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Case of the Month - Subacute Triad Reconstruction

Subacute Triad Reconstruction

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

August 2018

 

Elbow triad fracture/dislocations are serious injuries that almost always require surgical treatment to restore elbow stability and lessen the risk of post-traumatic arthritis.  These injuries can vary in complexity but are made more difficult to manage by a delay in treatment or reduction of the elbow joint.

 

38 YOF WITH SUBACUTE UNREDUCED TRIAD INJURY

The patient was a high school softball coach who fell at practice backwards onto her outstretched arm and sustained the injury shown on the X-ray below. Neurovascular exam was normal, and her skin healthy. She was given IV sedation and her elbow reduced in the ER just a couple of hours after her injury, with a posterior splint applied. Post reduction X-rays confirmed the reduction. She presented to my office two weeks later, where an interval CT scan in her long arm splint revealed recurrent dislocation with a comminuted radial head fracture as shown below. The CT was performed two days after her injury. Given the severity of her injury, delayed presentation, and increased BMI, I was concerned about the quality of her lateral soft tissue envelope in particular. For that reason, I chose to perform a lateral collateral ligament reconstruction with a palmaris longus autograft, in addition to radial head replacement and coronoid fracture repair.

 

The Procedure

   The patient was placed in the supine position utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. The radial head fragments were loose and were removed. Non-absorbable sutures were passed through the anterior capsule immediately adjacent to the coronoid fracture and passed dorsally through drill holes in the ulna metaphysis. A radial head replacement was inserted. A palmaris longus autograft was harvested and secured as a looped graft using 5.5 mm tenodesis screws.  The patient’s post op course was uneventful. The patient had normal forearm rotation, no pain, and an ulno-humeral arc of motion of 10 > 135 degrees at 10 weeks post op. Her 4 month follow up X-rays are below.

 

Supine patient positioning and a posterior approach allows excellent surgical exposure and access to the elbow joint for triad injuries. The ElbowLOC Supine Positioner stabilizes the humerus vertically, and gives the surgeon independent control of the elbow joint. This markedly simplifies placement of tunnels for collateral ligament reconstruction, not to mention drilling and suture passage for the coronoid fracture repair.

 

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month - Distal Humeral Shaft Fracture

 

Distal Humeral Shaft Fracture

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

June 2018

 

Humeral diaphyseal fractures in active adults are fairly common and often require surgical treatment to ensure proper healing. Fractures involving the distal third of the humeral shaft are often approached posteriorly, as access and plate application to the anterior aspect of the distal humerus is limited.

 

35 YOM WITH COMMINUTED DISTAL DIAPHYSEAL HUMERUS FRACTURE

The patient was involved in a motor vehicle accident and sustained a comminuted distal humeral diaphyseal fracture. Neurovascular exam was normal. Given the length and comminution of the fracture, and thus the challenges maintaining alignment non-operatively, surgical treatment was elected.

The Procedure

The patient was placed in the lateral decubitus position utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. The radial nerve and vascular bundle were identified, mobilized, and protected. Dual acetabular reconstruction plates were utilized and extended from above the radial neurovascular bundle to engage on either humeral column distally. The patient’s post op course was uneventful and radiographic union occurred by 10 weeks.

 

The posterior approach allows excellent exposure for diaphyseal humerus fractures such as this. The lateral position requires an arm support to stabilize the upper arm for the procedure. A low profile arm support, such as the ElbowLOC® Lateral Positioner, works very well for these procedures. In my experience, sterile Mayo tables are too bulky and hinder intraoperative arm and elbow motion and access. Similarly, many commercially available lateral arm positioners are unnecessarily complicated, difficult to apply, and cumbersome to use. The ElbowLOC Lateral Positioner is completely sterile, low profile, and is easily applied and adjusted by the surgeon as needed intraoperatively.

 

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month - Proximal Ulna and Radial Neck Nonunions

Proximal Ulna and Radial Neck Nonunions

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

April 2018

Proximal forearm nonunions can be difficult to manage, particularly when both the radius and ulna are involved. Gross instability of the proximal forearm can complicate these procedures and make patient positioning even more important regarding simplifying and accelerating the surgical procedure.

72 YOF WITH PROXIMAL ULNA AND RADIAL NECK NONUNIONS

The patient fell from a standing height and suffered proximal ulna and radial neck fractures of her right elbow. She underwent surgery to repair her ulna fracture, as well as a later operation to remove symptomatic hardware. She presented to my office 13 months after her injury, complaining of pain, “floppiness” of her elbow and loss of use of her arm. The patient had no history of infection, labs revealed no suspicion of infection, and her clinical exam was otherwise unremarkable with healthy skin. The patient has never smoked, and is not a diabetic.

The Procedure

   The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. Fibrous scar tissue was removed from the ulna nonunion site, and several millimeters of bone resected proximally and distally to expose more healthy cancellous bone. The radial head was floating loose in the joint, was removed, and a radial head replacement inserted. An autogenous iliac crest bone graft was then inserted in the ulna nonunion site, and a plate and screw construct applied. There was no clinical suspicion of infection intraoperatively, and cultures were negative. The X-rays below are 6 weeks post op, motion is 10/130 with normal forearm rotation, and the elbow is essentially painless.

 

In this case, I felt the patient would be best served by revision fracture surgery. If a nonunion develops, conversion to a total elbow replacement would likely be the best option. The posterior approach and supine positioning give wonderful surgical access to the elbow region for problems such as this and terrible triads. The Reducer/Distractor component of the ElbowLOC provides support to the proximal forearm anteriorly, and in this case, prevented the ulna nonunion section from sagging and shortening during debridement, bone grafting, and stabilization of the nonunion site.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month-Adult Monteggia Fracture/Dislocation

Adult Monteggia Fracture/Dislocation

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

February 2018

 

Monteggia variant fracture dislocations in adults generally require surgical treatment and can be challenging cases. Malunion, non-union, and persistent elbow instability are well-recognized complications. Supine patient positioning is ideal for these injuries, allowing the surgeon circumferential access to the elbow joint if necessary, as well as ease of intraoperative elbow joint and forearm manipulation.

82 YO Female With Monteggia Variant Fracture/Subluxation

The patient fell and sustained a comminuted proximal ulna fracture involving the metaphysis at the level of the coronoid process as well as a radial neck fracture. Both fractures were displaced with a flexion moment and thus required surgical intervention.

The Procedure

   The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. The ulna fracture was exposed first. The bulk of the lateral collateral ligament fortunately remained attached to a large butterfly fragment of the ulna containing the supinator crest and was preserved. This large bone fragment was retracted, and a longitudinal split made in the posterolateral capsule to expose the lateral aspect of the joint. The radial head was floating freely, and was removed. A press fit radial head implant was inserted and reduced. Next the Reducer/Distractor component of the ElbowLOC was attached to the Supine Positioner to grossly reduce and stabilize the ulna fracture and keep it from sagging into extension. The ulna fracture reduction was then easily finalized and held with bone clamps while an extended olecranon plate along with interfragmentary screws applied.

The Reducer/Distractor component of the ElbowLOC easily maintains gross fracture reduction and length. Thus the surgeon can focus on “fine tuning” the reduction and applying the fixation, while not having to constantly fight to maintain the gross fracture length and alignment.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month - Olecranon Bursa Excision

Olecranon Bursa Excision

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

January 2018

 

Olecranon bursitis is a common problem that occasionally requires surgical treatment. Supine positioning is ideal for these procedures.  Excision of larger olecranon bursas can be complicated by instability of the humerus and drifting of the surgical field, making many of these cases unnecessarily difficult and frustrating.

45 YOM WITH LARGE CHRONIC OLECRANON BURSITIS

The patient had a large right olecranon bursa that had failed chronic conservative care with repeated cortisone injections and compressive garments. Given the size, and his persistent symptoms, surgical treatment was offered. There was no history of infection, arthritis, gout, or other inflammatory process.

The Procedure

   The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. The bursa sac was sharply dissected from the overlying dermis and proximal ulna periosteum and excised en bloc. Redundant skin was removed and the wound closed in layers. The patient’s recovery was unremarkable.

While certainly this procedure does not absolutely require a positioning device, humeral instability and the subsequent constant “drift” of the surgical field complicates these cases. The posterior surface of the bursa sac is usually densely associated with the dermis, and thus sharply dissecting the bursa sac off the dermis requires a stable surgical platform to prevent unnecessary skin injury. The unique ability of the ElbowLOC® to hold the humerus fixed vertically, while allowing the surgeon unrestricted control of the forearm and elbow simplifies and expedites these procedures.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month - Intraarticular Distal Humerus Fracture

Intraarticular Distal Humerus Fracture

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

December 2017

 

Distal humerus fractures can be challenging cases, primarily due to the inherent difficulty in positioning the limb to create a stable surgical platform. Supine positioning is optimal and enables excellent surgical exposure of the entire distal humeral articular surface and the majority of the humeral shaft. The ElbowLOC® Arm Positioning System greatly simplifies and expedites these cases by allowing the surgeon to quickly and easily restore humeral length, and thus gross reduction of the fracture with the patient positioned supine.

60 YOF WITH COMMINUTED DISTAL HUMERUS FRACTURE

The patient sustained a terribly comminuted distal humerus fracture as shown below. She has a history of MS, but remains very active. Given her relatively young age and activity level, surgical repair of her fracture as opposed to joint replacement was recommended.

The Procedure

   The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made, along with an olecranon osteotomy. The distal half of the humeral shaft was exposed in the usual manner. The fragments of the distal humerus were reduced and provisionally pinned. Thereafter, two 90/90 plates were applied. The fracture healed uneventfully, with ROM 20> 130 degrees and full forearm rotation by 3 months postop.

The Reducer/Distractor component of the ElbowLOC® allows the surgeon to rapidly restore normal humeral length and thus obtain (and maintain) gross reduction of the fracture. This ability greatly simplifies and expedites the surgery as the surgeon can now “fine tune” the reduction, provisionally stabilize the fracture, and then apply the definitive fixation. In my experience, supine positioning using the ElbowLOC® Arm Positioning System can reduce procedural times (as compared to lateral decubitus or prone positioning) literally in half for these difficult cases.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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ElbowLOC Arm Positioning System Featured at ASSH 2017 Conference

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The ElbowLOC Arm Positioning System had a terrific reception at the 2017 Annual Meeting of the  American Society for Surgery of the Hand in San Francisco September 7-9th. Surgeons continue to realize the value it brings to their practice in terms of simplifying and expediting many surgeries on and about the elbow and lower arm. Trial the ElbowLOC and see for yourself the future of elbow surgery.

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Case of the Month - Total Elbow Arthroplasty

Total Elbow Arthroplasty

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

Total Elbow Arthroplasty (TEA) is a very reliable procedure to improve pain and restore function in cases of severe arthritis, complex elbow fractures in select patients, and even unstable elbows that have failed prior stabilization procedures. TEA is gaining in popularity as techniques improve and outcomes are validated. Supine patient positioning is ideal for these procedures.

 

68 YOF WITH RHEUMATOID ARTHRITIS

 

The patient had chronic rheumatoid arthritis, with progressive left elbow disease despite appropriate medical management including biologic agents. Her right elbow joint remained relatively well preserved.

The Procedure

   The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. The triceps insertion was reflected laterally. The procedure was performed by one surgeon with two surgical technicians. The procedure was uncomplicated, with a total procedural time (patient in the room > patient out of the room) of 1 hour and 10 minutes. The patient had a planned overnight stay, and was discharged home the next day. Her postoperative course and rehab were unremarkable, with excellent range of motion and pain relief achieved.

Supine patient positioning is ideal for TEA from both a surgical exposure and visualization standpoint. Additionally, many of these patients have medical comorbidities that make turning the patient lateral or prone undesirable. The unique ability of the ElbowLOC® to hold the humerus stable vertically, while allowing the surgeon unrestricted control of the elbow and forearm makes elbow arthroplasty technically easier and accelerates these procedural times significantly.

This case is another great example of how the ElbowLOC® simplifies and expedites many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month - Lateral Ulna Collateral Ligament Reconstruction

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

July 2017

Chronic lateral elbow instability can be treated successfully with a lateral ulna collateral ligament reconstruction. Supine patient positioning is ideal for these procedures.

45 YO RHDM WITH CHRONIC LATERAL ELBOW INSTABILITY

The patient had chronic lateral elbow instability, with a history of prior open tennis elbow release and more than 10 years of activity-related lateral elbow pain. Conservative treatment included activity modification and repeated supervised physical therapy courses over several years. Routine x-rays were unremarkable. Clinical exam revealed a palpable defect in the posterolateral elbow soft tissue, along with exam findings consistent with lateral instability. MRI revealed at least a partially intact wrist extensor origin, but no identifiable LUCL tissue.

The Procedure

   The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. A posterolateral approach was made.  An autograft palmaris longus tendon graft double looped was utilized. The graft was secured proximally and distally with PEEK interference screws, and the sutures additionally woven through surrounding capsular tissue. Postoperatively, a controlled motion brace with a 20 degree extension block was utilized for 3 weeks, then unlocked. At a year follow up, patient had a 5 degree flexion contracture, otherwise full motion with subjectively normal strength and no pain

The ElbowLOC® Supine Positioner markedly simplified and expedited this case by stabilizing the humerus vertically while allowing excellent visualization of and access to the joint. With the elbow stable, proper seating/congruency of the proximal ulna within the trochlear groove is assured.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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Case of the Month - Supine Arthroscopy for Lateral Epicondylitis

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Case of the Month - Supine Arthroscopy for Lateral Epicondylitis

Supine Arthroscopy for Lateral Epicondylitis

 Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

March 2017  

Lateral epicondylitis usually resolves spontaneously. Persistent cases are readily amenable to arthroscopic treatment. Supine elbow arthroscopy is faster, optimizes patient airway access, and is more intuitive than lateral decubitus or prone positioning.  

40 YO RHDM CONSTRUCTION WORKER WITH RECALCITRANT LATERAL EPICONDYLITIS

 The patient had right elbow lateral epicondylitis for more than a year. Conservative treatment included activity modification, two separate cortisone injections, bracing, and supervised physical therapy. Routine x-rays were unremarkable. No additional imaging studies were obtained. Due to continued symptoms and functional disability arthroscopy was recommended.

 The Procedure  

 The patient was positioned supine utilizing the ElbowLOC® Arm Positioning System. Standard anteromedial, anterolateral, soft spot, and posterior midline arthroscopic portals were developed. An impressive full thickness tear of the wrist extensor origin was found and is shown, along with other aspects of the joint, in the photos below. Degenerative tendon tissue and capsule were debrided. The tendon origin on the lateral epicondyle was abraded with a curette and smoothed with a shaver to promote vascular ingrowth into the area and healing. The patient was essentially pain free within 48 hours post op. He had resumed his normal job duties with near normal grip strength and was pain free by 6 weeks.

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Figure 1 Wrist Extensor Origin Tear

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Figure 2 Coronoid and Medial Joint View

Figure 3 Radial Head, Capitellum, and Sigmoid Notch View via Soft Spot Portal

Figure 4 Radio-Capitellar Joint View

Figure 5 Intraoperative View 1

Figure 6Intraoperative View 2

With supine positioning for elbow arthroscopy, the anterior capsule naturally tends to sag away from the articular surface. This simplifies navigation and improves visualization. Posterior compartment arthroscopy is greatly facilitated by the surgeon’s ability to “dial In” the desired static elbow extension, relaxing the triceps and thus opening up the posterior aspect of the joint. Given these benefits, the optimized patient airway access, and the marked time savings versus lateral or prone positioning, it’s easy to see why supine elbow arthroscopy is becoming so popular. Additionally many surgeons have found that the unique ability to hold the humerus fixed vertically, while maintaining unrestricted control of the forearm accelerates procedural times significantly.

 This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!   

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Case of the Month – Technique Article Regarding Supine Elbow Arthroscopy

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Case of the Month – Technique Article Regarding Supine Elbow Arthroscopy

I would like to complement Dr. Chris Camp and his surgeon team on a job well done with the above referenced (and attached) article which was recently published in Arthroscopy Techniques. Dr. Camp and his team nicely review the supine technique and point out the significant advantages of supine patient positioning for elbow arthroscopy. We encourage everyone interested in elbow arthroscopy to give it a read. It’s concise and will be time well spent.

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Case of the Month - Supine Arthroscopy for Post Traumatic Loose Bodies

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

December 2016

Supine positioning for elbow arthroscopy is rapidly growing in popularity, given its comparative ease and many advantages over lateral or prone positioning. Intraarticular loose body removal is one of the most common indications for elbow arthroscopy.

 

52 YO RHDF WITH TRAUMATIC POSTEROMEDIAL ELBOW DISLOCATION AND MULTIPLE LOOSE OSTEOCHONDRAL FRAGMENTS

The patient sustained a posteromedial elbow dislocation from a fall. Her injury x-ray and a post-reduction CT film are seen below.

Arthroscopy was performed with the patient supine using the ElbowLOC®Arm Positioning System. The coronoid fracture fragment was from the anterolateral aspect of the coronoid and devoid of soft tissue attachments. It was simply removed, as the anterior capsule remained attached to the intact coronoid. The small comminuted trochlea fragments could easily be seen arthroscopically, but were removed through a small arthrotomy due to their location immediately beneath the ulnar nerve. The elbow was stable after loose body removal, and no ligament repairs were required. The patient was treated with a controlled motion brace for 8 weeks and regained full motion with no pain.        

The ElbowLOC® allows the surgeon to perform supine elbow arthroscopy while maintaining complete control of the forearm. This is a huge advantage versus other positioners. The ability to “dial in” the desired amount of static elbow extension makes posterior compartment arthroscopy particularly easier.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

 

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Case of the Month - Chronic Triceps Tendon Rupture With Achilles Tendon Allograft

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

November 2016

Supine positioning is fast, efficient, and optimizes patient airway access for the Anesthesiologist. Traditionally, however, it has been difficult to control static elbow extension to appropriately tension tricep repairs with the patient supine. Assistants can fatigue, and sterile bolsters or props can shift, frustrating the surgeon, compromising the repair and thus the outcome. The surgery can be performed with the patient lateral, or even prone. These methods, however, cost precious operating room time, offer suboptimal or challenging airway access for the anesthesiologist, and require extra assistants to hold the arm and manipulate it throughout the procedure. This case represents how tricep tendon repairs can now be performed easily, faster, and efficiently, with supine positioning using the ElbowLOC®Arm Positioning System.

The Case

35 YO RHD MALE WITH 3 MONTH OLD SUPERFICIAL HEAD TRICEPS TENDON RUPTURE

The patient presented to my office with a three month history of weakness and activity-related soreness in his left arm after falling off a deck at his home.  The physical exam was consistent with a triceps tendon injury, and his MRI is below:

The procedure was performed using the ElbowLOC® in supine positioning mode, with one assistant.  After identifying and protecting the radial nerve, I mobilized the stump of the superficial head of the triceps. Even with aggressive mobilization, I still had about a 2 inch gap between the native tendon and the olecranon. An Achilles tendon allograft was woven into the native triceps proximal in a Pulvertaft type weave. Distally, I ran double Krakow type sutures through three drill holes in the proximal ulna and tied the sutures over body bridges. These sutures were then doubled back through the allograft.

The ElbowLOC® allows the surgeon to “dial in” the desired elbow static extension with the patient supine. This enables surgeons now to repair these challenging triceps tendon tears with faster, more efficient, and safer patient positioning.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

 

 

 

 

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Case of the Month - Terrible Triad Elbow Injury with Coronal Shear Trochlea Fracture

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

October 2016

So called “terrible triad” injuries of the elbow (radial head fracture, coronoid fracture, with elbow dislocation) can be difficult to repair and achieve a satisfactory outcome. The anatomic complexity of the elbow can make visualization and secure repair of the coronoid fracture particularly challenging. Humeral shear fractures are quite seldom encountered with these injuries, but when present can make these injuries even more complicated to treat.

The Case

30 yo RHDM Terrible Triad Elbow Injury with Coronal Shear Trochlear Fracture

The patient fell down steps at his home, injuring his left elbow. He was seen in the local ER the day of his injury, and presented to my office two days later with x-rays and a CT scan (see below). These studies showed a displaced, comminuted radial head fracture, a widely displaced coronoid avulsion fracture, and a displaced coronal shear fracture involving the entire trochlea, with the coronoid process subluxed into the trochlea fracture gap. The skin about the elbow was healthy and neurovascular exam was normal.

 

The surgical procedure was performed utilizing the ElbowLOC® Arm Positioning System in supine mode with one surgical assistant.  An olecranon osteotomy was performed and the ulnar nerve decompressed. The radial head fragments were floating loose in the joint, and were removed and the joint space irrigated free of small fracture debris. The proximal ulna was retracted and the trochlea fracture easily exposed, reduced and secured with multiple headless screws. The coronoid fracture and anterior capsule were stabilized with sutures passed through the intact coronoid using an ACL drill guide. The radial head was then replaced. Interestingly, as the elbow was not completely dislocated, much of the lateral collateral ligament was intact. The ulnar collateral ligament was intact as well. Physical therapy was started three days post op, and follow up office x-rays 10 days post op are shown below.

 

The ElbowLOC® Arm Positioning System was used in this procedure to stabilize the humerus vertically while supporting the forearm; creating a stable platform for exposure, manipulation, and stabilization of the various injuries. As the forearm is only supported, not “captured”, by the ElbowLOC® the surgeon maintains unrestricted ability to rotate the forearm and manipulate the elbow joint without having to adjust the positioner or alter the surgical orientation. These benefits save a great deal of intraoperative time and frustration in challenging cases like this.

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

 

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Supine Elbow Arthroscopy For Osteochondritis Dissecans In A Throwing Athlete

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Supine Elbow Arthroscopy For Osteochondritis Dissecans In A Throwing Athlete

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

September 2016

Osteochondritis Dissecans of the elbow presents in various stages of severity, which govern the treatment. Treatment options for unstable osteochondral fragments include surgical stabilization if possible, or removal of loose bodies and debridement with microfracture of the base versus osteochodral grafting. The size and location of the lesion on the capitellum also influence the treatment method. Sometimes the location of the lesion and the presence of the overlaying radial head can make treatment difficult. The case illustrated below is a great example.

The Case: 14 year-old RHD Baseball Player with Osteochondritis Dissecans

The patient presented with the primary complaint of activity related lateral elbow pain for more than a year. When working out recently, he felt a painful click, and since then has had stiffness and more discomfort. Radiographs revealed a large, displaced osteochondral lesion with the bed measuring roughly 14 x 14 mm. 

Arthroscopy was performed using the ElbowLOC® in supine positioning mode. This allows very good arthroscopic or open visualization of all parts of the distal humeral articular surface. Additionally, the surgeon maintains complete control of the forearm and can “lock” the elbow statically in the exact positon needed, without relying on one or multiple surgical assistants and the inevitable drifting and motion that brings. The lesion was treated with removal of the loose bodies and debridement/microfracture of the base. Its relatively anterior position on the capitellum, made it more a bit more challenging to visualize and access than the relatively posterior centered lesions. 

The attached photos show how the ElbowLOC® helped simplify and expedite this case. Elbow hyperflexion is easily accomplished by placing the patient’s hand on his chest, which allows visualization and treatment of the posterior aspect of the capitellum. Static elbow extension was facilitated by using the ElbowLOC® Reducer/Distractor component instead of the standard Wrist Support. This maximizes the surgeons ability for static elbow joint extension and enables visualization and treatment of the anterior aspect of the capitellum.  This may be particularly important during elbow arthroscopy on patients of shorter stature, as it allows the ElbowLOC® Supine Arm to remain fully seated in the Base Support and creates maximum working area for arthroscopic instruments.

 

 

 

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Case of the Month - Obese Patient Ulnar Nerve Decompression

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Case of the Month - Obese Patient Ulnar Nerve Decompression

Obese Patient Ulnar Nerve Decompression
Lee Hunter MD, MBA
Hunter Medical Founder and Chief Medical Officer
July 2016


Ulnar nerve decompression in the cubital tunnel, usually a very straightforward and simple procedure, is made much more technically difficult by obesity. The relatively deeper position of the nerve, the abundance of subcutaneous fat, and the inevitable visual blending of the fatty tissue with the bridging subcutaneous nerves and the ulnar nerve make things more difficult. A stiff ipsilateral shoulder, even mildly so, can make the case that much more frustrating!


The Case:
45 year old female patient with BMI of 55 and chronic cubital tunnel syndrome

 

 As the elbow is held vertically by the ElbowLOC® (in the supine positioning mode), gravity helps the fatty tissue separate more easily and the ulnar nerve is held closely to the distal humerus during the exposure. This makes identification and protection of the many bridging subcutaneous nerves easier, and visualization and release of the ulnar nerve in the cubital tunnel straightforward. The surgeon doesn’t have to strain and lower his/her head to look around to the posteromedial corner of the elbow and find the ulnar nerve in a “sea” of fat, which is generally the case with the surgery performed utilizing an arm board. Visualization of the ulnar nerve can be particularly frustrating if the patient has ipsilateral shoulder stiffness and assistants find it difficult to maximally externally rotate the shoulder.
This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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