Coonrad/Morrey

Total Elbow

Surgical Technique

Interchangeability, Anterior Flange, Clinical History

 Coonrad/Morrey Total Elbow Surgical Technique 1

Coonrad/Morrey Total Table of Contents

Elbow Surgical Technique
Indications/Contraindications 2

Preoperative Considerations 2

Surgical Technique 3
Incision 3
Humeral Resection 4
Preparation of the Ulna 6
Trial Reduction 7
Cement Technique 7
Humeral Bone Graft 8
Assembly and Impaction 8
Closure 9

Postoperative Management 9
2 Coonrad/Morrey Total Elbow Surgical Technique

Indications/ Preoperative
Contraindications Considerations
Indications include: post—traumatic Additionally, distant foci of infection, For those inexperienced in the technique
lesions or bone loss contributing to such as genitourinary, pulmonary, skin of elbow arthroplasty, a trial with a
elbow instability; ankylosed joints, (chronic lesions or ulcerations), or other fresh amputated, or cadaver specimen,
especially in cases of bilateral ankylosis sites, are relative contra-indications is recommended. The surgeon should
from causes other than sepsis; advanced because hemotogenous dissemination be aware of the coupling mechanism
rheumatoid or degenerative arthritis to the implant site may occur. The foci and the technique of articulating and
with incapacitating pain; revision of infection should be treated prior to, disarticulating the two stems at the
arthroplasty; and instability or loss of during, and after implantation. hinge joint. Attention should also be
motion when the degree of joint damage given to the need for bone grafting
Joints that are neuropathic because
precludes less radical procedures. beneath the anterior flange. The
of diabetes of other disease involving
insertion of a bone graft anteriorly
The candidate for total elbow peripheral neuropathy are relative
enhances thickening of the bone stock
arthroplasty should exhibit joint contraindications to total elbow
at the point where maximum stress
destruction which significantly arthroplasty.
has been found to occur. The flange
compromises the activities of daily
and bone graft were designed to resist
living. Patients with single joint
torsional and posteriorly directed
involvement (generally those with
forces associated with loosening of the
traumatic or degenerative arthritis) or
constrained implants.
significant lower extremity disability
which require walking aids are less In those patients having both shoulder
amenable to treatment than patients and elbow pathology, the most
with advanced and predominately upper severely involved joint should be done
extremity involvement. If possible, elbow first. In patients with a pre-existing
replacement should be done after hip or or anticipated ipsilateral shoulder
knee surgery to avoid excessive stress to replacement, the four-inch implant is to
the prosthesis required by crutch walking be used. A bone-graft plug is inserted in
during total hip or knee rehabilitation. the canal at a depth of approximately 4.5
inches. At least 3cm distance between
Prior infection, paralysis, joint
the cement of the shoulder and elbow
neuropathy, significant hand
components is desirable.
dysfunction, or excessive scarring of
the skin which could prevent adequate
soft tissue coverage are each distinct
contraindications.

Use of the Coonrad/Morrey Total Elbow

should not be considered for patients
whose activities would subject the
device to significant stress (i.e., heavy
labor, torsional stress, or competitive
sports).

Lateral View Anterior/Posterior View

 Coonrad/Morrey Total Elbow Surgical Technique 3

Surgical Technique Make an incision over the medial Remove the tip of the olecranon and
aspect of the ulna and elevate the ulnar release the medial and lateral collateral
periosteum along with the forearm ligaments from their humeral attachment
Incision fascia (Fig. 3). Then retract the medial (Fig. 5). Flex the elbow to separate the
Position the patient according to aspect of the triceps along with the distal articulation from the humerus
preference. The recommended position is posterior capsule. Remove the triceps (Fig. 6). Externally rotate the forearm to
supine with a sandbag under the scapula from the proximal ulna by releasing allow further flexion and separation of
and the arm placed across the chest. Sharpey’s fibers from their insertion. the articulation.
Make a straight incision approximately Further reflect the extensor mechanism
15cm in length and centered just lateral laterally including the anconeus,
to the medial epicondyle and just medial allowing complete exposure of the distal
to the tip of the olecranon (Fig. 1). humerus, proximal ulna, and the radial
head (Fig. 4).Sublux the entire extensor
Ulnar Crest mechanism laterally.

Motor branch of ulnar n.

Sharpley’s fibers

Fig. 5

Ulnar Nerve

Fig. 1

Identify the medial aspect of the triceps Fig. 3

mechanism and isolate the ulnar Released LCL
nerve using ocular magnification and Released MCL
a bipolar cautery. Mobilize the ulnar
nerve to the first motor branch and very
Ulnar nerve
carefully translocate it anteriorly into
the subcutaneous tissue (Fig. 2). The
nerve must be protected throughout the
remainder of the procedure.

Flexor carpi
ulnaris m. Triceps

Fig. 6
Fig. 4

Medial
epicondyle
Fig. 2
4 Coonrad/Morrey Total Elbow Surgical Technique

Humeral Resection Remove the T-handle from the alignment

Remove the mid-portion of the trochlea guide and slide the cutting guide onto
with a rongeur or saw (Fig. 7) to facilitate the posterior side of the alignment guide.
access to the medullary canal of the The arm should rest on the capitellum in
humerus. order to provide the appropriate depth of
cut (Fig. 10).

Fig. 7

Identify the canal by removing a small

portion of cortical bone from the roof
of the olecranon fossa with a burr
or rongeur (Fig. 8). Then enter the Fig. 10
medullary canal with the Awl Reamer
(Fig. 9). Identify the medial and lateral Fig. 9
Use the plane formed by the posterior
aspects of the supracondylar columns, cortices of the medial and lateral
and visualize them throughout the columns to determine the rotational
preparation of the distal humerus to orientation of the humeral resection
Attach the T-handle to the Humeral
assure proper alignment and orientation. (Fig. 11). The cutting guide should be
Alignment Guide and insert the guide into
the humeral canal. parallel to this plane. When the cutting
guide is properly aligned, tighten the
Attach the side arm to the radial side of thumb screw.
the selected size Humeral Cutting Guide
so the “Right” or “Left” indication on
the side arm is adjacent to the “Right”
or “Left” indication on the cutting guide.
Tighten the knurled knob.

Fig. 8
Fig. 11
 Coonrad/Morrey Total Elbow Surgical Technique 5

The width of the Humeral Cutting To prepare a position for the humeral
Guide corresponds to the selected size flange and bone graft, release the
humeral component, and allows accurate anterior capsule from the anterior aspect
removal of the articular surface of the of the distal humerus and use a 12mm-
distal humerus. Use an oscillating saw 20mm curved osteotome to elevate the
to remove only the remaining trochlea brachialis muscle (Fig. 15).
by cutting first along the medial and
lateral planes of the cutting guide
(Fig. 12), and then along the proximal
Fig. 13
planes. Be careful to avoid violating
either supracondylar bony column as Begin rasping the humeral canal with the
this may cause a stress riser that can Starter Rasp. If necessary, gently twist
result in fracture of this structure (Fig. the rasp to further open the canal. Then
13). The proximal cut usually leaves use the Humeral Rasp that corresponds
the cortical bone intact on either side to the selected size humeral component
of the guide. If preferred, remove the (Fig. 14). If implanting the extra-small
cutting guide and the alignment guide sized humeral component, only the
to finish the resection down to the roof starter rasp is to be used (moderate
of the olecranon fossa. Then remove the burring of the distal section of the
fragments. If desired, inserting the distal canal may be required to assure trial
end of the appropriate size Humeral and implant fit). This results in a final
Provisional between the bony columns opening in the roof of the olecranon
can check the accuracy of the cut. fossa that is smaller than that of the
diameter of the medullary canal.

Fig. 15

Fig. 12

Fig. 14
6 Coonrad/Morrey Total Elbow Surgical Technique

Preparation of the Ulna Use the Pilot Rasp to further open the To prepare the last several millimeters of
Identify the medullary canal of the ulna canal. Then use the right or left Starter the ulnar canal, use a mallet to remove the
by using a high-speed burr to remove Rasp. If implanting the extra-small ulnar subchondral bone around the coronoid
the subchondral bone at the base of the component, the Starter Rasp is the final and the medullary canal. If desired, and
coronoid (Fig. 16). If necessary, remove rasp, and must be fully seated in order the canal is small, flexible reamers can
more bone from the tip of the olecranon to allow proper depth of insertion of the be used to prepare the canal (Fig. 20).
or “notch” it to allow the incrementally extra-small implant (this may require Determine the final orientation of the
sized Starter Awls to be introduced removal of additional intramedullary implant by placing the rasp down the
axially down the medullary canal (Fig. bone stock proximally using a Steinmann canal with the handle perpendicular to
17). Use the Starter Awls with a twisting pin or similar instrument). If implanting the “flat” of the olecranon (Fig. 21).
motion to further identify and widen the a small or regular ulnar component, use
canal. Place a finger over the exposed a gentle twisting motion to insert the
proximal shaft of the ulna to help prevent Small or Regular Rasp in the appropriate
violation of the medullary canal (Fig. 18). right or left configuration (Fig. 19). If
implanting a small component and
the canal is large enough, follow the
Small Rasp with the Regular Rasp to
provide a greater cement mantle around
the implant.

Fig. 16
Fig. 20
Fig. 19

Fig. 17
Fig. 21

Fig. 18
 Coonrad/Morrey Total Elbow Surgical Technique 7

Trial Reduction
Insert the appropriate size ulnar and
humeral provisionals. Articulate the
two provisionals, and connect them by
placing the pin provisional across the
two components. After the provisional
prosthesis has been coupled, perform
a trial reduction and range of motion. Fig. 23
Then remove the provisional
components. After the cement has hardened and
excess has been removed from around
the ulnar component, follow an identical
Cement Technique process for injecting the cement in
Using a pulsating lavage irrigation
the humeral canal. Remember that
system, thoroughly clean and dry the
the humeral orifice is smaller than
medullary cavities of both bones. Inject
the medullary canal. Use a specially
cement down the medullary canal of
designed plug or pieces of bone graft
the ulna, or both the ulna and humerus,
to provide cement retention when
with a delivery system designed to fit
indicated. Cut the injection tubing to the
down even the smallest ulnar canal. Cut
appropriate length and inject the cement
the flexible tubing to the appropriate
down the medullary canal in a routine
length for either the humeral or ulnar
fashion (Fig. 24).
component (Fig. 22). Because of high
resistance, inject the cement early in the
polymerization process.

Fig. 22

Insert the ulnar component first as far

distally as the coronoid process. The
center of the ulnar component should
align with the projected center of the
greater sigmoid notch (Fig. 23). The
flat of the ulnar component should be
parallel to the flat of the olecranon.

Fig. 24
8 Coonrad/Morrey Total Elbow Surgical Technique

Humeral Bone Graft Assembly and Impaction

Prepare a bone graft from the excised Articulate the ulnar and humeral
trochlea, or from the iliac crest or bone components, and connect them by
bank for revision surgery. The graft placing the hollow, outer axis pin across
should measure about 2mm to 3mm in the two components and securing it with
thickness and be about 1.5cm in length the solid internal axis pin (Fig. 26). Be
and 1cm in width. Place approximately sure that the two pins are fully engaged.
one-half of the bone graft anterior to the A click should be heard and felt when
anterior cortex of the distal humerus, the two pins are connected. If not, soft
and expose the other half through the tissue is likely trapped between the pin
resected trochlea. Insert the humeral and the implant preventing complete
component down the canal to a point engagement. After the prosthesis has
that allows articulation of the device. At been coupled, use the Humeral Impactor
this position the bone graft is “captured” to impact the humeral component down
by the flange (Fig. 25). the medullary canal (Fig. 27). Typically,
the component should be inserted so
that the axis of rotation of the prosthesis
is at the level of the normal anatomic
axis of rotation. This is approximately
where the base of the flange is flush with
the anterior bone of the coronoid fossa.
Flex and extend the elbow to identify
areas of impingement, and remove any Fig. 27
impinging bone with a rongeur.

Fig. 25

Fig. 26
 Coonrad/Morrey Total Elbow Surgical Technique 9

Closure
Deflate the tourniquet and obtain
hemostasis. Insert a drain, if desired,
and close the wound in layers. Return
the triceps mechanism to its anatomic
position and secure it with sutures
placed through cruciate and transverse
drill holes in the proximal ulna. Place
a heavy #5 nonabsorbable suture in a
crisscross fashion in the triceps, and a
C
second suture in a transverse manner.
Tie these sutures with the elbow flexed at
90 degrees (Fig. 28). To protect the ulnar
nerve, place it in a subcutaneous pocket
(Fig. 29). There is no need to repair the B
A
collateral ligaments. Use absorbable Fig. 28
sutures to repair the remaining portion
of the triceps mechanism. Then complete
the closure in a routine fashion. Apply a
compressive dressing with the elbow in
D
full extension.

Postoperative
Management
Elevate the arm postoperatively for
two to four days with the elbow above
shoulder level. Remove the drains, if
used, at approximately 24 to 36 hours,
and the compressive dressing on the
second day after surgery. Apply a light
dressing and allow elbow flexion and
Fig. 29 Subcutaneous
extension as tolerated. Use a collar and pocket
cuff, and instruct the patient on activities Ulnar n.
of daily living. Typically, no formal
physical therapy is required or indicated
unless necessary for the shoulder or
hand. Avoid strengthening exercises. The
patient should be advised not to lift more
than one pound during the first three
postoperative months and not lift more
than five pounds with the operated arm.

Lateral View Anterior/Posterior View

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