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Osteoid osteoma has been reported infrequently around the elbow joint, and is usually treated with radiofrequency ablation or open excision. Elbow arthroscopy is useful for excision of accessible lesions, and the accompanying elbow stiffness can be treated concurrently. This report describes an arthroscopic excision of an osteoid osteoma located in the juxta-articular distal humeral bone. An initial adhesiolysis and capsulectomy is performed to gain access to the region above the capitellar articular margin. A 70° arthroscope is necessary to visualize this region via the anteromedial portal. An accessory lateral portal is used to detach the capsule from the distal humerus; the scar tissue overlying the lesion is debrided and the circumferential lesion is visualized and probed for identification of its extent. A biopsy is performed, and thereafter the lesion is excised piecemeal. The sclerotic margins are curetted, and radiofrequency ablation is performed. The technique is cosmetic and minimally invasive, and can be performed in revision scenarios involving recurrences after open surgery or needle radiofrequency thermal ablation. Early rehabilitation restores range of motion and strength. Technical tips for identification and curettage of the lesion are presented.

Elbow bicipitoradial bursitis and partial distal biceps tendon (DBT) tears are a result of chronic overuse or other infective/inflammatory pathology and may be refractory to conservative treatment. The all-endoscopic approach provides minimally invasive access to the bursal space and DBT, and diagnostic and therapeutic procedures can be performed under direct endoscopic vision. The technique uses 2 portals, the proximal parabiceps portal and distal anterior portal, and the bursa is insufflated to create a working space. Tissue biopsies are obtained under direct endoscopic visualization, and debridement along 6 bursal zones can be effectively performed. An endoscopic probe test is demonstrated for assessment of partial DBT tears, and low-grade tears are debrided to stable tissue. The all-endoscopic technique is safe and reproducible, and it is a stepping-stone in the learning curve of all-endoscopic repair and reconstruction of distal biceps ruptures.

Rotator cuff repairs are associated with suboptimal outcomes and possibly greater incidence of retears if the biological healing environment is compromised. Strategies to optimize tendon–bone healing include the use of bioinductive scaffolds and regenerative stem cell therapy. The subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing and has the advantage of easy accessibility and no added cost. However, a reproducible surgical technique for bursal mobilization, harvest, and vascularity preservation has not been described. We describe our technique for vasculature-preserving bursal mobilization and harvest of the entire posterosuperior and lateral subacromial bursa, and its use in rotator cuff repair augmentation is presented. The technique involves mobilization of the bursa as a continuous layer by maintain its medial and lateral vascularity. The bursa is advanced laterally, and the “vascular bursal duvet” and cuff tendons are repaired together as a tendon–bursa unit.

Proximal humerus fracture fixation may be complicated by persistent postsurgical stiffness or implant-related problems. Arthroscopic plate removal is a cosmetic and functionally beneficial procedure; however, the procedure is technically difficult in the presence of severe subdeltoid scarring. The technique described here shows an arthroscopic subdeltoid adhesiolysis and proximal humerus plate removal using systematic access to 5 regions of screw positions on the plate. After initial glenohumeral adhesiolysis, a thorough subacromial and subdeltoid bursectomy is performed. The axillary nerve and deltoid are retracted via an anterosuperolateral portal, and a posterolateral portal is used for panoramic viewing along the plate length. Lateral portals are placed above and below the axillary nerve, and these are used for screw removal. Finally, the plate is removed via a 1-inch incision along the previous surgical scar. The technique is cosmetic and minimally invasive, and early rehabilitation restores range of motion and strength. Technical tips for safe dissection in the scarred subdeltoid space and guidelines for protection of neurovascular structures are presented.

Displaced radial head fractures are treated with open reduction and internal fixation using implants. Failure of fixation may occur in the presence of comminution and in multifragmentary fractures; open surgical approaches are necessary for removal of the implants and radial head resection. Arthroscopic radial head resection has been described as a minimally invasive and effective treatment for failed radial head fracture fixation; however, periarticular adhesions and prominent implants add to the complexity and technical difficulty of the procedure. The described technique uses 3 portals for adhesiolysis, implant removal, and radial head resection. Resection is performed in stages; smaller-diameter instruments are used to gain and improve access, and larger resectors are used subsequently. Adequacy of resection is assessed arthroscopically and with biplanar imaging. The arthroscopic technique avoids the need for an open surgical approach and prevents subsequent morbidity. In addition, the rehabilitation time is shorter and patient satisfaction is high.

An acute perilunate wrist injury that is unreduced for more than 6 weeks results in severe disability, and even open reduction with stabilization through wide dorsal and volar approaches is technically challenging. This report describes an arthroscopic technique for reduction and percutaneous wire stabilization of a chronic perilunate wrist dislocations. The technique involves initial radiocarpal and midcarpal access through the 6R and 3-4 portals, and these portals are used for synovectomy and debridement of capsular flap tears. The midcarpal joint is accessed initially through the radiocarpal joint, and additional midcarpal portals are used for sequential perilunate adhesiolysis before carpal mobilization and reduction. A percutaneous wire drilled into the lunate is used as a joystick to manipulate the lunate into its anatomic alignment along the carpal bones, and percutaneous transcarpal wire fixation is performed to stabilize the carpus. Arthroscopic and fluoroscopic guidance is used to optimize anatomic reduction and to confirm stability. The wrist is immobilized for 6 weeks; the percutaneous wires are removed thereafter, and the wrist is mobilized. Overall, the arthroscopic technique provides a safe and reproducible method for treatment of this complex chronic injury.

Distal biceps rupture is associated with significant functional disability, and surgical treatment involves open or endoscopic-assisted repair of the ruptured tendon through an anterior incision. This report describes an endoscopic approach that is performed with 2 portals for visualization and instrumentation. Preoperative sonography is used to identify bony and soft-tissue landmarks. The viewing portal is a proximal anterolateral “parabiceps portal” developed by the author, and the landmarks and relevant anatomic relations have been derived from a preliminary anatomic study. The working portal is a distal anterior portal and permits access to the radial tuberosity through the internervous muscular plane. The parabiceps portal permits visualization of the anterior and medial region of the radial tuberosity. A detailed description of the endoscopic pathoanatomy of the distal biceps tendon region is presented. The distal anterior portal is used for retrieval of the ruptured tendon, and thereafter the tuberosity is debrided and anchors are placed under vision. The ruptured tendon is whipstitched and docked onto the tuberosity, and nonsliding knots are used to securely reattach the tendon to bone. Overall, the 2-portal technique provides a method for tendon repair under direct visualization and is safe and reproducible.

Chronic painful snapping scapula is characterized by inflammation and scarring of 1 or more bursae in the infraserratus space and is often refractory to conservative treatment. Surgical treatment involves excision of the bursae, as well as partial scapulectomy of the superomedial impinging region; both open and endoscopic approaches have been described with good results. Scapulothoracic endoscopy is technically difficult, and the potential complications can be serious. This report describes an endoscopic approach that can be performed with only 2 medial parascapular portals for visualization and instrumentation. The endoscopic anatomy of the infraserratus space is revisited, and 3 anatomic landmarks (serratus anterior, subspinous bursal curtain, and superomedial bony angle) are identified for safe dissection and intraoperative orientation. The surgical field is subdivided into 3 anatomic zones (superomedial space, subspinous space, and scapular bony angle), and the anatomic boundaries of these zones are demonstrated. The decompression procedure is subdivided into 4 stages (superomedial bursectomy, subspinous adhesiolysis, tuberoplasty, and scapuloplasty), and a measured resection technique for scapuloplasty is performed. The use of newer motorized rasps permits optimal bony resection, and additional portals are unnecessary. Overall, the step-by-step technique provides a methodical approach for safety, reproducibility, and optimization of the procedure.

Intraosseous ganglion cysts (IOGs) are uncommon lesions of the carpal bones and can present with persistent pain and stiffness of the wrist. Surgical decompression is recommended, and a variety of approaches to decompress symptomatic IOGs of the wrist have been described. We describe an arthroscopic approach that can be performed with only 2 portals and offers excellent access for visualization and instrumentation. The procedure involves creating a 3.2-mm tunnel into the lunate cyst; this is performed through the dorsal non-articular surface of the lunate, under direct vision, and the position is confirmed with fluoroscopy. A 2.4-mm arthroscope is passed through the drill hole, and a direct “cystoscopic” view of the IOG is obtained. Biopsy of the cyst contents is performed under direct vision, and small-joint shavers and burrs are used for effective debridement. Advantages of this technique are actual visualization of the pathology, complete intracystic debridement, and simultaneous treatment of any coexistent intra-articular pathology. In addition, the minimal 3.2-mm lunate tunnel access maintains the structural integrity of the lunate and reduces the need for additional bone graft supplementation.

The arthroscopic remplissage procedure is an effective addition to a standard anterior repair in traumatic anterior shoulder instability associated with large humeral defects. The double-barrel remplissage is an all–intra-articular technique that uses a double-pulley, sliding, and self-retaining knot mechanism called the double-barrel knot. A 70° arthroscope (posterior portal) is necessary for adequate visualization of the humeral defect and the rotator cuff. Trans-tendon anchors (single or double loaded) are inserted into the superior and inferior aspects of the humeral defect through a cannula that is placed posterior to the infraspinatus. Placement of anchors is facilitated by insertion of a guidewire, as well as an anchor sleeve that is threaded over it. The double-barrel knot is formed using the anchors as a double-pulley system, and the knot is tensioned after the anterior repair is complete. Intra-articular visualization confirms adequate approximation and compression of the infraspinatus tendon and capsule into the defect. Advantages include an increased surface area (footprint) for healing and ease of knotting without the necessity for additional subacromial dissection.