Indications

Fixation of condylar fractures, radial head excision and repair or reconstruction of the lateral ligaments.

Technique

Either a posterior skin incision with dissection of a full-thickness lateral fasciocutaneous flap or a limited distal lateral skin incision may be used. The anconeus and extensor carpi ulnaris muscles are identified by palpation. A thin strip of fat can almost always be observed in the interval between these muscles (Fig. 6.1). The muscle fibres of the anconeus and the extensor carpi ulnaris muscles tend to blend together towards the insertion, so it is easier to develop the interval in its distal part and then progress proximally. The deep fascia is then opened and the interval is developed by dissecting the anconeus posteriorly. The lateral elbow capsule with the annular ligament is identified and incised longitudinally anterior to the lateral ulnar collateral ligament.

Figure 6.1 Kocher approach. (A) The interval between the anconeus and the extensor carpi ulnaris (ECU) can be easily identified by a thin strip of fat distally. (B) After developing this interval, the recurrent interosseous artery can be found seated superficial to the capsule.

Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

Modifications

For reconstruction of the lateral ulnar collateral ligament, this approach can be extended proximally above the lateral epicondyle by developing the interval between the triceps and the brachioradialis (Fig. 6.2A). Once this is done, the rest of the extensor mass can be sharply incised from the epicondyle, respecting the insertion of the lateral ulnar collateral ligament. In order to achieve adequate exposure of the crista supinatoris, the anconeus along with the lateral aspect of the triceps tendon are reflected posteriorly (Fig. 6.2B).⁵

Figure 6.2 Extended Kocher approach. (A) If a more extensile approach is required, the brachioradialis and extensor carpi radialis longus (ECRL) can be sharply detached from the humerus anteriorly and the triceps posteriorly, allowing access to the anterior and posterior capsule. (B) Distally, the extensor–supinator muscle mass can be detached from the humerus and the anconeus reflected posteriorly to allow access to the proximal ulna and lateral ligamentous complex. (ECU, extensor carpi ulnaris; LCL, lateral collateral ligament.)

Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

Mansat and Morrey described the use of a limited proximal lateral approach for capsular release for stiff elbows, which they termed the ‘column procedure’.⁶ This exposure may be a proximal extension of the Kocher approach or a focused isolated proximal approach. The exposure is based on a dissection made anteriorly to the lateral border of the distal humerus, elevating the distal aspect of the brachioradialis and the extensor carpi radialis longus from the humerus and entering the interval between the brachialis and the capsule. Access to the posterior capsule involves elevation of the triceps to form the posterior part of the humerus.

Indications

Fixation of radial head fractures, particularly those that involve the anterior half.

Technique

A skin incision is made on the lateral aspect of the elbow from the epicondyle extending distally 4 cm towards the ulnar styloid process. The interval between the extensor digitorum communis and the extensor carpi radialis brevis and longus is developed exposing the underlying capsule which is incised longitudinally to gain access to the radial head (Fig. 6.3).

Figure 6.3 Kaplan approach. (A) The incision is made in line with the interval between the extensor carpi radialis brevis (ECRB) muscle and the extensor digitorum muscle (EDC–EDM, extensor digitorum communis–extensor digiti minimi). (B) After entering this interval, the supinator muscle (1) and underlying capsule (2) should be longitudinally incised, allowing access to the most anterior part of the radial head. Note the close location of the posterior interosseous nerve (3). (ECU, extensor carpi ulnaris.)

The radial nerve is at particular risk during this approach but this can be reduced by pronation of the forearm, which moves the nerve away from the operative field.⁷

Indications

Open reduction and internal fixation of fractures, resurfacing elbow replacement, and interposition arthroplasty.

Technique

This exposure is an extension of the limited exposures described earlier and involves the release of the collateral ligaments and capsule. A midline posterior skin incision is used. The triceps is elevated from the posterior aspect of the humerus, and dissected anteriorly from the brachioradialis and the extensor carpi radialis longus. The Kocher interval is identified and developed to expose the joint capsule. The anconeus is elevated from the ulna and the triceps attachment to the lateral epicondyle is also reflected posteriorly, leaving its insertion to the olecranon intact. The lateral collateral ligament is then released from the humeral origin, allowing dislocation of the elbow joint by applying a varus stress (Fig. 6.4).

Figure 6.4 Kocher posterolateral extensile triceps-sparing approach. Release of the lateral collateral ligament (LCL) complex allows complete exposure of the joint. (ECU, extensor carpi ulnaris.)

Reproduced by permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

Modifications

This approach was modified in the Mayo Clinic to include complete release of the triceps from the olecranon, reflecting the triceps mechanism and anconeus from lateral to medial. The triceps and anconeus sleeve is reflected from the tip of the olecranon by releasing Sharpey’s fibres (Fig. 6.5).²

Figure 6.5 Mayo Clinic modification of Kocher posterolateral extensile triceps-sparing approach. (A) Detachment of the triceps insertion on the olecranon allows exposure of the posterior joint (B). This approach combines an extensile Kocher approach with posterior triceps and anconeus reflection. (ECU, extensor carpi ulnaris.)

Indications

This approach was initially described for releasing elbow contractures. It provides excellent exposure of the medial aspect of the joint with access to the posterior and anterior capsules. It allows treatment of concomitant ulnar nerve pathology and access to the coronoid and humeral condyle.

Technique

Although a medial skin incision can be used, it is our preference, as previously mentioned, to use a straight posterior skin incision for any extensile approach around the elbow.

The subcutaneous dissection must be performed cautiously to avoid injury to the medial antebrachial cutaneous nerve. This nerve can be localized running on top of the superficial fascia (Fig. 6.6A). The ulnar nerve should be identified proximally and mobilized. The medial intermuscular septum should then be released for a distance of about 5 cm. An incision is made on the supracondylar ridge 5 cm proximal to the medial epicondyle and continued distally towards the pronator and a portion of the common flexor tendon. A portion of the flexor carpi ulnaris tendon is left attached to the epicondyle posteriorly as this facilitates closure at the end of the procedure. A Cobb elevator is helpful in elevating the anterior structures from the distal humerus until a wide retractor can be introduced (Fig. 6.6B).

Figure 6.6 Extensile medial approach (Hotchkiss). (A) On superficial dissection, it is mandatory to locate and preserve the medial antebrachial cutaneous nerve (MACN). (B) The interval between the flexor digitorum superficialis (FDS) and the flexor carpi ulnaris (FCU) is entered and the underlying capsule with the anterior band of the medial collateral ligament (MCL) and brachialis muscle are localized, allowing exposure of the joint.

Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

As the dissection proceeds laterally and distally, the brachialis muscle is elevated from the capsule. Another option is to start the dissection distal to the coronoid process, which can be palpated, and proceed proximally. The flexor tendon can then be incised with the knife blade placed almost parallel to the plane of dissection and around the sublime tubercle. This manoeuvre allows the plane to be found between the medial collateral ligament and the flexor muscle mass, while protecting the former. The dissection can then be continued proximally until it links up with the previously performed proximal dissection (Fig. 6.7).

Figure 6.7 Extensile medial approach (Hotchkiss). After detaching the flexor pronator group and retracting the anterior joint capsule (1) and the brachialis muscle (2), it is possible to gain access to the coronoid process (3) and the medial collateral ligament (4). The ulnar nerve (5) can be transposed over the flexor carpi ulnaris muscle (6).

The posterior capsular exposure can be safely continued by mobilizing the ulnar nerve anteriorly while avoiding proximal or distal kinking of the nerve. The triceps is then elevated from the capsule with the use of a periosteal elevator. In cases of severe flexion contracture the posterior band of the medial collateral ligament may have to be incised to gain full flexion.

Indications

Initially described for managing paediatric supracondylar fractures, this approach can be used for simple distal humeral fractures in adults, non-unions, tumours, and total elbow arthroplasty or hemiarthroplasty in comminuted distal humerus fractures.

The major advantage of this approach is that it preserves triceps continuity and does not require postoperative protection. The main disadvantage is that it may increase the difficulty of the procedure, due to the limited exposure. Forearm manipulation must be done with care to avoid traction injuries to the ulnar nerve.

Technique

A posterior skin incision is made medial or lateral to the tip of the olecranon. Full-thickness fasciocutaneous flaps are elevated. The medial and lateral borders of the triceps are incised and elevated from the posterior aspect of the distal humerus. The ulnar nerve must be identified and protected. The distal humerus can be buttonholed medially or laterally to gain access to the proximal forearm (Fig. 6.9).

Figure 6.9 Triceps-preserving approach (Alonso-Llames). After isolation of the ulnar nerve (1), the triceps (2) is subperiostically detached from the posterior aspect of the humerus (3) on both sides, preserving its insertion on the olecranon.

Modifications

Morrey described a variation of this technique primarily for distal humeral non-unions treated with elbow replacement. On the lateral side, the extensor origin and the lateral collateral ligament complex are released from the lateral epicondyle. Medially, the common flexor muscle and tendon mass are elevated along with the medial collateral ligament. After resection, the forearm can be rotated to facilitate exposure of the proximal ulna.²

Patterson et al¹² also described a modification of this approach in order to increase distal exposure. Laterally, the interval between the extensor carpi ulnaris and the anconeus is developed and continued distally with subperiosteal dissection of the extensor carpi ulnaris. On the medial side, the flexor carpi ulnaris is elevated subperiosteally.

Indications

Total elbow arthroplasty, distal humeral fractures, sepsis, synovectomy, ulnohumeral arthroplasty, anklylosis and unreduced elbow dislocation.

This is a simple exposure that can be easily extended proximally up to the level of the radial nerve and distally along the ulna. Closure must be meticulous to avoid buttonholing of the olecranon through a defect in the triceps tendon.

Technique

The triceps tendon and muscle are longitudinally incised, exposing the distal humerus proximally and proceeding distally by reflecting the anconeus laterally and the flexor carpi ulnaris medially (Fig. 6.10). Subperiosteal dissection should be done at the level of the olecranon attachment. The ulnar nerve may be visualized medially and protected. Closure of the aponeurosis is done with side-to-side sutures. Transosseous sutures at the triceps insertion may be added to augment the repair.

Figure 6.10 Posterior triceps-splitting approach. (A) The tricipital aponeurosis (1) is longitudinally opened. The underlying medial head of the triceps brachii muscle (2) and the triceps tendon (3) are incised, exposing the posterior aspect of the humerus and the olecranon (4). (B) After the triceps tendon is completely detached from the olecranon, the FCU (5) is retracted medially and the anconeus muscle (6) laterally, allowing a complete exposure of the posterior aspect of the joint. The olecranon fat pad (7) is preserved with the triceps brachii muscle in order to avoid adherences in the future. The ulnar nerve should be located throughout the procedure (8). Trochlea humeri (*).

Modifications

Gschwend¹⁵ reported a modification of this approach in which the proximal ulna is exposed with the use of a fine osteotome to create osteoperiosteal flaps, in an effort to promote healing of the extensor mechanism.

Indications

Indications are the same as in the previous exposure, but this approach has been mostly used for chronic elbow dislocations.

The advantage of this approach is that it gives good exposure and, at the same time, allows lengthening of the extensor mechanism by using a V-Y advancement technique. Its main disadvantages are that it weakens the triceps and has a reported higher infection rate than other approaches due to vascular compromise of the distal flap. For this reason, we prefer a slight modification of this approach in which complete sectioning of the triceps muscle is avoided.

Technique

In the original approach, the deep head of the triceps is divided in its midline for a length of about 8 cm. The flap is distally based and should extend to the outer part of the humeral condyles in order to allow an adequate approach (Fig. 6.11). Sufficient tendon tissue at both sides of the flap must be preserved to obtain a good repair. To perform a V-Y advancement the triceps is sutured in the midline for the required length. The rest of the flap is then repaired at its new length to the outer edges of the aponeurosis with interrupted sutures.

Figure 6.11 Triceps splitting–tendon reflection: V-Y approach. (A) After the ulnar nerve (1) is located, the tricipital aponeurosis (2) and the medial head of the triceps brachii muscle (3) are divided, using a V-Y incision. (B) The flap is distally based and should extend to the outer part of the humeral condyles to allow exposure of the olecranon fat pad (4), the olecranon fossa (5) and the posterior aspect of the distal humerus (6).

Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

We think this approach has an unacceptable rate of infection and triceps disruption. We avoid complete triceps disruption by elevating a flap with the superficial triceps aponeurosis and then entering the true triceps tendon longitudinally, through an avascular area (Fig. 6.12). This approach preserves the vascularity of the distal flap and allows a much better repair.

Figure 6.12 Triceps-preserving V-Y approach. (A) The superficial aponeurosis of the tríceps brachii is elevated as a flap (1) and the true intramuscular tendon is exposed (2). The tendon is longitudinally incised through an avascular area to enter the posterior aspect of the joint. (B) A Z-plasty of the tendon is performed (2) in order to allow further elongation if necessary. The approach can be extended distally by elevating the anconeus muscle (3). The posterior aspect of the humerus is well exposed (4). (C) At the end of the surgical procedure, the tendon edges are sutured longitudinally and the flap of the superficial aponeurosis is closed over the repair, reinforcing the suture and limiting the risk of adhesions.

Modifications

Van Gorder¹⁶ described a modification of this technique in which the incision on the medial head of the triceps runs obliquely in order to avoid cutting off the triceps proximally. The incision runs from anterior distal to posterior proximal, leaving the entire thickness of the muscle attached to the base of the flap.

Wadsworth¹⁸ described a modification to enhance the exposure. After creating the flap, the incision is extended distally between the anconeus and the extensor carpi ulnaris, reflecting the anconeus medially and allowing access to the lateral aspect of the joint.

Indications

Elbow arthroplasty, distal humerus fractures, elbow stiffness.

The advantage of this approach is that it provides excellent exposure, allowing access to the ulnar nerve or medial collateral ligament. The main disadvantage is the possibility of developing postoperative triceps insufficiency if the tendon repair fails or the tissue quality is poor, as in rheumatoid patients.

Technique

A midline skin incision is used from 8 cm proximal to 8 cm distal to the tip of the olecranon. The ulnar nerve is dissected proximally, where it is easily found medial to the triceps, and followed distally until it gives its first motor branch. The nerve must be protected throughout the procedure, and it is either transposed anteriorly or left in place, depending on surgical preference.

The triceps is released from the entire posterior aspect of the distal humerus. The forearm fascia and ulnar periosteum are elevated from the medial margin of the ulna. The triceps tendon is carefully detached from the tip of the olecranon by sharp dissection of Sharpey’s fibres. The lateral margin of the proximal ulna is then identified and the anconeus is elevated from its ulnar bed. Finally, the extensor mechanism is reflected laterally from the margin of the lateral epicondyle (Fig. 6.13).

Figure 6.13 Posteromedial extensile: Bryan–Morrey approach. (A) After the ulnar nerve (1) is identified, the triceps brachii is subperiostically dissected (2) to expose the posterior aspect of the distal humerus (3). (B) The tricipital tendon (4) is sharply detached from the olecranon, and the anconeus muscle (5) from the ulna, allowing anterior reflection of the triceps–anconeus flap and complete exposure of the joint.

Reproduced with permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

Modifications

Wolfe and Ranawat¹⁹ reported a modification of this approach in which the ulnar nerve is exposed but not transposed and the triceps is released by osteotomizing its attachment on the olecranon through a thin wafer of bone, in an effort to achieve reliable healing.

Shahane and Stanley²⁰ have also described a modification of this approach with the aim of reducing the incidence of ulnar neuropathy. After decompression of the ulnar nerve the triceps is split, with one-third medial and two-thirds lateral. The medial third is reflected medially with the ulnar nerve and the lateral two-thirds are reflected laterally, allowing excellent exposure of the distal humerus.

In every instance in which the triceps has been completely reflected either from lateral to medial or from medial to lateral, it should always be securely reattached to the olecranon with a crisscross type of suture through drill holes placed in a cruciate fashion through the olecranon.

Indications

This approach was initially described for treating ankylosed joints. Its main indication today is open reduction and internal fixation of distal humeral fractures.

The chevron osteotomy has an advantage over the originally described MacAusland osteotomy as it has an increased surface area for bony healing and increased stability.

Technique

A posterior midline skin incision is used. The ulnar nerve must be located and protected throughout the procedure. A 3.2 mm drill hole can be made that crosses the osteotomy site to introduce a lag screw at the completion of the procedure. The joint is exposed at the greater sigmoid notch and a sponge may be placed in the joint to protect the articular surface. The osteotomy is made with a distal chevron and should be started with a saw and finished with an osteotome. This allows the formation of cracks that may facilitate repositioning of the bony fragment. The fragment and the tendon are retracted proximally (Fig. 6.14). Capsular attachments and the posterior component of the collateral ligaments may need to be divided to gain more access to the joint. At the completion of the procedure the osteotomized fragment is reduced and fixed with a cancellous lag screw, a cerclage with K-wires or a plate.

Figure 6.14 Olecranon osteotomy approach. (A) After the ulnar nerve (1) is isolated, the olecranon is osteotomized (2) in the area denuded of cartilage (*). The olecranon is retracted proximally by disrupting the union between the anconeus and triceps (3 and 4). Olecranon fat pad (5); olecranon fossa (6). (B) After complete retraction of the olecranon, wide exposure of the distal humerus and intermuscular septa (7) is achieved.

Reproduced by permission of Sales JM, Llusá M, Forcada P, et al. Orozco. Atlas de osteosíntesis. 2nd edn. Fracturas de los huesos largos. Vías de acceso quirúrgico. Barcelona: Elsevier-Masson; 2009.²⁴

Modifications

Concerns about splitting the anconeus after completing the osteotomy have prompted the development at the Mayo Clinic of an approach in which the anconeus is sharply dissected distally and reflected proximally respecting its fascial attachment to the triceps. It preserves the anconeus in continuity with the triceps and can be used for later reconstructive procedures, should they be needed.

Indications

Neurovascular exploration in cases of local nerve entrapment or vascular injury, the reconstruction of the distal biceps, the reduction and osteosynthesis of anteriorly displaced fracture fragments and the excision of local tumours with anterior involvement of the elbow.

The proximity of important neurovascular structures is the main disadvantage of this approach. These include the proximity of the lateral antebrachial cutaneous nerve in the superficial plane and the median nerve and brachial artery in the deep plane of dissection. The brachialis muscle is between the joint and the median nerve, and the radial nerve is in the interval between the brachialis and the brachioradialis muscle. These anatomical features must be kept in mind at all times to avoid inadvertent injury (Fig. 6.15).

Figure 6.15 Anterior approach of the elbow. (A) Superficial surgical dissection. Note the close relationship of the biceps tendon and the lateral antebrachial cutaneous nerve (LACN). (B) Deep surgical dissection. In the external bicipital canal, the posterior interosseous nerve (PIN) and the superficial radial nerve (SRN) should be protected. In the medial bicipital canal, the brachial artery (BA) and the median nerve (MN) lie immediately deep to the lacertus fibrosus.

Reproduced by permission of Llusá M, Ballesteros JR, Forcada P and Carrera A. Atlas de disección anatomoquirúrgica del codo. Barcelona: Elsevier-Masson; 2009.²⁴

Technique

The incision is S-shaped, with the transverse arm parallel to the elbow flexion crease. Proximally it follows the lateral border of the biceps, and distally it follows the medial border of the brachioradialis. The plane of dissection lies between the brachioradialis and brachialis muscle proximally, and the brachioradialis and pronator teres distally.

During superficial dissection the lateral antebrachial cutaneous nerve must be localized and protected. This nerve is found in the interval between the biceps tendon and the brachialis muscle. The aponeurosis is incised with care to avoid injury to the radial artery that runs immediately beneath it. The vein and the median nerve are medial to the artery. If the radial nerve has to be identified, it emerges between the brachialis and the brachioradialis, in front of the radiocapitellar joint. The radial nerve can be safely retracted laterally with the brachioradialis, while the pronator teres is retracted medially revealing the radial artery, the muscle branch and the recurrent radial artery.

Modifications

Henry’s approach can be extended proximally and distally as needed. A more limited approach can, however, be used for reconstruction of distal biceps ruptures.