Download A posterior approach to the elbow joint

A posterior approach to the elbow joint
S. A. Shahane, D. Stanley
From the Northern General Hospital, Sheffield, England
e describe a posterior approach to the elbow
which combines the advantages of both splitting
and reflecting the triceps. It gives protection to the
ulnar nerve and its blood supply during the operation
while providing excellent exposure of the distal
humerus. During closure, the triceps muscle can be
tensioned, thereby improving stability of the elbow.
This approach has particular relevance to unlinked
total elbow arthroplasty allowing early rehabilitation
of the joint.
W
J Bone Joint Surg [Br] 1999;81-B:1020-2.
Received 2 December 1998; Accepted after revision 23 April 1999
Many surgical approaches to the elbow have been described, of which the posterior is the most common. It
provides excellent access for the fixation of fractures of the
distal humerus and olecranon, and is the approach used
1-4
In the
most commonly for total elbow arthroplasty.
3,5,6
posterior approach the triceps
is either split or reflec4,7
1,8
ted or the olecranon is divided.
Osteotomy of the olecranon is particularly valuable in
the treatment of comminuted distal fractures of the humerus
involving the articular surface. It cannot be used, however,
for total elbow arthroplasty since this requires an intact
ulna for the fixation of the distal component of the prosthesis. Techniques in which the triceps is split or reflected
can be used for fixation of fractures and for total elbow
arthroplasty, but they give a less satisfactory exposure of
the distal humerus than can be achieved by olecranon
osteotomy when fractures of the distal humerus are comminuted and involve a significant portion of the articular
surface.
We describe an approach in which the triceps is both
split and reflected.
S. A. Shahane, MS Orth, MCh Orth, FRCS G (Orth), Orthopaedic Specialist Registrar
D. Stanley, BSc, FRCS, Consultant Orthopaedic Surgeon
Orthopaedic Department, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.
Correspondence should be sent to Mr D. Stanley.
©1999 British Editorial Society of Bone and Joint Surgery
0301-620X/99/69696 $2.00
1020
Operative technique
The anaesthetised patient is placed in the lateral decubitus
position. A sterile tourniquet is applied high on the arm
which is supported so that it is horizontal, with the forearm
hanging vertically and freely.
A posterior incision is made in the skin beginning 8 cm
proximal to the olecranon, extending distally, skirting the
ulnar aspect of the tip of the olecranon, and continuing for
a further 8 cm along the subcutaneous border of the ulna.
The ulnar nerve is identified and decompressed superficially.
The medial border of the belly of the triceps is identified.
An incision is then made proximally in the triceps tendon
so that 75% of the muscle lies laterally and 25% medially
(Fig. 1). This incision is deepened through the triceps to the
tip of the olecranon and continues distally to split the
superficial fascia of the forearm for about 6 or 7 cm. The
medial triceps, with the superficial fascia of the forearm
and the periosteum over the medial aspect of the olecranon,
is then reflected medially as a single unit (Fig. 2).
Care is taken to maintain the continuity of the extensor
envelope where the triceps blends into the fascia of the
forearm. The elbow is slightly extended at this stage to
relieve the tension at this tenuous junction. The dissection
extends subperiosteally, deep to the ulnar nerve and over
the tip of the medial epicondyle. The lateral 75% of the
triceps is then reflected from the tip of the olecranon. The
dissection is extended laterally according to the needs of
the procedure being undertaken. The anconeus is then
reflected subperiosteally from the proximal ulna to expose
the radial head. The posterior capsule is reflected with the
triceps, exposing the entire joint (Fig. 3).
The dissection is carried out deep to the ulnar nerve
which is safely mobilised with its deep soft tissues and
blood supply, reducing the risk of postoperative ulnar
neuritis. The distal humerus and elbow are exposed entirely, allowing fixation of fractures or total elbow arthroplasty
to be carried out safely.
At the end of the procedure, reconstruction of the soft
tissues is undertaken. Drill holes are placed in the olecranon through which the triceps is reattached to the bone. The
medial portion of the triceps is brought back to the olecranon and the ulnar nerve is seen to fall into its anatomical
THE JOURNAL OF BONE AND JOINT SURGERY
A POSTERIOR APPROACH TO THE ELBOW JOINT
1021
Fig. 1
Diagram of the posterior view of the elbow showing the incision through the triceps and the line of
incision to decompress the ulnar nerve.
Fig. 2
Diagram showing the medial 25% of the triceps
with the superficial fascia of the forearm and the
periosteum reflected medially as a single unit,
deep to the ulnar nerve.
Fig. 3
Diagram showing the retraction of the entire triceps exposing the back of the elbow.
position. Reattachment of the triceps to the olecranon
allows adjustment of soft-tissue tension. Balancing of the
two components of the triceps mechanism can be undertaken so that the risk of postoperative dislocation for
unlinked surface replacement arthroplasties is minimised.
VOL. 81-B, NO. 6, NOVEMBER 1999
Clinical experience
Since 1993, we have undertaken 86 total elbow arthroplasties and reconstructed 20 distal fractures of the humerus
using this approach, encountering only one case of post-
1022
S. A. SHAHANE,
operative neurapraxia of the ulnar nerve. Spontaneous
recovery occurred in this patient after eight weeks. Dehiscence of the triceps was seen on one occasion in a patient
who had undergone several previous surgical procedures
through posterior approaches after an infected comminuted
distal fracture of the humerus.
Discussion
5
Campbell described the posterior split of the triceps muscle in the midline, and continued the exposure distally in
the forearm by elevating the anconeus and flexor carpi
3
ulnaris. Steiger et al modified this approach by raising
6
osteoperiosteal flaps from the olecranon. Van Gorder created an inverted ‘V’-shaped flap of the triceps mechanism
to expose the distal humerus. In all of these approaches
there is considerable mobilisation of the ulnar nerve. Petalling of the olecranon, described in the Gschwend approach,
can be difficult to achieve safely in patients with rheumatoid arthritis who have marked bony erosion of the ulna.
9
The technique, described by Boyd, involves reflecting the
entire triceps mechanism from the lateral to the medial side.
7
Bryan and Morrey used a similar technique but with
reflection of the triceps from medial to lateral, beginning at
the medial intermuscular septum. The triceps was reflected
in continuity with the fascia of the forearm and the periosteum. The advantage of this approach is that the muscle
is neither split nor violated and continuity of the extensor
mechanism is maintained with the forearm fascio-ulnarperiosteal complex. Ten out of 80 total elbow arthroplasties
2
carried out by Morrey et al had ulnar neuropathies, eight
temporary and two permanent. They presumed that the
D. STANLEY
cause was traction or pressure on the nerve during the
operation.
Our technique allows the raising of the major part of the
triceps in continuity. Protection of the ulnar nerve by the
medial part of triceps reduces the possibility of damage to
its blood supply and at the end of the operation it can glide
and slide in its original position. The availability of the two
segments of the triceps muscle for the repair allows satisfactory balancing of the medial and lateral sides of the
elbow, reducing the risk of postoperative dislocation.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
References
1. MacAusland WR. Ankylosis of the elbow, with report of four cases
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arthroplasty: a five-year experience at the Mayo clinic. J Bone Joint
Surg [Am] 1981;63-A:1050-63.
3. Steiger JU, Gschwend N, Bell S. GSB elbow arthroplasty: a new
concept and six years’ experience. In: Kashiwagi D, ed. Elbow joint.
Amsterdam: Elsevier Science Publishers BV (Biomedical Division),
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total elbow arthroplasty. J Bone Joint Surg [Am] 1990;72-A:684-8.
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6. Van Gorder GW. Surgical approach in supracondylar ‘T’ fractures of
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joint: a triceps sparing approach. Clin Orthop 1982;166:188-92.
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9. Boyd HB. Surgical exposure of the ulna and proximal third of the
radius through one incision. Surg Gynecol Obstet 1940;71:86-8.
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