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Name:
Total Elbow Replacement
Description:
Total Elbow Replacement
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https://cadmoremediastorage.blob.core.windows.net/dffd988e-99d2-4c42-ba24-b29d703aac0d/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H22M26S
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https://cadmoreoriginalmedia.blob.core.windows.net/dffd988e-99d2-4c42-ba24-b29d703aac0d/Total Elbow Replacement.mp4?sv=2019-02-02&sr=c&sig=2kx0ckYrGdKZSS21d%2BZttf3apZbpCNOMOE2qaByOHFY%3D&st=2024-11-21T16%3A21%3A30Z&se=2024-11-21T18%3A26%3A30Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. Today, I'm going to demonstrate a total elbow replacement. This is a 65-year-old lady who presents with an osteoarthritic elbow on the left side and we are performing a total elbow replacement using the neck cell system from Zimmer Biomet. Patient is in a lateral decubitus position with a sterile tourniquet applied.
BIJAYENDRA SINGH: I have marked the skin incision, I gently curve it around medially to facilitate less tension on the skin, but this also allows an easier exposure of the ulnar nerve. Raise thick flaps on both the sides and the best way to hold the flaps in place is by putting a few stay sutures around the flap.
BIJAYENDRA SINGH: There are various ways how the deeper dissection can be carried out, including doing a triceps peel a Bernard Maury or a trap approach. I've used their triceps, tongue and a flap, which has worked in my practice. Essentially, I do a v-shaped triceps flap and then turn it on itself, followed by peeling the, splinting the triceps in the midline and then carrying the dissection further along on both the sides of the ulna, leaving a cuff of fascia next to the anconeus to come back to repair it.
BIJAYENDRA SINGH: Generally before doing that, I would isolate the ulnar nerve, but here we're doing the ulnar nerve isolation second and it's important to release it both proximally and distally, making sure it's not tangled and remembering where the ulnar nerve is during the whole procedure.
BIJAYENDRA SINGH: I put a vascular loop around the ulnar nerve and then tie the loop on itself but do not hang any instruments as they're likely to be tangled up during the procedure and cause nerve damage.
BIJAYENDRA SINGH: Once the ulnar nerve has been isolated, then do the dissection, both proximally and distally to release the adequate amount of nerve. The nerve does not need to be transposed routinely. After this you continue with the dissection of the soft tissue, and it requires a lot of soft tissue releases. It's generally more than what one would anticipate, especially if you're starting off removing all the collateral ligaments to be able to dislocate the elbow is key.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Next just continuing the dissection around the radial head and neck are isolating the radial head as this is the first step in the bony procedure by doing a radial neck osteotomy.
BIJAYENDRA SINGH: I suture the triceps tongue on itself, which is the best way, in my opinion, to keep these triceps out of the way.
BIJAYENDRA SINGH: Now continuing the release on the medial side, remembering that the ulnar nerve is quite close by so one has to be very careful. Again, leaving a cuff on the ulnar is a good idea, which will help at the closure stage. Now we can identify the radial head and neck and we're ready to do the radial neck osteotomy.
BIJAYENDRA SINGH: Usually do not take off enough, just adequate so that there is no pain from radial capitallar articulation.
BIJAYENDRA SINGH: Once you have done an adequate release of the ligaments, that you will be able to dislocate the whole elbow. Even then, you may need to do further anterior release. I'm removing the osteophytes now on the olecranon, which will provide easy access to the ulnar when preparing the upper end of the ulnar.
BIJAYENDRA SINGH: After the prep of the distal humerus, I'm taking off a part of the center and the humeral condyle which will allow exposure to the medullary canal of the humerus. The central dowel of the distal humerus is removed and then a handheld reamer is used to open the medullary canal of the distal humerus.
BIJAYENDRA SINGH: Once this has been done, use a pilot reamer to further broach the distal humerus. After the pilot reamer, this is followed by serial reaming from different sizes to get enough catch. At this stage, it's very important to make sure that the alignment of the humeral axis and the ingrowing prosthesis is going to be maintained.
BIJAYENDRA SINGH: Once you've reached the adequate size, you can mark the axis along the way as seen here. I use a high speed burr to fashion the distal humerus as this allows a bit more precision as to how much bone is removed without the fear of breaking the cortex, especially the medial side, which can be quite thin in some of the patients with inflammatory arthropathy.
BIJAYENDRA SINGH: This is the guide to perform the final prep of the distal humerus using a dowel reamer. Then performing a trial introduction of the distal humerus prosthesis, making sure it's seating properly and again, if required, use the high speed burr to
BIJAYENDRA SINGH: do some final prep. Once I'm happy with the seating of the distal humerus trial, I open up the medullary canal again. Often the kit will have a sharp hole, but I find using the high speed burr provides a bit more precision and accuracy to do this.
BIJAYENDRA SINGH: Once this is done, then use a red eye or T and firm or a hand held reamers to open up the medullary canal of the ulnar. I always do per-operative imaging to make sure that my alignment is proper. Once I'm happy with the reaming, then you start preparing again further with the high speed burr to prepare the upper ulnar.
BIJAYENDRA SINGH: Then use the brooches to prepare the upper ulnar. Starting from the pilot reamer to next size up. This prosthesis allows different size of the humerus and the ulnar component to be used.
BIJAYENDRA SINGH: Now trying to insert the trial ulnar component to see where it's catching, and again, I use the high speed burr to reshape the upper end of the ulna. Once the trial ulnar nerve component is in satisfactory, then try and do a trial reduction of the elbow joint.
BIJAYENDRA SINGH: This device also has a nice little gadget to trim any excess bone on the sides where the bearings are going to go. You may need to use a saw to do some final prep and fashioning of this bone ends. Prepping for the actual prosthesis, the poly in the distal humerus is inserted and locked in place.
BIJAYENDRA SINGH: A device that goes across allows this plastic to settle in place before inserting into the patient. The ulnar component is similarly prepared by putting the bushing on the holder with a central pin. Then the ulnar component and a second bushing on the other side goes in and we're ready to cement the prosthesis in.
BIJAYENDRA SINGH: Normally use a low viscosity cement in elbow replacements as this provides enough time to curette at the end. Preparing the intramedullary cement restrictor for the humerus, I use a small plastic flange device that is inserted with the cement gun after measuring the appropriate amount of length that it needs to go in. For the ulnar,
BIJAYENDRA SINGH: I often leave it without any cement restrictor or stick a small piece of bone for cementation. I use a low viscosity cement as this allows adequate amount of time for it to cure without setting too soon. I prefer to put the cement first in the ulnar.
BIJAYENDRA SINGH: It allows it to trickle down to the narrow medullary canal, then into the humerus. And again, same with the prosthesis. Try and get the ulnar component in it's position before inserting the humoral component. In putting the humoral component, I put a small slither of bone in front of the flange that provides a additional rotational stability
BIJAYENDRA SINGH: and then this is tamped in place. Try and reduce the condyles onto the humeral components. Once the condyles are in place, you can use this little Cobra device to push the condyles over the distal humeral component.
BIJAYENDRA SINGH: And finally, a locking screw is inserted to hold the bearings in place.
BIJAYENDRA SINGH: And a final check on the image intensifier to assess the overall position of the implant. The closure of the extensor paritas is quite important and I start off from distally suturing the ends on the sides of the distal ulnar, of the proximal ulnar and then doing a continuous suture.
BIJAYENDRA SINGH: And as I had shown while doing the early dissection, that leaving a cuff on either side of the ulnar facilitates this repair. Once I have done the initial prep, then you suture the triceps in place. The triceps has been approximated, then I repair the fascial tongue back to the main paritas of the extensor mechanism.
BIJAYENDRA SINGH: To continuous repair of the whole of the extensor mechanism, making sure I'm happy with the
BIJAYENDRA SINGH: position of the triceps. Most of the time the ulnar nerve is left in place and it glides easily.
BIJAYENDRA SINGH: The fascial layer is then closed with 2.0 vicryl and the skin is sutured with a monocryl subcuticular. The arm is then wrapped up in woolen crepe and I put them in an above elbow back slab for two weeks in about 60 degrees of flexion till the wound heals and then start mobilization.
BIJAYENDRA SINGH: These are the post-op radiographs on this patient, which shows good position of the prosthesis. I definitely get them moving at two weeks time. I hope you do like the video and have learned from it. If you have any questions or queries, then please do not hesitate to contact via the above details.
BIJAYENDRA SINGH: There are plenty more videos on my YouTube and VuMedi channel. Thank you for watching. [VIDEO ENDS]
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. Today, I'm going to demonstrate a total elbow replacement. This is a 65-year-old lady who presents with an osteoarthritic elbow on the left side and we are performing a total elbow replacement using the neck cell system from Zimmer Biomet. Patient is in a lateral decubitus position with a sterile tourniquet applied.
BIJAYENDRA SINGH: I have marked the skin incision, I gently curve it around medially to facilitate less tension on the skin, but this also allows an easier exposure of the ulnar nerve. Raise thick flaps on both the sides and the best way to hold the flaps in place is by putting a few stay sutures around the flap.
BIJAYENDRA SINGH: There are various ways how the deeper dissection can be carried out, including doing a triceps peel a Bernard Maury or a trap approach. I've used their triceps, tongue and a flap, which has worked in my practice. Essentially, I do a v-shaped triceps flap and then turn it on itself, followed by peeling the, splinting the triceps in the midline and then carrying the dissection further along on both the sides of the ulna, leaving a cuff of fascia next to the anconeus to come back to repair it.
BIJAYENDRA SINGH: Generally before doing that, I would isolate the ulnar nerve, but here we're doing the ulnar nerve isolation second and it's important to release it both proximally and distally, making sure it's not tangled and remembering where the ulnar nerve is during the whole procedure.
BIJAYENDRA SINGH: I put a vascular loop around the ulnar nerve and then tie the loop on itself but do not hang any instruments as they're likely to be tangled up during the procedure and cause nerve damage.
BIJAYENDRA SINGH: Once the ulnar nerve has been isolated, then do the dissection, both proximally and distally to release the adequate amount of nerve. The nerve does not need to be transposed routinely. After this you continue with the dissection of the soft tissue, and it requires a lot of soft tissue releases. It's generally more than what one would anticipate, especially if you're starting off removing all the collateral ligaments to be able to dislocate the elbow is key.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Next just continuing the dissection around the radial head and neck are isolating the radial head as this is the first step in the bony procedure by doing a radial neck osteotomy.
BIJAYENDRA SINGH: I suture the triceps tongue on itself, which is the best way, in my opinion, to keep these triceps out of the way.
BIJAYENDRA SINGH: Now continuing the release on the medial side, remembering that the ulnar nerve is quite close by so one has to be very careful. Again, leaving a cuff on the ulnar is a good idea, which will help at the closure stage. Now we can identify the radial head and neck and we're ready to do the radial neck osteotomy.
BIJAYENDRA SINGH: Usually do not take off enough, just adequate so that there is no pain from radial capitallar articulation.
BIJAYENDRA SINGH: Once you have done an adequate release of the ligaments, that you will be able to dislocate the whole elbow. Even then, you may need to do further anterior release. I'm removing the osteophytes now on the olecranon, which will provide easy access to the ulnar when preparing the upper end of the ulnar.
BIJAYENDRA SINGH: After the prep of the distal humerus, I'm taking off a part of the center and the humeral condyle which will allow exposure to the medullary canal of the humerus. The central dowel of the distal humerus is removed and then a handheld reamer is used to open the medullary canal of the distal humerus.
BIJAYENDRA SINGH: Once this has been done, use a pilot reamer to further broach the distal humerus. After the pilot reamer, this is followed by serial reaming from different sizes to get enough catch. At this stage, it's very important to make sure that the alignment of the humeral axis and the ingrowing prosthesis is going to be maintained.
BIJAYENDRA SINGH: Once you've reached the adequate size, you can mark the axis along the way as seen here. I use a high speed burr to fashion the distal humerus as this allows a bit more precision as to how much bone is removed without the fear of breaking the cortex, especially the medial side, which can be quite thin in some of the patients with inflammatory arthropathy.
BIJAYENDRA SINGH: This is the guide to perform the final prep of the distal humerus using a dowel reamer. Then performing a trial introduction of the distal humerus prosthesis, making sure it's seating properly and again, if required, use the high speed burr to
BIJAYENDRA SINGH: do some final prep. Once I'm happy with the seating of the distal humerus trial, I open up the medullary canal again. Often the kit will have a sharp hole, but I find using the high speed burr provides a bit more precision and accuracy to do this.
BIJAYENDRA SINGH: Once this is done, then use a red eye or T and firm or a hand held reamers to open up the medullary canal of the ulnar. I always do per-operative imaging to make sure that my alignment is proper. Once I'm happy with the reaming, then you start preparing again further with the high speed burr to prepare the upper ulnar.
BIJAYENDRA SINGH: Then use the brooches to prepare the upper ulnar. Starting from the pilot reamer to next size up. This prosthesis allows different size of the humerus and the ulnar component to be used.
BIJAYENDRA SINGH: Now trying to insert the trial ulnar component to see where it's catching, and again, I use the high speed burr to reshape the upper end of the ulna. Once the trial ulnar nerve component is in satisfactory, then try and do a trial reduction of the elbow joint.
BIJAYENDRA SINGH: This device also has a nice little gadget to trim any excess bone on the sides where the bearings are going to go. You may need to use a saw to do some final prep and fashioning of this bone ends. Prepping for the actual prosthesis, the poly in the distal humerus is inserted and locked in place.
BIJAYENDRA SINGH: A device that goes across allows this plastic to settle in place before inserting into the patient. The ulnar component is similarly prepared by putting the bushing on the holder with a central pin. Then the ulnar component and a second bushing on the other side goes in and we're ready to cement the prosthesis in.
BIJAYENDRA SINGH: Normally use a low viscosity cement in elbow replacements as this provides enough time to curette at the end. Preparing the intramedullary cement restrictor for the humerus, I use a small plastic flange device that is inserted with the cement gun after measuring the appropriate amount of length that it needs to go in. For the ulnar,
BIJAYENDRA SINGH: I often leave it without any cement restrictor or stick a small piece of bone for cementation. I use a low viscosity cement as this allows adequate amount of time for it to cure without setting too soon. I prefer to put the cement first in the ulnar.
BIJAYENDRA SINGH: It allows it to trickle down to the narrow medullary canal, then into the humerus. And again, same with the prosthesis. Try and get the ulnar component in it's position before inserting the humoral component. In putting the humoral component, I put a small slither of bone in front of the flange that provides a additional rotational stability
BIJAYENDRA SINGH: and then this is tamped in place. Try and reduce the condyles onto the humeral components. Once the condyles are in place, you can use this little Cobra device to push the condyles over the distal humeral component.
BIJAYENDRA SINGH: And finally, a locking screw is inserted to hold the bearings in place.
BIJAYENDRA SINGH: And a final check on the image intensifier to assess the overall position of the implant. The closure of the extensor paritas is quite important and I start off from distally suturing the ends on the sides of the distal ulnar, of the proximal ulnar and then doing a continuous suture.
BIJAYENDRA SINGH: And as I had shown while doing the early dissection, that leaving a cuff on either side of the ulnar facilitates this repair. Once I have done the initial prep, then you suture the triceps in place. The triceps has been approximated, then I repair the fascial tongue back to the main paritas of the extensor mechanism.
BIJAYENDRA SINGH: To continuous repair of the whole of the extensor mechanism, making sure I'm happy with the
BIJAYENDRA SINGH: position of the triceps. Most of the time the ulnar nerve is left in place and it glides easily.
BIJAYENDRA SINGH: The fascial layer is then closed with 2.0 vicryl and the skin is sutured with a monocryl subcuticular. The arm is then wrapped up in woolen crepe and I put them in an above elbow back slab for two weeks in about 60 degrees of flexion till the wound heals and then start mobilization.
BIJAYENDRA SINGH: These are the post-op radiographs on this patient, which shows good position of the prosthesis. I definitely get them moving at two weeks time. I hope you do like the video and have learned from it. If you have any questions or queries, then please do not hesitate to contact via the above details.
BIJAYENDRA SINGH: There are plenty more videos on my YouTube and VuMedi channel. Thank you for watching. [VIDEO ENDS]
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