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Figs. 1-C and 1-D Lateral (Fig. 1-C) and medial (Fig. 1-D) views of the elbow with 3-dimensional CT reconstructions can provide useful information to characterize a radial head fracture and may also be valuable for preoperative planning.
Figs. 1-E and 1-F Postoperative lateral (Fig. 1-E) and anteroposterior (Fig. 1-F) radiographs demonstrate appropriate implant size. The medial ulnohumeral joint space is symmetric on the anteroposterior radiograph with no evidence of varus alignment of the elbow.
Figs. 1-G and 1-H Lateral (Fig. 1-G) and anteroposterior (Fig. 1-H) radiographs made 2 years postoperatively demonstrate that the radial head prosthesis remains in good alignment. There is radiographic evidence of mild stem lucency.
The involved arm is placed over the chest with a padded bolster. A midline posterior skin incision is utilized. It is intended to minimize potential injury to cutaneous nerves and provide better cosmesis than a lateral incision.
A full-thickness lateral fasciocutaneous flap is developed and elevated laterally. The flap is elevated off the deep fascia of the forearm and off the triceps fascia approximately 3 cm anterior to the lateral epicondyle.
Illustration demonstrating the use of an extensor tendon split for the deep interval when the LUCL is thought to be intact. The radial collateral ligament, joint capsule, and annular ligament are incised to gain access to the radial head. The anconeus is left intact as the LUCL lies deep to its anterior margin. (Image courtesy of Wright Medical. Reproduced with permission.)
When the LCL is found to be disrupted, the Kocher interval between the anconeus and extensor carpi ulnaris is utilized. Once through the fascia between the anconeus and extensor carpi ulnaris, a bare lateral epicondyle may be present from avulsion of the lateral ligament complex and the extensor origin. The fractured radial head (plus sign) and the disrupted LCL (arrow) are identified.
The native radial head has an elliptical shape. Select the minor rather than the major diameter when determining the size of the radial head prosthesis. This will most closely replicate the diameter of the articular dish rather than the outer diameter of the radial head. (Image courtesy of Wright Medical. Reproduced with permission.)
To facilitate exposure to the radial neck for stem broaching, a Hohmann retractor (arrow) is placed carefully around the posterior aspect of the radius to deliver it laterally. Avoid placing a retractor anteriorly as this places the PIN at risk of injury.
Selection of the stem collar height is performed by placing the trial stem into the trial head to compare the total height with that of the native radial head that was excised. The height of the radial head prosthesis should closely replicate the height of the native head in order to ensure concentric articulation of the radial head with the lesser sigmoid notch. (Image courtesy of Wright Medical. Reproduced with permission.)
The posterior aspect of the forearm fascia has been whip-stitched (black arrow) using a number-2 nonabsorbable suture. Using the isometric point (white arrow) on the lateral epicondyle, a pair of 2-mm drill-holes is placed anterior and posterior to the lateral supracondylar ridge to shuttle the sutures, which were previously passed through the LUCL (asterisk) and through the extensor fascia.