1.APPROACHES TO THE DISTAL HUMERUS DR.S.SENTHIL SAILESH SEN O R A STA T PRO FESSO R I SSI N I STI N TUTE O F O RTHO PA CS & TRA A LO G Y EDI UM TO M DRA M CA CO LLEG E & RG G G H, CHEN A A S EDI L N I

2. GREETINGS FROM MMC, CHENNAI 3. CHOICE OF EXPOSURE DETERMINANTS Age (paediatric / adult) Fracture pattern (articular comminution) Total Elbow Arthroplasty? Associated injuries ( Neurovascular injury) 4. APPLIED ANATOMY 5. OSSEOUS ANATOMYPOSTERIOR ASPECTANTERIOR ASPECT 6. The medial and lateral columns support the articular segment. The distal most part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle. The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and medial epicondyle. The articular segment functions architecturally as a tie arch. 7. SURGICAL ANATOMY Posterior Structures : Skin & Subcutaneous Tissue Triceps Muscle With Aponeurosis Ulnar Nerve Behind Medial Epicondyle Posterior Capsule 8. SURGICAL ANATOMY Anterior Structures : Skin, Subcutaneous Tissue With Superficial Veins Layer 1: Biceps With Bicipital Aponeurosis Layer 2: Median Nerve With Brachial Vessels Layer 3: Brachialis, Brachio-radialis, Radial Nerve Layer 4: Anterior Capsule 9. SURGICAL ANATOMY LATERAL STRUCTURES: LCL Anconeus Extensors Of The Wrist 10. SURGICAL ANATOMY MEDIAL STRUCTURES: MCL Flexor Group Of Muscles Ulnar Nerve passes from behind the medial epicondyle and distally between the FCU and FDP 11. WHY POSTERIOR APPROACH? Most orthopaedic procedures (m.c: fracture fixation) in and around the distal procedures predominantly done through posterior approaches owing to: SAFER - Less chance of damage to vital structures (comparing anterior) EASIER - Posterior structures are aponeurotic and dissection is easier with less bleeding CLEARER Better visualisation of articular surface Very few indications where other approaches may be necessary: Anterior: excision of myositic mass, fractures associated with vascular injuy Medial & Lateral approaches partially articular/condylar fractures 12. POSTERIOR APPROACHES TO THE DISTAL HUMERUS 13. POSTERIOR APPROACHES TO DISTAL HUMERUS 14. PATIENT POSITIONING LATERAL DECUBITUS POSITION(s wim m e rs p o s itio n) Arm hanging over a post Sterile tourniquet if desired Very convenient for the surgeon Bit less convenient for the anaesthetist especially if the patient has to be intubated halfway during surgery following regional 15. COMMON STEPS FOR ALL POSTERIOR APPROACHES 1) Longitudinal midline skin incision over the posterior aspect of the elbow 2) Raising of subcutaneous flaps on either side to expose the tricipital aponeurosis 3) Isolation of ulnar nerve 16. 1) SKIN INCISION Beginning atleast 5cm proximal to the tip of the olecranon, curving slightly laterally at the tip, then returning to the midline and extending 5 cm distal to the tip of the olecranon 17. 2) RAISING OF SUBCUTANEOUS FLAPS 18. 3) ISOLATION OF ULNAR NERVE Identification of the ulnar nerve first done proximally where the nerve pierces the septum Release it from its tunnel by dividing the arcuate ligament that passes between the two heads of the flexor carpi ulnaris muscle Gently retract it with a rubber sling or a penrose drain Extensive dissection of the nerve is inadvisable, as this increases the risk of tethering and damage to its vascularity. 19. ISOLATION OF ULNAR NERVE 20. OLECRANON OSTEOTOMY APPROACH 21. OLECRANON OSTEOTOMY APPROACH TRANSVERSECHEVR ON Technically easier to do Technically more difficult 30% incidence of nonunion (Gainor et al, (1995) j s o uth o rtho p a s s o c 4:263) More stable Olecranon implant removal may be necessary due to irritation Lesser incidence of nonunion Olecranon implant removal may be necessary due to irritation 22. PLAN THE FIXATION OPTION BEFORE THE OSTEOTOMY 23. OLECRANON OSTEOTOMY APPROACH If planning to use a screw for fixation (most common) of the osteotomy, pre-drill and tap for screw placement down the ulna canal Expose the tip by sharp dissection of soft tissues to see the bone 24. OLECRANON OSTEOTOMY APPROACH A gauze swab is inserted from medial to lateral through the joint across the notch to protect the articular surfaces The line of osteotomy (V shaped) is marked with a pen or a cautery 25. OLECRANON OSTEOTOMY APPROACH Small, thin oscillating saw used to cut 95% of the osteotomy along the line of marking Alternatively a 2mm drill bit can be used for multiple drilling and joining them 26. OLECRANON OSTEOTOMY APPROACH Osteotome used to crack and complete it 27. OLECRANON OSTEOTOMY APPROACHExposure of the distal humerus especially the inter condylar area is excellent after an osteotomy approach 28. OSTEOTOMY FIXATION OPTIONS 29. OSTEOTOMY FIXATIONSINGLE SCREW WITH TBW TECHNIQUE:1) Expose the tip by sharp dissection of soft tissues to see the bone 2) Pre-drilling & tapping should be done prior to osteotomy 3) Beware of the varus bow of the proximal ulna, which may cause a malreduction of the tip of the olecranon after screw placement 4) We prefer using a 6.5mm cannulated cancellous screw of length 60-70mm 5) Large-diameter screw threads may engage ulnar diaphysis (small medullary canal) prior to full seating of screw head, Bite of screw may be strong without full compression Hak and Golladay, 6) A Tension band wiring done before full tightening of the JAAOS, 8:266-75, 2000 30. Length of screw may be important to resist toggling and loss of reduction 31. OSTEOTOMY FIXATION TENSION BAND TECHNIQUE WITH K-WIRES: Easy to place May be less stable than independent lag screw or plate Implant irritation is a problem Mullett et al (2000) I njury 31:427, Prayson et al (1997) J O rtho p Tra um a 11:565Engage anterior ulnar cortex here with wires to improve fixation stability/strength 32. OSTEOTOMY FIXATION DORSAL PLATING Low profile periarticular implants now available When using this method the plate is prefixed to the olecranon and then removed before conducting the osteotomy. Axial screw through plate can be usedHewin et al (2007) J O rtho p Tra um a 21:58 Tejwani et al (2002) Bull Ho s p Jt Dis 61:27 33. THE OSTEOTOMY APPROACHPEARLSPERILSProvides The Best Visualization Of The Distal Humerus Articular SurfaceNonunion, malunion at the osteotomy site Hardware irritation due to osteotomy fixation 34. THE OSTEOTOMY APPROACH INDICATIONSCONTRAINDICATIONS (RELATIVE)Although all articular fractures are best visualised by this approach, the AO/OTA type C3 fracture is best managed by this approachVery anterior articular fractures (AO/OTA type B3), which can be difficult to visualize through an osteotomy Total elbow arthroplasty 35. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH [ALONSO-LLAMES ] 36. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH [ALONSO-LLAMES ] The medial and lateral borders of the triceps are incised or alternatively erased from their respective intermuscular septae and elevated from the posterior aspect of the distal humerus. The distal humerus can be button holed medially or laterally to gain access to the proximal forearm 37. Full-thickness fasciocutaneous flaps are elevatedThe medial and lateral borders of the triceps are incised and elevated from the posterior aspect of the distal humerus 38. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH [ALONSO-LLAMES ]PEARLS Avoidance of an olecranon osteotomy, therefore the risks of nonunion and symptomatic olecranon hardware are avoided The triceps tendon insertion is not disrupted, allowing early active range of motionPERILS Limited visualization of the articular surface of the distal humerus The approach is usually inadequate for fixation of type c3 fractures.Preserves the innervation and blood supply of the anconeus muscle, which provides dynamic posterolateral stability to the elbow. If required,The several advantages of this approach certainly indicate its use for can be converted into an AO/OTA olecranon osteotomytypes A2, A3, B1, B2, and possibly C1 and C2 fractures 39. TRICEPS SPLITTING APPROACHES Developed to attempt to overcome the morbidity & the risk of hardware complications associated with the use of olecranon osteotomy Although some authors have reported a better functional outcome following the use of a triceps-splitting approach compared with olecranon osteotomy, others have reported the converse The intact trochlear notch may be used as a template, against which the reduction of the trochlea can be assessed Either internal fixation or total elbow arthroplasty (TER) can be performed but internal fixation is technically difficult. 40. TRICEPS- midline SPLITTING APPR OACH (CAMPBELL) Splitting the triceps longitudinally through the midline of the triceps aponeurosis down to bone followed by sub-periosteal elevation of the triceps medially and laterally. Triceps split extends distally onto the olecranon and proximally, the radial nerve limits the extent of dissection. 41. TRICEPS- midline SPLITTING APPR OACH (CAMPBELL) In order to improve triceps healing, GSCHWEND et al modified the approach to incorporate a flake of olecranon bone, to be later fixed Mckee et al compared the extensor mechanism strength of patients treated with an olecranon osteotomy versus a triceps splitting approach and found no statistical significant difference, concluding that both approaches are effective 42. TRICEPS- midline SPLITTING APPR OACH (CAMPBELL)PEARLS Relative technical ease The ability to convert from open reduction and internal fixation to total elbow arthroplasty with few consequencesPERILS Limited visibility of the articular surface Disruption of the extensor mechanism requiring postoperative protection and the risk of triceps dehiscence 43. Triceps V-Y splitting approach (campbell van gorder) This Approach Was Described By Campbell, And Later Modified By Van Gorder And Wadsworth The deep head of the triceps is divided in its midline for a length of about 8 cm. The flap is distally based and should extend to the outer part of the humeral condyles in order to allow an adequate approach . Sufficient tendon tissue at both sides of the flap must be preserved to obtain a good repair. Thickness of flap: 1/3rd of the muscle thickness proximally, 2/3rd in the middle, full thickness distally To perform a V-Y advancement the triceps is sutured in the midline for the 44. Triceps V-Y splitting approach (campbell van gorder) 45. Triceps V-Y splitting approach (campbell van gorder) PEARLSPERILSAvoidance of an olecranon osteotomy, therefore the risks of nonunion and symptomatic olecranon hardware are avoidedLimited visibility of the articular surfaceLengthening of the extensor mechanism can be done if requiredHigher rate of infectionRisk of triceps necrosisThis approach is indicated for Total Elbow arthroplasty ORIF of distal humerus fractures when there is an associated complete or high grade partial triceps tendon laceration. Chronic Elbow dislocations 46. Triceps reflecting postero-medial approach (Bryan-Morrey Approach) Medial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterally along with a thin wafer of bone to facilitate bone-to-bone healing Resection of extra-articular tip of olecranon Now the entire triceps muscle with the posterior capsule is reflected upwards and laterally, and the elbow is flexed to expose the joint. 47. Triceps reflecting postero-medial approach (Bryan-Morrey Approach) 48. Triceps reflecting postero-medial approach (Bryan-Morrey Approach) PEARLS Avoidance of an olecranon osteotomy & its complicationsPERILS Risk of triceps pull out if careful transosseous resuturing is not done properly or if the tendon repair fails or the tissue quality is poor, as in rheumatoid patients. Delayed active mobilisationThis approach is best suited for unrepairable distal humerus fractures in which primary elbow arthroplasty is planned. 49. Triceps-Reflecting Anconeus Pedicle (TRAP) Approach The approach begins laterally at the kocher interval, between the extensor carpi ulnaris and the anconeus. TRAP approach incorporates modified kocker's approach on lateral side and a triceps reflecting approach on the medial side. both approaches converge distally at the tip of the anconeusTriceps insertio n Ancone us 50. Triceps-Reflecting Anconeus Pedicle (TRAP) Approach The anconeus-triceps flap was detached from its distal attachment (5-7 cm from the tip of olecranon) and dissected off the lateral side of the elbow and proximal ulna, preserving the integrity of the lateral collateral ligament complex, including annular ligament The flap is reflected to expose the lower end of the humerus 51. Triceps-Reflecting Anconeus Pedicle (TRAP) Approach The dissection started distally and working proximally. The posterior capsule incised and the dissection was carried out proximally between the triceps and posterior humerus. the fibers of the deep head of the triceps were dissected off the posterior humerus by sharp and blunt dissection Fixation of the fracture proceeded The triceps was reattached with interrupted number-2 braided polyester sutures, with use of drill-holes through bone in the region of the olecranon 52. THE TRAP APPROACH PEARLS Avoidance of an olecranon osteotomy & its complications Protects the neurovascular supply to the anconeus musclePERILS Risk of triceps dehiscence Possible extensor weakness 53. DONT FORGET THE RADIAL NERVE Dissect and protect the radial nerve when the exposure is extended on the lateral aspect for fixing the lateral column Gerwin et al : if further proximal exposure is required for associated fractures of the humeral shaft, the lateral side of the approach can be converted into the Gerwin approach, which involves reflection of the triceps muscle unit from lateral to medial to expose 95% of the posterior humeral shaft and the radial nerve 54. MEDIAL & LATERAL APPROACHES LATERAL - Extended Kocher Approach MEDIAL Campbells medial approach 55. CAMPBELLS MEDIAL APPROACH PLA E O F DI N SSECTI N O : PRO XI A M LLY: The internervous plane lies between the brachialis muscle (musculocutaneous nerve) and the triceps muscle (radial nerve) DI STA LLY The plane lies between the brachialis muscle (musculocutaneous nerve) and the pronator teres muscle 56. TECHN QU I E incision centering joint on 10 cm J shaped medial aspect Identify the ulnar nerve in the groove behind the medial condyle of the humerus, and isolate the nerve along the length of the incision Retract the skin anteriorly with the fascia to uncover the common origin of the superficial flexor muscles from the medial epicondyle Enter the interval between the pronator teres and the brachialis. retract the pronator teres 57. Make sure that the ulnar nerve is retracted inferiorly, osteotomize the medial epicondyle (pre drilling & tapping can be done) and retract it with its attached flexors. Superiorly, continue the dissection between the brachialis, retracting it anteriorly, and the triceps, retracting it posteriorly The medial side of the joint now can be seen. incise the capsule and the medial collateral ligament to expose the joint 58. CAMPBELLS MEDIAL APPROACH 59. THE MEDIAL APPROACH PEARLSPERILSAvoidance of disruption of extensor mechanismInadequate visualisation of inter condylar regionNo risk of postoperative triceps pull out, dehiscence, need for immobilisationCannot approach the lateral aspectI DI TI N : N CA O S Removal of loose bodies Fixation of fractures of the coronoid process of the ulna Fixation of fractures of the medial humeral condyle and epicondyle 60. EXTENDED KOCHER APPROACH Utilizes the intermuscular interval between the anconeus and the extensor carpi ulnaris. TECHN QUE : I The anconeus and extensor carpi ulnaris muscles are identified by palpation. A thin strip of fat can almost always be observed in the interval between these muscles The muscle fibres of the anconeus and the extensor carpi ulnaris muscles tend to blend together towards the insertion, so it is easier to develop the interval distally and then progress proximally. The deep fascia is then opened , the anconeus is dissected posteriorly The lateral elbow capsule with the annular ligament is identified and incised longitudinally anterior to the lateral ulnar collateral ligament 61. IDENTIFYING THE KOCHERS INTERVALAncone usEC U 62. EXTENDED THE KOCHERS INTERVAL PROXIMALLY TO EXPOSE THE LATERAL ASPECT OF DISTAL HMERUS 63. THE EXTENDED KOCHERS APPROACH PEARLSPERILSAvoidance of disruption of extensor mechanismInadequate visualisation of inter condylar regionNo risk of postoperative triceps pull out, dehiscence, need for immobilisationCannot approach the medial aspect of distal humerusI DI TI N : N CA O S Fixation of lateral condylar fractures Partially articular fractures Repair or reconstruction of the lateral ligaments. 64. TAKE HOME MESSAGE Choose the appropriate approach Safeguard the ulnar & radial nerve Respect the soft tissues Get familiarized with a particular approach 65. PR OGR AMME SCHEDULE