Lateral Approaches

Many surgical approaches have been described for the lateral aspect of the joint. The most well-known approach, which Kocher described, involves the interval between the extensor carpi ulnaris and the anconeus.37 Other lateral approaches have been described.54-56

The position of the posterior interosseous nerve is important when using any of the lateral approaches to the elbow. Kaplan stressed the importance of performing the procedure with the forearm in pronation to translate the nerve anteriorly, thus increasing the zone of safety.55 The posterior interosseous nerve moves approximately 1 cm medially when the forearm is pronated.15

Kocher's Lateral Approach

Indications for Kocher's lateral approach (Fig. 1.23)37 include fixation of distal humeral and radial head fractures, total elbow arthroplasty, radial head arthroplasty, release of soft tissue contractures, removal of loose bodies, and repair or reconstruction of the lateral collateral ligament and associated structures.

Triceps

Supracondylar ridge

Lateral skin I incision

■J Olecranon

Anconeus

Triceps

■J Olecranon

Anconeus

Brachioradialis muscle

ECRL

Lateral epicondyle

ECRB

Brachioradialis muscle

ECRL

Lateral epicondyle

ECRB

Capsular

Annular ligament

FIGURE 1.23. Modified Kocher's approach. (A) Incision is made from the supracondylar ridge to past the radial head. (B) Lateral capsule is incised anterior to the lateral ulnar collateral ligament. (C) Posterior capsular sleeve released from epicondyle to allow insertion of metallic radial head replacement. (ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.)

Capsular

Annular ligament

FIGURE 1.23. Modified Kocher's approach. (A) Incision is made from the supracondylar ridge to past the radial head. (B) Lateral capsule is incised anterior to the lateral ulnar collateral ligament. (C) Posterior capsular sleeve released from epicondyle to allow insertion of metallic radial head replacement. (ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.)

The surgeon makes a lateral incision from the supra-condylar ridge of the humerus distally to 5 cm past the radial head. The interval between the triceps muscle posteriorly and the brachioradialis and extensor carpi radialis longus muscles anteriorly is developed to expose the lateral condyle of the distal humerus and the lateral capsule. Distal to the radial head, the interval between the extensor carpi ulnaris and the anconeus is developed, and the common extensor origin then can be reflected anteriorly to complete the exposure of the lateral capsule and joint. Morrey recommends a modification in which the capsulotomy is performed anterior to the lateral ulnar collateral ligament to prevent posterolateral rotatory insta-bility47 (see Fig. 1.23B). We have modified this procedure and include a step-cut (Z) incision of the annular ligament anterior to the lateral ulnar collateral ligament. This incision preserves the lateral ulnar collateral ligament and ensures that the annular ligament can be repaired easily without undue tension. This incision is ideal for open reduction of radial head fractures. If a metallic radial head replacement is to be inserted, the posterior capsular sleeve, which includes the lateral ulnar collateral ligament, must be released from the epicondyle and later repaired with transosseous sutures.

The exposure can be extended proximally or distally, as required, to provide greater exposure of the humerus and ulna, respectively.65 A triceps-anconeus flap can be raised from the olecranon and reflected medially to allow the elbow to dislocate, hinging on the medial collateral ligament. The medial collateral ligament can be released to disengage the humerus and ulna. From this perspective, the surgeon can visualize the entire elbow joint.

We recommend carefully closing the lateral ligamen-tous complex with transosseous, nonabsorbable, interrupted sutures to prevent posterolateral rotatory instability. The ulnar nerve may be injured during manipulation by a small bony spur, which is commonly present in patients who have rheumatoid arthritis, at the ulnar attachment of the medial collateral ligament.66 This approach offers more protection to the posterior interosseous nerve and is converted easily to an extensile posterolateral approach if exposure of the entire distal humerus is necessary.

Modifications. The direct lateral approach that Kaplan55 describes uses the interval between the extensor digito-rum communis and the extensor carpi radialis brevis (Fig. 1.24). To move the posterior interosseous nerve as far away from the surgical field as possible, full pronation of the forearm is recommended during this approach. According to Strachan and Ellis, the posterior interosseous nerve moves approximately 1 cm medially with full pronation of the forearm.15 Even with full pronation of the forearm, the posterior interosseous nerve is still quite close to the surgical field. For this reason, this approach is not used as frequently as that described by Kocher.37

In his modification, Cadenat exposes the radial head via

Brachio radialis muscle

FIGURE 1.24. Kaplan's direct lateral approach. (A) Arm is placed in extreme pronation to protect posterior interosseous nerve. (B) Incision is made between the ECRB and the EDC. (C) Posterior interosseous nerve is at risk. (ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.)

Superficial branch of the radial nerve

Posterior interosseous nerve

Superficial branch of the radial nerve

Posterior interosseous nerve

FIGURE 1.24. Kaplan's direct lateral approach. (A) Arm is placed in extreme pronation to protect posterior interosseous nerve. (B) Incision is made between the ECRB and the EDC. (C) Posterior interosseous nerve is at risk. (ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.)

the interval between the extensor carpi radialis longus and extensor carpi radialis brevis.54 This approach can place the nerve to the extensor carpi radialis brevis55 at risk.

Key and Conwell56 modified the approach by exposing the radial head between the brachioradialis and the extensor carpi radialis longus. If the exposure is extended proximally, it can place the nerves to the extensor carpi radialis longus and brevis55 at risk.

In his modified approach, Pankovich exposes the lateral compartment of the elbow by developing the Kocher interval and reflecting the insertion of the anconeus sub-

periosteally from the ulna52 (Fig. 1.25). This dissection exposes the supinator muscle, and the dissection can continue in the same fashion as the Boyd approach.

Patterson and associates describe the "global approach" to the elbow with a lateral epicondylar osteotomy to increase exposure of the radial head.49 The details of this approach are provided in the combined medial and lateral approaches section.

Campbell describes another lateral approach: the trans-epicondylar approach.38 The value of this approach is limited and rarely indicated today.

FIGURE 1.25. Pankovich's approach. (A) Incision to release the anconeus from the humerus. (B) Anconeus retracted to expose the lateral joint.

ECRL

Lateral epicondyle

ECRB

-EDC

w*— Brachioradialis muscle

ECRL

Lateral epicondyle

ECRB

-EDC

Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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