This elbow surgery case involves a sixty-six-year-old patient who underwent a right total elbow arthroplasty. During the procedure, the ulnar nerve was severely damaged. The surgical note reports that the ulnar nerve was transposed to the anterior side of the medial epicondyle. This signifies there was some direct manipulation to the nerve site. The patient underwent a second surgery to attempt to relieve inflammation, numbness, and pain. During this procedure, the subsequent treating surgeon found that the ulnar nerve to be displaced to the posterior side of the epicondyle. There was also significant scar tissue formation with severe ulnar neuropathy from compression of the nerve at the elbow. The surgeon claims to have constructed a tunnel and secured the nerve in place to prevent migration. However, there was no reference of this in the operative report.
Question(s) For Expert Witness
- What is the proper technique for an elbow arthroplasty?
Expert Witness Response
Pain is the main indication for total elbow arthroplasty. Pain relief following total elbow replacement is excellent in most patients with derangements. In some younger patients, excision of the radial head and synovectomy of the elbow have offered a conservative and effective method of treatment for refractory elbow pain. However, subsequent conversion of this procedure to a standard capitellocondylar total elbow replacement is more difficult. In one series, the degree of improvement in such patients was lower than in those who underwent primary elbow arthroplasty. In patients with radiographic evidence of advanced joint destruction and with pain, stiffness, and instability that limits activities, implant arthroplasty is preferred to radial head excision with synovectomy. Two types of total elbow arthroplasties are frequently chosen by orthopedists. One is a semiconstrained metal-to-polyethylene hinge; the other is an unconstrained capitellocondylar design.