SURGICAL TECHNIQUE

Elbow Arthroscopy: The Basics

J. Michael Bennett, MD
Elbow arthroscopy has become an accepted surgical option for treating numerous conditions
of the elbow, including septic, degenerative, or traumatic arthritis; capsular release; removal
of loose bodies; synovectomy or plica excision; and chondral lesions of the capitellum.
Surgeon experience, knowledge of elbow anatomy, patient positioning, and portal selection
and placement are important factors for successful arthroscopy and avoiding complications.
This article describes the basic surgical setup and technique for elbow arthroscopy. (J Hand
Surg 2013;38A:164167. Copyright 2013 by the American Society for Surgery of the
Hand. All rights reserved.)
Key words Surgical technique, indications, elbow, arthroscopy.
Surgical Technique

technique and instrumentation have allowed elbow arthroscopy to

develop into a safe and effective treatment option for multiple elbow pathologies.

DVANCES IN ARTHROSCOPIC

INDICATIONS AND CONTRAINDICATIONS

Indications for elbow arthroscopy include septic arthritis, degenerative/traumatic arthritis, capsular release,
removal of loose bodies, synovectomy/plica excision,
assessment and treatment of chondral lesions/osteochondritis dessicans of the capitellum, and diagnosis of
instability. Evolving indications include lateral epicondylitis, olecranon bursectomy, and fracture management.1,2
Contraindications to elbow arthroscopy include any
distortion of normal anatomy including extensive heterotopic ossification, soft tissue pedicle flaps, skin
grafts, or burns that make joint accessibility difficult
and put neurovascular structures at risk.3 Relative contraindications include submuscular or subcutaneous ulnar nerve transposition, unless the nerve is identified
before establishing a medial portal.
From the Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas.
Received for publication September 11, 2012; accepted in revised form October 15, 2012.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Correspondingauthor:J.MichaelBennett,MD,FondrenOrthopedicGroup,7401S.MainStreet,
Houston, TX 77030; e-mail: jmbenn01@yahoo.com.
0363-5023/13/38A01-0031$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2012.10.023

164 ASSH Published by Elsevier, Inc. All rights reserved.

SURGICAL TECHNIQUE
Most surgeons prefer using general anesthesia to provide total muscular relaxation and better patient comfort. Disadvantages include the potential for greater
postoperative pain and postanesthesia nausea. Some
surgeons prefer regional anesthesia (upper extremity
nerve blocks with or without intravenous sedation) to
optimize postoperative pain control and minimize postoperative nausea. A disadvantage includes difficulty
assessing neurologic status postoperatively owing to an
extended axillary or supraclavicular nerve block.4
The preferred arthroscopic system used in elbow
arthroscopy is a 4.0-mm, 30 arthroscope, also commonly used in shoulder and knee arthroscopy. On occasion, a 2.7-mm arthroscope can be helpful for navigating through smaller spaces or joints. Cannulas
should be smooth without side vents, minimizing the
risk of fluid extravasation into the soft tissues.5 The
trocars for joint penetration should be blunted and conical to decrease the possibility of neurovascular and
articular injury. Careful monitoring of fluid pressures
using gravity or pump pressure control is required to
minimize risk of fluid extravasation and compartment
syndrome. Further instrumentation (eg, biters, shavers,
osteotomes) depends on the procedure.
Patient positioning is determined by the surgeons
preference for visualizing the anatomy and access to the
posterior compartment.
The supine position was originally described as placing the arm across the body on an arm board. This
position has largely been replaced by the supinesuspended position.6 The shoulder is placed at 90 of

ELBOW ARTHROSCOPY

abduction; the elbow is flexed at 90 degrees; and the

wrist, forearm, and hand are suspended by traction
(pulley, arm holder). This position allows visualization
of the intra-articular anatomy in an upright position
with full access to the airway.
For the prone position, the patient is placed prone on
chest rolls with the arm stabilized with an arm holder
and hanging off the end of the table.7 This position
eliminates the need for traction and places the elbow in
a more stable position, allowing easier access to the
posterior joint. The surgeon has to be comfortable viewing the joint in an upside-down position. General
anesthesia is required because there is poor airway
access.
The lateral decubitus position has similar advantages
to the prone position but airway access is uncompromised.8 Access to the anterior compartment is difficult,
the patient may require repositioning, and the joint is
viewed in an upside-down position. The lateral position places the shoulder flexed at 90 over a padded
bolster or elbow holder (Figs. 1, 2).
Setup
Either a sterile or a nonsterile tourniquet can be used
and set to 250 mm Hg. If the patient is placed prone or
in the lateral decubitus position, the forearm is wrapped
with elastic bandage from just below the elbow to the
fingers to minimize swelling and fluid extravasation.
All bony landmarks of the elbow are palpated and
marked. The ulnar nerve is identified, marked, and
palpated, and its stability is assessed. It has to be noted
before making medial portal incisions whether the
nerve is subluxating or stable. Following tourniquet
inflation, the surgeon will insufflate the joint with 20 to
30 mL of saline through the soft spot portal site,

FIGURE 2: Padded elbow holder for supporting the elbow in

the lateral position.

Surgical Technique

FIGURE 1: The lateral position for elbow arthroscopy places

the shoulder flexed at 90 over a padded bolster or elbow
holder.

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FIGURE 3: Lateral view of locations for the proximal

anterolateral (AL), posterolateral (PL), midlateral soft spot
(SS), and straight posterior (P) portal sites.

which lies within the borders of the radial head, the

lateral epicondyle, and the olecranon tip. Distention of
the joint allows for safe entry of arthroscopic instruments by shifting the neurovascular structures away
from the joint.2
Portal placement
Multiple portal sites have been described in the literature; however, the most common portals utilized are the
anterolateral, midlateral soft spot portal, anteromedial, proximal anteromedial, proximal anterolateral, and
straight posterior.3 We commonly use the proximal
anteromedial, proximal anterolateral, midlateral, posterolateral, and straight posterior (Figs. 35).
Surgeon preference will dictate whether the diagnostic arthroscopy begins at the medial or the lateral aspect
of the joint. After the soft spot portal and joint insuf-

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ELBOW ARTHROSCOPY

Surgical Technique

FIGURE 4: Medial view of locations for the proximal

anteromedial (AM), posterolateral (PL), midlateral soft spot
(SS), and straight posterior (P) portal sites. UN marks the
ulnar nerve.

FIGURE 5: Posterior view of locations for the posterolateral

(PL), midlateral soft spot (SS), and straight posterior (P)
portal sites. UN marks the ulnar nerve.

flation, we create an anteromedial portal first and then

create an anterolateral portal site under direct visualization using needle localization.
The proximal anteromedial portal is located approximately 1 fingers breadth anterior to the intermuscular
septum and 2 cm proximal to the medial epicondyle4
(Fig. 4). The ulnar nerve is identified 3 to 4 cm posterior
from this portal and is palpated before making this
portal. The intermuscular septum is also palpated to
confirm that the portal is made anterior to the septum,
minimizing the risk of injury to the nerve. Blunt dissection with hemostats and blunt trocars should always
be used after incision to protect superficial sensory
nerves. Diagnostic arthroscopy begins by visualizing
the radiocapitellar joint, coronoid, coronoid fossa, and

the surrounding anterior capsule through this portal. A

needle may be inserted from the proximal lateral joint
and used to create the proximal anterolateral portal site.
The proximal anterolateral portal is located 1 to 2 cm
proximal to the lateral epicondyle and approximately 1
fingers breadth anterior to the distal humerus9 (Fig. 3).
This portal site allows visualization of the medial ulnohumeral articulation, the radiocapitellar joint, and coronoid. Because this portal site is proximal, risk of neurovascular injury to the radial nerve is diminished.
Risk of neurovascular injury increases the more distal the portal is located. The anterolateral portal is
located 3 cm distal and 2 cm anterior to the lateral
epicondyle, putting the radial nerve at significant risk.10
The anteromedial portal is located 2 cm anterior and 2
cm distal to the medial epicondyle, putting the medial
antebrachial cutaneous nerve at risk.6 Both of these
portals are considered high risk; therefore, it is recommended to place portals at a more proximal position.
The direct posterior portal is located centrally 3 cm
proximal to the tip of the olecranon (Fig. 5). This portal
site pierces the triceps above the musculotendinous
junction within 23 mm of the posterior antebrachial
cutaneous nerve and within 25 mm of the ulnar nerve.
This portal provides visualization of the entire posterior
compartment including the medial and lateral gutters.
The proximal posterolateral portal is also located 3
cm proximal to the olecranon tip but lateral to the
border of the triceps tendon (Figs. 3, 5). This portal
allows visualization of the olecranon tip, olecranon
fossa, and posterior trochlea. This is an excellent working portal when visualizing through the direct posterior
portal or vice versa. The neurovascular structures at risk
are the same as the direct posterior portal.
Normal elbow anatomy allows any portal to be
placed between the proximal posterolateral portal and
the lateral soft spot. Any of these portal sites allow for
access to the posterolateral recess.
The midlateral soft spot portal used for joint insufflation allows for visualization of the inferior capitellum
and inferior radioulnar joint (Fig. 3). The posterior
antebrachial cutaneous nerve is within 7 mm of the
portal.
COMPLICATIONS
Nerve injury is the most commonly reported complication of elbow arthroscopy.6,10 These injuries are rare
and often transient, but there have been reports of
complete neurological injury. Injuries can be the direct
result of a laceration from a knife or cannula, or they
can be secondary to compression from a cannula, fluid
extravasation, or exposure to local anesthetics. Other

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ELBOW ARTHROSCOPY

REFERENCES
1. Abboud JA, Ricchetti ET, Tjoumakaris F, Ramsey ML. Elbow
arthroscopy: basic setup and portal placement. J Am Acad Orthop
Surg. 2006;14(5):312318.
2. Dodson CC, Nho SJ, Williams RJ, Altchek DW. Elbow arthroscopy.
J Am Acad Orthop Surg. 2008;16(10):574 585.
3. Walcott GD, Savoie FH, Field LD. Arthroscopy of the elbow: setup, portals
and diagnostic technique. In: Altchek DW, Andrews J, eds. The Athletes
Elbow. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:249273.
4. Baker CL Jr, Jones GL. Arthroscopy of the elbow. Am J Sports Med.
1999;27(2):251264.
5. Ramsey ML, Naranja RJ. Diagnostic arthroscopy of the elbow. In:
Baker CL Jr, Plancher KD, eds. Operative Treatment of Elbow
Injuries. New York, NY: Springer-Verlag; 2002:163169.
6. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy.
1985;1(2):97107.
7. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy:
a new technique. Arthroscopy. 1989;5(3):222224.
8. ODriscoll SW, Morrey BF. Arthroscopy of the elbow: diagnostic and
therapeutic benefits and hazards. J Bone Joint Surg Am. 1992;74(1):8494.
9. Field LD, Altchek DW, Warren RF, Obrien SJ, Skyhar MJ, Wickiewicz TL. Arthroscopic anatomy of the lateral elbow: a comparison
of three portals. Arthroscopy. 1994;10(6):602 607.
10. Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular
anatomy and elbow arthroscopy: inherent risks. Arthroscopy. 1986;
2(3):190 197.

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Surgical Technique

complications described in the literature include infection, articular cartilage injury, synovial fistula formation, instrument breakage, and tourniquet-related problems.8
Complications can be prevented and/or minimized
by the surgeon adhering to strict surgical technique and
portal placement protecting the neurovascular structures. Therefore, it is crucial that surgeons have proper
training and experience before performing elbow arthroscopy. Surgeons can gain this experience by taking
a number of cadaveric courses or completing a fellowship with an emphasis on elbow arthroscopy.
In conclusion, elbow arthroscopy has become an
accepted surgical option for treating numerous conditions of the elbow.4 Successful arthroscopy depends on
a number of factors including surgeon experience, appropriate knowledge of elbow anatomy, patient selection, and portal placement. Indications for elbow arthroscopy will continue to emerge along with advances
in arthroscopic instrumentation and the refinement of
newer techniques.

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