A Basic Initial Outpatient Evaluation and Management 1 Focused history and physical Document neurovascular status Concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies radiographs of the elbow AP lateral 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 remove the plaster splint 7 to 10 days postop start range of motion exercises Postop: 4-6 week postoperative visit by week 4 advance the ROM to 15-105 degrees initiate gentle isometrics for 4 weeks begin total body conditioning at 10 weeks diagnose and early management of complications begin total body conditioning at 10 weeks postop:3 month postoperative visit light medicine ball underhand toss and light bench press begin throwing progression program at 20 weeks short toss lofted long toss long toss on a line ground level throwing throw from mound By 7-8 months should be throwing off mound at 50% speed (fastballs only to start) 8-10 months: simulated games 11-12 months: allow complete return to game competition (must be pain free) B Advanced Initial Outpatient 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 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 infection ulnar nerve injury fracture of the ulnar bone bridge medial antebrachial cutaneous nerve injury
E Preoperative Plan 1 Template repair 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 Tendon stripper 2 Room setup and equipment C-arm perpendicular to OR table 3 Patient positioning Supine position Place affected extremity over hand table 4 Patient draping Place non-sterile tourniquet Place a webril under the tourniquet Place a rolling stockinet up to the tourniquet Place down sheets X2 Cut the stockinet around the wrist Roll stockinet up to the tourniquet use Ioban to seal off proximally and distally Place the hand extremity drape make sure that it is facing the proper way- there is an arrow towards where the hand is G Palmaris Graft Harvest 1 Mark and start the incision Make a 1.5 cm transverse incision over the distal palmar crease centered over the palmaris. The patient must be examined preoperatively to determine whether the patient has a palmaris or not Dissect down to the palmaris with scissors then isolate Place a hemostat under the palmaris and pull it to make sure that the wrist flexes do not dissect any deeper because of the location of the median nerve 2 Place a locking stitch 3 Flex the wrist to maximize the length of the graft Use no 1 ethibond suture to place a krackow locking stitch in the tendon This should comprise of three rows up and three rows back Cut sutures so that they are at even lengths 4 Harvest the graft Pass the sutures through a 4 mm closed tendon stripper followed by the palmaris Aim for the medial condyle Place the graft in a moist sponge on the back table 5 Exsanguinate the arm 6 Identify the neurovascular structures Identify the lateral antebrachial cutaneous nerve Nerve is identified in the antebrachial fossa where it exits between the biceps and the brachioradialis H Medial Approach to the Elbow 1 Mark and make the incision Start the incision 3 cm proximal to the medial epicondyle Extend the incision approximately 10 cm which should be approximately 2 cm past the sublime tubercle The incision needs to be distal enough to expose nerve to avoid injury when drilling the ulnar tunnel and proximal enough to avoid the nerve when drilling the exit holeswith a 10 blade bipolar the skin bleeders Perform the skin incision Bipolar the skin bleeders 2 Identify and protect neurovascular structures protect the medial antebrachial cutaneous nerve 3 Expose the pronator mass Isolate the superficial aspect of the flexor pronator mass want to be right over fascia here to try to keep all the nerves in the dermal tissue be careful to avoid the medial antebrachial cutaneous nerve here as it courses from anterior to posterior, usually in the posterior aspect of the incision 4 Incise the ligament Incise the ligament in line with the fibers to expose the joint it is recommended to tag each side of the ligament with 2-0 vicryl suture to aid in closure be mindful of the ulnar nerve when placing suture in the posterior half of the ligament depending on where you place your exiting drill holes on the medial epicondyle will dictate the amount of exposure you need in this area 5 Use the posterior hole Use mets to open the intermuscular septum proximal to the medial epicondyle Release the intermuscular septum from its insertion on the medial epicondyle Isolate the ulnar nerve for about 2cm proximal to the medial epicondyle this will allow visualization and protection while drilling the exit holes on the medial epicondyle Incise the fascia on the anterosuperior medial epicondyle to expose the spot where the anterior exit hole will be drilled on the epicondyle Dot out the proposed area of the FCU muscle splitting approach ideally the split is right along the raphe Incise this with a 15 blade take the knife all the way down to native UCL and use this to clean off any muscle that is on the UCL bluntly dissect the ulnar nerve off of the posterior aspect of the native UCL Dot out your proposed split in it Split the native UCL w/ a 15 blade it helps to have towels placed under the elbow here so the assistant can impart a valgus force on the elbow while supinating the hand try to split this in the middle going from distal heading proximal with a 15 blade I Ulnar Tunnel Preparation 1 Expose the anatomy Expose the sublime tubercle while protecting the ulnar nerve posteriorly use a large Gelpie for exposure 2 Make burr holes Drill with the 3.0mm burr to create 2 converging holes on either side of the sublime tubercle (anterior and posterior to it) make sure to go in and out with the burr to open up the orifice to help w/ graft passage can also use a chamfer here to open this up leave about 4mm between the proximal aspect of the tunnel and the joint line leave at least a 5mm bone bridge in between the 2 tunnels Drill the posterior one first, making sure to stay centered in the ulna Put the curette in the hole and use as target for the anterior hole, and then drill the anterior hole Take a small curved curette and connect the two holes you drilled, taking care not to violate the one bridge Place a suture passer (basically a needle with a looped wire on it) through the tunnel, and then pass a suture through the tunnel that you’ll use later to pass the graft Snap this suture and leave this in place J Humeral Tunnel Preparation 1 Create humeral tunnel Use a 4.0mm drill bit to create the socket on the humerus this should be at the anatomic insertion of the UCL hold the drill in one hand and use the thumb and index finger of the other hand to pinch the medial epicondyle in between them so you get a feel of his trajectory should be aimed at the medial epicondyle try to start this opening as far lateral (deep in the incision) as you can direct this socket up the medial epicondyle do not perforate the posterior humeral cortex ideally socket length should be 15-20mm this is the length of graft in the tunnel Make a 1.5mm drill hole, starting on the posterior aspect of the medial epicondyle, exiting into the 4.5m socket you just drilled retract the ulnar nerve posteriorly here to protect it Create a second 1.5mm drill tunnel from the anterior aspect of the medial epicondyle, just anterior to the medial intermuscular septum, aiming towards the socket you just createdr use, and remove the suture passer repeat this with the posterior exit hole the bone bridge between these two exit holes should be at least 1.0cm use same needle with the metal loop on it and pass this from the anterior exit hole into the 4.0mm socket place a looped passing suture here for late K Graft Placement 1 Secure the graft Suture the native UCL side to side using a running 2-0 Vicryl whipstitch run from distal to proximal If there is good native UCL anteriorly and posteriorly, do not tie the suture but leave two tails, one anterior and one posterior that you will later tie over the new UCL graft If the anterior or posterior native UCL is not good quality, then tie this 2-0 Vicryl off proximally and cut it pass graft through the ulnar tunnel using previously placed shuttling suture mineral oil can help pass this graft Place the posterior limb of the graft into the tunnel using the posterior passing suture Lay the anterior limb over the medial epicondyle and mark with a marking pen just distal to where the socket ends so you make sure you can get all the graft in the tunnel before having it bottom out Place a varus stress on the elbow while measuring this to make this measurement accurate Prep the graft using a #1 Ethibond suture in running, locking Krakow like the other end if the graft bottoms out before full tension is taken up, you’re screwed and will need to remove it and cut it shorter cut off the excess graft Pass the anterior limb into the humerus using the previously placed passing stitch watch and feel both limbs of the graft dock into the humerus make sure both ends go in and are not getting hung up Cycle the elbow to minimize creep Flex and extend the elbow the anterior limb should be tight in extension and slightly more lax in flexion the posterior limb should be slightly more lax in extension and tight in flexion Tie these sutures over the epicondylar bone bridge elbow should be in: 30°-60° of flexion with a varus stress placed on the elbow Check tension on both limbs of the graft if the 2-0 Vicryl is still around the graft, tie these ends together Take a senn and retract proximally Use a free needle to pass the Ethibond suture that you ties over the bone bridge into the FCU Tie these ends together this helps bury the knot L Wound Closure 1 Irrigation and hemostasis Copiously irrigate the wound 2 Deep closure Repair 2-0 Vicryl for split in FCU and subcutaneous tissue 2-0 Monocryl for palmaris harvest sites 3 Superficial closure 3-0 running Monocryl for skin Steri-strips, 4x4, webril, 3” ace wrap, elbow brace Locked at 70° of flexion 4 Dressings and immobilization Immobilize the arm in a posterior splint with the elbow flexed 45 degrees and the forearm supinated
O Postoperative Inpatient Management (includes outpatient surgery) 1 Discharge patient appropriately Pain meds Wound care Schedule follow up in 2 weeks Physical therapy R Complex Patient with Complication Evaluation & Management 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.