Surgical Approaches to the Elbow

Chapter 6 Surgical Approaches to the Elbow



Raul Barco Laakso, Pau Forcada-Calvet, José R. Ballesteros-Betancourt, Manuel Llusa-Pérez, Samuel A. Antuña



Introduction


The number of surgical exposures available and the potential for complications, make it essential that the surgeon who treats elbow injuries and performs elective elbow surgery has a sound knowledge of the local anatomy. Adherence to general surgical principles will help reduce the incidence of complications and will maximize the clinical result.


The complex anatomy around the elbow dictates many of the most commonly used approaches. Anterior approaches are rarely required and often avoided due to the location of vascular and nervous structures. Extensibility and flexibility of any approach is desirable in order to cover the full spectrum of elbow surgery. An extensile posterior cutaneous incision to access the elbow has been named by some authors the ‘universal approach’, owing to its safety and the possibility of accessing the medial, lateral or anterior part of the joint. Limited lateral or medial approaches have some indications and require special attention to the superficial nerves in order to avoid painful neuromas. In addition, the surgeon should be able to expand these limited approaches to address more complex procedures.


Arthroscopic surgery has more recently modified surgical exposures of the elbow, and many of the limited approaches that were used in the past have been substituted by arthroscopic techniques.



General principles


The application to the elbow of general surgical principles is probably more important than when these principles are applied to any other anatomical site.1,2 The following should be carefully considered when elbow surgery is undertaken:


1. Correct identification of the injury and evaluation of the potential surgical difficulties as these may alter the initial exposure.

2. Patients with previous elbow surgery should be carefully examined to assess the site of the scars and the condition of the skin and subcutaneous tissues. Medical records should be reviewed to identify previous surgical procedures on the ulnar nerve, extensor mechanism or any other anatomical structure.

3. Adequate positioning and free mobility of the limb.

4. Select exposures that do not disrupt the normal anatomy during dissection and closure. The use of a tourniquet aids in the identification of dissection planes.

5. Maintain complete orientation and adequate visualization together with protection of all vital structures throughout the procedure.

6. Provide dissection along natural tissue planes rather than across muscle, tendon or ligamentous structures. The use of intermuscular septa and internervous planes aids in reducing haemorrhage and scarring.

7. Careful haemostasis must be undertaken particularly after extensile dissections, to avoid haematomas that may lead to fibrosis and diminished range of joint motion.

8. Closure must respect tissue planes. An adequate soft tissue closure will provide reliable healing and predictable rehabilitation. Avoid wound closure under tension.

9. Adequate use of compression dressings, splints, elevation and ice will minimize haemorrhage and inflammation sequelae.


Clinical Pearl 6.1


Anticipate common patterns of injury when preparing and deciding on the surgical approach.


Exposure is an important part of the procedure but reconstruction and repair are as critical.


Use full-thickness flaps when exposing the elbow.


Always maintain anatomical orientation during the procedure to decrease neurovascular complications.


The use of an extension splint and elevation can decrease wound healing complications in posterior approaches to the elbow.



Lateral approaches


Lateral approaches are probably the most commonly used in elbow surgery. Indications for their use include: fixation of intra-articular fractures, capsulectomy, removal of osteophytes, removal of loose bodies, radial head excision and repair or reconstruction of the lateral ligaments.


Access to the lateral aspect of the elbow can be performed through limited incisions placed in line with the fascial interval through which the joint will be entered. These limited incisions can be distal or proximal to the lateral epicondyle depending on the pathology to be addressed. If a more extensile approach is required, these two incisions can be joined. Alternatively, if an extensile approach is anticipated preoperatively, our preference is to use a straight posterior skin incision with mobilization of a thick lateral fasciocutaneous flap in order to allow a lateral approach to the joint.


Several intermuscular intervals have been described. Kocher’s approach utilizes the interval between the anconeus and the extensor carpi ulnaris and can be extended proximally and distally.3 Kaplan described an approach in the interval between the extensor digitorum communis and the extensor carpi radialis brevis and longus.4


The radial nerve is in close proximity when using these approaches, especially with Kaplan’s approach, so care must be taken to protect the nerve during the surgical procedure.



Kocher approach


Kocher’s approach utilizes the intermuscular interval between the anconeus and the extensor carpi ulnaris. This interval permits safe access to the lateral elbow joint. The radial nerve is protected by the extensor carpi ulnaris muscle.



Indications


Fixation of condylar fractures, radial head excision and repair or reconstruction of the lateral ligaments.



Technique


Either a posterior skin incision with dissection of a full-thickness lateral fasciocutaneous flap or a limited distal lateral skin incision may be used. The anconeus and extensor carpi ulnaris muscles are identified by palpation. A thin strip of fat can almost always be observed in the interval between these muscles (Fig. 6.1). The muscle fibres of the anconeus and the extensor carpi ulnaris muscles tend to blend together towards the insertion, so it is easier to develop the interval in its distal part and then progress proximally. The deep fascia is then opened and the interval is developed by dissecting the anconeus posteriorly. The lateral elbow capsule with the annular ligament is identified and incised longitudinally anterior to the lateral ulnar collateral ligament.


image

Figure 6.1 Kocher approach. (A) The interval between the anconeus and the extensor carpi ulnaris (ECU) can be easily identified by a thin strip of fat distally. (B) After developing this interval, the recurrent interosseous artery can be found seated superficial to the capsule.


Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.24



Modifications


For reconstruction of the lateral ulnar collateral ligament, this approach can be extended proximally above the lateral epicondyle by developing the interval between the triceps and the brachioradialis (Fig. 6.2A). Once this is done, the rest of the extensor mass can be sharply incised from the epicondyle, respecting the insertion of the lateral ulnar collateral ligament. In order to achieve adequate exposure of the crista supinatoris, the anconeus along with the lateral aspect of the triceps tendon are reflected posteriorly (Fig. 6.2B).5


image

Figure 6.2 Extended Kocher approach. (A) If a more extensile approach is required, the brachioradialis and extensor carpi radialis longus (ECRL) can be sharply detached from the humerus anteriorly and the triceps posteriorly, allowing access to the anterior and posterior capsule. (B) Distally, the extensor–supinator muscle mass can be detached from the humerus and the anconeus reflected posteriorly to allow access to the proximal ulna and lateral ligamentous complex. (ECU, extensor carpi ulnaris; LCL, lateral collateral ligament.)


Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.24


Mansat and Morrey described the use of a limited proximal lateral approach for capsular release for stiff elbows, which they termed the ‘column procedure’.6 This exposure may be a proximal extension of the Kocher approach or a focused isolated proximal approach. The exposure is based on a dissection made anteriorly to the lateral border of the distal humerus, elevating the distal aspect of the brachioradialis and the extensor carpi radialis longus from the humerus and entering the interval between the brachialis and the capsule. Access to the posterior capsule involves elevation of the triceps to form the posterior part of the humerus.



Kaplan approach



Indications


Fixation of radial head fractures, particularly those that involve the anterior half.



Technique


A skin incision is made on the lateral aspect of the elbow from the epicondyle extending distally 4 cm towards the ulnar styloid process. The interval between the extensor digitorum communis and the extensor carpi radialis brevis and longus is developed exposing the underlying capsule which is incised longitudinally to gain access to the radial head (Fig. 6.3).


image

Figure 6.3 Kaplan approach. (A) The incision is made in line with the interval between the extensor carpi radialis brevis (ECRB) muscle and the extensor digitorum muscle (EDC–EDM, extensor digitorum communis–extensor digiti minimi). (B) After entering this interval, the supinator muscle (1) and underlying capsule (2) should be longitudinally incised, allowing access to the most anterior part of the radial head. Note the close location of the posterior interosseous nerve (3). (ECU, extensor carpi ulnaris.)


The radial nerve is at particular risk during this approach but this can be reduced by pronation of the forearm, which moves the nerve away from the operative field.7



Kocher posterolateral extensile triceps sparing approach



Indications


Open reduction and internal fixation of fractures, resurfacing elbow replacement, and interposition arthroplasty.



Technique


This exposure is an extension of the limited exposures described earlier and involves the release of the collateral ligaments and capsule. A midline posterior skin incision is used. The triceps is elevated from the posterior aspect of the humerus, and dissected anteriorly from the brachioradialis and the extensor carpi radialis longus. The Kocher interval is identified and developed to expose the joint capsule. The anconeus is elevated from the ulna and the triceps attachment to the lateral epicondyle is also reflected posteriorly, leaving its insertion to the olecranon intact. The lateral collateral ligament is then released from the humeral origin, allowing dislocation of the elbow joint by applying a varus stress (Fig. 6.4).


image

Figure 6.4 Kocher posterolateral extensile triceps-sparing approach. Release of the lateral collateral ligament (LCL) complex allows complete exposure of the joint. (ECU, extensor carpi ulnaris.)


Reproduced by permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.24



Modifications


This approach was modified in the Mayo Clinic to include complete release of the triceps from the olecranon, reflecting the triceps mechanism and anconeus from lateral to medial. The triceps and anconeus sleeve is reflected from the tip of the olecranon by releasing Sharpey’s fibres (Fig. 6.5).2


image

Figure 6.5 Mayo Clinic modification of Kocher posterolateral extensile triceps-sparing approach. (A) Detachment of the triceps insertion on the olecranon allows exposure of the posterior joint (B). This approach combines an extensile Kocher approach with posterior triceps and anconeus reflection. (ECU, extensor carpi ulnaris.)



Medial approach


Medial approaches to the elbow are less frequently used than lateral approaches to the joint. They may be indicated to address pathology of the ulnar nerve, injuries of the medial collateral ligament, fractures of the coronoid process and contracture release. Recently, less invasive approaches through the pronator teres have been described for medial joint surgery, including medial ligament reconstruction and other procedures that affect medial structures.8



Extensile medial approach (Hotchkiss)9



Indications


This approach was initially described for releasing elbow contractures. It provides excellent exposure of the medial aspect of the joint with access to the posterior and anterior capsules. It allows treatment of concomitant ulnar nerve pathology and access to the coronoid and humeral condyle.



Technique


Although a medial skin incision can be used, it is our preference, as previously mentioned, to use a straight posterior skin incision for any extensile approach around the elbow.


The subcutaneous dissection must be performed cautiously to avoid injury to the medial antebrachial cutaneous nerve. This nerve can be localized running on top of the superficial fascia (Fig. 6.6A). The ulnar nerve should be identified proximally and mobilized. The medial intermuscular septum should then be released for a distance of about 5 cm. An incision is made on the supracondylar ridge 5 cm proximal to the medial epicondyle and continued distally towards the pronator and a portion of the common flexor tendon. A portion of the flexor carpi ulnaris tendon is left attached to the epicondyle posteriorly as this facilitates closure at the end of the procedure. A Cobb elevator is helpful in elevating the anterior structures from the distal humerus until a wide retractor can be introduced (Fig. 6.6B).


image

Figure 6.6 Extensile medial approach (Hotchkiss). (A) On superficial dissection, it is mandatory to locate and preserve the medial antebrachial cutaneous nerve (MACN). (B) The interval between the flexor digitorum superficialis (FDS) and the flexor carpi ulnaris (FCU) is entered and the underlying capsule with the anterior band of the medial collateral ligament (MCL) and brachialis muscle are localized, allowing exposure of the joint.


Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.24

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Sep 8, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Surgical Approaches to the Elbow

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