Transcript Open Capsular Release of the Elbow

Open Capsular Release
of the Elbow
William R. Beach, M.D.
“The Column Procedure: A
Limited Lateral Approach for
Extrinsic Contracture of the
Elbow”
• Mansat and Morrey, JBJS Nov. 1998.
Classification
• Extra-articular or extrinsic
– capsule, ligament, muscle or combination
– heterotopic ossification of the soft tissue
• Intra-articular or intrinsic
– articular cartilage abnormality
Conservative Treatment of Elbow
Stiffness
• Flexion and/or extension splints
– best if begun early
– dynamic splinting if tolerated
• Manipulation under anesthesia
Surgical Release
• Arthroscopic
• Open
Advantages of an Open
Approach
• Safer and easier for most surgeons
• More predictable result
• Better anterior visualization of a severely
scarred anterior compartment
• Easier conversion to conjunctive
procedures
Disadvantages of an Open
Approach
• Larger incision
• More difficult inspection of the
entire joint
Indications for Open Release
(Anterior and/or Posterior)
• Symptomatic extrinsic extension deficit
(flexion contracture)
– 20-30 degrees “gray zone”
– >30 degrees
• Symptomatic extrinsic flexion deficit
(extension contracture)
– Flexion < 110 degrees
Open Conjunctive Procedures
•
•
•
•
Biceps tendon lengthening
Brachialis myotomy
Collateral ligament release
Radial head resection
Open Release Surgical Technique
• Pre-operative and intra-operative
assessment of neurovascular status and
range of motion
• Patient in supine position
• High arm tourniquet
Technique
• Exsanguinate the arm and elevate the
tourniquet
• Prep and drape the arm in a sterile
fashion
Incisions
• Posterior
– long and requires large skin flaps
• Medial
– requires mobilization of the ulnar nerve
• Anterior
– greater risk to the neurovascular structures
• Lateral
– Preferred for safety and versatility
Interval
• Along the anterior border of the lateral
humeral epicondyle
• The distal 1/3 of the brachioradialis and the
extensor carpi radialis longus and brevis
are released off the epicondyle
• This will allow exposure of the anterior
joint capsule
• The capsule is often scarred to the bone
extending to the articular surface
Capsule
• Once the capsule is identified a retractor is
placed between the capsule and the
brachialis
• This retractor must be long enough to
extend across the entirety of the anterior
elbow and wide enough to provide
protection the anteriorly retracted
neurovascular structures
“The Release”
• The capsule is incised from the radial side
of the humerus from as far proximal as
possible and down to the joint line
• The release is wide (2 cm) radially and
tapers medially
• The ulnar side of the capsule is hard to
visualize so go carefully
“Fine Tuning”
• With the capsule released and the retractor
removed palpate the joint and slowly extend
the elbow to determine if any capsule
remains
• If so replace the retractor and take an
elevator and bluntly finish the capsular
release
Flexion Deficit
• Flex the elbow and determine if the
coronoid process or the radial head abuts
the anterior humerus
• If so a coronoid process osteotomy or
debridement of the anterior lateral surface
of the humerus may be required
Posterior Release
• At the level of the epicondyle the anconeus
and triceps are elevated off the posterior
humeral surface
• The posterior joint capsule is identified and
incised
Posterior Release
• The olecranon process and olecranon fossa
are identified and inspected
• The fossa is debrided of fibrous tissue,
osteophytes or loose bodies
• Osteophytes are aggressively removed from
the olecranon process
Limited Flexion
• Determine if the triceps tendon or muscle
are adherent to the posterior humerus
• If so a Cobb elevator is used to release the
adhesions
Final Check
• With all retractors removed palpate both the
anterior and posterior sites to determine if
there are any restrictions to flexion or
extension
• If so address these structures
Post-operative Protocol
• Neurovascular exam in recovery room
• Extension splint from the axilla to the wrist
• Pad the wrist excessively to avoid a
pressure ulcer
• Hang the arm in a “sky hook” sling to
elevate the arm overhead for 18-24 hours
Post-operative Protocol
• 1st day post-op - axillary catheter (indwelling) or scalene block
• CPM for ROM as tolerated
• DC 2nd day to daily PT and home CPM
• Extension or flexion splinting
Post-operative Protocol
• Check incision 7-10 days and remove
sutures
• Indocin or NSAID to limit swelling and HO
• Dynamic splinting or turnbuckle splints if
motion is slow