Elbow Resection for Deep Infection After Total Elbow Arthroplasty by Joaquin Sanchez Sotelo, Peter Zarkadas, Thomas Throckmorton, and Bernard F. Morrey.

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Elbow Resection for Deep Infection After Total Elbow Arthroplasty by Joaquin Sanchez Sotelo, Peter Zarkadas, Thomas Throckmorton, and Bernard F. Morrey JBJS Essent Surg Tech Volume 2(1):e5 January 11, 2012 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The patient is positioned supine, the upper extremity is draped free, and the surgery is performed with the arm across the chest. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The ulnar nerve is best identified either proximally or distally, is isolated and protected with a vessel loop, and is dissected thorough its whole course only when needed. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The radial nerve is best identified by deep palpation along the posterolateral aspect of the humeral shaft. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Figs. 3-A through 3-G Extended olecranon osteotomy. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The medial longitudinal and distal transverse limbs of the osteotomy have been created with a microsagittal saw and a high-speed burr. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Perforations are created on the opposite cortex through the soft tissues prior to elevation of the dorsal cortex with osteotomes. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Elevation of the osteotomy provides excellent access to the ulnar component and cement. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The components and cement have been removed. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Wires are passed in preparation for osteotomy closure. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Postoperative radiograph with the osteotomy closed and antibiotic spacers in place. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Figs. 4-A, 4-B, and 4-C Longitudinal humeral split. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The split is gently pried open with osteotomes over a period of three to five minutes. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Once the cement is debonded from bone, the component and cement are removed with a slap- hammer extractor. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Figs. 5-A, 5-B, and 5-C Posterior humeral window. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Elevation of the osteotomy provides access to the humeral component and cement. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The osteotomy site can be fixed with circumferential wires or sutures. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

When reamers are used in the humerus or ulna, care must be taken to avoid cortical perforation if cement causes the course of the reamer to deviate. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Figs. 7-A and 7-B Cement spacers are created after mixing polymethylmethacrylate with antibiotics and methylene blue. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Spacers may be reinforced with small wires. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

Figs. 8-A, 8-B, and 8-C Inadequate soft-tissue coverage is a major source of wound complications and persistent infection. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

A radial forearm flap is raised to assist in wound closure at the elbow. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

The forearm flap has been completed. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

. Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.

These anteroposterior (Fig. 9-A) and lateral (Fig. 9-B) postoperative radiographs show a “stable” elbow resection; preservation of both humeral condyles facilitates a fulcrum for elbow flexion and extension). Joaquin Sanchez Sotelo et al. JBJS Essent Surg Tech 2012;2:e5 ©2012 by The Journal of Bone and Joint Surgery, Inc.