The patient is positioned in a stable lateral position with the upper arm
resting in a separate arm support (Fig.
2). The elbow is flexed 90° with the forearm hanging freely. A
longitudinal, slightly laterally curved skin incision (to avoid the tip of the
olecranon) is made on the dorsal side of the elbow
(Fig. 3), as described by
Crenshaw3. The skin
flaps are reflected as far as the medial and lateral epicondyles, and, on the
ulnar side, the ulnar nerve is localized medial to the triceps muscle. The
fibrous arch that covers the ulnar sulcus is incised, and the ulnar nerve is
left undisturbed in its bed; transposition is not performed. The posterior
aponeurosis of the triceps is mobilized and is transversely incised
approximately 8 cm proximal to the elbow. On the radial side of the olecranon,
a longitudinal incision is made through the fascia of the triceps and the
anconeus. The posterior aponeurosis of the triceps is reflected distally as a
tongue separating it medially from the underlying deep tendinous lamina of the
triceps. It remains attached distally to the olecranon
(Fig. 4). The muscle of the
deep part of the triceps is then divided longitudinally along the lateral side
of this deep tendinous lamina. This deep tendon of the triceps is released
from the olecranon and, with the muscle, is reflected medially as far as the
epicondyle.
On the lateral side, the superficial fascia of the anconeus is undermined
to the ulnar crest. The anconeus is released from the ulna with a periosteal
elevator, and, in continuity with the medial head of the triceps, is reflected
laterally. The annular ligament is exposed and is divided sharply from its
insertion on the ulna. Two small retractors are placed around the neck, and
the neck is osteotomized with a micro-oscillating saw just distal to the
radial head. Cutting the whole circumference of the neck is made easier by
pronating and supinating the forearm when sawing. The radial head is then
removed.
On the medial side of the ulnar crest, the fascia over the flexor carpi
ulnaris and the flexor digitorum profundus is incised longitudinally, and the
interval between the two muscle bellies is opened proximally. The ulnar head
of the flexor carpi ulnaris is stripped medially, and consequently the ulnar
nerve is protected by this muscle belly. The anterior band of the medial
collateral ligament is saved for stability. After this ligament is lifted with
a small periosteal elevator, any osteophytes along the medial side of the
olecranon can be removed. At this stage, a synovectomy can be performed.
Flexing the elbow maximally exposes the distal part of the humerus. If
necessary, osteophytes at the margin of the trochlea are removed to allow
adequate exposure of the trochlea. A humeral saw guide, with the size defined
by the size of the humeral component as determined by preoperative templating,
is aligned over the distal part of the humerus in such a manner that its stem
lies parallel to the shaft of the humerus while the medial margin is lined up
with the medial tip of the trochlea (Fig.
5). The bone to be resected as defined by the saw guide is marked
with methylene blue. It is also helpful to mark the axis of the humeral shaft.
At this time, the trochlear cuts are made with the micro-oscillating saw. The
medial trochlear cut is made through the medial lip of the trochlea with its
top at the apex of the olecranon fossa. When the cuts are completed, the whole
trochlea can be removed without force (Fig.
6). The saw cut is made conservatively, and sometimes a small
remnant of the medial lip of the trochlea has to be removed with a
rongeur.
CRITICAL CONCEPTSINDICATIONS:• Grade-IV or V destruction of the elbow due to rheumatoid arthritis
or juvenile rheumatoid arthritisCONTRAINDICATIONS:Recent septic arthritis or bursitisInsufficient bone stock of the distal part of the humerus or the proximal
part of the ulnaSevere ligamentous instability of the elbowParalysis of the muscles around the elbow or a neuropathic jointAn acute comminuted distal humeral fracturePITFALLS:Intraoperative fracture of the medial or lateral epicondylar ridge. The
bone of the distal part of the humerus may be destroyed by the rheumatoid
process, weakening the epicondylar and supracondylar ridges. The radial head
is often subluxated anteriorly, and the anterior cortex of the capitellum and
the supracondylar ridge may be eroded by direct contact with the subluxated
radial head in flexion. Excavation of this ridge will further weaken the bone
support, and a long-stemmed prosthesis is indicated in these cases.Dislocation during the trial reduction. After trial insertion of the
prosthesis and reduction of the joint, the ulnar component might be tilted
from the cut surface (resection area) of the olecranon. This might be caused
by a malrotation of the cut surface of the olecranon and should be corrected
before cementing to avoid dislocation of the prosthesis. If it cannot be
corrected, it is better to use a snap-fit ulnar component to provide
stability.If the bone mass of the olecranon is too weak to support the ulnar
component, it is better to use a long-stemmed metal-backed ulnar
component.If the elbow is distracted because the humeral component was not inserted
deeply enough, closure of the triceps and the skin may be compromised.AUTHOR UPDATE:All patients in the series reported on in our original article were
operated on with the same surgical technique, as was taught by the designer of
the prosthesis, W.A. Souter. New instruments have since been developed, but
they are not yet available for use.
CRITICAL CONCEPTS
INDICATIONS:
• Grade-IV or V destruction of the elbow due to rheumatoid arthritis
or juvenile rheumatoid arthritis
CONTRAINDICATIONS:
Recent septic arthritis or bursitisInsufficient bone stock of the distal part of the humerus or the proximal
part of the ulnaSevere ligamentous instability of the elbowParalysis of the muscles around the elbow or a neuropathic jointAn acute comminuted distal humeral fracture
Recent septic arthritis or bursitis
Insufficient bone stock of the distal part of the humerus or the proximal
part of the ulna
Severe ligamentous instability of the elbow
Paralysis of the muscles around the elbow or a neuropathic joint
An acute comminuted distal humeral fracture
PITFALLS:
Intraoperative fracture of the medial or lateral epicondylar ridge. The
bone of the distal part of the humerus may be destroyed by the rheumatoid
process, weakening the epicondylar and supracondylar ridges. The radial head
is often subluxated anteriorly, and the anterior cortex of the capitellum and
the supracondylar ridge may be eroded by direct contact with the subluxated
radial head in flexion. Excavation of this ridge will further weaken the bone
support, and a long-stemmed prosthesis is indicated in these cases.Dislocation during the trial reduction. After trial insertion of the
prosthesis and reduction of the joint, the ulnar component might be tilted
from the cut surface (resection area) of the olecranon. This might be caused
by a malrotation of the cut surface of the olecranon and should be corrected
before cementing to avoid dislocation of the prosthesis. If it cannot be
corrected, it is better to use a snap-fit ulnar component to provide
stability.If the bone mass of the olecranon is too weak to support the ulnar
component, it is better to use a long-stemmed metal-backed ulnar
component.If the elbow is distracted because the humeral component was not inserted
deeply enough, closure of the triceps and the skin may be compromised.
Intraoperative fracture of the medial or lateral epicondylar ridge. The
bone of the distal part of the humerus may be destroyed by the rheumatoid
process, weakening the epicondylar and supracondylar ridges. The radial head
is often subluxated anteriorly, and the anterior cortex of the capitellum and
the supracondylar ridge may be eroded by direct contact with the subluxated
radial head in flexion. Excavation of this ridge will further weaken the bone
support, and a long-stemmed prosthesis is indicated in these cases.
Dislocation during the trial reduction. After trial insertion of the
prosthesis and reduction of the joint, the ulnar component might be tilted
from the cut surface (resection area) of the olecranon. This might be caused
by a malrotation of the cut surface of the olecranon and should be corrected
before cementing to avoid dislocation of the prosthesis. If it cannot be
corrected, it is better to use a snap-fit ulnar component to provide
stability.
If the bone mass of the olecranon is too weak to support the ulnar
component, it is better to use a long-stemmed metal-backed ulnar
component.
If the elbow is distracted because the humeral component was not inserted
deeply enough, closure of the triceps and the skin may be compromised.
AUTHOR UPDATE:
All patients in the series reported on in our original article were
operated on with the same surgical technique, as was taught by the designer of
the prosthesis, W.A. Souter. New instruments have since been developed, but
they are not yet available for use.
The medullary cavities of the medial epicondyle, the supracondylar ridge,
and the capitellum are opened with a ball-shaped burr
(Fig. 7). For protection of the
soft tissues, a broad periosteal elevator is placed anterior to the humeral
shaft. A trial humeral prosthesis of the proper size is then fitted, but no
force should be used. Often, some additional excavation is needed before the
trial component can be inserted (Fig.
8).
The ulna is prepared without the use of a cutting guide. The articular
surface and the tip of the olecranon and coracoid are removed with a
micro-oscillating saw, with two cuts made perpendicular to each other
(Fig. 9). The cut in the
olecranon determines the rotation of the ulnar component, and the coracoid
process and the outer bone contour of the olecranon are the best landmarks to
use. The ulnar shaft is then opened with a ball-shaped burr until the properly
sized ulnar component fits (Fig.
10). The trial prosthetic components, starting with the humeral
one, are then inserted, and the joint is reduced to check the stability and
the range of motion. A small flexion contracture of =30° is accepted.
If the contracture is greater, the humeral component has to be fitted more
deeply through more excavation of the distal part of the humerus, or a volar
capsulotomy has to be performed.
After a successful trial insertion of the components and reduction of the
joint, the humeral component and then the ulnar component are inserted and
fixed with cement. An 8-mm cement restrictor is inserted into the humerus to
avoid excessive proximal penetration of the cement. Before cementing, three
small holes are drilled into the ulna for perosseous suturing of the annular
ligament and the triceps muscle (Fig.
11). After the cementing (Fig.
12) and before the closure, the tourniquet is released and the
bleeding points are coagulated. A suction drain is inserted. At closure, the
annular ligament is sutured back to the ulna under proper tension. If too much
tension is created in the reconstituted ligament, the ulnar component has a
tendency to tilt. Similarly, the deep tendinous band of the triceps is sutured
to the posteromedial tip of the olecranon under proper tension so that the
soft tissues on both sides of the joint are well balanced without any tilting
of the ulnar component. The reflected musculotendinous flaps of the triceps
are sutured to the olecranon, and the reflected triceps aponeurosis is sutured
to its original position. After the operation, a bulky compressive bandage is
applied with the elbow held in 90° of flexion.
The elbow is immobilized for five days, after which time supervised active
motion is started. For six weeks, a collar and cuff is used during the day and
a splint is worn at night.