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