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The Lateral Para-Olecranon Approach for Total Elbow Arthroplasty
SCIENTIFIC ARTICLE
The Lateral Para-Olecranon Approach for Total Elbow Arthroplasty Alexis Studer, MD, George S. Athwal, MD, Joy C. MacDermid, PhD, Kenneth J. Faber, MD, Graham J. W. King, MD
Purpose To describe and evaluate the lateral para-olecranon approach for total elbow arthroplasty and to compare it with the paratricipital and triceps splitting approaches. Methods A total of 34 patients who underwent total elbow arthroplasty were evaluated: 25 with rheumatoid arthritis (28 elbows) and 9 with fractures. The average duration of follow-up was 54 months (range, 12e105 mo). Of the 28 elbows with rheumatoid arthritis, 17 underwent a triceps splitting approach, 6 a lateral para-olecranon, and 5 a paratricipital approach. Of the 9 fracture cases, 5 patients underwent a lateral para-olecranon and 4 a paratricipital approach. Extension strength, range of motion, elbow function (Mayo Elbow Performance Index), and complications related to triceps insufficiency were compared for all 3 approaches. In addition, we compared triceps strength after lateral para-olecranon and paratricipital approaches with the contralateral healthy elbow in the 9 fracture cases. Results Patients with rheumatoid arthritis had better extension torque when the prosthesis was implanted through the lateral para-olecranon approach (20 8 N-m) compared with the triceps splitting (13 4 N-m) or paratricipital approaches (12 6 N-m). In the fracture group, the extension strength of the replaced elbow was similar to the contralateral normal elbow in both the paratricipital and lateral para-olecranon groups. Conclusions The lateral para-olecranon approach avoids triceps tendon detachment from and repair to the olecranon, thereby reducing the risk of triceps insufficiency while maintaining better extension strength relative to a triceps splitting approach. (J Hand Surg 2013;38A:2219e2226. Copyright Ó 2013 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Total elbow arthroplasty, surgical approach, triceps insufficiency, paratricipital approach, triceps-splitting approach.
N
UMEROUS SURGICAL APPROACHES have been described for total elbow arthroplasty.1e9 The optimal exposure should allow adequate visualization while limiting morbidity. From the Hand and Upper Limb Centre, St. Joseph’s Healthcare London, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada. Received for publication July 25, 2012; accepted in revised form July 24, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Alexis Studer, MD, Celeste 22, E-28043 Madrid, Spain; e-mail: [email protected]. 0363-5023/13/38A11-0022-$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.07.029
Surgical approaches used for total elbow arthroplasty can be categorized as triceps releasing or reflecting, in which the triceps is detached from the olecranon, and triceps-on approaches, in which most of the triceps insertion on the olecranon is preserved. The ideal surgical exposure remains controversial because each approach has advantages and disadvantages. The triceps reflecting and releasing approaches, including triceps splitting,3,5,8 the BryaneMorrey approach,2 and the extended Kocher approach,6 maximize ulna exposure compared with triceps-on approaches. Detaching the triceps insertion facilitates ulna preparation and instrumentation. However, these
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Published by Elsevier, Inc. All rights reserved.
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approaches are associated with a higher risk of triceps insufficiency or rupture.5,10e13 Modifications of these approaches have been described to improve tendon fixation to enhance boneetendon healing.9 Whereas the reported incidence of triceps weakness needing reconstructive surgery has been reported to be only 2% after total elbow arthroplasty,10 other authors have reported clinically relevant weakness in up to 29% of patients.11e13 Alonso-Llamas1 described a bilateral tricipital approach, also known as the paratricipital approach, in which access is achieved on both sides of the triceps tendon while not violating the insertion in an effort to avoid triceps insufficiency. However, preservation of the triceps tendon insertion reduces visualization of the ulna, which makes preparation and component insertion more challenging. To improve exposure of the proximal ulna, the original Alonso-Llamas approach has undergone a number of modifications.14e16 The purpose of this study was to describe and evaluate the lateral para-olecranon approach, a modified triceps splitting approach that preserves most of the insertion of the triceps tendon on the olecranon while providing improved visualization of the proximal ulna relative to the paratricipital approach. We compared the functional outcome, strength, and complications of the lateral para-olecranon approach with the paratricipital and triceps splitting approaches in patients who underwent total elbow arthroplasty. MATERIALS AND METHODS We identified patients who were eligible for this study from a cohort that underwent primary total elbow arthroplasty (Latitude; Tornier, Stafford, TX) from June 2001 to April 2009, with the diagnosis of rheumatoid arthritis (RA) or acute fractures. Inclusion criteria included a total elbow arthroplasty approached through 1 of 3 exposures: lateral paraolecranon, triceps splitting, or the paratricipital approach. Exclusion criteria included preoperative triceps insufficiency such as an olecranon fracture, revision surgery, compensation, or legal claims (1 patient was excluded because of legal issues, because she openly expressed her unwillingness to improve). A total of 44 patients were identified as eligible for the study and 34 patients consented to return for clinical assessment. All implants were inserted by, or under the supervision of, 1 of the 3 fellowship-trained upper extremity surgeons at a single tertiary care referral JHS
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center. The triceps splitting approach was used primarily for RA at the beginning of the case series, whereas the paratricipital approach was used for fracture cases. With the development of the lateral para-olecranon approach in 2005, it became the primary approach for all total elbow replacements. The study cohort consisted of 28 women and 6 men. Of these 34 patients, 3 had bilateral involvement (37 elbows). There were 28 linked and 9 unlinked prostheses. In the RA group, 17 patients had a triceps splitting approach (Appendix A, available on the Journal’s Web site at www.jhandsurg.org), 4 patients (5 elbows) had a paratricipital exposure (Appendix B, available on the Journal’s Web site at www.jhandsurg.org), and 6 had a lateral para-olecranon approach (Appendix C, available on the Journal’s Web site at www.jhandsurg.org). Three patients with RA had bilateral elbow replacements. In the fracture group, 5 prostheses were implanted through the lateral para-olecranon approach (Appendix D, available on the Journal’s Web site at www. jhandsurg.org) and 4 using the paratricipital exposure (Appendix E, available on the Journal’s Web site at www.jhandsurg.org). Follow-up included an interview, administration of the Mayo Elbow Performance Index, physical examination, active range of motion, and strength measurements. A clinical fellow not involved with the original surgery performed the follow-up. The triceps tendon was examined for palpable gaps, and muscle strength was graded 0 to 5 according to the Medical Research Council scale. Triceps disruption was defined as elbow extension strength of grade 2 or less. We performed objective extension strength testing using the Lido Workset (Loredan Biomedical, West Sacramento, CA). Comparative testing was done on the contralateral elbow. Group differences were compared by t-tests and side-to-side differences by paired t-tests. Lateral para-olecranon surgical technique A longitudinal, 15-cm, posterior skin incision was centered just medial to the tip of the olecranon. Fullthickness fasciocutaneous flaps were elevated on the deep fascia, and the ulnar nerve was exposed and transposed in all patients. The lateral para-olecranon approach exposed the ulnohumeral joint through medial and lateral arthrotomies, leaving most of the triceps insertion intact on the olecranon.17 After ulnar nerve transposition, we excised the medial intramuscular septum and carried out dissection between brachialis and the medial head of the triceps. This exposed the medial
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FIGURE 2: The posterolateral arthrotomy is performed using the Boyd approach. A small cuff of the antebrachial facia is left attached to the subcutaneous ulnar shaft for closure.
FIGURE 1: Posterior midline skin incision is centered just medial to the tip of the olecranon.
supracondylar area. The triceps muscle was elevated from the posterior humerus, and the posterior capsule and fat pad were excised to improve exposure. We developed the interval between the ulna and anconeus muscle as in a Boyd approach18 (Fig. 1). The incision was extended proximally, in line with the Boyd interval separating the portion of the triceps tendon that inserts directly on the olecranon tip from the portion that blends with the anconeus fascia to become the lateral cubital retinaculum. The triceps tendon inserting on the olecranon tip was maintained. The anconeus was subperiosteally elevated from the lateral aspect of the ulna to expose the lateral aspect of the greater sigmoid notch and the posterior radiocapitellar joint. The lateral collateral ligament was released from its origin on the lateral epicondyle, while care was taken to preserve its insertion on the crista supinatoris. The lateral cubital retinaculum and the lateral aspect of the triceps tendon with the superficial fascia of the forearm and the anconeus were reflected laterally as a single unit (Fig. 2). We took care to maintain continuity of the extensor mechanism with this forearm fascia. To gain medial exposure, we divided the posterior bundle of the medial collateral ligament and released the anterior bundle of the medial collateral ligament JHS
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FIGURE 3: The medial collateral ligament and the common flexor-pronator origin are released from the medial epicondyle to allow dislocation of the elbow.
and common flexor origin from the medial epicondyle (Fig. 3). The anterior capsule and brachialis were elevated off the anterior humerus, and dislocation was accomplished by dislocating the proximal radius and ulna off the distal humerus, which was delivered through either the triceps split or the medial window (Fig. 4).
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FIGURE 4: The distal humerus is delivered through either the medial or lateral arthrotomy to allow for humeral preparation and implant insertion. As shown, the humerus has been delivered medially and the ulna with the triceps tendon insertion is anterior to the humerus.
FIGURE 5: Exposure of the proximal ulna with the triceps intact requires reflection of the anconeus and lateral cubital retinaculum forearm as a single unit. External rotation of the ulna allows visualization of the greater sigmoid notch and the base of the coronoid.
Retraction of the triceps tendon and external rotation of the ulna facilitated exposure of the greater sigmoid notch and the base of the coronoid (Fig. 5). When accessing the ulna through a triceps-on approach, we created a small split in the triceps to allow more direct access to the ulnar canal with flexible reamers and rasps. With the lateral paraolecranon approach, exposure of the proximal ulna was facilitated by hypersupination of the forearm. An JHS
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FIGURE 6: The inserted prosthesis with an intact triceps insertion.
adjunctive triceps split was not required. Distal humerus preparation can be performed before or after the ulnar cuts are done; however, in the setting of thin and osteopenic distal humeral condyles, ulnar preparation can be performed first to avoid iatrogenic condylar fractures. After insertion of the elbow prosthesis (Fig. 6), we closed the interval between the triceps tendon and the lateral cubital retinaculum using buried nonabsorbable sutures. If an unlinked arthroplasty was performed, the collateral ligaments were reattached to the epicondyles by placing sutures through a cannulated bolt in the prosthesis and tying them over bone. The flexor-pronator origin was repaired to the medial triceps and medial epicondyle if present. This ensured a thick posterior soft tissue envelope to cover and protect the prosthesis (Fig. 7). Triceps splitting surgical technique Skin incision, flap elevation, and ulnar nerve transposition were performed as described above.19 Once the triceps tendon was exposed, it was split in the midline extending proximally from the central olecranon insertion. The triceps was subperiosteally elevated from the tip of the olecranon both medially and laterally, until completely detached. We released the collateral ligaments from the medial and lateral epicondyles to allow dislocation of the elbow joint. We inserted the prosthesis using the manufacturer’s recommended technique. If an unlinked arthroplasty was performed, the collateral ligaments and muscular
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Postoperative management The rehabilitation protocol varied depending on the management of the extensor mechanism, the type of implant used, and the stability achieved in the operating room. The elbows were immobilized for 10 days to ensure skin healing. Patients receiving the lateral para-olecranon and paratricipital approaches were managed with active flexion and extension without triceps protection. Patients receiving the triceps splitting approaches were protected with gravity-assisted extension exercises during the first 4 to 6 weeks, and active flexion was gradually increased during this period. Flexion greater than 90 was not permitted in the early postoperative period, to avoid stretching or rupture of the triceps mechanism. Flexion was gradually increased to full over 6 weeks.
FIGURE 7: After implantation of the arthroplasty, the medial and lateral arthrotomies are closed, as is the split between the lateral aspect of the triceps tendon and the lateral cubital retinaculum.
origins were reattached to the epicondyles. Triceps reattachment was accomplished using transosseous sutures. We drilled 2 oblique holes and a single transverse tunnel through the olecranon and reattached the triceps to the olecranon with heavy nonabsorbable sutures. Paratricipital surgical technique After ulnar nerve transposition, we identified the medial and lateral borders of the triceps and elevated them from the medial and lateral intermuscular septa. The triceps was released from the posterior humerus. The lateral and medial collateral ligament and their associated common extensor and flexor origins were released from the epicondyles. Distally, the anconeus was detached from the radial column. We then dislocated the elbow and delivered the distal humerus either medially or laterally to prepare and insert the humeral component. To achieve correct ulna visualization and proper angle of approach for component insertion, the bulk of the extensor mechanism had to be retracted. After cementing the components, we reduced the joint and repaired the common flexor and extensor origins to the margins of the triceps. JHS
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RESULTS Table 1 lists patient demographics, surgical approach, and Mayo Elbow Performance Index scores. The mean age of the patient cohort with RA arthritis was significantly younger than that of the cohort undergoing total elbow arthroplasty for fracture. The average duration of follow-up was 54 months (range, 12e105 mo). The duration of follow-up was longer for the RA population compared with the fracture group. The duration of follow-up was shorter for the lateral para-olecranon approach, because this exposure had been used since 2005, compared with the previously used paratricipital or triceps splitting approaches. The average Mayo Elbow Performance Index score for the patients with RA was not significantly different from that of the group with traumatic conditions. Patients with RA who had a triceps splitting approach had a significantly greater flexion contracture than did those who had a lateral para-olecranon or a paratricipital approach. There were no differences in flexion range in patients with RA (Table 2). Strength scores, whether measured using the Lido Workset or the Medical Research Council grade, favored the lateral para-olecranon approach. These comparisons were subdivided by pathology, given the difference in strength anticipated for RA (pathological contralateral side) versus fracture patients (older patients but uninjured contralateral side). In the RA group, there was 1 case of ulna perforation when using the paratricipital approach. Radiographic review at a mean of 5 years’ follow-up showed 2 cases of loosening of the ulna component in the triceps splitting cohort. In the fracture group, a patient who was operated on through a paratricipital approach experienced a humeral stem perforation
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TABLE 1.
LATERAL PARA-OLECRANON APPROACH
Subjects Diagnostic Subgroups Rheumatoid Arthritis (25 Patients, 28 Elbows)
Technique/pathology
17 triceps splitting; 5 paratricipital; 6 lateral para-olecranon
Technique Subgroups
Fracture (9 Patients, 9 Elbows)
Triceps Splitting 17 RA
4 paratricipital; 5 lateral para-olecranon
Lateral ParaOlecranon
Paratricipital 5 RA (2 bilateral) 4 Fracture
6 RA (1 bilateral) 5 Fracture
Age at operation, y
63 9*
82 6*
63 8
70 14*
73 11*
Duration of follow-up, mo
59 26*
45 28*
73 18
61 23*
24 11*
Sex (M/F)
5/23
2/7
2/15
1/8
4/7
Side (L/R)
13/15
6/3
7/10
6/3
6/5
MEPI motion
17 3
19 2
16 2
19 2*
18 3*
MEPI total
86 12
89 16
83 12
91 16
91 10
Values are given as means and standard deviations. MEPI, Mayo Elbow Performance Index; RA, rheumatoid arthritis. *Significant difference.
TABLE 2.
Extension Torque Rheumatoid Arthritic Group Triceps Splitting
Extension torque affected Extension torque unaffected Flexion
Paratricipital
13 4
Lateral Para-Olecranon
Paratricipital
Lateral Para-Olecranon
20 8*
19 3
21 8
12 6
17 8* 127 9
Fracture Group
12 8
15 8
22 9
20 6
136 6
135 8
132 6
115 15
Extension
44 16*
24 10
16 12
11 8
12 8
Pronation
73 12
77 14
81 6
76 11
76 11
Supination
55 23
71 15
61 10
61 16
78 3
Medical Research Council Grade
3.9 0.5
4.6 0.5*
4.8 0.4*
5
5
MEPI
83 12
95 9*
90 9
85 21
93 11
MEPI motion
16 2
19 2*
18 3
20
18 3
Values are given as means and standard deviations, in Newton-meters per kilogram. MEPI, Mayo Elbow Performance Index. *Absolute differences were significant.
while we were revising a humeral component that became stuck because of cement that cured too quickly. We found no intraoperative complications in the lateral para-olecranon cohort. At an average of 4 years’ follow-up, no radiographic signs of loosening were identified in the fracture group. Rheumatoid arthritis Patients with RA treated with a triceps splitting approach had a lower extension torque than in their JHS
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contralateral arm (13 4 vs 17 8 N-m; P < .01), whereas this comparison was not different when the surgery was performed using the paratricipital approach (12 6 vs 12 8 N-m; P ¼ .95) or a lateral paraolecranon approach (20 8 vs 15 8 N-m; P ¼ .06). When comparing each approach, we found significantly greater extension torque with the lateral para-olecranon approach (20 8 N-m) compared with the paratricipital (12 6 N-m) and triceps splitting approaches (13 4 N-m) (P < .001 and P ¼ .011, respectively).
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There was no significant difference between the triceps splitting and paratricipital approaches. On physical examination, 1 patient who had undergone a triceps splitting approach showed obvious triceps disruption at the time of latest follow-up. Strength was graded as M2 according to the Medical Research Council scale, and a gap could be palpated in the extensor mechanism. All patients in the lateral paraolecranon or paratricipital approach groups had strength of M4 or greater. There were no significant differences in the average Medical Research Council strength grade between the lateral para-olecranon and the paratricipital approaches; however, there were significant differences between the lateral para-olecranon and the paratricipital approach compared with the triceps splitting approach (P < .001 and P < .005, respectively). Fracture In the fracture group, there were no significant differences among techniques or between arms for either the Medical Research Council grade or torque strength, which indicated that patients regained similar strength with the paratricipital and the lateral para-olecranon approach. DISCUSSION This study demonstrated that the lateral para-olecranon approach can provide functional outcomes and strength equal to or better than more traditional approaches that detach the triceps tendon from the olecranon. This approach can likely be used with any of the total elbow prosthesis designs currently available. With the lateral para-olecranon approach, nearly half of the triceps is mobilized out of the way, thereby increasing the overall exposure compared with a triceps-on approach. Triceps strength is maintained and triceps disruption can be avoided. In this study, the lateral para-olecranon approach was not associated with a higher intraoperative complication rate or a difference in survival of the implant. Information is limited concerning the influence of the surgical approach on strength after total elbow arthroplasty. Morrey et al20 studied elbow strength after 31 total elbow arthroplasties and reported that extension torque was the least improved. The BryanMorrey approach had better extension strength than the triceps splitting and extended Kocher approaches. Hildebrand et al11 also reported less extension torque after total elbow arthroplasty compared with the contralateral elbow in both posttraumatic patients and those with RA. In the current study, we found that an arthroplasty implanted through a triceps splitting approach had reduced extension strength compared JHS
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with that of the contralateral elbow. In contrast, prosthesis implanted through a paratricipital or a lateral para-olecranon approach had extension strength similar to the contralateral elbow. This seems logical because preservation of the triceps insertion reduces the risk of extensor weakness or rupture, therefore leading to improved extension strength. Unfortunately, triceps weakness is a common finding after total elbow arthroplasty.11,12,21e25 In our series, there was only 1 case of a complete triceps disruption, in a patient who had a triceps splitting approach. No cases of triceps rupture were identified when the paratricipital or lateral para-olecranon approach was used. Surgical approaches to the elbow joint that partially or completely detach the triceps from the olecranon predispose to triceps avulsion, weakness, and healing problems. The complication of triceps dehiscence and weakness is probably underreported, particularly in low-demand patients. In the Mayo Clinic experience with 887 total elbow arthroplasties, 16 elbows (15 triceps reflecting approaches and 1 triceps splitting approach), with triceps insufficiency underwent revision surgery for triceps repair or reconstruction.22 The incidence of functionally disabling triceps weakness may have been underestimated in this study, because only patients who opted for surgical management of triceps insufficiency were included. Other studies reported a higher incidence of triceps insufficiency after triceps releasing or reflecting approaches. Pierce and Herndon12 reported 4 cases of complete triceps avulsion and 2 cases of triceps weakness out of 13 patients who had a Bryan-Morrey approach. Hildebrand et al11 reported on 36 patients, 3 of whom had triceps rupture after a Bryan-Morrey approach. This compares with a 1 of 17 incidence of triceps insufficiency in patients who had a triceps splitting approach in the current series. In contrast, when examining triceps-on approaches, Boorman et al,14 Prokopis and Weiland,16 and Pierce and Herndon12 reported no cases of triceps insufficiency when the triceps insertion was not detached. In our series, there were also no cases of triceps insufficiency when the insertion was not violated. These findings suggest that the decision not to detach the triceps insertion would reduce the risk of triceps disruption and also enable the patient to start an earlier active unrestricted rehabilitation program. Differences in range of motion encountered in extension in our study may be related to the rehabilitation program. Whereas patients with a paratricipital or lateral para-olecranon approach followed an early active flexion and extension
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program, patients with a triceps splitting approach had the extensor repair protected for the first 6 weeks. Flexion contracture with the triceps splitting approach may partly result from the triceps weakness, which manifests itself mostly during elbow extension. There are some limitations in our study design that should be considered when interpreting the results. There is a potential for bias in retrospective and nonrandomized study designs. In this study, there was potential for a historical bias because patients undergoing the lateral para-olecranon approach were treated more recently. This study had a small sample size, which is inherent when studying a relatively uncommon procedure. This could explain the difference noted in the extension strength between the different approaches in the RA group, but which was not seen in the fracture group. In addition, patients operated on through the lateral para-olecranon approach were older, possibly because newer medications have had a major impact on controlling RA. The lateral para-olecranon approach avoids triceps tendon detachment from the olecranon and subsequent repair, which is particularly problematic in patients with RA and compromised soft tissues. Preserving the extensor mechanism reduces the risk of triceps insufficiency and allows an active physiotherapy program to begin shortly after surgery. The lateral para-olecranon approach also allows for improved ulna visualization compared with the paratricipital approach; nevertheless, ulna visualization is still compromised compared with other triceps releasing or reflecting approaches. REFERENCES 1. Alonso-Llames M. Bilaterotricipital approach to the elbow. Acta Orthop Scand. 1972;43(6):479e490. 2. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow: a triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188e192. 3. Campbell WC. Incision for exposure of the elbow joint. Am J Surg. 1932;15:65e67. 4. Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior elbow incision: an anatomical appraisal. J Bone Joint Surg Br. 1995;77(5):696e699.
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5. Gschwend N, Scheier NH, Baehler AR. Long-term results of the GSB III elbow arthroplasty. J Bone Joint Surg Br. 1999;81(6): 1005e1012. 6. Kocher T. Textbook of Operative Surgery. 3rd ed. London, UK: Adam and Charles Black; 1911. 7. Patterson SD, Bain GI, Metha JA. Surgical approaches to the elbow. Clin Orthop Relat Res. 2000;(370):19e33. 8. Van Gorder GW. Surgical approach in supracondylar “Y” fractures of the humerus requiring open reduction. J Bone Joint Surg. 1940;22(2):278e292. 9. Wolfe SW, Ranawat CS. The osteo-anconeus flap: an approach for total elbow arthroplasty. J Bone Joint Surg Am. 1990;72(5): 684e688. 10. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. J Shoulder Elbow Surg. 2011;20(1):158e168. 11. Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ. Functional outcome of semi constrained total elbow arthroplasty. J Bone Joint Surg Am. 2000;82(10):1379e1386. 12. Pierce TD, Herndon JH. The triceps preserving approach to total elbow arthroplasty. Clin Orthop Relat Res. 1998;(354):144e152. 13. Inglis AE, Pellicci PM. Total elbow replacement. J Bone Joint Surg Am. 1980;62(8):1252e1258. 14. Boorman RS, Page TP, Weldon EJ III, Lipitt S, Matsen FA III. A triceps-on approach to semi-constrained total elbow arthroplasty. Tech Shoulder Elbow Surg. 2003;4:139e144. 15. Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral non-union. J Bone Joint Surg Br. 1995;77(1):67e72. 16. Prokopis PM, Weiland AJ. The triceps-preserving approach for semi constrained total elbow arthroplasty. J Shoulder Elbow Surg. 2008;17(3):454e458. 17. Athwal GS, McGill RJ, Rispoli DM. Isolated avulsion of the medial head of the triceps tendon: an anatomic study and arthroscopic repair in 2 cases. Arthroscopy. 2009;25(9):983e988. 18. Boyd HB. Surgical exposure of the ulna and proximal third of the radius through one incision. Surg Gynecol Obstet. 1940;71:86e88. 19. Morret BF. Surgical exposure of the elbow. In: Morrey BF, SanchezSotelo J, eds. The Elbow and Its Disorders. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2009:115e142. 20. Morrey BF, Askew LJ, An KN. Strength function after elbow arthroplasty. Clin Orthop Relat Res. 1988;(234):43e50. 21. Guerroudj M, de Longueville JC, Rooze M, Hinsenkamp M, Feipel V, Schiund F. Biomechanical properties of triceps brachii tendon after in vitro simulation of different posterior surgical approaches. J Shoulder Elbow Surg. 2007;16(6):849e853. 22. Celli A, Arash A, Adams RA, Morrey BF. Triceps insufficiency following total elbow arthroplasty. J Bone Joint Surg Am. 2005;87(9):1957e1964. 23. Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: a 10 to fifteen-year followup study. J Bone Joint Surg Am. 1998;80(9):1327e1335. 24. Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop Relat Res. 1982;170:204e212. 25. Morrey BF, Bryan RS, Dobyns JH, Linsheid RC. Total elbow arthroplasty: a 5 year experience at the Mayo Clinic. J Bone Joint Surg Br. 1987;69(7):116e120.
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APPENDIX A.
Patient No.
Fracture Group Treated Through Paratricipital Approach
Gender
Age, y
Side/ Dominance
AO Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo
100
20
105
1
F
84
L/RHD
C3.2
130
13
70
75
16.2
14.3
No
M5
2
F
76
R/RHD
C3.2
136
18
85
35
20.7
28.7
No
M5
55
20
68
3
F
85
L/RHD
B3.3
138
0
64
73
16.7
14.7
No
M5
100
20
49
4
F
75
L/RHD
C3.2
125
12
85
60
23.2
30.5
No
M5
85
20
40
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MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
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APPENDIX B.
Patient No.
Fracture Group Treated Through Lateral Para-Olecranon Approach
Gender
Age, y
Side/ Dominance
AO Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo
5
F
77
L/RHD
C3.1
127
3
86
75
24.5
21
No
M5
100
20
48
6
F
84
R/RHD
C2.2
125
21
90
84
8.6
10.1
No
M5
100
20
39
7
M
89
L/RHD
C2.1
124
7
70
76
22.8
21.5
No
M5
100
20
13
8
F
76
L/RHD
C3.3
98
21
65
78
16.4
18.9
No
M5
75
15
25
9
M
88
R/RHD
C2.1
100
8
70
75
30
26.6
No
M5
90
15
20
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
2226.e1
2226.e2
APPENDIX C. Patient No.
Rheumatoid Arthritis Group Treated Through Triceps Splitting Approach
Gender
Age, y
Side/ Dominance
Larsen Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo 100
M
65
R/RHD
IIIA
134
57
64
30
13.9
26.7
No
M4
85
15
11
F
56
L/RHD
IIIA
138
30
78
80
17.1
23.4
No
M4
95
20
96
12
F
55
L/LHD
IIIA
115
42
45
68
16.1
7.2
No
M4
75
15
100 92
F
55
R/RHD
IIIB
119
58
60
0
12.1
15.8
No
M4
70
15
14
F
56
R/RHD
IIIB
122
38
71
60
11
26.6
No
M4
80
15
86
15
F
63
R/RHD
IIIA
125
54
76
60
12.2
11.7
No
M4
95
15
70
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Vol 38A, November 2013
16
F
56
L/RHD
IIIA
138
45
85
83
17.1
24.2
No
M4
95
15
72
17
F
73
L/RHD
IIIA
125
41
60
84
14.3
18.8
No
M4
95
15
66
18
F
58
L/RHD
IIIB
124
50
85
45
3.1
9.1
Yes
M2
75
15
66
19
F
73
R/RHD
IIIA
114
56
85
67
15.5
16.3
No
M4
95
15
73
20
M
55
R/RHD
IIIA
126
27
81
55
23.2
31.9
No
M4
100
20
68
21
F
71
L/RHD
IIIA
136
37
73
54
10.7
7.9
No
M4
75
15
69
22
F
63
R/RHD
IIIB
125
55
85
37
10.6
23.5
No
M4
55
15
69
23
F
60
R/RHD
IIIB
142
25
86
43
7.9
12.4
No
M4
80
20
62
24
F
84
R/RHD
IIIA
135
60
75
81
14.1
12.6
No
M4
80
15
57
25
F
59
Rt/RHD
IIIA
124
3
76
63
10.9
19.9
No
M4
80
20
31
26
F
68
Lt/RHD
IIIB
119
65
53
30
13.4
7.7
No
M4
75
15
57
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
LATERAL PARA-OLECRANON APPROACH
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APPENDIX D. Patient No.
Rheumatoid Arthritis Group Treated Through Paratricipital Approach
Gender
Side/ Dominance
Age, y
Larsen Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo 86
27
F
72
L/RHD
IV
143
27
90
90
8.5
5.4
No
M5
100
20
28
F
74
R/RHD
IV
133
30
84
85
5.4
8.5
No
M4
100
20
61
29
F
41
L/RHD
IIIA
137
16
60
67
13.5
15.3
No
M5
100
20
39
30
F
61
L/RHD
IIIA
137
10
85
55
12.4
31
M
58
R/RHD
IIIA
128
35
64
60
21.8
7.9 25
No
M4
80
20
59
No
M5
95
15
42
Gap on Palpation
Elbow Strength†
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MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale. r
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APPENDIX E. Rheumatoid Arthritis Group Treated Through Lateral Paraolecranon Approach
Patient No.
Gender
Age, y
Side/ Dominance
Larsen Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
MEPI
MEPI Motion
Follow-Up, mo
32
F
76
L/RHD
IIIA
131
33
70
75
20.5
0
No
M5
80
15
14
33
M
65
R/RHD
IIIA
121
21
83
66
28.3
18.2
No
M4
95
15
25
34
F
57
R/RHD
IIIA
135
4
85
68
24
22.4
No
M5
80
20
12
35
M
60
L/RHD
IIIA
135
20
76
50
25
21.8
No
M5
100
20
21
36
F
60
R/RHD
IIIA
141
17
85
60
15.5
11.6
No
M5
85
20
26
37
F
70
L/RHD
Inflamatory arthririts
145
0
85
78
22
19
No
M5
100
20
24
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
2226.e3
The Lateral Para-Olecranon Approach for Total Elbow Arthroplasty Alexis Studer, MD, George S. Athwal, MD, Joy C. MacDermid, PhD, Kenneth J. Faber, MD, Graham J. W. King, MD
Purpose To describe and evaluate the lateral para-olecranon approach for total elbow arthroplasty and to compare it with the paratricipital and triceps splitting approaches. Methods A total of 34 patients who underwent total elbow arthroplasty were evaluated: 25 with rheumatoid arthritis (28 elbows) and 9 with fractures. The average duration of follow-up was 54 months (range, 12e105 mo). Of the 28 elbows with rheumatoid arthritis, 17 underwent a triceps splitting approach, 6 a lateral para-olecranon, and 5 a paratricipital approach. Of the 9 fracture cases, 5 patients underwent a lateral para-olecranon and 4 a paratricipital approach. Extension strength, range of motion, elbow function (Mayo Elbow Performance Index), and complications related to triceps insufficiency were compared for all 3 approaches. In addition, we compared triceps strength after lateral para-olecranon and paratricipital approaches with the contralateral healthy elbow in the 9 fracture cases. Results Patients with rheumatoid arthritis had better extension torque when the prosthesis was implanted through the lateral para-olecranon approach (20 8 N-m) compared with the triceps splitting (13 4 N-m) or paratricipital approaches (12 6 N-m). In the fracture group, the extension strength of the replaced elbow was similar to the contralateral normal elbow in both the paratricipital and lateral para-olecranon groups. Conclusions The lateral para-olecranon approach avoids triceps tendon detachment from and repair to the olecranon, thereby reducing the risk of triceps insufficiency while maintaining better extension strength relative to a triceps splitting approach. (J Hand Surg 2013;38A:2219e2226. Copyright Ó 2013 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Total elbow arthroplasty, surgical approach, triceps insufficiency, paratricipital approach, triceps-splitting approach.
N
UMEROUS SURGICAL APPROACHES have been described for total elbow arthroplasty.1e9 The optimal exposure should allow adequate visualization while limiting morbidity. From the Hand and Upper Limb Centre, St. Joseph’s Healthcare London, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada. Received for publication July 25, 2012; accepted in revised form July 24, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Alexis Studer, MD, Celeste 22, E-28043 Madrid, Spain; e-mail: [email protected]. 0363-5023/13/38A11-0022-$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.07.029
Surgical approaches used for total elbow arthroplasty can be categorized as triceps releasing or reflecting, in which the triceps is detached from the olecranon, and triceps-on approaches, in which most of the triceps insertion on the olecranon is preserved. The ideal surgical exposure remains controversial because each approach has advantages and disadvantages. The triceps reflecting and releasing approaches, including triceps splitting,3,5,8 the BryaneMorrey approach,2 and the extended Kocher approach,6 maximize ulna exposure compared with triceps-on approaches. Detaching the triceps insertion facilitates ulna preparation and instrumentation. However, these
Ó 2013 ASSH
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approaches are associated with a higher risk of triceps insufficiency or rupture.5,10e13 Modifications of these approaches have been described to improve tendon fixation to enhance boneetendon healing.9 Whereas the reported incidence of triceps weakness needing reconstructive surgery has been reported to be only 2% after total elbow arthroplasty,10 other authors have reported clinically relevant weakness in up to 29% of patients.11e13 Alonso-Llamas1 described a bilateral tricipital approach, also known as the paratricipital approach, in which access is achieved on both sides of the triceps tendon while not violating the insertion in an effort to avoid triceps insufficiency. However, preservation of the triceps tendon insertion reduces visualization of the ulna, which makes preparation and component insertion more challenging. To improve exposure of the proximal ulna, the original Alonso-Llamas approach has undergone a number of modifications.14e16 The purpose of this study was to describe and evaluate the lateral para-olecranon approach, a modified triceps splitting approach that preserves most of the insertion of the triceps tendon on the olecranon while providing improved visualization of the proximal ulna relative to the paratricipital approach. We compared the functional outcome, strength, and complications of the lateral para-olecranon approach with the paratricipital and triceps splitting approaches in patients who underwent total elbow arthroplasty. MATERIALS AND METHODS We identified patients who were eligible for this study from a cohort that underwent primary total elbow arthroplasty (Latitude; Tornier, Stafford, TX) from June 2001 to April 2009, with the diagnosis of rheumatoid arthritis (RA) or acute fractures. Inclusion criteria included a total elbow arthroplasty approached through 1 of 3 exposures: lateral paraolecranon, triceps splitting, or the paratricipital approach. Exclusion criteria included preoperative triceps insufficiency such as an olecranon fracture, revision surgery, compensation, or legal claims (1 patient was excluded because of legal issues, because she openly expressed her unwillingness to improve). A total of 44 patients were identified as eligible for the study and 34 patients consented to return for clinical assessment. All implants were inserted by, or under the supervision of, 1 of the 3 fellowship-trained upper extremity surgeons at a single tertiary care referral JHS
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center. The triceps splitting approach was used primarily for RA at the beginning of the case series, whereas the paratricipital approach was used for fracture cases. With the development of the lateral para-olecranon approach in 2005, it became the primary approach for all total elbow replacements. The study cohort consisted of 28 women and 6 men. Of these 34 patients, 3 had bilateral involvement (37 elbows). There were 28 linked and 9 unlinked prostheses. In the RA group, 17 patients had a triceps splitting approach (Appendix A, available on the Journal’s Web site at www.jhandsurg.org), 4 patients (5 elbows) had a paratricipital exposure (Appendix B, available on the Journal’s Web site at www.jhandsurg.org), and 6 had a lateral para-olecranon approach (Appendix C, available on the Journal’s Web site at www.jhandsurg.org). Three patients with RA had bilateral elbow replacements. In the fracture group, 5 prostheses were implanted through the lateral para-olecranon approach (Appendix D, available on the Journal’s Web site at www. jhandsurg.org) and 4 using the paratricipital exposure (Appendix E, available on the Journal’s Web site at www.jhandsurg.org). Follow-up included an interview, administration of the Mayo Elbow Performance Index, physical examination, active range of motion, and strength measurements. A clinical fellow not involved with the original surgery performed the follow-up. The triceps tendon was examined for palpable gaps, and muscle strength was graded 0 to 5 according to the Medical Research Council scale. Triceps disruption was defined as elbow extension strength of grade 2 or less. We performed objective extension strength testing using the Lido Workset (Loredan Biomedical, West Sacramento, CA). Comparative testing was done on the contralateral elbow. Group differences were compared by t-tests and side-to-side differences by paired t-tests. Lateral para-olecranon surgical technique A longitudinal, 15-cm, posterior skin incision was centered just medial to the tip of the olecranon. Fullthickness fasciocutaneous flaps were elevated on the deep fascia, and the ulnar nerve was exposed and transposed in all patients. The lateral para-olecranon approach exposed the ulnohumeral joint through medial and lateral arthrotomies, leaving most of the triceps insertion intact on the olecranon.17 After ulnar nerve transposition, we excised the medial intramuscular septum and carried out dissection between brachialis and the medial head of the triceps. This exposed the medial
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2221
FIGURE 2: The posterolateral arthrotomy is performed using the Boyd approach. A small cuff of the antebrachial facia is left attached to the subcutaneous ulnar shaft for closure.
FIGURE 1: Posterior midline skin incision is centered just medial to the tip of the olecranon.
supracondylar area. The triceps muscle was elevated from the posterior humerus, and the posterior capsule and fat pad were excised to improve exposure. We developed the interval between the ulna and anconeus muscle as in a Boyd approach18 (Fig. 1). The incision was extended proximally, in line with the Boyd interval separating the portion of the triceps tendon that inserts directly on the olecranon tip from the portion that blends with the anconeus fascia to become the lateral cubital retinaculum. The triceps tendon inserting on the olecranon tip was maintained. The anconeus was subperiosteally elevated from the lateral aspect of the ulna to expose the lateral aspect of the greater sigmoid notch and the posterior radiocapitellar joint. The lateral collateral ligament was released from its origin on the lateral epicondyle, while care was taken to preserve its insertion on the crista supinatoris. The lateral cubital retinaculum and the lateral aspect of the triceps tendon with the superficial fascia of the forearm and the anconeus were reflected laterally as a single unit (Fig. 2). We took care to maintain continuity of the extensor mechanism with this forearm fascia. To gain medial exposure, we divided the posterior bundle of the medial collateral ligament and released the anterior bundle of the medial collateral ligament JHS
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FIGURE 3: The medial collateral ligament and the common flexor-pronator origin are released from the medial epicondyle to allow dislocation of the elbow.
and common flexor origin from the medial epicondyle (Fig. 3). The anterior capsule and brachialis were elevated off the anterior humerus, and dislocation was accomplished by dislocating the proximal radius and ulna off the distal humerus, which was delivered through either the triceps split or the medial window (Fig. 4).
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LATERAL PARA-OLECRANON APPROACH
FIGURE 4: The distal humerus is delivered through either the medial or lateral arthrotomy to allow for humeral preparation and implant insertion. As shown, the humerus has been delivered medially and the ulna with the triceps tendon insertion is anterior to the humerus.
FIGURE 5: Exposure of the proximal ulna with the triceps intact requires reflection of the anconeus and lateral cubital retinaculum forearm as a single unit. External rotation of the ulna allows visualization of the greater sigmoid notch and the base of the coronoid.
Retraction of the triceps tendon and external rotation of the ulna facilitated exposure of the greater sigmoid notch and the base of the coronoid (Fig. 5). When accessing the ulna through a triceps-on approach, we created a small split in the triceps to allow more direct access to the ulnar canal with flexible reamers and rasps. With the lateral paraolecranon approach, exposure of the proximal ulna was facilitated by hypersupination of the forearm. An JHS
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FIGURE 6: The inserted prosthesis with an intact triceps insertion.
adjunctive triceps split was not required. Distal humerus preparation can be performed before or after the ulnar cuts are done; however, in the setting of thin and osteopenic distal humeral condyles, ulnar preparation can be performed first to avoid iatrogenic condylar fractures. After insertion of the elbow prosthesis (Fig. 6), we closed the interval between the triceps tendon and the lateral cubital retinaculum using buried nonabsorbable sutures. If an unlinked arthroplasty was performed, the collateral ligaments were reattached to the epicondyles by placing sutures through a cannulated bolt in the prosthesis and tying them over bone. The flexor-pronator origin was repaired to the medial triceps and medial epicondyle if present. This ensured a thick posterior soft tissue envelope to cover and protect the prosthesis (Fig. 7). Triceps splitting surgical technique Skin incision, flap elevation, and ulnar nerve transposition were performed as described above.19 Once the triceps tendon was exposed, it was split in the midline extending proximally from the central olecranon insertion. The triceps was subperiosteally elevated from the tip of the olecranon both medially and laterally, until completely detached. We released the collateral ligaments from the medial and lateral epicondyles to allow dislocation of the elbow joint. We inserted the prosthesis using the manufacturer’s recommended technique. If an unlinked arthroplasty was performed, the collateral ligaments and muscular
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2223
Postoperative management The rehabilitation protocol varied depending on the management of the extensor mechanism, the type of implant used, and the stability achieved in the operating room. The elbows were immobilized for 10 days to ensure skin healing. Patients receiving the lateral para-olecranon and paratricipital approaches were managed with active flexion and extension without triceps protection. Patients receiving the triceps splitting approaches were protected with gravity-assisted extension exercises during the first 4 to 6 weeks, and active flexion was gradually increased during this period. Flexion greater than 90 was not permitted in the early postoperative period, to avoid stretching or rupture of the triceps mechanism. Flexion was gradually increased to full over 6 weeks.
FIGURE 7: After implantation of the arthroplasty, the medial and lateral arthrotomies are closed, as is the split between the lateral aspect of the triceps tendon and the lateral cubital retinaculum.
origins were reattached to the epicondyles. Triceps reattachment was accomplished using transosseous sutures. We drilled 2 oblique holes and a single transverse tunnel through the olecranon and reattached the triceps to the olecranon with heavy nonabsorbable sutures. Paratricipital surgical technique After ulnar nerve transposition, we identified the medial and lateral borders of the triceps and elevated them from the medial and lateral intermuscular septa. The triceps was released from the posterior humerus. The lateral and medial collateral ligament and their associated common extensor and flexor origins were released from the epicondyles. Distally, the anconeus was detached from the radial column. We then dislocated the elbow and delivered the distal humerus either medially or laterally to prepare and insert the humeral component. To achieve correct ulna visualization and proper angle of approach for component insertion, the bulk of the extensor mechanism had to be retracted. After cementing the components, we reduced the joint and repaired the common flexor and extensor origins to the margins of the triceps. JHS
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RESULTS Table 1 lists patient demographics, surgical approach, and Mayo Elbow Performance Index scores. The mean age of the patient cohort with RA arthritis was significantly younger than that of the cohort undergoing total elbow arthroplasty for fracture. The average duration of follow-up was 54 months (range, 12e105 mo). The duration of follow-up was longer for the RA population compared with the fracture group. The duration of follow-up was shorter for the lateral para-olecranon approach, because this exposure had been used since 2005, compared with the previously used paratricipital or triceps splitting approaches. The average Mayo Elbow Performance Index score for the patients with RA was not significantly different from that of the group with traumatic conditions. Patients with RA who had a triceps splitting approach had a significantly greater flexion contracture than did those who had a lateral para-olecranon or a paratricipital approach. There were no differences in flexion range in patients with RA (Table 2). Strength scores, whether measured using the Lido Workset or the Medical Research Council grade, favored the lateral para-olecranon approach. These comparisons were subdivided by pathology, given the difference in strength anticipated for RA (pathological contralateral side) versus fracture patients (older patients but uninjured contralateral side). In the RA group, there was 1 case of ulna perforation when using the paratricipital approach. Radiographic review at a mean of 5 years’ follow-up showed 2 cases of loosening of the ulna component in the triceps splitting cohort. In the fracture group, a patient who was operated on through a paratricipital approach experienced a humeral stem perforation
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TABLE 1.
LATERAL PARA-OLECRANON APPROACH
Subjects Diagnostic Subgroups Rheumatoid Arthritis (25 Patients, 28 Elbows)
Technique/pathology
17 triceps splitting; 5 paratricipital; 6 lateral para-olecranon
Technique Subgroups
Fracture (9 Patients, 9 Elbows)
Triceps Splitting 17 RA
4 paratricipital; 5 lateral para-olecranon
Lateral ParaOlecranon
Paratricipital 5 RA (2 bilateral) 4 Fracture
6 RA (1 bilateral) 5 Fracture
Age at operation, y
63 9*
82 6*
63 8
70 14*
73 11*
Duration of follow-up, mo
59 26*
45 28*
73 18
61 23*
24 11*
Sex (M/F)
5/23
2/7
2/15
1/8
4/7
Side (L/R)
13/15
6/3
7/10
6/3
6/5
MEPI motion
17 3
19 2
16 2
19 2*
18 3*
MEPI total
86 12
89 16
83 12
91 16
91 10
Values are given as means and standard deviations. MEPI, Mayo Elbow Performance Index; RA, rheumatoid arthritis. *Significant difference.
TABLE 2.
Extension Torque Rheumatoid Arthritic Group Triceps Splitting
Extension torque affected Extension torque unaffected Flexion
Paratricipital
13 4
Lateral Para-Olecranon
Paratricipital
Lateral Para-Olecranon
20 8*
19 3
21 8
12 6
17 8* 127 9
Fracture Group
12 8
15 8
22 9
20 6
136 6
135 8
132 6
115 15
Extension
44 16*
24 10
16 12
11 8
12 8
Pronation
73 12
77 14
81 6
76 11
76 11
Supination
55 23
71 15
61 10
61 16
78 3
Medical Research Council Grade
3.9 0.5
4.6 0.5*
4.8 0.4*
5
5
MEPI
83 12
95 9*
90 9
85 21
93 11
MEPI motion
16 2
19 2*
18 3
20
18 3
Values are given as means and standard deviations, in Newton-meters per kilogram. MEPI, Mayo Elbow Performance Index. *Absolute differences were significant.
while we were revising a humeral component that became stuck because of cement that cured too quickly. We found no intraoperative complications in the lateral para-olecranon cohort. At an average of 4 years’ follow-up, no radiographic signs of loosening were identified in the fracture group. Rheumatoid arthritis Patients with RA treated with a triceps splitting approach had a lower extension torque than in their JHS
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contralateral arm (13 4 vs 17 8 N-m; P < .01), whereas this comparison was not different when the surgery was performed using the paratricipital approach (12 6 vs 12 8 N-m; P ¼ .95) or a lateral paraolecranon approach (20 8 vs 15 8 N-m; P ¼ .06). When comparing each approach, we found significantly greater extension torque with the lateral para-olecranon approach (20 8 N-m) compared with the paratricipital (12 6 N-m) and triceps splitting approaches (13 4 N-m) (P < .001 and P ¼ .011, respectively).
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There was no significant difference between the triceps splitting and paratricipital approaches. On physical examination, 1 patient who had undergone a triceps splitting approach showed obvious triceps disruption at the time of latest follow-up. Strength was graded as M2 according to the Medical Research Council scale, and a gap could be palpated in the extensor mechanism. All patients in the lateral paraolecranon or paratricipital approach groups had strength of M4 or greater. There were no significant differences in the average Medical Research Council strength grade between the lateral para-olecranon and the paratricipital approaches; however, there were significant differences between the lateral para-olecranon and the paratricipital approach compared with the triceps splitting approach (P < .001 and P < .005, respectively). Fracture In the fracture group, there were no significant differences among techniques or between arms for either the Medical Research Council grade or torque strength, which indicated that patients regained similar strength with the paratricipital and the lateral para-olecranon approach. DISCUSSION This study demonstrated that the lateral para-olecranon approach can provide functional outcomes and strength equal to or better than more traditional approaches that detach the triceps tendon from the olecranon. This approach can likely be used with any of the total elbow prosthesis designs currently available. With the lateral para-olecranon approach, nearly half of the triceps is mobilized out of the way, thereby increasing the overall exposure compared with a triceps-on approach. Triceps strength is maintained and triceps disruption can be avoided. In this study, the lateral para-olecranon approach was not associated with a higher intraoperative complication rate or a difference in survival of the implant. Information is limited concerning the influence of the surgical approach on strength after total elbow arthroplasty. Morrey et al20 studied elbow strength after 31 total elbow arthroplasties and reported that extension torque was the least improved. The BryanMorrey approach had better extension strength than the triceps splitting and extended Kocher approaches. Hildebrand et al11 also reported less extension torque after total elbow arthroplasty compared with the contralateral elbow in both posttraumatic patients and those with RA. In the current study, we found that an arthroplasty implanted through a triceps splitting approach had reduced extension strength compared JHS
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with that of the contralateral elbow. In contrast, prosthesis implanted through a paratricipital or a lateral para-olecranon approach had extension strength similar to the contralateral elbow. This seems logical because preservation of the triceps insertion reduces the risk of extensor weakness or rupture, therefore leading to improved extension strength. Unfortunately, triceps weakness is a common finding after total elbow arthroplasty.11,12,21e25 In our series, there was only 1 case of a complete triceps disruption, in a patient who had a triceps splitting approach. No cases of triceps rupture were identified when the paratricipital or lateral para-olecranon approach was used. Surgical approaches to the elbow joint that partially or completely detach the triceps from the olecranon predispose to triceps avulsion, weakness, and healing problems. The complication of triceps dehiscence and weakness is probably underreported, particularly in low-demand patients. In the Mayo Clinic experience with 887 total elbow arthroplasties, 16 elbows (15 triceps reflecting approaches and 1 triceps splitting approach), with triceps insufficiency underwent revision surgery for triceps repair or reconstruction.22 The incidence of functionally disabling triceps weakness may have been underestimated in this study, because only patients who opted for surgical management of triceps insufficiency were included. Other studies reported a higher incidence of triceps insufficiency after triceps releasing or reflecting approaches. Pierce and Herndon12 reported 4 cases of complete triceps avulsion and 2 cases of triceps weakness out of 13 patients who had a Bryan-Morrey approach. Hildebrand et al11 reported on 36 patients, 3 of whom had triceps rupture after a Bryan-Morrey approach. This compares with a 1 of 17 incidence of triceps insufficiency in patients who had a triceps splitting approach in the current series. In contrast, when examining triceps-on approaches, Boorman et al,14 Prokopis and Weiland,16 and Pierce and Herndon12 reported no cases of triceps insufficiency when the triceps insertion was not detached. In our series, there were also no cases of triceps insufficiency when the insertion was not violated. These findings suggest that the decision not to detach the triceps insertion would reduce the risk of triceps disruption and also enable the patient to start an earlier active unrestricted rehabilitation program. Differences in range of motion encountered in extension in our study may be related to the rehabilitation program. Whereas patients with a paratricipital or lateral para-olecranon approach followed an early active flexion and extension
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LATERAL PARA-OLECRANON APPROACH
program, patients with a triceps splitting approach had the extensor repair protected for the first 6 weeks. Flexion contracture with the triceps splitting approach may partly result from the triceps weakness, which manifests itself mostly during elbow extension. There are some limitations in our study design that should be considered when interpreting the results. There is a potential for bias in retrospective and nonrandomized study designs. In this study, there was potential for a historical bias because patients undergoing the lateral para-olecranon approach were treated more recently. This study had a small sample size, which is inherent when studying a relatively uncommon procedure. This could explain the difference noted in the extension strength between the different approaches in the RA group, but which was not seen in the fracture group. In addition, patients operated on through the lateral para-olecranon approach were older, possibly because newer medications have had a major impact on controlling RA. The lateral para-olecranon approach avoids triceps tendon detachment from the olecranon and subsequent repair, which is particularly problematic in patients with RA and compromised soft tissues. Preserving the extensor mechanism reduces the risk of triceps insufficiency and allows an active physiotherapy program to begin shortly after surgery. The lateral para-olecranon approach also allows for improved ulna visualization compared with the paratricipital approach; nevertheless, ulna visualization is still compromised compared with other triceps releasing or reflecting approaches. REFERENCES 1. Alonso-Llames M. Bilaterotricipital approach to the elbow. Acta Orthop Scand. 1972;43(6):479e490. 2. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow: a triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188e192. 3. Campbell WC. Incision for exposure of the elbow joint. Am J Surg. 1932;15:65e67. 4. Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior elbow incision: an anatomical appraisal. J Bone Joint Surg Br. 1995;77(5):696e699.
JHS
r
5. Gschwend N, Scheier NH, Baehler AR. Long-term results of the GSB III elbow arthroplasty. J Bone Joint Surg Br. 1999;81(6): 1005e1012. 6. Kocher T. Textbook of Operative Surgery. 3rd ed. London, UK: Adam and Charles Black; 1911. 7. Patterson SD, Bain GI, Metha JA. Surgical approaches to the elbow. Clin Orthop Relat Res. 2000;(370):19e33. 8. Van Gorder GW. Surgical approach in supracondylar “Y” fractures of the humerus requiring open reduction. J Bone Joint Surg. 1940;22(2):278e292. 9. Wolfe SW, Ranawat CS. The osteo-anconeus flap: an approach for total elbow arthroplasty. J Bone Joint Surg Am. 1990;72(5): 684e688. 10. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. J Shoulder Elbow Surg. 2011;20(1):158e168. 11. Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ. Functional outcome of semi constrained total elbow arthroplasty. J Bone Joint Surg Am. 2000;82(10):1379e1386. 12. Pierce TD, Herndon JH. The triceps preserving approach to total elbow arthroplasty. Clin Orthop Relat Res. 1998;(354):144e152. 13. Inglis AE, Pellicci PM. Total elbow replacement. J Bone Joint Surg Am. 1980;62(8):1252e1258. 14. Boorman RS, Page TP, Weldon EJ III, Lipitt S, Matsen FA III. A triceps-on approach to semi-constrained total elbow arthroplasty. Tech Shoulder Elbow Surg. 2003;4:139e144. 15. Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral non-union. J Bone Joint Surg Br. 1995;77(1):67e72. 16. Prokopis PM, Weiland AJ. The triceps-preserving approach for semi constrained total elbow arthroplasty. J Shoulder Elbow Surg. 2008;17(3):454e458. 17. Athwal GS, McGill RJ, Rispoli DM. Isolated avulsion of the medial head of the triceps tendon: an anatomic study and arthroscopic repair in 2 cases. Arthroscopy. 2009;25(9):983e988. 18. Boyd HB. Surgical exposure of the ulna and proximal third of the radius through one incision. Surg Gynecol Obstet. 1940;71:86e88. 19. Morret BF. Surgical exposure of the elbow. In: Morrey BF, SanchezSotelo J, eds. The Elbow and Its Disorders. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2009:115e142. 20. Morrey BF, Askew LJ, An KN. Strength function after elbow arthroplasty. Clin Orthop Relat Res. 1988;(234):43e50. 21. Guerroudj M, de Longueville JC, Rooze M, Hinsenkamp M, Feipel V, Schiund F. Biomechanical properties of triceps brachii tendon after in vitro simulation of different posterior surgical approaches. J Shoulder Elbow Surg. 2007;16(6):849e853. 22. Celli A, Arash A, Adams RA, Morrey BF. Triceps insufficiency following total elbow arthroplasty. J Bone Joint Surg Am. 2005;87(9):1957e1964. 23. Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: a 10 to fifteen-year followup study. J Bone Joint Surg Am. 1998;80(9):1327e1335. 24. Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop Relat Res. 1982;170:204e212. 25. Morrey BF, Bryan RS, Dobyns JH, Linsheid RC. Total elbow arthroplasty: a 5 year experience at the Mayo Clinic. J Bone Joint Surg Br. 1987;69(7):116e120.
Vol 38A, November 2013
APPENDIX A.
Patient No.
Fracture Group Treated Through Paratricipital Approach
Gender
Age, y
Side/ Dominance
AO Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo
100
20
105
1
F
84
L/RHD
C3.2
130
13
70
75
16.2
14.3
No
M5
2
F
76
R/RHD
C3.2
136
18
85
35
20.7
28.7
No
M5
55
20
68
3
F
85
L/RHD
B3.3
138
0
64
73
16.7
14.7
No
M5
100
20
49
4
F
75
L/RHD
C3.2
125
12
85
60
23.2
30.5
No
M5
85
20
40
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LATERAL PARA-OLECRANON APPROACH
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
r
Vol 38A, November 2013
APPENDIX B.
Patient No.
Fracture Group Treated Through Lateral Para-Olecranon Approach
Gender
Age, y
Side/ Dominance
AO Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo
5
F
77
L/RHD
C3.1
127
3
86
75
24.5
21
No
M5
100
20
48
6
F
84
R/RHD
C2.2
125
21
90
84
8.6
10.1
No
M5
100
20
39
7
M
89
L/RHD
C2.1
124
7
70
76
22.8
21.5
No
M5
100
20
13
8
F
76
L/RHD
C3.3
98
21
65
78
16.4
18.9
No
M5
75
15
25
9
M
88
R/RHD
C2.1
100
8
70
75
30
26.6
No
M5
90
15
20
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
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2226.e2
APPENDIX C. Patient No.
Rheumatoid Arthritis Group Treated Through Triceps Splitting Approach
Gender
Age, y
Side/ Dominance
Larsen Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo 100
M
65
R/RHD
IIIA
134
57
64
30
13.9
26.7
No
M4
85
15
11
F
56
L/RHD
IIIA
138
30
78
80
17.1
23.4
No
M4
95
20
96
12
F
55
L/LHD
IIIA
115
42
45
68
16.1
7.2
No
M4
75
15
100 92
F
55
R/RHD
IIIB
119
58
60
0
12.1
15.8
No
M4
70
15
14
F
56
R/RHD
IIIB
122
38
71
60
11
26.6
No
M4
80
15
86
15
F
63
R/RHD
IIIA
125
54
76
60
12.2
11.7
No
M4
95
15
70
r
13
Vol 38A, November 2013
16
F
56
L/RHD
IIIA
138
45
85
83
17.1
24.2
No
M4
95
15
72
17
F
73
L/RHD
IIIA
125
41
60
84
14.3
18.8
No
M4
95
15
66
18
F
58
L/RHD
IIIB
124
50
85
45
3.1
9.1
Yes
M2
75
15
66
19
F
73
R/RHD
IIIA
114
56
85
67
15.5
16.3
No
M4
95
15
73
20
M
55
R/RHD
IIIA
126
27
81
55
23.2
31.9
No
M4
100
20
68
21
F
71
L/RHD
IIIA
136
37
73
54
10.7
7.9
No
M4
75
15
69
22
F
63
R/RHD
IIIB
125
55
85
37
10.6
23.5
No
M4
55
15
69
23
F
60
R/RHD
IIIB
142
25
86
43
7.9
12.4
No
M4
80
20
62
24
F
84
R/RHD
IIIA
135
60
75
81
14.1
12.6
No
M4
80
15
57
25
F
59
Rt/RHD
IIIA
124
3
76
63
10.9
19.9
No
M4
80
20
31
26
F
68
Lt/RHD
IIIB
119
65
53
30
13.4
7.7
No
M4
75
15
57
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
LATERAL PARA-OLECRANON APPROACH
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10
APPENDIX D. Patient No.
Rheumatoid Arthritis Group Treated Through Paratricipital Approach
Gender
Side/ Dominance
Age, y
Larsen Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
Gap on Palpation
Elbow Strength†
MEPI
MEPI Motion
Follow-Up, mo 86
27
F
72
L/RHD
IV
143
27
90
90
8.5
5.4
No
M5
100
20
28
F
74
R/RHD
IV
133
30
84
85
5.4
8.5
No
M4
100
20
61
29
F
41
L/RHD
IIIA
137
16
60
67
13.5
15.3
No
M5
100
20
39
30
F
61
L/RHD
IIIA
137
10
85
55
12.4
31
M
58
R/RHD
IIIA
128
35
64
60
21.8
7.9 25
No
M4
80
20
59
No
M5
95
15
42
Gap on Palpation
Elbow Strength†
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LATERAL PARA-OLECRANON APPROACH
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale. r
Vol 38A, November 2013
APPENDIX E. Rheumatoid Arthritis Group Treated Through Lateral Paraolecranon Approach
Patient No.
Gender
Age, y
Side/ Dominance
Larsen Classification
Flexion
Extension
Pronation
Supination
Extensor Torque Affected*
Extensor Torque Unaffected*
MEPI
MEPI Motion
Follow-Up, mo
32
F
76
L/RHD
IIIA
131
33
70
75
20.5
0
No
M5
80
15
14
33
M
65
R/RHD
IIIA
121
21
83
66
28.3
18.2
No
M4
95
15
25
34
F
57
R/RHD
IIIA
135
4
85
68
24
22.4
No
M5
80
20
12
35
M
60
L/RHD
IIIA
135
20
76
50
25
21.8
No
M5
100
20
21
36
F
60
R/RHD
IIIA
141
17
85
60
15.5
11.6
No
M5
85
20
26
37
F
70
L/RHD
Inflamatory arthririts
145
0
85
78
22
19
No
M5
100
20
24
MEPI, Mayo Elbow Performance Index. *Values are given in Newton-meters per kilogram. †Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale.
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