Berdusco Randa, Louati Hakim, Desloges William, Papp Steven R, Pollock J Whitcomb
The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
JBJS Essent Surg Tech. 2015 Dec 23;5(4):e30. doi: 10.2106/JBJS.ST.N.00048.
In comparison with the frequently used modified Kocher approach, the extensor digitorum communis (EDC) splitting approach allows improved access to the anterior half of the radial head, which is most commonly fractured, while reducing the risk of iatrogenic injury to the lateral collateral ligament.
STEP 1 MAKE THE INCISION MODIFIED KOCHER APPROACH: Make an oblique 7-cm lateral incision beginning at the proximal edge of the lateral epicondyle and extending distally over the center of the radial head toward the posterior ulnar border of the extensor carpi ulnaris muscle belly.
STEP 2 DEVELOP THE INTERVAL BETWEEN THE ANCONEUS AND THE EXTENSOR CARPI ULNARIS: Identify and develop the intermuscular interval between the anconeus and the extensor carpi ulnaris.
STEP 3 PERFORM THE LATERAL ELBOW CAPSULOTOMY: Longitudinally incise the lateral elbow capsule and annular ligament anterior to the lateral ulnar collateral ligament.
STEP 4 THE EXTENDED MODIFIED KOCHER APPROACH: Extend the exposure by elevating the common extensor origin (extensor carpi radialis brevis, EDC, and extensor carpi ulnaris) proximally off the lateral epicondyle and reflect it anteriorly.
STEP 5 MAKE THE INCISION EDC SPLITTING APPROACH: Make a longitudinal oblique 5 to 6-cm lateral incision beginning at the proximal edge of the lateral epicondyle and extending distally over the radial head toward the Lister tubercle.
STEP 6 IDENTIFY AND SPLIT THE EDC: The EDC tendon is identified and bisected longitudinally starting proximally at its origin on the lateral epicondyle and extending 20 mm distally from the radiocapitellar joint.
STEP 7 PERFORM THE LATERAL ELBOW CAPSULOTOMY: The annular ligament and joint capsule are then incised collinear with the EDC split anterior to the equator of the capitellum.
STEP 8 EXTENDED EDC SPLITTING APPROACH: Extend the exposure by detaching the anterior half of the EDC tendon and the extensor carpi radialis brevis tendon from the lateral epicondyle.
STEP 9 LAYERED CLOSURE: Perform an interrupted layered closure.
In our recent cadaveric study, we quantitatively compared the modified Kocher and EDC splitting approaches in order to determine which provided the greatest exposure of the anterior aspect of the radial head, which is most commonly fractured.IndicationsContraindicationsPitfalls & Challenges.
与常用的改良Kocher入路相比，指总伸肌（EDC）劈开入路能更好地显露最常发生骨折的桡骨头前半部分，同时降低医源性损伤外侧副韧带的风险。
步骤1 做切口 改良Kocher入路：在外侧髁近端边缘做一个7厘米的斜行外侧切口，向远端延伸，越过桡骨头中心，朝向尺侧腕伸肌肌腹的后尺侧边界。
步骤2 分离肘肌与尺侧腕伸肌之间的间隙：识别并分离肘肌与尺侧腕伸肌之间的肌间隙。
步骤3 进行外侧肘关节囊切开术：在尺侧副韧带前方纵向切开外侧肘关节囊和环状韧带。
步骤4 改良Kocher入路的扩展：通过将共同伸肌起点（桡侧腕短伸肌、EDC和尺侧腕伸肌）从外侧髁近端抬起并向前翻转来扩大显露范围。
步骤5 做切口 EDC劈开入路：在外侧髁近端边缘做一个5至6厘米的纵向斜行外侧切口，向远端延伸，越过桡骨头朝向Lister结节。
步骤6 识别并劈开EDC：识别EDC肌腱，从其在外侧髁的起点开始向近端纵向二等分，并从桡骨头关节向远端延伸20毫米。
步骤7 进行外侧肘关节囊切开术：然后在肱骨小头赤道前方与EDC劈开线共线切开环状韧带和关节囊。
步骤8 扩展EDC劈开入路：通过将EDC肌腱的前半部分和桡侧腕短伸肌腱从外侧髁分离来扩大显露范围。
步骤9 分层缝合：进行间断分层缝合。
在我们最近的尸体研究中，我们对改良Kocher入路和EDC劈开入路进行了定量比较，以确定哪种入路能最大程度地显露最常发生骨折的桡骨头前侧。适应证 禁忌证 陷阱与挑战
