ELBOW ARTHROSCOPY

INTRODUCTION
The field of arthroscopy has experienced remarkable growth and advance in the treatment of elbow disorders in recent years. It is now being performed by an ever increasing number of surgeons for a wide variety of conditions. Useful both for diagnosis and treatment, arthroscopic techniques are demanding, and potentially devastating neurovascular injuries are a concern. As elbow arthroscopy assumes a greater role in the diagnosis and management of elbow problems, new indications continue to emerge.
INDICATIONS / CONTRE-INDICATIONS
The indications for elbow arthroscopy include: removal of osteophytes due to impingement or osteoarthritis, synovectomy in patients with inflammatory arthritis, removal of adhesions and capsular release in patients with contractures, resection of symptomatic plicae, removal of loose bodies, and evaluation of patients with chronic elbow pain. In addition, elbow arthroscopy has been used to treat patients with osteochondritis dissecans, septic arthritis, epicondylitis and elbow fractures.
GENERAL TECHNIQUES
The operative techniques in general have been well described elsewhere. I prefer the lateral decubitus position with the forearm allowed to swing free. A soft elastic bandage is then wrapped around the hand and forearm to within ten centimeters of the olecranon. The tourniquet, which is used routinely, is inflated to 250 mm/Hg. The elastic bandage is left on until the end of the procedure to limit the periarticular swelling to the elbow area. When the bandage and tourniquet were removed, any accumulated edema rapidly dissipated into the tissues of the forearm and arm.
With the increasing complexity of the procedures performed, the number of portals used has increased (Figure 1). In addition, more of an emphasis has been placed on utilizing the more proximal portals (proximal anterolateral and anteromedial) portals.
The method and sequence of portal placement varied and evolved over the years. Currently, we generally start in the direct midlateral portal and establish access through the posterior portals immediately as well. Open drainage outflow through one or more sites is immediately instituted and maintained throughout the procedure. The posterior compartment is usually treated first and then the anterior portals established for correction of anterior compartment pathology. Portal placement is determined by careful palpation of the underlying bony structures and we do not rely on skin markings, as the skin markings do not correctly indicate the underlying structures after swelling occurs. We now rely on the use of retractors to permit visualization in the anterior compartment, rather than pressurization to accomplish joint distention. This reduces the risk of edema and even more greatly expands the complexity of surgical procedures that can be performed inside the elbow.
Anterior portal placement has been accomplished using both the outside-in and inside-out techniques, but over time the outside-in technique has become the preferred one. Initially, we believed that edema could be minimized by placing a cannula in each portal and keeping it there throughout the duration of the procedure, but our practice has been changed. Currently, cannulae are used only in one or two of the anterior portals. The proximal anterolateral portal is usually used for a retractor and the anterolateral and proximal anteromedial portals for the scope and working instruments. The bulkiness of the cannulae can outweigh their advantages except in the working instrument portal. In more complicated procedures such as those in which extensive bone and capsular work are required, the cannulae may be discarded as periarticular edema develops. This edema actually permits retention of the portal pathway and permits instruments to be readily moved in and out of the elbow, which is usually required.
A previously described system for pressurized irrigation was routinely used and recommended. The system is a modified pulsatile lavage system that is used to lavage the canal during joint replacement and for the irrigation of open fractures. The spray nozzle is cut off from its connecting tubing, which is then connected to the arthroscope via a standard intravenous line. The driving pressure is set at fifty mm/Hg and flow is controlled by the assistant using the intravenous flow control knob. The auditory feedback (“putt-putt”) of the pulsatile lavage system is invaluable in permitting the surgeon to monitor the fluid flow into the joint without having to consult others or a display panel. Edema is controlled by always maintaining direct outflow through one or more portals and also through the shaver device. No drainage tubings are connected to the outflow cannulas or shaver, so that the flow can simply drain to the floor where it is collected by suction.
Entry into a contracted joint is best accomplished using a custom made switching stick that has been machined to a taper-point at the end. This is machined from a Steinmann pin such that the point is blunt enough so that it will not cut into tissues, yet tapered enough so that it can be used to penetrate the capsule without deflecting off it. Once this blunted Steinmann pin has been placed, the arthroscope sheath is slid into the joint over the pin and the pin withdrawn. We believe this to be easier, safer, and more effective than trying to place the arthroscope sheath containing an obturator into the joint. It also obviates the problem of not being able to distend the capsule in stiff elbows, a step that moves the radial nerve away from the instruments in a normal elbow.

For more details please contact:
Dr. Prateek Gupta (Senior Surgeon)
Arthroscopy Surgery Clinic
C2/5 Safdarjung Development Area (SDA),
Aurobindo Marg, New Delhi - 110016
INDIA
Telephones: +91 9810852876, +91 11 26517776
24 x 7 Helpline & Appointment: +91 9810633876
Email: sportsmedicinedelhi@yahoo.com,
sportsmedicineclinics@gmail.com
Website: http://www.sportsmedicineclinicdelhi.com/arthroscopy.htm,
http://www.sportsmedicineclinicdelhi.com,
http://www.arthroscopysurgeryindia.com