Good evening. Thank you for joining us tonight for the fellows webinar basics of elbow arthroscopy. Tonight's esteemed faculty are doctors, Christopher John Conway and Matthew Smith. Dr is head team position of the New York Yankees and the New York City football club. Chief sports medicine service, vice chair of clinical research and professor of orthopedic surgery. At New York, Presbyterian Columbia University. Dr. Conway is a sports surgeon orthopedics in Fort Worth. Consultant at Texas Christian University and former head team position of the Texas Rangers. Dr. Smith is associate professor of sports medicine at Washington University in Saint Louis and his team position of the Saint Louis Blues and Washington University Bears. To submit a question on the webinar panel on your screen, click the questions drop down arrow on the right hand side of the panel. This slide shows where you input your question and then click send. I will now turn this over to Dr. Smith. All right, welcome everybody. Thanks for joining us this evening. We're going to split this up into 3 different talks, and I'll start off with the basics. We're going to really discuss the principles of elbow arthroscopy and get started on position some portal placement. Some of this will be repeated in other talks, some of the other talks. I have some videos, but I just want to get you started on some of the concepts. And sometimes the repetition will help quite a bit. So indications set up positioning portals, some arthroscopic anatomy, and we'll briefly discuss complications just to know what you can get in trouble with with elbow arthroscopy. This is a list of the most common things that we use elbow arthroscopy for. Pretty much elbow arthroscopy can be done for anything that involves the need to look inside of the joint, whether it be for treatment or diagnosis. And the most common thing that we will take care of with elbow scopes is going to be loose body removal for arthritis. Osteophyte debridement, whether it be in a throwing athlete with some impingement or again in the setting of arthritis. Very effective for rheumatoid arthritis or septic arthritis in terms of doing a synovectomy. It's a very straightforward procedure for this. This problem caps the releases for stiffness. Very common technique now for osteochondritis desiccans of the capitellum, again, going along the lines of unstable cartilage or loose bodies. And then lateral epicondylitis is another indication. And this is certainly not an exhaustive list, but these are the things that you're going to commonly see in a sports medicine practice. There are some contraindications. If you have significant soft tissue deformity or bony deformity that distorts the landmarks, either from prior surgery or prior trauma, this arthroscopy may not be the appropriate method for treating the problem. Prior ulnar nerve transposition. Some people think this is a significant contraindication. I would say it's more of a relative contraindication. You can either explore the nerve, open the nerve, find the nerve and make sure that it's protected during the procedure and still perform an adequate arthroscopy. Some people will do nerve mapping so they can see where the nerve is with an ultrasound and mark it out before surgery. The key here is, though, if you have altered anatomy, you want to make sure that you know how to stay out of trouble. And ulnar nerve transposition is one way that you can get in trouble if you don't know where the nerve is during work on the medial side. So there's several ways to set the scopes up, and some of it depends on comfort level and how you have been trained or how you've had experience doing this. Some of it also depends on what you're trying to accomplish. So if you are looking in to the elbow for a scope and then you need to transition to an open procedure, say you want to do a stress exam for an ulnar collateral ligament reconstruction and you're not clear that it's injured and you want to do a diagnostic scope, maybe the supine position is a little bit easier so you can then convert to an open. The advantage to this is that you can access the anterior aspect of the elbow pretty easily. It's actually pretty easy to set the patient up in the operating room. And again, it's an easy conversion to an open procedure. The disadvantage is that you need a suspension device. Sometimes it can be a little challenging to stabilize the elbow when you're working. And if you have the elbow in this particular position, sometimes getting into the posterior elbow can be a little bit awkward. So, again, you have to know what you feel comfortable with and what you're trying to accomplish. Here's another example of the suspension device. You can see that the picture on the left, the arm is hung in a traction device. And you can see in the picture on the right that there is a special device that you can have the arm across the body. And again, it's really what you feel comfortable with and what you're trying to accomplish. Prone position is another easy way to position the patient. It's also a lot simpler to access the posterior aspect of the elbow because you can see in this position, the elbow, the posterior aspect of the elbow is going to be facing up and it's going to be very easy to get to. If you are positioned appropriately on the bed, you can also easily flex the elbow and extend the elbow. It gives you good access to different parts of the posterior elbow. Again, the anterior portion of the elbow is not terribly challenging to get into, but you have to leave room from where the elbow is to where the patient's body is to make sure that your scope doesn't get blocked off from being able to access the anterior elbow. Your anesthesiologist probably won't like you as much using this position just because of the airway control issues. If you think you're going to be there for a long time, maybe consider a different position. And if you have to convert to an open procedure where you have to access any part of the anterior elbow, this can be a bit of a challenge. So again, you have to know what you're trying to accomplish and what you feel most comfortable with. Here's an example of the OR setup for the prone position. Again, you've got plenty of access for reflection and extension. I would argue that this is a good setup because you would have plenty of room when you're trying to use your scope coming from the anterior work that you need to do. But again, if you have a short arm or you can't get the elbow positioned appropriately and then your scope is hitting up against the body during the procedure, that can be a challenging situation to get through once you're already in the surgery. Lateral positioning is another option which can make it a little bit easier. If you're not sure if you're going to convert to an open, you can easily flip the patient to the supine position. It has the advantages of the prone position in terms of the position of the elbow with access to the posterior elbow. Again, you have to be careful in this position that you leave yourself enough room if you're going to do any work in the anterior elbow. In this position, you have to be careful, though. You have to pad the down leg so that you can protect the perineal nerve. You have to put an axillary roll in as well. So you just don't want to create other problems that the patient didn't have prior to your surgery. Again, here's an example of a lateral position. A significant challenge in a smaller arm is making sure that you have access between the elbow and the body. The other issue is you've got to make sure that they can stay tilted slightly forward. So you don't want the body to be falling back because then, again, you lose the ability to hold the arm in a good position. Some people will strap the elbow down in this position just to make sure it doesn't fall back. But again, once you have it positioned appropriately and you're able to flex and extend the elbow in a way that you need to to get to wherever you need to be, then you can usually have a very successful operation in this position. So in general, when you're starting out doing elbow scopes, you just need to stay out of trouble. And I find it, or at least I did find it helpful when I first started, to draw out the landmarks so that you can know exactly where you are. I always either put X's or put a line as I palpate the ulnar nerve. I will always put an M or an L. So when I look down, if I'm disoriented, if I'm doing something else, I know which side is medial and which side is lateral so I can stay out of trouble with the ulnar nerve. I don't always draw out all these landmarks these days, but when you're first starting, it's just really helpful to know where you are. First general principle, it's really helpful to distend the elbow joint up to 20 cc's of fluid. You can go a little bit more than 20 cc's of fluid, but you just don't want to distend the elbow joint so much that you rupture the joint capsule, because then it's going to be very hard to do the scope procedure. The benefit of distending the joint, it helps you get the scope in the joint. It also moves the nerve vascular structures away from the joint and helps push things that can get you in trouble out of the way. Usually to distend the joint through the soft spot portal, I would say the angle of this injection needle coming in here is probably not the angle that you want to take. And for me, it's a little bit more of a 10 to 15 degrees going sort of in this direction. If you think about the knee, if you do knee arthroscopy, you kind of want to match the slope of the radiocapitular joint and the ulnar-tumoral joint, so that the angle is going to be kind of in line with the joint where people get in trouble as they try to poke it into the distal humerus, and that just doesn't work very well. So again, about 10 to 15 degrees angled distal and maybe 10 degrees angled more medial, that usually will help get you in the joint. So general rule of thumb for me is establish anterior portals with the elbows flexed. I usually use a nick and spread technique, so I take a 15 blade, just get through the skin and then use a hemostat to create a track for my scope or for the dilation needle that I use. I always use a standard arthroscope, a 30 degree arthroscope. I will use a small joint scope, a wrist scope for the radiocapitular joint. I'll show you a picture of that positioning later, but it's a little bit easier to manipulate a smaller scope in the radiocapitular joint, but you can also use a 30 degree scope as well. I tend to use portal dilation cannulas, so I put my needle in to the portal position that I want, and then I use a dilator to expand the soft tissue to whatever size I need. And then I typically keep the fluid pressure between 30 to 35 millimeters of mercury. Just basically don't want to put it up so high that you're starting to get distension of the forearm compartments. You don't want to develop a compartment syndrome from your scope procedure. So anterolateral portals, again, the working portals laterally, you have the proximal anterolateral portal. You have the anterosuperolateral portal and the standard anterolateral portal. My working portal here is primarily the middle portal here. If you have your elbow flexed and you put your finger on the lateral epicondyle, you can roll your finger right into the sulcus just anterior to the lateral epicondyle, and that's going to put you right about where that portal is. And that's fairly safe. You got plenty of room in that location. As you get farther distal, you can see that you're going to get closer and closer to the radial nerve. Again, goal here is to minimize risk of iatrogenic injury to the elbow and to the nerves. The direct lateral portal is a very safe portal. That's the soft spot portal, what we talk about. That's not really around anything significant that you have to worry about. There is the posterior antebrachial cutaneous nerve that's in the region, but again, if you do a good nick and spread technique, you'll be fairly safe. The proximal anterolateral portal is going to be approximately one to two centimeters proximal and one centimeter anterior to the lateral epicondyle. And again, the risk of radial nerve injury is minimal, but it's in the neighborhood, so you just got to be careful that you're not drifting too anterior or too proximal. The middle anterolateral, the anterolateral superior portal, again, that's the one that I talked about going right in the sulcus just anterior to the lateral epicondyle. That's fairly safe. There's really not much in that location that you have to be worried about. But again, you just don't want to drift too anterior. The distal anterolateral portal is going to be one centimeter anterior and one to three centimeters distal to the lateral epicondyle. So it's this portal here. Again, as you get farther down, the radial nerve comes into play and the lateral anterobaric cutaneous nerve comes into play as well. So I don't really go down that in that portal very often. I usually stay more proximal with my lateral portal. Your anteromedial portals, the two working portals that we've commonly used, the proximal anteromedial portal and then the more distal anteromedial portal. The important part about making your anterior portals is you have to stay anterior to the intermuscular septum. That's going to be critical that you stay anterior so you don't hit the ulnar nerve. And again, that's the portal that you can get in trouble with if you've had an ulnar nerve transposition. So the proximal anteromedial portal is two centimeters proximal and two centimeters anterior to the intermuscular septum. If you get too anterior, you're going to get into the median nerve. If you get too posterior, you're going to be into the ulnar nerve. So I basically take my scope trocar, I twang the intermuscular septum to make sure I know that I'm anterior to that, and then just slide right on top of the intermuscular septum right on the anterohumeral ridge. And that usually pops you in nicely into the joint. Again, the anteromedial portal is two centimeters anterior and two centimeters distal to the medial epicondyle. And again, you can see that that puts you a little bit farther down. So if you need better access, that is certainly an option as well. But again, the workhorse for me is going to be the proximal anteromedial portal. Posterior portals, again, you have to know medial and lateral. So the ulnar nerve is drawn out nicely here. If you need to be more proximal, you can make the portal more proximal above the lacrinon tip. If you need to be more distal, for whatever reason, you can stay anywhere in this range and be safe. The posterolateral portal right off the lateral edge of the triceps, again, a soft spot portal. You can have a distal poster portal anywhere in this range is safe. And then I'll argue that you can also make an accessory posterolateral soft spot portal over here, which I'll show you in a second, which is good for capitellar work. And the only real risk posteriorly is the posterior anterobrachial cutaneous. The ulnar nerve, you have to know where it is. And if you get too medial, you'll be in trouble. But for the most part, that's not going to be too much of a risk for you. So, again, getting back to what we use this for, and again, the most common thing that I would say I use it for outside of capitellar OCDs would be for loose bodies related to osteoarthritis. And here's an example of a 50-year-old gentleman who's got a large coronoid osteophyte, a large loose body in the posterior recess. His range of motion is I think it was like 30 degrees up to 110 degrees and had a solid end point where he couldn't get any more motion. So he was really struggling with manual labor. So what we do is we are able to easily access the joint. Again, I'm in a lateral position. Here's the capitellum. Here's the radius. You see some of the synovitis in the joint here. You see some of the capitellar chondrosis with the capitellar flap anteriorly. As you become more medial, you see this big coronoid osteophyte right here. And you have this big veil of bone coming over the anterohumeral ridge and the coronoid fossa and over the rate of capitellar fossa. And you can see that as this gentleman is flexing his elbow, this will get pinched up against the osteophyte here. So our goal here is we have to remove this bony impingement. And if you've made a nice anteromedial portal or an anterolateral portal, depending on your working space, you can come across with an osteotome. You can use a burr, whatever you need to do to reshape this bone and take down the impingement. And here, again, working through the proximal anteromedial portal, you see this osteophyte in the coronoid fossa. Then you can take a burr and basically shave down that fossa so you can give that coronoid more room to flex. And, you know, you can, this is a little bit like, take a little bit, check and see how you like it, flex the elbow, make sure you can get where you want to be. And usually you can come out with a really good outcome or you can restore a good portion of their motion. Here's looking in the olecranon fossa, again, kind of a red inflamed fossa, not really a whole lot of depth to this fossa. It's because he's got a big osteophyte in the fossa and you can see part of that right here. So we can take this osteophyte out, we can take the loose body out, we can take some of the osteophyte off the capitellum and we can now make a little bit more of a normal olecranon fossa, which we don't have a great picture of here, but where this olecranon tip is not impinging against any bony structure that prevents motion. And so here's kind of what you're aiming for here is, again, this is all the osteophytes that you see along the anterior humeral ridge. And again, you're not going to necessarily make it a perfect X-ray, but it's a whole lot better. And this gentleman got all but five degrees of terminal extension back. So, again, very happy patient. It's a great operation for people. It's one of the few operations that works with arthritis. And then I'll talk about the accessory soft spot lateral portal. So, again, if you know where your rated capitellar joint is, you can make a portal anywhere here if you like to look in the rated capitellar joint. I found it really simple to take a small joint scope, which is not shown here, and just do a side to side portal placement. Again, you've got to be careful about the posterolateral antebrachial cutaneous nerve. But again, a nick and spread technique is very safe. And then it gives you a really nice view of the rated capitellar joint. Again, you see this nice, large, loose body sitting in the rated capitellar joint. We have taken this loose body out. Now you see this capitellar OCD defect that we have easy access to. I'm looking through the soft spot portal. I'm coming in from the lateral accessory soft spot portal. And it's very simple to access that area. Nerve palsy is the big concern. The greatest risk for nerve palsy is if you're doing a scope with an elbow contracture and also if you have underlying rheumatoid arthritis. Some of that synovial tissue can be very thick and disorienting. Transient nerve palsy is most common in the ulnar nerve. The second most common is radial nerve palsy. And then again, you can get neuromas and injuries to the medial antebrachial cutaneous and the PIN. So again, very low risk. There's a great paper written about five or six years ago that shows that if you do a good arthroscopy, the risk is very, very low, but not zero. And then direct injury, whether you cut too aggressively or if you hit it with the instruments. Those are the two reasons why people get the direct nerve injury and then compartment syndrome or local anesthetic extravasation. If you choose to use local anesthetic, there's another reason for people to wake up with transient nerve injuries. I don't use local anesthesia. We usually do regional nerve block after surgery if the patient's needed. But most people don't really need a block. And then you have to watch out for stiffness after elbow scopes. In general, we're doing this to improve motion. We'd like to get them moving fairly quickly. But it's not very common, but it can happen. Thank you. Any questions? Meredith, I have show my screen. Do you want to send it to John? Let me see if I can get this to run. So is that showing as a split screen or regular? All right. So. It looks good, John. Okay, good. So I don't have any conflicts. As Matt just went over, there are a lot of indications for elbow arthroscopy, both in the everyday person and in the athlete. This can be everything from simple to complex, but it's often combined with an open procedure. And as he just went over with you, some reasons for why you might choose one position over another. If you're doing tendinopathy procedures, neuropathy procedures, ligament repair, reconstruction procedures, trauma procedures, for me, being in the supine position affords you the best, safest option across the board. And if you get really proficient at doing it in a supine position, then you don't need to be able to switch back and forth. A prone position makes my anesthesia people very uncomfortable. Small people like gymnasts make a lateral cubitus position very difficult to give you full access to the joint. So I've just over 30 years have become very comfortable doing everything in the supine position. And I don't do supine hanging. I do supine cross body with either an assistant or an arm holder. My charge tonight is to talk about impingement. So we'll stay focused on that. But before I do, I will emphasize a couple of things. Charlotte Driscoll taught us all 20 years or more ago that you have to stay beneath your learning curve. We make these little switching sticks out of 3.2 millimeter switching sticks. We use them for retractors. You can make them with several different shapes we use, but they work great for every cubby hole in the elbow and we make them so we can still hang on to them at one end or the other. And they really help a lot to get tissues out of the way, particularly as you're learning. You have to know the anatomy. You have to know it really well and you have to have reasonable expectations about what you can accomplish. The OR is not a place to try new things. This was a kid that was sent to me who had a OCD lesion that actually went on to heal on its own, open growth plates. But then the surgeon's attempt to get to the joint, a significant part of the radial nerve was resected. Again, because many of these procedures are combined with open procedures, you need to find a way to be able to do that comfortably. And I think the supine crossbody with an assistant or an arm holder, there's some new arm holders out that really make that easier to do. I'm not going to go over the anterior portals, but I'll just say start medial, stay high. That's going to save you the most trouble. I really think you should stay away from the ulnar nerve. A lot of people hug the medial intermuscular septum. I say don't. Get more anterior. We've done a number of cadaveric studies over the years looking at where the median nerve is. You can be more anterior. As long as you're pointing straight at the joint, you're not going to get into the median nerve. Posterior portals is where I'm going to spend my time because that's what I'm going to be talking about. Posterior central portal, I still draw my outlines every single time I do this procedure, all the outlines. I always palpate and outline the ulnar nerve because sometimes it's more anterior, sometimes it's deep. Your posterior central portal is an important working portal, but it's really close, so I don't make it first. We start with this posterior lateral portal, and you can make it high or low, but it's really important that you make it utilitarian, which means you've got to be able to get both the olecranoplasma and the lateral gutter. A direct posterior portal is the portal you use for all your lateral gutter work, but you can do paired portals in this department, particularly if you're working with three millimeter shavers. This is the mid-radial capitellar portal, and it does, as Matt just described, afford a very clear view of the radial capitellar joint, but for the most part, I'm using it for my working instrument, not my scope, and then there's a distal ulnar portal that's very effective. In truth, you can be in this location anywhere as long as you're smart and be aware that you can get into some sensory branches, but it's extremely rare. As far as elbow impingement goes, there's really three separate types, posterior lateral, posterior and posterior medial. Posterior lateral also has three types, radial capitellar plica, lateral gutter plica, and posterior lateral band. Posterior is just straight posterior bone spurs and things that can occur with degenerative arthritis, but it can also occur in sports, and then posterior medial is the typical valgus extension overload problems, and there are a number of different presentations for that. So, we'll start with posterior lateral impingement. The radial capitellar plica, it's both anterior and posterior, it's more commonly symptomatic. Posterior, it often leads to radial head condomination, but also capitellum condomination of the lateral gutter plica. It can be symptomatic both distally and proximally, so don't disrespect the distal portion because you'll leave a symptomatic proximal portion on occasion. It causes both lateral ulnar and trochlear condomination lesions. It also is something you can identify with some special tests sometimes, and for the most part it's just location, where they hurt, how they hurt, and the history they provide, which is, I have pain right here when I do these activities. Tests like the moving valgus stress test that are hurt in this location are positive tests for it. While people talk about passive flexion pronation tests and active flexion pronation tests and active flexion supination tests, those are useful tests, but they're less often sensitive in my mind than moving valgus stress tests that hurts over the posterior lateral gutter. The radial capitellar plica can snap, pop, catch, lock. Most times it's just painful. We'll see it in hypertrophic, head frayed margins, look inflamed, but when you get in there and you look, what you're looking for is chondromalacia lesions like on the capitellum and radial head. These are really common. This is the radial capitellar plica, and when you extend the elbow and supinate, you can see it. This is pronation here. When you roll back into supination, it opens that side and it allows you to see the lesion, but it also gives you the room you need to be able to put a three millimeter shaver down in there and resect it. It's really important that you use the three millimeter smooth shavers to resect these because anything else is going to tear up the cartilage. Posterior lateral plica, the cartilage should look like this, but it gets beat up by this big large plica that folds back in between these three bones where they come together. In time, it begins to cause hibernation, principally of the lateral ulna, and some people think that this is a benign normal finding. Most of the time it's not because usually the cartilage is normal, and then eventually you start seeing true osteochondral lesions in the lateral trochlea, which often show up on the right or on the lateral ulna. You get to these areas, again, through two working portals, posterior lateral and direct posterior. You sometimes need to have a mid-radial capillary portal, and if you are popping anteriorly, you're going to end up needing anterior portals to get to the anterior radial capillary plica. I strongly recommend you use a three millimeter shaver. This is an example of use of a four millimeter serrated shaver, and it's just impossible to resect the plica without taking the anconeus fascia. I just show it to give you a sense of what happens. If you're not careful, it just removes way too much, and that posterior lateral capsule is still important, so use three millimeter shavers. There are a number of studies that have looked at outcomes resecting these. For the most part, outcomes are really good. One recent study suggested that they're not as good as you might think in sports, but there's a really mixed bag of people, and it's hard to tell who they were talking at. There's a thing called a proximal lateral band that's not really described in the literature, something I've seen for a long time. It's a band that runs from the lateral margin of the trochlea. You can see it here where it says plica band. It forms a thick band, then it attaches on the triceps. What happens is that in extension with rotation, it will catch on the lateral margin of the olecranon and pop, and this is most often seen in athletes that do activities near extension, such as gymnasts, golfers, boxers, and they'll present with pain that's along the proximal margin of the lateral olecranon with activity. Some of them will have popping. You get to it by simply putting the scope in the direct posterior portal behind the radial capital articulation and look proximally. You'll see it as a big, thick band, and you simply resect it. Post-direct posterior pagement, you see this in osteoarthritis just as it was demonstrated. You simply define it. I think CT scan is essential when you're trying to decide how much of this you need to remove, but we also see these in athletes that get hyperextended, linemen, gymnasts, baseball players, people who get extended, and if you do get this big, thick band across the back, you just simply resect it. There's usually not a lot of bone along the medial lateral side, and you're just taking a spur out of the deep olecranon fossa. Now, the more common thing people talk about with elbow arthroscopy is valgus extension overload and posterior medial impingement. Compression of the posterior medial olecranon against the posterior medial trochlea. It was described many, many years ago by many different people. There have been a number of papers that have been published on it many years ago. Not as much recently you'd think there would be, but it's one of the most common reasons why elbow arthroscopy is done in throwers. Chris and his guys did some really nice papers looking at how ligament insufficiency and increased valgus laxity affect the contact pressure on the area of the posterior medial olecranon. It explains some of the development of the posterior medial olecranon osteophytes. And similarly, Osbard and some of his guys did a nice study looking at how ligament insufficiency and increased valgus laxity would cause an increase in the total contact pressure and a decrease in the overall contact area and move the contact area medially. So when I see lesions that are more medial off the rim, I get worried that maybe they have some underlying ligament insufficiency. Also, that explains why many years ago in the 90s, why over half the people who had elbow arthroscopy for bone spurs in the back of their elbow had a second operation within two years that included ligament reconstruction. So posterior medial impingement can be just synovial plicas. It's not commonly synovial plicas, but we do see it or there's nothing else going on. More often, it's something going on the olecranon, the trochlear, or both. So we do see stress reactions. Most times, it's a little olecranon tip stress fractures. Rarely, it's in a transverse proximal olecranon fracture that requires surgical treatment. We did a study many years ago looking at healthy asymptomatic throwers in the pros. Those who are at college age, 12% already had bone spurs. By the time they were 30 years old, 50% had bone spurs. So not all of these are symptomatic, but be aware. Really common to see posterior medial trochlear lesions, if you look for them, that the radiologist never describes. So if a patient has posterior medial elbow pain or just medial elbow pain, you've got to be looking at the MRI for these little subtle areas of increased signal because otherwise, you'll miss them. So it can be simple, little bitty dots. So they can be really big, broad areas. This player here doesn't look like much, but he just had this pinch in the back of his elbow. Could not play. Once we cleaned it up, it was actually much bigger than what it looks right there. Similarly, sometimes, there are big, broad areas of eroded or damaged cartilage. Sometimes, there are big ruts where a lot of cartilage is gone. Again, MRI scans can be very valuable in helping you find it. Sometimes, CT scans can be as well. So what do we do when we see these lesions? Well, from the Electronon standpoint, we used to take a lot of bone away. Now, we just remove the least we possibly can. And there are several really good biomechanical and kinematic studies that show that removing anything other than normal amount of bone to leave normal anatomy puts the medial articular ligament at risk. So the goal is just to restore the normal contour. So you can see, we're just removing the little loose, unstable fragment from the edge of the bone. So after you clean these off, you can usually get to where you can find the loose fragment. So don't just start chopping away there. If you give it some time and start cleaning away some soft tissues, you can usually find the part that you need to reset. There are just some examples of the posterior medial trochlea. Lots of different types of lesions. Some of them just needed to be treated with simple chondroplasty, some with microfracture, and some of them you're virtually excavating big holes from subchondral insufficiency fractures. Even so, most of them still do really well. Here are a couple examples. One's prone, one's supine, but you can see they're pretty big lesions. One's got a big Electronon exostosis that goes with it. One on the left, we just simply trimmed away the damage, delaminated cartilage, and got rid of the necrotic bone, and that's all we did on that side. On the one on the right, we took away the loose fragments on the Electronon, and then I did a similar debridement of that osteochondral lesion. I won't take us all the way through that. Here's another one. Looks very small on the MRI scan, but these are often very painful, and you can see it looks like it's relatively stable. But once you get down into it, you'll see that it's cavitated, there's necrotic bone beneath. And once you start to clean these out, they actually become quite big, and that was some really dead bone. We used a 0.62 twist drill to drill that out. So, there are a bunch of studies that have looked at these. For the most part, outcomes are reasonably good, but not perfect. There are several recent studies that have looked at it as well. 78, 62, 73% returning to their previous levels for participation. And recent studies have also looked at mediocre ligament insufficiency with impingement. And in each of these studies, the outcomes were slightly worse if the ligament reconstruction was combined with impingement surgery. So, pearls, safety first, experience and knowledge, reasonable expectations, strategic preoperative planning. I think supine position gives you the best opportunity to manage all problems, be able to see well, create space in which to work, use retractors. And I use Coban on the forearm to limit forearm swelling, and I use extension splints because in most cases, it's going to minimize how much elbow and forearm swelling they can get, as well as how much blood they can get in the joint. Thank you. Thanks, John. Great job. John Mack, can you see my screen okay? I can. Beautiful. Well, welcome, everybody. And it's great to be with you guys. I'm going to speak on capitellar OCD and then touch on some stiffness. And as you all know from other OCD lesions, there is a problem in the elbow in this population of adolescent athletes, primarily gymnasts and throwers. With the repetitive force, there's some level of disruption to the bone blood supply, and the bone gets weak, and then you lose that integrity of the bone in that area, and you get mechanical symptoms. And we do know that the feature of this is related to poor blood supply because of the vascular anatomy. I mean, there's just not great vascular anatomy to that part of the capitellum, similar to the medial thermal condyle or to aspects of the talus. So these primarily happen in throwers and gymnasts. I see an occasional golfer who's an adolescent who's hitting balls like crazy, maybe some softball players and tennis players, but almost always it's a thrower of a gymnast. And here's some work done in Japan, where the incidence tends to be a little bit higher than the United States. The prevalence in a large cohort of baseball players was just less than 4%. So it's not that common an injury compared to, say, posterior medial impingement that John just spoke about. And it has to do with the volume of throwing, just like any other injuries. They start young, they throw hard, they throw more, and it's associated with pain. Here's something that was interesting. When we think of gymnast versus baseball players, and we think about what their elbow is doing, the baseball players have force on the outside of their elbow, more in a flex position compared to gymnasts who are tumbling where their elbow is more extended. So what was the finding in a study that compared location between baseball players and gymnasts? Baseball players, the lesion is more anterior. Just an interesting finding that correlates with the biomechanics. Here's the history. Lateral elbow pain. Early on, there's a sense that an athlete who's a baseball player or gymnast with lateral elbow pain has tennis elbow. They do not have tennis elbow. Tennis elbow is somebody my age. They have something else. And usually, if there's mechanical symptoms, high on your list is going to be plica or capitella OCD. And one of the biggest factors on exam is that they don't have full motion. They lose some extension. And yeah, there might be tenor over the radial capitella joint, the capitella. And you can appreciate crepitus in that area with certain motions. We get x-rays and MRI scans. The value of the MRI is how big is it? Where is it located? Is it stable or unstable? And are there loose pieces? So here you can see the central and there's a loose piece posterior to the radial capitella joint. The most mild, non-displaced cartilage is intact, just like other OCD lesions can be treated non-operatively, especially small size, long, short duration of symptoms, skeletal immaturity. You can get by with a period of non-operative treatment. If it's partially separated and there's mechanical symptoms or if it's fully displaced, those patients are going to wind up requiring surgery. And this is where it gets a little more controversial. What is the best surgery for this type of lesion? It may be from experience, your own hands. The literature is not perfect to guide us here. We talked about the portal, so I'll go through this quickly. But the portals that we're going to use are posterior-lateral primarily for getting at the OCD lesion for the treatment. Radial capitella softbox portal, you're familiar with that. We heard about putting in a smaller scope if you need it. I generally never use the smaller scope, to be honest. I've just been lucky. Just get enough space. You can put in a standard scope. And then you can use two posterior soft swap portals. They're side by side. If you spread them apart, you don't have competition as much. So try to get a little spread if you need those portals. And Scott Simon said, how about making the portal even lower, more distal? This is a typical soft swap portal. We can visualize through here. It goes through the onchineus and gives you a nice view looking at the capitella. I actually use that portal to instrument, not to view. Here's my preference. Visualize from posterior-lateral to start. This posterior-lateral portal is typically higher except for an OCD lesion that I know I'm treating. I will cheat this low. So we can look from here, instrument from here, use an accessory lateral portal if we need it. Or here's this portal where we're drawing an OCD lesion where you can go percutaneous and you can get nice angles. The surgery starts in the pre-op area. This patient scares me. This patient scares me because in the holding area, I'm examining his ulnar nerve. I want to know every ulnar nerve position in an elbow scope candidate patient because the ulnar nerve may not be in situ. This particular patient, no surgery, and his ulnar nerve is lying anterior to the epicondyle. Now, that's dangerous for making a proximal-anterior portal. You can essentially cut the nerve if you're not aware of this. This is the technique. I'm showing it in a video now, and I will demonstrate some features. Everybody has tricks about elbow arthroscopy. The setup is critical to the success of the case, and the fellows help with the setup during their year with me, and I give them a grade on every setup. They either get a B, B+, A, A-, I'm waiting to give one of them an A. The setup has to be ideal, and the ideal setup allows the instruments to gain access and not be encumbered in this lateral position by the beanbag along the chest, especially as John was saying. Some of these gymnasts have short humeri, and it's challenging to get the scope in the proximal-anterior portal. So you see the standard outlining. We've seen this already. I'll go over a case, start with this one. That other patient is, that presentation's on ViewMedi if you want to see it in longer detail, but this is a thrower. He's got catching. OCD often has catching, and that's the one that's likely going to fail non-operative treatment. Plus, he's 17. He lacks full extension. He's got tenderness in the area. He's got an unstable OCD lesion. You can see it here. There's deformity of his capitolum. Essentially, it's not round, and you don't see the cartilage in this area. So this is a fragmented lesion. Camera's in the front right now. This capitolum looks perfect. You have to extend the elbow to see it from the front, and when you extend, you close the anterior space down. So it's hard to work on the capitolum lesion. You see some of the fragmented cartilage here, but it's hard to work on it from the front. You can visualize it, but then you go to the back. Proximal and lateral portal here off of the triceps, and this is the soft spot portal, and this is what we get to do. We get the probe, and we see the unstable fragmented cartilage, and we're going to define the borders between bad cartilage, good cartilage, and really, this is a disease of bones. So we want to find out where the bone disease is and where the cartilage is not supported well. Here's the issue, and we saw some features of prone. You get good elbow flexion. If you're lateral and you need more elbow flexion, you can externally rotate the arm and flex more if you're hitting against the bed or the table. So I don't put any arm straps here, we can lift the arm, we can move it around, we can do things, and it's not unusual to externally rotate and flex to get more visualization. Here's the visualization, we're using a curette, we wanna get the fibrous tissue out of the defect. And John was talking about that in the trochlea. So we can curette and we can shave and we can make vertical borders. And then if you notice, we were visualizing here, this is the proximal anterolateral, this is the soft spot portal, now the camera is in the soft spot portal, and now we're instrumenting from yet another lower portal, that Scott Steinman portal that we showed before, and we can put a K wire in, I typically don't microfracture, I like drilling, there's less bone formation response. In reality, we've done a lot of debridement of the bone here, so this likely is going to work with narrow elements as it is, but we do like to do the drilling to make sure that we get the marrow elements that will enhance the healing and create fibrocartilage. This is what it looks like after you make some perforations two to three millimeters apart, you let the tourniquet down, you stop the inflow, and you can see that you're getting extravasation from those drill holes. All right, terrific, what happens after that? Well, the literature is not strong for results in this, but here's a study that I like, and it's done by one of my former fellows, Greg Lervick, 10 patients who underwent that operation that we just saw had an MRI scan done a year or so afterwards, and 80% had fill of some repair type of cartilage. Now we know repair cartilage is not as good as hyaline cartilage, but there is some satisfaction that you will have cartilage that grows back. Those cases that I showed before, those patients had central lesions. Do you guys see a difference here? This lesion is more lateral, lateral is to the right. There's common room, Malaysia, the radial head, so this lesion is big, and it's lateral, and it's borderline, these soft tissue attachments, doesn't have a good shoulder on the lateral side. That's a lesion that sometimes benefits from an osteochondral graft. This is how I started doing it in the beginning. Lateral position, we've been talking about set up all night, and look at this, we have the leg prepped out, and you can externally rotate the hip, and you can operate on the knee to harvest autologous osteochondral grafts, and you can place them into the elbow, and in this situation, I'm showing how it's done arthroscopically. You can take small plugs, and you can do that mosaicplasty type technique, and you can fill a cartilage lesion in that way, and we did a little bit of research because this type of surgery is challenging. It's an elbow, it's complex geometry, it's small. You need the elbow flexed maximally, and we decided to study, can you actually get to typical OCD lesions with the elbow flexed through that posterior portal, and in fluoroscopy cadaver studies, the answer is yes, you can, you can get there. Having said that, my technique of 2020, soon to be 2021, is an open procedure. This is a 19-year-old collegiate gymnast still competing in college. She had prior elbow arthroscopy and micro fracture, maintaining symptoms after a year of feeling good competing, and has mechanical symptoms. This is what we're doing here. We got the camera in that typical posterior lateral. We're making a soft spot portal, and you see a line for an incision. That incision is going to be midway between the olecranon and the lateral epicondyle. Here we are, we are taking out the synovium. The space is challenging because there's a large loose body here. Okay, we removed the loose body, and in reality, for presentation purposes, this is a different patient. This is illustrating osteochondrograph, but here's some more loose bodies that come out, and you can see the lateral aspect of this lesion. It doesn't even lend itself to perfect arthroscopic approach to get perpendicular. You make an incision, as you saw, midway between olecranon and lateral epicondyle. You split the onchineus, you put it in the galpi, and bingo, you flex the elbow by externally rotating the humerus, and you can put a retractor anterior to the epicondyle, and you can expose the lesion. We have a pretty good look at it, and in this situation, instead of doing multiple plugs, we can put one large plug, and we can now use allograft plugs, fresh allograft plugs, because they're so readily available. In fact, some companies have them pre-contoured. You can set up a drill so that you can make sure you're perpendicular. That's the big deal with this. You gotta get the plug perpendicular. You drill a socket about eight millimeters so that you make sure that your plug is stable. If you go a little bit shallower, you may not get all the diseased bone, and your plug may not be stable. So you drill your hole, you make sure that you tamp it. It looks pretty good there, and then you can size match from a hemicondyle, or these can be pre-contoured now, and you can harvest, and you can put it in position. So here's our approach. We tamp it in, and with the same style of lesions that we might do in other areas, such as the medial femoral condyle of the knee, we impact it flushing. You can see we're doing just a little bit of contouring, and the results of this are encouraging. It's good cartilage, and the bone heals underneath. It's a disease of bone. This small report here, nine baseball players from Raffy Merzine, one of my co-fellows, all players return. There's more and more reports on this, a lot of it on mosaicplasty. A recent systematic review is encouraging. So SP is the sister, JP is the brother. She is the gymnast, he is the baseball player, and they both got the disease. Look at this one. Maybe a little more posterior, maybe this one's a little more anterior. Okay, I'm showing this just to contrast because I do elbow arthroscopy in the supine position as well. This is supine now, and I'm just contrasting it because you saw lateral position, and I'll do this in one room a patient's supine, another patient's lateral. This is most commonly for me because we're gonna convert to a procedure where we're gonna operate on the patient's ligament, and it's very facile. If you have an arm holder like this, while portals are being closed, you can undo the suspension device, and then very quickly you're in this position, you're operating on the medial aspect of the elbow, taking care of potentially on the collateral ligament issue. Probably the most common arthroscopic procedure I do is posterior impingement, posterior medial impingement, and the baseball player. I'm gonna quickly touch on stiffness, and then we're gonna take some questions. Stiffness is the hardest operation I do. Stiffness in an elbow is the hardest operation. The anatomy's altered, there's danger everywhere with nerves and vessels, and the geometry is tough. You have a time limit on how much you can do with the tourniquet up, and they're swelling if you go too long. Here's a typical patient, loss of extension. I do this frequently. I expose the ulnar nerve and decompress the ulnar nerve to avoid post-op symptoms for patients who will lack flexion and will suddenly get flexion. And also, it's so appealing to have protection when you're gonna be working in this area. It takes about three to four minutes to make this incision and do a posterior decompression of the ulnar nerve. And throwers, we always do a transposition, so this is a population mostly that has arthritis. John talked about the retractor. He taught me how to use it. I use it all the time. And this is what I mean that it's hard. The anatomy is challenging. The first thing is creating a space to work. That's Sean O'Driscoll's advice, and I live by it. We wanna make sure we don't get disoriented with the anatomy, and here we're using some ablation to clear off all of the scar tissue, and this is the olecranon. This is where the ulnar nerve lives. My assistant is holding the ulnar nerve out of position. Don't sit on the corduroy and heat this up too much in this area. Get off the corduroy and give a chance for the heat to dissipate. And then just showing some techniques in the back. You saw some osteophytes from that. You can use osteotomes. This is the olecranon fossa with a huge brick osteophyte in it. You can use osteofoams. You can use the shavers to contour it. And here we're working the medial gutter. And what we see here is there's a retractor up here, John's retractor. We also have the nerve protected, so we can go aggressively and take out this mouse here that it's often referred to. Large osteophyte on both the medial and the lateral side. We can contour the olecranon, contour the olecranon fossa. And then we move anterior. This is lateral. We got two portals here. One's gonna be a retractor, and these are working. And here's the typical osteophyte in the front. Matt already showed it. I'm highlighting right here in the back this retractor. It is pushing the capsule away, and we're taking care of that osteophyte so we can achieve flexion without impingement. Here it is as we've progressed a little further. We changed the camera. This is lateral. Here's the capitellum. Here's the radial head. We're working lateral. We changed the camera to lateral. Now we're instrumenting medial, and this retractor is still to the right helping us. And this is the coronoid. So we can get at the coronoid. We can use a shaver, or we can use osteotomes. Here is probably the trickiest part of this operation and the most risk. We are doing a capsulotomy here. We're working from medial. You see the retractor lateral. We've released capsule along the humerus, and now we're resecting, or we're transecting the capsule. We stay intimate with the capsule, and we come towards the radial head, and then we slow down, because that's where the posterior interosseous nerve is. Here we see the brachialis muscle, and I did not do this in my first number of cases where I put a shaver inside, but occasionally I will take a shaver, and I will resect and do an actual capsulectomy, and then we can switch to the other side, and we complete the capsulotomy, and that's the best way to get motion. As John said, there is a huge learning curve to this, and it's taken me a long time always working below my ability with the complexity and the risk of the operation. That's the best way to stay safe, because with all of this in front of the elbow, the injuries are reported. Okay, I'm gonna stop there, and I'm gonna stop sharing my screen, and I'm gonna look for some questions. We have a couple of minutes, and I wanna thank everybody for being on the call tonight, the webinar. John and Matt, are you guys on? Yeah, we're on. Well, terrific. Maybe I'll start with a couple of questions. I'll work backwards. John, the throwers get symptomatic during the season, and you illustrated how to fix them. When do you fix them? Can you get them through the season, and how do you get them through the season, or do you need to fix them right away? What's your criteria and indication for surgery, and if you can get them through the season, how do you do that? So for posterolateral plicas, ultrasound-directed steroid injection directly into the plica, not the joint, can sometimes shrink the plica enough that it no longer impinges or gets entrapped. For people with posterior impingement, posterior medial impingement, steroid shots don't last long, or are not very effective very long, but we have found that leukocyte-poor PRP sometimes is remarkably effective in these guys, even if they have rough cartilage, and it'll buy them a lot of time, sometimes months, and it can be repeated safely, because leukocyte-poor PRP has a positive impact on chondrocyte metabolism. It's not gonna hurt anything, and as long as you don't think there's a, you know, some other underlying problem, then it's okay for them to play with it. Then at the end of the season, you can operate them, but to operate on somebody with just loose stuff that they can play with is not effective. I will say that I did have a player, a second baseman at the end of the season who just flat could not play, and this was really before PRP, and we didn't have any other options, and so we scoped him, and he played in a playoff game eight days after I scoped him. So if you make, we made two poke holes, cleaned up the back, got rid of what was bothering him, and got out, and he was able to play within eight days, and he played, you know, it was actually a playoff season for us, and he played through the whole playoff, so there weren't any problems. So he was- One last question, and then I'm gonna ask Matt. Let's go to the other end. You got a player who you're gonna do Tommy John on, and he's got a fragment on his olecranon tip that you can see on x-ray and MRI, but he has no tenderness, negative moving valgus stress test towards full extension, negative bounce test. Do you routinely take that out, or is there a need for symptoms? If it's truly, if it's just a dark line, and I think it's just, it's caused in part by the fact that he has ligament insufficiency and increased valgus laxity, but there's no fluid in it, and there's no edema around it. I'll leave it alone, thinking that it'll probably heal on its own after I fix his ligament, particularly if there's nothing in the posterior medial trochlea. If, on the other hand, there's clearly a posterior medial trochlea osteochondral lesion, or that fragment is clearly unstable, then I'll scope it. Okay, makes sense. So not all, and there's not a all or none. Matt, we're running out of time, but. Chris, I've had that exact same scenario heal. Matt, for the fellow's benefit, for my benefit, and I've had my share of complications, what kind of advice would you give for fellows who are gonna go out and practice and they're going to do elbow arthroscopy? What have you personally experienced that you said, you know, I learned something from this, I need to share it? Yeah, so I think first and foremost, don't let your patients, your live patients be your practice, go to the lab. Every company out there has a wet lab, go practice. If you need to go see somebody who does it well, see if you can watch them and see where I learned from Dr. Andrews and Dr. Dougas and Dr. Cain. And you can learn a lot once you're a fellow and early in your attending years, you can learn a lot from watching. But I think practicing in a lab is number one thing. And then when you're starting out, give yourself adequate time with your surgery schedule. Like schedule a scope, if it's a simple loose body, schedule it for a lot longer than you think it'll take so you're not feeling the pressure of having your day completely messed up by taking longer than you need to. And I will tell you, the first elbow scope I did in practice for a simple loose body removal, took me probably an hour to an hour and a half. And now it takes me 10 minutes. I mean, it just depends on how fast how you are and things get better and easier as you go along. And then also don't be afraid to ask for help. If you got partners who do it or have done it before, just do your first couple with somebody who can help you stay out of trouble. But as you said, you got a lot of stuff that can cause trouble all around the elbow so if you're very diligent and meticulous about how you do it, you can have really good outcomes and it's a really good patient population. Elbow patients are extremely happy most of the time. It's a good practice to have. You just need to be smart about how you approach it. That's great advice, Matt. Terrific. Yeah, thanks. And Sean, what advice do you have for the fellows who are gonna be out in practice and are gonna start doing elbow scopes? What wisdom do you have? Well, I think Matt talked about some of the things but Sean Driscoll, if you go back and look up some of the old videos that Sean did, they taught me so much. Get in, create space in which to work, stay beneath your lowering curve, use retractors, don't use shavers around nerves, get proficient in the back before you get proficient in the front, make sure you have reasonable expectations about what you're gonna accomplish. I absolutely believe that if you're trying to do complex things, you need CT scans. I use Coban on the forearm to minimize forearm swelling. I use three millimeter shavers anytime I'm shaving anything near a nerve or around an important structure because I think it minimizes how much smooth three millimeter shavers because it just won't suck up tissue. The anterior capsule, absolutely, you should learn how to take it down by undermining it and taking it down piecemeal to begin with. You should take all the bone out before you take any of the capsule out because otherwise the bone will get buried in the muscle and you'll get heterotopic bone. I learned using osteotomes but in time, it became so much easier to use burrs but if you use burrs, you've got to make sure that you're getting all the bony debris because otherwise you'll be dealing with iatrogenic heterotopic ossification and there are ways to learn how to avoid that and manage that. I think that you have to, I think that the nick and spread technique, I always called it something else but it's a very safe way to create portals and I use microhemostats to do that instead of the larger hemostats because it helps you get down where you want to be. I think for me, I think staying more, you know, start medial, stay high, I think that's a really good thing to remember. I think it keeps people out of trouble and I think learning how to do everything supine makes it so you're not having to do things in two different positions and I think that it makes your anesthesiologist a whole lot happier and the time it takes you to position somebody lateral is time and so if you can get good at doing all of it supine, I think it'll serve you through your career and you know, after doing it for 30 years, I've tried every method and every position and I think that's the most comfortable. That's great advice, John, thanks. I don't have much to add. Everybody has their comfort level once they get it. I do do it supine. For stiffness cases, I like being to check flexion extension repeatedly so I find that a little cumbersome in the supine position as opposed to lateral. The only other things I would offer in a lot of these presentations with pearls is my first stiffness case, I could not get the camera in from the proximal medial portal and my trick when I can't get the camera in is to start using smaller devices. Use a switching stick to start rather than just the trocar and if you can't get a switching stick, there is instrumentation where you can dilate over but we have our sequence, it's okay to start. That case I started laterally and I put the camera in laterally and the amount of ossification medially was so enormous it would not allow the, say the camera to go in. So it's okay to deviate in your sequence but your portals as you'll see from all the presentations, they don't deviate. You can change your position of setup, you can change your sequence of strategy but your portals generally are so respectful to the anatomy that they don't change much and I agree with John early in my elbow arthroscopy, I thought closer to the epicondyle was better but as the elbow swelled a little bit, I couldn't work in the anterior compartment. If you start a little more anterior and aim deep to it, you won't get in trouble with the median nerve and not only will you be okay with the ulnar nerve but I find it much easier to work. So any last comments from you guys? Yeah, I think to your point on that last comment about being more anterior, I think it's a really good point and one of the pearls that I have is I always aim toward the radiocapitella joint. I've got my finger on the radiocapitella joint. If my trocar is going toward the radiocapitella joint then I should be in the joint at a pretty good spot. So I think that's more anterior is I think a little bit better as you said. Okay, terrific. I wanna thank Meredith for putting this together so seamlessly and Matt and John for taking time and of course AOSSM for putting this fellows webinar series where John is the consummate educator. I call him and email him once or twice a month with hard things that I can't take care of and now I know I need to call Matt when John doesn't answer. So these guys have been terrific. Meredith, any last comments? I was just gonna add thank you so much to the three of you for your time and preparation for tonight's webinar. Today I was assigned the right to remind the fellows about candidate membership in the Surgical Video Library. If you have not already applied, you may apply online for free candidate membership during your fellowship year by clicking on the membership tab at sportsmed.org. Visit the online AOSSM playbook and Surgical Video Library at sportsmed.org. And we will see you next month at the follows webinar on January 12th. Happy holidays and thank you for participating. Good night. Good night everyone. Happy holidays everybody. Thank you. Thanks again.

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