Objectives:
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
Maneuver
- 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
Closure
- 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