insufflation. The elbow's going to hold anywhere between 20 and 30 cc's of water. If you inject 5 cc's, it's not going to help you. It's not going to get your anywhere. You can do a soft-spot portal. You can go straight through the tendon if you want to go into the fossa because you're not sure. If you did soft-spot - especially in pediatric cases or in trauma - going in, you should feel some bone, you should feel the water flowing quite gently, and then you should look for and extension of the hand and a horseshoe in the back of the elbow. You can see quite nicely how it flows out in the back - can even redirect your needle.
Getting started with your portals, you want to think about a nip and tuck technique, so you're just going to be cutting skin big enough so that you can move your scope okay but not any deeper.
Now the way I was trained - and I like it - is you're going to have a scope hand and an instrument hand based on position of the patient - not on your right or left hand dominance. You're going to feel for the ulnar nerve. Once you can palpate it, you're going to hold it out of the field. Then you're going to take this straight snap. You're going to put it through the portal. You're going to be behind the septum, and you want to move forward when you're anterior. You're going to feel a little pop, moving back, making sure you're behind it again, moving anterior again so you're exactly sure where the septum is, and then you pierce him. Personally, I don't go through the capsule just yet - just down to the capsule to make sure I don't have a double penetration losing extra fluid. You get your obturator. You repeat the same motion. Find ulnar nerve - find ulnar nerve. Pull it back. Get your septum behind septum - anterior, posterior, anterior just follow back in - into the joint. Make sure you feel some bone. As you disengage the obturator, you want to pull back the obturator. At the same time, push forward the trocar a little bit to make sure you don't fall out of the capsule again. You see the water flowing back, which is going to tell us we're right in.
If you have any concerns about being in the joint, you can bring in your needle on the other side, inject more water here, and you're going see it flow out of the cannula on this side. Come in. Our eye is going to be looking straight up into humerus. Horizon is just level.
Well at this point, we're in the joint. As you can see, first of all, there's not a lot of flow going on. Secondly, this person had cortisone injections in the past, and this is what it's going to be doing to the joint. If you want to look at my left hand again, the way I was trained, I'm still using the pistol grip because the play of millimeters in an elbow scope is going to mess up your procedure if you fall out of the joint. So using my index finger and my ring finger, at all times I can tell how far in or out I am without even looking at the - my hand itself, so if I'm looking for my assistant to get something, I'm still in the stable position right here.
Now we want establish our proximal anterolateral portal. My marking might have been a bit too proximal. You can see the light on your camera basically right here. Remember, you have a 30 degree scope - so you come in through here, and you're going to be falling right into the joint. While coming into the joint, there's a couple of things you want to remember. If you bring your needle in too close to the humeral head like this, you're going to have a hard time coming around into the joint. You might just not reach where you want to go, so make sure you keep a little bit of a distance before you set your portal. If you were looking at a tennis elbow, there would be a defect in the capsule right here, so you'd put your portal right through that defect because you don't have to create a second capsulotomy. The other thing - the more holes you make in a capsule, the harder it's going to be to fill the joint and keep it under the pressure, and it's going to collapse on you.
Once the needle is in, we can see the humerus up here, capitulum down here, and radial head somewhere in the water. We know the radial nerve is going to be in a safe spot, so we can just use your knife and plunge right in - into a longitudinal direction. Again, remember, the mobile wad and it's direction. And sort of just do a little capsulotomy right here, and we're going to be using the straight after. If you look at the hand on the outside, it's a 90, 90 degree. So it's 90 from here, 90 from here, so any other instrument you put in, you just go in at the same direction, and you're going to fall into that same hole hopefully. A very useful instrument at this point will be a switching sick or just the backside of a probe, which will come in - remember again, in that straight 90, 90 direction? And then you can use it to hold away the capsule, out of your field of view, and hopefully establish a bit more visibility in that joint. There's some - there's nothing coming in or out.
Alright, having established our second portal, we can take the - the scope through a diagnostic arthroscopy. We're looking at the capitulum. We're seeing the remnants of the injections for the lateral epicondylitis. This is the cortisone shots that destroyed the capsule and left the precipitations in the joint. This is humerus and the attachment of the capsule is going to be up here.
Down here, we can fall into the lateral gutter. And you can actually see the torn capsule, and you can see behind it to ECRB. This will be taken out for epicondylitis. It's a nice type 3 defect. Capsule is entirely torn. You can see the mobile wad right behind it. So that's a Baker type 3 defect.
We're going to the radial head at the bottom of the picture. You can take it through a course of pronation and supination, and it should r - just roll. If there's any tilting like that, you can see this is an unstable elbow most likely. Based on that huge information, probably through the repeated injections, they did get the lateral, collateral ulnar ligament, and now you can see how the joint first of all opens and also pivots to the back - and roll back forward into a reduced position. Going back further down, we can make our way to the annular ligament.
Alright, as we back up a little bit, we follow radial head into this spot right here. This position between the ulna and the radial head is a prime location for loose bodies. If they're the anterior joint, they might just end up right in this spot. We fall off the trochlea. We can see the coronoid fossa to our right. Alright, at this point we have switched our positions to the anterolateral portal, which gives us better exposure of the coronoid right here. The medial gutter over here and just - for our medial gutter down there. If you're suspect - suspecting UCL instability, this would be your - your view. That way you take the elbow through valgus va - and varus extension and see if there's instability, but this guy doesn't really move all that much. At this point we could conclude our anterior compartment diagnostics and go back into posterior compartment after having checked our favorite spot for the loose bodies one more time. Alright, classic teaching for the posterior compartment arthroscopy: don't go medial.
You can follow a line on a lateral edge of this biceps tendon as high up as crossing at radial nerve. If you're not sure where that is, if you take the diameter between the epicondyles and you go up 140% of it, that's usually where it should be. So if you don't go higher than one diameter - one epicondyle diameter - the radial nerve should not be at risk. The biceps tendon here is at risk for a painful ner - scar tissue formation if you poke it too often. So pull just shy of it will give you great exposure for the posterior and posterolateral compartments - at the same time, allow a lot of maneuverability. Mobile wad is engaging here onto the humerus, so this no man's land down here really is predisposed for this portal. We're still going to do a working portal straight trans-tricipital right here, and you're going to be using a soft-spot portal down here in a second. Establishing this por - portal is as easy as it could be because there's nothing bad in here - you just plunge all the way into the joint. At the same time, you just plunge here all the way to the joint.
Remember, that in about 5% of all people there's what we call perforated olecranon fossa where there's no bone and I just plunge all the way through into anterior compartment. The other thing is in children, the main vasculature of the to - of the trochlea and capitulum comes through the posterolateral aspect of right here, so this portal might get you a lot of trouble and might end up in a fistula deformity. As the operator goes in - because of the usually quite extensive scar formation down there in adult people, especially in arthrofibrosis, it makes sense to loosen up everything a little bit. Just scrape along the bone. Create some space for yourself. You're not going to regret it after. Also, if you have a flexion lag, just moving up here - even using an osteotome or something - is going to create another 5 or 10 degrees of flexion postoperatively. So our scope is in the posterolateral accessory portal. We come through trans-tricipital, and we can see the olecranon down here going into the fossa up here. At this point, coming in with our second instrument - this one we might need to do some planning. You're going to see that strap of cartilage right here, and in a normal joint, this should be roughly 7 millimeters. If this is not 7 millimeters, either there's arthritis going on up here or, more likely, you have osteophytes on your olecranon. So if your taking away, just take away as much as you need to take away to get that 7 millimeters again. If you take more, you might destabilize the whole elbow. Going over medially, we can work our way into the medial gutter, theoretically. And there's our medial gutter.
You can see quite nicely the humerus is on top, ulnar at the bottom, and you will see that right underneath that soft tissue right there is your ulnar nerve - somewhere in here. In some publications, people have spoken about taking away the synovial and just, you know, looking at the nerve to make sure it's right where it's supposed to be. I would not recommend doing that. Coming back again into the posterolateral compartment without disengaging our camera too much, you can follow the joint into - down lateral. Even if we were doing lateral, using a little extension of the arm into what is called the tri-state area.
You can see the lateral compartment, and looking down this way, keep going a little further, you will see the ulna at the bottom, moving right here, and the humerus on top. Now if we shift our camera in here, we'll get another prime location for loose bodies. If you fall into here quite easily, that's an indication for lateral stabilit - instability. The other thing - at the top left corner of the monitor, you want to see a little bit of bare bone, but it's cartilage all around. This is not pathological. As a matter of fact, this is more normal in most people. So at this point right here, there's no cartilage on bone, and this is where we do our ulnar osteotomies for a posterior approach. We got right this area - right here where in most patients there is no bone. The soft tissue here around the needle is the plica syndrome that is usually doubted by a lot of people. Following our needle down that way, moving this way, we'll see the groove, the saddle that used to be the ulnar radial joint right here. Now we're going to assess our posterior plica. Going through our soft-spot portal right here, we're going to take out the plica right there. Again, since there's nothing bad down here, you can just do one stab incision and bring in your shaver.
Now at this point, we should see the radial head right exactly where the shaver is because it's again yanking these muscles right on the screen - on the right-hand side of the screen - which makes me wonder if this was a person who actually had a radial head resection in their younger days. Because right in that groove, right here - no radial head. A beauty of not having radial head is it's going to the approach to the captal - capitulum more easier. You can see where your osteotomy should have been. We've, you know, scraped it up with our shave a little bit. And what we're going to do - we're going to switch your camera into this soft-spot portal right here. We get a little better exposure of the posterior capitulum right up here. So looking into - on the humeral joint at this point, all the moving down there - we're going to roll back, we're going to come around this way, and we'll be seeing the posterior capitulum right there.
Now if you'd be suspecting an OCD, you'd be right here. If you're going to flexion, you're going to have a hard time readin - reaching this from the anterior part. If you're in the posterior compartment, you're still going to have a very hard time reaching this. This is where the accessory distal ulna portal comes into play. You follow the edge of your ulnar down here, and staying right next to your ulnar, you'll come long up - straight into the joint.
You can still see that the shape will be in straight shot for say microfracture or drilling of an OCD right back here.
Now if you ev - you ever find yourself in a position like this where your - the suction for your shaver's really creating so much trouble that you can't work, you're going to use a elevator - for example, through the accessory posterolateral portal, coming down this way, into your field of view, pulling the capsule out of the way - Femke, you can hold this for a second? And then can use your accessory portal to come straight at your defect be it here, be it there, be it anywhere in that place. And with that view of the posterior capitulum, we will conclude our diagnostic arthroscopy at this point.