- Triceps-elevating approach
Make a straight incision, beginning level with the junction of the middle and distal thirds of, and centered on, the humeral shaft. Some surgeons make a straight incision, whereas others prefer to curve the incision around the olecranon to the radial side. The incision ends over the ulnar diaphysis.
An ulnar-based subcutaneous flap is developed.
The ulnar nerve is identified proximally along the medial border of the triceps.
It is then released from the cubital tunnel distally, through the flexor pronator aponeurosis to the level of its first anterior motor branch.
Whenever possible, care should be taken to preserve the perineural vessels.
A vessel loop is placed around the ulnar nerve, which is protected throughout the entire procedure.
This intraoperative view shows the ulnar nerve freed and tagged with a vessel loop.
Incise the fascia over the flexor carpi ulnaris muscle at the border of the ulnar bone, as the first step in the preparation of the extensor apparatus flap.
The fascia is detached subperiosteally from the ulna towards the radial side.
At the level of the olecranon the extensor apparatus is detached together with a sliver of bone using a fine chisel.
Proximal to the olecranon the posterior capsule is incised.
At the level of the humerus the extensor muscles are freed from the bone. Now the entire extensor apparatus flap can be retracted to the radial side.
Distally the flap is based on the anconeus muscle.
To enhance visualization of the articular surface, the elbow should be flexed beyond 100°.
Optionally, the tip of the olecranon can be removed.
For closure, the extensor apparatus is pulled into place using a Kocher clamp.
Some surgeons place the ulnar nerve back in the cubital tunnel, whereas other surgeons perform an anterior subcutaneous transposition.
It is essential that the OR report should clearly describe how the ulnar nerve has been protected, and the location of the nerve at the end of the operation.
The bone sliver is reattached to the olecranon with transosseous sutures.
Distally, the incision of the flexor carpi ulnaris fascia is closed.