Valgus Extension Overload: Arthroscopic Decompression in the Supine-Suspended Position

Abstract

Elbow arthroscopy is a useful tool for managing diseases of the elbow, including valgus extension overload, when conservative treatments have failed. Arthroscopic access to the elbow in the supine-suspended position is simple and reproducible with the technique described in this report. Synovial tissue can be cleared, optimizing visualization of the anatomic structures in the elbow including the posterior ulnohumeral joint. This report describes, in detail, arthroscopy of the elbow in the supine-suspended position and basic principles for arthroscopic decompression of the posterior elbow for valgus extension overload.

Fig 1

(A, B) Our preferred patient positioning for elbow arthroscopy: the supine-suspended position. A right elbow is shown with the operative arm placed in balanced suspension with 5 to 8 lb of weight.

Fig 2

The elbow is palpated to identify important anatomic landmarks. A marking pen can be used to outline the olecranon, medial epicondyle, ulnar nerve, radial head, and capitellum. The relations of the medial portals to the major neurovascular structures in the area are shown.

Fig 3

Establishing the anterior-lateral portal (right elbow): A blunt trocar is introduced over the lateral condylar ridge of the humerus into the elbow joint.

Fig 4

With the arm near full extension, the straight posterior portal is created under direct visualization while viewing from the posterior-lateral portal (right elbow). This portal is typically about 90° from the posterior-lateral portal to avoid traffic with the instrumentation.

Fig 5

Arthroscopic decompression for valgus extension overload viewed from the posterior-lateral portal (right elbow) with the patient in the supine-suspended position. (A, B) Osteophyte decompression is begun with a standard arthroscopic shaver and burr. (C) An osteotome can be used to loosen the fibrous tissue between the spur and olecranon tip. (D) After completion of the procedure.

Fig 6

The posterior-medial elbow viewed arthroscopically from the posterolateral portal (right elbow) with the patient in the supine-suspended position. The surgeon should always be cognizant of the ulnar nerve (n) and posterior band of the ulnar collateral ligament (UCL) when debriding the posterior-medial olecranon.