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Techniques in Shoulder and Elbow Surgery 7(1):72–76, 2006
Ó 2006 Lippincott Williams & Wilkins, Philadelphia
R E V I E W
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Anterior Elbow Capsulodesis
Donald H. Lee, MD, Douglas R. Weikert, and Jeffry T. Watson
Department of Orthopaedic Surgery
Vanderbilt Orthopaedic Institute
Nashville, TN
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ABSTRACT
The technique and role of an anterior elbow capsulodesis in restoring elbow instability following an unstable
elbow fracture-dislocation are described. Six patients
with an unstable posterior elbow fracture-dislocation
were retrospectively reviewed. The average age of the
patients was 45.5 years. Five of the 6 patients had a type
I coronoid fracture, and 5 patients had a radial head
fracture. All patients had an associated posterior dislocation of the elbow. Two patients had previous surgery.
All patients underwent elbow reconstruction with restoration of the ulnohumeral joint and lateral collateral
ligament complex repair. Five patients had a radial head
replacement. An anterior elbow capsulodesis was performed in all patients for residual, postreconstruction,
posterior elbow instability. A hinged fixator was used in
1 patient. At an average follow-up of 19 months (range,
6Y33 months), all patients had a stable elbow. The average extension-flexion arc was 26 to 133 degrees.
Pronation and supination averaged 54 and 69 degrees,
respectively.
Conclusion: A stable elbow joint can be achieved by
restoring ulnohumeral joint congruency, repairing the
lateral collateral ligament complex, and repairing or
replacing an injured radial head. An anterior elbow
capsulodesis is used when further stabilization of residual
posterior elbow instability is needed.
Keywords: elbow, complex elbow fracture-dislocations,
anterior elbow capsule, capsulodesis
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INTRODUCTION
Complex elbow fracture-dislocations often occur with
a similar pattern of injury. Axial compression of the
forearm in combination with forearm supination and a
valgus load on the elbow, as seen with a fall on an
outstretched arm, produces a common posterior elbow
fracture-dislocation pattern.1Y8 An injury pattern, starting
laterally and extending medially, is seen. Identifying the
Address correspondence and reprint requests to Donald H. Lee, MD,
Department of Orthopaedic Surgery, Vanderbilt Orthopaedic Institute,
Medical Center East, South Tower, Suite 3200, Nashville, TN. E-mail:
[email protected].
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pattern and components of a complex elbow fracturedislocation allows for the use of a treatment algorithm.
The purpose of this study is to retrospectively review
the results of an anterior capsulodesis or repair of an
avulsed anterior capsule to the coronoid process and its
role in stabilizing the unstable elbow during reconstruction of a posterior elbow fracture-dislocation.
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MATERIALS AND METHODS
Following an institutional review board approval, 7 patients with a complex elbow fracture-dislocation were
retrospectively reviewed. There were 6 men and 1 woman (Table 1). One male patient was lost to follow-up at
2 months, leaving 6 patients for review. The average
age of the patients was 45.5 years (range, 21Y77 years).
The right dominant elbow was involved in 2 patients
and the left elbow in 4 patients. Two patients had a
concomitant fracture of the distal radius and a patient
with a fracture of the distal ulna. Five of the 6 patients
had a type I coronoid fracture.9 All patients were noted
to have a distal avulsion of the anterior joint capsule off
the coronoid process. Two patients had undergone previous surgery: one elbow open reduction and internal
fixation (ORIF) of a comminuted proximal ulnar fracture with iliac crest bone grafting and internal fixation
of a comminuted radial head fracture. A second patient
had internal fixation of a proximal ulnar fracture.
The indications for surgery included a complex posterior elbow fracture-dislocation with a displaced proximal ulnar and/or radial head/neck fracture, persistent
posterior elbow joint instability following joint reconstruction, and intraarticular loose bodies. Two patients
had a displaced proximal ulnar fracture. Five patients
had a radial head/neck fracture. Five patients had a type
1 coronoid fracture. The indication for an anterior elbow
capsulodesis (suture capsulorraphy of the anterior joint
capsule to the coronoid process) was residual posterior
elbow instability following reconstruction of the ulnohumeral joint and the lateral column structures (radial
head and lateral collateral ligament complex).
Reconstructive surgery included ORIF of a proximal ulnar fracture (2 patients) or reduction of a dislocated ulnohumeral joint (4 patients), repair of the lateral
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Anterior Elbow Capsulodesis
TABLE 1. Demographics
Age
(y)
Type of
injury
Previous
surgery
Radial head
fracture
1
2
77
21
Fall
Fall
Yes
Yes
3
4
5
6
41
29
44
61
Fall
MCA
Fall
MCA
No
ORIF ulna/
RH
No
No
No
ORIF ulna
Patient
Average
Yes
No
Yes
Yes
45.5
RH, radial head; MCA, motorcycle accident.
collateral ligament complex (all patients), and radial head
replacement (5 patients). All patients had persistent posterior elbow joint instability following reconstructive surgery when examined under intraoperative fluoroscopy.
One patient who had underwent repeat surgery 3 weeks
after previous ORIF of a proximal ulnar and radial head
fractures had placement of a hinged external fixator.
Operative Technique
Reconstructive surgery should include (1) the use an
extended posterolateral Kocher approach with a posterior midline incision or lateral incision, (2) ORIF of a
proximal ulnar fracture, including a coronoid fracture, if
present and fixable, (3) repair or metallic radial head
replacement of a radial head/neck fracture, if present,
(4) repair of the lateral collateral ligament complex
using a transosseous suture technique, (5) use of intraoperative fluoroscopy to test for residual posterior elbow stability, (6) use of an anterior elbow capsulodesis,
if persistent posterior instability is noted, and (7) use of
a hinged external fixator for additional stability or to
protect repaired structures, if needed.
tion plate or dynamic compression plate. Type 2 or 3
coronoid fractures are repaired using screw or small
plate fixation with or without incorporation of the screw
into the proximal ulnar plate. Type 1 coronoid fractures
are left alone, if following reconstruction of the proximal ulnar fracture or following reduction of the ulnohumeral joint; the joint remains stable in extension.
Repair or Replace a Radial Head/Neck Fracture. An
ORIF of repairable radial head and/or neck fracture is
performed if stable fixation is obtainable. Severely
comminuted radial head and/or neck fractures not amenable to internal fixation should undergo a metallic radial
head replacement.
Use a Transosseous Suture Technique to Repair the
Lateral Collateral Ligament Complex. Two drill holes
are place in an anterior to posterior direction through the
lateral epicondyle. In the sagittal plane, a hole is placed
slightly superior and one slightly inferior to the distal
humeral central axis of rotation. Two, no. 2, nonabsorbable braided sutures are weaved through the proximal
lateral collateral ligament complex using a grasping
suture technique. The sutures are then placed through
epicondylar bone holes in an anterior to posterior direction using a suture passer (Fig. 1). The avulsed lateral
collateral ligament complex is reapproximated to its
origin by tensioning but not tying the sutures.
Use Intraoperative Fluoroscopy to Determine Elbow
Stability. After the lateral collateral ligament complex
is reapproximated to its insertion site, the ulnohumeral
and radiocapitellar joints are passively ranged and visualized with intraoperative fluoroscopy. The elbow is
flexed and especially extended, observing for signs of
Key Surgical Points
Use an Extended Posterolateral (Kocher) Approach.
A posterior or posterolateral longitudinal incision is used.
An extended posterolateral or Kocher approach between
the anconeus and the extensor carpi ulnaris is developed.
The dissection is carried proximally along the lateral
supracondylar ridge. The lateral collateral ligament
complex is usually partially or completely avulsed from
its proximal insertion onto the lateral epicondyle. The
dissection is continued superiorly along the supracondylar ridge and extended anteriorly and medially along the
distal humerus. The radial head and coronoid process are
visualized. The anconeus can be elevated subperiosteally
to expose the proximal ulna, if needed, for internal
fixation of a proximal ulnar fracture.
Repair the Proximal Ulna if a Proximal Ulnar Fracture
is Present. An open reduction of the proximal ulna is
performed by preferably using a precontoured commercially available plate or a contoured pelvic reconstruc-
FIGURE 1. Illustration of the repair of the lateral collateral
ligament complex using nonabsorbable sutures placed
through transosseous lateral epicondylar suture holes.
The holes are placed at the level of the distal humeral
central axis of rotation.
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Lee et al
through each drill hole from an anterior to posterior
direction through the ulna. With the elbow flexed, the
sutures are tied along the subcutaneous border of the
ulna. Following repair of the anterior joint capsule and
with tensioning of the lateral collateral ligament sutures,
the elbow is then reexamined under fluoroscopy to note if
ulnohumeral joint stability is restored (Fig. 3).
Use a Hinged External Fixator if Needed. The main
indications for a hinged external fixator are to stabilize a
grossly unstable elbow, a chronically unstable or dislocated elbow, and to protect bone fixation or ligament
repair. In general, hinged external fixator is not needed.
The options for the fixator include a preferred unilateral
or monolateral hinged fixator or a semicircular hinged
fixator.
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FIGURE 2. Illustration of the repair of the anterior elbow
joint capsule using nonabsorbable sutures placed through
transosseous proximal ulnar suture holes. The suture
holes are placed so that the anterior capsule, when repaired, forms a congruent articular surface with the
anterior portion of the greater sigmoid notch.
posterior ulnohumeral joint instability. Forearm rotation,
particularly supination in combination with elbow extension, is observed for signs of posterolateral instability of
the radial head. If residual posterior ulnohumeral joint
instability with elbow extension is noted, an anterior
elbow capsulodesis is performed (see below). If residual
posterolateral radiocapitellar joint instability is noted, an
additional suture hole can be placed more proximally,
and the ligament repair is shifted superiorly.
Restore Stability of the Ulnohumeral Joint Using an
Anterior Elbow Capsulodesis. A grasping Bunnell-type
suture using two, no. 2, nonabsorbable braided sutures is
placed into the anterior elbow joint capsule. The joint
capsule is usually avulsed off its distal insertion. A
portion of the brachialis can be incorporated into the
repair if needed to reinforce the repair. Two drill holes
are placed into the base of the coronoid fracture. Two
converging drill holes are placed from the subcutaneous
border of the ulna toward the coronoid process fracture
site. Care is taken to insure that the drill holes exit at the
proximal edge of the coronoid fracture immediately adjacent to the greater sigmoid notch articular surface. The
suture holes are positioned in this manner to insure that
the anterior capsule, when repaired, forms a congruent
articular surface with the anterior portion of the greater
sigmoid notch (Fig. 2). Two sutures strands are passed
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RESULTS
The average follow-up was 19 months (range, 6Y33
months; Table 2). The final range of motion was 26 degrees of elbow extension (range, 10Y40 degrees), 133
degrees of elbow flexion (range, 125Y140 degrees), 54
degrees of forearm pronation (range, 40Y75 degrees), and
69 degrees forearm supination (range, 40Y85 degrees).
The ulnohumeral and radiocapitellar joints were radiographically congruent. There was no clinical evidence of
varus, valgus, or posterolateral instability in any patient.
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DISCUSSION
Elbow joint stability is the result of the combination of
osseous structures (ulnohumeral and radiocapitellar
joints) and soft tissue restraints (collateral ligaments
and anterior and posterior capsules).3,10Y13 Complex
elbow fracture-dislocations frequently occur with a
similar pattern of injury. The injury usually starts
laterally and extends medially.3Y8 Following avulsion
of the lateral collateral ligament complex off its
insertion onto the lateral epicondyle, disruption of the
anterior and posterior capsule occurs. The anterior
capsule is usually avulsed off its insertion onto the
coronoid process.14,15 Subluxation and subsequent dislocation of the radiocapitellar and ulnohumeral joint
then occur. Finally, disruption of the medial collateral
ligament occurs as the elbow fully dislocates.
Elbow dislocations can occur with only soft tissue
(collateral ligaments and joint capsule) injuries or with
associated fractures (radial head and/or neck, coronoid
process, proximal ulna, and distal humerus). An elbow
dislocation associated with a radial head/neck fracture
and coronoid fracture produces a particularly unstable
fracture-dislocation pattern.1Y3,5Y7
The coronoid process working in conjunction with
the radial head is recognized as an important stabilizer
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Anterior Elbow Capsulodesis
FIGURE 3. A, A lateral radiograph showing residual posterior subluxation of the ulnohumeral and radiocapitellar joints
before an anterior elbow capsulodesis. B, A lateral elbow radiograph showing improvement of the ulnohumeral and
radiocapitellar joint subluxation following an anterior elbow capsulodesis. Note the transosseous suture holes (arrows) in the
proximal ulna.
to resist the posteriorly directed joint reactive forces
produced by the biceps and triceps muscles.3Y5,7Y9
Failure to stabilize these fractures frequently results in
posterior elbow instability.
Less commonly recognized is the importance of the
anterior joint capsule. The anterior elbow joint capsule
is a fibrous-type structure originating proximal to the
coronoid and radial fossae and extends distally to attach
to the anterior margin of the coronoid process medially
and to the annular ligament laterally.10,13 Avulsion of
the anterior capsule usually occurs at its distal attachment.14,15 The brachialis inserting into the base of the
coronoid process, distal to the anterior capsular insertion, usually has some muscle fibers inserting into the
anterior joint capsule.3,13 Avulsion of the brachialis can
also occur with an elbow dislocation.14 The anterior
capsule has been variably described as providing no
elbow joint stability,16 valgus joint stability,11 or resistance to posterior elbow stability.2,7,14,15
Previous reports have described insertion of the anterior capsule with or without a type 1 coronoid fragment attached to the capsule2,6,7,14,15 to help restore
elbow stability. Capsular reattachment provides a buttress effect to the coronoid process similar to a volar
plate arthroplasty for an unstable dorsal proximal
interphalangeal joint fracture-dislocation.17 Similar to a
digital volar plate arthroplasty, the sutures holes and
sutures used to repair the anterior elbow capsule are
placed at the junction of the greater sigmoid notch
articular surface and the coronoid fracture site. This
placement insures recreation of a congruent and smooth
transition between the articular surface of the greater
sigmoid notch and the repaired anterior capsule.
An anterior capsular repair is not, however, needed
in all cases of posterior elbow fracture-dislocations. Frequently following restoration of the ulnohumeral joint,
reapproximation of the lateral collateral ligament complex to the lateral epicondyle, and radial head reconstruction or replacement, elbow stability is restored.
If residual posterior instability with elbow extension is
noted under fluoroscopic examination, then an anterior
capsular repair should be considered.
A hinged external fixator is also generally not
needed. In this series, the external fixator was used in
only one case involving a chronically posteriorly subluxed elbow. Its use should be considered also in cases
where residual instability is noted even following all
soft tissue repairs or in cases when the soft tissue and
osseous repairs may need to be protected.
In summary, an anterior elbow capsulodesis is an
additional surgical option that should be considered
when dealing with complex elbow fracture-dislocations.
TABLE 2. Treatment and Results
Patient
1
2
3
4
5
6
Average
Radial head replacement
Yes
Yes
Yes
No
Yes
Yes
Hinged external
fixator
No
Yes
No
No
No
No
Follow-up
(mo)
22
15
33
18
20
6
Extension/flexion
(degrees)
30/135
15/135
10/130
40/125
40/135
20/140
Pronation/supination
(degrees)
75/85
40/40
45/85
45/85
50/50
70/70
19
26/133
54/69
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Lee et al
If persistent posterior elbow instability, with elbow extension, occurs following reconstruction of the articular
surfaces and the lateral collateral ligament complex, then
an anterior elbow capsulodesis should be considered.
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10. Morrey BF. Anatomy of the elbow joint. In: Morrey BF
ed. The Elbow and Its Disorders, 3rd ed. Philadelphia,
PA: WB Saunders, 2000:13Y42.
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