Surgical Exposures of the Elbow

Published on 11/04/2015 by admin

Filed under Orthopaedics

Last modified 22/04/2025

Print this page

This article have been viewed 18751 times

CHAPTER 7 Surgical Exposures of the Elbow

Bernard F. Morrey

INTRODUCTION

Few joints require familiarity with as many surgical exposures as does the elbow. Depending on the lesion and the surgical goal, the joint and the surrounding region may be approached from the lateral, posterior, medial, or anterior direction.

Exposures from the medial and lateral aspects that once allowed the removal of loose bodies and the treatment of certain localized fractures are used less commonly today. Instead, some form of an extensile posterior exposure is used for most complex fractures and joint reconstructive procedures, and this is considered the universal approach to the joint.

It is not the purpose of this chapter to discuss all of the approaches to the joint but rather to provide a comprehensive collection and critique of those relevant exposures that should prove helpful to the practicing orthopedic surgeon.³³

GENERAL PRINCIPLES

Rigorous adherence to the principles of good surgical technique is of no greater importance in any anatomic part than at the elbow.^6,^8,³⁵ The most appropriate surgical approach depends on the specific goal of the surgical intervention and on the lesion. As for any orthopedic procedure, the choice of the surgical approach should be based on the following criteria (Box 7-1):

1. Potential to be extended to meet unforeseen circumstances.

2. Capability for providing adequate visualization to define and completely correct the problem.

3. Safety: avoidance of vital structures or visualization of these structures to avoid injury during the procedure.

4. Preservation of the normal anatomy as much as possible during the exposure, the procedure, and at closure.

5. Dissection along natural tissue planes rather than across muscle, tendon, or ligamentous structures.

6. Provision of careful hemostasis and adequate drainage after extensile exposures and dissections.

7. Careful soft tissue closure that reliably heals and ensures rapid and predictable rehabilitation.

BOX 7-1 Principles of Exposure of the Elbow Region

1. Flexible—allows extension

2. Adequate—visualization of pathology

3. Safety—especially nerves

4. Preservation—respect anatomy

5. Natural plane—extend along fascial, subcutaneous planes

6. Hemostasis—release tourniquet, drain as necessary

7. Closure—modified by specific features of case.

A thorough understanding of the anatomy of the elbow region and the relationship of the nerves and vessels is particularly important to selecting the exposure that best satisfies these requirements (Fig. 7-1).

FIGURE 7-1 Cross-sectional anatomy shows the important neurovascular and muscular relationships that must be understood to achieve a complication-free exposure of the elbow.

(Modified from Eycleshymer, A. C., and Schoemaker, D. M.: A Cross Section Anatomy. New York, D. Appleton and Co., 1930. In Darrach, W.: Surgical approaches for surgery of the extremities. Am. J. Surg. 67:93, 1945.)

LATERAL APPROACHES

A lateral exposure, probably the most commonly used approach to the elbow joint, offers many variations. It is used for radial head excision, removal of loose bodies, and repair of lateral ligaments, to fix condylar and Monteggia fractures, to release the joint capsule, and to remove osteophytes. Access to the radiohumeral articulation has been described by several authors.^7,^18,^21,^24,³⁶ The techniques differ according to the muscle interval entered and the means of reflecting the muscle mass from the proximal ulna. With any of the lateral exposures to the joint or to the proximal radius, the surgeon must be constantly aware of the possibility of injury to the posterior interosseous or recurrent branch of the radial nerve.

Kaplan has described an approach through the interval between the extensor digitorum communis and the extensor carpi radialis longus and brevis muscles. Because of the proximity of the radial nerve, pronation of the forearm during exposure has been recommended to assist in carrying the radial nerve out of the surgical field. The effect of this maneuver has been quantified by Strachan and Ellis, who found that approximately 1 cm of mediolateral radial nerve translation can occur with forearm pronation (Fig. 7-2).⁴²

FIGURE 7-2 Approximately 1 cm of medial to lateral translation of the posterior interosseous nerve occurs as the forearm is rotated from supination to pronation.

(Redrawn from Strachan, J. H., and Ellis, B. W.: Vulnerability of the posterior interosseous nerve during radial head resection. J. Bone Joint Surg. 53B:320, 1971.)

Even with this maneuver, however, the radial nerve is precariously close to the surgical field, so this approach is used less often than that described by Kocher. Knowledge of Kaplan’s interval ²⁴ is useful to expose the posterior interosseous nerve when decompression is performed in conjunction with tennis elbow release (see Chapter 44).⁴¹

THE KOCHER APPROACH AND ITS VARIATIONS

Some variation of the Kocher exposure is the most frequently used approach to the lateral aspect of the joint. This has the advantage of being extensile, affording a full complement of surgical options as the exposure is extended. This approach enters the joint through the interval of the anconeus and extensor carpi ulnaris, thus providing protection to the deep radial nerve. The interval is also anterior to the lateral ulnar collateral ligament, which reduces the likelihood of severing it at arthrotomy. In addition to providing a limited exposure for radial head excision and loose body removal, the particular value of this technique is that it may be converted to an extensile posterolateral approach to the entire distal humerus. If an extensile exposure is anticipated, a posterior incision is made. The same deep exposure can be accomplished by extending the posterior lateral skin incision and elevating the lateral skin cutaneous flap.

Limited Distal Lateral Approach: Kocher “J”

(Redrawn from Banks, S. W., and Laufman, H.: An Atlas of Surgical Exposures of the Extremities. Philadelphia, W. B. Saunders Co., 1953.)

Interval

The interval between the anconeus and extensor carpi ulnaris is identified and entered (Fig. 7-3B). For excision of the radial head, the extensor carpi ulnaris and a small portion of the supinator muscle are dissected free of the capsule and retracted anteriorly (see Fig. 7-3C). The annular ligament is then identified and entered. Care should be taken to enter the annular ligament approximately 1 cm above the crista supinatoris to avoid injury to the lateral ulnar collateral ligament (see Fig. 7-3D).

Expanding the Distal Lateral Exposure

Indication

Reconstruction of the lateral ulnar collateral ligament, harvest anconeus for anconeus arthroplasty.³¹

Landmarks

Lateral epicondyle; posterior border of the extensor carpi ulnaris, anterior edge of anconeus, crista supernatoris of ulna.

Skin Incision

If the lateral ulnar collateral ligament is to be reconstructed, the skin incision described earlier is simply extended proximally about 3 cm.

Interval

After the interval is entered, the anconeus is more completely reflected from its ulnar insertion (Fig. 7-4A). The lateral collateral ligament complex is identified by first elevating the extensor carpi ulnaris from the annular ligament just distal to the lateral epicondyle (see Fig. 7-4B). The fleshy attachment of the extensor carpi radialis longus is identified just above the common extensor tendon. This origin is freed from the supracondylar ridge. The dissection then elevates the common extensor tendon and the posterior edge of the extensor carpi radialis brevis from the lateral ligament complex (see Fig. 7-4D). This is done very carefully to identify and leave intact the lateral collateral ligament complex, and thus, reconstruction of the lateral ulnar collateral ligament can take place (see Chapter 48).

FIGURE 7-4 A, The anconeus is easily reflected posteriorly from its bed to expose the crista supinatoris (arrowheads). B, Lifting the anterior musculature, including the common extensor tendon and the extensor carpi ulnaris, adequately exposes the lateral collateral ligament complex, allowing reconstruction of this structure.

The Limited Proximal Lateral Exposure (Column Approach)

Indication

Stiff elbow: Anteroposterior capsular release; also termed the column procedure.^28,³¹

Landmarks

Extensor carpi radialis longus, lateral epicondyle, radial head, anterior capsule.

Note

This may truly be termed a minimally invasive procedure.

Skin Incision and Technique

This limited exposure of the anterior (and posterior) capsule has been described by Mansat and Morrey.²⁸ The skin incision is over the lateral column, extending distally over the lateral epicondyle to the radial head (Fig. 7-5A). The extensor carpi radialis longus and distal fibers of the brachial radialis are elevated from the lateral column and epicondyle (see Fig. 7-5B). The brachialis muscle is separated from the anterior capsule, which can be safely performed if the joint has been entered at the radiocapitellar articulation. Since the arthrotomy provides accurate spatial orientation across the joint, damage to neurovascular structures is avoided. The procedure then continues as described in Chapter 44.

FIGURE 7-5 A, The column procedure provides a limited exposure of the anterior capsule. The incision is approximately 3 to 4 cm and extends from the distal aspect of the origin of the brachioradialis across the radiohumeral joint and common extensor tendon. B, The distal fibers of the brachioradialis as well as the extensor carpi radialis longus are elevated from their attachment on the humerus. C, By elevating the brachioradialis a retractor can be placed behind the anterior musculature exposing the capsule. This is facilitated if an arthrotomy has been carried out. Note that the ability to access the posterior joint is readily accomplished through the so-called posterior interval which elevates the triceps attachment from the posterior aspect of the lateral supracondylar ridge.

POSTEROLATERAL EXPOSURES

THE BOYD POSTEROLATERAL EXPOSURE ⁷

Exposure of the lateral ulnohumeral and radiohumeral joint is accomplished with several variations of a posterolateral approach described by Boyd. Depending on the need to expose the proximal ulna or the distal humerus, these approaches can be extended and thus provide significant versatility.⁴⁰

Indications

Monteggia fractures, Mayo type II olecranon fractures.

Skin Incision

Begin the incision just posterior to the lateral epicondyle and lateral to the triceps tendon, and continue the incision distally to the lateral tip of the olecranon and then down the subcutaneous border of the ulna to the junction of its proximal and middle thirds or as necessary in order to expose the fracture (Fig. 7-6A).

FIGURE 7-6 The Boyd approach. A, The incision begins along the lateral border of the triceps approximately 2 to 3 cm above the epicondyle and extends distally over the lateral subcutaneous border of the ulna approximately 6 to 8 cm past the tip of the olecranon. B, The ulnar insertion of the anconeus and the origin of the supinator muscles are elevated subperiosteally. C, More distally, the subperiosteal reflection includes the abductor pollicis longus, the extensor carpi ulnaris, and the extensor pollicis longus muscles. The origin of the supinator at the crista supinatorus of the ulna is released, and the entire muscle flap is retracted radially, exposing the radiohumeral joint. D, The posterior interosseous nerve is protected in the substance of the supinator, which must be gently retracted. To extend the incision farther distal, the dorsal interosseous artery must be ligated.

(Redrawn from Crenshaw, A. H.: Surgical approaches. In Edmonson, A. S., and Crenshaw, A, H. [eds]: Campbell’s Operative Orthopaedics, 6th ed. St. Louis, C. V. Mosby, 1980. A and B modified from Boyd, H. B.: Surgical exposure of the ulna and proximal third of the radius through one incision. Surg. Gynecol. Obstet. 71:86, 1940; D modified from Eycleshymer, A. C., and Schoemaker, D. M.: A Cross Section Anatomy. New York, D. Appleton and Co., 1930.)

Technique

The anconeus and extensor carpi ulnaris are stripped subperiosteally from the ulna, beginning on the lateral subcutaneous crest of the bone and reflecting the muscles volarward. The supinator is released subperiosteally from its ulnar insertion, and the entire muscle mass is reflected anteriorly (see Fig. 7-6B). Be careful not to detach the ulnar attachment of the lateral ulnar collateral ligament. Thus, the lateral surface of the ulna and the proximal portion of the radius are adequately exposed (see Fig. 7-6C). The substance of the reflected supinator protects the deep branch of the radial nerve (see Fig. 7-6D). If greater exposure of the radius is desired, the recurrent interosseous artery (not the dorsal interosseous artery) is divided in the proximal portion of the wound, and the muscle mass is further reflected volarward to expose the interosseous membrane. The deep branch of the radial nerve remains protected.

EXTENSILE POSTEROLATERAL EXPOSURE (KOCHER)

This is an extension of the limited exposures described above involving the release of collateral ligament and capsule.²⁴

Indications

Extensile exposure to the joint surface for reconstructive procedures including open reduction internal fixation, total elbow arthroplasty (resurfacing), and interposition arthroplasty.

Landmarks

Proximal: lateral column; distal Kocher interval.

Skin Incision and Technique

The triceps may be elevated from the posterior aspect of humerus by extending the skin incision proximally up the lateral column (Fig. 7-7A). This may proceed 6 to 7 cm proximal to the lateral epicondyle without fear of violence to the radial nerve.

FIGURE 7-7 A, The incision is made 8 cm proximal to the joint just posterior to the supracondylar bony ridge and extending distally over the anconeus for approximately 6 cm. B, The interval between the anconeus and the extensor carpi ulnaris is identified and entered. C, The anconeus is reflected subperiosteally from the proximal ulna along with its fascial attachment to the triceps, which is likewise reflected medially, exposing the supinator muscle. The insertion of the triceps on the tip of the olecranon is released by sharp dissection, and the supinator muscle is released from the proximal portion of the ulna and the humerus as necessary to expose the capsule, which is entered via a longitudinal incision. D, The release of the radiocollateral ligament at its humeral origin allows joint subluxation to expose the entire distal humerus.

Proceed as shown in Figure 7-7B by completely elevating the anconeus from the ulna. The triceps is easily elevated from the posterior humerus in the normal situation, and even in post-traumatic contractures, the triceps can be elevated with a periosteal elevator without much additional difficulty (see Fig. 7-7C). The lateral collateral ligament is released from the humeral origin as a separate structure or if prior surgery has caused scarring, with the common extensor tendon complex. The anterior capsule is then incised. A varus stress is applied to the elbow, which opens like a book hinging on the medial ulnar collateral ligament and common flexor muscles (see Fig. 7-7D). The triceps remains attached to the ulna.

MAYO MODIFIED KOCHER EXTENSILE POSTEROLATERAL EXPOSURE

Essential Characteristic

The triceps attachment is further released from the olecranon and the triceps mechanism is reflected from lateral to medial (Fig. 7-8A).

FIGURE 7-8 The triceps attachment to the tip of the olecranon may be released by sharp dissection (A), allowing complete translation of the extensor mechanism medially and providing more extensile exposure to the joint (B).

Indications

Ankylosis release, resurfacing arthroplasty, open reduction with internal fixation (ORIF), lateral column, distal humerus.

Landmarks

Triceps insertion at olecranon.

Technique

If more extensile exposure is required than has been obtained with the previous steps (see Figs. 7-5 and 7-6), a medial skin flap is elevated and the ulnar nerve identified. It is protected or translocated according to the merits of the case and after the release has proceeded according to the steps shown in Figure 7-6. The triceps and anconeus muscle sleeve is reflected from the tip of the olecranon by releasing Sharpey’s fibers (see Fig. 7-8A). The entire extensor mechanism including anconeus is thus reflected from lateral to medial (see Fig. 7-8B). After the triceps has been reflected and the posterior capsule released, the lateral collateral ligament may be detached from the humerus depending on the goal of the specific procedure and the additional exposure required. By flexing the elbow and removing the tip of the olecranon, the articular surface and the entire posterior humerus can be exposed.

Note

We have found that the described surgical exposures to the elbow are sufficient to perform virtually all of the reconstructive procedures we currently employ. All may be executed after a posterior skin incision. The surgeon should be aware that the classic extensile approach described by Kocher does imply that the anterior capsule has been incised and the lateral collateral ligament has been released. When the Mayo modified Kocher release has been performed, the ulnar nerve must be exposed and released as necessary to avoid compression with varus angular forearm manipulation.

POSTERIOR EXPOSURES

Extensile posterior exposure implies effective management of the triceps mechanism.^5,³⁷ In recent years, there has been a marked increased interest in revisiting and modifying previously described posterior surgical approaches.

A posterior exposure of the elbow joint may be used for virtually any surgical indication. In fact, a posterior skin incision is now considered to be the universal approach to any deep structure of the elbow. Because the dissection may be readily extended and tissues mobilized medially and laterally, distal humeral and proximal ulnar fractures, joint reconstruction, tumors, infections, and synovial processes are amenable to treatment through a posterior exposure.

Several skin incisions and techniques have been described. Although MacAusland ²⁷ used a transverse incision, most posterior skin incisions are longitudinal. The S incision of Ollier today is not as often used as the straighter incision recommended by Langenbeck.²⁵ Probably the most important aspect of any incision is that it should not cross the tip of the olecranon. Smith also attributed better healing to a medial incision as compared with a lateral one.³⁸

Releasing the triceps transverse section of the triceps mechanism at its musculotendinous junction has been described but does not afford adequate repair for optimal rehabilitation.⁴⁶ Releasing the triceps at its attachment to the olecranon²⁶ is not advisable, owing to the difficulty of adequate repair and possible disruption during rehabilitation.⁹ Today we categorize triceps management into four categories: (1) triceps splitting, (2) triceps reflecting, (3) triceps preserving, and (4) olecranon osteotomy (Fig. 7-9). A midline splitting incision was described as early as 1918 by James Thompson to expose the distal humerus for fractures, but it did not include release from the ulna to provide exposure of the joint itself.⁴⁴

FIGURE 7-9 The posterior approach to the elbow may be some form of triceps approach that splits (A) or releases (B) the tendon in continuity with or without a fleck of bone by preserving the triceps tendon attachment (C) or by intra-articular (D), extra-articular oblique osteotomy (E), or chevron (F).

Splitting the triceps in line with the muscle fibers and at its insertion to expose the humerus and the elbow joint was described by Langenback ²⁵ and Campbell.¹⁰ This approach has had considerable resurgence of interest in recent years. When contracture is present, Campbell first separated the tendon from the muscle as an inverted V and then released the muscle fibers longitudinally. This technique, recommended later by Van Gorder⁴⁶ for distal humerus fractures, allows lengthening of the musculotendinous unit, which may be necessary to fully mobilize the ankylosed joint. This triceps torque exposure has also faced a renewed interest and popularity in recent years.

POSTERIOR TRICEPS SPLITTING (CAMPBELL)¹⁰

Indications

Elbow arthroplasty,¹ unreduced elbow dislocation, distal humeral fracture, posterior exposure of the joint for ankylosis, sepsis, synovectomy, and ulnohumeral arthroplasty.

Note

When releasing the triceps attachment from the medial attachment at the olecranon, care must be exercised to maintain continuity of the triceps expansion with the forearm fascia in continuity with the flexor attachment. Laterally, the anconeus and triceps form a more stable composite structure that has less chance of disruption with reflection of the lateral attachment.

Technique

The skin incision begins in the midline over the triceps, approximately 10 cm above the joint line, curves gently laterally or medially at the tip of the olecranon, and continues distally over the lateral aspect of the subcutaneous border of the proximal ulna for a distance of approximately 5 to 6 cm. If the incision is curved medially at the olecranon, the scar may have less tendency to contract.³⁸

The triceps is exposed along with the proximal 6 cm of the ulna. A midline incision is made through the triceps, fascia, and tendon and is continued distally across the insertion of the triceps tendon at the tip of the olecranon and down the subcutaneous crest of the ulna (Fig. 7-10). The muscle is elevated medially and laterally exposing the distal humerus. Sharp dissection releases the triceps and the anconeus, which are reflected subperiosteally laterally. The insertion of the triceps is carefully released from the medial olecranon, leaving the flexor mechanism in continuity with the forearm fascia. The ulnar nerve is visualized and protected in the cubital tunnel. Only closure of the triceps fascia is required proximally, but the triceps insertion may be supplemented with a suture passed through the tip of the olecranon. The incision is then closed in layers.

FIGURE 7-10 The Campbell posterior approach. The original description calls for a curved incision, but we prefer a straight one just lateral to the tip of the olecranon and the subcutaneous border of the ulna. The triceps may be released from its attachment to the ulna by a thin osteotomy at its site of attachment.

(Redrawn from Anson, B. J., and Maddock, W. G.: Callander’s Surgical Anatomy, 4th ed. Philadelphia, W. B. Saunders Co., 1958.)

Triceps Release at Osseous Attachment (Gschwend)

Gschwend modified the triceps splitting technique by osteotomizing the triceps attachment with flecks of bone medially and laterally. Closure is with circumferential sutures placed through drill holes in the ulna.

TRICEPS SPLITTING, REFLECTION OF TRICEPS APONEUROSIS

Indications

Same as those for the midline-splitting approach described earlier, plus elbow contracture and unreduced elbow dislocations (see Chapter 30).^10,⁴⁷

Note

This approach allows lengthening of the triceps mechanism. It has also become more popular for primary elbow replacement in recent years.

Technique

The skin incision is begun 10 cm proximal to the olecranon and extends over the lateral aspect of the proximal ulna, ending 4 cm distal to the joint (Fig. 7-11). The triceps fascia and aponeurosis are isolated along with the tendinous insertion into the ulna. The aponeurosis is elevated and reflected from the muscle from proximal to distal, freeing the underlying muscle fibers while preserving the tendinous attachment to the olecranon. Proximally, the triceps muscle is then split in the midline, and the distal humerus is exposed subperiosteally. The dissection continues distally to the olecranon fossa, exposing the posterior aspect of the joint. If more extensive exposure is desired, the subperiosteal dissection is extended to the level of the joint, exposing the condyles both medially and laterally. The ulnar nerve should be identified and protected.

FIGURE 7-11 The Campbell (Van Gorder) aponeurosis turn-down approach. The triceps aponeurosis is identified and reflected distally. The remaining fibers of the triceps are then split in the midline and reflected from the humerus, and the anconeus is reflected subperiosteally from the ulna to expose the joint.

(Redrawn from Campbell, W. C., Edmonson, A. S., and Crenshaw, A. H. (eds.): Campbell’s Operative Orthopedics. In Surgical Approaches, 5th ed., Vol. I. St. Louis, C. V. Mosby Co., 1971, p. 119.)

After the procedure, if an elbow contracture has been corrected, the joint should be flexed to about 110 degrees allowing the tendon to slide distally from its initial position. The proximal muscle and tendon are reapproximated in the lengthened relationship with nonabsorbable No. 0 sutures. The distal part of the triceps is then securely sutured to the fascia of the triceps expansion with the same suture, and the remainder of the wound is closed in layers.

REFLECTION OF THE TRICEPS IN CONTINUITY

The triceps mechanism may be preserved in continuity and simply reflected to one side or the other. Three surgical approaches have been described that preserve the triceps muscle and tendon in continuity with the distal musculature and forearm fascia and expose the entire joint. These exposures were designed to allow rapid rehabilitation while limiting the risk of triceps disruption.

Mayo Modified Kocher’s Posterolateral, Extensile Triceps-Sparing Approach

This technique has been described earlier, along with the family of Kocher exposures (see Fig. 7-7).²³

Mayo Triceps Reflection Technique of Bryan and Morrey

Indications

Ankylosis release, semiconstrained total elbow arthroplasty, ORIF medial column, distal humerus fractures.⁹

Skin Incision and Technique

A 14-cm skin incision is made just medial to the tip of the olecranon. The dissection is carried to the medial aspect of the triceps 6 cm proximal and 4 cm distal to the tip of the olecranon. The ulnar nerve is identified, and if a femoral translocation is carried out, it is released from the margin of the triceps and elevated from its bed (Fig. 7-12A). The cubital tunnel retinaculum is split and the nerve released to the first motor branch. A subcutaneous pocket is developed, the intermuscular septum removed (see Fig. 7-12B), and the nerve is translocated anteriorly. The triceps is released from the entire posterior aspect of the distal humerus. Forearm fascia and ulna periosteum are elevated from the medial margin of the ulna. The Sharpey fiber attachment of the triceps to the olecranon is released by sharp dissection (see Fig. 7-12C). The distal forearm fascia and ulnar periosteum is elevated from the ulna. The lateral margin of the proximal ulna is then identified and the anconeus is elevated from its ulnar bed (see Fig. 7-12D). The extensor mechanism and capsule continues to be reflected from the margin of the lateral epicondyle (see Fig. 7-12E). If a medial column fracture has occurred, the tip of the olecranon is removed and the fracture may be addressed. For semiconstrained total elbow arthroplasty, the lateral and medial collateral ligaments are released and the extensor mechanism is reflected lateral to the epicondyle. The elbow is flexed and the tip of the olecranon is removed to expose the joint (see Fig. 7-12F).

FIGURE 7-12 The Bryan-Morrey posterior approach. A, Straight posterior skin incision (approximately 14 cm). The triceps has been exposed, as has the superficial forearm fascia originating from the medial epicondyle and olecranon. The line of incision of the distal fascia-periosteum complex is identified. B, The ulnar nerve has been translocated anteriorly into subcutaneous tissue, and the intravascular septum is removed. C, The medial border of the triceps is identified and released, and the superficial forearm fascia is sharply incised to allow reflection of the fascia and periosteum from the proximal ulna. D, The extensor mechanism has been reflected laterally, and the anconeus has been released subperiosteally from the ulna, allowing exposure of the radial head. E, The proximal portion of the olecranon is removed for joint exposure. F, The shoulder is rotated externally, and the forearm is hyperflexed. Release of the collateral ligaments allows the ulna to separate from the humerus, providing excellent exposure for replacement or interposition.

(From Bryan, R. S., and Morrey, B. F.: Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin. Orthop. 116:188, 1982.)

In every instance in which the triceps has been completely reflected either from lateral to medial (see Fig. 7-7) or medial to lateral (see Fig. 7-12), it is always securely reattached to the olecranon with a locked crisscross type of suture. Drill holes about 3 cm in length are placed in a cruciate fashion in the olecranon from proximal to distal (Fig. 7-13). A third transverse hole is drilled through the olecranon to secure a second stabilizing suture. The margin of the triceps is first grasped with an Allis clamp and brought over the olecranon. It is important to over correct the reattachment medially to ensure that the sleeve of tissue does not sublux laterally with flexion. A No. 5 nonabsorbable suture is introduced with a straight needle from distal to proximal for the modified Kocher and from distal medial to proximal lateral for the Mayo exposure. The suture is first brought through the osseous tunnel emerging at the tip of the olecranon and passes through the triceps tissue at its anatomic attachment site with the elbow flexed 70 degrees. The suture is locked at this site. It is then brought across the tendinous portion and locked medially. The suture then enters the medial hole in the olecranon and is passed from proximal medial to distal lateral. After the suture has emerged from the second hole in the olecranon, it is brought back over the top of the ulna through the soft tissue distal expansion of the extensor sleeve. Care is taken to leave the knot off to the side of the subcutaneous border of the ulna to avoid irritation or skin erosion. The second suture, which is very important to hold the triceps tendon securely applied to the olecranon attachment, is placed transversely across the ulna again beginning on the side from which the triceps reflection began. It is simply brought back across the triceps tendon in a transverse fashion and is locked in the midline to snugly stabilize the triceps insertion against the olecranon. All sutures are tied with the elbow in 70 to 90 degrees of flexion, again with the knots off the subcutaneous border.

FIGURE 7-13 (A) The triceps is reattached by a heavy (No. 5), nonabsorbable suture placed through crossed and transverse holes in the ulna. (B) The stitch is placed from distal to medial through the olecranon tunnel and pierces the triceps tendon at the site of attachment as the elbow is flexed to 70 degrees. (C) This stitch is locked, and a second locked stitch is placed over the medial hole in the olecranon. The stitch is brought through this hole, across the periosteal sleeve to join the free end of the suture. (D) An additional transverse suture placed from medial to lateral is locked at the center of the triceps as it overlies its attachment.

Skin closure is with staples or in some instances, a subcuticular stitch is used, particularly in women. The aftercare varies dramatically depending upon the pathology being addressed, and this is discussed in the appropriate chapter. It is worthy of note, however, that I typically splint the elbow in extension with an anterior splint for 2 to 3 days. This protects the incision and may help reduce the tendency to develop flexion contracture.

OSTEOCUTANEOUS FLAP

One variation of the Mayo approach reflects the triceps with a sliver of bone while executing the same basic exposure philosophy.⁴⁸

Indications

An extensile triceps-reflecting procedure similar in concept to the Mayo approach and most often used for joint replacement arthroplasty, it also may be used for distal humeral fractures.

Triceps Release (Wolfe and Ranawat)

Technique

The triceps attachment is released from the ulna by osteotomizing the attachment with a thin wafer of bone that continues the attachment of the triceps tendon. This is the essential difference from the Mayo approach. The medial aspect of the triceps is elevated proximally, and the triceps attachment, with the wafer of bone, is elevated from the lateral aspect of the ulna in continuity with the anconeus muscle and the fascia (see Fig. 7-12).

After the surgical procedure, the olecranon osteotomy is secured to its bed by 20 nonabsorbable sutures placed through bone holes. Interrupted sutures are used to repair the remaining distal portion of the extensor mechanism.

Triceps-Preserving Technique

It is possible to elevate the triceps from the medial and lateral intramuscular septae while leaving the triceps attached to the olecranon.^2,³⁰

Several variations are included with this description.

Indications

Absence of distal humerus such as tumor resection, joint reconstruction for resection of humeral nonunion, or revision joint replacement.³⁰

Technique

The technique is usually used for failed reconstructive procedures, so the previous skin incision is followed when possible. Otherwise, a posterior incision is made either medial or lateral to the tip of the olecranon. Medial and lateral skin flaps are elevated with as much subcutaneous tissue and fascia as possible. The medial and lateral aspects of the triceps are identified, and the ulnar nerve is isolated unless it was previously translocated anteriorly (Fig. 7-14A). The distal humeral nonunion or acute fracture fragments are sharply mobilized. The lateral collateral attachment to the humerus is severed, along with the common extensor tendon (see Fig. 7-14B). The common flexor tendon and muscle mass are elevated from the medial epicondyle along with the medial collateral ligament, and the distal segment is removed (see Fig. 7-14C). The distal aspect of the humerus usually is buttonholed laterally to the margin of the triceps (see Fig. 7-14D). Occasionally, the humerus is brought through the medial interval between the triceps muscle and the ulnar nerve. Regardless of the side to which the humerus is delivered, distal traction on the forearm must be avoided because it could stretch the ulnar nerve. The ulna is rotated appropriately to allow exposure to prepare and insert the ulnar component. At this point, a portion of the triceps attachment can be released to better expose the ulna (see Fig. 7-14E).

FIGURE 7-14 A, The medial and lateral aspects of the triceps and extensor mechanism are identified along with the ulnar nerve. B, The distal humeral fracture or nonunion is sharply dissected from the lateral aspect. C, Similarly, the distal humerus is freed of its medial soft tissue attachments, including the ligaments. Partial release of the triceps, either medially or laterally, allows the forearm to be more easily displaced and rotated. D, The loose fragments, tumor, or area of nonunion is removed, and the distal humerus is exposed from the lateral aspect. E, In some circumstances, such as with long-standing valgus deformity, exposure from the medial margin of the triceps is more efficient. Note rotation of the ulna is required to identify the medullary canal.

After the implant has been inserted, the joint is articulated. There is no need to close or repair the extensor mechanism. Skin closure is routine, and motion is begun immediately and without restriction.

Comment

I have employed this exposure since 1989 in cases in which the distal humeral articulation is absent or resected. I have expanded the application, which was first used for nonunions ²⁹ to treat acute fractures and type IV rheumatoid arthritis. Because the triceps is not detached from its insertion at the tip of the olecranon, rapid rehabilitation is possible. It is expected that complete sparing of the triceps attachment will be used more frequently in the future and that the indications will increase. The most important caution is to avoid axial traction to the ulnar nerve from forearm manipulation.

Editor’s Note

Special comment is required to place these exposures in context. In all instances, the proponent reveals excellent outcomes. Of course, what is important is to honestly decide what works for you. We developed the Bryan-Morrey exposure specifically because we experienced unreliable strength outcomes after the Campbell splint and aponeurosis take-down, as well as thin osteotomy of the triceps insertion. All of these exposures are described earlier and are all being revisited with some degree of enthusiasm. In the final analysis, do what works for you.

POSTERIOR TRANSOSSEOUS EXPOSURES

Worldwide, a transosseous approach is probably the exposure most often used, especially for distal humeral fractures. The oblique osteotomy has almost been abandoned, and the transverse osteotomy has largely been replaced by the chevron.

OBLIQUE OSTEOTOMY

Approach

Oblique osteotomy of the olecranon.³⁴

Indications

T or Y condylar fracture.

Technique

A 14-cm incision is made just lateral to the midline, extending past the tip of the olecranon. The insertion of the triceps tendon to the proximal ulna is carefully identified, and a 3.2-mm hole is drilled through the tip of the olecranon, centered down the medullary canal and on the insertion of the triceps tendon (Fig. 7-15). The triceps attachment is then carefully isolated and osteotomized in an oblique fashion with an oscillating saw. With its attachment to the osteotomized segment, the muscle is reflected proximally. At the completion of the procedure, the osteotomized fragment is reattached with a lag screw and the wound is closed in layers.

FIGURE 7-15 The Müller posterior oblique olecranon osteotomy. The lateral margin of the triceps is identified and reflected medially to expose the distal humerus. A, The proximal ulna is predrilled for reattachment later. B, An oblique extra-articular osteotomy, including the attachment of the triceps, is made across the proximal ulna. C, The triceps with its attachment to bone is then reflected proximally, and as the elbow is flexed the entire distal humerus and elbow joint may be exposed. D, After the procedure, the triceps is reattached with a malleolar or cancellous-type screw, which provides good compression across the osteotomy site.

(Redrawn from Müller, M. E., Allgower, M., and Willenegger, H.: Manual of Internal Fixation: Technique Recommended by the AO Group. New York, Springer-Verlag, 1970.)

CHEVRON TRANSOLECRANON OSTEOTOMY

Indications

Ankylosed joints; T or Y condylar fracture.²⁷

Comment

The intra-articular osteotomy first described by MacAusland was originally recommended for ankylosed joints. It has been adopted by some ²⁰ for radial head excision and synovectomy and used or modified by others¹² for T and Y condylar fractures. However, in persons with rheumatoid arthritis, this portion of the bone may be thin, and therefore, this is not a suitable exposure for total elbow arthroplasty. The chevron design markedly enhances the repair and thus allows early motion.

Technique

Originally, a transverse incision across the elbow was described for the transverse osteotomy. At the present time, a straight incision is recommended (Fig. 7-16A). It is made posteriorly just lateral to the midline and measures approximately 14 cm centered on the olecranon. The ulnar nerve is isolated, dissected from the cubital tunnel, and protected. A 3.2-mm drill hole crosses the proposed osteotomy site for anatomic replacement at the completion of the procedure (see Fig. 7-16B). The joint is exposed at the midportion of the greater sigmoid notch. An apex distal chevron, or V, osteotomy initiated with the saw and completed with an osteotomy. By allowing the subchondral bone to “crack” facilitates accurate repositioning with the interdigitated surfaces. The capsular attachments, including the posterior portion of the ulnar collateral ligament, are released. The triceps tendon, along with the osteotomized portion of the olecranon, may then be retracted proximally, and by flexing the elbow joint, the tendon can be exposed (see Fig. 7-16C). Occasionally, the radial or medial collateral ligament may be released for better exposure, but it must later be reattached to the bone to avoid instability. At the completion of the procedure, the tip of the olecranon is secured with a single cancellous screw. The elbow usually is immobilized for 2 to 3 weeks, at which time a gentle, active rehabilitation program is instituted when clinically indicated.

FIGURE 7-16 Chevron olecranon osteotomy. A, A straight incision is made just lateral to the tip of the olecranon approximately 7 cm proximal and 7 cm distal to the tip of the olecranon. The proximal ulna is predrilled with a 3.2-mm drill, and the margins of the triceps are identified. B, The triceps is released medially and laterally, while the ulnar nerve is protected. The chevron osteotomy with a distal apex is initiated with an oscillating saw and, C, the proximal portion containing the triceps tendon is retracted proximally, exposing the elbow joint.

COMBINED OSTEOTOMY PLUS TRICEPS SPLITTING

A recent report ¹⁴ has suggested the value of combining the chevron osteotomy with a triceps-splitting technique. This would seem to offer little advantage over the chevron osteotomy as described with the associated triceps reflection techniques.

ANCONEUS SPARING OLECRANON OSTEOTOMY (MAYO TECHNIQUE)

Comment

Concern with regard to transecting the anconeus attachment to the triceps has prompted the development of an olecranon osteotomy that preserves the anconeus origin and viability. The attractiveness of this exposure is that the anconeus dissection can be done very safely and quickly. This does preserve the anconeus triceps continuity in the event that a later reconstructive procedure may be necessary that uses the anconeus.

TECHNIQUE

The patient is supine with the arm across the chest.²⁸

The exposure is as required by the pathology. Deep exposure is at the Kocher’s interval between the extensor carpi ulnaris and anconeus.

The interval is entered and the anconeus is identified and isolated (Fig. 7-17A).

FIGURE 7-17 A, The anconeus interval is exposed through a mid-line incision of the distal forearm and extended laterally and distally over the anconeus. The muscle is elevated and the midportion of the lateral ulnohumeral joint identified. B, The medial ulnohumeral joint is entered as the ulnar nerve is protected, and a Chevron osteotomy as described in Figure 7-16 is completed. The olecranon and anconeus are reflected proximally.

The anconeus is elevated from its bed by sharp dissection leaving the attachment of its origin at the fascial expansion of the triceps; the mid portion of the sigmoid notch is identified laterally (see Fig. 7-17B).

Medially, the ulnar nerve is identified, and the midportion of the articulation is exposed (see Fig. 7-17C).

A V-shaped Chevron osteotomy is carried out as described earlier with an oscillating saw. The osteotomy is completed with an osteotome (see Fig. 7-17D).

The osteotomized olecranon, along with the attached anconeus, is elevated proximally.

Closure consists of the standard AO reattachment of the olecranon. The anconeus is brought back to its insertion on the ulna, and the fascia over the anconeus is closed with a running 2-0 absorbable suture.

Note

The ulnar nerve does not need to be mobilized unless dictated by the pathology.

Pitfalls

Avoid osteotomy in rheumatoid arthritis because the thin olecranon compromises healing if an osteotomy is carried out.³¹ The transverse osteotomy of McAusland is associated with an approximately 5% nonunion rate.³¹ Although for distal humeral fractures the Chevron osteotomy may improve these results and decrease the nonunion rate, I personally have not had the clinical need to osteotomize the olecranon in the last 14 years, and osteotomy should be avoided if the olecranon is resorbed.

MEDIAL APPROACHES

There are relatively few indications for medial exposure of the elbow joint, which has been superseded by arthroscopic approaches. The transcondylar approach described independently by Molesworth and Campbell provides excellent exposure of the joint, but it involves dissection of the ulnar nerve and healing of the osteotomized epicondyle, both of which increase the complexity, and thus limit the use, of this approach. In 1969, Taylor and Scham ⁴³ described a medial approach to the proximal ulna that was used for fractures in this region. The most valuable contribution to medial joint exposure is that described by Hotchkiss.²¹ This extensile exposure provides great flexibility, particularly for exposure of the coronoid and for contracture release.

TRANSEPICONDYLAR APPROACH

Indications

Medial epicondylar fractures, loose bodies, medial lesions whose symptoms require ulnar nerve exploration, and resurfacing arthroplasty.^10,²⁹

Comment

This procedure was described independently by Molesworth in England and by Campbell in the United States. Because it requires osteotomy of the medial epicondyle, which causes more concern about reattachment and healing than other exposures, the indications for its use today are limited.

Technique

With the elbow flexed at 90 degrees, a medial incision is made from 5 cm above to approximately 5 cm below the elbow over the medial epicondyle. The ulnar nerve is identified, released, and retracted from the medial epicondyle, which is freed from soft tissue. It is helpful to make a longitudinal incision in the capsule just anterior to the ulnar collateral ligament and to place a periosteal elevator under the ligament as a landmark before performing the osteotomy. In this way, healing of the osteotomy restores the integrity of the ulnar collateral ligament. With a small osteotome, the epicondyle is freed and turned downward with its muscular attachments. Blunt dissection allows distal retraction of the flexor muscles, and careful technique avoids injury to the innervation of the muscle mass. The medial aspect of the coronoid process is exposed, along with the anterior and posterior capsules, which may be reflected from the humerus as necessary for additional exposure. Valgus stress hinges the joint on the lateral ligament and the remaining portions of the capsule, and provides generous exposure of virtually the entire elbow joint. Care must be taken to protect the median nerve as it passes over the anterior aspect of the joint. The epicondyle is returned to its anatomic position and secured with a small screw or with sutures placed through the bone. This step is important, because the quality of the repair affects the integrity of the ulnar collateral ligament, which is essential to the stability of the elbow joint.

EXTENSILE MEDIAL APPROACH (“OVER-THE-TOP” [HOTCHKISS])

Indications

1. Access to the coronoid and anterior osteophytes with intact radial head ²²

2. Ulnar nerve exploration required

3. Need to preserve posterolateral ulnohumeral ligament complex

4. Anterior and posterior access to the joint

5. May be converted to triceps-sparing exposure of Bryan-Morrey

Limitations

1. Need for excision of heterotopic bone on the lateral side

2. Access to radial head

Technique

The patient is usually supine and supported by a hand table. It is helpful to bring the patient as far as possible onto the hand table. The patient’s head may require support, and a roll is placed under the scapula.

The skin incision can vary between the boundaries of a pure posterior skin incision and a midline medial incision. The key to this exposure is identification of the medial supracondylar ridge of the humerus, the medial intermuscular septum, the origin of the flexor pronator muscle mass, and the ulnar nerve.

The subcutaneous skin is elevated, and the medial intermuscular septum is identified. Anterior to the septum, running just on top of the fascia (and not in the subdermal tissue), the medial antebrachial cutaneous nerve is identified and protected. It is occasionally necessary to divide this nerve to gain full exposure and to adequately mobilize the ulnar nerve, especially in revision surgery. If the patient previously had surgery, the ulnar nerve should be identified proximally before the surgeon proceeds distally. If anterior transposition was performed previously, the nerve should be mobilized carefully before the operation proceeds.

The surface of the flexor pronator muscle mass origin is found by sweeping the subcutaneous tissue laterally with the medial antebrachial cutaneous nerve in this flap of subcutaneous tissue. The medial intermuscular septum is excised from the supracondylar ridge about 5 cm proximally (Fig. 7-18A). The ulnar nerve is protected, and the veins at the base of the septum are cauterized.

FIGURE 7-18 A, After routine medial exposure, and taking care to protect or resect the distal branches of the medial antebrachiocutaneous nerve, the surgeon identifies the intermuscular septum and excises it for approximately 5 cm. B, The pronator and a portion of the common flexor tendon are excised from the medial epicondyle, leaving a cuff of tissue on the medial epicondyle. The muscle mass is split longitudinally leaving the ulnar head of the extensor carpi ulnaris to protect the nerve. The nerve at this point has been isolated but not translocated. C, With the nerve protected, the capsule is identified, and the undersurface of the flexor pronator group is elevated from the capsule identifying the medial aspect of the brachialis muscle. D, The brachialis muscle is elevated and the entire anterior capsule is exposed. If the primary purpose is capsular release, care is taken to transect as much of the capsule as possible rather than simply releasing it. The coronoid is readily identified on completion of the capsular release. E, A posterior exposure may also be necessary; the periosteal elevator lifts the medial aspect of the triceps from the posterior aspect of the medial condyle and medial column. The ulnar nerve is translocated anteriorly.

The supracondylar ridge is located, and elevation of the anterior muscle begins with a wide Cobb elevator. Subperiosteally, all of the anterior structures of the distal humeral region are elevated enough to allow placement of a wide Bennett retractor. The median nerve and brachial vein and artery are superficial to the brachialis muscle. Once the septum is excised, the flexor pronator muscle mass should be divided parallel to the fibers, leaving approximately a 1.5-cm span of flexor carpi ulnaris tendon attached to the epicondyle (see Fig. 7-18B). A small cuff of fibrous tissue of the origin can be left on the supracondylar ridge as the muscle is elevated. This facilitates reattachment when closing. A proximal, transverse incision in the lacertus fibrosus may also be needed to adequately mobilize this layer of muscle. The flexor pronator origin should be dissected down to the level of bone but superficial to the joint capsule. As this plane is developed, the brachialis muscle is encountered from the underside. This muscle should be kept anterior and elevated from the capsule and anterior surface of the distal humerus. Dissection of the capsule proceeds laterally and distally to separate it from the brachialis muscle (see Fig. 7-18C).

At this point, it is helpful to feel for the coronoid process by gently flexing and extending the elbow. A deep, narrow retractor is used and, after capsular excision, the radial head and capitellum can be visualized. In the case of contracture, the capsule, once separated from the overlying brachialis and brachioradialis, can be sharply excised (see Fig. 7-18D). The radial nerve is identified running between the brachialis and the brachioradialis. Care should be taken to stay deep to these two muscles when elevating over to the lateral side.

In a contracture release, the anteromedial portion of the capsule often requires release. To expose this area, a small narrow retractor can be inserted to pull the attached flexor carpi ulnaris medially. This affords adequate visualization and protection of the anteromedial collateral ligament.

The ulnar nerve is mobilized to permit anterior transposition with a dissection carried distally to the first motor branch to allow the nerve to rest in the anterior position without being sharply angled as it enters the flexor carpi ulnaris. With the Cobb elevator, the triceps is elevated from the posterior distal surface of the humerus (see Fig. 7-18E). The posterior capsule can be separated from the triceps as the elevator sweeps from proximal to distal.

The flexor pronator mass should be reattached to the supracondylar ridge with nonabsorbable braided 1-0 or 0 suture through holes in bone or to the fibrous cuff, if it is adequate. After being reattached to the medial supracondylar region, the ulnar nerve should be transposed and secured with a fascial sling (or by the surgeon’s preference) to prevent posterior subluxation.

ANTERIOR EXPOSURES

Because of the vulnerability of the brachial artery and median nerve, the anterior medial approach to the elbow is not recommended (Fig. 7-19). The extensile exposure described by Henry, as modified from Fiolle and Delmas, is the best known and the most useful for anterior exposure of the joint. Minor modifications of the Henry approach have been described,^22,³⁹ and a limited anterolateral exposure has been described by Darrach.¹⁴

FIGURE 7-19 Because the brachial artery and median nerve occupy the anteromedial aspect of the elbow joint, an anterior medial approach to the joint is not an option.

(Redrawn from Anson, B. J., and Maddock, W. G.: Callander’s Surgical Anatomy, 4th ed. Philadelphia, W. B. Saunders, 1958.)

The skin incision begins about 5 cm proximal and lateral to the flexor crease of the elbow joint and extends distally along the anterior margin of the brachioradialis muscle (Fig. 7-20A). Below the elbow joint, the incision turns medially to avoid crossing the flexor crease at a right angle, thus discouraging hypertrophic scar formation. The incision continues transversely to the biceps tendon and then turns distally over the medial volar aspect of the forearm, ending approximately 6 or 7 cm distal to the flexion crease. The interval between the brachioradialis laterally and the biceps and brachialis medially is identified and entered. The fascia is released distally between the brachioradialis and the pronator teres (see Fig. 7-20B).

FIGURE 7-20 The anterior Henry approach. A, An incision is made approximately 5 cm proximal to the elbow crease on the lateral margin of the biceps tendon. It extends transversely across the joint line and curves distally over the medial aspect of the forearm. B, The interval between the brachioradialis and brachialis proximally and the biceps tendon and pronator teres in the distal portion of the wound is identified. The radial nerve is protected and retracted along with the brachialis muscle. C, The radial recurrent branches of the radial artery and its muscular branches are identified and sacrificed if more extensive exposure is required. The biceps tendon is retracted medially, along with the brachialis muscle. D, The supinator muscle is released from the anterior aspect of the radius, which is fully supinated. E, This interval may now be developed to expose the entire anterior aspect of the elbow joint, including the capitellum, the proximal radius, and the radial tuberosity.

(Redrawn from Banks, S. W., and Laufman, H.: An Atlas of Surgical Exposures of the Extremities. Philadelphia, W. B. Saunders Co., 1953.)

The interval then is entered proximally, and gentle, blunt dissection demonstrates the radial nerve coursing on the inner surface of the brachioradialis muscle. Care is taken to avoid injuring the superficial sensory branch of the radial nerve. Because the radial nerve gives off its branches laterally, it can safely be retracted with the brachioradialis muscle. At the level of the elbow joint, as the brachioradialis is retracted laterally and the pronator is gently retracted medially, the radial artery can be observed where it emerges from the medial aspect of the biceps tendon, giving off its muscular and recurrent branches in a mediolateral direction (see Fig. 7-20C). The muscle branch is ligated, but the recurrent radial artery should be sacrificed only if the lesion warrants the more extensive exposure that can be realized with this maneuver.

The dorsal interosseous nerve enters the supinator and continues along the dorsum of the forearm distally. The dissection continues distally, exposing the supinator muscle, which covers the proximal aspect of the radius and the anterolateral aspect of the capsule. Muscle attachments to the anterior aspect of the radius and those distal to the supinator include the discrete tendinous insertion of the pronator teres and the origins of the flexor digitorum sublimis and the flexor pollicis longus. The brachialis muscle is identified, elevated, and retracted medially to expose the proximal capsule.

If more distal exposure is needed, the forearm is fully supinated, demonstrating the insertion of the supinator muscle on the proximal radius. This insertion is incised, and the supinator is subperiosteally retracted laterally (see Fig. 7-20D). The supinator serves as protection to the deep interosseous branch of the radial nerve, but excessive retraction of the muscle should be avoided. The proximal aspect of the radius and the capitellum are thus exposed. Additional visualization may be obtained both proximally and distally, because the radial nerve has been identified and can be avoided proximally. The posterior interosseous nerve is protected distally by the supinator muscle, and the radial artery is visualized and protected medially if a more extensile exposure is required (see Fig. 7-20E).

Note

The recurrent and muscular branches of the radial artery and vein should be ligated before the radial artery is released, to avoid hematoma formation that could cause ischemic contracture of the forearm. Retraction of the brachioradialis and the extensor carpi radialis longus and brevis muscles is facilitated if the elbow is flexed 90 degrees. This affords easier exposure of the supinator muscle. When the supinator muscle is stripped subperiosteally from the radius, the bursa between the biceps tendon and the radius is usually identified and should be entered, facilitating subperiosteal exposure of the muscle. The proximal radius is further exposed by subperiosteal dissection as the forearm is being pronated and supinated.

RESULTS

There have been limited attempts to document the efficacy of one or the other of the various types of triceps-sparing approaches. In the original description, we compared the clinical result of the Mayo approach to that of the triceps splitting or transverse release of the triceps reattachment.⁹ There were no triceps disruptions after approximately 75 procedures done with the triceps being released in continuity (Mayo approach) compared with an approximately 20% complication rate when the triceps was released transversely. Wolfe and Ranawat⁴⁸ have also observed no instances of triceps insufficiency with their modification of this approach. The use of the Mayo medial exposure was also shown to have improved triceps strength after total elbow arthroplasty.³² This manner of exposing the elbow was found to be associated with approximately 20% greater extension strength than with the Campbell (Van Gorder) type of exposure.

An additional consideration in those with rheumatoid arthritis is the thin olecranon that compromises healing if an osteotomy is carried out.²⁰ The transverse osteotomy of McAusland is associated with an approximately 5% nonunion rate.³¹ Although for fractures the chevron osteotomy may improve these results and decrease the nonunion rate, I personally have not had the clinical need for osteotomized the olecranon in the last 20 years and this should be avoided if the olecranon has been thinned.

COMPLICATIONS

One advantage of the above-described exposures is their relative freedom from complications. Today most problems are related to the pathology rather than the surgical approach.

WOUND HEALING

Difficult ankylosis release procedures are associated with a significant amount of swelling as often occurs in patients undergoing total elbow arthroplasty. Wound healing is generally not a problem, however, and is related to the presence of prior incisions and the magnitude of the dissection as is typical for release of the stiff elbow.

INFECTION

The infection rate after total elbow arthroplasty has been reduced at our institution from a high of 11% in 1970 to approximately 3% over the last 10 years.³² This reduction is coincident with adopting the Mayo approach to the elbow but other technique changes have occurred in this period, including using antibiotic-impregnated cement and splinting the elbow in extension.

ULNAR NERVE INJURY

Injury to the ulnar nerve appears to be more common in those instances in which the ulnar nerve is not exposed and the elbow is flexed on the medial collateral ligament such as with the classic extensile Kocher approach.^16,⁴⁵ Simply exposing the ulnar nerve, while decreasing this complication, does not completely obviate it. The theoretical disadvantage of the Mayo approach, which allows translocation of the ulnar nerve, is that this maneuver devascularizes the nerve, and the dissection itself may cause ulnar nerve irritation. Having used this particular exposure in more than 500 cases, the incidence of permanent ulnar nerve injury with motor dysfunction is less than 1%. Therefore, I am comfortable in exposing and moving the ulnar nerve in a subcutaneous pocket as an essential and integral part of the Mayo triceps-sparing approach.