Table Of ContentMaster Techniques in
Orthopaedic Surgery
The Elbow
1st Edition
2002
Lippincott Williams & Wilkins
Philadelphia
530 Walnut Street, Philadelphia, PA 19106 USA, http://www.lww.com/
0-7817-1991-7
All rights reserved. This book is protected by copyright. No part of it may be reproduced in any form or by
any means, including photocopying, or utilized by any information storage and retrieval system without
written permission from the copyright owner, except for brief quotations embodied in critical articles and
reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S.
goverment employees are not covered by the above-mentioned copyright.
Printed in China
Library of Congress Cataloging-in-Publication Data
The elbow / editor, Bernard F. Morrey; illustrator, Jim Postier.—2nd ed.
p.; cm. — (Master techniques in orthopaedic surgery; [v. 1])
Includes bibliographical references and index.
ISBN 0-7817-1991-7
1. Elbow—Surgery. I. Morrey, Bernard F., 1943- II. Master techniques in orthopaedic surgery (2nd ed.);
[v. 1]
[DNLM: 1. Elbow—surgery. 2. Orthopedics. WE 168 M423 1994 v.1]
RD558.E423 2001
617.5′74—dc21
2001029921
Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the authors, editor, and publisher are not responsible for errors or
omissions or for any consequences from application of the information in this book and make no warranty,
express or implied, with respect to the currency, completeness, or accuracy of the contents of the
publication. Application of this information in a particular situation remains the professional responsibility
of the practitioner.
The authors, editor, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package insert
for each drug for any change in indications and dosage and for added warnings and precautions. This is
particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health care provider
to ascertain the FDA status of each drug or device planned for use in their clinical practice.
10 9 8 7 6 5 4 3 2
Editor
Bernard F. Morrey M.D.
Professor of Orthopedic Surgery
Mayo Medical School, Emeritus Chairman, Department of Orthopedics, Mayo Clinic, Rochester, Minnesota
Illustrators
Jim Postier
Matthew Morrey
Secondary Editors
James Merritt
Acquisitions Editor
Pam Sutton
Developmental Editor
Janice Stangel
Production Editor
Tim Reynolds
Manufacturing Manager
Karen Quigley
Cover Designer
Maryland Composition
Compositor
Contributors
Ralph W. Coonrad M.D.
Associate Professor
Emeritus, Division of Orthopedic Surgery, Duke University; and, Medical Director and Chief Surgeon,
Emeritus, Lenox Baker Childrens Hospital, Durham, North Carolina
Jon R. Davids M.D.
Assistant Consulting Professor
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina; and,
Medical Director, Motion Analysis Laboratory, Shriners Hospital, Greenville, South Carolina
Neal S. ElAttrache M.D.
Associate Clinical Professor
Department of Orthopaedic Surgery, University of Southern California School of Medicine; and, Director,
Sports Medicine Fellowship, Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California
Avrum I. Froimson M.D.
Clinical Professor
Department of Orthopaedics, Case Western Reserve University; and, Department of Orthopaedic Surgery,
Cleveland Clinic, Cleveland, Ohio
Gerard T. Gabel M.D.
Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
Robert N. Hotchkiss M.D.
Chief
Hand Service, Hospital for Special Surgery; Director, Alberto Vilar Center for Research of the Hand and
Upper Extremity; and, Associate Professor of Clinical Surgery (Orthopaedics), Weill Medical College of
Cornell University, New York, New York
Frank W. Jobe M.D.
Clinical Professor
Department of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles,
California
Jesse B. Jupiter M.D.
Professor
Department of Orthopaedic Surgery, Harvard Medical School; and, Chief, Orthopaedic Hand Surgery,
Massachusetts General Hospital, Boston, Massachusetts
Pierre Mansat M.D.
Clinical Assistant
Department of Orthopaedics and Traumatology, University Hospital of Toulouse–Purpan, Toulouse,
France
Bernard F. Morrey M.D.
Professor of Orthopedic Surgery
Mayo Medical School; and, Emeritus Chairman, Department of Orthopedics, Mayo Clinic, Rochester,
Minnesota
Scott J. Mubarak M.D.
Clinical Professor
Department of Orthopedics, University of California, San Diego; and, Medical Director of Orthopedic
Clinical Program, Department of Orthopedics, Children's Hospital, San Diego, California
Robert P. Nirschl M.D.
Clinical Professor
Department of Orthopedic Surgery, Georgetown University Medical School, Washington, D.C.; and,
Director of Orthopedic Sports Medicine Fellowship Program, Arlington Hospital/Nirschl Orthopedic Sports
Medicine Clinic, Arlington, Virginia
Shawn W. O'Driscoll M.D., Ph.D.
Professor of Orthopedic Surgery
Mayo Medical School, Mayo Foundation, Rochester, Minnesota
Felix H. Savoie III M.D.
Codirector
Upper Extremity Department, Mississippi Sports Medicine, Jackson, Mississippi
Alberto G. Schneeberger M.D.
Department of Orthopedic Surgery, Balgrist University of Zurich, Zurich, Switzerland
Morton Spinner M.D.
Clinical Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York
Robert J. Spinner M.D.
Assistant Professor
Departments of Neurologic Surgery and Orthopedics; Senior Associate Consultant, Department of
Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
David Stanley B.Sc., F.R.C.S.
Consultant Orthopaedic Surgeon
Northern General Hospial, N.H.S. Trust, Sheffield, England
John K. Stanley M.Ch.Orth.
Professor of Hand Surgery
University of Manchester, Manchester, England; and, Consultant Hand Surgeon, Upper Limb Unit,
Wrightington Hospital NHS Trust, Lancashire, England
Ian A. Trail M.D., F.R.C.S.
Honorary Clinical Lecturer
Department of Orthopaedic Surgery, Manchester, England; and, Consultant in Hand and Upper Limb
Surgery, Hand and Limb Department, Wrightington Hospital NHS Trust, Lancashire, England
Master Techniques in Orthopaedic Surgery
Series Editor
Roby C. Thompson, Jr., M.D.
THE FOOT AND ANKLE
RECONSTRUCTIVE KNEE SURGERY
KNEE ARTHROPLASTY
THE HIP
THE SPINE
THE SHOULDER
THE ELBOW
THE WRIST
THE HAND
FRACTURES
Dedication
To My orthopaedic mentors at Mayo Clinic who introduced me to the intriguing world of elbow surgery.
My colleagues at the Mayo Clinic who have generously referred to me interesting elbow problems
throughout the years; and particularly Doctor An who has been my “partner” in investigating the workings
of this complex joint.
All orthopaedic surgeons who have shared their interesting cases with me so that strides might be made in
the diagnosis and management of this often overlooked joint.
And to our families who understand and support us in our endeavors.
Acknowledgments
It is with a growing sense of appreciation that I acknowledge the shared contribution of so many of my
colleagues in the orthopedic community. Our current understanding of the problems of elbow
management has grown steadily over the years, not in small part due to the willingness of the orthopedic
community to share experiences with this challenging and capricious joint. It is with a sense of
indebtedness that I, therefore, acknowledge the numerous interactions and shared consultations with so
many of my associates and colleagues in the orthopedic community. I would particularly acknowledge and
recognize my partner, Shawn W. O'Driscoll, for his ongoing stimulus and innovative, creative, and probing
thought process. During the preparation of the second edition, I found myself continuing to reflect on the
confidence and support of my mentors Dick Bryan, Ron Linscheid, and Jim Dobyns. I wish to specifically
recognize the contributions of Doctor An in the biomechanics laboratory as a basis of so much of our
original thinking, as well as a source of inspiration and encouragement to continue the process of
developing a scientific basis for clinical practice. It is with a great sense of humility and appreciation that
I recognize these individuals' genuine commitment to education, to integrity, and to the inquisitiveness
that has characterized our Mayo practice and with which I have been fortunate to be associated. I also
wish to recognize the tireless efforts of my special colleagues, Bob Adams and Sherry Koperski, who
manage the increasing complex logistics of my practice, as well as Donna Riemersma who was also
responsible for manuscript preparation.
Finally, the numerous hours and considerable time that is required to prepare such a volume comes at no
small expense to one's personal life, therefore, I acknowledge once again with sincere appreciation, the
patience and understanding of my wife, Carla.
Series Preface
The first volume of the series Master Techniques in Orthopaedic Surgery was published in 1994. Our goal
in assembling the series was to create easy-to-follow descriptions of operative techniques that would help
orthopaedists through the challenges of daily practice. The books were intended to be more than just
technical manuals, they were designed to impart the personal experience of the “master orthopaedic
surgeons.”
Master Techniques in Orthopaedic Surgery has become precisely what we hoped for—books that are used
again and again, and are found at home and in the offices of practicing orthopaedists and residents in
training. Most importantly, they are recommended by orthopaedists who look to them for practical advice
and suggestions concerning the difficult but common problems they encounter.
The series is now entering its second edition phase. You will again find recognized leaders as volume
editors, known for their contributions to research, education, and the advancement of the surgical state
of the art. Chapter authors have been selected for their experience, operative skills, and recognized
expertise with a particular technique. The classic procedures are still included; some techniques have
changed as new technology has been incorporated; and new procedures that have been popularized
during the last several years have been added.
We are maintaining the same user-friendly format that was so well-received when the series was first
introduced—a standardized presentation of information replete with tips and pearls gained through years
of experience, with abundant color photographs and drawings to guide you step-by-step through the
procedures.
With these new editions, we again invite you into the operating room to peer over the shoulder of the
surgeon at work. It is our goal to offer the orthopaedic surgeon seeking an improved proficiency in
practice access to the maximum confidence in selecting and executing the appropriate surgery for the
individual patient.
Preface
In recent years there has been increasing attention paid to the elbow by the orthopedic community. I
believe this is due to a set of converging factors, including the increasingly difficult problems posed by
the pathology of this joint with the realization that an emerging set of solutions are becoming available.
In this volume the complexity of elbow pathology is addressed by a series of established and innovative
solutions, some of which have been developed since the first edition. Advances in surgical techniques
have included a better understanding of elbow exposure such as for coronoid fractures. The scientific
basis of improved management of complex trauma is based upon a clear definition of the relative
contributions of the articular and soft tissue elements of elbow stability. Advances in arthroscopy have
been significant both for elective and traumatic conditions and these advances are reflected in the
current text. The current techniques for total elbow arthroplasty and longterm follow-up are presented in
greater detail along with descriptions of two resurfacing implant designs.
The alternative to total elbow arthroplasty, including interposition with the Achilles' tendon allograft, is
discussed in detail. Details on the indications for and broadening use of external fixation is also provided.
Challenging pathology and encouragement by the ongoing communication of my colleagues has resulted in
undertaking this edition's preparation with enthusiasm and excitement. I genuinely hope and sincerely
believe that this book will be of value to my colleagues and to the orthopedic community, just as it has
been to myself and my coauthors.
Bernard F. Morrey M.D.
