Kevin Renfree, MD, FAAOS | Sean Renfree, MD | Jose Iturregui, MD| Katelyn Koschmeder, MD

The patient is a 61-year-old male with severe osteoarthritis of the left elbow. He was referred to our clinic for consideration of total elbow arthroplasty. However, given his high activity level, the decision was made to proceed with interposition arthroplasty.

The patient received a supraclavicular block and was placed under general anesthesia. The left upper extremity was prepped and draped in the usual sterile fashion. The limb was exsanguinated using an Esmarch bandage, and a tourniquet was inflated on the upper arm.

A posterior longitudinal midline incision was made over the lateral aspect of the olecranon. Subcutaneous flaps were elevated, and the ulnar nerve was decompressed and mobilized throughout the surgical field. The triceps was mobilized off the distal humerus, and a para-triceps portal approach was performed by separating the triceps tendon from the flexor and extensor origins.

The extensor tendons were elevated off the lateral epicondyle, and the lateral collateral ligament complex was released. Its footprint was marked with an indelible marker. The anterior and posterior capsules on the lateral side were released using electrocautery. Multiple loose bodies were identified and removed.

Attention was then directed to the medial elbow. The flexor origin was released off the medial epicondyle, and the ulnar collateral ligament complex was released. Its footprint was similarly marked with an indelible marker. The anterior and posterior capsules were released.

The radius and ulna were subluxed medially off the distal humerus. The distal humerus was then prepared using rongeurs, osteotomes, and a pineapple bur to remove osteophytes and restore normal contour. The coronoid and olecranon fossae were anatomically recreated. Osteophytes at the coronoid and olecranon tips were excised, and a large loose body was removed from the anterior capsule.

A fresh frozen Achilles tendon allograft was reconstituted on the back table. Three drill holes were placed in the distal humeral metaphysis just proximal to the olecranon fossa. Two #2 FiberWire sutures were passed through the central hole in a posterior-to-anterior direction, then through the folded allograft in a mattress fashion, and back through the lateral and medial holes. A free needle was used to pass the sutures through the posterior aspect of the allograft, which was then tied to drape the graft over the distal humerus.

Two additional drill holes were made in the lateral and medial epicondyles just proximal to the articular surface. A 2.0 PDS suture was passed through these holes to secure the distal aspect of the graft. The ulna was then reduced back to the humerus, and full passive range of motion was confirmed with excellent gliding and stability.

Two Super G anchors were placed at the lateral and medial collateral ligament footprints, each loaded with #2 FiberWire. These were used to further secure the graft and reattach the collateral ligaments and the flexor/extensor origins to their respective bony footprints.

The medial intermuscular septum was excised, and a subcutaneous transposition of the ulnar nerve was performed. The subcutaneous fat from the medial flap was sutured to the fascia of the flexor-pronator mass.

The wound was irrigated thoroughly with antibiotic solution, and 1 g of vancomycin powder was placed in the depths of the wound. Subcutaneous tissue was approximated with 2-0 Vicryl sutures, and the skin was closed with staples.

A sterile bulky dressing was applied, incorporating a posterior fiberglass splint with the elbow positioned at 90° of flexion, forearm in neutral rotation, and wrist in neutral flexion/extension. Fluoroscopic imaging confirmed concentric reduction of the ulnohumeral joint. The tourniquet was released, and the patient was extubated in stable condition.