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Radial Head Replacement

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

  • screws, headless screws and plating system

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

Kocher Approach to the Elbow

1

Mark anatomic landmarks

  • palpate the radial head and the lateral epicondyle

2

Make 5cm posterolateral incision

  • make an oblique 5 cm incision starting from the posterolateral aspect of the lateral epicondyle to a point that is three fingerbreadths below the olecranon
  • this incision should be inline with the radial neck
  • divide the fascia in line with the skin incision

3

Identify the Kocher interval

  • interval between the anconeus and the ECU
  • this is distally identified by penetrating veins
  • use blunt dissection to develop the interval
  • visualize the ligamentous complex and joint capsule
  • pronate the arm to move the PIN nerve distally
E

Deep Dissection

1

Expose radiocapitellar joint

  • elevate the anconeus and ECU
  • reflect the anconeus posteriorly and the ECU anteriorly

2

Make arthrotomy

  • visualize the radial head fracture
F

Preparation of the Radial Head and Neck

1

Visualize the radial head

  • irrigate the wound and remove loose bodies

2

Excise the radial head and neck

  • remove the radial head and neck at a right angle to the medullary canal
  • this makes a smooth surface for seating of the radial head implant
  • ensure that complete excision has been performed with fluoroscopy

3

Evaluate the capitellum for chondral injuries or osteochondral injury

G

Size Radial Head Prosthesis

1

Template head size

  • reassemble the radial head
  • place radial head on sizing template
  • diameter of the prosthesis should be 2mm smaller than the outer diameter of the radial head that is excised
H

Trial and Place Implant

1

Place radial head implant

  • insert trial head onto the stem

2

Evaluate placement

  • check diameter, height, tracking and congruency of the prosthesis
  • the radial head prosthesis should articulate at the same height as the radial notch of the ulna
  • should also be 1 mm distal to the tip of the coronoid

3

Place Final Implant

4

Check Implant with Fluoroscopy

I

Evaluate Elbow Range of Motion and Stability

1

Check elbow flexion and extension

2

Check stability in various rotations of the elbolw

  • pronation
  • supination
  • neutral
J

Wound Closure

1

Irrigation and hemostasis

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

2

Deep Closure

  • 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 anterior splint in extension
  • sling for comfort

Patient Care

K

Preoperative H & P

1

Obtain history and basic physical

  • 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

Splint fracture appropriately

  • place in posterior splint

3

Order basic imaging studies

  • order biplanar radiographs and/or CT scan of the elbow

4

Perform operative consent

  • describe complications of surgery including
  • stiffness
  • wound breakdown
  • heterotopic ossification
  • symptomatic hardware
  • nonunion
  • PIN injury
  • prosthetic loosening
  • instability
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • pain control
  • elevate for 24 hours
  • antibiotics
  • continue antibiotics for 24 hours postoperatively
  • advance diet as tolerated
  • inpatient pt
  • non weightbearing
  • postoperative radiographs
  • order biplanar radiographs of theelbow
  • DVT prophylaxis
  • wound management

2

Discharges patient appropriately

  • pain meds
  • wound care
  • schedule follow up in 2 weeks
  • outpatient physical therapy
  • initiate active range of motion on post op day 1 when the LCLs were spared
  • place in a collar and cuff with the elbow maintained at 90 degrees in between exercises
  • use a static progressive extension splint for nighttime use for 12 weeks
  • nonweightbearing
  • active range of motion allowed when tolerated
  • 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

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 passive stretching
  • initiate strengthening exercises on week 8
  • postop: 1 year postoperative visit

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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