Column procedure - Elbow

Indication

The column procedure allows for joint arthrotomy, release of the capsule, and excision of osteophytes through a limited lateral approach.

It allows for anterior and posterior capsular release and exposure adequate to remove osteophytes from the coronoid process and olecranon.

Anatomy

See general anatomical considerations about the elbow (link)

Considerations

If need to debride olecranon fossa and deepen it consider OK procedure

Consider arthroscopic capsular release if you have the technical ability.

Think about the ulna nerve! Consider release if symptomatic.

Positioning

Supine with a sandbag under shoulder arm draped free and brought across the chest.

Skin Incision

The proximal one-half of a Kocher incision (6 cm proximal and 3 cm distal to the lateral  epicondyle).

If ulna nerve symptoms and also need medial exposure, consider midline skin incision and elevation of medial and lateral skin flaps or two separate incisions.

Superficial dissection

Identify and release the fleshy origin of the extensor carpi radialis longus and the distal fibres of the brachioradialis from the humerus. Exposing the superolateral
aspect of the capsule. Enter the capsule anteriorly at the radiohumeral joint to allow assessment of the thickness of the capsule.

Sweep brachialis off the anterior aspect of the capsule with a periosteal elevator.

Use a modified knee retractor with a blade-shaft angle of 130º degrees to protect the brachialis, radial nerve and brachial artery.

Excise the lateral half of the anterior aspect of the capsule at least the level of the coronoid.

The most medial aspect of the capsule, which can sometimes be difficult to see, can be palpated and incised to complete the release.

Extend the elbow to release any remaining anterior adhesions.

If full/ near full extension is achieved (within 10º) and no obvious ostephytes on olecranon no further treatment required.

If flexion is limited or if extension is not complete, proceed to a posterior release and excision of olecranon osteophyte.

Elevate triceps from the posterior aspect of the humerus, release the posterior capsule and clear the olecranon fossa.

Excise the tip of the olecranon if there are osteophytes.

If this achieves at least 130º degrees of flexion, nothing more needs to be done posteriorly.
If flexion remains limited (less than 130º) inspect the coronoid and remove any osteophytes.

Consider the ulna nerve and decompress or translocate as needed (preferably simply decompression if good bed and no tendency to sublux).
 

Closure

Routine closure, do not repair the capsule

Post operatively

Consider peripheral nerve block/ indwelling brachial plexus block for pain relief.

Elevate arm

Begin immediate range of motion exercises.

Consider Continuous range of motion exercises.

Consider night splinting as needed. Adjusting splint to achieve maximum flexion or extension, whichever is needed more, but not to an
extent that prevents the patient from sleeping for at least six hours because of discomfort.

Consider an opposing splint during the day when not actively mobilising the elbow.

References

PIERRE MANSAT and B. F. MORREY; The Column Procedure: A Limited Lateral Approach for Extrinsic Contracture of the Elbow
J. Bone Joint Surg. Am., Nov 1998; 80: 1603 - 15.
 

Page created by: Lee Van Rensburg

Last updated 11/09/2015