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 (in-dwelling) 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