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Total Elbow Arthroplasty with Triceps-Reflecting Approach, Supine

Planning

B

Preoperative Plan

1

Template fracture

  • identify fracture pattern, displacement, comminution, and presence of dislocation

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • unlinked total elbow arthroplasty set

2

Room setup and equipment

  • c-arm perpendicular to OR table

3

Patient positioning

  • supine position
  • place affected extremity over arm bolster
  • arm should be in 90 degrees of flexion
  • place bump under ipsilateral scapula
  • place sterile tourniquet

Technique

D

Superficial Posterior Approach to the Elbow

1

Exsanguinate the extremity

2

Mark and start the incision

  • make a straight posterior incision just off the tip of the olecranon
  • incision should extend 9 cm proximal and 8 cm distal to the tip of the olecranon
  • create subcutaneous flaps

3

Identify the ulnar nerve

  • palpate the ulnar nerve and fully dissect it out
  • is helpful to pass tape or penrose for identification at all times
  • create a subcutaneous pocket for the ulnar nerve
  • excise 1 cm of the distal intermuscular septum
  • this is to prevent constriction of the nerve
E

Deep Dissection and Elbow Dislocation

1

Elevate the triceps

  • lift the triceps directly from the humerus and the intermuscular septum
  • elevate the medial aspect of the triceps off of the posterior humerus all the way down to the tip of the olecranon

2

Incise fascia between FCU and anconeus

  • incise the superficial fascia between the anconeus and the FCU from the posteromedial border of the ulna distally

3

Perform medial and lateral release

  • perform lateral release
  • elevate this with the triceps
  • Divide or dissect the anconeus on its lateral side
  • expose the radiocapitellar joint laterally
  • release the lateral and medial collateral ligaments from the origins of the humeral condyles
  • Release medial collateral ligaments
  • release medial collateral ligaments

4

Dislocate Elbow

  • externally rotate the shoulder and flex the elbow
  • separate the ulna from the humerus
F

Resect Bone and Broach Humerus and Ulna

1

Resect and broach humeral side

  • remove the central portion of the trochlea
  • identify the roof of the olecranon
  • enter intrmadullary canal
  • create a window in the olecranon fossa expose the intramedullary canal of the humerus
  • use the cutting jig of the specific implant system to guide the resection of the distal humerus
  • ensure the anatomic fit of the component between the humeral condyles

2

Resect and broach Ulnar side

  • enter the intramedullary canal of the ulnar side
  • use a high speed burr at the base of the coronoid
  • enlarge the canal to allow passage of the ulnar broach
  • broaches must be passed parallel to the subcutaneous border of the ulna
  • this ensures proper placement
G

Trial Implants

1

Place the implants

2

Perform a trial reduction

  • check the range of motion of the joint
  • full flexion and extension should be achieved

3

Test for bony impingement

  • check olecranon impingement on the humerus posteriorly
  • check the coronoid tip anteriorly
  • remove any impingements with a rongeur

4

Assess implant placement

  • assess alignment, stability and component tracking
H

Cement Implants

1

Place the cement

  • introduce antibiotic impregnated cement into the intramedullary canal with a long flexible cement nozzle
  • cement should have a relatively liquid consistency
  • place methylene blue into the cement to identify the bone cement interface

2

Add cement restrictors in the humerus and ulna

  • this improves canal pressurization

3

Place the final implants

  • the humeral components axis of rotation is at the level of the medial and lateral epicondyles
  • the ulnar components axis of rotation through the center of the greater sigmoid notch
I

Reattach Collateral Ligaments and Triceps

1

Repair collateral ligaments

  • reattach the medial and lateral collateral ligaments to there origin on the humerus

2

Reattach the triceps

  • pass No. 5 nonabsorbable suture in cruciate tunnels through the triceps
  • suture should be passed in a Bunnell fashion
  • pass suture through an additional horizontal tunnel
  • this allows the suture to cinch down to the olecranon

3

Tie knots

  • place elbow in 90 degrees of flexion
  • tie knots to the side
  • this is to prevent subcutaneous prominence
J

Wound Closure

1

Irrigation and hemostasis

  • irrigate wounds thoroughly
  • deflate tourniquet (if elevated)
  • coagulate any bleeders carefully

2

Deep Closure

  • repair the fascia of the FCU and anconeus to surrounding tissue with nonabsorbale suture
  • transpose the ulnar nerve into the prepared pocket
  • use 0-vicryl for deep closure

3

Superficial Closure

  • use 3-0 vicryl for subcutaneous closure
  • place subcutaneous drain
  • close skin with 3-0 nylon

4

Dressing and immediate immobilization

  • soft dressing (gauze, webril)
  • place in volar splint in extension
  • sling for comfort

Patient Care

K

Preoperative H & P

1

Obtain history and physical exam

  • age
  • gender
  • mechanism of injury
  • deformity
  • skin integrity
  • open/closed injury
  • check neurovascular status
  • need to assess for associated injuries such as radial head and capitellum fractures

2

Order basic imaging studies

  • order biplanar radiographs of the elbow

3

Perform operative consent

  • describe complications of surgery including
  • deep infection
  • wound breakdown
  • loosening
  • instability
  • periprosthetic fractures
  • triceps insufficiency
  • ulnar neuropathy
L

Perioperative Inpatient Management

1

Write comprehensive postoperative orders

  • pain control
  • antibiotics
  • DVT prophylaxis
  • wound management
  • inpatient pt
  • non weightbearing
  • advance diet as tolerated
  • check appropriate labs

2

Discharges patient appropriately

  • outpatient physical therapy
  • remove splint in 24-48 hours
  • nonweightbearing
  • avoid active extension for six weeks
  • gravity assisted and passive extension are permitted
  • ice, elevation and compression
M

Outpatient Evaluation and Management

1

Focused history and physical

  • check range of motion of the elbow
  • document neurovascular status
  • concomitant and associated orthopaedic injuries

2

Knowledge of imaging studies/lab studies

  • radiographs of the elbow
  • AP
  • lateral
  • oblique

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • indications

4

Provides postoperative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • check radiograph
  • postop: 4-6 week postoperative visit
  • check radiograph
  • start active extension
  • postop: 1 year postoperative visit
  • permanent weight restrictions of 10 lbs of lifting at once
  • permanent weight restrictions of 5lbs on repetitive lifting

5

Diagnose and early management of complications

  • Dx from periop xrays
  • recognize infection
N

Advanced Evaluation and Management

1

Order appropriate imaging studies

  • radiographs
  • CT scan/3D reconstruction

2

Provides post-op management and rehabilitation

  • increase ROM as healing progresses
  • adequate/proper postop xrays
O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives

  • use of external fixation
  • radial head replacement
  • elbow arthroplasty

2

Modify and adjust post-op plan as needed

  • dynamic/static stretch splinting
  • revise therapy

3

Understands how to avoid/prevent potential complications

4

Treat simple complications both intraoperatively and postoperatively.

  • revise hardware placement
  • recognize improper hardware position
 

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