Proximal Portal Research Articles

Anteromedial Elbow Arthroscopy Portals in Patients With Prior Ulnar Nerve Transposition or Subluxation

The purpose of this study was to document management strategies and complications relating to the use of anteromedial portals for elbow arthroscopy in a series of patients with subluxating or previously transposed ulnar nerves. A review of 913 elbow arthroscopies showed that 59 elbows with a subluxating or previously transposed ulnar nerve required anterior compartment arthroscopic surgery. The patients with subluxating nerves had proximal anteromedial portals established by reducing and holding the nerve behind the epicondyle with a thumb while establishing or entering the portal. In cases of prior nerve transposition, the following techniques were used if, by palpation, localization of the ulnar nerve was considered to be (1) unequivocal, (2) equivocal, or (3) impossible: In group 1 (unequivocal) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (equivocal) a 1-cm incision was made at the planned proximal anteromedial portal site and blunt dissection down to the capsule was performed without identification of the nerve. In group 3 (impossible) a 2- to 4-cm skin incision was made and the nerve was identified before placement of the portal. We found that 59 elbows in 56 patients had a subluxating ulnar nerve (31 elbows) or previous ulnar nerve transposition (28 elbows). The transposition had been subcutaneous in 21 and submuscular in 7. The proximal anteromedial portal was used in all but 3 cases (2 patients) of submuscular transposition that were early in the series. In those cases only 2 lateral portals were used for anterior compartment surgery. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal. Neither elbow arthroscopy nor specifically the use of the proximal anteromedial portal is contraindicated in patients with prior transposition or subluxation of the ulnar nerve. The management of the nerve can be based on the degree of certainty with which the nerve can be localized by palpation in the region of the planned portal. Level IV, therapeutic case series.

Arthroscopic Resection of the Cam Deformity of Femoroacetabular Impingement

Resection of the cam deformity of the femoral head-neck junction in order to avoid femoroacetabular impingement and the development of secondary damage to the anterolateral acetabular rim. Femoroacetabular cam impingement. Initial femoroacetabular pincer impingement. Advanced femoroacetabular pincer impingement with degenerative tear of the labrum. Femoroacetabular pincer impingement with significant retroversion and intact acetabular labrum, coxa profunda or circumferential ossification of the labrum. Advanced osteoarthritis. Arthroscopy of the peripheral compartment via three portals with and without traction. The proximal anterolateral portal is used for the arthroscope, instrumentation is done via the anterior and classic anterolateral portal. After resection of the zona orbicularis and the inner parts of the iliofemoral ligament, the anterolateral cam deformity is resected without traction via the anterior portal. After distraction of the head from the acetabulum, the lateral and posterolateral cam deformity is trimmed via the classic anterolateral portal. Pain-controlled progression to full weight bearing over 1-4 weeks, continuous passive motion therapy and stationary bike for 6 weeks in order to avoid intraarticular adhesions. From 2004 through early 2007, 72 hip arthroscopies were performed for femoroacetabular impingement. So far, 48 patients (25 men, 23 women, mean age 37 years [17-65 years]) were followed up. After a mean follow-up of 18 months, the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) was significantly improved from 65 +/- 21 to 82 +/- 18 and the NAHS (Non Arthritic Hip Score) from 57 +/- 19 to 78 +/- 19. two persistent branch lesions of the lateral femoral cutaneous nerve. One patient was surgically dislocated after 8 months for the treatment of a significant retroversion of the acetabulum; one patient underwent total hip arthroplasty after 1 year.

Endoscopic-assisted repair of acute Achilles tendon rupture with Krackow suture: An anatomic study

To study the feasibility of applying Krackow locking stitches in the endoscopic-assisted repair of acute Achilles tendon rupture and the possible complications encountered. Anatomic study. Twelve Achilles tendons in six cadavers were cut at 6cm from its insertion and endoscopic-assisted repair of Achilles tendon was performed. These legs were then cut open in midline to study (i) the locking stitches formed and (ii) the relation of the sural nerve to the locking stitches. With endoscopic-assisted technique, Krackow-type locking stitches can be formed in eight legs. In four legs, the stitches fell into the ruptured gap and lie deep to the tendon. The tendon rupture end was grasped by the suture rather than forming a Krackow-type locking stitch when the suture was tightened. There was no sural nerve laceration noted. However, in two legs, the sural nerves were found trapped in the sutures at around the proximal portal. Krackow locking stitches can be formed by the minimally invasive technique. However, there are risks of stitches falling into the ruptured gap and lie deep to the tendon and risk of sural nerve entrapment at the proximal medial portal. The original technique is not suitable for clinical application. Modification of the technique by grasping the tendon end with Allis tissue forceps before passing the suture may prevent the suture from falling into the ruptured tendon gap.

Anatomic relationship between portals and nearby nerves at different positions in elbow arthroscopy

Objective To evaluate the safety and value of standard portals used in elbow arthroscopy by comparing the anatomic relationships between the arthroscopic portals and nearby neurovascular structures at different positions. Methods The dissections were performed in 10 fresh cadaveric elbows. The minimum distances from the 9 standard paths of the arthroscopie sheath to nearby neurovascular structures were then measured and the value of each portal was assessed in terms of its effects on the elbow arthroscopy. Results The approach-to-nerve distance was affected by joint distention with fluid, elbow extension/flexion and forearm supination/pronation. The radial nerve showed significant proximity to the anterolateral portal in full elbow extension and forearm supination, the minimum distance from the anterolateral portal to radial nerve was （2.9 ± 1.1） mm, （4.5 ± 1.5） mm, （5.8 ± 1.7） mm respectively when the elbow was in 90° of flexion with the forearm supinated midpronation and pronation, and nerve-pin contact was observed in 2 elbows in the extended positions. The proximal medial portal and the proximal lateral portal for the anterior compartment, and the posterocentral portal for the posterior compartment, were shown to have an optimum effect with the least complications. All of the posterior approaches were safe. Condusions The proximal approaches are safer than the anteromedial and anterolateral approaches. The proximal medial portal, proximal lateral portal and posterocentral portal should be used as standard portals in elbow arthroscopy. Key words: Elbow; Arthroscopy; Anatomy; Approach

Anatomy of the Portal Tract for Endoscopic Decompression of the First Branch of the Lateral Plantar Nerve

Our purpose is to study the anatomy of the portal tract for endoscopic decompression of the first branch of the lateral plantar nerve. The anatomy of the portals and portal tract with endoscopic release of the first branch of the lateral plantar nerve was studied in 12 feet in 6 cadaveric bodies. The proximal portal is located at the fascial opening for the first branch of the lateral plantar nerve and is about 16 mm inferior and 23 mm posterior to the tip of the medial malleolus. The distal portal is located at the inferior edge of the deep fascia of the abductor hallucis muscle and just distal to the medial calcaneal tubercle. The portal tract is deep to the deep surface of the whole width of the deep abductor fascia. In 1 of 12 specimens, the nerve lay superficial to a rod placed between the portals, whereas the nerve was deep to the rod in the remaining 11 specimens. In all specimens the first branch of the lateral plantar nerve, after it pierced the deep fascia of the abductor hallucis at the fascial defect, ran anteriorly and distally, approximately parallel to the direction of the rod. The proximal portal for endoscopic decompression of the first branch of the lateral plantar nerve is located at the fascial opening for the first branch of the lateral plantar nerve. This can be consistently located with the Wissinger rod technique. The portal tract thus created is effective for deep abductor fascia release. However, percutaneous release without endoscopic visualization of the first branch of the lateral plantar nerve is not safe because of the potential risk of nerve injury, because the nerve can be sandwiched between the instrument and the deep abductor fascia without being noticed. The study confirmed the first branch of the lateral plantar nerve can be effectively released endoscopically.

Extra-articular Arthroscopic Lateral Elbow Release

We describe a unique extra-articular approach for arthroscopic lateral release for lateral epicondylitis. An arthroscopic extra-articular approach allows better direct visualization of diseased structures with a 30° arthroscope and only requires a small hole in the joint capsule. The camera is placed into the joint through the middle anterolateral portal. The camera is then pulled back through a small rent in the capsule over the lateral radiocapitellar joint to provide an extra-articular view of the diseased structures. The shaver is then placed 1.5 cm proximal to the camera in a proximal anterolateral portal. Debridement of the common extensor fiber tendinosis and decortication of the lateral epicondyle are performed under direct visualization. This is different from the intra-articular technique, where visualization with the 30° arthroscope is more difficult despite a large capsulotomy to aid visualization. The advantage of this extra-articular technique is 2-fold. First, the extra-articular viewing portal allows direct visualization of diseased structures, improving accuracy for debridement compared with an intra-articular viewing portal. The intra-articular technique uses the 30° arthroscope to work around a corner after a large capsulectomy. The second advantage of the extra-articular viewing portal is that it only requires a small capsulotomy. The small capsulotomy decreases the risk of transient radial nerve palsy associated with a capsulectomy. The small capsulotomy also results in less fluid extravasation into the soft tissues. Less fluid extravasation decreases swelling and the risk of compartment syndrome.

Endoscopic Extracapsular Capsulectomy of the Elbow: A Neurovascularly Safe Technique for High-Grade Contractures

Arthroscopic management of elbow contractures is rapidly becoming the primary operative form of treatment for many physicians. Safety concerns remain the primary limiting factor in its more widespread use. We use an extra-articular starting point in extremely difficult fixed contractures, and this technique is documented in this report. The ulnar nerve is initially identified and protected with a palpating finger, while a periosteal elevator is introduced through a proximal medial skin portal. A channel between the anterior humeral cortex and anterior musculature is created, and an arthroscope is introduced through a proximal lateral portal at the lateral aspect of the channel. The anterior capsule is dissected from the musculature/neurovasculature under direct vision and safely excised once the medial and lateral margins are safely identified. A useful technical tip is that retractors can be placed in auxiliary portals to deflect the muscles and fat pad to improve the ability to perform dissection under direct vision.

Arthroscopically assisted Z-lengthening of extensor hallucis longus tendon

Extensor hallucis longus tendon contracture can lead to hyperextension deformity of the big toe. We describe an endoscopic approach of Z-lengthening of the tendon. Extensor hallucis longus tendoscopy is performed with a distal portal at the level of the metatarsal neck and a proximal portal at the level of the navicular. At the distal portal, the medial half of the extensor hallucis longus tendon is cut and a stay stitch of No. 2 ethibond is applied. It is then stripped proximally with a tendon stripper to the proximal portal. A stay stitch of No. 2 ethibond is applied to the lateral half of the tendon at the proximal portal and it is cut proximal to the stitch. With the ankle plantarflexed and the big toe kept in the similar position as the lesser toes, the tendon segments are kept in tension through the stay stitches via the proximal and distal portals. The stay stitches of distal tendon segment are sutured to the proximal segment at the same level of the cut end of the distal fragment with the aid of an eyed needle under arthroscopic visualization through the distal portal. The needle is passed through the tendon and then the skin. The suture is also passed through the skin and then retrieved to the proximal portal by a hemostat. It is then sutured to the proximal tendon segment at the proximal portal. Similarly, the proximal tendon end is sutured to the distal tendon segment at the corresponding level and the endoscopic Z-lengthening of the extensor hallucis longus tendon is then completed.

Arthroscopic ‘Filling’ of Hill Sachs Lesions (SS-03)

Arthroscopic ‘Filling’ of Hill Sachs Lesions (SS-03)

Arthroscopic-Assisted Reduction and Percutaneous External Fixation of Lateral Condyle Fractures of the Humerus

Lateral condyle fractures in children are the second most common fracture about the elbow. Anatomic reduction of intra-articular displacement is considered a priority. Most experts agree that the treatment of choice of mildly displaced (>2 mm) lateral condyle fractures is open reduction–internal fixation or intraoperative arthrography followed by closed reduction and percutaneous pinning. In this report we described an alternative approach using closed arthroscopic-assisted reduction. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal anteromedial portal with no pump, and a proximal anterolateral portal was created for instrumentation. The fracture line was easily visualized after blood, fibrin, and loose articular debris were irrigated from the joint. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and via rotation until there was no step in the articular cartilage. Two lateral Kirschner wires were placed percutaneously, which result in firm fixation of the fracture. We think that the advantages of arthroscopy are further superior to intraoperative arthrography because arthroscopy not only allows for better anatomic reduction and visualization with minimal surgical trauma and less radiation time but also provides a valid diagnostic and treatment alternative for associated injuries.

Internal Fixation of Fifth Metatarsal Metaphyseal–Diaphyseal Stress Fractures With an Intramedullary Screw

The fifth metatarsal metaphyseal–diaphyseal stress fracture is a notoriously difficult fracture with a history of delayed healing and prolonged treatment times. The prominent location of the metatarsal head at the lateral foot reduces the utility of typical screw fixation. The advent of cannulated systems has improved the technical ease of intramedullary insertion, but requires a larger screw head which produces an even greater source of mechanical irritation at the lateral foot. A solution to this challenge is presented with the Acutrak screw (Acumed, LLC, Hillsboro, OR), a titanium alloy, cannulated, headless, tapered, variable-pitched, fully threaded compression screw. The headless design of the Acutrak screw and its proximal insertion portal eliminate the potential for mechanical irritation at the lateral border of the foot. The tapered, fully threaded design provides excellent intramedullary contact along the entire length of the screw with the benefit of immediate stability. The variable pitch, with a faster leading pitch, provides significant compression across the fracture site. The surgical technique uses a portal proximal to the metatarsal base and is dependent on radiographic assistance for intramedullary positioning. The device and technique allow for a predictable and rapid return to athletic activity.

Microsurgical Dissection of the Carpal Tunnel With Respect to Neurovascular Structures at Risk During Endoscopic Carpal Tunnel Release

The goal of this descriptive study was to investigate the anatomy of the carpal tunnel with respect to the related neurovascular structures, because a detailed knowledge of the complex anatomy of this region is essential to perform endoscopic carpal tunnel release. Sixteen fresh-frozen cadaveric hands were used for the study. Dissection of the palmar aspect of the hand was performed by use of magnifying loupes, an operative microscope, and microsurgical instruments. All anatomic components were photographed, and dimensions were recorded by use of a micrometer. The distance from the radial aspect of the os pisiformis and the proximal and distal portals to the main structures that may be injured was measured. Topography of the transverse ligament and possible adhesions to the tendons and median nerve were also recorded. The mean distance from the radial aspect of the os pisiformis to the radial border of Guyon's canal and the ulnar edge of the palmaris longus tendon was 10.3 mm (range, 9 to 12 mm) and 16.1 mm (range, 12 to 22 mm), respectively. The mean distance from the distal portal to the superficial palmar arch and the ulnar artery was 10.4 mm (range, 5 to 15 mm) and 7.6 mm (range, 4.5 to 9 mm), respectively. The mean distance from the distal edge of the transverse ligament to the thenar branch of the median nerve was 2.7 mm (range, 0 to 4.1 mm). The mean length of the transverse ligament was 31 mm (range, 25 to 34.5 mm). In 14 hands we also identified the palmaris longus tendon. In 11 hands we found adhesions between the transverse ligament and the sheath of the flexor tendons. The palmaris longus can be used as a guide for the placement of the proximal portal. Staying at the ulnar side of the palmaris longus keeps the superficial palmar branch of the median nerve at a safe distance from the instruments. The "fat drop sign" is also a useful guide for the placement of the distal margin of the transverse carpal ligament, keeping the distal portal away from the superficial palmar arch. Synovial adhesions can usually cover the inferior surface of the transverse ligament, and they need to be removed for clear endoscopic identification of the transverse fibers before the ligament is cut. Detailed knowledge of the complex anatomy of the carpal tunnel is essential to perform endoscopic carpal tunnel release.

Endoscopic Iliotibial Band Release for External Snapping Hip Syndrome

The external snapping hip syndrome is caused by slippage of the iliotibial band over the greater trochanter. Most cases are treated conservatively but if this fails, open surgical treatment is commonly performed by Z-plasty or by creating a defect on the iliotibial band. We present a series of 11 hips that were surgically treated by an endoscopic technique. Prospective consecutive series of patients. Diagnosis of external snapping hip syndrome was clinical in all cases and anteroposterior pelvis radiographs were taken to evaluate the hip joint. Endoscopic release was performed with the patient in the lateral decubitus position without traction using 2 portals, the superior trochanteric and inferior trochanteric. A standard 4-mm, 30 degrees arthroscope was introduced at the inferior trochanteric portal over the iliotibial band. A needle was placed at the proximal trochanteric portal and visualized endoscopically. The portal was then established and subcutaneous tissue resection was performed with radiofrequency (RF) probes and a shaver until the iliotibial band was identifiable and released with a vertical cut made using an RF hook probe. The arthroscope was introduced into the space created under the iliotibial band and a transverse cut at the middle of the vertical release was then made, creating a cross-shape. Next the 4 resulting flaps were resected to make a diamond-shaped defect. Between September 2001 and December 2003, we treated 11 patients, 9 female (1 bilateral) and 1 male with an average age of 26 years, for external snapping hip syndrome using an endoscopic technique. At an average 2-year follow-up, we had 1 patient with nonpainful snapping. The rest of the patients in the series had no complaints and returned to their previous level of activity. We present a reproducible endoscopic technique for the treatment of external snapping hip syndrome. Our results are comparable to those reported for open procedures. Level IV.

Arthroscopic Treatment of Fractures of the Radial Head

Abstract An original technique for the arthroscopic diagnosis and treatment of the fractures of the radial head is proposed and described. The elbow arthroscopy is started with a 4.5-mm 30° arthroscope from the proximal anteromedial portal and the anterior elbow is examined; then a proximal anterolateral portal is created and a full-radius blade inserted to take out the hematoma and to allow visualization of the radial head that is explored through the whole range of motion to visualize the fracture fragment. The fragment is manipulated by means of arthroscopic tools to reduce the anteromedial surface of the radial head. The arthroscope is now switched to the posterolateral portal and the posterior aspect of the humeral radial joint is visualized. The soft spot portal is used to insert a periosteal elevator to complete the reduction and firmly hold the fragment in the reduced position. An anterolateral portal is now created to allow the safe insertion of a guidewire, angled 45° to the longitudinal axis of the radius, to pierce the fragment with. A 14-mm long cannulated screw is inserted along the guide after specific drilling. Finally, the reduction and the stability of the fixation are checked with during full rotation of the elbow. The described procedure has been performed in 6 patients. Short-term preliminary results show a satisfactory functional outcome. Among the advantages of the technique are the minimally invasive approach, the direct visualization of the fracture, and the benefits derived from the radiation-free procedure.

Anatomy of Neurovascular Structures Around the Carpal Tunnel During Dynamic Wrist Motion for Endoscopic Carpal Tunnel Release

The purpose of this study is to investigate the anatomic relationship between neurovascular structures and the transverse carpal ligament (TCL) so as to avoid complications during an endoscopic carpal tunnel release procedure. Fresh cadaver hands from seven men and 12 women (age range, 48-74 yr) were used. The neurovascular structures just over and under the TCL were meticulously dissected under loupe magnification. Several anatomic landmarks were calculated (average length of the TCL; average distance between the TCL distal margin and the neurovascular structures; and average lengths of the superficial palmar arch, ramus communicantes, recurrent motor branch, and palmar cutaneous branch of the median nerve). The ulnar neurovascular structure was studied with the wrist positioned in neutral, ulnar flexion, and radial flexion. The anatomic relationships between the TCL and vascular and neural structures were measured. The ulnar neurovascular structures usually passed just over ulnar to the superior portion of the hook of the hamate. However, in 11 hands, a looped ulnar artery coursed 1 to 4 mm radial to the hook of the hamate and continued to the superficial palmar arch. The looped ulnar artery migrates on the ulnar side of Guyon's canal (-2-2 mm radial to the hook of the hamate) with the wrist in radial flexion (of the wrist). During ulnar flexion of the wrist, the ulnar artery shifts more radially beyond the hook of the hamate (2-7 mm). It is appropriate to transect the ligament over 4 mm apart from the lateral margin of the hook of the hamate without placing the edge of the scalpel toward the ulnar side. We would also recommend not transecting the TCL in the ulnar flexed wrist position to protect the ulnar neurovascular structure. The proximal portal could be made just ulnar to the palmaris longus tendon to spare the neurovascular structures in the proximal portion of the TCL.

Comparative study between endoscopic technique by a proximal port and mini palmary incision in the surgical treatment of carpal tunnel syndrome

The authors present a prospective study comparing two surgical techniques for carpal tunnel release. A minimal - incision open decompression(3) is compared with an endoscopic release(2), that utilizes only a single proximal portal. There were operated on, 28 wrists in 28 patients, with clinical signs and EMG changes consistent on idiopathic carpal tunnel syndrome, that failed under previous conservative treatment. They were randomized into two groups , undertaken surgical treatment, either by endoscopic release or by open decompression. Grip strength (measured by dynamometric), sensitivity (measured by Semmes-Weinstein monofilaments), presence of pain and paresthesia, date of return to activities of daily living and complications were evaluated pre-operative and at 1, 2, 4, 6, 12 weeks after surgery. After 12 months average follow up, the results indicated that this proximal portal endoscopic technique can be safely performed, showing advantages over open conventional method, in terms of sooner return of grip strength, date of return to activities of daily living, and less incidence of pillar pain. No differences in paresthesia resolution, sensibility improvement or complications incidence were found.

Arthroscopic excision of the radial head: Clinical outcome in 12 patients with post-traumatic arthritis after fracture of the radial head or rheumatoid arthritis

Purpose: We performed arthroscopic radial head excision in a series of patients with either post-traumatic arthritis after a radial head fracture or rheumatoid arthritis of the elbow as an expanded indication for elbow arthroscopy. The purpose of the study was to critically examine the results of arthroscopic chondroplasty of the radial head to determine the safety and effectiveness of the procedure. Type of Study: Outcome study and retrospective analysis. Methods: From 1990 to 1997, arthroscopic radial head resection was performed in 12 patients with either post-traumatic arthritis (n = 10, Mason type II or III) or with rheumatoid arthritis (n = 2). Functional outcome and radiographs were analyzed after a mean follow-up period of 39 months (range, 12 to 97 months). Elbow arthroscopy was performed using a standardized technique. The anterior three quarters of the radial head and 2 to 3 mm of the radial neck were resected with the abrader in the anterolateral portal and the arthroscope in the proximal medial portal. For resection of the posterior portion of the radial head, the abrader may be transferred to the mediolateral portal. This permits resection of the remnants of the radial head posteriorly and also at the proximal radioulnar joint. Results: Preoperatively, patients lacked 23° (range, 5° to 40°) of extension of the elbow on average. Mean flexion was 111° (range, 60° to 145°). Patients had unrestricted pronation (limitation of 5° in 2 patients). Two patients had a lack of supination of 15° and 30°. Mean follow up was 39 months (range, 12 to 97 months). Postoperatively, patients lacked 9° (range, 0° to 20°) of extension of the elbow on average. Mean flexion was 136° (range, 90° to 150°). No patient had subjective or objective evidence of instability of the elbow. All patients except one reported significant improvement in pain relief and complete relief of mechanical symptoms. Conclusions: This technically demanding surgical procedure should be reserved for situations of persistent, restricted range of motion and chronic pain. Arthroscopic radial head resection combined with arthroscopic synovectomy relieves elbow stiffness. The surgeon is able to deal with the intrinsic joint pathology, as well as with accompanying symptoms such as synovitis, capsular contracture, or loose bodies.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 918–923

Arthroscopic Release of the Stiff Elbow

Arthroscopic Release of the Stiff Elbow

Basics of Elbow Arthroscopy

Summary: Advances in arthroscopic surgery and equipment during the past several years have made elbow arthroscopy an effective and safe alternative for the management of a variety of elbow disorders. The positioning of a patient is a matter of personal preference. Originally, elbow arthroscopy was performed with the patient supine and the hand suspended to traction. The prone position allows better access to the posterior aspect of the elbow and easier conversion to open procedure. However, the lateral decubitus position allows better access to both the anterior and posterior compartments. A thorough knowledge of neurovascular anatomy of the elbow is required to safely perform elbow arthroscopy. The elbow anatomy is marked, specifically that of the ulnar nerve, and the elbow insufflated with a posterior soft spot or straight posterior portal. A proximal medial portal is established for initial visualization of the anterior aspect of the elbow. Proper placement of the portal allows a complete diagnostic arthroscopy of the anterior compartment, including the medial gutter. A lateral portal is established if necessary. Once the initial diagnostic arthroscopy of the anterior aspect of the elbow joint is completed, a posterior central portal is established. Accessory portals are established posterolaterally or in the soft spot to allow surgical procedures to be performed. Circumstances that may require arthroscopic surgery include removal of loose bodies, debridement of osteochondritis dissecans, synovectomy, arthritis, and fixation of fractures. The most commonly reported complications of elbow arthroscopy are injuries to neural structures. Additional complications include infection, instrument breakage, iatrogenic injury to articular cartilage, synovial fistula formation, and problems associated with use of a tourniquet. A thorough knowledge of regional anatomy, use of meticulous surgical technique, and strict attention to detail will minimize the risk of neuralgic complications. Strict adherence to the principles outlined will allow the use of arthroscopy to treat a variety of elbow disorders in a safe and effective manner.

Modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon: Operative technique and case study

This article presents an operative technique for modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon sheath. The procedure uses two stacked posterolateral subtalar joint portals, rather than the customary anterolateral and posterolateral portal combination. By visualizing the os trigonum with an arthroscope positioned in a distal portal and introducing instrumentation through a proximal portal, the ossicle may be quickly exposed and excised with minimal dissection. A case study with a 22-month follow-up and a discussion of os trigonum syndrome are included to illustrate this procedure as an alternative to open excision or traditional arthroscopic excision.