Capsular Release for Flexion Contracture: The Column Procedure

Bernard F. Morrey

Pierre Mansat

INTRODUCTION

In those with primary degenerative arthritis or instances of elbow trauma in which the articular surface has not been badly injured, loss of motion results in part from thickening of the anterior capsule. This type of stiffness is termed extrinsic, and several treatment options are available. The technique described below is used in preference to an anterior exposure and may be used as an alternative to arthroscopic release especially for those with limited arthroscopic experience (1,2). Arthroscopic release of the anterior capsule is discussed in Chapter 15 (3). The author has found the technique described herein to be simple and reliable with a low complication rate (4) and that it avoids the more aggressive release needed for intrinsic contracture (1,2,5).

CLINICAL PRESENTATION

The column procedure provides access to the anterior and posterior capsules. It also affords exposure of the coronoid and olecranon processes as well as the anterior margins of the capitellum and trochlea and of the coronoid and olecranon fossae. As such, it is well suited for those patients with primary osteoarthritis as well as extrinsic traumatic conditions. Specifically, from a surgeon’s perspective, it is ideal for those lacking arthroscopic experience.

INDICATIONS/CONTRAINDICATIONS

Indications include flexion contracture with loss of extension of at least 30 degrees and preservation or minimal changes of the articular surface. Posttraumatic etiology such as dislocation is an ideal indication as is primary osteoarthritis. If limitation of motion includes loss of flexion, an additional step of posterior release may be performed.

This “simple” release cannot be done in instances requiring interposition of the joint. Interposition is used if any of the following three contraindications to the column procedure are present (6): a significant alteration of the articular contour, loss of joint cartilage (50%), or pathology that requires release of one or both collateral ligaments (see Chapter 31).

Additional contraindications include motor deficiency or spasticity especially involving the flexor muscles and residual impairment from closed head injury. The ulnar nerve symptoms must be addressed by a separate medial incision or by a posterior incision elevating medial and lateral flaps. If less than 90 degrees flexion is present, or preoperative symptoms exist, the ulnar nerve should be decompressed.

Finally, open procedures to address contracture in the adolescent or child have not provided as reliable correction (7) as does arthroscopy by an experienced surgeon which now may be the better option.

PREOPERATIVE PLANNING

The column release is indicated in those with extrinsic pathology, that is, extrinsic to the joint surface: capsule thickening, marginal osteophytes, and ectopic bone. This is determined in my practice by a simple lateral radiograph. This is the least expensive and is an accurate manner of evaluating the joint prior to surgery. There is no indication for an MR in treating patients with capsular contracture or posttraumatic loss of motion in my opinion. Today, a CT or a three-dimensional CT reconstruction is useful in the presence of ectopic bone, but is not needed routinely.

The second consideration before surgery is whether there are both flexion and extension elements to the contracture. If the patient has normal or near-normal flexion without ulnar nerve symptoms, then the dissection may be limited to the anterior capsule with the simple elevation of the common extensor tendon and exposure of the anterior capsule. If the patient has limitation of flexion, then elevation of the triceps and removal of the posterior capsule are necessary. While the determination of the extent of such resection is obviously done at the time of surgery, it is important to discuss the nature of the surgery preoperatively with the patient in the context of the anticipated rehabilitation and ultimate result.

Since the original description of the technique, we have become increasingly aware of the implications of ulnar nerve irritation before surgery. The ulnar nerve is addressed surgically if (a) the patient has ulnar nerve symptoms, especially with flexion; (b) examination reveals ulnar nerve irritation or has a positive Tinel sign; and (c) preoperative flexion is less than 90 degrees. Whether it is simply decompressed or translocated is the surgeon’s preference/judgment.

If the pathology suggests that there is intrinsic involvement or that a release of the collateral ligament is necessary to obtain adequate exposure, then the surgeon should be prepared to apply the distraction device protecting the collateral ligament repair and separating the joint surfaces for approximately 3 weeks after surgery (see Chapter 12). It is uncommon to be faced with this option if the proper determination of the nature of the contracture and adequate imaging and assessment of the joint surface has occurred prior to the surgery as discussed above.

Finally, it is important for the patient to have a clear understanding of the recovery time that is required after such surgery. The emphasis on the maintenance of the splinting program for several weeks or even months following the procedure is quite important, particularly depending upon the type of occupation and the expectations that the patient may hold.

CONCEPT

The column procedure consists of arthrotomy, release of the anterior and posterior capsule if needed, as well as excision of osteophytes through a limited lateral approach (Fig. 19-1).

TECHNIQUE

Positioning and Exposure

Either general or regional anesthesia may be used. The patient is placed supine with a sandbag under the ipsilateral extremity, or the table is tilted to 10 degrees away from the involved extremity. The arm is draped free and brought across the chest. The proximal one-half of a Kocher incision, which extends 3 to 5 cm proximal to and 3 cm distal to the epicondyle, is used if there is no previous incision and if there are no symptoms related to the ulnar nerve (Fig. 19-2). Note: It is useful to palpate the “column” and the radial head to properly orient the skin incision. If there are symptoms related to the ulnar nerve and there is any thought that the patient may require an elbow replacement or interposition, the long posterior incision is used. The nerve is explored by elevating the medial flap.

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