Posterior Approaches

The surgeon has a number of options for managing the triceps when approaching the elbow joint (Fig. 1.17). The surgeon can split (Campbell38), tongue (Van Gorder39), reflect (Kocher37, Bryan and Morrey43), retract (Alonso-Llames,50 Patterson et al.49), or osteotomize the triceps mechanism.

Campbell's Posterolateral Approach

Campbell originally described the triceps splitting approach in 193238 (Fig. 1.18). Indications for this pos-terolateral approach include total elbow arthroplasty and fixation of extra-articular fractures of the distal humerus. After a posterior skin incision is made, a midline incision is made through the triceps fascia and tendon. This incision is continued distally onto the tip of the olecranon and down the ulna. The triceps insertion is released from the olecranon, leaving the extensor mechanism in continuity with the forearm fascia and the medial and lateral muscles. During this approach, the ulnar nerve should be identified and protected.

In the muscular plane, the triceps aponeurosis and the

FIGURE 1.16. (A) Cross section of the elbow at the level of the humeral epicondyles. (B) Location of the named approaches to the elbow. (ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.)

Coronoid process

Brachial

Median nerve

Superficial branch of the radial nerve

Posterior interosseous nerve

Bra chio radialis muscle

ECRL

ECRB

Coronoid process

Brachial

Median nerve

Superficial branch of the radial nerve

Posterior interosseous nerve

FIGURE 1.16. (A) Cross section of the elbow at the level of the humeral epicondyles. (B) Location of the named approaches to the elbow. (ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.)

ECRB

Ulnar nerve

Capitellum Anconeus muscle

Triceps tendon

Capsule Olecranon

Subcutaneous olecranon bursa

Ulnar nerve

Capitellum Anconeus muscle

Triceps tendon

Capsule Olecranon

Subcutaneous olecranon bursa and Conwell and Conwell

Cadenat

Kaplan

Molesworth

Kocher. Global (lateral)

Bryan and Morrey Global (medial)

Campbell, Van Gorder

Cadenat

Kaplan

Molesworth

Kocher. Global (lateral)

Bryan and Morrey Global (medial)

Campbell, Van Gorder

deep medial head are split in the midline. The other muscles around the elbow (anconeus and flexor carpi ulnaris) are released subperiosteally from the humerus and proximal ulna. In the periosteal plane, the joint capsule and the periosteum of the humerus and ulna are divided sharply in the midline to expose the humerus, ulna, and joint.

The soft tissues can be elevated subperiosteally from the distal humerus and olecranon. The surgeon can visualize the posterior distal humerus and elbow joint. The surgeon closes with interrupted sutures to the triceps aponeurosis. We recommend using heavy nonabsorbable transosseous sutures for closure of the triceps mechanism over the point of the olecranon to prevent a boutonnière of the triceps repair.

Wadsworth's Posterolateral Approach

Wadsworth11 also described a posterolateral approach. Indications for this approach include fixation of distal humeral fractures and total elbow arthroplasty. In the muscular plane, the triceps aponeurosis, along with the underlying deep head of the muscle, is divided in an inverted V with the base attached to the olecranon, leaving a peripheral rim attached to the triceps for later repair. Distally, the surgeon dissects the interval between the extensor carpi ulnaris and the anconeus. The anconeus is reflected medially with the underlying capsule. In the pe-riosteal plane, the lateral exposure can be enhanced by subperiosteal elevation of the common extensor origin and the lateral ligamentous complex.

TABLE 1.3. Authors' preferred approaches

Indication

Recommended approach

Alternative approach

Total elbow arthroplasty

Soft tissue release Supracondylar fracture Radial head, capitellar, or lateral condyle fracture Monteggia fracture Coronoid fracture Metaphyseal humeral fracture

Radioulnar synostosis

Campbell38 muscle splitting

Global (lateral and medial)49 Chevron olecranon osteotomy53 Global (lateral)49

Gordon63 Global (medial)49 Alonso-Llames50

Boyd12_

Bryan and Morrey,43 Kocher37

Kocher,37 Bryan and Morrey,43 Hotchkiss67

Wadsworth,11 Campbell38

Kocher37

Chevron olecranon osteotomy53

Henry41 Campbell38

Anterolateral approach to humerus Kocher37

This exposure extends proximally along the posterior distal humerus and distally along the subcutaneous border of the ulna. The surgeon can visualize the distal humerus and elbow joint. He or she closes the triceps aponeurosis with strong interrupted sutures. Triceps weakness is minimized with secure closure of the aponeurosis.

Modifications. Van Gorder's modification of this technique involves elevating a distally based tongue of approximately 10 cm of triceps aponeurosis (Fig. 1.19).39 The deep medial head is divided obliquely (posterior proximal to anterior distal) so that no muscle is attached to the proximal tip of the aponeurotic flap, and the entire thickness of the muscle and its insertion are attached to the base of the flap.

Campbell described another modification to this technique.38 His modified technique involves elevating the tongue of triceps aponeurosis with division of the deep head in the midline. Campbell recommends using the tri ceps tongue approach only if a triceps contracture is present, and then closure can be performed using a V-Y lengthening. This technique can increase elbow flexion by as much as 40°,43 but it produces triceps weakness.44 We believe that the triceps tongue approach should be limited to that originally recommended by Campbell, and, if it is used, we prefer to split the deep medial head in the midline as Campbell described. An advantage of this modification is that it reduces necrosis of the deep head.

Alonso-Llames50 also reported a modification to the posterolateral technique. Through a midline incision, the surgeon approaches the triceps muscle from the medial and lateral aspects and elevates it from each intermuscular septum. The triceps muscle is simply retracted to expose the distal humerus. He described this approach primarily for the management of supracondylar fractures in children. We have used it successfully to manage extra-articular humeral fractures in adults. When using this approach, the surgeon must protect the ulnar and radial nerves.

FIGURE 1.17. Surgical options for the triceps mechanism include split, tongue, reflect laterally, reflect medi-,-.|-n-„ ally, or retract techniques. (The surgical option of an osteotomy is not shown here.)

FIGURE 1.18. Campbell's posterolateral approach.

Bryan and Morrey's Extensive Posterior Approach

Bryan and Morrey describe an extensive posterior approach43 (Fig. 1.20). Indications for this approach include total elbow arthroplasty, fixation of distal humeral fractures, and other cases requiring extensive medial exposure around the elbow.

In the muscular plane, the medial aspect of the triceps is elevated and released from the humerus and the medial intermuscular septum down to the level of the pos-

FIGURE 1.19. Van Gorder's tongue approach.

terior capsule. The fascia of the forearm is incised along the medial aspect of the proximal ulna for approximately 6 cm.

In the periosteal plane, the surgeon elevates and reflects the triceps muscle and its insertion and the fascia and ulnar periosteum as a single unit from medial to lateral. The medial aspect of the junction between the triceps insertion and the ulnar periosteum is the weakest portion of this musculoperiosteal flap, and meticulous care is required during its elevation. Bryan and Morrey43 recommend that this elevation be accomplished at 20° to 30° of flexion to relieve tension on the flap.

The radial head can be exposed by subperiosteal elevation of the anconeus from the proximal ulna. The posterior capsule usually is reflected with the triceps mechanism, and the tip of the olecranon can be osteotomized to expose the trochlea (see Fig. 1.20B). The medial collateral ligament complex may be reflected by sharp dissection from the humerus to increase the exposure during total elbow arthroplasty.

This exposure extends proximally by subperiosteal dissection of the humerus and distally along the subcutaneous ulna. From this approach, the surgeon can visualize the elbow joint.

For closure, Morrey48 recommends that the periosteum and triceps insertion be reattached to the proximal ulna with a number 5 crisscrossed transosseous suture (see Fig. 1.20C). An additional transverse suture secures the triceps to the tip of the olecranon. Failure to closely approximate this layer can result in a "sliding" extensor mechanism, with associated pain and weakness. If the medial collateral ligament complex is detached from the humerus, it should be secured with transosseous sutures. The forearm fascia overlying the flexor carpi ulnaris is repaired.

Remember that rupture of the triceps mechanism can occur if care is not taken with elevation of the extensor mechanism from the olecranon. Reattachment should be performed as Morrey48 recommends.

Modifications. Transosseous exposures require some type of osteotomy. In their modification of Bryan and Mor-rey's approach, Wolfe and Ranawat recommend that the triceps attachment be released from the ulna by os-teotomizing the attachment with a thin wafer of bone and that the entire extensor mechanism with its wafer of bone be reflected laterally.61

Boyd's Approach

Boyd12 describes a posterolateral approach for Monteggia fracture-dislocation, radial head fracture, and reconstruction of the annular ligament (Fig. 1.21). He recommends that a posterolateral incision be made along the lateral border of the triceps muscle and extended distally for 6 cm along the subcutaneous border of the ulna. In

Line of incision to release the medial triceps and forearm fascia

Line of incision to release the medial triceps and forearm fascia

Olecranon tip osteotomy

Ulnar nerve transposition

Medial collateral ligament released from humerus to increase exposure

Reflection of triceps from medial to lateral

Olecranon tip osteotomy

Reflection of triceps from medial to lateral

Subperiosteal release of the

Medial collateral ligament released from humerus to increase exposure

Subperiosteal release of the

The triceps tendon is reattached to the olecranon vuith transosseous sutures

Forearm fascia-periostei complex is sutured to the margin of the FCU muscle

FIGURE 1.20. (A) and (B) Bryan and Morrey's extensive posterior approach. (C) Closure of the extensive posterior approach. (FCU, flexor carpi ulnaris.)

the muscular and periosteal planes, the muscles on the lateral side of the ulna (anconeus and supinator) should be elevated in the subperiosteal plane from the ulna. Retraction of the anconeus and supinator muscles exposes the joint capsule overlying the radial head and neck. This lateral capsule contains the lateral ligamentous complex, and its division can lead to posterolateral rotatory instability. The supinator muscle protects the posterior inter-osseous nerve.

To expose the radial shaft, the muscles of the lateral aspect of the ulna may be elevated (extensor carpi ulnaris, abductor pollicis longus, and extensor pollicis longus). The muscular flap is retracted at the level of the interos-

seous membrane. The posterior interosseous and recurrent interosseous arteries may need ligation.

With this approach, the surgeon can view the radio-capitellar joint, proximal quarter of the radius, and the lateral surface of the ulna. For closure, we strongly recommend that the surgeon reattach the lateral ligamentous complex to the supinator crest. The deep fascia is closed.

We have seen posterolateral rotatory instability and ra-dioulnar synostosis result from the Boyd approach and recommend that the surgeon reserve its use for excision or "formation" of radioulnar synostosis (i.e., one-bone forearm). Posterolateral rotatory instability may occur due to detachment of the lateral ligament complex from

FIGURE 1.21. Boyd's approach. (A) Posterior skin incision. (B) Incision is made along the lateral border of the triceps. (ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.) (C) The joint capsule is exposed. (D) The supinator muscle overlies the radial head and neck and protects the posterior interosseous nerve. (E) Retraction of the supinator muscle exposes the radial head and neck.

FIGURE 1.21. Boyd's approach. (A) Posterior skin incision. (B) Incision is made along the lateral border of the triceps. (ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; ECU, extensor carpi ulnaris.) (C) The joint capsule is exposed. (D) The supinator muscle overlies the radial head and neck and protects the posterior interosseous nerve. (E) Retraction of the supinator muscle exposes the radial head and neck.

the supinator tubercle. Radioulnar synostosis may occur because the proximal radius and ulna are exposed sub-periosteally.62 The posterior interosseous nerve needs to be protected.

Modifications. For the Monteggia fracture-dislocation, Gordon63 recommends that the surgeon should expose the ulna with subperiosteal dissection and expose the radial head between the anconeus and the extensor carpi ulnaris (the Kocher interval). Gordon preferred this technique because it preserves the vascularity of the proximal ulnar fragment. We recommend the Gordon modification for the management of Monteggia fracture-dislocation because of the potential complications associated with the Boyd approach.

Olecranon Osteotomy Approach

MacAusland originally described the transolecranon osteotomy approach in 19 1 542 (Fig. 1.22). Indications for this approach include fixation of intra-articular fractures of the distal humerus and AO type C3 fractures. In the periosteal plane, the olecranon is exposed and predrilled. The anconeus is elevated from the olecranon, and large

FIGURE 1.22. Chevron olecranon osteotomy. (A) Predrilling of the olecranon. (B) Completion of osteotomy with an osteotome. (C) Point of the osteotomy faces distally. (D) Distal articular surface of the humerus is exposed.

FIGURE 1.22. Chevron olecranon osteotomy. (A) Predrilling of the olecranon. (B) Completion of osteotomy with an osteotome. (C) Point of the osteotomy faces distally. (D) Distal articular surface of the humerus is exposed.

AO bone-holding forceps are used to distract the joint so that the nonarticular area of the olecranon can be identified. The surgeon accomplishes a chevron osteotomy53 at this site with a thin-bladed oscillating saw up to the anterior cortex and completes it with an osteotome. The ole-cranon and the triceps mechanism are elevated to expose the distal humerus.64 The advantage of the chevron osteotomy is that it increases the area for healing and provides some intrinsic rotational control. The point of the chevron osteotomy faces distally so that the collateral ligaments remain attached to the shaft fragment and so that the olecranon fragment is less likely to fracture.

The exposure extends proximally by elevation of the triceps from the humerus and distally by subperiosteal muscular elevation from the proximal ulna. The surgeon can visualize the entire distal articular surface of the humerus.

The olecranon is reattached with a large cancellous screw and tension-band wire. We use a long-threaded, large-fragment AO cannulated screw because it helps to align the olecranon. The guide wire centers the drill and screw into the intramedullary canal. Bone-holding forceps are used to provide rotational control as compression is applied across the osteotomy.

Complications include a 5% incidence of olecranon osteotomy nonunion.64 Ligamentous instability can occur if the collateral ligaments are violated. Osteoarthritis can occur if the osteotomy is not reduced anatomically. The surgeon needs to avoid malrotation and overtightening of the osteotomy.

Modifications. Müller et al. modified MacAusland's approach and recommend an extra-articular olecranon osteotomy.51 However, this osteotomy does not provide exposure of the anterior articular surface, which often is comminuted in supracondylar fractures.

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