During débridement arthroplasty for primary osteoarthritis of the
elbow, it is important to remove medial-side osteophytes without disturbing
the anterior oblique bundle of the medial collateral ligament. Moreover, the
ulnar nerve should be decompressed when there is evidence of nerve irritation,
which is frequently the case. We have chosen the posteromedial approach for
débridement arthroplasty to facilitate access to these medial
structures under direct vision.
Patient Positioning and Preparation
The patient is placed in the supine position, with the arm supported by a
hand table. The skin preparation extends to and includes the axilla to allow a
sterile tourniquet to be applied. For the surgeon to visualize the anterior
and posterior surfaces of the distal part of the humerus, the patient should
have free external rotation of the shoulder.
Skin Incision and Superficial Exposure
A curved posteromedial skin incision is made, beginning along the distal
border of the pronator teres, passing 1 cm posterior to the medial epicondyle
of the humerus, and extending 4 cm proximal to the olecranon process
(Figs. 1-A and 1-B). The medial
cutaneous and medial antebrachial cutaneous nerves are identified immediately
on top of the fascia, traced distally, and protected in this approach. The
ulnar nerve is identified and decompressed. It is carefully retracted with use
of a vessel loop and is protected for the remainder of the procedure. If the
patient has had previous surgery, the ulnar nerve is identified proximally
before the dissection proceeds distally. If an anterior transposition has been
performed previously, the nerve is fully identified and mobilized before
proceeding.
Exposure of the Anterior Compartment
The origin of the flexor-pronator muscle group is elevated from the medial
epicondyle with use of cautery and a Cobb elevator
(Fig. 1-C). All of the anterior
structures in the distal humeral region are elevated subperiosteally and
reflected distally. The median nerve and the brachial artery lie superficial
to the brachial muscle. A small fibrous cuff of the origin can be left on the
supracondylar ridge as the muscle is elevated. This will facilitate
reattachment during closure. The anterior oblique bundle of the medial
collateral ligament should be preserved. It is located just under the humeral
head of the flexor carpi ulnaris. As it is sometimes difficult to distinguish
the anterior oblique bundle from the muscle origin, a 1.5-cm span of the
flexor carpi ulnaris tendon can be left attached to the epicondyle together
with the anterior oblique bundle. The flexor-pronator origin and the anterior
capsule are dissected down to the bone. The anterior aspect of the ulnohumeral
joint as well as the radiocapitellar joint now can be visualized
(Fig. 1-D).
Osteophytes are removed from the coronoid process, the coronoid fossa, and
the radial fossa with use of a rongeur or a chisel. It is very important to
resect osteophytes from the medial edge of the coronoid meticulously, without
disturbing the continuity of the anterior oblique bundle
(Figs. 2-A and 2-B). To
facilitate visualization of this area, a small narrow retractor is inserted to
pull the anterior oblique bundle medially. This allows for visualization of
the osteophytes and affords protection of the bundle.
Exposure of the Medial and Posterior Compartments
The ulnar nerve is fully mobilized so that it can be transposed anteriorly.
The medial joint line is exposed up to the anterior oblique bundle, and the
posterior oblique bundle of the medial collateral ligament is excised. Next,
the posterior capsule is excised by elevating the triceps with a deep
retractor (Figs. 3-A and
3-B)1.
Osteophytes are removed from the medial edge of the olecranon.
The triceps muscle is exposed along with the proximal 4 cm of the ulna, and
the fascia is split along the lateral border of the triceps tendon
(Fig. 3-C). This approach
allows for adequate visualization of the lateral edge of the olecranon and the
olecranon fossa. Bone spicules and osteophytes are removed completely from the
olecranon and olecranon fossa. Débridement through an additional,
lateral approach is performed when (1) the preoperative pain is located on the
lateral side or (2) the increase in elbow motion is not satisfactory after the
medial-side procedures have been completed.
CRITICAL CONCEPTSINDICATIONS:Long-standing elbow pain that is not responsive to conservative treatment,
including antiinflammatory medication and modification of activity for three
monthsLoss of extension of >30° and/or <110° of flexionIrritation of the ulnar nerve or ulnar nerve neuropathyCONTRAINDICATIONS:Patients who will not participate in a postoperative therapy programPoor quality of the articular surface of the ulnohumeral joint as assessed
radiographicallyPITFALLS:The eventual postoperative range of motion is always less than the
intraoperative range of motion. Therefore, it is essential to gain as much
range of motion as possible intraoperatively.Failure to completely clear osteophytes underneath the anterior oblique
bundle at the medial edge of the coronoid will compromise the result
(Figs. 2-A and 2-B).More osteophytes need to be excised than one would expect, especially
around the olecranon (Figs. 5-A
and 5-B).AUTHOR UPDATE:The operative procedure has not changed since the original publication of
our article in the February 2004 issue of The Journal of Bone and Joint
Surgery. Although we used continuous passive motion for postoperative
rehabilitation early in our clinical experience, we now use active and
assisted exercise under the supervision of a physiotherapist.
CRITICAL CONCEPTS
INDICATIONS:
Long-standing elbow pain that is not responsive to conservative treatment,
including antiinflammatory medication and modification of activity for three
monthsLoss of extension of >30° and/or <110° of flexionIrritation of the ulnar nerve or ulnar nerve neuropathy
Long-standing elbow pain that is not responsive to conservative treatment,
including antiinflammatory medication and modification of activity for three
months
Loss of extension of >30° and/or <110° of flexion
Irritation of the ulnar nerve or ulnar nerve neuropathy
CONTRAINDICATIONS:
Patients who will not participate in a postoperative therapy programPoor quality of the articular surface of the ulnohumeral joint as assessed
radiographically
Patients who will not participate in a postoperative therapy program
Poor quality of the articular surface of the ulnohumeral joint as assessed
radiographically
PITFALLS:
The eventual postoperative range of motion is always less than the
intraoperative range of motion. Therefore, it is essential to gain as much
range of motion as possible intraoperatively.Failure to completely clear osteophytes underneath the anterior oblique
bundle at the medial edge of the coronoid will compromise the result
(Figs. 2-A and 2-B).More osteophytes need to be excised than one would expect, especially
around the olecranon (Figs. 5-A
and 5-B).
The eventual postoperative range of motion is always less than the
intraoperative range of motion. Therefore, it is essential to gain as much
range of motion as possible intraoperatively.
Failure to completely clear osteophytes underneath the anterior oblique
bundle at the medial edge of the coronoid will compromise the result
(Figs. 2-A and 2-B).
More osteophytes need to be excised than one would expect, especially
around the olecranon (Figs. 5-A
and 5-B).
AUTHOR UPDATE:
The operative procedure has not changed since the original publication of
our article in the February 2004 issue of The Journal of Bone and Joint
Surgery. Although we used continuous passive motion for postoperative
rehabilitation early in our clinical experience, we now use active and
assisted exercise under the supervision of a physiotherapist.
Exposure of the Lateral Compartment
The lateral compartment is exposed through a J-shaped lateral skin incision
approximately 10 cm in length, that extends distally from the lateral
supracondylar ridge of the humerus to the posterior border of the ulna.
Dissection between the triceps and the brachioradialis muscles exposes the
lateral condyle and the joint capsule. Dissection through the radial edge of
the anconeus muscle allows the radial head to be exposed by incising the
annular ligament longitudinally. The lateral collateral ligament is released
longitudinally, and the anterior joint capsule is dissected subperiosteally.
Spurs are removed from the radial head, the radial fossa, and the posterior
edge of the capitellum. The joint is observed from both the medial and the
lateral incision, and the osteophytes that limit motion are cleared
completely. The goal of the procedure is to regain full extension and flexion,
or at least an arc of motion from 20° to 120° intraoperatively.
Closure
After hemostasis and irrigation, the lateral collateral ligament and the
annular ligament are repaired on the lateral side and the origin of the
flexor-pronator muscle group is repaired on the medial side. The
flexor-pronator muscle origin is reattached to the supracondylar ridge with
nonabsorbable braided 1-0 sutures. If enough fibrous tissue has not been left
behind, drillholes in the edge of the supracondylar ridge are made to secure
the muscle origin. The ulnar nerve is transposed subcutaneously. A
subcutaneous fat sling is fashioned to hold the nerve anteriorly without
constriction. The joint is flexed and extended to ensure that the nerve moves
freely. The wound is closed over a suction drain in the joint
(Figs. 4-A through 4-F).
Postoperative Management
The elbow is immobilized for two days until the suction drain is removed.
Active and assisted exercises are then begun under the supervision of a
physiotherapist. Emphasis is placed on slow stretching of the elbow under
gravity, which decreases pain and allows stress relaxation to occur.