A Outpatient Evaluation and Management 1 Focused history and physical perform hook test document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies radiographs of the elbow AP lateral advanced imaging MRI ultrasound 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides postoperative management and rehabilitation postop: 10 day postoperative visit wound check remove sutures continue active assisted flexion continue active extension with gravity start full active range of motion at 4 weeks postop: 4-6 week postoperative visit start strength training at 10 weeks 5 Diagnose and early management of complications recognizes healing incision vs. infection B Advanced Evaluation and Managment 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 C Preoperative H & P 1 Perform focused orthopedic physical exam age gender mechanism of injury check neurovascular status 2 Order basic imaging studies obtain radiographs of the elbow AP and lateral 3 Perform operative consent describe complications of surgery including neurovascular injury infection heterotopic ossification
E Preoperative Plan 1 Template repair template placement of the anchor device 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 F Room Preparation 1 Surgical instrumentation anchor device 2 Room setup and equipment mini c-arm on same side as operative extremity 3 Patient positioning supine radiolucent armboard pad all bony prominences place sterile tourniquet G Superficial Dissection 1 Mark and start the incision mark and make a 2cm incision distal to elbow crease over biceps attachment 2 Develop interval develop interval between pronator teres and brachioradialis and palpate radial tuberosity 3 Locate and tag the biceps tendon tag tendon with heavy suture tendon may be retracted requiring accessory proximal incision 4 Identify neurovascular structures identify and protect location of lateral antebrachial nerve H Deep Dissection 1 Expose the tuberosity dissect down to the radial tuberosity place retractors 2 Remove any remaining soft tissues clear tuberosity of residual soft tissue I Tendon Preparation 1 Locate and tag the biceps tendon tag tendon with heavy suture tendon may be retracted requiring accessory proximal incision 2 Identify neurovascular structures identify and protect location of lateral antebrachial nerve 3 Place anchor device deliver anchor device into tuberosity 4 Secure tendon using anchor device to tuberosity J Bone Preparation 1 Drill guide pin 2 Use fluoroscopy for placement confirmation confirm proper placement in tuberosity with fluoroscopy 3 Measure diameter of tendon 4 Overdrill guide pin overdrill guide pin with appropriate sized bit through near cortex K Tendon Fixation 1 Place anchor device deliver anchor device into tuberosity 2 Secure tendon using anchor device to tuberosity L Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound perform meticulous hemostasis 2 Deep closure close subcuticular tissue avoid button-holing atraumatically handle tissue 3 Superficial closure close skin +/- local anesthetic 4 Dressings and immobilization apply sterile dressing apply splint and sling
O Perioperative Inpatient Management 1 Discharge patient appropriately pain meds wound care schedule follow up in 2 weeks physical therapy R Complex Patient Care 1 Comprehensive pre-op planning/alternatives 2 Modify and adjust post-op plan as needed revise therapy 3 Understands how to avoid/prevent potential complications 4 Treat simple complications both intraoperatively and postoperatively. recognize improper hardware position