Elbow Arthroscopy: A New Setup to Avoid Visual Paradox
and Improve Triangulation
Apurv Sinha, M.R.C.S., F.R.C.S.(Tr&Orth),
Satya Kanth V. Pydah, M.S.Orth., M.Ch.Orth., F.R.C.S.(Tr&Orth), and
Mark Webb, F.R.C.S.(Tr&Orth)
Abstract: Elbow arthroscopy is a useful diagnostic and therapeutic tool for various conditions. Conventional arthroscopy
with the patient in the prone or lateral position where the screen is placed on the opposite side makes it difficult to
interpret the image, results in visual paradox, and is associated with difficult triangulation. We present a modified setup for
the operating room to help eliminate these problems and improve triangulation.
E lbow arthroscopy is a useful diagnostic and thera-
peutic tool for an orthopaedic surgeon. This
procedure is useful in the treatment of a wide variety of
elbow conditions, including removal of loose bodies,1
osteochondritis dissecans, persistent synovitis,2 sus-
pected cartilaginous lesions, osteoarthritis,3,4 selected
radial head fractures, stiffness,5 and chronically undi-
agnosed painful elbows. Most recently, the indications
for arthroscopy have been extended to include fracture
management (e.g., radial head fractures) and the
treatment of lateral epicondylitis.6
The elbow is a challenging and difficult joint on which
to perform arthroscopy because of its narrow joint
space and close proximity of important neurovascular
structures. Therefore the surgeon must be especially
careful while entering the joint and should have good
triangulation skills and spatial orientation. Various
patient and elbow positions are described for perform-
ing elbow arthroscopy, including supine, prone, and
lateral decubitus.7,8
From the Department of Orthopaedics & Trauma, Countess of Chester
Hospital, Chester, England.
The authors report that they have no conflicts of interest in the authorship
and publication of this article.
Received October 23, 2012; accepted November 21, 2012.
Address correspondence to Satya Kanth V. Pydah, M.S.Orth., M.Ch.Orth.,
F.R.C.S.(Tr&Orth), Department of Orthopaedics & Trauma, Countess of
Chester Hospital, Liverpool Road, Chester, England. E-mail: satya_kanth@
yahoo.com
Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the
Arthroscopy Association of North America. Open access under CC BY-NC-ND
license.
2212-6287/12688
http://dx.doi.org/10.1016/j.eats.2012.11.003
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e65-e67
For the lateral decubitus and prone positions, the
elbow joint has a similar orientation. For these posi-
tions, conventionally, the surgeon stands on the same
side as the elbow and the screen is positioned on the
opposite side, as shown in Fig 1 and Video 1. Using
either the anterolateral or anteromedial portal to visu-
alize the joint in this setup results in visual paradox.
This is because the direction in which the arthroscope is
introduced is almost opposite to the line of vision of the
surgeon. This is shown in Fig 1 with 2 arrows pointing
in opposite directions. This makes orientation of the
joint more difficult, and triangulation and instrumen-
tation will consequently be complex and potentially
increasing the chance of extra-/intra-articular iatro-
genic injury. This technique will also require a steep
learning curve. To help triangulation and decrease the
visual paradox, we created a simple modification of the
operating room setup.
Technique
In our setup the patient is positioned in the same way
as routine arthroscopy, in the lateral decubitus position
with the arm draped over a padded gutter. The stack
along with the screens is moved toward the head end of
the patient. The anesthetic machine and the scrub team
are positioned as shown in Fig 2 and Video 1. The
operating surgeon stands on the axillary side of the
arm, and an anteromedial portal is used to visualize
the joint, as shown in Fig 3. This portal has been shown
to be safer than the anterolateral portal, which has been
associated with increased complications, particularly
iatrogenic injury to the radial nerve.9 With this setup,
the direction of the arthroscope will be almost parallel
to the line of vision of the surgeon, thus avoiding visual
e65
e66 A. SINHA ET AL.

Fig 1. Setup with the patient in

the right lateral decubitus position
for left elbow arthroscopy with
the arm supported over a gutter
support with the use of an ante-
romedial portal. The green arrow
shows the surgeon’s line of vision,
and the red arrow shows the
direction of the arthroscope. The
arrangement of the scrub team,
monitor stack, and anesthetic
machine is also shown.

Fig 2. New setup with the patient

in the right lateral decubitus
position for left elbow arthroscopy
with the arm supported over
a gutter support with the use of an
anteromedial portal. The green
arrow shows the surgeon’s line of
vision, and the red arrow shows
the direction of the arthroscope.
The arrangement of the scrub
team, monitor stack, and anes-
thetic machine is also shown.
 ELBOW ARTHROSCOPY
Fig 3. New setup with the patient in the right lateral decu-
bitus position for left elbow arthroscopy with the arm sup-
ported over a gutter support with use of an anteromedial
portal.
paradox, and allows better ergonomic positioning for
the surgeon. The triangulation in this setup is almost
identical to that in shoulder arthroscopy.
Discussion
Our simple modification of the operating room setup
for elbow arthroscopy avoids visual paradox and
e67
reduces operative time, along with easy training and
triangulation. This technique does not require any
additional equipment and has no limitations or addi-
tional risks compared with the conventional elbow
arthroscopy setup.
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