ANTEROLATERAL APPROACH

USES

This approach is useful for biceps tendon repairs. (Sometimes just the middle part of the approach is needed for biceps repair.) It can also be used for coranoid process open-reduction internal fixation. Additionally, it may be used for exploration of radial tunnel.

ADVANTAGES

This approach can be extended proximally and distally as necessary. By staying lateral to the biceps tendon, it stays in the internervous plane between the median and radial nerves.

DISADVANTAGES

There are important structures at risk with this approach and great care must be taken to identify and protect them.

STRUCTURES AT RISK

Laterally, the structure at risk is the radial nerve. This nerve enters the forearm underneath the brachioradialis muscle, which is the first muscle identified with this approach. The anterior edge of that muscle should be dissected and the nerve will be found on the inner border of the muscle. It should be retracted out of the way and protected.

The brachial artery and the median nerve are at risk if you are dissecting medial to the biceps tendon. As long as you stay lateral to those tendons, there is no significant risk.

The recurrent branch of the radial artery is at risk with this approach if you are dissecting distally. It will need to be clamped and sacrificed, which can be done without any major problem for the patient.

TECHNIQUE

A curved incision is made starting 5 or 6 cm proximal to the elbow flexor crease along the lateral side down to the lateral elbow joint, crossing the flexor crease at an angle almost parallel to the crease, going over to the medial side, and then going distally. This incision is carried through the subcutaneous tissue. The brachioradialis is identified and its anterior border developed so that the radial nerve can be identified and protected.

The muscle just medial to the brachioradialis is the brachialis muscle, and it is traced distally. The biceps tendon sheath is anterior to the brachialis and, once opened, the tendon of the biceps is identified and traced distally. If the surgery is being done for a biceps tendon rupture, then it is frequently necessary to work proximally along the brachialis until you encounter the retracted end of the biceps. This may require a fairly long proximal extension of the incision. If the surgery is to free up the radial nerve, dissection along the brachialis and biceps is not necessary.