Improve pain and range of motion (flexion contracture problematic in RA)

Surgical Approach and Ulnar Nerve Decompression

  • Identify landmarks
  • Skin incision – Identify medial and lateral epicondyle and tip of olecranon
  • Palpate ulnar nerve
  • Straight incision either to medial or lateral aspect of olecranon
  • Length 14-16 cm
  • Subcutaneous tissue to fascia, elevate medially
  • Palpate ulnar nerve
  • Place tension on medial edge triceps with cerebellar retractor. Dissect ulnar nerve proximal to distal towards cubital tunnel
  • Elevate medial subcutaneous flap over forearm to level of forearm fascia (Note: blade laid flat on fascia)
  • Vessel loop around nerve. Place knot not staple to prevent catching
  • Cubital tunnel retinaculum released. Can use a dental probe to separate from ulnar nerve
  • Flexor carpi ulnaris superficial and deep layers released
  • Bipolar cautery used for vessels around nerve
  • Release nerve to first motor branch
  • Elevation of subcutaneous tissue, identify medial epicondyle and elevate tissue off.
  • Grasp intermuscular septum with Kocher and release. Remove 1-2 cm.
  • Place ulnar nerve in subcutaneous pocket Triceps elevated from medial to lateral
  • Start distally just off ulnar border
  • Continue towards medial edge of triceps on humerus
  • Plane of dissection identified with Young elevator passed under medial edge of triceps

Lateral Dissection

  • Identify level of lateral dissection
  • Flat knife technique to elevate subcutaneous tissues
  • Proceed laterally to level of lateral epicondyle
  • Additional landmark is border between anconeus and FCU. Can incise to mobilize and centralize triceps.
  • Release extensor mechanism from proximal ulna. Identify Sharpey fibers and release with Beaver blade.
  • Elevate anconeus from lateral aspect proximal ulnar and lateral column. Enter radial humeral joint distally
  • Release tissue off lateral epicondyle


  • Externally rotate and flex elbow
  • Hand rests behind left ear Posterior capsule removed
  • Identify roof of olecranon
  • Release medial structures ie,.MCL from epicondyle for adequate exposure

Establishing Humeral Canal

  • Remove tip of olecranon with Rongeur or Oscillating saw
  • Identify landmarks of medial and lateral columns
  • Remove tissue medially and place curve Homan behind columns.
  • Remove roof of olecranon fossa. Avoid varus valgus twist
  • Continue until snapping sound and removal of cortical bone
  • Twist reamer placed down humeral canal
  • Medial epicondyle thin and should be protected
  • Cutting guide place
  • Plane of cut is collinear with plane of medial and lateral supracondylar columns
  • Mark cuts and then remove cutting block
  • Complete cuts
  • Start in oblique fashion on medial and lateral columns to prevent fracture Trial implant in reverse to check width and alignment Rasp
  • 4 inch in Rheumatoids Prepare anterior aspect humerus, release tissue Trial reduction
  • Depth of insertion – depth of implant at level of capitellum

Establish Ulnar Canal

  • Use high speed burr. Burr between fingers. Widen hole with burr
  • Use Pistol grip reamer.
  • Notch olecranon so can obtain a straight shot.
  • Pilot reamer
  • Serial rasp – small rasp orient handle perpendicular with ulnar
  • Ulnar may need to be stabilized with clamp depending on bone quality
  • If resistance met then use high speed burr
  • Irrigation and preparation, rasp tapped to tooth off final placement
  • Trial implant

Radial Head

  • Debride or resect on RA. Do a synovectomy and remove margin of radial head.

Cementing Implants

  • Clean and dry canals
  • Water pick canal
  • Medullary cement retaining cut to length of implant
  • Cement in retrograde fashion in humerus and then nozzle cut and ulnar Insert ulnar component and then humeral component
  • Depth of insertion of ulna – center of implant conincident with center of anatomy of greater sigmoid fossa Check that humerus does not impinge
  • Capture graft with flange of humerus
  • Leave humerus proud and connect
  • Impact humerus to correct depth


  • Cruciate drill hole technique
  • Anterior to subcutaneous border
  • Transverse drill hole placed
  • Alice clamp to medialize triceps
  • Start medially from distal to proximal
  • #5 Ethibond
  • Lock suture
  • Second stitch and then come across and lock
  • Pass from medial to lateral thru hole
  • Thru forearm fashion
  • Tie on medial side
  • Transverse suture medial to lateral then more proximally then lateral to medial, elbow in 70 degrees and tie sutures
  • Cruciate suture first then Transverse suture second
  • Ulnar Nerve placed in subcutaneous pocket. Use a 2-0 Vicryl to create a pocket between subcutaneous fat and fascia near medial epicondyle. Pass Haworth elevator to make sure there is no compression in full flexion and extension
  • Medial fascial interval closed with running #0 Vicryl
  • Skin closure
  • Full extension
  • Anterior splint