OpenCapsularReleaseoftheElbow肘關(guān)節(jié)囊釋放開實用教案

1、“The Column Procedure: A Limited Lateral Approach for Extrinsic Contracture of the Elbow” Mansat and Morrey, JBJS Nov. 1998.第1頁/共60頁第一頁，共61頁。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頁/共60頁第二頁，共61頁。Conservative Treatment of Elbow StiffnessFlexion and/or extension splintsbest if begun earlydynamic splinting if toleratedManipulation under anesthesia第3頁/共60頁第三頁，共61頁。Surgical ReleaseArthroscopicOpen第4頁/共60頁第四頁，共61頁。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頁/共60頁第五頁，共61頁。Disadvantages of an Open ApproachLarger incisionMore difficult inspection of the entire joint第6頁/共60頁第六頁，共61頁。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頁/共60頁第七頁，共61頁。Open Conjunctive ProceduresBiceps tendon lengtheningBra

5、chialis myotomyCollateral ligament release Radial head resection第8頁/共60頁第八頁，共61頁。Open Release Surgical TechniquePre-operative and intra-operative assessment of neurovascular status and range of motionPatient in supine positionHigh arm tourniquet第9頁/共60頁第九頁，共61頁。TechniqueExsanguinate the arm and elev

6、ate the tourniquetPrep and drape the arm in a sterile fashion第10頁/共60頁第十頁，共61頁。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頁/共60頁第十一頁，共61頁。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頁/共60頁第十二頁，共61頁。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頁/共60頁第十三頁，共61頁?！癟he 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頁/共60頁第十四頁，共

10、61頁?！癋ine 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頁/共60頁第十五頁，共61頁。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頁/共60頁第十六頁，共61頁。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頁/共60頁第十七頁，共61頁。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頁/共60頁第十八頁，共61頁。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頁/共60頁第十九頁，共61頁。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頁/共60頁第二十頁，共61頁。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頁/共60頁第二十一頁，共61頁。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頁/共60頁第二十二頁，共61頁。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頁/共60頁第二十三頁，共61頁。第24頁/共60頁第二十四頁，共61頁。第25頁/共60頁第二十五頁，共61頁。第26頁/共60頁第二十六頁，共61頁。第27頁/共60頁第二十七頁，共61頁。第28頁/共60頁第二十八頁，共61頁。第29頁/共60頁第二十九頁，共61頁。第30頁/共60頁第三十頁，共61頁。第31頁/共6

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