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Surgical Approaches to the Elbow

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Summary Table of Surgical Approaches

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1. Posterior Approaches

1a. Posterolateral Approach (Campbell)

• Skin incision begins 10 cm proximal to the elbow on the posterolateral aspect, extends 13 cm distally
• The triceps aponeurosis is fashioned into a tongue-shaped flap with its base at the olecranon, retracted distally
• If triceps is not contracted, the muscle and aponeurosis are split longitudinally in the midline
• Periosteum is elevated from the posterior distal humerus for 5 cm
• The ulnar nerve must be protected at all times during medial capsule stripping

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1b. Extensile Posterolateral Approach (Wadsworth)

• Patient prone, elbow flexed 90° over support, forearm dependent
• Curved skin incision from proximal posterior arm, down to the posterolateral epicondyle, then medially to the posterior ulnar border 4 cm distal to the olecranon tip
• The ulnar nerve is identified and released from its tunnel by dividing the arcuate ligament between the two heads of flexor carpi ulnaris, then retracted with a rubber sling
• A tongue of triceps tendon is fashioned with its base attached to the olecranon; the remaining peripheral tendinous rim stays attached for later repair
• The incision extends distally through the triceps aponeurosis to separate the anconeus from the extensor carpi ulnaris
• The posterior capsule is divided in the same line

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2. Lateral Approach

2a. Lateral (Simple) Approach

• Incision begins ~5 cm proximal to the lateral epicondyle, extends distally to the epicondyle, then 5 cm along the anterolateral forearm
• Develop the interval between the triceps (posterior) and the origins of extensor carpi radialis longus and brachioradialis (anterior)
• In the proximal wound, avoid the radial nerve where it enters between brachialis and brachioradialis
• Separate the common extensor origin from the lateral epicondyle (or elevate it with a thin flake of bone)
• Reflect the common extensor origin distally to expose the radiohumeral joint
• Always protect the deep branch of the radial nerve as it enters the supinator

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2b. Kocher Lateral J Approach

• Incision begins 5 cm proximal to the elbow over the lateral supracondylar ridge, extends to the epicondyle, then 5 cm distal to the radial head, curving medially and posteriorly to end at the posterior ulnar border
• The dissection plane is between the anconeus (posterior) and extensor carpi ulnaris (anterior)
• The elbow can be dislocated laterally when full exposure is needed

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3. Medial Approach

3a. Medial Approach with Osteotomy of the Medial Epicondyle (Molesworth-Campbell)

• Elbow flexed to a right angle; medial incision centered over the tip of the medial epicondyle (5 cm proximal to 5 cm distal)
• Isolate the ulnar nerve in the groove posterior to the epicondyle and retract it posteriorly
• Detach the medial epicondyle with a small osteotome (with common flexor origin undisturbed) and reflect it distally
• Continue subperiosteally to free the medial coronoid process; incise the capsule
• Strip periosteum and capsule anteriorly and posteriorly as needed
• Avoid the median nerve which crosses the anterior joint
• With the lateral capsule as a hinge, the joint can be dislocated

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4. Medial and Lateral (Bilateral) Approach

• An incision 5-7 cm long on either or both sides of the joint, just anterior to the condyles, parallel with the epicondylar ridges
• The flexion crease of the elbow lies proximal to the joint line (a useful landmark)
• Capsule incised from proximal to distal on each side
• On the medial side: carefully avoid the ulnar nerve

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5. Global (Circumferential) Approach (Patterson, Bain, Mehta)

1. Straight posterior midline incision
2. Sharp dissection through deep fascia to the triceps tendon and subcutaneous border of the ulna
3. If medial exposure needed: open cubital tunnel, isolate ulnar nerve, transpose anteriorly, protect with Penrose drain
4. Develop full-thickness medial or lateral fasciocutaneous flaps as needed

• Develop the Kocher interval (anconeus-ECU) to expose the elbow capsule and lateral epicondyle
• Reflect anconeus and triceps medially to expose the olecranon fossa and posterior distal humerus

• Reflect the medial fasciocutaneous flap to expose the posteromedial joint and sublime tubercle

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Key Nerves at Risk - Summary

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Quick Reference: Choosing the Right Approach

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Surgical Approaches to the Ankle

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Overview

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Summary Table

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1. Anterolateral Approach - The "Universal Incision"

1. Incision begins over the anterolateral leg, medial to the fibula, 5 cm proximal to the ankle joint
2. Carried distally over the joint, anterolateral talus, calcaneocuboid joint, ending at the base of the 4th metatarsal
3. Incise fascia and superior/inferior extensor retinacula down to the periosteum and joint capsule
4. Find and protect the intermediate dorsal cutaneous branches of the superficial peroneal nerve
5. Divide the extensor digitorum brevis in the direction of its fibers
6. Retract the extensor tendons, dorsalis pedis artery, and deep peroneal nerve medially; incise the capsule

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2. Anteromedial Extensile Approach (Assal, Ray, Stern)

1. Skin incision runs just lateral to the tibialis anterior tendon, then curves toward the tip of the medial malleolus
2. Incise extensor retinaculum medial to the tibialis anterior tendon
3. Develop the interval medial to the tibialis anterior to expose the anterior tibia and tibial plafond
4. Protect the saphenous nerve and greater saphenous vein medially

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3. Lateral Approach to the Distal Fibula

1. Mark skin incision along anterior or posterior border of the distal fibula (surgeon preference)
2. Elevate full-thickness flaps; avoid the superficial peroneal nerve (located ~10 cm proximal to distal fibular tip, range 3-18 cm)
3. Incise fascia; elevate peroneal musculature posteriorly in a supraperiosteal fashion
4. For posterior/posterolateral plating: partially incise the superior peroneal retinaculum (avoid complete disruption to prevent peroneal subluxation)
5. For syndesmosis visualization: dissect anteriorly over fibula, partially incise extensor retinaculum; protect intact AITFL fibers

Key Precautions: The superficial peroneal nerve location is highly variable. Avoid complete disruption of the superior peroneal retinaculum. Do not inadvertently suture the superficial peroneal nerve during wound closure.

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4. Kocher Lateral Approach to the Tarsus and Ankle

1. Incision begins just lateral and distal to the head of the talus
2. Curves 2.5 cm inferior to the tip of the lateral malleolus, then posteriorly and proximally
3. Ends 2.5 cm posterior to the fibula, 5 cm proximal to the lateral malleolus tip
4. Incise fascia; retract peroneal tendons posteriorly - protect the lesser saphenous vein and sural nerve (posterior to incision)
5. For larger field: divide peroneal tendons by Z-plasty
6. Deepen distally; divide the calcaneofibular ligament to expose the subtalar joint
7. Divide talofibular ligaments and dislocate the ankle medially for full articular access

Disadvantage: Risk of skin sloughing at incision margins, especially if ankle dislocation is performed (e.g., talectomy). In most cases the anterolateral approach is preferred.

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5. Ollier Approach to the Tarsus

1. Skin incision begins over the dorsolateral aspect of the talonavicular joint
2. Extends obliquely inferoposteriorly, ending ~2.5 cm inferior to the lateral malleolus (see line C in figure below)
3. Divide the inferior extensor retinaculum in line with the incision
4. Superiorly: expose long extensor tendons and retract medially
5. Inferiorly: expose peroneal tendons and retract inferiorly
6. Divide the origin of extensor digitorum brevis to expose all three joints

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6. Transfibular Posterolateral Approach (Gatellier-Chastang)

1. Incision: 12 cm proximal to the lateral malleolus tip, along posterior margin of fibula, curving anteriorly 2.5-4 cm in line with peroneal tendons
2. Expose fibula supraperiosteally; incise peroneal retinacula sheaths; displace peroneal tendons anteriorly
3. If fibula is intact: osteotomize it 10 cm proximal to the lateral malleolus tip
4. Divide the interosseous membrane and anterior/posterior tibiofibular ligaments
5. Preserve the calcaneofibular and talofibular ligaments as a hinge
6. Rotate the distal fibula laterally on this ligament hinge to expose the posterior tibia and lateral ankle
7. Closure: Replace fibula; fix with transverse syndesmosis screw (overdrill fibula hole to allow compression). Dorsiflex ankle while tightening the screw (talar dome is wider anteriorly)

Key Precautions: In children with open physes - extra care to avoid fracture through the distal fibular physis. Always overdrill the fibula to get compression across the syndesmosis; failure causes mortise widening and arthrosis.

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7. Posterior Approach to the Ankle

1. Patient prone; 12-cm incision along the posterolateral border of the Achilles tendon down to its calcaneal insertion
2. Divide superficial and deep fasciae; divide the Achilles tendon by Z-plasty or retract it
3. Dissect through fat and areolar tissue to the posterior tibia, between the FHL and the peroneal tendons
4. Retract the flexor hallucis longus (FHL) medially - this exposes 2.5 cm of the distal tibia, posterior ankle joint, posterior talus, subtalar joint, and superior calcaneus
5. Keeping the dissection lateral to the FHL protects the posterior tibial vessels and tibial nerve (FHL acts as a barrier)
6. Alternative: split the Achilles tendon longitudinally (lower wound complication rate, equivalent exposure)

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8. Medial Approach to the Medial Malleolus

1. Curved incision along the anterior aspect of the medial malleolus, ending at the tip of the anterior colliculus
2. For associated talar fracture: apex posterior incision extending into an anteromedial talar approach
3. Identify and protect the saphenous nerve and greater saphenous vein
4. Incise through anteromedial joint capsule along the anterior border of the medial malleolus
5. Gently retract medial malleolus; irrigate and inspect the ankle joint; reduce and fix with plate or screws

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9. Transverse Medial Approach with Malleolar Osteotomy (Koenig-Schaefer)

1. Curved incision just proximal to the medial malleolus
2. Osteotomize the malleolus with an osteotome or power saw; preserve the deltoid ligament attachment
3. Subluxate the talus and malleolus laterally to expose all joint surfaces
4. Pre-drill screw holes before the osteotomy (simplifies replacement)
5. At closure: replace malleolus and fix with two screws using interfragmentary compression technique (prevents rotation)

Note: Not commonly used due to proximity of tibial vessels and nerve, and the transverse skin incision. The anterolateral approach is usually preferred.

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10. Medial Approach to the Posterior Tibia (Colonna-Ralston)

1. Begin 10 cm proximal and 2.5 cm posterior to the medial malleolus; curve inferior to the malleolus
2. Reflect capsule and periosteum
3. Retract the posterior tibial tendon, flexor digitorum longus, flexor hallucis longus, and neurovascular bundle posteriorly and medially
4. This exposes both the medial and posterior malleoli

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Anterolateral Osteotomy for Lateral Talar Dome Lesions (Tochigi)

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Key Nerves and Vessels at Risk - Summary

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Quick Reference: Choosing the Right Approach

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