Technical Note

Arthroscopic Elbow Debridement Using

Anterocentral Transbrachialis Portal
Kenichi Otoshi, M.D., Ph.D., Shinichi Kikuchi, M.D., Ph.D., Kinshi Kato, M.D., Ph.D.,
Ryohei Sato, M.D., Ph.D., Takahiro Igari, M.D., Ph.D., Takahiro Kaga, M.D., and
Shinichi Konno, M.D., Ph.D.

Abstract: Arthroscopic debridement for elbow osteoarthritis has been widely used as a minimally invasive treatment;
however, in some cases, it can be a technically demanding procedure, such as in patients with severe osteoarthritis with
large spur formation and severe synovitis. The anterocentral transbrachialis portal is a recently developed portal for elbow
arthroscopy, which allows easy and convenient access to the anterior compartment for sufficient debridement. This report
describes in detail the anterocentral transbrachialis portal and its usefulness for debridement of the elbow joint in
osteoarthritis.

A s the understanding of elbow anatomy is

advancing and better equipment and surgical
skills are being developed, elbow arthroscopy has
unclear visualization and difficulties during arthro-
scopic maneuvers. In particular, complete resection of
the bony spur at an anteromedial facet of the coronoid
become a popular and widely accepted treatment op- process and the bottom of the coronoid fossa can be
tion for various elbow disorders.1 Compared with quite challenging using standard anterior portals.
traditional open techniques, arthroscopic elbow The anterocentral transbrachialis portal is a newly
debridement for elbow osteoarthritis (OA) is a mini- developed arthroscopic portal to access the anterior
mally invasive, safe, and effective treatment method.2-4 compartment of the elbow joint directly. This portal is
This method makes it possible to begin rehabilitation based on the open anterior transbrachialis approach
early after the operation for the elbow to return to its described by Itoh in 19946 (Fig 1). The difference
normal function, as it prevents muscle stripping and between this open approach and the standard ante-
dissection of muscular attachments, with better romedial approach is that in the former, there is no
cosmetic results than the traditional technique.5 need to expose the median nerve and the brachial
Despite these advantages, in patients with certain artery. Because the open anterior transbrachialis
conditions, such as severe OA with large spur formation approach is a muscle-splitting procedure, the major
and severe synovitis, arthroscopic debridement for neurovascular bundle is retracted with the large bulk of
elbow OA is a technically demanding procedure. These the brachialis muscle. Although it offers a limited
conditions complicate resection of the spur, because of operative field, this approach is reported to be conve-
nient for accessing the anterior compartment directly
From the Department of Sports Medicine, Fukushima Medical University and to perform debridement of the anterior compart-
(K.O., T.K.); and Department of Orthopaedic Surgery, Fukushima Medical
University School of Medicine (S.K., K.K., R.S., T.I., S.K.) Fukushima City,
ment and capsulectomy much more easily compared
Fukushima, Japan. with the standard anterior approach. Similar to the
The authors report that they have no conflicts of interest in the authorship open transbrachialis approach, the anterocentral
and publication of this article. Full ICMJE author disclosure forms are transbrachialis portal makes it possible to access the
available for this article online, as supplementary material. anterior compartment directly without any risk of
Received November 29, 2020; accepted February 7, 2021.
Address correspondence to Kenichi Otoshi, 1 Hikarigaoka, Fukushima City,
major neurovascular injuries and facilitates the safe
Fukushima, 960-1295, Japan. E-mail: kootoshi@fmu.ac.jp removal of bony spurs and free bodies, compared with
Ó 2021 THE AUTHORS. Published by Elsevier Inc. on behalf of the using standard anterior arthroscopy portals. Here, we
Arthroscopy Association of North America. This is an open access article under introduce the procedures of this new portal in detail
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ and describe the clinical advantages of arthroscopic
4.0/).
2212-6287/201927
debridement for elbow OA using the anterocentral
https://doi.org/10.1016/j.eats.2021.02.006 transbrachialis portal.

Arthroscopy Techniques, Vol 10, No 6 (June), 2021: pp e1425-e1430 e1425

e1426 K. OTOSHI ET AL.

Fig 1. Open anterior transbrachialis approach. (A) Schema of this approach (anterior view of the right elbow joint). (B) Incision
of the brachialis fascia (arrows) is performed, followed by dissection of the brachial muscle fiber (*) to reach the joint capsule.
(C) The anterior capsule is cut, and the intra-articular structures (trochlea, coronoid process, and radial head) are exposed.

Surgical Technique distance between the capsule and neurovascular

structures (Video 1). A standard proximal ante-
Patient Positioning and Preparation romedial portal is established at 2 cm proximal to the
The patient is positioned supine on a surgical table, medial epicondyle and just anterior to the inter-
and an air tourniquet is applied proximally to the muscular septum. A standard 4.0-mm, 30 arthroscope
upper arm with the pressure set at 250 mm Hg. A (Smith & Nephew) is inserted from this portal into the
slightly elevated surgical arm table is positioned ipsi- anterior compartment of the elbow joint. A standard
lateral to the surgical table at the level of the patient’s anterolateral portal is established under arthroscopic
upper arm. The upper arm is completely free (arm-free visualization from the proximal anteromedial portal at
supine position), and there is no need to use a traction 3 cm distal and 1 cm anterior to the lateral epicondyle.
device. This position allows access to not only the After diagnostic arthroscopy, synovectomy is per-
anterior compartment, but also the lateral and poste- formed to obtain a clear visualization using a 4.5-mm
rior compartments of the elbow joint, without the need arthroscopic shaver (DYONICS INCISOR Plus PLAT-
for specialized equipment or devices (Fig 2 A-D). The INUM blade; Smith & Nephew) or a radiofrequency
video monitor is positioned in front of the operating device (Short Bevel 35, QUANTUM 2 COBLATION
surgeon on the side opposite to the affected arm. The system; Smith & Nephew). Thereafter, the ante-
patient’s skin is sterilized with povidone iodine, and rocentral transbrachialis portal is established as the
sterile drapes are applied. The elbow is palpated to working portal at the anterior elbow joint. The biceps
identify important anatomic landmarks, and a marking tendon is palpated through the skin in the elbow-
pen is used to outline the biceps tendon, medial extended position, and a 1.5- to 2.0-cm skin incision
epicondyle, olecranon, radial head, and humeral is made just lateral to the biceps tendon, along the
capitellum. anterior elbow crease (Fig 3A). Blunt dissection of
subcutaneous tissue is carried out to avoid injuring the
Portal Placement and Debridement of the Anterior biceps tendon and the lateral antebrachial cutaneous
Compartment nerve (Fig 3B). After retracting the biceps tendon
After inflating the air tourniquet, the joint is medially and the lateral antebrachial cutaneous nerve
distended with 20 mL of saline solution to increase the laterally, an incision of approximately 1 cm is made in
 ANTEROCENTRAL PORTAL FOR ELBOW ARTHROSCOPY e1427

Fig 2. Patient positioning and preparation (right elbow). (A) A slightly elevated surgical arm table is positioned ipsilateral to the
surgical table at the level of the patient’s upper arm. (B) Right side view of the arm table positioning. (C) The patient is positioned
supine on a surgical table. The upper arm is completely free, and there is no need to use a traction device (arm-free
supine position). (D) The patients’ shoulder is internally rotated when the operator approaches to the lateral or posterior
compartment.

the fascia of the brachialis muscle, dissecting the impingement is resolved (Fig 4 C-F). Anterior capsu-
muscle along with the fiber to reach the joint capsule lectomy is done if the patient shows moderate to severe
(Fig 3 C and D). An 8.0  90-mm plastic cannula flexion contracture. Capsulectomy is started around
(CLEAR-TRAC FLEXIBLE Shoulder Cannula; Smith & the anterocentral transbrachialis portal using the
Nephew) is inserted to the elbow joint through the radiofrequency device and taking care not to injure the
brachialis muscle (Fig 3E). Under arthroscopic visual- neurovascular bundles, and the capsule is detached
ization from the anterolateral portal, the tip of the from the humerus to achieve complete extension of the
cannula is guided to the region located just above the elbow. Because resection of the anterior capsule causes
coronoid fossa (Fig 4A). Since it is sometimes difficult low visibility, anterior capsulectomy should be per-
to penetrate the joint capsule with a blunt-tip cannula, formed after completing resection of the bony spurs in
a radiofrequency device is useful to pierce the joint the anterior compartment. Debridement of the lateral
capsule and widen the portal. After fully inserting the and posterior compartments is done subsequently us-
cannula into the joint, debridement of proliferative ing standard lateral and posterior portals. The patient’s
synovium is performed to obtain a clearer visualization shoulder is fully internally rotated, and the elbow is
around the spur of the coronoid process, coronoid slightly extended. Dual direct lateral portals7 are
fossa, and radial fossa using a arthroscopic shaver and a established, and the proliferating synovium and syno-
radiofrequency device (Fig 4B). Next, the abnormal vial plica are debrided around the radiocapitellar joint
bony spur of the coronoid process, coronoid fossa, and and lateral ulnohumeral joint using a motorized shaver
radial fossa is resected using a 6-mm-wide chisel and a radiofrequency device (Fig 5A). After finishing
(Smith Peterson Osteotome, 6-mm wide, straight) and the procedure in the lateral compartment, the operator
a 4.0-mm abrader burr (DYONICS 4.0mm ELITE moves to the head of the surgical bed, and debridement
Abrader Burr; Smith & Nephew) until the bony of the posterior compartment is done using a
e1428 K. OTOSHI ET AL.

Fig 3. Portal placement (anterior view of the right elbow joint). (A) A skin incision is made just lateral to the biceps tendon along
the anterior elbow crease. (B) Blunt dissection is carried out to avoid injuring the biceps tendon (T) and the lateral antebrachial
cutaneous nerve (N). (C) The biceps tendon is retracted medially, and the lateral antebrachial cutaneous nerve is retracted
laterally (*: brachialis fascia). (D) An incision of about 1 cm is made in the fascia of the brachialis muscle (arrows), and the muscle
is dissected along with the fiber to reach the joint capsule. (E) An 8.0-mm  90-mm plastic cannula (CLEAR-TRAC FLEXIBLE
Shoulder Cannula; Smith & Nephew) is inserted to the elbow joint through the brachialis muscle.

posterolateral and posterocentral transtricipital portal8 standard anterior, anteromedial, proximal ante-
(Fig 5B). Posterior capsular release is performed, and, if romedial, or anterolateral portals. Second, there is little
the limitation of flexion remains after debridement of possibility of harming neurovascular structures during
the anterior compartment, the posterior oblique the establishment of the portal or due to the use of
ligament is detached from the medial epicondyle. several arthroscopic devices during surgery. Because
this portal penetrates the brachialis muscle, major
Postoperative Care and Rehabilitation nerves and vessels can be retracted and are protected
Compressive, sterile dressing is applied, and the by a large bulk of muscle. Furthermore, the use of a
patient is placed in a simple sling. Self-assisted range of cannula also can reduce the risk of soft tissue injuries
motion exercises begin the day after the operation. during surgery and make the maneuver much safer. If
Patients are allowed to return to light duty or a mod- a cannula is not used, there is the potential for lateral
erate activity level when they are free from pain. antebrachial cutaneous nerve palsy caused by repeti-
Muscle-strengthening exercises are started at 3 weeks tive insertion of the arthroscopy burr in the
after surgery, and patients are allowed to gradually anterocentral transbrachialis portal. Because removal
return to normal daily living and sports activities at 10 of the devices can easily lead to accidental extraction of
to 12 weeks. the canula, the surgeon should hold the cannula when
switching devices.
Discussion One of the disadvantages of the anterocentral trans-
There are several methodological advantages to brachialis portal is that it is accessible only in supine
using the anterocentral transbrachialis portal for position, not in lateral or prone position. The advantage
arthroscopic elbow debridement (Table 1). First, of elbow arthroscopy in supine position is that it per-
because this portal is located just above the anterior mits easy conversion to an additional open procedure
elbow joint, it is possible to adequately and easily resect such as ulnar nerve decompression.9 It also provides
the spur at the coronoid process and coronoid fossa. easy access for airway management, which facilitates
Furthermore, this portal enables removal of the bony the use of either regional or general anesthesia. How-
spur at the anteromedial corner of the coronoid, ever, the critical disadvantage of elbow arthroscopy in
whereas such removal would be difficult using this position is the limited access to the posterior
 ANTEROCENTRAL PORTAL FOR ELBOW ARTHROSCOPY e1429

Fig 4. Debridement of the anterior compartment using the anterocentral transbrachialis portal (right elbow). (A) Under
arthroscopic visualization from the anterolateral portal, the tip of the cannula (*) is guided to the region located just above the
coronoid fossa. (B) Debridement of proliferative synovium is performed for a clearer visualization around the spur of the
coronoid process, coronoid fossa, and radial fossa using a 4.5-mm arthroscopic shaver and a radiofrequency device. (C) Bony
spur of the coronoid process was resected using a 6-mm-wide chisel (Smith Peterson Osteotome, 6-mm wide, straight). (D) Bony
spur of the anteromedial corner of the coronoid process was resected using a 4.0-mm abrader burr. (E) Bony spur of the coronoid
fossa was also resected using a 4.0-mm abrader burr. (F) After resecting the spur at the coronoid fossa.

Fig 5. Debridement of the lateral and posterior compartments in supine position (right elbow). (A) Dual direct lateral portals are
established (①, ②), and debridement of the lateral compartment is performed in the position that patient’s shoulder is fully
internally rotated and the elbow is slightly extended. fully internally rotated position. (B) After finishing the procedure in the
lateral compartment, the operator moves to the head of the surgical bed, and debridement of the posterior compartment is done
using posterolateral (③) and posterocentral transtricipital portal (④).
e1430 K. OTOSHI ET AL.

Table 1. Advantages and Disadvantages We also recommend extending the anterior skin
Advantages incision to confirm and identify several important
 Ability to resect the spur at the coronoid process (especially the structures, including the lateral antebrachial cutaneous
anteromedial corner) as well as the coronoid fossa adequately and nerve, the medial cubital veins, and the biceps tendon,
easily.
 Little possibility of harming major neurovascular structures during
until the surgeon is familiar with making this portal.
establishment of the portal or due to the use of several arthroscopic In conclusion, the anterocentral transbrachialis portal
devices during surgery. is a useful and safe portal for arthroscopic elbow
Disadvantages debridement, especially in the anterior compartment.
 The portal is only accessible when the patient is in supine position, Although this portal is available only in supine position,
not lateral or prone position.
 Possibility of lateral antebrachial cutaneous nerve injury during
arm-free supine position can be used to overcome this
establishment of this portal. disadvantage and to allow access to all compartments
without any specialized equipment or devices.

compartment and the need for special equipment or Acknowledgments

additional assistance to hold the arm.10,11 Our tech- We thank Yoshiyasu Itou, Narihiro Toshiki, and Yuki
nique of arthroscopy in arm-free supine position allows Kawasaki for their invaluable help in conducting the
easy access to the posterior compartment without any study.
special device. If access to the posterior portal is
complicated because of severe limitation of the shoul-
der’s internal rotation, placing the patient in a slightly References
head-up position (semi-Fowler’s position) can be 1. Adams JE, King GJ, Steinmann SP, Cohen MS. Elbow
arthroscopy: Indications, techniques, outcomes, and
helpful. An additional problem is the difficulty in
complications. Instr Course Lect 2015;64:215-224.
penetrating the joint capsule when introducing the
2. Elfeddali R, Schreuder MHE, Eygendaal D. Arthroscopic
cannula into the joint. Because it is sometimes difficult elbow surgery, is it safe? J Shoulder Elbow Surg 2013;22:
to penetrate the thickened capsule with the blunt tip of 647-652.
the inner cannula, we recommend using a radio- 3. Sochacki KR, Jack RA 2nd, Hirase T, et al. Arthroscopic
frequency device to penetrate the capsule after insert- debridement for primary degenerative osteoarthritis of
ing the cannula at a sufficient depth to reach the the elbow leads to significant improvement in range of
anterior joint capsule (Table 2). In addition, sufficient motion and clinical outcomes: A systematic review.
synovectomy is needed to visualize the intra-articular Arthroscopy 2017;33:2255-2262.
joint space clearly before inserting the cannula, which 4. Guerrero EM, Bullock GS, Helmkamp JK, et al. The
makes it possible to establish the portal in a proper clinical impact of arthroscopic vs. open osteocapsular
debridement for primary osteoarthritis of the elbow:
position.
A systematic review. J Shoulder Elbow Surg 2020;29:
689-698.
5. Reddy AS, Kvitne RS, Yocum LA, ElAttrache NS,
Table 2. Pearls and Pitfalls Glousman RE, Jobe FW. Arthroscopy of the elbow: A
Pearls Pitfalls long-term clinical review. Arthroscopy 2000;16:588-594.
6. Itoh Y. Arthrolysis for post-traumatic contracture of
The anterolateral portal is A surgeon who is not familiar
recommended as a viewing with this procedure may
the elbow joint. Hokkaido J Orthop Traumatol 1994;10:
portal for sufficient harm the lateral 131-144.
visualization of the coronoid antebrachial cutaneous 7. Davis JT, Idjadi JA, Siskosky MJ, ElAttrache NS. Dual
process and coronoid fossa. nerve, the medial cubital direct lateral portals for treatment of osteochondritis
vein, or the biceps tendon. dissecans of the capitellum: An anatomic study. Arthros-
Extending the anterior skin copy 2007;23:723-728.
incision is highly 8. Moskal MJ. Arthroscopic treatment of posterior
recommended. impingement of the elbow in athletes. Clin Sports Med
Sufficient synovectomy before Resection of the anterior 2001;20:11-24.
inserting the cannula makes capsule during synovectomy
9. Andrews JR, Carson WG. Arthroscopy of the elbow.
it possible to visualize the may cause low visibility.
intra-articular joint space Anterior capsulectomy
Arthroscopy 1985;1:97-107.
clearly and helps to establish should be done after 10. Barousse P, Saper M, Meijer K, Roth C, Andrews JR.
the portal in the proper resection of bony spurs is Valgus extension overload: Arthroscopic decompression
position. complete. in the supine-suspended position. Arthrosc Tech 2016;5:
A radiofrequency device can Removal of the devices can e845-e850.
be used to penetrate the easily lead to accidental 11. Chen AC, Weng CJ, Chiu CH, Chang SS, Cheng CY,
anterior capsule if this is extraction of the canula. Chan YS. A modified approach for elbow arthroscopy
problematic using a Holding the cannula in place using an adjustable arm holder. J Orthop Surg Res
standard inner cannula. will mitigate this problem. 2017;12:20.