Great. So our last section before lunch is elbow section with really terrific speakers coming up. It will begin with Dr. Mark Barretts from Pittsburgh who is truly a master surgeon and as all his residents and fellows will attest, truly an extraordinary teacher. Thanks Craig. He's also an equally talented musician. Very important. Mark. Thanks. Props to you and Craig for a very ambitious program that you're pulling off. We're going to talk about the terrible triad. But I do have a major disclosure. I do have a prosthesis that will be shown here in which I have a financial interest. What I'll tell you is that the essence of this operation isn't the hardware. The essence of this operation is how you manage the soft tissues. So the steps that we're going to talk about are the lateral approach, resecting or fixing the radial head, fixing the coronoid, replacing the radial head, doing your lateral complex and then testing your stability. Do I need to click or will this run? Click? Click. Bam. And so this is the lateral approach to the elbow. We want to find the lateral condylar ridge and then use our thumb and index finger to find the anterior and posterior aspects of the radial shaft. The radial head should be dusted in the injury. And then we're going to come down that lateral condylar ridge and come across the radiocapitellar joint down the midline of the radial shaft. And we do that again once we're through the soft tissues. Find your ridge. Find your shaft. And you're going to be bisecting the common extensor origin, which is going to be some ECU, some ECRB, so you're coming through that. It's all tendinous. If you're in muscle in this part, you're off-centered. So this is a pure tendinous exposure. We're coming along. Your ECRB is going to be coming up, a little bit of your ECU, and then you'll hit a muscular portion, which is your ECRL, right there. And then beneath that, that's your capsule. And this is a great utilitarian exposure to the elbow, a nice approach to the lateral aspect of the elbow. Here I'm bisecting the anterior ligament, and now I'm seeing the radial head. And beneath the ECU is the fascia of the supinator. And you can incise a little bit of that because your posterior osseous nerve is going to be distal. We've got our fragments of radial head that we're resecting. We're going to use this little guide to decide whether we want to take this so that the ultimate implant will be distracted. This is an implant that telescopes with it, is distracted one or three millimeters. I generally set it up to be a three millimeter distraction. We're going to make our line for our provisional cut and make that cut. Now there is evidence that there really doesn't seem to be a difference in terrible triads between fixing the radial head and replacing it. So you've just got to do what's going to give you the best construct. So in this particular instance, I want to take a little bit more bone away. I'm setting up with the elbow reduced in the form of neutral position to take out a known amount of bone, and I'm going to replace that with a similar amount of prosthesis. And you can do this with any prosthesis. You basically want what you take away to be replaced by what you put in. Now what you can see here is that in pronation, the radial head goes anterior and medial. In supination, it goes posterior. Here we're doing the tug test to see whether there's any longitudinal instability, and then a valgus stress test to see if the MCL is intact. I've got a simulated coronoid fracture, and in order to see that, I'm going to peel away what's left of the lateral complex. You're going to have rupture of the LCUL fibers, which is going to contribute to the instability that I'm showing here. All I'm taking away now is what remains of the common extensor origin, and then you'll see just posterior to that a little bit of the capsule. And when you release this little bit of capsule, what it's going to do is it's going to really let you hinge open the elbow and get a good look there at your coronoid. Now for fixing this, you can try and put screws in. You can try and do a lasso technique. Dave Ring and Dave Roosh did a multi-center study where they suggested that the lasso technique was better. For the purposes of demonstration, I'm going to do this with a wire. Wires for fixing bone, I think, can be really, really nice because they can be very strong. I believe they're stronger than sutures and more rigid than sutures. The downside is with breakage. In this particular case, I'm actually coming through the radiocapitellar joint. You can do that with suture. I would not advise doing that with a wire. But once you do your lasso technique here, either tying a knot or tightening your wire, you then can see that you got a nice restabilization of the coronoid. We're going to undersize the radial head. So we're going to try and find a diameter that is slightly smaller than the radial head. And then we're going to broach the canal here in this particular system. There's two broaches. One is 6.5 millimeters. The other one is 7.5. And what we're trying to do is we're just trying to get a loose fit within that canal. We're going to share loads between the shaft and the stem in this particular implant. It's bipolar, so there's going to be a shared load between the stem and the head itself, and then finally between the head and the capitellum. This system has a set screw, which allows the inner portion of the stem to telescope. Once you bring it out to a certain length, you can put a set screw back in. And this is just to kind of simplify the number of options. So the stem is inserted. We then have a little hexagonal hole here for the head. The head is inserted. And then we're going to just couple these in situ. And you can do this with the lateral complex on or off. With the lateral complex off, really any implant that you use is going to be easily inserted. So here it's coupled. And we've made our initial, our final bone cut on the radius, such that I know how much implant I'm going to put back in. So I've designed my initial cut to match what has been taken out. And in order to recreate that, I'm going to put a shim and then a second shim between the stem and the head. And those two shims are going to distract the head with respect to the shaft. So that I, again, put back in what has been taken out. And then those shims will line this hole up with some little fenestrations that are on that inner portion of the stem. And this will lock the inner stem to the outer stem and put our head in an appropriate position with respect to the capitellum and the sigmoid notch. So now we've got metal in place, which is good. But as I said, that's not the key of the operation. The key of the operation is to deal with the associated instability. And so the associated instability is going to be first addressed by dealing with that lateral ulnar collateral ligament and, in fact, that entire extensor complex. So I'm making a little crosshair here to try and find the center of the capitellum on the lateral side. And I'm going to cheat a little anterior and a little distal so that the posterior aspect of this hole that I create, and that the posterior aspect is where my suture is going to ride and where my ligament is going to go down to bone, I want that dead center on the capitellum. And so you can see now that the forearm will sag away from the humerus, and we want to eliminate that sag of the forearm from the upper arm. And we can eliminate that in most cases by simply repairing the lateral complex. So this is a technique that I learned from watching Graham King, and it is basically a series of running, locking sutures that are designed to go to fan out from the lateral epicondyle down to the lateral crista on the ulna. And so it's designed to put the sutures in the same place that your lateral ulnar collateral ligament would normally run. Now I have seen a couple cases where the lateral ulnar collateral ligament has actually pulled off the ulna. And in those cases I've used a technique of de Ruch's where you use a suture as a artificial LUCL. But with this you can see that we're pulling the pants up on the forearm. And when we do that, now we rotate the forearm, that head centers nicely on the capitellum. And the final thing that I'm going to do from a stability testing standpoint is I'm going to support the brachium, and you can't see it, but that forearm is free. I'm just going to let it hang. And if the radiocapitellar joint stays reduced just with the weight of the forearm, then we're good to go. If not, in all of these cases I have an external fixator in the room. There are some instances where you may consider repairing the medial side. I do that infrequently. I don't have time to go through it, but there's a wonderful article by George Athwal on rehabilitation of elbow fracture dislocations, and I'd refer you to that. Thank you very much. Thank you.

terrible triad

elbow injuries

soft tissue management

lateral approach

radial head resection