Open Surgical Approaches
A variety of surgical approaches for contracture release have been advocated, including the lateral (''column'') approach, medial (''over-the-top'') approach, the global posterior approach with deep medial and lateral approaches, and the anterior approach. Alternatively, dual medial and lateral approaches may be used provided a minimal skin bridge of 5 cm is observed. The choice of surgical approach should be based on the location of pathology, previous surgical scars, and surgeon comfort with the chosen approach. A recent study comparing outcomes of medial, lateral, posterior, and combined medial and lateral approaches did not demonstrate a significant difference with respect to outcomes at 24-month follow-up in 100 patients.
A lateral Kocher incision is made along the intermuscular septum and extends 5 cm distal to the lateral epicondyle. Reflection of the triceps and anconeus exposes the posterolateral ulnar-humeral joint (lateral gutter) and the olecranon. Elevation of the triceps from the humerus exposes the posterolateral joint capsule to allow capsular resection and debridement of the olecranon and the olecranon fossa. Elevation of the brachialis muscle along with the brachioradialis and extensor carpi radialis longus muscles reveals the anterior capsule. Resection of the anterior capsule allows debridement of the coronoid and the coronoid fossa. Identification and protection of the radial nerve may be required if extensive scarring or heterotopic ossification is present to prevent injury especially where it lies close to the joint capsule anterior to the radial head. The median nerve is protected by the brachialis muscle and should be at little risk for injury if the retractors are properly placed. If additional release is required, a secondmedial incision may be placed over the cubital tunnel to identify the ulnar nerve and resect the posteromedial joint capsule.
The medial approach is favored if the ulnar nerve requires decompression or significant medial heterotopic ossification formation is present. To access the anterior aspect of the humeral ulnar joint, a plane is developed between the brachialis and the humerus. Through this interval, anterior capsular excision and anterior joint debridement is possible. Triceps elevation will allow resection of the posterior joint capsule and posterior joint debridement. The posterior band of the medial collateral ligament forms the posteromedial joint capsule and can be excised to improve flexion. The anterior band of themedial collateral ligament should be preserved, but should be reconstructed if deficient or excised.[18,19] The ulnar nerve may need transposition to either a subcutaneous or submuscular position if unstable after elevation.
Curr Orthop Pract. 2014;25(3):213-216. © 2014 Lippincott Williams & Wilkins