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