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Release of Elbow Flexion Contracture Thru Kocher Approach

- See:
      - Kocher Approach:
      - Elbow Flexion Contracture:

- Discussion:
    - goal of procedure is elevation of common extensor tendon and transection of the anterior joint capsule;
    - indicated for significant flexion contractures (more than 30 deg) which arise from soft tissue (capsular contracture);
           - loss of extension due to posterior osteophytes should be addressed w/ ulna-humeral arthroplasty;
    - often these patients will have concomitant osteoarthritis with spur formation at the olecranon tip and loose bodies in the olecranon 
           fossa (limits extension) and often spur formation at the coronoid process and loose bodies in the coronid fossa (which limits flexion);

- Technique:
    - wide postero-lateral exposure is performed in the usual manner;
    - proximally the incision is made over the lateral supracondylar ridge and crosses over the lateral epicondyle;
           - carry the incision down to the lateral supracondylar ridge, and then strip the anterior musculature subperiosteally until the anterior 
                  capsule is reached;
           - the anterior retractor will contain the ECRL, BR, and the brachialis;
           - proximally, the ECRL is elevated off lateral epicondyle
           - medially, elevate the fibers of the ECRL and the brachalis off the capsule;
           - flex the elbow, and then elevate the common extensor tendon and the brachialis off the joint capsule;
           - identify and protect the LCL:
           - common extensor tendon is sharply dissected off the LCL and joint capsule;
    - distally, the skin incision may have a gentle curve toward the posterior border of the ulna, with the dissection proceding in the usual 
           manner (between the aconeus and ECU);
    - w/ care to preserve the LCL (laterally) and the ulnar nerve (medially), incise a retangular portion of the capsule under direct 
          - this is facilitated by initially transecting the capsule just anterior to the LCL;
          - this allows the capsule to be elevated, which protects the underlying joint cartilage during the dissection;
          - before transecting the medial side of the capsule, consider running a nerve stimulator up and down the medial capsule to ensure 
                  that the median nerve is not scar down on the capsule;
                  - likewise the tourniquet can be released and the surgeon can palpate the brachial artery;
    - bring the elbow in to full extension;
          - if extension is lacking, then dissect into the olecranon fossa;
          - free the triceps from any adhesions and remove the soft tissue contents of the olecronon fossa;
          - if necessary, remove a portion of the olecranon if it appears to limit extension;

- Technique to Gain Flexion:
    - tenolysis of the triceps and posterior capsulotomy;
    - soft tissue contents of the coronoid fossa are removed;
    - if the coronid process is enlarged, the portion which is proximal to the brachialis insertion should be removed;
    - abnormal spurs from the radial head and coronoid process are also removed;

- Wound Closure:
    - lateral tissue sleeve is repaired using drill holes (to restore stability);

- Post Operative Care:
    - patients undergo continuous passive motion is carried out for several days;
    - when patients are not engaged in PT, they should wear an extension splint

The lateral approach for operative release of post-traumatic contracture of the elbow.

Debridement arthroplasty for osteoarthritis of the elbow.

Progressive surgical release of a posttraumatic stiff elbow. Technique and outcome after 2-18 years in 46 patients.

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