The patient is placed supine on a standard operating table. The affected
upper extremity is draped across the patient's chest, with an arm rest that is
oriented parallel to the operating table being used to support the elbow. A
foam pad is placed under the medial side of the elbow to protect the ulnar
nerve from compression against the arm rest. The operative procedure is
performed under tourniquet control. A standard Kocher lateral approach to the
elbow is used. The skin incision begins just proximal to the lateral
epicondyle of the humerus and extends distally and posteriorly, in an oblique
manner, to about 3 in (7.6 cm) distal to the olecranon
(Fig. 2). The fascia over the
anconeus and extensor carpi ulnaris muscles is exposed, and the interval
between these two muscles is identified either visually or digitally. The
dissection should be continued in this interval down to the level of the joint
capsule. If necessary, the humeral insertion of the anconeus can be elevated
subperiosteally to increase the exposure of the capsule. It is desirable to
pronate the forearm as much as possible to move the deep branch of the radial
nerve away from the operative field. A longitudinal incision is then made in
the joint capsule, exposing the radiohumeral joint
(Fig. 3). If necessary, the
common extensor origin is reflected from the lateral epicondyle and the distal
part of the humerus to gain exposure to the posterior aspect of the
ulnohumeral joint for débridement and synovectomy.
Once the joint capsule has been opened and the radiohumeral joint has been
exposed, small Hohmann reverse retractors are carefully placed around the
radial neck to facilitate the exposure of the proximal part of the radius
(Fig. 4). Proximal to the
anular ligament, the deep branch of the radial nerve is protected by the
extensor carpi ulnaris and the extensor digitorum communis muscle mass.
However, care should be taken to avoid excessive muscle retraction with the
retractors, which could create tension in the deep branch of the radial nerve
and possibly a nerve palsy. The dissection should not be carried distal to the
level of the anular ligament because the deep branch of the radial nerve is
located within the mass of the supinator muscle and could be injured.
Once the proximal aspect of the radius is completely exposed, a transverse
osteotomy of the radial neck is performed with an oscillating saw
(Fig. 5). The osteotomy should
be located just distal to the ulnar facet and proximal to the anular ligament.
An osteotomy distal to the level of the anular ligament should be avoided in
order to prevent creating instability of the proximal part of the radius. Once
the osteotomy has been completed, the radial head can be removed from the
joint with use of a towel clip or an angled curette
(Figs. 6-A and 6-B).
At this point, the joint should be carefully explored in search of
thickened, hyperpigmented synovium (Fig.
7). The presence of thick hyperpigmented synovium is suggestive of
chronic hemophilic synovitis, which could lead to further bleeding. Therefore,
this tissue is carefully removed from the joint with rongeurs. If necessary,
the triceps is elevated from the distal part of the humerus to gain exposure
to the posterior aspect of the ulnohumeral joint for débridement and
synovectomy. Débridement of osteophytes from the coronoid process
and/or the olecranon is performed to eliminate mechanical impingement and to
improve range of motion. Care should be taken to remove only the most anterior
portion of the coronoid in order to avoid damage to the anterior insertion of
the medial collateral ligament.
After the osteotomy through the radial neck has been completed
(Fig. 8), bleeding is
controlled with the application of bone wax to the exposed bone surfaces. The
tourniquet is deflated prior to wound closure in order to achieve hemostasis.
A medium drain should be left in the wound. The muscle interval and the
subcutaneous tissues are then closed with simple, interrupted, absorbable
sutures. The skin is closed with running, subcuticular, monofilament,
nonabsorbable suture.
A compression dressing and plaster splint are then applied with the elbow
flexed to 90° and with the forearm in maximum supination for the first
three to four postoperative days. Physical therapy, including active and
passive motion, is started on the fourth postoperative day, with the goals of
preserving the amount of forearm rotation that was gained intraoperatively and
maintaining the preoperative flexion arc. Because hemophilic arthropathy often
leads to arthrofibrosis, physical therapy is performed twice a day while the
patient is in the hospital and then should be continued three times a week for
at least eight weeks after discharge.
CRITICAL CONCEPTSINDICATIONS:Excision of the radial head is typically indicated for patients with
hemophilia and a history of chronic synovitis of the elbow who have an
enlarged and irregular radial head with narrowing of the radiohumeral joint
space associated with posterolateral elbow pain and chronic, progressive, and
disabling limitation of forearm rotation.CONTRAINDICATIONS:In patients who have hemophilic arthropathy of the elbow and pain, there
are three main clinical scenarios in which the excision of the radial head is
not indicated.A patient in whom the hemophilic arthropathy is limited only to the
ulnohumeral joint, with minimal or no involvement of the radiohumeral
joint.A patient in whom the hemophilic arthropathy of the elbow has affected only
the flexion-extension range of motion, without major limitation of pronation
and supination. The excision of the radial head will not result in a
substantial increase in the range of flexion-extension of the elbow.A young patient with an open physis of the proximal part of the radius.PITFALLS:The most common pitfalls are as follows.Excessive muscle retraction or dissection distal to the level of the anular
ligament, resulting in paralysis of the deep branch of the radial nerve.Resection distal to the anular ligament, resulting in proximal radial
instability.Expectation on the part of the patient that the flexion-extension arc will
improve.AUTHOR UPDATE:No major changes have been made to the technique since it was originally
described.
CRITICAL CONCEPTS
INDICATIONS:
Excision of the radial head is typically indicated for patients with
hemophilia and a history of chronic synovitis of the elbow who have an
enlarged and irregular radial head with narrowing of the radiohumeral joint
space associated with posterolateral elbow pain and chronic, progressive, and
disabling limitation of forearm rotation.
CONTRAINDICATIONS:
In patients who have hemophilic arthropathy of the elbow and pain, there
are three main clinical scenarios in which the excision of the radial head is
not indicated.
A patient in whom the hemophilic arthropathy is limited only to the
ulnohumeral joint, with minimal or no involvement of the radiohumeral
joint.A patient in whom the hemophilic arthropathy of the elbow has affected only
the flexion-extension range of motion, without major limitation of pronation
and supination. The excision of the radial head will not result in a
substantial increase in the range of flexion-extension of the elbow.A young patient with an open physis of the proximal part of the radius.
A patient in whom the hemophilic arthropathy is limited only to the
ulnohumeral joint, with minimal or no involvement of the radiohumeral
joint.
A patient in whom the hemophilic arthropathy of the elbow has affected only
the flexion-extension range of motion, without major limitation of pronation
and supination. The excision of the radial head will not result in a
substantial increase in the range of flexion-extension of the elbow.
A young patient with an open physis of the proximal part of the radius.
PITFALLS:
The most common pitfalls are as follows.Excessive muscle retraction or dissection distal to the level of the anular
ligament, resulting in paralysis of the deep branch of the radial nerve.Resection distal to the anular ligament, resulting in proximal radial
instability.Expectation on the part of the patient that the flexion-extension arc will
improve.
The most common pitfalls are as follows.
Excessive muscle retraction or dissection distal to the level of the anular
ligament, resulting in paralysis of the deep branch of the radial nerve.
Resection distal to the anular ligament, resulting in proximal radial
instability.
Expectation on the part of the patient that the flexion-extension arc will
improve.
AUTHOR UPDATE:
No major changes have been made to the technique since it was originally
described.