1. Open Capsular Release of the Elbow William R. Beach, M.D.

2. “The Column Procedure: A Limited Lateral Approach for Extrinsic Contracture of the Elbow” Mansat and Morrey, JBJS Nov. 1998.

3. Classification Extra-articular or extrinsic –capsule, ligament, muscle or combination –heterotopic ossification of the soft tissue Intra-articular or intrinsic –articular cartilage abnormality

4. Conservative Treatment of Elbow Stiffness Flexion and/or extension splints –best if begun early –dynamic splinting if tolerated Manipulation under anesthesia

5. Surgical Release Arthroscopic Open

6. Advantages of an Open Approach Safer and easier for most surgeons More predictable result Better anterior visualization of a severely scarred anterior compartment Easier conversion to conjunctive procedures

7. Disadvantages of an Open Approach Larger incision More difficult inspection of the entire joint

8. Indications 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

9. Open Conjunctive Procedures Biceps tendon lengthening Brachialis myotomy Collateral ligament release Radial head resection

10. Open Release Surgical Technique Pre-operative and intra-operative assessment of neurovascular status and range of motion Patient in supine position High arm tourniquet

11. Technique Exsanguinate the arm and elevate the tourniquet Prep and drape the arm in a sterile fashion

12. 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

13. Interval 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 articular surface

14. 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 structures

15. “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

16. “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

17. Flexion Deficit Flex the elbow and determine 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

18. Posterior Release At the level of the epicondyle the anconeus and triceps are elevated off the posterior humeral surface The posterior joint capsule is identified and incised

19. 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 the olecranon process

20. 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

21. Final Check With all retractors removed palpate both the anterior and posterior sites to determine if there are any restrictions to flexion or extension If so address these structures

22. 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” sling to elevate the arm overhead for 18-24 hours

23. 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

24. Post-operative Protocol Check incision 7-10 days and remove sutures Indocin or NSAID to limit swelling and HO Dynamic splinting or turnbuckle splints if motion is slow