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Posttraumatic Elbow Stiffness
Lindenhovius, A.L.C.
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Citation for published version (APA):Lindenhovius, A. L. C. (2009). Posttraumatic Elbow Stiffness.
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PART I CURRENT ISSUES
30
Abstract
Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the
posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this
review of the literature, the biologic response to trauma and the possible etiologic events that
may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as
nonsurgical and surgical management of stiffness and expected outcomes of treatment.
Introduction
Stiffness of the elbow joint has long been recognized as a complication of elbow trauma.1-3
Hippocrates (400 BC) emphasized the importance of immediate reduction and recommended
immobilization in 90° of flexion: “an arm ankylosed in the extended position would be better
away for it would be of great hindrance and of little use to the patient”.4 Despite advances in
the management of injuries about the elbow, loss of elbow motion remains a common result.5-
7 restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-
consuming, and costly challenge. In this review of the literature, the biologic response to
trauma, the possible etiologic events that may lead to fibrosis of the capsules and heterotopic
ossification, nonsurgical and surgical management of stiffness, and expected outcomes of
treatment will be discussed.
Etiology
Loss of motion of the elbow is commonplace after elbow trauma.1,5-8 The etiology of
posttraumatic stiffness can be multifactorial and can include arthrosis9,10, heterotopic bone11-
13, or failure of fracture healing14-16 along with contracture of the soft tissues
around the elbow7. Why the elbow is so prone to contracture has been open to debate and
deserves further investigation. Regan and Reilly17 postulated 3 potential factors: (1) the
complex articular congruity and conformity of the elbow, (2) the brachialis muscle that covers
the anterior capsule, predisposing it to posttraumatic heterotopic ossification, and (3) the often
prolonged immobilization due to the difficult challenge of achieving stable fixation of
complex comminuted fractures.
Kay18 established a classification system of the stiff elbow based on the specific components
involved. According to his classification, type 1 involved soft tissue contracture; type 2, soft
tissue contracture with ossification; type 3, undisplaced articular fracture with soft tissue
contracture; type 4, displaced intra-articular fracture with soft tissue contracture; and type 5,
involved posttraumatic bony bars. Morrey9 classified stiffness on the basis of the anatomic
location of the contracture: intrinsic factors (intra-articular changes), extrinsic factors (extra-
articular changes), or a combination of the two. Intrinsic factors include intra-articular
adhesions, articular malalignment, loss of articular cartilage, or a multifaceted cause, whereas
LITERATURE REVIEW CHAPTER 2
31
extrinsic factors encompass contracture of the soft tissues (eg, the joint capsule or collateral
ligaments), heterotopic ossification, or extra-articular malunions. Because there is often more
than 1 anatomic structure involved, it is useful to use this classification. Mixed involvement is
most common (ie, extrinsic contractures will almost always have an intrinsic component).7
Most authors agree that prolonged immobilization can lead to capsular contracture19 and that
early active mobilization after the initial injury will be a factor in limiting residual stiffness.19-
21 Although several reports in the literature have described the beneficial effects of
manipulation therapy without exacerbation of heterotopic ossification22-25, there remains
some debate regarding the relationship of passive elbow mobilization and resultant
heterotopic ossification.21,26,27 We recommend that forceful and repeated manipulation of the
stiff elbow should be avoided as experimental models have shown the development of
heterotopic ossification under these circumstances27, yet gentle passive motion may be
indicated postoperatively11. In addition, multiple surgical interventions within the first weeks
after trauma11, thermal burns28,29, and associated head trauma30 have been suggested to
predispose for heterotopic ossification.
Soft Tissue Contracture
Pathophysiology
Contracture of the soft tissues around the elbow primarily concerns the capsule and the
ligaments. Animal models have demonstrated elevated numbers of myofibroblasts31,32 that
have highly contractile properties33 and increased proliferation of extracellular matrix34 in
experimentally induced contracture of knee and elbow capsules. In addition, increased
formation of collagen cross-links, together with decreased proteoglycan content and decreased
water content, may be characteristics of abnormal tissues in experimentally induced joint
contractures.35 All of the above may be related to the increased expression of transforming
growth factor beta (TGF-�) that was found in contracted rabbit elbow capsules.36 These
processes may result in scarring of the capsule by fibrosis with resultant contracture of the
joint.
It has been suggested that mechanical stimulation of injured periarticular structures, such as
may occur with efforts to gain or maintain motion, may contribute to tissue contracture37,38 by
an alteration in collagen synthesis.38 The medial collateral ligament may be prone to scarring
that results in stiffness because of the persistent stress it sustains as a consequence of the
carrying angle of the elbow.21 The exact mechanism that leads to contracture of the soft
tissues merits further investigation. Better understanding of the pathogenesis of the fibrotic
elbow capsule will potentially lead to more effective nonsurgical management of
posttraumatic stiff elbows in the future.
PART I CURRENT ISSUES
32
Heterotopic Ossification
Pathophysiology
Heterotopic ossification leading to loss of motion is uncommon after elbow trauma.26 When
associated with identified risk factors such as concomitant head trauma, the incidence
increases substantially.30 Heterotopic ossification is the inappropriate formation of mature
lamellar bone in soft tissues, which differs from the commonly seen periarticular
calcifications, in which amorphous calcium deposits form in soft tissues around the elbow
after injury.20,39 The formation of heterotopic bone is caused by pluripotential mesenchymal
stem cells that differentiate into osteoblasts (stimulated by, eg, trauma, surgery, or
inflammation), which produce osteoid40 that mineralizes into bone.41 This requires osteogenic
precursor cells, an inductive agent (most likely a growth factor), and an environment
conducive to osteogenesis.42 The heterotopic bone that subsequently develops is
histologically identical to native bone but is more metabolically active and does not have a
true periosteal layer.43
Prevention
Prevention of heterotopic ossification is based on 3 principles: (1) disrupting the signaling
pathways, (2) altering the relevant progenitor cells in the target tissue, and (3) modifying the
environment conducive to heterotopic osteogenesis.42 Anti-inflammatory drugs (for disruption
of inductive signal), preoperative irradiation (for disruption of responsive cells), and
postoperative etidronate (for disruption of conducive environment) may all have an inhibitive
effect.42
Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the enzyme cyclooxygenase, which is
needed for the production of prostaglandins. Lowering prostaglandin levels raises the
threshold for heterotopic ossification44, because the induction of heterotopic ossification is
stimulated by prostaglandins together with bone morphogenetic proteins45. The use of
nonselective NSAIDs, such as indomethacin, ibuprofen, and naproxen, have all been related
to reduced formation of heterotopic bone, in particular in the hip.46-50 Although frequently
used8,21,51-53, the role of NSAIDs in prevention of heterotopic ossification around the elbow is
unclear, and a comparative trial is needed54. The possible beneficial role of selective NSAIDs
that inhibit cyclooxygenase 255,56 is uncertain because of the associated risk of serious
cardiovascular side effects57. Diphosphonates that interfere with the calcification of osteoid
are also considered a poor choice, as rebound calcification is to be expected after
discontinuation58, and side effects include serious gastrointestinal complaints and
osteomalacia59. Gene therapy with BMP antagonists might offer some potential for future
treatment, as a preventive effect on the formation of heterotopic bone has been shown in an
experimental animal model.60
LITERATURE REVIEW CHAPTER 2
33
An alternative prophylaxis is the use of low-dose irradiation within 72 hours after the trauma
to alter the progenitor cells in the target tissue. Stem cells are particularly radiosensitive, and
irradiation prevents them from differentiating into osteoblasts.61 A possible inhibiting effect
on the formation of heterotopic bone has been described with doses ranging from 600 to 1,000
cGy.62-65 The prevalence of radiation-induced osteosarcoma is low in humans.66 In addition, in
a retrospective review of medical records from a period of 50 years, radiation-induced bone
sarcoma was not reported with doses of less than 3,000 cGy.67 High doses of sodium
etidronate may inhibit the angiogenesis needed for the mineralization of bone matrix and
thereby reduce ossification68,69 but are not recommended as they predispose to osteomalacia
and impair the ossification of normal bone.70
Malunions and Nonunions
Intra-articular and extra-articular malunions and nonunions of the distal humerus, proximal
ulna, and radial head may cause pain, instability, and severe limitation of elbow function.
Extra-articular malunions of the distal humerus
The lateral column of the distal humerus is curved anteriorly with the lateral epicondyle
translated anteriorly with respect to the humeral diaphysis, whereas the medial column and
medial epicondyle are more in line with the diaphysis. The use of straight plates on the lateral
column of the distal humerus may lead to loss of anterior translation of the articular surface of
the distal humerus. This can result in a smaller axis of rotation that causes less space for the
coronoid and muscles and soft tissues during elbow flexion.71 The use of precontoured plates
on the lateral column may be helpful to restore the original anatomy of the distal humerus and
thereby prevent malunion.72,73 Treatment of a distal humerus fracture in which there is
metaphyseal comminution may lead to shortening in spite of bridging the comminution. This
may cause loss of the fossae, which results in limited flexion and extension.71 In addition,
implants, scar tissue, fracture callus, and heterotopic bone may obstruct the coronoid, radial,
and olecranon fossae. In the treatment of elbow stiffness due to malunion of a distal humerus
fracture, the fossae should be cleared of heterotopic bone, scar tissue, and implants with a burr
used to deepen or enlarge the fossae, even to the point of creating a hole through the distal
humerus using the Kashiwagi technique.74 An extra-articular osteotomy with subsequent bone
grafting and internal fixation may be considered in the case of an unsuccessful capsular
release and debridement of fossae.
Intra-articular malunions
Malunion of intra-articular distal humerus fractures is commonly associated with loss of
motion.75-77 Malunited anterior shearing articular fractures may be treated with osteotomy
and capsular release to restore motion.75 Uneven articular surfaces with subsequent
PART I CURRENT ISSUES
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incongruency of the ulnotrochlear articulation can lead to stiffness and arthrosis. The
preservation of appropriate contact between the medial trochlea and the anteromedial facet of
the coronoid process and between the capitellum and the radial head is considered important
in maintaining a mobile joint.78 Malunited fractures of the radial head typically present as
forearm stiffness rather than ulnohumeral stiffness and radiocapitellar or radioulnar arthrosis78
and in most instances can be treated successfully by radial head resection.79,80
Arthrosis and stiffness after intra-articular fractures of the proximal ulna can be related to both
instability as well as joint incongruity.78 Adequate restoration of the normal anatomy of the
ulnotrochlear notch and the coronoid process is important to prevent arthrosis and instability
of the elbow.81-83 Lack of the coronoid as an anterior buttress can result in malalignment with
subsequent anterior subluxation of the distal humerus.78,84-86 Inadequacy of the coronoid is
difficult to treat.85,87 The use of an osteoarticular autograft or allograft may prove useful to
restore the coronoid84-86,88, particularly for small coronoid fractures that are part of a terrible
triad injury85.
Nonunions
Nonunion after intra-articular fractures of the distal humerus occurs usually at the
supracondylar level rather than at the intra-articular level.16,78,89 Nonunited distal humeral
fractures may lead to pain, instability, and stiffness, the latter in many patients caused by
motion occurring at the nonunion site16 with ankylosis or near-ankylosis of the joint itself.90,91
Intra-articular nonunions add to incongruity, increased articular adhesions, and presence of
malpositioned articular fragments that have limited blood supply.15,78 A combination of
debridement of the nonunion site, realignment and stable internal fixation, autogenous bone
grafting, elbow capsulectomy, and an intensive postoperative rehabilitation program have
been shown to result in improvements in union rate and elbow function.14-16,91-93 In the older
patients with limited demands, a total elbow arthroplasty may be considered. Epicondylar
nonunions may contribute to instability94, but motion usually is not an issue78.
Unstable nonunion of the proximal ulna is infrequently seen after olecranon fracture-
dislocations and posterior Monteggia fractures.95,96 As with distal humeral nonunions,
capsulectomy in conjunction with stable fixation of the nonunion may reduce stress on the
nonunion site and restore motion. If there is an additional nonunion of the coronoid process, it
may be internally fixed when the fragment is large and reconstructed when the fragment is
small or absent.78,84-88 Nonunion may also be the result of a neglected or inadequately treated
simple olecranon fracture95,97 or an ununited olecranon osteotomy96. Fortunately, significant
loss of motion is not common78,95,97, and an eventual surgical intervention would consist of
debridement, bone grafting, and internal fixation but may not be necessary in all patients78.
Recently, satisfactory results for treatment of olecranon nonunions during total elbow
arthroplasty were reported98.
LITERATURE REVIEW CHAPTER 2
35
Nonunions of nonsurgically treated (isolated) radial head fractures are uncommon99,100 and in
general cause little or no pain and usually do not interfere with motion99, therefore surgical
treatment of the nonunion may not be needed78,99. Nonunions of surgically treated radial head
fractures are usually caused by broken or loose implants and lead to restricted forearm
rotation and pain.101,102 Removal of radial head and implants usually relieves pain and restores
motion.101 In view of the fact that total elbow arthroplasty has the potential risk of loosening
over time as well as requiring marked limitation of function, it has been indicated primarily
for older patients whose major problem is a painful stiff elbow.9,103,104
Assessment
A functional arc needed to perform most basic daily activities is defined as an arc of flexion
from 30° to 130° and an arc of forearm rotation from 50° of pronation to 50° of supination.105
However, the functional impairment depends on the individual requirements of each
patient.106
It is important to understand the original injury and initial treatment as well as other
associated conditions such as neurologic dysfunction, infection, and ipsilateral limb
injury.106,107 In most cases, posttraumatic stiffness is not painful, especially at rest, and pain
usually is not present during flexion and extension. Pain with motion suggests the presence of
arthrosis and/or ulnar nerve dysfunction106, whereas patients with pain at rest and a history of
surgery are at risk for a lowgrade infection; therefore, laboratory studies should include a C-
reactive protein level and an erythrocyte sedimentation rate107. The elbow should be aspirated
prior to surgery if these values are abnormal and warmth or other evidence of inflammation is
present. The ulnar nerve is commonly involved in elbow trauma and deserves special attention
during the examination of the entire upper extremity.
Although anteroposterior and lateral radiographs are sufficient in most patients107, assessment
may be more complete with computed tomography (CT) scans65 and even more with 3-
dimensional CT scans, particularly when heterotopic bone is present11,53,106,108 (Fig. 1).
Although magnetic resonance imaging (MRI) defines the soft tissues around the elbow, it is
not considered useful in the evaluation of elbow contracture because it does not define the
heterotopic ossification and joint anatomy as well as CT imaging.20
Heterotopic ossification presents as local soft-tissue swelling, warmth and tenderness, easily
mistaken for infection, cellulitis, thrombophlebitis, tumor, or soft tissue (nonosseous)
calcification.20,39,42 The end points of motion become rigid or abrupt instead of compliant as
seen with some soft tissue contractures, and motion at the limits may be painful.20 Pain
through the central flexion arc suggests joint incongruity or degeneration of the ulnotrochlear
PART I CURRENT ISSUES
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Figure 1. (A–C) Three-dimensional reconstruction of CT scans clearly depict the heterotopic bone around the elbow which may be helpful for operative planning. (Images courtesy of David Ring, MD, PhD.)
joints or the radiocapitellar joint in the case of pain through the central arc of forearm
rotation.20 Heterotopic ossification can manifest from 2 to 12 weeks after the inciting event
(trauma, surgery, burn, or neurologic insult).109 The maturity of the heterotopic bone as well as
the time since onset is important for the timing of eventual surgical intervention. Technetium-
99m bone scans are no longer used to evaluate bone metabolic activity, because they do not
provide useful prognostic information.39,65 The progression of heterotopic ossification should
be evaluated radiographically; a cloudy periarticular density may be seen within several
weeks after injury and subsequent maturity is indicated by smooth, well-demarcated cortical
margins and defined trabecular markings20, generally about 3 to 6 months after its
appearance7,39. Although early excision of heterotopic bone was not recommended because
this was thought to predispose to recurrence110, most authors do now agree that surgical
excision can safely proceed as soon as maturity is seen radiographically65,106,111,112.
Advantages of early resection include minimizing capsular and ligamentous contracture,
muscle atrophy, and cartilage degeneration, and allowing a more rapid functional recovery53.
In skeletally immature individuals, nonbridging heterotopic bone may resorb over time,
therefore it may be wise to wait longer in children.20
The classification system of Hastings and Graham113 is useful for clinical assessment,
treatment, and operative planning. Class I represents heterotopic ossification not causing
functional limitation and is therefore clinically insignificant, although prophylactic treatment
may be considered. Patients with class II heterotopic bone have a functional limitation of
motion: class IIA represents ulnohumeral limitation less than a (100°) flexion arc from 30° to
130°, class IIB concerns limitation of forearm rotation less than a (100°) arc from 50°
pronation to 50° supination, and class IIC concerns heterotopic bone causing limitation in
both planes. Patients with class III heterotopic ossification have ankylosis that prevents either
C B A
LITERATURE REVIEW CHAPTER 2
37
ulnohumeral motion, forearm rotation, or both. It may be useful to subclassify class III
according to the planes of limited motion: class IIIA no ulnohumeral motion, class IIIB no
forearm rotation, and class IIIC no motion in either direction.20
Heterotopic bone was traditionally considered a complicating factor for surgical release and
associated with poor outcomes, in particular in presence of a complete bony bridge.114-116
However, more recent studies have suggested that patients with nonbridging heterotopic
ossification that complicates capsular contracture may regain even more motion after surgical
release than patients with a capsular contracture alone.8,21
Nonsurgical Treatment
If posttraumatic stiffness develops in spite of precautionary measures such as early active
motion, it has the potential for successful nonsurgical treatment. Regaining joint motion in the
most time-efficient manner is critical for return to function, control of rehabilitation costs,
and to prevent the need for additional surgery.
The use of turnbuckle-like splints to restore motion of the posttraumatic stiff elbow was
described in the Medieval era by the German surgeon Hans von Gersdorff (1455–1529)3 (Fig.
2). Today, adjunctive splinting devices are still added to the traditional rehabilitation program
and may help to prevent the need for surgical intervention. Splints are especially effective in
patients with contractures of relatively short duration and little articular involvement.19
Satisfactory restoration of motion with use of static progressive turnbuckle splints (that apply
a static stress relaxation force to the elbow tissues, which is sequentially increased as motion
is achieved) has been described in several studies.117-121 Dynamic splints that apply a constant
prolonged force to the tissues as additional motion is achieved are a popular alternative with
satisfactory results reported.21,122-124
Surgical Treatment
If nonsurgical treatment fails to restore a functional arc of motion, surgical treatment may be
considered.8,19,106,125,126 Traditionally, surgery has been offered to patients with flexion
contractures or extension contractures of at least 30°. However, the justification of surgical
intervention is highly individualized, and the patient’s needs and the ability of the surgeon to
realize these expectations should be considered, with a mutual assessment of risks and
benefits of the intervention.20,64,107 There should be radiographic union of the fractures, and
the patient must have the ability and motivation to complete a rigorous and prolonged
postoperative elbow rehabilitation program.20,64,127
Surgical release of the elbow has proved to be an effective way to restore motion, both with
an open procedure5,8,9,19,21,52,125,126,128-142 and after arthroscopic release143-151. Good functional
results after an open release for posttraumatic stiffness have been described in several case
PART I CURRENT ISSUES
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Figure 2. The mechanism of the “Instrument zu dem Krume Arm” (“Instrument for the crooked arm”) that was recommended by the German surgeon Hans von Gersdorff in 1517 to address elbow stiffness is the same as that of today’s static progressive turnbuckle splints. (Reproduced from von Gersdorff, H. Feldtbuch der Wundartzney. 1st ed. Strassburg: Getruckt durch Joanne Schott, 1517.)
LITERATURE REVIEW CHAPTER 2
39
series5,8,9,19,21,52,125,126,128-142, with an average minimal improvement in ulnohumeral motion
from 21° up to a maximum average improvement of 66°.9,21
Results of arthroscopic release have been reported less widely, and only few papers143-145,148
report results for posttraumatic stiffness separately from those for stiffness originating from
other causes. In the ones that do report results separately143-145,148 average improvements from
29°145 up to 70°144 have been reported. Although the safety of arthroscopy is still being
studied, in particular with regard to iatrogenic nerve damage, the application of this approach
may be extended to even the most severe contractures. The choice between both techniques
depends on the extent of the pathology and the experience of the surgeon.107 The need for
articular reconstruction, as is usual after an intra-articular fracture, is an indication for open
release, because articular involvement makes an arthroscopic release more difficult. In
addition, previous anterior transposition of the ulnar nerve may preclude use of the
anteromedial portal and as a consequence be a contraindication for arthroscopic release.152,153
Other treatment modalities include an interposition arthroplasty when extensive loss of the
articular surface is present, especially in younger patients.9,89,103,107,154-158 In older patients with
very stiff or ankylosed elbows with extensive articular involvement, a total elbow arthroplasty
may be considered.89,107,155,157
A young age9,136 and arthrosis19 have been associated with less favorable outcomes after a
contracture release, whereas patients with heterotopic ossification due to burns or head injury
seem to have better functional outcomes8,53. However, Bae and Waters139 reported results of
contracture release in adolescents that were virtually similar to those reported for adults. The
timing of surgery has also been associated with the outcomes. The longer the intervention is
delayed, the more contracted muscles and tendons become the articular cartilage may also
suffer, particularly when there is complete ankylosis of the elbow.53 Therefore, patients should
preferably be treated within 1 year after onset of stiffness, as better functional results may be
expected then.21,51,53
Open Contracture Release
Depending on the plane of elbow contracture, the location of previous elbow incisions, the
need for nerve decompression, and the location and extent of heterotopic ossification, the
surgeon can choose between medial, lateral, and anterior approaches. Either a posterior
midline incision or separate medial and lateral incisions will permit both posteromedial and
posterolateral arthrotomies and access to the ulnar nerve and anterior elbow via deep lateral
and medial approaches.7 Separate medial and/or lateral skin incisions may be useful to avoid
skin flap devascularization in the case of previous incisions or if there is concern about the
integrity of the soft tissue covering the elbow. Avoidance of injury to the median, radial,
posterior interosseous, and ulnar nerves is of utmost importance.64
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Good results have been described with use of a lateral approach8,51,52,125,126, often referred to
as the lateral column procedure8,159. It is a highly versatile approach, although the ulnar nerve
will often need to be exposed on the medial side to ensure its safety. The lateral column
procedure may be used to address extrinsic contracture of the anterior and posterior capsules
with articular involvement of the radiohumeral joint.8 If articular involvement requires
attention to structures other than the radiohumeral joint, this exposure is inadequate.107,159
A medial approach may be used to address limited medial articular pathology with
involvement of the ulnar nerve, presence of heterotopic bone on the medial side, and
ossification or deficiency of the medial collateral ligament (MCL).107,133 Although an
advantage of this approach is the direct view on the ulnar nerve, a drawback is that the radial
nerve is at risk at the depth of exposure on the far side anteriorly. The median nerve is farther
away from the capsule than the radial nerve.160 This limited exposure may not be effective
when there is articular involvement.107
An anterior approach, which has been reported in several articles19,132,142 for the correction of
flexion contractures, has only very limited indications and may only be used for an isolated
flexion contracture with normal full flexion and no evidence of bony abnormalities at the
olecranon or in the olecranon fossa. Neurovascular structures are at risk when using the
anterior approach19,125,126, and an additional posterior release may frequently be needed132,136.
Regardless of the approach that is used, every attempt is made to preserve the lateral collateral
ligaments and the anterior oblique band of the MCL.20,21,133 This greatly facilitates
rehabilitation and virtually eliminates the potential for postoperative instability. Only in long-
standing and very severe cases may a partial release of the anterior oblique band of the MCL
and the lateral collateral ligaments be indicated.18
The most common complications of open contracture release include neuropathies, infection,
and recurrence of elbow stiffness and/or heterotopic bone.1,8,12,19,20,52,53,125,127,128,132,134,
135,137,138,142
Lateral column procedure
Either a lateral or midline posterior incision is used, fasciocutaneous flaps are elevated and
started proximally, and the lateral supracondylar ridge of the humerus is exposed by
reflecting the extensor carpi radialis longus (ECRL) anteriorly off the humerus and the triceps
off the humerus posteriorly.159 The dissection is continued for 2 to 3 cm distally through the
common extensor tendon from the epicondyle in a line toward Lister’s tubercle. This
generally passes in the interval between the ECRL and the extensor carpi radialis brevis
(ECRB), along the anterior edge of the extensor digitorum communis. The entire anterior soft
tissues are then reflected anteriorly off the capsule, which can then be excised. The release
should continue right to the level of the collateral ligaments. The coronoid and radial fossae
are cleaned, and spurs and loose bodies are removed. On the posterior side of the elbow, the
LITERATURE REVIEW CHAPTER 2
41
triceps is reflected posteriorly from the distal humerus and dissected off the capsule. The
capsule is elevated from the humerus, and the olecranon fossa is cleared of spurs and loose
bodies. When dissecting medially, it is safe to expose the ulnar nerve through a separate
medial exposure (by raising the medial skin flap). The nerve runs along the medial border of
the triceps adjacent to the intermuscular septum. It is exposed by following the plane of
dissection under the triceps medially to the intermuscular septum, just proximal to the elbow,
then exposing between the septum and the triceps. The nerve can then be exposed along its
course and retracted while the capsule and scar are excised with the nerve in direct view.
Although this approach is quick and obviates a medial skin flap or separate medial incision,
the ulnar nerve may frequently need to be transposed anteriorly to prevent delayed onset of
ulnar neuropathy by compression of the nerve in the cubital tunnel (Fig. 3).52,161
Figure 3. A lateral approach may be used to address extrinsic contracture of the anterior and posterior capsules with intrinsic involvement of the radiocapitellar joint. (A) A lateral interval is identified between the triceps posteriorly and the ECRL anteriorly, and dissection continues 2–3 cm distally. (B) The anterior soft tissues are reflected off the capsule, which can then be excised. (C) The release of the anterior capsule continues to the level of the medial collateral ligaments. Radial and coronoid fossae are cleaned, and spurs and loose bodies are removed. (D) Subsequently, the triceps is reflected posteriorly from the distal humerus and dissected off the capsule. The capsule is elevated from the humerus, and the olecranon fossa is cleared out. (Reproduced with permission from the Mayo Foundation.)
A B
C D
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Medial column approach
The medial column approach162 is conceptually similar to the lateral column procedure. The
medial antebrachial cutaneous nerve is protected and the ulnar nerve is freed up and
transposed anteriorly. The anterior half of the origin of the flexor pronator muscles are
reflected from the medial supracondylar ridge. From there, the common flexor-pronator
tendon is split longitudinally for 2 cm distally. The brachialis and the anterior portion of the
flexor-pronator group are dissected subperiosteally off the anterior humerus and capsule from
proximal to distal. The capsule can then be excised. If there is concern about the safety of the
radial nerve, a separate limited exposure can be made on the lateral side as described above to
resect the lateral capsule under direct vision. The posterior release from the medial side is
identical to that decribed for the lateral column procedure, except that the ulnar nerve must be
first transposed. If there is difficulty to release the posterolateral capsule to restore adequate
flexion, a separate lateral exposure may be required (Fig. 4).
Figure 4. A medial approach may be used to address medial articular pathology with involvement of the ulnar nerve, heterotopic ossification on the medial side, and ossification or deficiency of the MCL. The ulnar nerve is at direct view using this approach. It is conceptually similar to the lateral approach. The anterior half of the origin of the the flexor pronator muscles are reflected from the medial supracondylar ridge, and from there, the common flexor-pronator is split for 2 cm distally. The brachialis and the anterior portion of the flexor-pronator group are dissected subperiostally off the humerus and the capsule. The capsule can then be excised. (Reproduced with permission from the Mayo Foundation.)
Anterior approach19,132
A curvilinear anterior skin incision is used, starting proximally at the lateral side and
continuing distally on the medial side. The structures in the anterior aspect of the elbow are
exposed, taking care to protect the medial and lateral antebrachial cutaneous nerves. The
brachial artery is identified and protected together with the median, radial, and
musculocutaneous nerves. Starting medially, an interval between the flexor muscle origin and
the biceps tendon is developed. Using a blunt retractor, the brachialis muscle is dissected from
the joint capsule. A curved clamp is then passed from medial to lateral in the interval between
LITERATURE REVIEW CHAPTER 2
43
the brachialis muscle and the capsule. The interval between the biceps tendon and the
brachioradialis is then exposed, and the interval between the brachialis and the capsule is
further developed by blunt dissection. Placing a retractor deep to the brachialis allows direct
visualization of the entire anterior capsule, which can then be excised entirely.132 Sometimes,
sharp release of the brachialis may be needed to increase extension. The wound is closed over
suction drains and a bulky dressing and plaster splint are applied.
Heterotopic bone
Surgical resection of heterotopic bone is only indicated when the bone blocks motion39 and is
a technically challenging procedure20. Anterior heterotopic bone most commonly forms
beneath the brachialis muscle and is not continuous with the anterior articular surface. For
resection of anteriorly located heterotopic bone, a medial, lateral, or combined medial and
lateral approach65 may be chosen. In case of extensive anterolateral ossification, it is
important to identify the radial nerve and the posterior interosseous nerve. The median nerve
is most commonly protected by the brachialis muscle. Motion-limiting heterotopic bone in the
region of the proximal radioulnar joint requires special attention. The normal cortices of the
proximal forearm bones need to be defined, and iatrogenic injury to the lesser sigmoid notch
of the proximal ulna should be avoided. Posterior heterotopic bone is often in continuity with
the joint, beneath the triceps, and most commonly leads to ankylosis.39 Resection of
posteriorly located heterotopic bone requires elevation of the triceps from the olecranon. If
there is posteromedial involvement, extra attention should be paid to the ulnar nerve. After the
resection of the heterotopic bone, the surgeon continues with the elbow capsular release as
described above.
Complete bony ankylosis is a uniquely challenging problem, because the joint may be entirely
encased in bone.64,163 The capsule is usually distinct from the heterotopic bone anteriorly but
not posteriorly. It may be difficult to identify the junction between the heterotopic bone and
the original articular anatomy. An osteotome is used to resect the heterotopic bone in layers,
until the joint is encountered; quick and sharp blows with the osteotome will usually separate
the heterotopic bone from the underlying host bone along the anatomic planes. Some gentle
manipulation is needed intraoperatively. Because of the risk of an iatrogenic fracture, this
must be performed with great care. The limited force (applied with 2 fingers) is placed close
to the elbow. A hinged external fixator may be considered when there is a tendency for the
elbow to subluxate or dislocate after excision.64 Synostosis that is limited to the radial head or
neck level may best be treated with radial head resection.20 Results of resection of a proximal
radioulnar synostosis112,114,115 and complete bony ankylosis12,164 are not as promising as are
the results of excision of nonbridging heterotopic bone.
PART I CURRENT ISSUES
44
Arthroscopic Contracture Release
Only a small number of retrospective case series have been published over the past
decades.143-150 At the present time, arthroscopic release is best indicated in limited
contractures without complicating factors such as the presence of heterotopic bone or
neuropathies. Arthroscopic release of the stiff elbow should only be performed by surgeons
with a high level of experience and training. In spite of difficulties and risks that are
associated with arthroscopy, indications and techniques are evolving rapidly. A factor that
complicates the procedure is the limited intra-articular volume capacity that results from the
capsular contracture.165,166 This can obscure access and visualization of the joint145 and puts
the neurovascular structures at risk for iatrogenic injury by instruments165. Surgeons should
therefore be aware of the special techniques that are being developed when using the
arthroscopic approach to address stiff elbows. Some authors106,167 recommend the use of
retractors in the joint to facilitate the arthroscopic release of the capsule. This will add to
visualization and may permit more complex contractures to be addressed safely, without
damage to nerves. The surgeon may have to use multiple portals for the scope, shaver/cutter,
and the retractors.
Release of the posterior capsule168
A view is established (with the scope in the posterolateral portal and the shaver in the
posterior portal, or the scope in the direct midlateral and/or the shaver in the posterolateral
portal) by debriding the olecranon fossa. The capsule is elevated from the distal humerus with
use of a shaver or periosteal elevator, which further
increases the working space. A retractor may be used to maintain this space. In case of
synovitis, a synovectomy is performed. Osteophytes and loose bodies are removed, and
subsequently the posterolateral capsule is resected with a shaver or radiofrequency ablation
device, which is most easily done through the posterolateral portal. If there remains a lack of
flexion, the posteromedial capsule is released as well, and if needed, the posterior band of the
MCL may also be released. Given the anatomic location of this band near the cubital tunnel,
the ulnar nerve is at significant risk when this release is performed. Identification of the ulnar
nerve (arthroscopically or through a small incision167) during the posteromedial release is
paramount, retractors should be used, and release should be performed along the olecranon as
the nerve is closer to the medial epicondyle than to the olecranon. Eventually, the ulnar nerve
may be fully exposed or transposed during or prior to the release.
Anterior capsule release168
The first step, assessing the joint cavity, may be the most challenging part of the procedure.
Three anterior portals are established, starting with the scope and shaver in the anterolateral
and proximal anteromedial portals169-172 and a retractor in the proximal anterolateral portal. If
LITERATURE REVIEW CHAPTER 2
45
needed, a second retractor can be inserted through the anteromedial portal.106 The next step is
to create a view and to establish a working space. This involves identifying a sufficient
amount of normal articular anatomy to permit orientation and then stripping the capsule off
the humerus and supracondylar ridges. A synovectomy is performed and the capsule is
debrided. Loose bodies and osteophytes are removed, and abnormal bone is recontoured. The
capsule is now clearly delineated as a structure before it is cut. The capsule is divided from
medial to lateral with a wide-mouthed duckbill punch, as the plane of dissection between the
capsule and the brachialis muscle is more distinct on the medial side. The capsulotomy is
continued down to the level of the collateral ligaments on each side, and then the
capsulectomy is performed on the medial side, extending from proximal to distal. The final
step is the proximal and distal excision of the lateral capsule. During this part of the
procedure, the radial nerve, located just anterior from the radial head and between the
brachialis and ECRB, is unprotected and at risk (Fig. 5). The efficacy of the procedure may be
dependent on the completeness of the capsular excision.106
Figure 5. Transverse section of a normal elbow before and after distention. Capsular distention places the nerves away from surgical instruments in the normal elbow. In the stiff elbow, the capsular compliance is limited, and particularly the radial nerve is at risk for iatrogenic injury. (Reproduced with permission from Chantal Lichaa O’Driscoll.)
Interposition Arthroplasty
Whereas total elbow replacement may be a viable option to restore motion and relieve pain in
the older and less active patient with severely damaged articular surface89,107,155, interposition
arthroplasty may be indicated to restore function and relieve pain in younger and more active
PART I CURRENT ISSUES
46
patients, withstanding the functional demands.17,154,156,158,173,174 The goal of interposition
arthroplasty is to preserve functional stability and to reduce the likelihood of reankylosis by
interposing a substance between the resected bone ends.174 Resurfacing materials may include
autologous fascia lata from the thigh, autologous skin, or an allograft such as an Achilles’
tendon.156,158,173,175
When the ulnar nerve is symptomatic, a medial interval may be chosen.156,176 Otherwise, a
lateral interval is used. A posterior skin incision or previous incision may be used followed by
development of a Kocher’s interval between anconeus and extensor carpi ulnaris. The origins
of the common extensor muscle mass and the lateral ligament complex are released from their
origin on the humerus. The anterior and posterior ligaments and capsules are excised. The
radial head is preserved if forearm rotation is painless. A burr is used to remove a small
amount of bone to contour the articular surfaces of the distal humerus and ulna; this
accommodates the Achilles’ tendon allograft
and concentric fluid joint motion. However, the medial and lateral trochlear ridges should be
left intact, as these add to the inherent stability of the elbow.177 Drill holes are placed from
posterior to anterior in the distal humerus. The graft is contoured the size of the distal humerus
and draped over the trochlea and capitellum, and sutures are placed through the drill holes to
secure the graft.9,174 Ligaments are repaired; this may be done with suture anchors or excess
graft if Achilles’ tendon was used. When an articulated external fixator is applied, only a
minimal amount of bone needs to be resected, which helps prevent instability.158,178,179 The
triceps is reattached, and the interval is closed.
Few articles describe the outcome of interposition arthroplasty. Results have been reported
with various success for inflammatory158,178 and (post)traumatic conditions.9,103,158,176 Elbow
instability is associated with a poor outcome.103,158,176 Complications may include bone
resorption, nerve dysfunction, heterotopic ossification, triceps rupture, instability, infection,
seroma formation at the fascial donor graft site, and long-term failure.158,173,174 In cases of
failed interposition arthroplasty, later revision to a total elbow arthroplasty may result in a
satisfactory end result.158,180
Total Elbow Arthroplasty
Total joint replacement can be a salvage procedure for very stiff or ankylosed elbows with
considerable articular involvement in the older and less active patient, especially if there are
no other treatment options available anymore.89,107,155 Patients should have reasonable
expectations and be able to comply with an intensive postoperative rehabilitation program.6 In
elbows with posttraumatic contracture, which are often complicated by deficient bone stock,
deformity, and capsuloligamentous instability, linked designs are usually
recommended.6,10,107,155,157,177,181,182 These semiconstrained hinge devices are thought to limit
LITERATURE REVIEW CHAPTER 2
47
excessive loading of the bone-cement interface by allowing soft tissues to absorb some of the
forces.183
The technique is challenging and, in the case that no triceps-sparing approach is used, the
reattachment of the triceps is crucial. Specific techniques depend on the implants that are
used, presence of previous incisions, and the surgeon’s preference.184 However, in all cases,
the ulnar nerve should be identified, released from surrounding scar and soft tissue, and
eventually transposed.107,155,157,181,185 Aggressive soft tissue release that involves the collateral
ligaments, and posterior and anterior capsules, and often includes the origins of the common
flexors and extensors, is needed to balance soft tissue distortion of the joints.107,157 Adequate
bone may need to be resected to optimize the outcome; if there is complete osseous ankylosis,
the joint line may be established with a sagittal microsaw or small osteotome to create a space
as close to the center of rotation of the ulnohumeral joint as possible to offer the best
biomechanical and functional condition for the implant.157 In addition, it may be needed to
resect the radial head and heterotopic bone and to re-create an adequate medullary canal with
use of a small burr.157,184
Although preoperative presence of heterotopic bone157 and deformity10 have been associated
with a less favorable outcome, total elbow replacement for the treatment of posttraumatic
arthritis is associated with substantial functional improvement and pain relief in most
cases6,10,155,186,187. However, complications such as ulnar nerve dysfunction, mechanical
failure, loosening, infection, triceps disruption, and fracture (particularly in older women188)
may be seen frequently and result in the need for revision surgery and eventual unsatisfactory
outcomes6,10,98,155,157,186-201. Some of these complications157 may be attributed to the stress that
components are exposed to (which may depend on the activity level of patients with
posttraumatic arthritis187) and the typically high number of previous surgeries that patients
with posttraumatic arthritis have undergone10,190, which increases the risk for wound
complications or infection187,197,200.
Postoperative Management and Rehabilitation
Although the rehabilitation program for each of the surgical procedures has its unique
features, the postoperative management should be aimed at (1) restoring a functional arc of
motion, (2) regaining muscle power, and (3) reincorporating the limb into functional
activities.177 Most authors start mobilization of the elbow within 2 days after an open
contracture release8,51,52,64,65,125,126,128,133,134,137,202, which may be enhanced
by sufficient pain control8,125,127,132,202,203. Continuous passive motion (CPM) is used by many
authors5,8,9,51,52,125,132,134,135,142,203,204. However, there have been only 2 studies that investigated
the role of CPM in the postoperative management of operative elbow release, one of these
presumably being an extended follow-up of the other with new patients added.132,142 In both
studies, patients had a release for extension loss. In the first study142, a significant greater
PART I CURRENT ISSUES
48
improvement in flexion (and not extension) was found in patients that used CPM compared
with the control group that did not use CPM. This study may have been somewhat biased, as
some of the patients that were treated with CPM had had a more extensive release than did
patients in the other cohort. In addition, patients in the control group were not mobilized until
10 days postoperatively. In the second study132, a significant greater ulnohumeral arc was
found in patients that used CPM. In this study, it was not specified after how many days the
patients in the control group were mobilized. Patients in the cohort that used CPM had
substantially stiffer elbows preoperatively than did patients in the control group. A potential
advantage of CPM would be that it can be used to flex and extend the elbow until the
extremes of motion that were achieved in the operating room are reached. On the other hand,
there has been concern about the formation or recurrence of heterotopic ossification after
forceful manipulation of the elbow21,27, as described above. At our institution, CPM is
prescribed according to the preference of the treating surgeon.64 Continuous passive motion
should not be used if reconstruction of the ligaments was performed.205 Further research
should define the role of CPM in the postoperative management after elbow contracture
release.
Aggressive rehabilitation should be continued at least until no additional gains in motion are
made. A static progressive turnbuckle splint8,9,65,107,119,128,203,206 or a dynamic splint21,52,65,125
may be very helpful to restore a functional arc of motion. Some authors recommend the use of
NSAIDs52 or low-dose irradiation8,21,51,113 postoperatively to prevent recurrence of heterotopic
bone.
When an interposition arthroplasty is performed, motion may be started early. The external
fixator is removed under anesthesia after about 6 to 8 weeks with examination to determine
motion and stability. Gentle manipulation may be performed after removal of the external
fixator. In patients who had a total elbow arthroplasty, the rehabilitation program depends on
the implant that was used, the status of the triceps tendon, the stability as assessed in the
operating room, and the status of the ulnar nerve.182 In patients that have a linked prosthesis,
as is usually the case in the treatment of posttraumatic stiffness, the elbow is rarely unstable.
Regardless of the type of prosthesis, however, all patients will have to comply with guidelines
for upper-limb restrictions (for instance, a 5-lb lifetime weight limit for lifting).182 Gentle
passive stretching may begin for both flexion and extension after about 6 weeks, and gentle
strengthening exercises may be begun after 10 weeks, particularly addressing the triceps. If
the triceps was reflected and reattached during surgery, triceps contraction should be avoided
for 1 month. If the ulnar nerve was not transposed, compression of the nerve during flexion
should be avoided.182 Static progressive or dynamic splinting is rarely indicated after a total
elbow arthroplasty. Return to full activity may be indicated after 12 weeks.
In spite of the lack of knowledge about the pathology underlying the causes of posttraumatic
elbow stiffness, the pessimistic attitude toward surgical intervention for stiff elbow that
LITERATURE REVIEW CHAPTER 2
49
dominated the orthopedic literature of the 20th century has turned more optimistic over the
past 2 decades by the introduction of challenging but relatively safe and effective procedures
to restore elbow function. Heterotopic bone can successfully be resected with only little risk
for complications and good functional outcomes, unless there is complete ankylosis of the
elbow or synostosis of the proximal radioulnar joint.
References
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