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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.


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


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


34

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.


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


36

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


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


38

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.)


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


40

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


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


42

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


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.


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


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


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


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


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


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.

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