Tips to avoid nerve injury in elbow arthroscopy

Table 1 Recommendations in short

Step	Phase	Recommendations
1	Work-up	Determine a valid indication. Identify possible complicating factors. If needed obtain additional imaging studies for careful planning of surgery Routinely report a subluxing or previously transposed ulnar nerve for all patients in the outpatient clinic setting previous of elbow arthroscopy Critical assessment of CT-studies to determine if osteophytes compress or mobilize the nerves (Figure 4)
2	Preoperative preventive measures	Examination under anesthesia (ROM) Marking of anatomic landmarks and portal sites (Figures 5 and 6) Palpation of the ulnar nerve course
3	Anesthesia	General anesthesia is recommended because of patient comfort and disabling unexpected patient movement
4	Patient positioning	Lateral decubitus position is recommended because of additional gravitational displacement of nerves away from the anterior capsule and easy access to all compartments (Figure 7) Use a bean bag for stable patient positioning
5	Joint insufflation	Increases nerve-to-portal distance by expanding the joint space en pushing the neurovascular structures away from the surgical field. Recognize that joint insufflation does not increase nerve-to-capsule distance (Figures 8 and 9)
6	Elbow positioning	Elbow flexion increases distension capacity of the joint and increases nerve-to-portal distance Supportive arm holders should not compress the flexion crease
7	Portal placement	Portals proximal to the joint tend to be safer Mini-incision of the skin only and the use of a blunt trocar or clamp prevents injury to the antebrachial nerves Pronation and flexion of the elbow protects the posterior interosseous nerve when placing lateral portals Avoid use of the posteromedial portal as the posterolateral and midposterior portals are good alternatives when inspecting the posterior compartment
8	Use of instruments	Always visualize the tip of the instrument Avoid suction when in the vicinity of a nerve or against the capsule Use a retractor to lift the capsule away from the debriding instrument, particularly in compartments at risk The use of hooded burrs instead of unhooded burrs is recommended as it help prevent the burr tangling up in the soft tissues No suction while shaving Availability of different shaver sizes during surgery