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Olecranon Osteotomy

- Discussion:
    - used in conjunction w/ a posterior approach: for fixation of condylar fractures, as well as exposure of distal humeral non unions;
    - olecranon osteotomy can be either non-articularl or trans-articular;
           - usually the non-articular olecranon osteotomy is used for non-articular condylar fractures;
           - trans-articular osteotomy is reserved for articular condylar fractures;

- Intra-articular Osteotomy:
    - as always first elevate the ulnar nerve;
    - before performing olecranon osteotomy, its wise to predrill proximal ulna;
         - 1 cm longitudinal incision is made in the midline of the triceps;
         - 4.5 mm drill is used to make glide hole in proximal frx fragment;
         - golf tee is inserted, and 3.2 mm drill is inserted across distal fragment;
         - 6.5 mm tap is inserted across the frx site;
                - the hole is tapped until resistance is felt, which also marks the proper depth of the 6.5 mm cancellous screw;
    - elevate the aconeus off the olecranon to expose the articular surface;
    - a sponge may be placed across the articular surface for proctection;
    - intra-articular chevron olecranon osteotomy is then performed w/ oscillating saw perpendicular to long axis of ulna 3-4 cm proximal to its tip;
          - the chevron osteotomy prevents rotational malalignment;
          - osteotomy is made in center of olecranon sulcus because this area of olecranon has least amount of articular cartilage;
          - the hyaline cartilage of the proximal ulna is not continuous, but rather lacks cartilage w/ in the mid portion;
                - this is the optimal position for olecranon osteomy;
                - see: anatomy of olecranon;
    - chevron osteotomy is created a w/ thin oscillating saw until the far subchondral surface is reached;
          - the osteotomy should be completed w/ thin-bladed osteotome which cracks articular surface of semilunar notch;
    - cut is completed with osteotome using tension break of articular cartilage and subchondral bone;
          - a freer elevator may be placed over the articular surface for protection;

- Elevation of Extensor Mechanism:
    - residual portions of the capsule are removed;
    - as triceps is elevated on both medial and lateral sides, a small margin of triceps should be left on either side to allow for suture repair at completion of case;
    - proximal part of olecranon may then be elevated w/ triceps, which provides exposure as far as 7.5-10 cm above joint line before radial nerve is threatened
           on the lateral side of the exposure;
           - usually the branch to the brachioradialis will be encountered first;
           - see: posterior approach to the elbow;
    - further exposure is obtained by subluxation of the joint;

- Osteotomy Fixation:
    - 6.5 mm cancellous bone screw (over washer) in combination with a figure of 8 wire may be utilized for fixation of the olecranon osteotomy;
          - the proper screw length is based on the insertion depth of the 6.5 mm tap as it achieves moderate torsional resistance;
          - in small ulna, screw thread may not pass into meduallary cavity of shaft and a long 6.5 mm cancellous bone screw may jam before it achieves a good bite;

- Alternative Fixation:
    - secure osteotomy w/ two oblique 0.045-in (1.143-mm) smooth K wires & tension-band wire;
    - proximal ends of the K wires are carefully bent and anchored into bone;
          - tension wire is placed through a drill-hole in the ulna distal osteotomy and passed under K wires and triceps proximally to create tension band;

- Disadvantages of Osteotomy:
    - disadvantage is that osteotomy must be stabilized at conclusion of operative procedure;
    - non-union of olecranon osteotomy may occur upto 5 % of cases;
    - osteotomy hardware is often painful, requiring removal

The proximal ulna: An anatomic study with relevance to olecranon osteotomy and fracture fixation.

Olecranon Osteotomy for Exposure of Fractures and Nonunions of the Distal Humerus.

The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus.

Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures.