Thank you, Aaron, for putting this together, and I think it's a great concept for a course. I'm going to try to do the olecranon osteotomy real time. I think that the procedure is really the best approach for a distal humerus fracture. So the first thing we want to do is come down to the fascial layer, and then raise skin flaps all the way to the medial and lateral intramuscular septi. And I'm doing that here on the lateral side. On the medial side, of course, we are going to want to watch for the ulnar nerve. So we start distally, and stay suprafascial, and that way as we come proximal, it's a safer dissection. Once we've done that, the next thing to do is to find the ulnar nerve, and you want to not dissect it out of the space, but you do want to expose it and unroof it. And in the interest of time, we'll do that here, although it's safer to pick up the nerve proximally in this area right here. So there's my nerve right here, and I'm going to open the cubital funnel so that I can protect that, and go fairly distal, like that, and here's the nerve, and I'll take that about that far. So you can see the nerve. I haven't really circumferentially dissected it, but I want to expose it so that, and we'll carry that back into the soft, fleshy part of the triceps there. Once I've done that, then I want whatever form of fixation we're going to use for our osteotomy, we want to get that ready and prepare that before we do the osteotomy so that we don't need to deal with that at the end of the case. And my recommendation would be something other than an intramedullary device. You don't want the osteotomy not to heal, because that's a disaster with the distal humerus fracture, and it doesn't have to be complex, it can be tension band or whatever, but it has to be strong. So in this case, I'm just using this sled device, and we'll get everything set. This helps us find our way through the triceps. We can then slide this off at the wires, and we should be ready for our osteotomy. So we'll go ahead and advance this partially. I'll show you a couple of slides showing the difference that you get in exposure with an olecranon osteotomy versus other approaches. Really one of the most common problems that I see is people trying to do complex distal humerus fractures without adequate exposure, and that's what Aaron was speaking about. Now we're ready for our osteotomy, so I would take an x-ray at this point with a mini fluoro to confirm where the osteotomy is. We're not going to do that today, but basically we'll just expose the area of the bone. We've protected our ulnar nerve. I don't like to use a saw. I like to do this with an osteotome. Get a good grip on that. If you do like to use a saw, at least do the last part with an osteotome so that you get good interdigitation. But I think there's evidence in the literature of a higher non-union rate when the osteotomy is done with a saw. We don't have a particularly sharp osteotome here, but I go up to the anterior cortex. Fortunately, we have a big mallet, so you need one or the other. You can feel the anterior cortex, and once you're there, then you'll crack it like that. And then you want to take this down at the lateral intermuscular septum. So there's the supracondylar ridge, and I just go right down on the supracondylar ridge. So that's at the lateral border of the tricep, and then here's the capsule and the fat pad, and you just scoop that out like that. On the medial side, tell me if you can't see this. So I again come down on the supracondylar ridge, and there'll be vessels at the supracondylar ridge that you're going to want to preserve. So here's the posterior medial collateral ligament. You come through that, and then again at the medial border of the tricep, and you can just reflect that. And then here's the capsule, and once that's released, really then you can actually just use your finger or a cob, and you see that just comes off the distal humerus. Now the only other part to the exposure—am I doing okay on time? Okay. I do not like to take the nerve out of its gliding bed, so to get to the medial epicondyle, I'll actually do a little bit of a subperiosteal dissection. So I'm taking the intermuscular septum there, and then I'm going to elevate the nerve with its soft tissue attachment. And that gets me to the medial side. Just take down the medial intramuscular septum, and now if I'm using parallel plates, I have nice access to the medial epicondyle. Any questions on this so far? And then when I'm done, I'm basically all set for putting this back together, and I just need to advance my fixation device and fix it. Mike, I have one question for you. So if you have a patient with a very complicated distal humerus fracture, and you're concerned that you may have to have a bailout and convert to a total elbow replacement, what's your decision-making process for using an osteotomy versus other approaches? Sure. Don't compromise on your approach by not doing an electron-on-osteotomy because you're concerned that you might have to convert that to a total. You can do a total with an electron-on-osteotomy. You can either use a device like this, or you can put parallel K-wire sort of intercortically and a surplage wire, but you can definitely do a total elbow with an osteotomy. In fact, Mark Reitkamp wrote a paper about a trans-electron-on approach for a total elbow, and I actually think that might be a great way to do a primary total elbow. Can I get the slides? Okay, so let me just show you that I have one slide, and that was really to demonstrate the percentage of the articular surface that you see with the different approaches, paratricipital, trans-electron-on. You see twice as much of the distal articular surface with a trans-electron-on approach, and so you can see it there, and this is where, you know, if you have your coronal fragments, this is the only way you can see it. Here we can just take a little bit of the lateral capsule, and there's that capitellum, and really for everything, for aiming posterior to anterior screws, for aiming medial to lateral and lateral to medial, the only way I think that you can see enough of this to make sure that you're not intra-articular is this approach, so bear this picture in mind. There's nothing else that gives that to you. So Mike, you've mentioned that fixing the electron obviously is of paramount importance. Is your preferred method the slide that you have here, or do you have any thoughts on whether or not traditional tension band wiring is adequate enough for these? I think tension band is adequate. I personally use this device now because it's just very thin, but, you know, tension band, if well done, perfectly adequate. If we had the slide, I would show you plates and an intermediary device that both failed. So the important thing is to fix it well. If you get, if your osteotomy comes apart with a complex distal humerus fracture, or if it doesn't heal, that's a disaster, you know, because then you've got two complex problems. So I have seen a lot of failures with intermediary devices. That's probably not the best thing. Tension band, sled, anything like that. Yes, question. Can you talk to me about the intermediary device? Sure. So you'll want to actually find the nerve, and if you, you can actually feel it. Can I just, oh. So again, you come up here, and then you will see, and in the cadaver, the nerves are never quite as obvious, but you'll see that interval between the brachialis and the brachioradialis, and you'll actually be able to palpate the nerve, which is right here. So, but you always want to find it. I mean, that's a good, if you're concerned about a structure, the best way to protect it is to look at it. Any other questions? So just a quick show of hands, who uses an osteotomy as a primary approach to the distribution of fractures? I'd say 80 percent? Okay. So as a point and counterpoint, we have Bob Hoschkis, who will be hopefully speaking on his triceratops-bearing approach. Anybody? So, while we're waiting, do you have a preferential reason for using a trisysprine approach over an electron-osseotomy? Are there any specific procedures or… I have two. Yeah, I haven't done an electron-osseotomy in 25 years, for fractures or… that's the second one. And it's not… I just don't like… I treat a lot of secondary problems, and this is numerous fractures, and 50% of the time it's a non-union of the electron-osseotomy, where they've gone back and had a manipulation and things pulled apart. Look, it works, and this is really one of those things, you know, do you like Coke or Pepsi? I'm not sure it's the end of the world. Nope, that's Dr. Cohen's. It's this nice thin one, I got the really good one. Look at… I want to point this out. So, this was the arm I got, and this is the arm Cohen got. And again, if we're talking about distal humerus fractures or total elbows, that sort of thing, if you can maintain the triceps, and it's harder to do, I don't want to make any bones about it, and what Mike said is true, that it's easier to see the distal humerus. But if you don't take the triceps off, you can move the patient right away, there's only one side of fixation. You can do intra-articular fractures all the way around the block face, but you have to be comfortable with a lateral approach that Mark's going to show, an over-the-top medial approach, and be able to get the essence of the triceps out of the way. And so, it's a stepwise process, but let's start with… Can you zoom that in a little bit for me? So, let's assume we're doing a total elbow. One of the tricky things about the current editions of total elbows is they all require access to both sides of the joint. I think we'll begin to see versions of this that don't. Oh, there we go. So, we'll start with the idea that this is a distal humerus fracture. That's a fair comparison, so to speak. And I do those prone. I don't like doing a lateral position, especially with a larger person. I just tell the anesthesiologist, pretend you're doing a spine case, and they'll put them on the frame, and then it's, oh, so you can see everything. And now you've got perfect access, and it also helps reduce the fracture. So, straight posterior incision. I assume every case I do is going to fail. So, if the distal humerus internal fixation fails, I'm going to do a total elbow, so I want that posterior incision. And so, the idea here is to come down along the triceps, and I've already gotten the nerve out of the way. There's no way around that at all, nor should you be hesitant about that. So, the next point of entry that you want to be comfortable with is on the supracondylar ribs. Let's assume that the fracture level is right here. So, it's a pre-condylar fracture. We can talk about what happens as they get more distal. Typically, that fracture is going to be an extension. It's going to be shoved back. And as you come along here, you'll see, oh, wait, there's the fracture. And you can actually feel it right as you start to go through. And what you're going to do is come through this posterior medial window. Oh, sorry. Thank you. Don't hesitate to yell at me. And when you're doing that, you're going to come through the cubital tunnel. You're really dissecting the cubital tunnel off. And what you have to do on every tricep sparing approach, I think, is knock off the clitoride like a knife. So, I've already done that here. I need to turn this just a little bit so you can see it. Yeah. So, how about, can you all see that? That's not a bad idea. You guys are going to have to be treated to my posterior, but that's okay. I can see it too. So, it needs to be more like this. Just hold it like that. There we go. So, what I've tried to do is come down, this isn't my view normally, but anyway, is to come down this ridge. So, there's the posterior ridge. And reflect out the cubital tunnel. And now I'm going to come down and elevate the triceps off. You often have to excise the fat pad right in here. So, now you can see the electron faucet. And it's key to see the faucet because that's the key to the reduction. You're going to do this by looking at that alignment. And I continue this down. And I dissected this in advance. So, I'm going to take out my stage suture here. And now I've come around. Now, in a distal humerus fracture, I will leave the anterior collateral ligament intact. This I came around because partly we want to be able to show how to do a total elbow. So, this part would remain. Turn it a little bit more like that. So, there's an edge right here. And what you want to do is be right, don't go beyond the crista. Right there. Is that clear? So, what that allows me to do now is I can see all the way across the distal humerus. My finger can go all the way to the back and see all the way across. And the triceps is still well attached. Now, you can reflect more and more of this electron tissue. Remember that the insertion of the triceps is really right in here. Right here. So, if this was a distal humerus fracture, and we had two columns fractured on this, you'll see a little bit of Mark Cohen's exposure, but we'll go through it in more detail. You'll also come down the lateral supracondylar ridge. So, here's the lateral supracondylar ridge. And there's some symmetry here. Here's the medial supracondylar ridge here. I bring the triceps over here, and here's the lateral. If you're doing a total elbow, you don't need quite this much exposure. And again, what do I want to preserve in the fracture situation is the posterior lateral corner. So, there's a symmetry, right? The anterior medial corner you want to protect, and the posterior lateral corner. So, those are the two stabilizing features. So, here's the posterior lateral corner, and there's the anterior medial corner. Just hold that. So, I've now decided to come down the supracondylar ridge posteriorly, and do the same thing, although I'm not going to go all the way. And this is where it gets tricky, and I want to make clear. It's not as easy to do this reduction and internal fixation. However, if you do some contracture releases, and let's see if we can see this a little bit better. So, there is, hold on to this. Now, I've got access to both columns. There's the lateral column. The medial column's on the other side. Remember, this patient's sitting like this. So, I can push them forward, and I can bring a plate all the way down here. And I can flip this, and I can bring a plate all the way down here. Easy. And to go back to the radial nerve dissection, or where's Waldo. The easiest way to do that is put, it's about 7 centimeters. My hand happens to be 7 centimeters. And if I put it on the lateral side, the nerve's right there. Almost invariable. The index finger goes on the epicondyle, and the radial nerve will be right here. And I usually find it by going a little more anterior first. If I need to go down and do an interarticular fracture, let's say the capitellum, or it's a low, like a lambda fracture with an extension up into the shaft, then I can come down, and again, I don't want to steal the thunder of Dr. Cohen. But you can see, we can see all the way down here. And all I've done is elevate up through that same approach he's going to show you. And I can now steal all the way across. So I actually have control of the entire distal human. For plating, for fixation. You can see here, I invite people to come up afterwards and just look at it, because it is kind of tough, but you can actually get your finger all the way across. And it's easy, it's pretty simple to put plates on this without taking down the electronon, without taking down the triceratops. So, if we're doing a total elbow, so now tell me, show of hands, do you want to see a total elbow for fracture, which is now the most common reason to do a total elbow? So, let's assume, this is the hardest thing to show, this is one case where you need a headlight. But let's assume you've got a lambda component, that this whole piece, this whole piece, all the way over to the medial side is up, sitting up in here, which is where it is. I can push this down, it always takes, you have to kind of pop it back in, and now I've got access to put, I put a headed screw, I usually use a headed screw on the edge of it, and I don't think you need a headlight screw, it gives you great purchase, and then you can extend that down, and you can put another screw here. If afterwards, come back up, I can show you cases of this, and it's really not very hard, and again, I don't want to diminish at all what Mike said, if you're unsure, you can always go to the osteotomy, but if you start here, you haven't given up anything, and when you close all this up, now you don't have an osteotomy, you've got good fixation, and I just put them in a sling, because you're kind of done. So, if we're doing the total elbow, remember, all designs currently on the marketplace require access to both sides, because the locking mechanism comes in from the opposite side. So, let's say we were doing a Pumarad Mori, or the Biolab, then you would come around, and you would open up, and so, now we've got the triceps here, triceps are still on the electron, you'd carry this dissection around, better turn it this way guys, you'd carry this dissection around, all the way around, so I'm coming up, there's the medial collateral ligament, and as I go around up onto the coronoid, and remember, the elbow's intact, so we're not worrying about that, and now it's just open this up, and now I have access to put the humeral components in, it's tougher, not as easy as taking off the triceps, by the way, if you want the total elbow to last a long time, take the triceps off, because it'll pull apart and they won't have any strength to push, and it lasts forever, but, you know, like having the car that can't get out of the garage, but you have plenty of access here, you can really, and let's say you're having difficulty, let's say it's an old fracture, so a lot of times the fractures aren't fresh and you don't have beautiful tissue, you decide it later, you inherit it later, so you may have to be more aggressive and reflect more of this sleeve off here, and again, if you need to, you can, but you can take as much as you want, and notice right up here, I want to just show, so here's the coronoid, right here, and I can keep reflecting this off if I need to, but I want to stop here before going further, if anybody has any questions or things they want to see, it really is not complicated, if you think about coming down, in essence, both sides of the triceps, along the supracondylar ridge, elevating that tissue along the front and the back of the humerus, preserving the anterior medial collateral ligament, and the posterior collateral ligament, and as you walk through, prior to dislocation, you can get your fingers around all of that spool, and you can obtain great fixation. So, that's the triceps bearing approach. When you close it up, by the way, and that's why it's important to keep this envelope of tissue, when you pull this back up, you have a stitch, especially on the medial side. So, if you have a choice, let's say you can't quite see enough and you want a little more visualization, go medial, right, because when you're rehabbing an elbow, the shoulder tends to stay abducted, and the medial side won't give way. If you go and expose the lateral side, again, I'm talking about a practice, now suddenly they start getting varus and posterior lateral instability. So, the medial side is much easier, much more stable, they can do this all day long. You can take that all the way down and sew it back up and it won't dislocate. Where am I time-wise? I think we should move to the medial approach. Are there any questions about this approach we can move on? Yes. I don't know where it went. Yeah, that's a good question. You know, what you're trying to see, let me see if I can show it. What you're trying to see is the beginning, actually, it's easier for me to show it with, hold that right there for me. What I want to be able to see is the T-part. I want to have a visualization of the T-part. So, I can come in, and you can take a third of the thing, it's not going to, you know, just keep elevating it, triceps off, and it gives you this perfect view. And I seriously invite anybody, if you say, let me try to do this without the osteotomy, and you do that, you can see, especially in the T-convolute, you can see everything you need to do. And again, it's not been out of the, sort of, some sort of, let me do these and not do it like an osteotomy, I just haven't had a need to do it, and it's so much easier than we've had them. And by the way, at the end of the case, now if you've done it bad, just a little humorous and worked on it, and you're all tired, you know the last thing, if you'll put that electronon back together, it's always the part where everybody's kind of like, oh yeah, why don't you do that? And then it fails, and it's a mess. Anyway. You know, I did for a while, and actually I can show you examples of that, and they do fine as long as you don't take that on the lateral side. If you come to the medial side and do this, give us a quick stitch, I can do the medial closer. If you just close this interval. So I'm just going to come in here, and I'm going to come to this corner. I'm going to take a margin and put it in a figure of eight. Watch what happens. Look how that closes that down. And come a little bit more like that. Back for a second. I'm not really holding that tension. It's a sleeve of tissue, it's not the ligament, it's the whole sleeve that's coming back together. So that's triceps sparing for fracture at the lower level. And next we'll go on to the medial approach. The medial approach is a workhorse approach. I think both the lateral side, which will be done by Mark Cohen next, and the medial approach are those exposures that just really need to be mastered and very fast. And by the way, in the fracture, you can add this again. Remember, we came down the medial column posteriorly, now I'm going to come down the medial column anteriorly. So when do we use this? I use this for almost all contractures because the population that I see invariably have some ulnar nerve involvement. I either can't feel the nerve, I'm not sure where the nerve is, and they have some symptoms, they've been in therapy, and I realize that people talk about, you know, should you or shouldn't you? I just end up taking care of it 99% of the time. I've even had patients who've had radial head fractures and it became swollen afterwards, they had a febrile tunnel after you got their contracture relief. So, I'd like to have a little assistance here. So, and this has been written up, it's in Greens, it's in a couple of other publications, but I call this the view, where you can see where the ulnar nerve is, and what I find a lot of times, people don't elevate these flaps up. By the way, I use Evacel liberally, I don't know if you guys use this at all. It's a spray fibrin, and when you do these small cases, it's fantastic. You let the tourniquet down, get all the big bleeders, wash it out, put the tourniquet back up, and the last thing you do is you spray the Evacel in there, and it looks like snot, and then you wrap up the elbow, and then you let the tourniquet down for the last time, and the amount of drainage in these cases has dropped to me easily by 60-70%. Anyway, so we're now looking at the medial side of the elbow, here's the supracondylar ridge, and again, I'm going to get the, this is a little soupier for them, but I've already gotten the ulnar nerve out. Now, the difference here is, I typically start anteriorly, but not always, and the idea here is, if most of the contracture problem is, you have to get to the front and the back of the elbow. I want to be able to see posteriorly, and I want to see anteriorly. The only thing I have to protect on this side is the medial collateral. So, I come along, I'm going to just snip my holding stitch, I've come along the supracondylar ridge, and I start up high, and I'll take something like a cob elevator, and I've divided the FCU, so here's the FCU, and I just, I'm a simple person, I use fingers to measure things, I use a finger breadth of the FCU, that's all I need to keep, and I can make this L cut, here's the ridge, here's the FCU, and now I start to lift this up, and as I come across, the safe place to be is up above, now, I want you guys to roll this, this way. So, this is the humerus. So this is the anterior. I can put my finger on the anterior part of the humerus. Here's still the intact FCU, epitondyle, nerve-sitting posterior. And what I've done is I've just elevated this off all the way. And you have to elevate the muscle off the capillary contracture relief. And what I want you to do is bring this this way, roll it up that way. Can you move the camera, please? Hold this right there. So here is the entire anterior part of the anterior. Give me another headlight, please. This is the front of the humerus. Again, I invite people to come up. I'm all the way down to the coronoid with my fingertips. And I've come all the way across. And we've safely elevated and excised all this capsule. So I've done the anterior part, and that's seldom enough, by the way. Now you have to get the posterior part. So just as we did, same idea, by the way, is the triceps sparing. I'm now going to elevate and come back to the ridge here. Back to the ridge here. And now I'm coming the same way. I've elevated the triceps off. I've kept the collateral ligament in this case. That's right there. Collateral ligament is here. This is the posterior. And in a contracture, this is always where there's a lot of HO, right in this zone, right in the cubital tunnel. That's why you have to get the nerve out. And there's also a ton of scar tissue in the olecranon process. And you have to really excise it. And again, excise part of the olecranon. It's not helping you. It needs to come out. So if you think about it now, we've got all the way back. You can see all the way behind the humerus. Fold this this way. I can now see all the way across the humerus. You can see there's the ridge of the articular surface. And it's completely stable. And I've got full exposure on both sides. Now what happens in a contracture is that you get to the lateral side. It gets more and more narrow. And so I don't mind stopping. And Mark's going to show you. Make a counter-incision on the lateral side. Just finish it. Don't spend a lot of time digging deeper and deeper, especially in a big elbow. Just make a second incision. It's not that big. It doesn't hurt anybody. The other nice thing about this approach is, let's say you have a true cornoid fracture of the medial facet. The medial facet is actually in the cubital tunnel. So that's right here. There's the joint line. See it moving? And right here is where that medial facet is. I can repair. I can repair. Brachialis insertion is right here. Here's the medial facet. I can put a plate on all the way down the cubital tunnel in this regard as a buttress on that medial facet fracture. And it's very stable. You can do it with a 2-0 plate or 2-4 plate. And it's very strong. And then, again, when you're done, let that go. So that's the approach to that. And if I need to, I can make this anterior window, and I can put my fingers in between. So I have a backup plan. I can get to the front and I can get to the back. Oh, that's nice. Does it work? Except you're in the way. All right. Anything else, Aaron? Just a quick question. So if you're coming down the medial side during contracture release, let's say you take a little bit more of the medial collateral ligament than you'd expect, a little more anterior, is there anything you do to you on the table to reconstruct the medial collateral ligament? No. If you've taken it off as an envelope, and, again, you can see it sort of here. So I've come here. If I close this up and I close that up and I rehab them in this position, even the next day they're fine. You just don't want to put them in this position. You don't want them throwing the baseball. But I do 90% of my contracture releases and the big osteocyte cases. You know, there's two kinds of osteocytic elbows, right? There's big ones and the little ones. If you have a big one, just do this. If you've got to get the nerve out of the way, don't go to the arthroscopy. Any additional questions? I'll be back up, so I've got to go. I'm happy to show you in detail. What I'll often do, and I can show this later, I'll make a little subcutaneous fat. I'll lift it up, tuck the nerve under, and pack it with a few monocryl. Then I take it through a range of motion. I want to make sure that no place is too tight or sliding back and forth. When you have a big arm, like a weightlifter or a football player, sometimes you have to notch the muscle a little bit. But I haven't done it so muscular in a long, long time. So it's really just subcutaneous with just a layer of fat to pack it in place. Good question. It's right where your finger is. That's right where it is. So it's right over that zone of the FCU, when you've divided that. So if you come around, notice on the other one, what I had to do was lift all that up. But if I just stay there, it's fine. And you can actually, you can see all of a sudden it starts to go as you sneak beyond that little centimeter of FCU. Okay, great. I think we'll move on. I'll be back. I'm sorry, I'm sorry. Just to reiterate on that point, all the cadavers will be up here for as long as you guys need after the session is over. Most of us will be around to answer any other questions. I encourage you, especially for these things that are a little more difficult to see and that are very tactile, come up, play with it, just look at the elbow and convince yourself that these are usable and not usable approaches. Next is Mark Cohen doing the lateral approach to the elbow. He's going to start with some slides and some video first, then we'll go into the cadavers.

surgeon

surgical procedure

olecranon osteotomy

distal humerus fractures

exposure

fixation methods

articular surface

complex fractures