OpenCapsularReleaseoftheElbow肘关节囊释放开.pptx

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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ClassificationExtra-articular or extrinsiccapsule,ligament,muscle or combination heterotopic ossification of the soft tissueIntra-articular or intrinsicarticular cartilage

2、abnormality第2页/共60页Conservative Treatment of Elbow StiffnessFlexion and/or extension splintsbest if begun earlydynamic splinting if toleratedManipulation under anesthesia第3页/共60页Surgical ReleaseArthroscopicOpen第4页/共60页Advantages of an Open ApproachSafer and easier for most surgeonsMore predictable r

3、esultBetter anterior visualization of a severely scarred anterior compartmentEasier conversion to conjunctive procedures第5页/共60页Disadvantages of an Open ApproachLarger incisionMore difficult inspection of the entire joint第6页/共60页Indications for Open Release(Anterior and/or Posterior)Symptomatic extr

4、insic extension deficit(flexion contracture)20-30 degrees“gray zone”30 degreesSymptomatic extrinsic flexion deficit(extension contracture)Flexion 110 degrees第7页/共60页Open Conjunctive ProceduresBiceps tendon lengtheningBrachialis myotomyCollateral ligament release Radial head resection第8页/共60页Open Rel

5、ease 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TechniqueExsanguinate the arm and elevate the tourniquetPrep and drape the arm in a sterile fashion第10页/共60页IncisionsPosteriorlong and r

6、equires large skin flapsMedialrequires mobilization of the ulnar nerveAnteriorgreater risk to the neurovascular structuresLateralPreferred for safety and versatility第11页/共60页IntervalAlong the anterior border of the lateral humeral epicondyle The distal 1/3 of the brachioradialis and the extensor car

7、pi radialis longus and brevis are released off the epicondyleThis will allow exposure of the anterior joint capsuleThe capsule is often scarred to the bone extending to the articular surface第12页/共60页CapsuleOnce the capsule is identified a retractor is placed between the capsule and the brachialisThi

8、s retractor must be long enough to extend across the entirety of the anterior elbow and wide enough to provide protection the anteriorly retracted neurovascular structures第13页/共60页“The Release”The capsule is incised from the radial side of the humerus from as far proximal as possible and down to the

9、 joint lineThe release is wide(2 cm)radially and tapers mediallyThe ulnar side of the capsule is hard to visualize so go carefully第14页/共60页“Fine Tuning”With the capsule released and the retractor removed palpate the joint and slowly extend the elbow to determine if any capsule remainsIf so replace t

10、he retractor and take an elevator and bluntly finish the capsular release第15页/共60页Flexion DeficitFlex the elbow and determine if the coronoid process or the radial head abuts the anterior humerusIf so a coronoid process osteotomy or debridement of the anterior lateral surface of the humerus may be r

11、equired第16页/共60页Posterior ReleaseAt the level of the epicondyle the anconeus and triceps are elevated off the posterior humeral surfaceThe posterior joint capsule is identified and incised第17页/共60页Posterior ReleaseThe olecranon process and olecranon fossa are identified and inspectedThe fossa is deb

12、rided of fibrous tissue,osteophytes or loose bodiesOsteophytes are aggressively removed from the olecranon process第18页/共60页Limited FlexionDetermine if the triceps tendon or muscle are adherent to the posterior humerusIf so a Cobb elevator is used to release the adhesions第19页/共60页Final CheckWith all

13、retractors removed palpate both the anterior and posterior sites to determine if there are any restrictions to flexion or extensionIf so address these structures第20页/共60页Post-operative ProtocolNeurovascular exam in recovery roomExtension splint from the axilla to the wristPad the wrist excessively t

14、o avoid a pressure ulcerHang the arm in a“sky hook”sling to elevate the arm overhead for 18-24 hours第21页/共60页Post-operative Protocol1st day post-op-axillary catheter(in-dwelling)or scalene blockCPM for ROM as toleratedDC 2nd day to daily PT and home CPMExtension or flexion splinting第22页/共60页Post-ope

15、rative ProtocolCheck incision 7-10 days and remove suturesIndocin or NSAID to limit swelling and HODynamic splinting or turnbuckle splints if motion is slow第23页/共60页第24页/共60页第25页/共60页第26页/共60页第27页/共60页第28页/共60页第29页/共60页第30页/共60页第31页/共60页第32页/共60页第33页/共60页第34页/共60页第35页/共60页第36页/共60页第37页/共60页第38页/共60页第39页/共60页第40页/共60页第41页/共60页第42页/共60页第43页/共60页第44页/共60页第45页/共60页第46页/共60页第47页/共60页第48页/共60页第49页/共60页第50页/共60页第51页/共60页第52页/共60页第53页/共60页第54页/共60页第55页/共60页第56页/共60页第57页/共60页第58页/共60页第59页/共60页感谢您的观看！第60页/共60页