Global posterior approach to elbow

Indication

Complex reconstructive and traumatic conditions of the elbow.

Through single posterior incision and various intermuscular approaches you can obtain circumferential exposure of the elbow, including the collateral ligament complexes, anterior joint capsule, and coronoid process.
 

Anatomy

See general anatomical considerations in elbow surgery (link)

Considerations

Positioning

Lateral decubitus or supine position.

Tourniquet applied to the most proximal arm.

In the supine position, a bolster or padded Mayo stand (Lloyd Davis leg support from opposite side, or padded  up side down "L" bar) is used to support the extremity over the chest.

In the lateral position, the arm is positioned on a cushioned support, so that the elbow is extended and flexed easily. (over padded up side down "U" bar on side of table)

Skin Incision

Straight posterior midline longitudinal skin incision.

NB take skin incision straight down through the deep fascia to the triceps tendon and subcutaneous border of the ulna.

Superficial dissection

Elevate full thickness medial or lateral fasciocutaneous flaps as needed preserving the subcutaneous arterial plexus and cutaneous nerves.

Medially isolate ulna nerve consider placing sling around nerve, not for traction but as reminder of location.

If the posteromedial joint requires exposure, then transpose ulnar nerve anteriorly, by excising the medial intermuscular septum and  releasing the cubital tunnel retinaculum completely to allow the ulnar nerve to be mobilized anteriorly without compression or kinking.

Deep dissection

Within the global posterior approach it is possible to use the:

• Posteromedial approach

• Posterolateral approach

• Anteromedial approach

• Anterolateral approach

The Posteromedial Approach

Provides acces to:

• Anterior bundle of the medial collateral ligament

• Coronoid process

• Anterior joint capsule

Release subperiostealy the posteromedial muscles off the proximal ulna and retract them anteriorly.

The flexor carpi ulnaris fascia is left attached to the subcutaneous border of the ulna for later repair.
Place either a screw or transosseous sutures into the coronoid fragment or anterior capsule.

In reconstructive procedures, if a capsulotomy is required make it anterior to the anterior bundle of the medial collateral ligament. Leave the common flexor and pronator origin and medial collateral ligament attached to the medial epicondyle.

This approach is extensile proximally along the medial humeral supracondylar ridge and distally, by reflecting the flexor carpi ulnaris from the ulna.

The Posterolateral Approach

Provides access to:

• Radial head

• Capitellum

• Lateral ulnar collateral ligament

Split Kocher's interval posterolaterally between anconeus and extensor carpi ulnaris.

This interval is visualized as a thin white line along the deep fascia.

Splitting the interval exposes the joint capsule proximally and supinator distally.

For acces to:

• Olecranon fossa

• Posterior aspect of humerus

Reflect anconeus and triceps medially from the lateral side of the distal humerus.

To expose the radial head:

Elevate the common extensor origin from the underlying capsule, lateral collateral ligament complex, and lateral humeral epicondyle.

Make an arthrotomy along the anterior border of the lateral ulnar collateral ligament, dividing the annular ligament, but preserving the integrity of the lateral ulnar collateral ligament. (click for image lateral elbow)

If additional exposure is required for osteosynthesis of the radial head perform a lateral epicondyle chevron osteotomy.

The most lateral edge of the capitellum is identified to ensure that the distal limb of the osteotomy does not violate it. A chevron osteotomy is marked on the posterior aspect of the humerus with the apex directed medially. The epicondyle is predrilled and tapped to accept one or two 4-mm cancellous or 3.5-mm cortical screws. Either a small sagittal saw or osteotome is used to perform the cut. The muscles of the supracondylar ridge are elevated subperiosteally, so that they remain in continuity with the epicondyle and the common extensor origin. The lateral ulnar collateral ligament is not violated and remains in continuity with the epicondyle.

If this does not allow adequate anterior joint visualization, Kaplan's interval between extensor digitorum communis and extensor carpi radialis longus and brevis can be developed to the level of the posterior interosseous nerve, where it enters the supinator at the Arcade of Frohse. This allows the common extensor origin (extensor carpi ulnaris and extensor digitorum communis) and lateral ulnar collateral ligament, with the attached lateral epicondyle to be reflected anteriorly and distally.

On the lateral aspect the exposure is extensile proximally to where the radial nerve perforates the lateral intermuscular septum. Distally, the exposure is extensile along the proximal third of the radius, to the ulna. If the neck and shaft of the proximal radius require exposure, division of the annular ligament, and supinator are required, respectively. The forearm is pronated to translate the posterior interosseous nerve anteriorly to increase the zone of safety. The annular ligament is divided at least 5 mm from the edge of the lesser sigmoid notch, so that it can be repaired anatomically. The supinator muscle is released from the supinator crest and retracted with the posterior interosseous nerve, thereby exposing the radius. At the time of closure pay close attention to the repair of the lateral ulnar collateral ligament complex.
 

Anterior approaches

In some situations, exposure of the anterior elbow is required through alternative or additional anterior intermuscular approaches. Situations where this may occur.

• Release of complex elbow contractures.

• Osteosynthesis of anterior shear fractures of the capitellum or trochlea.

These exposures may be performed in isolation, or more commonly, in conjunction with one or more of the previously described approaches. These additional exposures are performed by additional anterior elevation of the posteromedial and posterolateral fasciocutaneous flaps. It is important when undertaking this degree of exposure, to ensure that the tissues are not allowed to desiccate, because this will increase the risk of complications, especially necrosis and infection.

The Anteromedial Approach (Hotchkiss)

This approach can be used in isolation when the injury is predominantly on the medial aspect of the joint.

For severe contractures, combine the anteromedial approach with the above posterior intermuscular lateral approaches.

Muscular interval - between flexor carpi ulnaris and flexor carpi radialis or palmaris longus, when present.

Internervous plane - ulnar nerve innervates flexor carpi ulnaris, median nerve innervates flexor carpi radialis, palmaris longus, and pronator teres muscles.

Identify the interval by the vessels that perforate the fascia between the two muscles.

Begin the dissection proximally by dividing the investing fascia lying medially over brachialis on the anterior aspect of the supracondylar ridge.

Elevate brachialis subperiosteally from the anterior humerus and joint capsule.

Develop the interval between the flexor carpi ulnaris and the palmaris longus/ flexor carpi radialis down to the joint capsule, where the anterior margin of the medial collateral ligament is identified.

Divide palmaris longus, flexor carpi radialis, and pronator teres 2 cm from their origin on the medial epicondyle and carefully reflect them anterolaterally from the medial epicondyle and capsule, along with the adjacent brachialis. This serves to protect the median nerve and brachial artery, which are also retracted laterally.

By performing this incision anterior to flexor carpi ulnaris, the anterior bundle of the medial collateral ligament is preserved beneath flexor carpi ulnaris, along with the origin of the flexor carpi ulnaris, which maintains elbow stability.

The anterior capsule can be opened or excised, heterotopic bone removed, or a trochlea fracture repaired.

This approach can also be used to reconstruct the deficient medial collateral ligament.

The Anterolateral Approach (Kaplan)

Uses

• Release of elbow contractures

• Exposure of posterior interosseous nerve

• Internal fixation of displaced capitellar or lateral condyle fractures.

Interval - Extensor digitorum communis and extensor carpi radialis longus muscles superficially.

The intermuscular interval is best found by observing where the vessels penetrate the fascia along the anterior margin of the extensor digitorum communis aponeurosis.

Split the fascia longitudinally and separate extensor carpi radialis longus from extensor digitorum communis.

As the dissection is carried deep to the extensor carpi radialis longus, the extensor carpi radialis brevis is encountered. Deep to the extensor carpi radialis brevis the transversely oriented fibers of the supinator are encountered, along with the posterior interosseous nerve, which usually is surrounded by fat. The posterior interosseous nerve defines the distal extent of the exposure. If required, proximal dissection with elevation of the extensor carpi radialis longus, extensor carpi radialis brevis, and brachioradialis anteriorly from the lateral supracondylar ridge of the humerus provides exposure of the anterior joint capsule. When the Kaplan approach is extended proximally along the lateral supracondylar ridge of the humerus, it is referred to as the extended lateral approach.

If the Kaplan and Kocher approaches are used together, the extensor digitorum communis, extensor carpi ulnaris, and the lateral ulnar collateral ligament remain attached to the lateral epicondyle preserving stability. This recently has been redescribed as the "column procedure".
 

Exposure extension

Closure

Post operatively

References

Clinical orthopaedics and related research; (370), January 2000, pp 19-33; Surgical Approaches to the Elbow; Patterson, Stuart D; Bain, Gregory I; Mehta, Janak A.
 

Page created by: Lee Van Rensburg

Last updated 11/09/2015