OpenCapsularReleaseoftheElbow肘关节囊释放开实用教案

1、“The Column Procedure: A Limited Lateral Approach for Extrinsic Contracture of the Elbow” Mansat and Morrey, JBJS Nov. 1998.第1页/共60页第一页，共61页。ClassificationExtra-articular or extrinsic capsule, ligament, muscle or combination heterotopic ossification of the soft tissueIntra-articular or intrinsic art

2、icular cartilage abnormality第2页/共60页第二页，共61页。Conservative Treatment of Elbow StiffnessFlexion and/or extension splintsbest if begun earlydynamic splinting if toleratedManipulation under anesthesia第3页/共60页第三页，共61页。Surgical ReleaseArthroscopicOpen第4页/共60页第四页，共61页。Advantages of an Open ApproachSafer an

3、d easier for most surgeonsMore predictable resultBetter anterior visualization of a severely scarred anterior compartmentEasier conversion to conjunctive procedures第5页/共60页第五页，共61页。Disadvantages of an Open ApproachLarger incisionMore difficult inspection of the entire joint第6页/共60页第六页，共61页。Indicatio

4、ns for Open Release (Anterior and/or Posterior) Symptomatic extrinsic extension deficit (flexion contracture) 20-30 degrees “gray zone” 30 degrees Symptomatic extrinsic flexion deficit (extension contracture) Flexion 110 degrees第7页/共60页第七页，共61页。Open Conjunctive ProceduresBiceps tendon lengtheningBra

5、chialis myotomyCollateral ligament release Radial head resection第8页/共60页第八页，共61页。Open Release Surgical TechniquePre-operative and intra-operative assessment of neurovascular status and range of motionPatient in supine positionHigh arm tourniquet第9页/共60页第九页，共61页。TechniqueExsanguinate the arm and elev

6、ate the tourniquetPrep and drape the arm in a sterile fashion第10页/共60页第十页，共61页。Incisions Posterior long and requires large skin flaps Medial requires mobilization of the ulnar nerve Anterior greater risk to the neurovascular structures Lateral Preferred for safety and versatility第11页/共60页第十一页，共61页。I

7、nterval Along the anterior border of the lateral humeral epicondyle The distal 1/3 of the brachioradialis and the extensor carpi radialis longus and brevis are released off the epicondyle This will allow exposure of the anterior joint capsule The capsule is often scarred to the bone extending to the

8、 articular surface第12页/共60页第十二页，共61页。Capsule Once the capsule is identified a retractor is placed between the capsule and the brachialis This retractor must be long enough to extend across the entirety of the anterior elbow and wide enough to provide protection the anteriorly retracted neurovascular

9、 structures第13页/共60页第十三页，共61页。“The Release” The capsule is incised from the radial side of the humerus from as far proximal as possible and down to the joint line The release is wide (2 cm) radially and tapers medially The ulnar side of the capsule is hard to visualize so go carefully第14页/共60页第十四页，共

10、61页。“Fine Tuning” With the capsule released and the retractor removed palpate the joint and slowly extend the elbow to determine if any capsule remains If so replace the retractor and take an elevator and bluntly finish the capsular release第15页/共60页第十五页，共61页。Flexion Deficit Flex the elbow and determ

11、ine if the coronoid process or the radial head abuts the anterior humerus If so a coronoid process osteotomy or debridement of the anterior lateral surface of the humerus may be required第16页/共60页第十六页，共61页。Posterior Release At the level of the epicondyle the anconeus and triceps are elevated off the

12、posterior humeral surface The posterior joint capsule is identified and incised第17页/共60页第十七页，共61页。Posterior Release The olecranon process and olecranon fossa are identified and inspected The fossa is debrided of fibrous tissue, osteophytes or loose bodies Osteophytes are aggressively removed from th

13、e olecranon process第18页/共60页第十八页，共61页。Limited Flexion Determine if the triceps tendon or muscle are adherent to the posterior humerus If so a Cobb elevator is used to release the adhesions第19页/共60页第十九页，共61页。Final Check With all retractors removed palpate both the anterior and posterior sites to dete

14、rmine if there are any restrictions to flexion or extension If so address these structures第20页/共60页第二十页，共61页。Post-operative Protocol Neurovascular exam in recovery room Extension splint from the axilla to the wrist Pad the wrist excessively to avoid a pressure ulcer Hang the arm in a “sky hook” slin

15、g to elevate the arm overhead for 18-24 hours第21页/共60页第二十一页，共61页。Post-operative Protocol 1st day post-op - axillary catheter (in-dwelling) or scalene block CPM for ROM as tolerated DC 2nd day to daily PT and home CPM Extension or flexion splinting第22页/共60页第二十二页，共61页。Post-operative Protocol Check inc

16、ision 7-10 days and remove sutures Indocin or NSAID to limit swelling and HO Dynamic splinting or turnbuckle splints if motion is slow第23页/共60页第二十三页，共61页。第24页/共60页第二十四页，共61页。第25页/共60页第二十五页，共61页。第26页/共60页第二十六页，共61页。第27页/共60页第二十七页，共61页。第28页/共60页第二十八页，共61页。第29页/共60页第二十九页，共61页。第30页/共60页第三十页，共61页。第31页/共6

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