Bryan and Morrey describe a modified posterior elbow approach in which the triceps is reflected in continuity with the forearm fascia and ulnar periosteum, rather than detached from bone. The paper compares triceps outcomes across three posterior exposure techniques used in 95 prosthetic elbow replacements at the Mayo Clinic. The central question: can preserving the extensor mechanism in continuity eliminate the triceps weakness seen with conventional approaches?
Every time you plan a posterior elbow approach, the exposure choice directly determines whether your patient will be able to extend against gravity postoperatively.
When performing total elbow arthroplasty, use the Bryan-Morrey triceps-sparing approach: reflect the triceps in continuity with the forearm fascia and ulnar periosteum from medial to lateral, reattach through drill holes in the proximal ulna, and protect the Sharpey's fiber junction by keeping the elbow in 20-30° of extension during reflection.
Never osteotomize the olecranon for total elbow arthroplasty. It compromises the bone-cement interface for the ulnar component, making secure fixation impossible. In rheumatoid patients, the Sharpey's fiber-periosteum junction is frequently attenuated medially. Reinforce it with sutures at closure or you risk delayed discontinuity even after a technically clean exposure.
Bryan and Morrey describe a modified posterior elbow approach in which the triceps is reflected in continuity with the forearm fascia and ulnar periosteum, rather than detached from bone. The paper compares triceps outcomes across three posterior exposure techniques used in 95 prosthetic elbow replacements at the Mayo Clinic. The central question: can preserving the extensor mechanism in continuity eliminate the triceps weakness seen with conventional approaches?
Every time you plan a posterior elbow approach, the exposure choice directly determines whether your patient will be able to extend against gravity postoperatively.
When performing total elbow arthroplasty, use the Bryan-Morrey triceps-sparing approach: reflect the triceps in continuity with the forearm fascia and ulnar periosteum from medial to lateral, reattach through drill holes in the proximal ulna, and protect the Sharpey's fiber junction by keeping the elbow in 20-30° of extension during reflection.
Never osteotomize the olecranon for total elbow arthroplasty. It compromises the bone-cement interface for the ulnar component, making secure fixation impossible. In rheumatoid patients, the Sharpey's fiber-periosteum junction is frequently attenuated medially. Reinforce it with sutures at closure or you risk delayed discontinuity even after a technically clean exposure.