Any questions on some of the earlier talks? I think the three of us will try to... David, why don't you come on up? Why don't you come on up? Oh, you want me to come up there? All right. Yeah. Yeah. But, Graham, you said you don't do capsulectomy when it's arthritis. And it fits me, it fits what I've been thinking. If there's bone in the way, if there's a piece of metal in the way, usually when you get it out of the way, you just push your arm and the capsule tears. Is that what you're saying? Yeah. I mean, I think post-traumatic arthritis and primary OA are different. So my experience with the primary OA is like kind of the weightlifters, the heavy manual labors that come in with this, as opposed to someone that's had a dislocation of their elbow. That's different. People with a dislocation that had a primary capsular injury, they'll need a capsulectomy to get range. But these people that just have osteophyte impingement, you won't get it perfect, but you can get it usually down within 10 to 20 degrees. And for me, adding a capsulectomy for 15 degrees of range, I have a careful discussion with the patient as to that issue because I think it adds a level of complexity and a level of risk to the patient. They better understand that very carefully. I document that very well. Question? I'm curious to know how you all feel about a 55-year-old man who has radiocapitular arthritis, the role of radial head replacement versus excision, and as it pertains to replacement with regards to the added stability or a long-term benefit of replacing versus just excising. Lisa, why don't you take that? I try never to excise the radial head. And never say never, but I have a slew of patients in my practice that have had injuries, remote history of injuries, either as children or somewhere along the road. And you think, oh, it must be okay to take the radial head out now. They don't have any risk symptoms. I'm just going to take it out. And I've seen those go on to have problems. So whenever possible, I try and figure out a way to keep that longitudinal stability, and whether that means a radiocapitular joint replacement or doing a radial head replacement and a hemi-interposition arthroplasty. I've done that at times when the ulna-humeral joint looks good. So I try and come up with some way of preserving the radial head. Thank you. Let me add to your question before I answer it. Graham, I wasn't hearing a lot about radiocapitular arthritis isolated. How often do you see that? Well, I think you see it commonly in people with primary OA, but usually that's asymptomatic. And that's what Scott showed in his series, that you don't have to take out the radial head, even when the joint doesn't look so good, in primary OA. Now, it's different, as I tried to show you in the case where someone's fractured their radial head, either treated operatively or non-operatively. Particularly if they've had it treated operatively, of course, and the fixation's failed and the plates and screws have now chewed up the capitulum. That's the real sad thing. So even though, as Jesse says, the radial head, try to fix it, but you have to be careful because I think you actually do burn a bridge with the capitulum and completely chew it up by the hardware. So in post-traumatic arthritis, when the problem is primarily pathology at the radiocapitular joint, then I do believe, as I showed you, that there are cases where the radial head has to go. If the capitulum's not too bad, and we published a series by Ben Shore, published in the JBGS, where we took out the radial head in patients with arthritis and put in an implant. But again, those capitulums had normal bony architecture, so they didn't have erosion of the bone, and they still had some cartilage or fibrocartilage remaining. When we do it in that circumstances, I always tell the patients, you know, that's a buff, not a shine operation. They're still going to have some discomfort, they're not going to be pain-free, and we always put the head in a little bit under-lengthened so that there's not an issue. Now, as Lisa said, if the capitulum looked worse, we'll throw in a little interposition at the same time. I actually have not yet done a radiocapitular replacement because I'm not fully satisfied with the implants that are currently available for that, but I think that that will become more popular. My spies in Great Britain have told me that they're having a lot of trouble with those implants and removing a lot of them, so you better be cautious because that's new technology, and I've got a lot of gray hair and I've seen it. I think you have to be careful when you look at the x-rays. It's very common to see significant radiocapitular arthritis in the arthritic elbow, but often it doesn't hurt. So you really need to—and I focus my exam and make sure I convince myself their pain is actually coming from the radiocapitular joint. Having said that in a 55-year-old worker, I still would do an arthroscopic approach to try and clean things up, see if I can make them feel better. And as Graham mentioned, there is the option to do a radiocapitular replacement. There are two essentially out on the market. There's one that's only in Europe. That's one company makes. There's one that I'm not conflicted, but one of my partners at the Yale Clinic developed, and that's one I'm familiar with. And surprisingly, the capitular component we haven't seen loosening to be an issue, and it seems to perform somewhat like the glenosphere of a total shoulder, but it's more compressive forces rather than sheer forces. I think it's interesting, the problems seem to be on the radial head side of that implant. So we still haven't really accomplished a radial head replacement, but we maybe have a decent capitular replacement. I know Dr. Mori has done some capitular replacements and not replaced the radial head, and they've gotten reasonable results in those situations. A little bit of controversy there, David. So I'll be, I seem to be in this position a lot, but I'll be the dissenting opinion. You know, it's very interesting that radial head resection has become almost taboo. Wouldn't you say you have that feeling? But if most of the time when you see a malformed radial head from a fracture, it's approximately a joint problem, and they have a restriction of form rotation. And if you take that radial head out, it's a simple, safe operation, and they get full form rotation. I do a little jig, pat myself on the back. I read the papers that were back-to-back in JBGS from Goldberg in Israel and from Broberg and Mori, and they report excellent results, and I have no reason to doubt those, because I've seen the same. And who knows what happens to metal on cartilage long-term? And you didn't see the Judae osteolysis, which they reported after about a 10-year follow-up. So the bipolars aren't perfect, and it's hard to make it just right, and that wears on the cartilage. So I really don't know. And I don't think we should forget history. We're going to have some talks about the shoulders we stand on at this meeting and stuff. I mean, radial head resection is a really good operation. I had a question with respect to Dr. Graham regarding post-operative management of an arthroscopic elbow debridement. And specifically, do you use CPM and do you use really passive range of motion? Again, it depends a little bit. I had to go very quickly through that on what you've done. If you've just done an arthroscopic debridement with osteophyte removal, no-cap selectomy, and the range of motion wasn't too bad pre-op, then we do those as outpatient procedures. They get a general for their case. They get a block, which lasts until morning. We get them to take their dressing off themselves, move in the dressing, and basically have them come back to see a therapist after a few days to get formal therapy. In terms of the patients that we're doing a big debridement, either arthroscopically or open, we've increased their range of motion substantially, and they want improved range of motion. Then those patients are admitted. We leave an indwelling brachial plexus block in for a couple of days. We tend to splint them overnight, and then the next morning we put them in a CPM, usually for 36 hours, and then we send them home on post-op day two, although three would probably be better, but I've got to get them out in two. It varies. It's hard to get insurance companies in the United States to pay for an arthroscopic procedure for two or three days in the hospital, so we've had that issue. In my practice, I look at the patient when they come back. I send everybody home after the outpatient procedure, see them back in two days if I can, if they're not from too far away or if they're from far away the next day. I put a very compressive dressing on in the OR, so I like to see the hand actually swollen at one or two days after surgery. I take the dressing off and the elbow is not swollen. Then half the time I give the patients splints, just whatever your favorite splint to crank them out. Those crank-out splints don't work very well for flexion, but they give you a little bit of flexion. The very stoic farmers and laborers, most of those patients, I just have them start going back to work. I find out what they do. They're self-employed. They need to get back to work. I say get back to work the second or third day. It's important to understand, David did a study on open release and CPM in the elbow showing not much of a difference or no difference. We have very good data in the knee that CPM after six months doesn't make a difference, but the first two to three months does. We don't have that data, unfortunately, in the elbow yet. I had a very interesting experience. I'm the editor for those evidence-based medicine reviews in the Journal of Hand Surgery, and so I have a guy from England, so it's different in the NHS, writing about, and he does arthroscopic release, post-traumatic contracture arthroscopic release, CPM. He and his registrar reviewed the evidence, and we went back and forth going over the evidence and how to interpret it. At the beginning, there's that section at the end where you get to say your opinion, and he said, oh, I use CPM every time, and that's what we do, and I assume that's what he was taught. But after he'd gone through all the evidence, there's no difference. There's only one comparative case control study that was ours from Jesse's, and I'll tell you that's not a great study, but it's the best thing that's out there. Then there's Robaniak's that have some CPM mixed in, but there's a selection bias for sure. And then everything else is case series, and the average is, actually, the average, and there are very few arthroscopic. It's mostly open, and the average motion for the CPM is lower than the, it's comparable, but it's lower than the no CPM. So the guy changed his practice, writing this article. Can you believe that? Unbelievable. Scientists. But I would like to make a comment about that, because, again, the problem is the evidence is no good, so trying to make a decision as to what to do is difficult. When I started practice 20 years ago, or a little more than that now, when we used CPMs, it was like a horror show for the patients, because we put in these blocks that didn't work, because they didn't know where they were putting the needle. The patients, we gave them a bunch of narcs, and they weren't even frozen half the time. I felt sorry for them. But now you go up in the wards, they've got a nice motor block, they get good range, they're not in pain, and I think it's actually a different thing than when it used to be, at least in my institution, where we're pretty good at blocks. But I still know the right answer. David's right. So it's kind of hard to argue with insurance companies when they talk about evidence-based medicine, but there is no evidence. I think one thing I'd encourage, I do every case, is I take a picture of the patient when I'm done, and flexion, and then an extension. And I did that for several years, without actually putting the patient's name on the picture. And one of my fellows said, why don't you just hand out the same picture to everybody? So now actually, he's in a very lucrative practice right now. But now I actually write the patient's name on the drapes, and take the picture, and by the time the patient's ready to go home, I have an 8x10 picture. The top of the 8x10 is extension, the bottom is flexion. There's a lot of times you say, hey, I got really good motion in your elbow, but one advantage of a block in CPM is they can see the range of motion. So I send them home with a picture, which is cheap, cheaper than the CPM, so they can see. Tell them to put it on the end of their bed, put it on the refrigerator, and that's their homework, to keep that same motion that we got. One more comment on CPMs. If I could get rid of CPMs, I would be so happy, because they're a pain in the butt for the surgeon and the patient, and mostly for the residents. But I don't have any evidence that if you use a CPM, the range of motion is better, but I do think that the swelling is better, and I think psychologically for the patients to see their elbow moving that much immediately post-operatively has some impact on some patients, not all patients. I think that some patients that develop contractures are those patients that co-contract, and their psychological component to what they're doing and why they got the contracture to begin with. Not always, sometimes it's heterotopic ossification and soft tissue contracture, but some of them there's a psychological component. So I think that there's potentially another benefit that's not just about ultimate range of motion with the CPM as well. Well, I think Graham touched upon a very important thing, talking about arthroscopy, is the importance or need to do a complete capsulectomy. When I first started doing arthroscopy for O.A. and R.A., particularly O.A. patients, I would do a complete capsulectomy, and the R.A. patients, it seems like the capsule came out quickly anyway. But now I do a capsulotomy. I strip the capsule off of the humerus ventrally, and then off the coronoid area, and on the neck of the radial head, I'll cut across the capsule, and I'll leave the capsule over where the radial nerve is, in that area, where I've released the capsule from either end. And an R.A. patient, I don't go after the caps at all. I don't think they need to. And Graham, why don't you address that again? I think you touched upon that. Yeah, I think I've kind of said what I wanted to say. I mean, I think you're right. If you're going to take the capsule out, we don't know how much to take out. When we do it open, when we came in from the lateral side, we always left a whole bunch medially, and if you go from the medial side and you don't go laterally, you always leave a bunch on the lateral side. But I think the key is that the elbow moves well during surgery. We don't really know if you need a full capsulectomy, and there's no question if a capsulectomy arthroscopically is a procedure which is some danger, for sure. Well, I think we'll run through some cases here with the panel. If we could turn the lights out a little bit, David, if that's possible. And we'll skip through this one. This one will be a little bit more of a discussion. I think the pins are out. This is a 75-year-old female who has a three-year after an ORIF of a right elbow fracture, but came to me specifically over the past year, loss of finger extension and ulnar intrinsic function. Medial nerve is intact. She has mild dementia. She had a benign brain tumor 15, 20 years earlier. Right knee has OA status plus a fracture. And she had a left proximal humerus fracture at the other side that was treated non-operatively. And here's her fracture. David, maybe describe your approach to this. So it's a posterior, like a non-fractured exertation, or a posterior monocasian interarticular head fracture is part of that. In a 75-year-old, slightly demented person, I think I'd probably just realign the ulna and see if the radial head block form rotation maybe stopped there. And if the radial head was potentially maybe replaced in it? Yeah, I'd probably replace it. I mean, you could definitely argue for excising it in the Mayo algorithm. In the Mayo algorithm, you could just simply excise this. But I'd probably put a cranial head proxy system. And it's an important point. An elderly patient, obviously, with an electron fracture, I actually just had a review article on non-operative treatment of electron fractures. But for the most part, I think most of us would fix that in a 75-year-old. She's slightly demented. She's going to start using that arm. But the radial head, maybe, maybe not. So that's pretty much what was done. It looks somewhat reasonable. But David didn't have the advantage in the eye, but there appears to be a coronoid fracture over here. That was ignored. We can't really see that over here. And this is a few weeks later. And unfortunately, she uses a cane because of that knee fracture, the knee OA that she has. So this is a few weeks later. I think now we can see the coronoid fracture over here that's coming up. And the fragment popping up over here. Graham, any thoughts now? That's one of the pitfalls, when they're very ostentatious. We've seen that in our place too, where there's a coronoid fracture and you don't notice it. So something to be very aware of. And then another thing is that you can see how plates don't get a good hold of the proximal electron fragment. That's why I still use, even when I use a plate, I use a tangent wire to grab the tricep. Well, yeah, this is sad. I mean, the issue about the electron plate, I mean, it's not a plate I use, but the critical hole that should have been used is not filled. I mean, that's the high hole on the plate. The nice thing about this plate is it is, you put it and split down through the triceps and actually wraps around. And then you've got to put that top screw in and bring it down the shaft. Like they've done the lower screw, but there was no bone there. If they put the upper screw in, it probably wouldn't have fallen apart, at least the olecranon wouldn't have fallen apart. In terms of the radial head implant, well, that's, you know, I actually tend to put an implant in these patients actually to protect the ulnar fixation as a primary reason to replace this primarily. But of course, the coronoid is the big issue here now because the elbow is now dislocated and, you know, we're heading for the final common pathway, unfortunately. Lisa, would you consider X-Fix or any, trying to fix that coronoid? I tried to fix one this week like that. It's been two hours and really didn't accomplish much. Any thoughts on going after the coronoid or external fixation at this point? You know, that's a tough question. I think in somebody who's demented, is using weight-bearing on their upper extremity, there's not a great answer because you also don't want them weight-bearing on a total elbow, which is your only other option to consider at this point. You know, if this happened a week or two weeks after it was fixed, then I probably would go back in and try and revise it with adequate fixation. And I also wonder, yeah, the coronoid's an issue, but are there soft tissue issues as well on the medial side? I mean, we all know that there are those injuries where there's a lot of soft tissue stripping, and sometimes in the elderly, you see this with a fracture dislocation. And if you don't address those medial soft tissues, you can see this even with a coronoid fragment that may not be that big, but if you address the medial collateral ligament, then sometimes you can stabilize the elbow and not have to worry about the coronoid. This looks like it's probably a bigger coronoid piece, so that probably doesn't apply here, but if she came back at six weeks looking like this, I may not try and revise it, but if it's at a week or two, I think I'd try and fix it appropriately with a different type of fixation. I had the unfair advantage of, a patient actually came to me in 2013, 2010, so you can imagine this is gonna get a little bit different here. So this is March of 10. The thing that's interesting is that the patient was going to the same physician and very dutifully documenting by x-ray elbow, and then I guess saying, looks good, keep it up. But I'll move ahead a little bit, but there's no intervention done here in March of 10. Come back in a few months. Okay, I'll be back in a few months. Looks about the same, maybe I keep on going. That's May of 10. Two years later, I do two-year follow-ups now on my radial head replacements. So something's not going well, and then I think this is when, yep, this is when she came to see me. Now, for me, when the radial head is flipped the other way, that's when it gets my attention. That's when I think something's going on here. David, back to you, that's that screw, I think. Remember, she came to me because of a little bit of pain, but primarily because she couldn't lift her fingers at all. Yeah, I've seen joints go bad. All their nerve was also not functioning, but her median nerve was great. The only thing is, she couldn't get her fingers up very well. Yeah, I've seen joints go bad like this, that infection, Charcot. I mean, is she a diabetic at all? I don't think there's any answer here. I mean, make sure there's no infection, get everything out of the way that's not working. If she's got a really floppy arm, arthrodesis, there's not a whole lot you can do here. I would probably just take out anything that's causing a problem, make sure there's no infection, and see what you can make of it. I'd just seen, I guess, a couple months before, a patient that we worked up that did have a Charcot elbow, and I was concerned that her radial head actually was the main problem right now, that it was compressing her PIN. And so we worked her up. CT doesn't show much bone. I thought I'd get an X-ray of that left shoulder that was treated non-operatively. It didn't seem to have a lot of function, and it's surprising it doesn't have a lot of function in her head, does it? So now my intent, I'm gonna reel it up, that maybe we're zeroing in on the problem. I got a CT scan, and she did that benign, quote-unquote benign tumor a decade or two later was in the area of the cerebellum. So we made the diagnosis of a Charcot elbow, and all I did was do an approach you usually don't do to the radial head, but for my anterior approach, that's how I got the PIN, and Dee was pushing on it. And just took out the radial head from an anterior approach and did nothing else at all, and just put her in a cast to try and get her as stiff as possible. She did recover some. She got to about a finger's billi, get her fingers up, but she didn't achieve full strength. And she went away. Just to point out, that's the classic X-ray for a Charcot, is that thick subchondral bone there. Did you look at the X-ray back, David? David? How's that, David? Can you go one back? Can you go one back, sir? I'm not listening. Never mind. Can't go back. Can't go back home. But you were saying, David, just to describe the... Well, it's just, it's, you can, Charcot's get, you don't see them very often. Jesse had a series of four or five, I took care of one, and they had this really thick bone. Like this guy, the guy I took care of looked like bone cement. I don't know, I thought somebody left something in that. It's really, really thick bone. You can see that in the trochlear, the new trochlear knot. She has very, very thick bone. This is another case, not to belabor things, but it was a 48-year-old male who actually had known syringomyelia, who's known to have a Charcot elbow. Someone did an elbow replacement that failed, was revised two years later, and then came to me at three years. And this is not the X-ray that I saw initially, but when he came to me initially, this pin was still going through here. And then I thought I had a dilemma. I mean, he's getting loose, he's loosening up both prostheses. I said, that may fall out. It was just halfway in. And he came back four months later, and it fell out. And I was so happy. They said, there's no longer any stress on the implants much, and I really don't think I can make you better by not by putting the pin back in, that's for sure. And by taking all this cemented implant out, that infection is higher in Charcot. They can get infected just spontaneously, even. So I left him alone. This is, I think, about eight, nine months ago, and he's doing okay. He understands his limitations. And he walks with a cane, by the way, always did. So, you know, patient selection. So try not to operate on Charcot elbows. And when you do a primary elbow, you have to be ready for potentially doing a revision elbow replacement. And we do a fair number of revision elbow replacements at home, and they're not fun all the time. And sometimes, this is your first incision on a revision elbow. Looks kind of like this when you make the incision, so. Just a public service announcement for what you're doing. Oh, oh. Dr. King says, can we move on? I think we will. Lunchtime. Oh. So we'll move on to another case. There's a 69-year-old gentleman with elbow pain. He had an intra-articular distal humerus fracture, and underwent several attempts. I think one that worked, and it didn't work, and another attempt. But he told me seven ORIFs. It's hard to believe seven, but I'll probably believe, like, maybe three. Then he had a total elbow in 2006, and that was revised in 2008. Quote-unquote, there's no evidence of infection at that surgery, but now he comes in with pain at the elbow and numbness in his fifth finger. Well, they kind of all have numbness at their fifth finger, or, if they can feel it at this point, after eight operations. So, fairly standard exam. Well-heeled poster incision, decreased ulnar nerve distribution. So here's what he looks like, maybe six operations later, but two revision of his total elbow. Graham, maybe you want to have some thoughts on this? Well, this is my life, really. You never want to be an expert in anything. I mean, this had an APC, looks like reconstruction, I guess, and that was in 2008. No, I don't know when this is. That lasted five years, you probably did pretty well, to be honest with you, in my own experience. It lasted two years. Two years, that'd be more like it. So, you know, this is a big problem. He's still only 69, he's now, you're working on operation number nine, or something like that. I mean, you, of course, want to rule out infection. The ulnar component, surprisingly, looks like it might still be okay, although, you know, one of the issues here, of course, is he has no triceps, so his elbow's unbalanced, which I think tend to cause them to loosen more. I'm not quite sure why. I don't understand that. The other thing is the ulnar component's quite proud, and it probably is biomechanically not good for the humerus, either. Having said that, if it was well-fixed, I still would have some trouble tearing it out. Ruling out infection's the first thing to do. The usual blood work, I would actually aspirate this elbow, but I would expect it to actually not be infected. And so, then, you come along with trying to decide what you're going to do. Your options are, if it's not infected, to redo it, either one side or both, or you can use a megaprosthesis-type approach they will use in the lower extremity. I actually have no experience with that, so I would tend to do another reconstruction with allograft with a longer stem until it's up in the shoulder. Yes? Do you tend to favor small 18-gauge wires like this looks like, or cables, and when you use struts, do you use fibular struts or humeral allograft struts or femoral struts? When I'm doing a humeral reconstruction, I like the humerus, actually, because the lower extremity guys don't want it anyway, so it's actually, we can buy it cheaper, and it actually tends to fit better. You know, if you've got a femur that's almost so big, it's hard to get the bone to actually not stick out through the skin, so I actually like a humerus for a humeral reconstruction. I like an ulna for an ulna reconstruction. I'm tired of getting the same side for the ulna, so it's got the same curve. In terms of the wires I use, we don't use heavy cables. We tend to use, I guess they'd be about 16-gauge wire, but maybe they're better. I don't know. CT scan showing a little bit more of the same. Looks obviously very loose in the canal going up to the shoulder. So as Graham said, we did a workup. SOCAP, not too bad, but in my experience after, you know, operation number five or nine, whatever it is, I always assume they're infected. It just hasn't been caught yet, so we always do a staged procedure, and quite honestly, taking everything out or whatever needs to come out, that can take you two or three hours, and me, it's a nice break. Take everything out, then I can turn my mind off, come back later and think about what I really want to do. So the allografts, it's interesting, nothing healed. It's like pieces of plastic coming out, which is often the case if they don't incorporate. To me, that's sometimes a sign of infection. If they incorporate, that's usually not a sign of infection, so I'm very curious about potential infection here, and, you know, it just lifted straight out, and with it, when you take away those allografts, there really wasn't much bone there to begin with, and so I packed it with beads. I always count my beads. More surface area with beads than a rod, but you can see not a whole lot of bone. I left the OLA component. It seemed to be well-fixed. I've done that many times. You know, it's there. You can take the poly out, as we did, and potentially come back and hook it up if you get that opportunity. Lisa, any thoughts at this point now? Governor Graham said to do, and he cleaned it up, took lots of cultures. They all came out negative, and there's no acute inflammation at the time. That bone looks fairly thin. Yeah, I mean, I agree that going in and cleaning everything out in one operation and then coming back is how I would approach this. I worry a little bit about leaving the ulna in if I saw infection, but if everything came back negative, frozen sections were negative, then I think that's the right answer, and then, you know, you're left with a very long revision prosthesis or something like a total humerus, which I've done once in my career for a tumor, not for this situation, so neither one's a great option. You don't have much left to get fixation and proximal to where you are, and impaction grafting, I'm not that thrilled about. I don't think it helps that much, so yeah, good luck with that. Those are my thoughts. David? Fortunately, we don't get this. I'm never coming to work at the Mayo Clinic. Poor London. I don't know, you know, what if she could get her hand to her mouth with these beads in when you stop? Oh, she's still a he. She's still he, sorry. I got the patients mixed up. We're on to the 69-year-old guy. Yeah, if he could get his hand to his mouth. He can. He can with the beads in? Yeah, I'd stop. I'd be done. Would you take the beads out? No. So this is a Tom Graham idea, the cue ball. I had one of these recently. It was a woman that I took care of. I saw her at the stage where she had distal humerus nonunion and got the idea from Graham to stage it. Just don't trust anything. Just take it out, culture it, come back. We did that, came back two weeks later, looked great, cultures were negative. Fixed it up, and then she had a periprosthetic fracture, and I fixed that, so it's two operations, and then she came back infected and loose. So I took everything out, and I thought, and she was, she got a little sick, I think. She had a new onset AFib, maybe NMI, something like that. So this was during the stage reconstruction. I put a structural spacer in it, a big chunk of cement, and she can get her hand to her mouth, and she's not that unstable, and she and I agree that we're done unless otherwise needed. Yeah, that's the conversation I had with this fella. I mean, after seven, eight, whatever number of operations, he's not infected now, probably not going to get infected again. And I said, you can do a total humerus, which I've only done in the tumor situation. I think that's a little crazy for someone who potentially can accept a little bit of disability. His biggest problem with a lot of these patients is when you try to have a cup of water into your mouth, that you can't do. You can flex if you have your elbow in front of your chest. You can flex, but when you hold it out to the side or reach in the refrigerator, it's a useless elbow. So I did an idea that I got from Bob Hodgkiss several years ago. I haven't been thrilled at packing bone graft in and then cementing an implant in all at once, the shifting sands. I haven't been too impressed with the impaction grafting. So I told him, if he can grow me a new humerus, come on back. So I filled up his humerus with allograft and BMP and sent him out with a brace, not this plaster, but a brace with also the feeling that if you enjoy life in your brace and your pain level is, you know, we'll just stop there. And you can live life with your brace and enjoy the BMP and allograft in your humerus. He was not happy a year and a half. I got a CT scan that looked like this was healing in. I said, OK, well, let's revise it. So this is actually not that long ago, probably three months now. And so we just put a long stem. That's just to show you the length of this humerus. That's an eight inch. It's an eight inch. And there's cement in there, but you can see there's not a lot of cement. And I use cables and really crank them down I use fibular allografts because I cut them like sticks. And I can put three sticks around. It doesn't take up that much room. But I also, like Graham, humeral allograft from time to time. And so he's happy. But again, now the clock has been reset and it's still ticking. Is this going to fall apart? His cultures were negative. I took cultures again. I always take about six cultures were negative after this case also. So maybe next year I'll give you some follow up. I think we'll probably stop there to get ready for the next session. Any questions on any of these cases or any questions of any of the speakers so far? Question. What do you do when you get an intraoperative? Well, what I do is I get pathology and intraoperative. And if during the case, if it shows gross acute inflammation, then I do another bead exchange. If I find out that two weeks later after I've done that, that it's infected, that's why I always take cultures. I always take six cultures because if one comes back, what does that mean? But if two out of the six come back and we have a very good ortho ID department that actually writes a lot of literature on this kind of stuff, just specifically ortho ID, not just ID, then I would follow the right recommendations for treatment. And we'd probably do, for him, chronic suppression for the rest of his life probably. I think it's important to know that. Don't put your head in the sand. Take lots of cultures if you're committing yourself to the operation. But be prepared to treat them with antibiotics. Any other questions? OK. So Mike Hausman is going to be up next. And he's going to talk about how and when to fix coronoid fractures. Thanks, Lisa. And thanks, Scott.

elbow injuries

capsulectomy

radial head replacement

excision

arthroscopic elbow debridement

Charcot elbow

revision elbow surgeries