Elbow Arthritis Pathway Updated: 6/3/2018
CPT Codes: 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow)

[Blocked from Release] TEA Diamond Popup Technique

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Preoperative Patient Care
Operative Techniques
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‚Äôs
  • 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
Postoperative Patient Care
 

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