All right, thank you, good morning. So just a quick question, and you don't have to raise your hands, but I'm just wondering, and as I was thinking about this myself as I went through the topic, you know, if you have an elbow scope on Monday or Tuesday, whenever you operate, or Wednesday, whatever your day is, how sure are you that things are going to be set up the way you need? You know, it probably depends a lot on how many elbow scopes you do, where you're doing that scope, maybe the size and age of the patient. But hopefully, this talk will go through some things that can help you, regardless of, you know, how sure you are that things will be the way you want and need your next case. I have no conflicts relevant to the topic. So as you build your volume, and hopefully you've had some experience in elbow arthroscopy, and hopefully you want to build that volume, that's why you're here. So you're looking for the right cases, you're looking to maybe expand your repertoire, what you can do with the scope. And I'd submit that in the elbow, there's quite a bit you can do, so there's a volume you can build up. But as you build that, you need to stay on top of your OR so that they're aware of how you need to set up. And it goes down to some simple things, even patient position, which I still get asked sometimes after 23 years, and it does, for me at least, it'll change once in a while. The monitor tower position, and I scope lateral decubitus 98% of the time, so even the setup, it's the same side of the patient, not really, but when the patient is rolled into the room, if you're going lateral decubitus, the monitor's on the right side of the patient, because it's the right elbow, you're going to roll that patient over, and you'll be opposite the patient. So the monitor's on the same side as the elbow you're scoping when you're lateral decubitus, to start with. So these are the things you need to communicate with your staff. You need to have an elbow support that will work for you if you're lateral decubitus. You need to understand what size you're going to use, and for me, that's 4 millimeters. It doesn't matter how big the patient is, and so I have to reiterate that to my staff. Sometimes I'll pull out a 2.7 scope or a smaller scope. Right size shavers, burrs, and then I don't use a lot of cautery, but if you're going to use that, which device you use, what the settings are set at. And then any specials or retractors that you need. So this is not the time to feel rushed. If you're going to take on a fracture reduction, and you've got the C-arm, and you've got special retractor or a pin alignment guides, it's not the time to be rushed as a surgeon to do this elbow case. It's not just a matter of if someone should do an elbow arthroscopic reduction. It's also, and even for me now, still doing this for a while, it's a matter of when and where it's scheduled. So if I'm going to do a pediatric elbow fracture, it has to be a time that I've got plenty of time to work. I'm not rushed. I have nowhere I need to go. The OR is ready. The OR is not rushed. I have good staff. And it's also a facility where I feel comfortable doing that sort of case. Even for me, that case is at the higher level of where I want to be for elbow arthroscopy. So it's not just that I'm going to put it on at 5 o'clock at the hospital with some travel staff, and I haven't done an elbow scope at that hospital in six years. It's going to be at my surgery center where I do them regularly with the staff that knows me that I know, and I've gotten a time probably with a lot of block, and nobody's going to rush me. I think that's an important concept as you look to advance your elbow arthroscopic skill set. Find the time to do the cases. Find the time to be relaxed to do them. It's really not a difficult endeavor if you're prepared for it. The rules, and Michael goes through this in a lot of the talks he gives, the rules are really no different for arthroscopic surgery than open surgery. We need to know what the procedure is, and obviously we need to know how to do it. We have to know our anatomy. We need to see. Then we need to get the job done with as little collateral damage as possible. Elbow arthroscopy allows us to see even better than open, or it should, or we shouldn't be doing it, and we should be able to do it with less collateral damage than an open procedure. Again, otherwise we shouldn't be doing it. Have a backup plan. Be ready to open if you need to. Maybe have a sequential steps that you're going to go through, and if you need to stop at one step and commit to being open at another step, that's fine, but have that mental preparation. Really should exceed open. It should be, I don't want to say bloodless, it bleeds sometimes, but it should be nearly bloodless with a tourniquet and with enough pressure, which we'll go through, and potentially even electrocautery. It's a magnified view, and it's a well-lit view, so with good arthroscopic equipment, you should be able to see better than if you're open, and if you're not, then you probably shouldn't be doing certainly an advanced procedure. It's one thing to chase a loose body. If you're starting off, you feel you probably can get it, maybe your visualization isn't great for a moment, then you take your time, and again, we'll go through it with some more things, with retractors especially, but if you're working on something complex, you really have to see what you need to see. So the requirements of elbow arthroscopy, I think there are some different things about elbow arthroscopy, and as I go through with my fellows and we talk about it and they reflect on the other arthroscopic procedures they've done, it's things that you come to realize that the more you do it, as Michael just referenced, we're working on both sides of the joint. When we do knee arthroscopy, which just looks like a knee and an elbow, and so a lot of times, especially when we start off early and we've just finished training, that's the mindset we have, but we don't scope the back of the knee, or most people don't at least, and we're scoping the antecubital fossa, the anterior aspect of the elbow, and we're scoping the back of the elbow as well, so we're working on both sides of the joints. We don't go between the joints, and so of course with wrist arthroscopy, we're sliding that small scope between the articular surfaces, and with knee arthroscopy, we're going between the articular surfaces, and with shoulder arthroscopy, sometimes it's a loose joint, we're going between the articular surfaces, but here, we're riding the rim of the articular surfaces most of the time. You may have an elbow arthroscopy where the elbow is extremely lax and you're sliding between the radial head and the capitellum, or maybe the ulna and the distal humerus, but most elbows are tight, they're too concentric, they're too tight, and you're not to go between the joint surfaces because you really can't, and that's why a 4mm scope works, even in a kid, because you're riding the rim of that capsule, so you have to have that mental preparation for that. Retractors are very important and very useful, and that's a little bit different than, again, a shoulder where sometimes we're increasing pressure, or a wrist where we're just working from multiple portals, and we have to understand multiple portals, which we'll hear about from, I think, both Michael and Mark. We need to have multiple portals so we can take that different viewing angle and see what we need to see. We have to have proper setup. Pressure management is critical here, especially if we're in a case where we're going to be working longer. I start with 20mm of pressure, and I'll work up from there, and I don't go much higher if I can. We have to have access to the elbow, we need to maybe have arthroscopy, we have to understand if we're going to use fluoroscopy, if we're going to use fluoroscopy, we have to understand how we're going to bring it in, small or large C-arm, how we're going to have access to see what we need to see, and then maybe some special equipment, I'll use variable wire guides, some angled curettes. I've got a curette that I've taken on a plate bender and bent it, it's a special, it's set aside for me so I can get around the corner and use a curette if I need to, chondral and dental picks. So everybody's been trained in elbow arthroscopy, you may be more comfortable in one position. My recommendation is to get as used as you can to one thing and just do that as much as possible. And Michael will speak, I think probably, and I don't know, Mark, how do you scope? Are you decubitus or? Yeah, lateral. So I was trained lateral, and fortunately or unfortunately my brain is pretty much stuck in that pattern. Michael will scope supine, and if you're real early and you're good at it, that may be better because there are times I do still go supine. But do what works well for you. To control swelling, it's helpful to have a sleeve for your scope that's a dedicated 30 degree sleeve without the fenestrations you see there on your left. And the reason for that is if, especially in the posterior lateral elbow, as you pull back on the scope, these fenestrations might be extra capsular while your camera is intra-capsular. So unbeknownst to you, you're putting fluid into the joint at pressure, or actually outside of the joint I should say, in pressure while you're looking in the joint. So you're filling up the soft tissues, not the capsules. So these typically are to be avoided. Unfortunately, at least for me in my world, the one or two sleeves I have that are long, I can no longer get. They won't make them anymore. I don't know why. And if you have a 30-70 degree combo sleeve, it does cut back further, and that may actually cause some fluid to go into the soft tissues as well. So preferably you have a fixed 30 degree with no fenestrations, but unfortunately that's harder to find. The bridge cannulas are like that, but there are some issues with those, which I'll show in a second too. So again, low pressure. Not all pumps go to 20. Know your pump. Years ago when I started, this is 20 plus years ago, one of the pumps had to be at the height of the patient to be accurate. Nobody knew that. They were used to shoulders. They had it up at the shoulder height. I'm doing an elbow, and chaos ensues. So know your pump. Know how it works at low pressure. 40 is fine, and some people prefer that. It's worked. I've used it when pumps have malfunctioned or in environments that don't have pumps, and it will work. It's very rare that I would go above 40. I can't recall the time that I will. Maybe I'll do it just temporarily. Tourniquet, again, I'm doing most of these under tourniquet as well. Sean O'Driscoll taught me to wrap Coban around a monitor to mitigate swelling. It's a gradient wrap. We all know that nerves don't like that sharp gradient cutoff, so we're wrapping with Coban and we're ending in a single level of Coban right here to have that gradient wrap that goes on before the case starts. Tourniquet proximal, if we get a lot of swelling, once we release the tourniquet, once we release that Coban, that swelling can go down and at least decrease that localized swelling. We may have lost visualization if it's that bad, but at least we've protected the nerves and the patient. For large cases, I will consider transaminic acid pre-tourniquet for major debridements or things like that. Dry will work. I don't do it often. I'll do it if it's a combo procedure. I do worry a little bit about the heat of the scope. It's a fixed setup. Your staff should know what you need. That scope, I use three switching sticks, and you'll see why in a second. I do use a needle for positioner. I'll come in and check my position from outside in. You need to have the proper arthroscopic positioner, 3-5 or 4-0 size devices. Cannulas and bridge, I'll show specials. I don't like the spinal needle. They often put it up on my set still, and it's too long, especially if you're new with elbow arthroscopy. You can start putting that needle, and if it's not going where you want, that's one thing, but if it's that long, it can really go places you don't want it to go. The bridge cannula is a way to go with a sleeve. Some people like that because they can go back and forth. You really have to be careful of this with patients who are Wisconsin size because you may not get in as far as you want to go, and again, you'll see that in a second. Setup for me is lateral decubitus. We have to make sure that we've got the elbow projected away from the body and either be able to lift it up so we can flex beyond 90 or have it maybe even flex a little bit beyond 90, especially for OCD lesions where we're debriding. I always mark the ulnar nerve. I haven't done it yet here, but that's the one mark I'll put on so I know where the nerve is so I won't get confused where I'm at and put something through it from the back side, and then years ago, someone told me, and I thought it was oversimplified, but I use it all the time in my head, and that's the head is where the head is, so when we're standing at the patient's elbow and we know where their head is, where they're intubated, that's where their radial head is. It's a quick mental check to not get lost. That with the ulnar nerve mark keeps me safe, so I won't do anything I don't want to do. Again, these large patients, they may tend to slide back and we can lose our antecubital fossil. We need that clearance, so we need to really make sure we've got them properly positioned before we're prepped, and again, a four-millimeter scope will work even in pediatric patients, and lateral decubitus will work in them, too. These are three different patients, and we can get in readily to these elbows and do some meaningful work even on a small elbow with a four-millimeter scope, and that's the sort of visualization you can get in a child's elbow, so I minimize my markings. I just want to, for me, almost all the time, it's just the ulnar nerve. That way, I'm never going to go in and try to put a portal there thinking I'm lateral when I'm medial. That's my biggest concern from outside-in work, from portal work, and then for me, lateral medial and lateral epicondyle, the outline of the olecranon, those things can change with swelling, so I typically don't mark them. There's no problem doing it, but I don't want to get confused. I don't want to have so many things that I lose sight of that ulnar nerve, and that's my one concern. So a supine can work. They're static elbow holders. I've never scoped with this holder, but this is one commercially available holder. This is what I use, and if I'm going to do an OCD grafting and I want to take it from the knee, I will scope in this position, but it's hard. It's a much harder scope for me to scope supine just because I'm completely flipped around. I have to go slower. It's another thing where you need to put the brakes on. So scoping with the bridge cannula, this is from Jeff King, my buddy. It's nice because you can put the scope or the shaver on either side. It's a great way to work, but we have to watch our lengths. So this is a quick video I want to show that's going to set up just a principle that I learned from Odrisco with portal salvage, and this is probably the biggest lesson or biggest thing I can teach you today. What do we do when I was trained and when I was doing scopes early, if I lost a portal, I really just panicked. That was a bad thing for me, and the thought of losing all my portals was just, you know, that would be a horrible day in the OR. And while we don't want to do that, it's not that bad if we think about ways to save or salvage our portals. So the setup here is you can see where the ulnar nerve is to the medial side. I've got my scope in distal. I've got a retractor for me as a switching stick, and this is another reason why I like the switching stick. So I have that proximal on the medial side, and then I'm instrumenting from the lateral side in a more distal portal. And this is a large patient. You'll see this in a second. I don't have any bridge cannulas, and especially with this technique, I couldn't use a bridge. I have no cannulas at all, so I'm scoping, I'm instrumenting, I should say, from the lateral side with just a shaver. And so as I play this, so my scope gets knocked out, and I've lost my visualization. So what I'm going to do is I'm going to push that shaver all the way through, and it takes me a second here to get it. He's a large guy. I've got to bury that. And once I get this through, now that's my way back into the joint. So I'm going to uncouple the scope just a little bit so I can safely put that sleeve over the shaver, not scratch the lens, and pull it back in, and then in the middle of the joint, pull them back out. So I've reestablished my visualization after I've lost it. Now I'm going to lose this portal, and the same thing. I've lost that retraction portal. As long as I have one portal, I can get the other ones. So now I'm going to use that bridge cannula just to go over as a sleeve, pull that shaver back, and now I've reestablished that proximal retraction portal, and I'm back in. So what happens if it's a real bad day in the OR and I've lost everything? Something gets knocked out, I panic, I pull back out, somebody takes something out, I've got nothing. So now I take my switching stick, and usually from the medial side, the soft tissues are deep enough I can't get in, but that lateral portal, especially the distal one, almost always is something I can reestablish, I can feel the cartilage against it, it bounces against it, I can come back and feel the cartilage. And now with my switching sticks, I've reestablished all three portals. So it's a way to just know you can get back to where you were, and that gives you that comfort to go forward. So just some tips then, and I'm running over so I'm going to speed up here. Avoid injury, we'll hear more about that. You have to see where you are, you have to use some sort of retractor. For me it's a switching stick. My switching stick's here, my switching stick's over here, I've pulled it out, I can see better. What's at risk when? We worry about the radial nerve if we make a portal too distal, we'll hear about that I think from Mark's talk. If we violate the capsule just in front of the direct anterior radial head, we really need to know where we are at that moment and maybe stop because there's a little bit of fat, but the radial nerve is very close by. If we're working on the brachialis, taking some capsule down, that's one thing if we have a retractor and we can see, but as soon as we can't see well, we have to stop. And Michael told me about a case the other day on Wednesday that the brachialis was missing. So we have to know what the pathology is like because behind the brachialis is the median nerve. And then again, in the back of the elbow, ulnar nerve, know where it is, was it transposed? If so, can you feel it? Don't get complacent in the back if it's a normal elbow and start wandering around more medial because that's where some people get into trouble with the ulnar nerve. Expose it if you need to, it's easy to do. So when not to scope, if you don't have the right equipment, don't do it. You don't have the scope you normally use, you don't have the position you normally use, it's not the right, if you don't have the time, the patience to do the harder cases, then don't do it that day. If you can't find the ulnar nerve, you can't go in the front. Submuscular, I've not done it, I'm sure Michael probably has, maybe Mark, but I've not done it, submuscular. Inaccessible pathology, this case is a case one of my partners I think sent to me. That's not a piece I can get into, it's between a joint, the joint's not that loose, I had to do an osteotomy to get that out. So think about those things, think about specials that are going to help you. ACL guides are nice, I use a variable angle guide that's made for the ankle. These are hard to find now, you can find them on eBay sometimes, I don't think they make them anymore, a microvector guide, which gives you the chance to shoot some wires and be able to put some things, there's this little probe almost where you can do some reduction maneuver and the pin should come close to that, it's not perfect but it's pretty good. Allows you to place guide wires, either suture things down or fix things. So as you increase your caseload, make sure you practice if you can, get to a lab, go and observe someone's experience, know your limitations, start small, have gradients you can work through, have a backup and bailout plan, recognize when issues aren't going the way you want, reorganize, know how to save your portals, use retractors. If you have to start, or when you start out, just maybe think about scoping one compartment and spend all your time with that and then open up and do another compartment. Convert to open when necessary and there's nothing wrong with, as orthopedic surgeons, I think we were drawn to the specialty because we can do so much and complete things and be done and go home and say, I really solved that problem in the OR and that's most of what we do. But there's no shame in saying, you know what, today's not the day I'm going to finish this operation. We're going to finish this arthroscopy safely and come back and maybe open something later or maybe even scope the patient again. Patients do understand that. These principles all transfer. This was August in Ethiopia where they had, with the hospital where I've been a few times in Soto, they had an arthroscopy set up and they had never done an elbow before. But with proper planning and positioning and a lot of time and a lot of gravity inflow with the saline that they make, we did a synovectomy that worked just fine and so these things can be done, but it's more a matter of knowing the principles, feeling comfortable, and sticking to the principles. Thanks. That was great, Rick. Thank you for that. All right. So I'm gonna talk to you about staying out of trouble with elbow arthroscopy, and these are my disclosures. They're not relevant to the content of the talk. The problem is, when you think about it, the biggest issue is the risk of nerve injury. In this survey, you can see that out of 372 docs, they came up with 222 nerve injuries, half of which required operative intervention. And in this particular survey, it was all radial and ulnar nerves, but anything can happen any time. And this was a 58-year-old who I took care of this spring who had had elbow arthroscopy, 58-year-old diabetic, came in with both median and ulnar nerve dysfunction post elbow arthroscopy. And what you can see here, the treating surgeon appropriately explored this. There was, he put a tube for the ulnar nerve. There was a gap there of about three centimeters, and in the median nerve, you can see there's a gap also of three centimeters. So really tough problem, and this is not the thing that you wanna find in your post-operative exam after your elbow arthroscopy. So the ways that we avoid this is selection, pre-op exam, good technique, and exam both prior and after. I don't do blocks for these in general. I do them under general anesthetic, do an examination before they get a post-op block, and then explore if you're not sure. Other things are, in general, if you're getting into this now, doing this after trauma is a challenge, particularly when there's been a dislocation. So there's been a commensurate injury to the capsule. There may have been a significant injury to the brachialis. Just getting a good working space and doing that safely is gonna be more challenging. With transposed ulnar nerve, it's a little bit tougher, but in general, if it's easy to feel, it's easy to identify and protect. Inflammatory arthritis is an upper-level case because getting that view is hard. The big arms are harder. And the person, this is something that I really didn't catch onto until I got burned by it. You look at people and you say, what's this arm gonna look like if I put this patient into a lateral position, put a tourniquet on them, how much working space am I gonna have? And one little pearl that I'd add to Rick's talk, because I've had these people slide out of the arm holders, is rather than using the strap alone, I use Coban to hold them into that arm holder. And that, for me, has been a lot more secure than just the strap itself. So then you need to think about those cases that are gonna be more problematic. So when a person has anterior bone, anterior heterotopic bone, and you're trying to create that portal, what's gonna happen, whether if it's medial and you're using a medial starting point, or lateral and you're using a lateral starting point, what it's gonna do is it's gonna push your trajectory anterior. And so if it's a tight elbow to start with, almost all of these have a contracture, if it's a tight elbow to start with, then you've got that anterior heterotopic bone, it's gonna make things more challenging. And so rather than getting frustrated, have it a part of your plan, listen, if I don't feel safe about this portal, then I'm gonna convert to an open procedure. And I use CT scan and the 3D imaging pretty liberally. I don't think I would need it as much now as I did earlier on in my experience, but it is an awesome teaching tool if you're at a place where you're taking people through operations, because this is a topographic map of what's gonna be in your way and what you're gonna go after. Make sure you document the status of the ulnar nerve. There are so many people who will say, oh yeah, it's fine. And then when you actually do two-point discrimination or SEMS, you find that there is a difference. Make sure you check it to NELS, make sure you do an elbow flexion test preoperatively. So I've got eight pearls for getting in safely. One is positioning, which Rick beautifully gave us, safe portal placement. The use of retractors. These are the things that he didn't talk about that were more my responsibility. So I think it's a really good thing once you're in the joint to close your eyes and move around the scope. And I'll show you an example of that, because a lot of this stuff is, you wanna be able to see, but when you're in that situation where you feel like in the joint, but you're struggling, you wanna have in your brain a sense of what's medial, what's lateral, what's anterior, what's posterior. I make everybody do arthroscopic calisthenics. I make everybody point shavers away from bad things, and when in doubt, explore that ulnar nerve to protect it. And as we've said, open if you feel like you're lost. So here's the positioning that Rick went through. This is what things look like. I love open tools, open instruments for arthroscopic procedures. So taking off the tip of your coronoid with an osteotome, for me, is a lot faster than burying it and worrying about if I'm gonna beat up the trochlea. Large curettes are great, and then you want something that's got big jaws and a big chomper when you have a preoperative imaging that shows big, loose bodies, because you don't wanna mess around with that too much. We talked about pressure, ulnar nerve decompression. This is a cadaver specimen where I put a light cord along the course of the radial nerve. And you just wanna have a picture of that in your brain, because that's something that you want to avoid. I used to start all of my scopes with an anteromedial portal, and I switched after learning from Scott Steinman, his success with starting with a lateral portal. So I now use a lateral portal for all my scopes. When you're first doing this, you're nervous about getting into the radial nerve. So you say in your mind, that radial nerve is anterior to the radiocapitellar joint. I wanna stay away from it. And your tendency is going to be to hug the radial head, but the part that you can feel is actually a little posterior to the actual zenith of the radial head. And so if you hug that radial head, your trajectory is gonna be anterior. If instead, you start a bit more anterior and point back toward the medial joint line, you're gonna be well out of the way of the radial nerve. And then after inserting the cannula and before inserting the camera, you need to try and get a sense of where you are. And this is, any people who've watched Caddyshack, this is Chevy Chase, blindfolded, doing his approach to the green. And this is what we want in elbow arthroscopy. We want that first shot that gets us in a position where we're successful. And so this is the fellow that's on my service right now. And I have her closing her eyes and I have her making circles in the anterior compartment. And I'm asking her, do you feel like you have room? Do you feel like you have a reasonable space as opposed to being able to move only in one plane? If you can only move in one plane, you're probably between capsule and brachialis. But if you can make a circle, you're in the joint. And if you can feel that cannula, just like Rick said, bouncing off the coronoid, hitting the articular surfaces, you have that sense of where you are and that'll help you when you struggle with visualization at any point during the case. So then you're gonna insert the camera. You're gonna get this lateral to medial view. I have this whole routine where I like you to look at the medial joint line. I like you to put the elbow in 60 degrees of flexion, valgus stress to look at the medial joint line, come up over the top of the coronoid, look down at the radiocapitellar joint. And then from there, what you're gonna do is use a switching stick to establish that straight medial portal. And so here it is here. And you can see that my finger right here, right there, is on a point on the cannula where I wanna end up in the joint. So I take my finger, put it on the cannula, lay it over top of the joint, and then before I put it on the switching stick, my index finger is going to be a stop for where I want to end up. When it comes to portal placement, we wanna feel, we wanna use a needle, we wanna use a knife, a hemostat, and then the instrument. So first, here I'm trying to establish an anterolateral portal, so you palpate. There's almost always a little bubble there. Then you get your needle, and your job is to pop that bubble. And then you use a knife and a hemostat and point that hemostat back toward the bone so it's curved in that direction, and then a big spread both directions, and then get your retractor in. And so this is now our anterolateral retractor portal. And just do that on even cases where you feel like you're only gonna be in the anterior compartment shortly for a short period of time, because it's good practice. And then I make everybody do arthroscopic calisthenics. So it's proximal, distal, anterior, posterior. Proximal, distal, anterior, posterior, until they are oriented with respect to how their hand moves and how their instrument moves with respect to the camera. I also have you do shaving calisthenics. So once you put that shaver in, the thing that you don't wanna do is you don't wanna lay the shaver up against the anterior capsule. So before you turn your shaver on, make a circular motion to it where you're brushing whatever synovium or whatever tissue you're breeding with that shaver so that you clean and clear. You don't wanna clean and leave it in place because the next thing you know, there's gonna be a hole in the anterior capsule and you're gonna be dangerously close to your posterior osseous nerve. Put your shaver on without suction. So in the anterior compartment, I don't use suction. And then this is a Sean O'Driscoll maneuver. What I've done here is I've put a trocar, a blunt trocar into my lateral portal. And unfortunately, this video isn't running, but I'm using that trocar to peel all the capsule off the anterolateral edge of the humerus. And what that does is all of a sudden, in a tight elbow, it gives you more room to work and more room to see. You clean out your loose bodies. Burr osteophytes, using here the Freer. I use a Freer as an elevator. Switching stick is a great idea, too, just so you have that option. And then know where that posterior osseous nerve is. So this is a cadaver specimen where I'm skewering the posterior osseous nerve. I've got it open and I'm putting a needle through it. And you can see that the needle is coming through right at the 50-yard line between your lateral and medial aspect of your annular ligament. So unless you're Mike Houseman, Graham King, or Rick, you don't wanna be there with your arthroscopic procedure. And here is after the capsule's been stripped. I put ink on the PIN, and so you can see. So there's gonna be capsule. In a cadaver specimen, you're not gonna see as much fat. There's typically gonna be some fat. And it'll be up into the muscle, right? But it's close, and so save yourself that. Just don't go there. This is doing a capsulotomy. There are many who think that you should go medial to lateral and that's probably safer. It's just still my routine to go lateral to medial. But I use these duckbill biters with the duckbill as an elevator to create a space between the brachialis and between the capsule. And then establishing your posterior portal. I like a posterolateral portal to start. And so you can see it marked there with a line right there. And same thing in the olecranon fossa. Here Carly has closed her eyes. And the big thing here is I'm asking her to feel the medial aspect of the olecranon fossa because we don't want to be going over the medial aspect of the olecranon fossa. So make a circle, stir the bowl, feel the medial side, feel the lateral side, then put your camera in. And so if you want to, you can use a posterolateral retractor as well. This is me making one there. So my nerve is over here. And then when you're putting that shaver in, look at where the teeth are and direct those teeth away from the ulnar nerve. I'm working this way, I'm not going like this. Okay, and so now we've got a posterolateral And so now we've got a shaver, a little bit of a view, beautiful principle of Sean O'Driscoll's, try to slowly expand your view, establish and then expand your view. And then get yourself down to the posterolateral gutter. I use a switching stick to put myself down into that gutter and then put the cannula over top. Here we can see the left, the coronoid, to the right, the radial head, and to top left, the trochlea and capitellum. There's some great distal portals that Scott Steinman described that you can use to look up into the radiocapitellar joint and deal with OCD lesions. The last thing that I think is really important is if you've got a patient who has a loss of elbow flexion, in order to restore elbow flexion, most of the time you're going to need to release post-remedial capsule. And there are people that are skillful doing that arthroscopically. I'm not skillful doing that arthroscopically. The other thing is, is that Dean Citerionis and I did a study where we looked at those people who would develop issues with their ulnar nerve post-contracture release. And if you had a loss of elbow flexion where you could only get yourself to about 100 degrees, and you didn't decompress the ulnar nerve, you stood a greater chance of developing symptoms afterwards even if you didn't have them preoperatively. So for me, a person that has a loss of elbow flexion, most of the time is gonna get an ulnar nerve decompression, and that's gonna do two things. One, free up the nerve, and two, give me access to that post-remedial capsule. So what I'm doing here is retracting the ulnar nerve to show myself the post-remedial capsule. And you don't have to do this with arthroscopic assistance. I'm just showing you this. But this post-remedial capsule gets thick, and you want to release that, and when you release that, that's gonna help you with restoring elbow flexion. And then as soon as that patient wakes up, do that nerve, you're gonna feel better. If you choose to do a post-operative block, you'll know that it's safe. The nerve's out if you're not sure. Explore it. And so my eight pearls are positioning, portal placement, retractors, closing your eyes and feeling, getting a sense of where you are. Take the time to do the arthroscopic calisthenics. It may take you a minute or two just to get in some reps. Point the shavers away from trouble, and when in doubt, explore the ulnar nerve and protect it. Open if you're lost. Thanks very much. Thank you. Thank you. Do you need the mouse? Uh, I don't need the mouse. Great. Well, thank you, these are, as you can see, I just lost the, oh, there we go. Common themes, and safety, I think, is really a sum of where you are and how you do this. Just to review the basic portals, the trans triceps portal, you mark the ulnar nerve, that that's absolutely critical, and if you can't feel it, then you stop right there. There's that trans triceps portal, and then there's a proximal and a distal posterolateral portal. Usually, we start with the distal posterolateral portal, because there's really nothing, you would have to be way off base to cause damage in that zone. On the anterior side, you're likely going to want two portals, a proximal and a distal anterolateral portal. And I'm a medial first guy, and the reason for that is the placement of that proximal anterolateral portal is super critical, because you need to be able to reach over across the radial head and get to the coronoid. And if you make that too distal or too anterior, you're gonna be blocked by the radial head. So I usually start on the medial side first, so that I can precisely locate that anterolateral portal. You can actually make an accessory portal on the medial side. So usually, we come in sort of just above the trochlea. There are cases in arthritic patients where there's that big medial osteophyte on the coronoid, and it's hard to reach that. And you can make a distal anteromedial portal, but you have to be careful of the ulnar nerve, obviously. So Rick and Mark have mentioned instrumentation. I've made a bunch of these different switching sticks out of Steinman pins that I've ground down. And for a stiff, contracted elbow, I'm gonna want something like the top one, which is a little sharper. I've also made like a spatula-shaped one, which is a little bit of a periosteal elevator. If I'm trying to find a portal that I've already made, then I want something that's gonna preferentially go for the established pathway, and that's gonna be one of these blunter or even a round hemisphere. So having a few of these, I think, is helpful. Rick mentioned the importance of not having fenestrated cannula. That will be a great source of frustration. And here, as I mentioned, is my setup. The patient is supine. Frequently, there's a monitor, because in New York, the patient wants to advise you on how to do the procedure. But for the posterior compartment, the arm is suspended across the patient's chest. And then for the anterior compartment, as you see on the right there, the arm is repositioned at the side. I mark the critical landmarks. Most importantly, the ulnar nerve. And be very careful in heavyset people. If you can't unambiguously feel this, you stop right there. Now, I think that making sharp portals is important. So I'm actually, for this posterior compartment, I'm using an 11 blade. And really, it's the center of the fossa is really at the height of the medial and lateral epicondyles. So I feel for the medial lateral epicondyles. I put the blade in. And then, really important, as you come out, make a little bit of a cut, like bend your wrist, and make a little bit of a cut. So that all the way through, you're making an adequate incision so that the probe and the cannula will preferentially take the path of least resistance. You don't wanna just incise the skin and then have to bluntly bludgeon your way through the triceps to get in. And you also wanna make sure that when you put your cannula, your trocar in, you keep pressure and keep that against the bone as you thread the cannula over the trocar. And I actually do sort of thread it and turn it as it goes on. Because if you just push it, even that little difference in diameter between the trocar and the cannula can just push the capsule off the end. And then, bingo, you're extra articular and you're struggling. And then, once you get in, you have to establish your view. And once you've done that, as Mark and Rick have said, you go down, find the tip of the olecranon, look medially, but don't work there yet, and then you can go around laterally. So what has really changed elbow arthroscopy for me? It's this instrument. And this needle and knife technique, I think, is just a huge step forward. Before doing that, we're going through all sorts of calisthenics to try to avoid losing a portal. And so we put a trocar in, we place it, it falls out, we leave a cannula, but then we lose our fluid pressure and all. And what you really need are portals that are easy to drive in and out. Because if you're doing the capsulectomy, as Mark showed, you're gonna take multiple bites, and you have to be able to get in and out super easily. So here in the posterior compartment, in the soft spot portal, I'm localizing where I want that portal to be with a needle. And then, again, I can take my 11 blade in line, like splitting the LUCL fibers rather than cutting across them. And I can just go right into the joint there and follow that pathway. My shaver, again, will preferentially take that pathway because I've made that the easiest approach. And there you see the base of the coronoid and the radial head. So how about that intermedial portal? Well, I think the most common mistake is starting to posterior. And we actually always want to be able to direct the instruments from anterior to posterior. So I wanna be able to put my trocar into the coronoid fossa. And if I am too posterior, I'm gonna be deflected by the medial supracondylar ridge, and I'll go too anteriorly. So on the medial side, I use a 15 blade, and I spread, and I feel the supracondylar ridge. And if there are any osteophytes or bony excrescences there medially, remember that that would tend to deviate me anteriorly, which is dangerous. So I have to be pointing posteriorly. Again, medial side, 15 blade, bluntly dissect, and then as I'm doing here, and then put your trocar in so that it is facing posteriorly. And then there's that very clear sensation of steel on cartilage. And once you feel that, you know you're in. And then advance it all the way over to the lateral side. And once again, thread the cannula on. Don't just push it, because it can push the capsule off. So then the next thing is to establish that proximal anterolateral portal. So you need a little bit of view through the crab meat there. And then I wanna probe with my 25 gauge needle so that I can get the exact place. And then I follow the needle with the 15 blade. And I'm actually gonna detach a little bit of the capsule and probably a little bit of the ECRL there, hugging the bone. But I wanna remember to cut with the blade facing posteriorly, cut on the way out, because otherwise I'm gonna have like an hourglass constriction. You know, the skin will be open, the capsule will be open, but that tough tendinous stuff is still tight. And I won't be able to get in and out. But this way I can get in and out easily and I can reach across the radial head and get all the way to the coronoid to do my work there. And then as Rick said, retractors are super useful. Once you've got this proximal interlateral portal, you can locate a more distal portal and you put your working instruments in there or swap off as needed. Now, there are accessory portals that you can make along the lateral side of the ulna. And so this for instance is a case of a proximal radial ulnar synostosis. And you can see the bone bridge there. And he's pretty stiff. No pronation and supination. So I'm going to have to go fairly distal there. There's my radial head and I can begin to expose that bony bridge. Again, we're in the posterior compartment there. And I'm locating with the needles, marching distal along the ulna. And as long as I hug the ulna there, there is, that's safe. I mean, you're not gonna be involved with the PIN. And you're gonna see the biceps tendon insertion before you get anywhere near PIN country. So you can see how those more distal portals allow good access to the interval between the radius and ulna. The other procedure that you'll find that very helpful with is treating OCD lesions of the capitellum because it allows you to get that angle that's perpendicular to the tangent of the capitellum. And then you can finish up your capsulectomy there and removing the bone in the supracapitellar area. And as Mark showed, doing your capsulectomy. So, again, the critical points that I would like to emphasize are making these easy in, easy out portals by sharply incising the tissue so that you're not struggling. And using the needle and knife technique to locate these portals precisely. I think that's probably made the biggest difference in my arthroscopic capability is really learning how to make these portals where the default is to go into the joint rather than having to struggle moving in and out of the joint. So I'd like to stop there. We have and call Rick up. And Graham, could you join us up here also? And if there are any questions or comments, please step up to the mic and let us know. Just wanna ask the panelists how easy and effective is the readment of the ECRB for lateral epicondylitis through the scope? How much do you do with that? Yeah, so tennis elbow release for the scope, I mean, I think it's a reasonable operation. That whole discussion of tennis elbow, I mean, I do tennis elbow procedures. I wait six to 12 months to do them. I do more of a, I use 10X often now. So I do less arthroscopy, which is unfortunate probably for my fellows. But it's a great arthroscopic case. It works. I think it works as well as anything else. It's been safely described. Mark Cohen I think has a paper, but it's accessible, it's doable. I just do a release when I do it. I just release the ECRB tendon with a hand instrument now. I don't use any RF and I don't worry about decorticating or debris in the epicondyle. There's a open paper that was done out of the Netherlands, I think, that looked at comparative debridement versus no debridement of the bone. And then there's no difference. So I just release the tendon. I can see it. I can preserve the capsule, release it. It's accessible. It's pretty straightforward. Thank you. Graham, any comment? I use the RF actually. I find it very fast. And I also think it kills nerves. So it's been good for me. It's the only instrument I use. I don't open anything else. Two portals, one RF probe, and really it should be done in 15 to 20 minutes. So you do everything anteriorly? Won't even look in the back. Now Michael, you've got some, don't you do it a little different? I do it a little differently. I start and look in the posterior radiocapitellar joint. And there's usually like some degenerated, almost meniscal kind of stuff there. I debride that. And then I do a partial anterolateral capsulectomy. So I kind of remove the capsule down to the neck of the radius. I want to uncover the radial head because the consistent finding that we've seen is there's that quadrant in the radial head where the cartilage is very thin, but in these patients it's not only thin, it's gone and there's this localized synovitis right in that area. So I want to adequately decompress that. But obviously there are multiple approaches and I think we're all pretty happy with the outcomes. I think it's a good case to start arthroscopy with because their normal elbows are not stiff. I look in the back too and there's almost always something to debride. The question is whether it needs to be debrided. But there are patients too who failed maybe a minimally invasive tennis elbow scope and they do have that posterior lateral plica sort of pain. And that's a real ideal patient. But in general, they're good patients to start with. I agree if they have posterior pain and they're not classic then I think you should scope in the back. I used to always scope in the back, but it takes a lot longer. And I also had a few people get stiff after doing front and back approaches. So now I just do the front unless they've got posterior lateral pain, which I think you should scope the back. And I think Mike's right. Sometimes that anterior ligament gets a little thick and starts infolding. I always take that as part of my anterior procedure. It's almost like a form first of a plica syndrome. Any other questions or comments? I have a question. I mean, it looks like from what I saw and I think Graham, I've seen this. I don't think either of you use canulas like the sports guys use with the big plastic canulas. You were talking about screwing in the canula, but you're screwing in the metal sleeve just to make sure the capsule doesn't get pushed in. Exactly. Are either of you using, you know, the plastic screw-in canulas, the larger portals with the rubber dams on them that we use in the shoulder if we do a shoulder arthroscopy? I don't. I just use metal ones. Yeah, we reuse them. I mean, I've seen people struggle more with them, I think, than benefit from them because they're in the, if you want to do a proximal and a distal portal on the medial or lateral side anteriorly, it's almost too close for those two. And then they're falling in or out, or I think they help less in the elbow than one might expect. If you definitely don't want the one with the little mushroom at the end to keep it from falling out, because it's really hard to get that one in. So is this help, how many of you scope elbows? And how many do more than half a dozen elbow scopes a year? Okay, so, I mean, is this helpful? And I think it's gonna, yeah, okay. Well, good. Well, we're at time. Thank you again for your attendance. Thank you all. Thank you.

elbow arthroscopy

portal placement

safety

retractors

access portals

lateral epicondylitis

OCD lesions

RF

complications