My Technique For The Release Of Stiff Elbows

Thierry Judet
Hôpital Tenon - Paris

The first rule to be observed is that the full range of movement must be restored at surgery: Any deficit left at the end of the operation will not be made up by physiotherapy afterwards.

The second rule is that this ROM must be achieved without sacrificing joint stability: Immediate postoperative exercise therapy over the entire ROM restored at surgery is predicated upon a fully stable joint.

The procedure follows a standardized pattern, with capsulectomy as required for the removal of any constricting structures that interfere with motion, and for the trimming of bony structures that are causing impingement. This soft tissue and bone surgery is always done via a medial and/or a lateral incision.

The only difference is whether the first incision should be medial or lateral. This will depend upon the condition of the elbow. The surgeon should opt for the approach most likely to allow full release without the need for a counter-incision.

The extent of the operation will depend upon the degree of ankylosis found preoperatively.

- I - PATIENT POSITIONING

The patient is supine. A tourniquet is applied high on the upper arm, and the arm is placed on a short (20-30 cm) side table that does not extend beyond the patient's elbow. In this way, the surgeon can readily, and without changing positions, perform a medial approach (with the patient's shoulder abducted and externally rotated) and a lateral approach (with the shoulder adducted and internally rotated).

- II - STANDARD MEDIAL AND LATERAL APPROACHES

Whichever approach is chosen, there are certain principles that must be observed:
1) The middle portion of the epicondylar muscle attachments must be left in situ; and
2) The entire anterior and posterior aspects of the elbow must be exposed. Thus, from a medial incision, complete anterior and posterior tissue release must be obtained, going as far as the head of the radius and the condyle of the humerus; the only structure not taken off will be the radial collateral ligament. Similarly, when a lateral incision is used, the only structure not released will be the ulnar collateral ligament.

If a counter-incision is required, it will be supplemental only.

A MEDIAL APPROACH

1 - Skin incision (Fig. 1)
The incision has an angled pattern, centred over the lower corner of the medial epicondyle. The two limbs of the incision are from 5 to 7 cm long. The ascending limb follows the axis of the upper arm towards the axilla, while the descending one is directed towards the styloid process of the ulna.

2 - Careful identification and mobilization of the ulnar nerve, preserving its blood supply and distally opening its muscolo-fascial bed as far as the origin of its first branch.

Figure 1 Medial approach. Skin incision

Figure 2 Medial approach. Identification of ulnar nerve, and approach of anterior aspect of elbow. Middle portion of the flexor pronator group is left in situ.

3 - Approach of the anterior aspect of the elbow (Fig. 2)

The entire upper and anterior portion of the flexor pronator origins is detached with a scalpel, from the medial border of the humeral metaphysis to the middle of the epicondyle. From that point onwards, the incision is routed, in the direction of the fascial and muscle fibres, towards the forearm, and developed in depth down to the anteromedial joint capsule.

The middle portion of the flexor pronator group (between this incision and the approach to the ulnar nerve in the forearm) is left in situ.

This provides access to the anterior joint capsule. The incision is made from the humeral metaphysis, extraperiosteally under the brachialis, which protects the neurovascular structures that cannot be seen. The dissection is carried distally using an elevator or a scalpel, moving from the extraperiosteal to the precapsular plane over the entire anterior aspect of the joint, from the anterior band of the collateral ligament medially to the coronoid process distally and the humeral condyle and the anterior aspect of the radial head laterally.

4 - Approach of the posterior aspect of the elbow (Fig. 3)

Figure 3
Medial approach. Access to posterior aspect of elbow.

Starting from the medial border of the distal portion of the medial intermuscular septum (which may be resected), the triceps is detached from the posterior surface of the humeral metaphysis, as far as the lateral border of the humerus. Dissection is extraperiosteal and extracapsular, and carried from proximal to distal; distally and medially, the triceps expansion is detached to expose the posterior band of the ulnar collateral ligament, the entire posterior capsule, and the tip of the olecranon to beyond the retrocondylar capsule.

5 - Standard associated procedures
As the incision is deepened and widened, any periarticular calcifications encountered are removed; in some cases of neurogenic ossification, this removal will form a major part of the release operation. In addition, the following procedures are performed, as required and until the joint is fully mobile:
- complete anterior and posterior capsulectomy;
- resection of any calcifications that interfere with the movement of the joint;
- wide excision of osteophytes, especially those high on the lateral and medial borders of the olecranon and the coronoid process;
- debridement of the humeral, olecranon and coronoid fossae, and of the trochlear and radial notches;
- in some cases (chondromatosis), removal of intra-articular loose bodies.
These procedures, or a selection thereof, may suffice to restore a full ROM. If mobility is not restored, a supplemental lateral approach should be used, or the special procedures described below should be instituted.

B LATERAL APPROACH (Fig. 4)

1 - Skin incision (Fig. 5)
The pattern is as described for the medial approach, but centred over the tip of the lateral epicondyle. The ascending limb is routed following the axis of the upper arm, while the descending limb is directed towards the ulnar crest at a point 7 cm distal to the tip of the olecranon.

Figure 4 Landmarks for lateral approach

Figure 5 Lateral approach. Skin incision

2 - Approach of the posterior aspect of the elbow (Fig. 6)
The fascia of the upper arm is incised over the lateral border of the humerus, and the triceps is detached. Distal to the epicondyle, the forearm fascia is opened over the anconeus-extensor interval (Cadenas approach).
The anconeus and triceps are left in continuity and reflected posteriorly, to give extracapsular access to the posterior aspect of the joint. This provides exposure of the posterior band of the radial collateral ligament; the posterior attachment of the annular ligament covering the posterior part of the head of the radius; and the entire posterior capsule to beyond the olecranon. In the most medial part of this dissection, care must be taken to ensure that the ulnar nerve is not damaged, if the nerve has not been released from its groove on the dorsum of the epicondyle earlier in the procedure.

3 - Approach of the anterior aspect (Fig. 7)
After undermining the anterior edge of the skin incision over a distance of 3 to 4 cm, a scalpel is used to make an incision on the lateral border of the humeral metaphysis over the distal 3 cm of the brachioradialis and the proximal portion of the tendon of the radial muscles. From there, the incision is continued in the direction of the tendon and muscle fibres, over a distance of 3 to 4 cm. This will allow the anterior portion of the muscles arising from the lateral epicondyle to be reflected forward, and give access to the following structures: the humeral metaphysis; the anterior capsule medially to beyond the coronoid process; and, distally, the anterior part of the annular ligament and the radial head down to the neck of the radius. This is the only site where the radial nerve passes close to the operative field.

Figure 6 Lateral approach. Access to posterior aspect of elbow

Figure 7 Lateral approach. Access to anterior aspect of elbow

4 - Standard associated procedures
These procedures are identical to the ones described for the medial approach. For the restoration of joint mobility, it may be necessary to combine the two approaches, as well as carrying out any requisite associated procedures. The muscles are partially reinserted with a few sutures, and the incision is closed over two intra-articular suction drains. A compression dressing is applied for a few hours, prior to the commencement of exercise therapy.

- III - ADDITIONAL SURGERY AND SPECIAL PROCEDURES

a muscle lengthening
This is done only in the brachialis, if excessive muscle tension limits elbow extension. Lengthening is achieved by simple tenotomy at the musculo-tendinous junction. A medial approach is used for access to the anterior tendinous and fascial aspect of the brachialis, in order to preserve continuity. In this procedure, the medial bicipital sulcus is opened, and care must be taken not to damage the neurovascular structures in that region.

No lengthening of the triceps or biceps is performed. Dividing the triceps would affect the posterior cover of the elbow joint, and would compromise the skin when the elbow is flexed. Lengthening the biceps would cause a major loss of elbow flexion power.

b sectioning of the collateral ligaments
Where the capsule is badly retracted, these ligaments have to be divided in order to achieve full mobility. This division does not affect the immediate or long-term stability of the elbow joint, providing that the ligaments are cut flush with the epicondylar attachments, and that care is taken to ensure that the superficial portions of the muscles still attaching at these sites are left in situ.

c joint incongruency and cam effect at the end of movement
This is indicative of osseous or fibrous impingement that interferes with the smooth working of the joint. The cause of impingement must be identified and removed.

d joint surface destruction and elbow ankylosis
In this condition, the use of a distraction device after contouring of the joint surfaces should be considered.

e transepicondylar approaches (Figs. 8 and 9)
These approaches are indicated in cases of high-grade stiffness with fibrous ankylosis or ensheathing calcifications. The medial or lateral epicondyle is taken off by sagittal osteotomy, detaching the bone with its soft tissue attachments. These approaches give a strictly lateral view of the joint line, and permit the elbow to be dislocated sideways, should this manoeuvre be required. The epicondyles are reattached by means of a screw and washer.

Figure 8 Medial transepicondylar approach

Figure 9 Lateral transepicondylar approach

f stiffness following radial head fractures
The radial head may have been resected in a previous operation. Where it has not been removed, it may be severely deformed, and may have to be excised as part of the release procedure.

Post-traumatic radial head deformity and hypertrophy may result in joint incongruency and/or impairment of flexion-extension and pronation-supination. If the radial head is resected and the other procedures (capsulectomy, release of ligaments) are performed in order to restore full mobility, the patient may be left with valgus instability or with posterior dislocation in near-extension.

In such cases, the elbow must be restabilized by the implantation of a radial head replacement and by attention to the restoration of an anatomically and physiologically correct pattern of the lateral (radiocapitellar) part of the joint. Where this stabilization has been achieved, exercise therapy may be instituted immediately after surgery, over the full ROM obtained at surgery.