A Outpatient Evaluation and Management 1 Focused history and physical Check range of motion of the elbow Document neurovascular status 2 Knowledge of imaging studies/lab studies Order 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 <br> wound check remove sutures check radiograph Postop: 4-6 week postoperative visit check radiographs 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 B Advanced Evaluation and Management 1 Order appropriate imaging studies Order radiographs Order CT scan/3D reconstruction 2 Provides post-op management and rehabilitation Increase ROM as healing progresses Order adequate/proper postop xrays C 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
E 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. Describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Use unlinked total elbow arthroplasty set 2 Room setup and equipment c-arm perpendicular to OR table 3 Patient positioning Place in supine position place affected extremity over arm bolster arm should be in 90 degrees of flexion place bump under ipsilateral scapula place sterile tourniquet G Posteromedial skin incision 1 Exsanguinate the extremity Use tourniquet to exsanguinate the extremity 2 Mark and start the incision Start incision just distal to and medial to the olecranon Release tissue on the lateral side of the anconeus Perform a posteromedial approach just around the tip of the olecranon leaving a flap of tissue to suture at the end of the case H Deep Dissection 1 Continue incision Continue incision 5 cm proximal to the olecranon tip cutting through the triceps tendon 2 Complete diamond incision Perform a posterolateral approach and complete the diamond of the incision Meet lateral incision at the proximal tip to create a diamond 3 Tag long head of triceps Place a tag stitch in the proximal portion of the diamond to grip the long head of the triceps this is done to grab the long head of the triceps tendon so it does not retract proximally this will avoid mal positioning of the triceps during closure Place another tag stitch on the medial and lateral aspect of the diamond in the triceps to avoid mispositioning of the triceps 4 Expose radius and ulna Reflect the anconeus on the lateral side of the ulna Release the insertion the LCL of the ulna at the supinator crest Place a tag stitch at the insertion of the ligament Release the FCU off of the subcutaneous border of the ulna you will see that you are very close to ulnar nerve and it is better to expose the ulnar nerve Expose the ulnar nerve Decompress the nerve through the cubital tunnel Retract the ulnar nerve Release the MCL off of bone Elevate and mark the tissue of the MCL elevate this ligament and place a marking suture being careful not to place the suture in the nerve 5 Dislocate the elbow Pop the radius and ulna as a sleeve away from the forearm externally rotate the shoulder pop the elbow up and dislocate I Sizing and Humeral Preparation 1 Place spool Remove some of the olecranon use a saw to take a little bit of the olecranon off to avoid impingement Size with the sizing spools 2 Place broach Make cuts into the trochlea Cut out pieces from the center of the trochlea Open up the canal into the humerus Hammer in a starting broach hammer broach until marking is at the inferior aspect of the medial condyle Broach to a medium size a medium broach is exactly the same size as a large prosthesis Place cutting tool and make sure the medial and lateral sides are symmetrical you want a tight fit so the cement only acts as a grouting you want the line of axis rotation to be at the inferior aspect of the medial epicondyles 3 Make cuts Make partial cuts with the block on and them remove and complete the cuts Use the gusset broach right and left accordingly when flipped to the correct side this has a risk of splitting the condyle’s one way to minimize this risk is to use a burr and remove all sclerotic bone J Place Trial Prosthesis 1 Place the implants Place both the trial humeral and ulnar implants 2 Reduce the elbow and check alignment Check alignment after reduction and take the elbow through full range of motion Reduce the elbow check to see that the radial head lines up with the capitellum 3 Perform anterior capsulectomy Start by coming down close the coronoid Come through to the brachialis Change to a dissecting scissor Dissect the capsule away from the brachialis behind the capsule the radial nerve is at the lateral side of the brachialis at the center of the radial head Excise the anterior capsule K Ulnar and Radial Preparation 1 Place the ulnar jig Place radial head protector Place the spool in the ulnar jig Place spool down on the radius and ulna Lock the jig on the flat spot of the ulna 2 Protect the ulnar nerve Place bent knee retractor to protect the ulnar nerve 3 Place ulnar trial Use the bell saw to cut from medial to lateral while lifting the ulna towards you Open up the canal of the ulna note that the central ridge of the ulna is more lateral than medial Cut down into the ulnar canal making a little bit of the notch for a stem Start with ulnar broaching Place the short stem trial 4 Check rotation Check if rotation is correct with the ulnar component Check if the radialhead is in line with the capitellum 5 Place temporary ligament Drill holes medially and laterally through the ulna at the insertion sites of the medial and lateral collateral ligaments Place fiberwire through drill holes Weave the suture through the lateral collateral ligament and annular ligament up to the elbow Pass this suture through the prosthesis Once the elbow is reduced tie the suture to the other side Place the locking stitch in the insertion of the MCL Place a locking stitch in the LCL complex down near the annular ligament L Cementing and Placement of the Ulnar and Humeral Components 1 Prepare canals Pack bone graft into both canals pack in with the broach pack to level where tip of the broach will be 2 Place cement Inject cement into both canals Pass No. 5 nonabsorbable suture in cruciate tunnels through the triceps 3 Place components Place the ulnar component 4 Pass suture Place humeral component Pass suture through humeral component then place the humeral component 5 Seat components Impact the humeral and ulnar component 6 Reduce the elbow Reduce elbow and check alignment and rotation 7 Perform ligament repair and soft tissue balancing Pass suture through the origin of the medial collateral ligament and the origin of the common flexor tendons Tie suture which will not allow the elbow to subluxate Tie the medial collateral ligament down to the sublime tubercle Tie down to the lcl N Triceps Repair and Wound Closure 1 Irrigation and hemostasis irrigate wounds thoroughly deflate tourniquet (if elevated) coagulate any bleeders carefully 2 Triceps repair Reattach a portion of the triceps to get it lined up correctly do this by using 1 vicryl at the corner of the diamond at the level of the olecranon do the same on the medial side Place a fiberwire stitch in the long head of the triceps tendon to use as a grasping stitch Place locked stitch down through the triceps tendon Run a locking stitch around the diamond to the corner Once the corner is reached run suture to the other side and suture back down through the medial side Close distally with a number one vicryl suture 3 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 4 Superficial Closure use 3-0 vicryl for subcutaneous closure place subcutaneous drain close skin with 3-0 nylon 5 Dressing and immediate immobilization soft dressing (gauze, webril) place in volar splint in extension sling for comfort
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders Order appropriate pain control Order appropriate antibiotics Order DVT prophylaxis Address wound management issues Begin inpatient pt non weightbearing Advance diet as tolerated Check appropriate labs 2 Discharges patient appropriately Order 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 R Complex Patient Care 1 Comprehensive pre-op planning/alternatives Understands use of external fixation Identify when a radial head replacement is required Plan elbow arthroplasty 2 Modify and adjust post-op plan as needed Identify when dynamic/static stretch splinting is needed Revise therapy 3 Treat simple complications both intraoperatively and postoperatively. revise hardware placement recognize improper hardware position