Rob Hartzler: Welcome to the Arthroscopy Association's Arthroscopy Journal podcast. The
views expressed in this podcast do not necessarily represent the views of the
Arthroscopy Association or the Arthroscopy Journal.
Rob Hartzler: Greetings, I'm Dr. Rob Hartzler from TSAOG Orthopedics in San Antonio. Today
on the podcast, we have the honor of hearing from Dr. Buddy Savoie, Chairman
of Orthopedics at Tulane University, a man who needs no introduction.
Dr. Savoie, welcome to the podcast.
Buddy Savoie: Thank you, Rob. It's an honor to be a part of it.
Rob Hartzler: Today we're going to be discussing your article from the June 2017 issue of the
Journal entitled “Modified Anterolateral Portals in Elbow Arthroscopy: A
Cadaveric Study on Safety.”
Dr. Savoie, what drove you to go back to the anatomy lab and revisit the issue of
elbow arthroscopy portals? What have we been missing here?
Buddy Savoie: So one of the things, Rob, is that I think elbow arthroscopy is much easier than
most people think. The biggest factor, the biggest worry that folks have, is the
safety of the procedure. And over the last 20 years we've modified almost all
the portals in elbow arthroscopy, moving them over a little bit and making them
more safe but also making them more useful to do more arthroscopic
procedures. I do a lot of cadaver labs, I do a lot of live surgeries, especially with
the elbow, and it's been pretty amazing to watch other folks as we do these
things, even well-recognized friends of ours, where I'll do an elbow
demonstration, they'll go, "Well, I've never used that portal. I've never seen that
view."
So we're sitting here thinking, you know what, let's go back to the drawing
board because there are so many things like the original distal anterolateral
portal that are not safe and so many things that we've modified to increase the
safety factor that if we can get this information out, I think more people will do
more elbow arthroscopy and it'll be safer.
Rob Hartzler: So you studied these anterolateral portals: just sum up for us, what's the take
home message on the article? We can move these further anterior and be safe,
is that right?
Buddy Savoie: That's correct. So, two parts to it: one is proximal portals, anything from the
radiocapitellar joint proximal is all safe; and number two, you can move them
pretty far anteriorly and still stay more than a centimeter away from the radial
nerve and that gives you access to put an anchor in, to do microfracture of the
capitellum, take the radial head out. It gives you a lot of variety in terms of what
you can do arthroscopically. So procedures that formerly you might not have
done, lateral collateral ligament repair, all these other things are actually much
easier with these new portals.
Rob Hartzler: So it sounds like both for visualization and working you have advantages, is that
right?
Buddy Savoie: So it's a huge advantage and like I said, I really didn't realize that I had cheated
them so far anteriorly until Steven Thon, who's the lead author on this paper,
and I were talking. We were doing an elbow dissection and I was coaching him
through it and he said, "Well the paper says we should go here," and I said,
"Well, that's not going to work. You have to be one centimeter more anterior."
And he kind of said, “You should really look into this, maybe we should look into
this and see because I don't think you do what everybody else does.” And he
was 100% correct. I think I did it over time without really realizing how different
the portals were for these advanced procedures.
Rob Hartzler: So we're talking about going more anterior on the lateral side: for a standard
size patient, minimal swelling, if you're starting in the anterior compartment,
how far anterior can we go?
Buddy Savoie: So you can go actually three centimeters anterior to the tip of the epicondyle
and still be safe. So what we'd normally do, most people would describe a mid-
lateral portal as about a centimeter anterior to the tip of the epicondyle, but
you can actually go up to three centimeters, and the more anterior you are, the
more you have a force back. So clearly whatever portal you were using, a full
centimeter anteriorly still gives you more than 15 millimeters' space before you
get to the radial nerve, so you have quite a bit of distance. The more proximal
you are, the more anterior you can go. So if you do a proximal anterolateral
portal and go two centimeters up from the intermuscular septum, you can
actually go three centimeters anterior and have a really good shot in to take out
a capitellar spur or put two lateral portals in and still have a huge safety margin.
Rob Hartzler: In the article you described better access for advanced procedures. What
operations are we going to be able to do better with this knowledge?
Buddy Savoie: Fracture fixation, radial head fracture, capitellar fractures. If you use one of
these more anterior portals, it's much easier to get them into reduction and
then fix them through these portals and you can do a combination of fluoro and
arthroscopic visualization.
Lateral collateral ligament repair, ECRB repair, also much easier through these
portals and if you view from one of these more anterior portals as you look to
the medial side, taking out a coronoid spur, fixing a coronoid fracture, or taking
out arthritic spurs along the medial joint line that primarily block flexion are all
much easier using these portals.
Rob Hartzler: In this article, you focused on your approach to the anterolateral side. Any
pearls for improving our portals for other parts of the elbow?
Buddy Savoie: So we're looking. Right now we have a study ongoing on the medial side
because we've done the same thing on the medial side. We actually have a
much more increased safety margin on the medial side, moving them more
anteriorly lets you do more and then posteriorly you can go anywhere up and
down the lateral side without any problems at all.
The one thing we can't do as a posterior medial portal because that's right
where the ulnar nerve is and, as you know, I do ulnar nerve decompressions
arthroscopically still with some of my capsule releases and release the posterior
band, but even so that portal has to stay away from the ulnar nerve.
Rob Hartzler: You do your elbow arthroscopies in the prone position, correct?
Buddy Savoie: I do.
Rob Hartzler: You want to try to sell me on prone versus lateral? What do you think the big
advantages are?
Buddy Savoie: So there's a bunch of advantages. One is that it's much easier to access medial
or lateral in the prone position just because you can rotate the shoulder internal
or external, access either side, so converting to open is a much more simple
operation. Secondly, the water goes downhill, so if you do it supine, all the
water runs into your scope and into your hands and you're constantly fighting it
the whole time. If you do lateral decubitus, which is essentially prone, you just
don't have the support when you rotate the shoulder to open either side. And
then the last thing about prone is it's really simple. So you just flip the patient,
so the airway is not really an issue because there are special masks for this, and
then you have a much easier time. You can stand, you're relaxed, you're not
fighting anything and the water goes to the floor instead of on you.
So I think prone is the much more simple way to do it, and we've actually done
people under regional blocks prone. They've been very happy. They just put
their head down, they'll go to sleep. It's not a problem. So I don't think there's
any advantage to doing it either supine or lateral decubitus over prone and we
can do many more things prone.
Rob Hartzler: Well, Buddy, we thank you for coming on the podcast today. Any closing
thoughts on elbow arthroscopy?
Buddy Savoie: Yeah, Larry Field and I've been thinking since the early '90s that the elbow
would be the next hot joint in orthopedics for arthroscopy and we keep doing
different things. My partner at Tulane, Dr. Michael O'Brien, we keep working on
it thinking that it's really going to catch on and everybody's going to start doing
it, and so part of our goal with papers like this one is to make it more safe so
more of our colleagues will do elbow arthroscopy. I think it's great fun. I think it
can help a lot of people and I think we're just going to need to make people
more comfortable so then they can do more procedures arthroscopically.
Rob Hartzler: You know, my experience in my practice doing elbow arthroscopy is that I
always worry and probably worry the patient a lot more than is due and it does
seem to be safe and effective and, as you said, a lot of fun and very helpful for
patients, so we congratulate you on the article and thank you very much for
continuing to work on this.
Buddy Savoie: Well, thank you, Rob. I really appreciate it. It's an honor to talk with you.
Rob Hartzler: This article from the June 2017 issue of the Arthroscopy Journal entitled
“Modified Anterolateral Portals in Elbow Arthroscopy: A Cadaveric Study on
Safety” can be found on the Arthroscopy Journal's website at
www.arthroscopyjournal.org.