There are several techniques that can be used to minimize the risk of neurovascular injury during arthroscopy, beginning with how to position the patient. Elbow arthroscopy can be performed with the patient supine, prone, or lateral decubitus. There are advantages and disadvantages to each position (Table 1), but once you decide upon a position, stick with it. No matter what the patient’s position is, the arthroscope most often is pointing toward the surgeon, making navigation confusing since everything is a reversed mirror image of what you expect. Familiarity breeds comfort in this case, so maintain the same positioning and learn how to scope well in that position.

The lateral decubitus position straddles the risks and advantages of the prone and supine positions and will be discussed here. After general anesthesia with endotracheal intubation is achieved, place the patient in the lateral decubitus position on a beanbag, surgical side up. A slightly more prone than a true lateral position allows for more distance between the table and the elbow, mitigating some of the instrumentation disadvantages of the true lateral position. An axillary roll is used to prevent compression of the brachial plexus during the procedure and should be placed just caudal to the axilla. Make sure that the peroneal nerve is free around the fibular head and that the lateral malleolus is well padded. The down arm should not be abducted more than 90° to prevent prolonged traction on the brachial plexus. The elbow is well padded and flexed to 90°. Avoid flexion beyond 90° to prevent ulnar nerve compression and maintain unrestricted vascular flow. Place the surgical limb over a padded arm holder with the patient at the very edge of the surgical table. The goal is to have as much clearance between the table/patient and the elbow to allow for unrestricted instrument maneuvering in the anterior compartment (Fig. 2a).

Place the monitor directly in front of where you will be doing the arthroscopy so that your view is clear and unrestricted. Set the arthroscope to maximal zoom and make sure the monitor is close to the field. A 4.0 mm 30° arthroscope is usually used, but a 2.7 mm scope may be appropriate for younger children. Fluid flow can be controlled by a pump or by gravity. Gravity is most reliable and easiest to control and requires no specialized equipment (Fig. 2b).

A sterile or nonsterile tourniquet can be used. Either way, the tourniquet should be as proximal on the arm as possible. For young children, a HemaClear (HemaClear, OHK Medical Devices, Grandville, Michigan, USA) tourniquet may be necessary to optimize the surgical field. Set the arm on a well-padded arm holder, and check once more to make sure that there is adequate room around the elbow to maneuver instruments in the anterior compartment. Make adjustments as necessary.

Prepare and drape the arm in the standard fashion. Place the hand and forearm into an impermeable stockinet secured with a self-adherent elastic bandage. If simultaneous access to the knee is required, drape out the leg concurrently over a nonsterile tourniquet (Fig. 2b). Mark out the relevant bony and soft tissue landmarks and the portal sites (Fig. 3). Make sure once again that the ulnar nerve does not subluxate. The most commonly used portals are the proximal anteromedial, proximal anterolateral, soft-spot, posterolateral, and direct posterior portals. Other accessory portals, particularly the posteromedial, may pose greater risks and should be used only when needed.

Exsanguinate the arm and inflate the tourniquet. Insufflate the joint with 20–30 ml of saline or 0.25 % bupivacaine with epinephrine via the direct posterior portal or the soft-spot portal. The posterior portal is easier and more reliable unless the patient has a fenestrated olecranon fossa, in which case the fluid can inadvertently be injected into the antecubital fossa. If the fluid is in the joint, the elbow will extend slightly as the capsule expands.

Begin with the proximal anteromedial portal. Incise the skin with a #15 blade (not a #11 blade), and dissect bluntly with a straight hemostat to the capsule. Direct the dissection angled proximally and laterally so as to skive off the anterior cortex of the humerus. Do not puncture the capsule with the hemostat, as this will deflate the capsule and increase the risk of median nerve injury. Use the camera cannula with a blunt trochar to pierce the capsule, following the line of dissection. The bony anatomy will be easily felt through the instrument if the cannula is in the joint. Whenever possible, minimize the number of passes of instruments in and out of the joint, as each pass carries a risk to nearby structures. Replace the trochar with the camera, connect the inflow tubing, and set up a drainage tube to gravity outflow into a bucket on the floor. Make sure that the inflow tubing is primed to minimize the amount of air in the joint and open the flow. Keep the outflow off to reinflate the joint.

Take a quick look around the joint, and make sure that the portal placement allows for adequate maneuvering and visualization (Fig. 4a). Place the camera against the far capsule at the entry point of the mid anterolateral portal. Maintaining the cannula in place, remove the camera and place a switching stick though the cannula and out of the joint. Incise the skin to allow passage of the switching stick. Place a working cannula over the switching stick into the joint, pushing the camera cannula to the center of the joint. Remove the switching stick and reinsert the camera into the camera cannula. Confirm placement of the working cannula. The switching stick can be used as a retractor, or the working cannula can convey a 3.5 mm shaver (Fig. 4b).

With the camera through the proximal anteromedial portal, inspect the radial head, the capitellum, the proximal radioulnar joint, the coronoid, and the lateral half of the capsule for pathology. The anterior compartment of the elbow is a wide open room that allows unrestricted visualization from the medial side unless the capsule is contracted (smaller capsular volume) or there is an exuberant inflammatory process (synovitis narrowing the visible space). If the capsule is contracted, proceed with caution. If there is inadequate visualization to achieve the surgical goals, conversion to an open procedure is appropriate unless the surgeon has experience with an arthroscopic capsular release. If synovitis is obscuring the view, a controlled synovectomy can be performed with a nonaggressive shaver using low intermittent suction or gravity outflow. The blades of the shaver should always point away from the anterolateral capsule so as not to inadvertently debride the posterior interosseous nerve (PIN). Maintain the capsule intact if possible and only debride the synovitis. This will minimize fluid extravasation.

Keeping both cannulas in the joint, replace the camera and the shaver each with a switching stick. Switch the cannulas and reinsert the camera and the shaver, now from opposite portals. Inspect the medial side, debriding as required for visualization (Fig. 4c). Remember that there is only so much fluid that the soft tissues can absorb before they become too saturated to allow good visualization. Work efficiently and have a plan. Extraneous steps are extraneous.

Make a direct posterior portal and place the shaver into the olecranon fossa. With the blades of the shaver pointing away from the ulnar nerve, debride blindly to remove the fat pad in the olecranon fossa. Insert the camera through the direct posterior portal, and reinsert the shaver through the posterolateral portal. Inspect the olecranon fossa, the medial gutter, and the olecranon (Fig. 4d, e). If the olecranon fossa is fenestrated, fat pad debridement will need to be done under direct visualization with the camera in the posterolateral portal. Switch the camera to the posterolateral portal and reinspect the olecranon fossa, the opening of the medial gutter, the ulnohumeral joint, and the olecranon. The ghostlike ulnar nerve can often be visualized on the other side of the joint capsule along the medial side (Fig. 4f).

Follow the ulnohumeral joint down to the lateral gutter with the camera in the posterolateral portal. Slight elbow extension can take tension off of the posterolateral soft tissues and open the lateral gutter. Place a needle though the soft-spot portal to confirm portal placement. The needle should emerge into view just proximal to the radial head. Pass a shaver through the soft-spot portal, and debride enough of the fat pad to allow for visualization of the proximal radioulnar joint, the radial head, and the capitellum (Fig. 4g). This is a relatively safe area to debride as long as the blades are pointed away from the articular surfaces. There are no neighboring neurovascular structures, and the collateral ligament inserts distally.

Moving the camera to the soft-spot portal allows close-up visualization of the radiocapitellar joint (Fig. 4h). A more bird’s eye view of the radiocapitellar joint is rarely possible due to the minimal capacitance of the lateral gutter. Accessory posterolateral or posterior portals may be used as needed and pose little additional risk.

Remove all instrumentation from the joint. Close the portal sites and deflate the tourniquet. Apply a sterile dressing and flip the patient back to a supine position. Place a splint or cast as required based on the procedure.

Some young athletes, particularly throwers, will develop olecranon impingement against the fossa. This may be the result of apophysitis or fracture leading to a longer olecranon. The lengthened olecranon then impinges on the fossa and blocks terminal extension. Secondary changes may be seen at the fossa. Arthroscopic treatment is fairly straightforward and may be an excellent technique for the novice arthroscopist to attempt. If the olecranon fossa is not fenestrated, begin by placing a shaver in the posterior portal, blades facing away from the ulnar nerve, and clearing away some of the fat pad. Insert a camera in the posterolateral portal. Using a burr always pointed away from the ulnar nerve, resect enough olecranon to make sure that there is no impingement. Make sure to remove any loose bony fragments from the joint. The defect created in the olecranon from a small amount of resection will appear enormous through the arthroscope. It is best to resect down to the level of resection required from proximal to distal, so that the burr itself can serve to measure the amount resected. Once the desired depth is reached, widen the path medially and laterally. Terminally extend to elbow to confirm adequate resection under direct visualization. Visualize the lateral and medial gutters and the sides of the olecranon. Fluoroscopy can be used as well but may be misleading since it cannot detail the three-dimensional architecture.