Olecranon medial flip osteotomy for total elbow arthroplasty : Triceps-preserving approach to the elbow.

OBJECTIVE: The olecranon medial flip osteotomy offers adequate exposure to the posterior elbow, while preserving the continuity of the triceps extensor complex and sparing the innervation of the anconeus muscle. It avoids soft-tissue injury due to strain and aids in protecting the ulnar nerve by medially reflecting the long head of triceps. INDICATIONS: This surgical approach allows the exposure required for total elbow arthroplasty and concomitant radial head excision. CONTRAINDICATIONS: Patients who underwent previous surgical procedures to the triceps tendon insertion. SURGICAL TECHNIQUE: A posterior midline incision is used, extending radial to the olecranon and parallel to the crista ulnaris. Incising the triceps aponeurosis, the long head of the triceps is separated from the lateral head to expose the medial tricipital head deeply. Dissection is performed between the long head and medial head of the triceps. A thin extra-articular medallion of the olecranon tip is elevated, in continuity with the long tricipital head proximally and in continuity with the ulnar head of the flexor carpi ulnaris distally. The integral functional complex, including the long head of triceps, the osseous medallion, and the flexor carpi ulnaris, is flipped to the ulnar side to gain access to the elbow joint. On the radial side, the anconeus muscle is kept in continuity with the medial tricipital head. POSTOPERATIVE MANAGEMENT: A sling or splint can be provided for comfort and to allow soft tissue healing in the early postoperative period. Immediate active-assisted range of motion exercises are allowed within the limits of discomfort. RESULTS: The olecranon medial flip osteotomy was safely performed in 11 consecutive patients who underwent total elbow arthroplasty. No triceps-related complications were encountered at a mean follow-up of 20 months. All patients regained an elbow extension strength of at least grade 4 on the Medical Research Council (MRC) scale. A mean flexion angle of 126° (range 90-150) and a mean extension lag of 38° (range 30-70) were found. In conclusion, the olecranon medial flip osteotomy is a safe and effective approach for total elbow arthroplasty.