Master Tech Ortho Surgery Elbow CH1


PART I Exposures

Results There have been limited attempts to document the efficacy of one or the other of the various types of triceps-sparing approaches. In the original description, we compared the clinical result of the Mayo approach to that of the triceps splitting or transverse release of the triceps attachment (5). There were no triceps disruptions after approximately 75 procedures done with the triceps being released in continuity (Mayo approach) compared with an approximately 20% complication rate when the triceps was released transversely. Wolfe and Ranawat (7) have also observed no instances of triceps insufficiency with their modification of this approach. The use of the Mayo medial expo- sure was also shown to have improved triceps strength after total elbow arthroplasty (8). This man- ner of exposing the elbow was found to be associated with approximately 20% greater extension strength than with the Campbell fascial turn-down (Van Gorder) type of exposure. Complications One beauty of the previously described exposures is that they are relatively free of complication. Today most problems are related to the pathology rather than to the surgical approach. Difficult ankylosis release procedures are associated with a significant amount of swelling as often occurs in patients undergoing total elbow arthroplasty. Wound healing is generally not a prob- lem, however, and is related to the presence of prior incisions and the magnitude of the dissection, as is typical for release of the stiff elbow. The elevation of the large medial and lateral flaps does not retard healing but occasionally can give rise to subcutaneous seroma. Rarely does this need to be addressed or drained. The infection rate after total elbow arthroplasty has been reduced at our institution from a high of 11% in 1970 to approximately 3% over the last 10 years (9). This reduction is coincident with adopting the Mayo approach to the elbow, but other technique changes have occurred in this period, including using antibiotic-impregnated cement and splinting the elbow in extension. Injury to the ulnar nerve appears to be more common in those instances in which the ulnar nerve is not exposed and the elbow is flexed on the medial collateral ligament, as with the classical extensile Kocher approach (9,10). Simply exposing the ulnar nerve, although it decreases the complication, does not completely obviate it. The theoretical disadvantage of the Mayo approach, which allows translocation of the ulnar nerve, is that this maneuver devascularizes the nerve and the dissection itself may cause ulnar nerve irritation. Having used this particular exposure in more than 500 cases, the incidence of permanent ulnar nerve injury with motor dysfunction is less than 1%. I am, there- fore, comfortable exposing and moving the ulnar nerve in a subcutaneous pocket as an essential and integral part of the Mayo triceps-sparing approach. Although posterior interosseous nerve palsy is known to occur with some approaches to the radial head (11–13), the complication is virtually unheard of when the joint is exposed through Kocher interval. Triceps disruption is very uncommon with either the Mayo-modified extensile Kocher exposure or the Mayo medial-to-lateral type of approach. The incidence of triceps disruption after total elbow replacement, therefore, is less than 1% in our experience (14). If, however, the triceps should become disrupted after either of the procedures described earlier, if adequate tissue is present, it may be reat- tached as described for the primary procedure (14). If the remaining tissue is inadequate, triceps power is restored by either an anconeus slide or an Achilles tendon allograft reconstruction (15). 1. Morrey BF: Surgical exposures. In: Morrey BF, ed. Masters technique in orthopedic surgery: the elbow . 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002. 2. Morrey BF: Surgical exposures of the elbow. In: Morrey BF, ed. The elbow and its disorders . 3rd ed. Philadelphia, PA: WB Saunders, 2000: 109–134. 3. Mansat P, Morrey BF: The column procedure: a limited lateral approach for extrinsic contracture of the elbow. J Bone Joint Surg 80A(11): 1603–1615, 1998. 4. Kocher T: Text-book of operative surgery . 3rd ed. London, UK: A and C Black, 1911. 5. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: a triceps-sparing approach. Clin Orthop 166: 188, 1982. 6. Kasparyan NG, Hotchkiss RN: Dynamic skeletal fixation in the upper extremity. Hand Clin 13: 643–663, 1997. 7. Wolfe SW, Ranawat CS: The osteo-anconeus flap: an approach for total elbow arthroplasty. J Bone Joint Surg 72A: 684, 1990. 8. Morrey BF, Askew LJ, An KN: Strength function after elbow arthroplasty. Clin Orthop 234: 43–50, 1988. 9. Morrey BF, Bryan RS: Complications of total elbow arthroplasty. Clin Orthop 170: 204–212, 1982. 10. Ewald FC, Jacobs MA: Total elbow arthroplasty. Clin Orthop 182: 137, 1984. 11. Hoppenfield S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach . Philadelphia, PA: J B Lippincott Co., 1984. 12. Kaplan EB: Surgical approaches to the proximal end of the radius and its use in fractures of the head and neck of the radius. J Bone Joint Surg 23: 86, 1941. REFERENCES

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