Introduction

Surgical release of posttraumatic stiff elbows was rarely performed until approximately 15–20 years ago, as the procedure was generally considered to be ineffective in restoring motion. However, following numerous reports of successful results^1–31 arthrolysis is now regarded as a reliable, rewarding, evidence-based operation with low risk of complications. The results in the recent literature^12–31 are broadly similar, reporting that elbow motion improves in nearly all patients, with a mean gain of 52° (Table 29.1), and that the majority achieve the functional arc of 30–130°. The key principles common to nearly all papers were achievement of as much movement as possible at surgery, and early motion postoperatively which required adequate pain control (Fig. 29.1).

Figure 29.1 Successful arthrolysis – based on obtaining as much motion as possible intraoperatively (ideally full) and maintaining movement postoperatively, which relies on good postoperative pain relief.

Controversy still remains regarding what constitutes optimal management, as a wide variety of different operative procedures and postoperative regimens have been described.^1–34 These surgical techniques range from arthroscopic procedures, through increasingly extensive open releases up to requiring a dynamic external fixator to provide stability. Postoperative passive stretching with manipulation³⁵ or splinting³⁶ is often advocated, but may be counter-productive if painful. This chapter gives an overview of the current situation, and proposes a new surgical guide to aid with the management of stiff elbows.

Background/aetiology

Restriction of movement after injury is common and is usually directly proportional to the severity of the trauma, although it can occur even after a relatively minor event. The capsule and often ligaments are contracted in a posttraumatic stiff elbow, although the muscles, fascia and skin are rarely involved. Bony bridging of the joint occasionally occurs, especially after a head injury. The majority of elbows undergoing arthrolysis have had prior surgery for displaced intra-articular fractures, which are also prone to stiffness even after anatomical reduction and stable internal fixation. In addition to soft tissue contracture, the presence of bony impingement, intra-articular adhesions and/or deformity may limit elbow motion. Finally, the ulnar nerve is vulnerable to injury given its subcutaneous position at the elbow, and ulnar neuropathy may result from compression or scarring following the initial trauma or subsequent surgery.

Presentation, investigation and treatment options

Open arthrolysis is indicated for patients with a functional deficit due to significant elbow stiffness which has failed to improve over a 6–9-month period. Usually, the restriction is less than 120° of flexion and greater than a 40° flexion contracture, and/or 50° restriction of forearm rotation. However, some can cope satisfactorily with considerably less movement than the ‘functional arc’ of 30–130°,³⁷ especially in the non-dominant arm. Occasionally and conversely, a patient may be unable to perform certain activities at work or sport despite relatively mild restriction of motion.

The decision to proceed to arthrolysis must be made on an individual basis, with clarity regarding the aims of surgery and the likelihood of meeting the patient’s expectations. A summary of the indications for arthrolysis is given in Box 29.1. Factors such as a major head injury, contralateral upper limb and multiple injuries, as well as burns and prolonged artificial ventilation have a detrimental effect on outcome, whether or not surgery is undertaken.²⁰

Examination

Careful observation of the posture and spontaneous use of the elbow, as well as noting any deformity, muscle wasting, scarring, prominent metalwork or inflammation is essential. Rarely, extensive scarring in the antecubital fossa may tighten on extension restricting movement. Active heterotopic ossification may produce inflammatory signs.

Palpation is especially useful at the elbow to localize problems, as the joint is largely subcutaneous. Pathology of the ulnar nerve, radiocapitellar joint and posterior compartment with the olecranon engaging in the fossa, as well as prominent metalwork or abnormal bone, is readily identified.

The ROM should be accurately measured and recorded at each visit in a standard fashion, ideally by the same examiner, as failure of progression on serial measurements can then be identified and arthrolysis considered. Measurements of flexion and extension are standardized by using a long-arm goniometer centred over the lateral epicondyle, giving an acceptable error of 10°.³⁹ Restriction of active and passive ROM to the same degree is the hallmark of bony impingement. A hard endpoint indicates a bony block, while a soft endpoint is more likely to be due to a soft tissue contracture. Impingement pain at the extremes of motion is the most common finding, with significant mid-range pain being unusual, even if articular damage exists. Supination and pronation must also be recorded.

Pain and/or crepitus due to radiocapitellar arthritis are usually the result of a previous radial head fracture and are reliably elicited with the ‘grip and grind’ test. This is performed with the patient applying an axial load by gripping while rotating their forearm, thus loading the radiocapitellar joint (Fig. 29.2). A positive test reproducing the patient’s symptoms indicates that surgery to the radial head will be required.

Figure 29.2 Positive grip and grind test. Pain at the radiocapitellar joint elicted by axial loading with patient gripping while rotating their forearm.

Careful examination of the ulnar nerve is essential, especially as pain due to ulnar neuropathy may be limited to the medial aspect of the elbow and forearm. Mild intrinsic muscle wasting and sensory dysfunction can easily be overlooked if they are not specifically sought. Tenderness, especially at the entrance of the cubital tunnel with a positive Tinel’s sign indicates compression and tethering due to scar tissue and may give pain on movement. Subtle weakness will only be elicited by detailed examination of the intrinsic muscles of the hand.

Investigation

Surgical treatment options

Several surgical options are available apart from open arthrolysis.

Arthroscopic arthrolysis

Arthroscopic arthrolysis is described in Chapter 30. Advocates of this method point out that statistically significant improvement in ROM can be safely achieved by this technique,^33,34 facilitating early mobilization and discharge.³² Arthroscopic techniques, are however, more difficult in cases of severe contracture or where previous surgeries have been undertaken, particularly when there is internal fixation in situ. The ulnar nerve may also be affected requiring decompression/transposition. In addition patients with significant flexion loss may require release of the posterior bundle of medial collateral ligament which cannot be achieved arthroscopically.³¹ Finally, incongruous joint surfaces with extensive intra-articular adhesions may require a complete lateral ligament complex/extensor origin release to be able to separate the joint surfaces with supination giving an adequate exposure for satisfactory correction. Arthroscopic arthrolysis can therefore only be used in selected cases (Fig. 29.3), and the technique is demanding with a steep learning curve. Open arthrolysis is therefore the simplest, safest, most effective method for the majority of patients with stiff elbows.

Figure 29.3 Open arthrolysis is required for the majority of posttraumatic stiff elbows as most patients have had internal fixation of intra-articular fractures.

Surgical techniques

The main aim of open arthrolysis is to achieve as near to a full range of elbow flexion, extension and forearm rotation as possible during the operation. This is essential as the final range of movement is never more than that obtained at surgery, and is likely to be at least 10° less in any direction. A variety of open surgical approaches have been reported,^12–31 each with specific advantages and disadvantages. The method chosen will be determined by a preoperative assessment of the pathology and the personal preference of the surgeon. However, any exposure must be extensile if a satisfactory ROM cannot initially be achieved, using supplementary incisions if necessary.

The exact location and extent of any soft tissue contracture, bony impingement, joint incongruity and intra-articular adhesions are defined at surgery. All constraints must be addressed until a full range of congruous movement is achieved. Surgeons who rely solely on a particular technique, risk accepting a suboptimal range of movement intraoperatively, with a probable disappointing clinical result.

A new ‘extension, flexion, grip and grind’, (EFG) surgical guide is proposed by the senior author (Fig. 29.4). It is based on addressing the pathology responsible for elbow stiffness in a sequential manner with an extensile approach, rather than focusing on individual techniques. In addition, the EFG surgical guide facilitates accurate documentation of the intraoperative findings and can therefore be used as a research tool to allow comparisons between different patient groups, surgical techniques and postoperative regimens.

Figure 29.4 The ‘EFG’ surgical guide E: Extension, F: Flexion, G: Grip and Grind, E1: block to extension due to tight/thickened anterior capsule, E2: impingement in posterior compartment, E3: intra-articular pathology, F1: impingement in anterior compartment, F2: tight/thickened posterior capsule, (+/− posterior band medial ligament), F3: intra-articular pathology. Pathology should be addressed sequentially until, ideally, full extension and flexion are achieved. G1: restriction of forearm rotation/positive grip and grind test treated with a radial head excision. G2: release of radial neck adhesions to restore forearm rotation, G3: removal scar/bone between radial tuberosity and ulna to improve forearm rotation with radial head intact – G3a, and radial head absent – G3b.

Figure 29.5 The anterior capsule in a normal elbow is extremely thin, whereas it is often grossly thickened in a posttraumatic contracture (white arrow). C = capitellum, RH = radial head.

Figure 29.6 (A) Tight anterior capsule preventing extension, (B) further extension possible after release of anterior capsule.

Figure 29.7A,B Removal of 3 mm of abnormal bone from the coronoid tip will improve flexion by approximately 15° provided there is no other pathology (F1).

Figure 29.8 (A,B) Millimetres become centimetres: excision of 6 mm of osteophyte from the olecranon tip/coronoid process will increase extension and flexion by approximately 30° respectively. However, the flexion gain in terms of distance (x) is over three times greater than extension (y) resulting in functionally greater improvements in flexion, allowing the hand to reach the mouth/head.

Figure 29.9 (A) Impingement of the osteophyte at the tip of the coronoid with bone covering the fossa restricting flexion to 90°. (B) After excision of tip of coronoid and burring out of fossa.

Figure 29.10 (A) Tight anterior capsule, olecranon osteophyte and olecranon fossa osteophyte preventing extension. (B) Clearing of olecranon fossa, excision of olecranon osteophyte and release of anterior capsule allowing further extension.

Figure 29.11 (A) Magnetic resonance imaging (MRI) – normal olecranon ‘docks home’ in the fossa on full extension. (B) Huge posterior olecranon osteophyte (white arrow) prevents extension past 75° – approximately 1.5 cm of the osteophyte needs to be excised.

Figure 29.12 (A) Separation of joint surfaces with forced supination after extensile posterolateral exposure allows intra-articular adhesions to be cleared. (B) Malunited fragments (white arrow) causing impingement have to be excised. (C) Full pronation reduces the joint and allows the range of motion to be carefully checked to ensure a smooth arc without hinging.

Figure 29.13 (A–D) Kocher lateral approach through anconeus interval to expose radiocapitellar joint.

(Courtesy Dr Praveen Kumar, Consultant Orthopaedic Surgeon, Chennai, India.)

Figure 29.14 (A,B) Excision of the radial head in an abnormal radiocapitellar joint.

Figure 29.15 Stripping of radial neck adhesions – where radial head excision alone fails to restore forearm rotation.

Figure 29.16 Debridement of bone/scar tissue between the radial tuberosity and ulna with the radial head intact (G3a) and radial head absent (G3b).

Incision(s)

The siting of incisions is determined by the pathology and surgeon’s preference. Frequently, any scar from previous internal fixation will be utilized, usually posterior or lateral, or occasionally medial. A posterior midline incision with elevation of full thickness skin flaps as far as the epicondyles, or bilateral lateral and medial incisions, allows identical exposure to the ulnar nerve, anterior and posterior capsule and joint via the medial and lateral ridges under brachialis and triceps. Alternatively, a triceps splitting approach gives an excellent view of the olecranon fossa. The anterior compartment can also be accessed to a certain extent by creating a hole in the humerus – the Outerbridge–Kashiwagi (OK) technique. The tip of the coronoid process can also be debrided through the defect when the elbow is flexed. However, if sufficient release has not been achieved, a small additional incision can be made laterally and, if necessary, medially so that all compartments of the elbow joint can be reached.⁴²

Approaches

Lateral approach

The ‘column procedure’,¹¹ a limited lateral approach with preservation of the lateral ligament complex, can be used to release the contracted capsule anteriorly and posteriorly. Excision of the radial head, tip of the coronoid and olecranon process can be performed through this approach, as well as deepening the coronoid, olecranon and radial fossae; i.e. E2 and F2.^10,11 However, if the range of movement obtained is still restricted, the lateral ligament complex may be completely released allowing subluxation of the joint⁵ (Figs 29.12, 29.13), i.e. E3/F3 – see above. At the end of the procedure the soft tissues are repaired, with the extensor origin and lateral ligament complex sutured down to bone using drill holes or suture anchors (Fig. 29.17). In the vast majority of cases the elbow will be stable at the end of the procedure allowing mobilization to be started in the immediate postoperative period.

Figure 29.17 (A,B) Reattachment of soft tissues with sutures through drill holes in the lateral condyle.

Medial approach

A flap of brachialis/pronator teres is elevated giving access to the anterior capsule/joint, tip and medial edge of coronoid. Similarly, after decompression of the ulnar nerve, a posterior flap beneath triceps gives exposure to the posterior capsule and joint (Fig. 29.18). The posterior band of the medial collateral ligament can then also be released as necessary, exposing the medial edge of the humero-ulnar joint. The anterior band of the medial ligament and flexor origin are left intact to ensure stability. As a consequence articular surface pathology cannot be addressed through this approach.

Figure 29.18 (A) Posterior midline incision with medial skin flap raised and (B) ulnar nerve decompressed. (C) Edge of triceps reflected and posterior band of medial ligament excised, exposing osteophytes extending under anterior band of medial ligament.

(Courtesy Dr Praveen Kumar, Consultant Orthopaedic Surgeon, Chennai, India.)

Surgical techniques and rehabilitation

Early mobilization of the elbow after arthrolysis is almost universally recommended.13–16,18,21–23,26,28,29,31–33^,34 Good quality pain control is, however, essential after surgery, otherwise active or passive elbow movement is too painful for effective mobilization to take place.^{13–15,18,21,23,26,27,31,44} Although the pain largely subsides within a few days, the elbow will then almost invariably be just as stiff, if not stiffer than before the operation.

Pain management is probably the single most important factor in establishing arthrolysis as a reliable intervention over the past 20 years, in contrast to the pessimism prior to this time. Although previously a satisfactory range of movement could usually be obtained intraoperatively, the clinical outcome was often disappointing. At that time, postoperative pain tended to be poorly controlled and therefore the improved range of movement often could not be maintained. More recently, however, acute pain services have come into existence with much better postoperative pain management. This improvement in pain relief creates a window of opportunity immediately after surgery to mobilize the joint through its improved ROM.

Postoperative analgesia can be provided in a variety of ways, but relies on a team approach. The use of an axillary or supraclavicular continual brachial plexus block, via a thin indwelling catheter has revolutionized pain management after surgery. This has been shown to be very successful in providing effective pain relief for up to several days with the infusion titrated against the patient’s symptoms.^{13,15,18,21,23,26,31,44} A patient-controlled analgesia (PCA) system using opiates is also frequently used either primarily or as a secondary measure if the block fails.^{14,23,26,31,44}

Apart from early motion, there is little agreement as to what constitutes optimal management after arthrolysis. A variety of different regimens have been recommended but there is relatively little evidence that one technique is superior to another.^12–31 Continuous passive motion (CPM) can be useful in maintaining the improved range of movement obtained at surgery, particularly in the immediate postoperative period, as active movement may be impossible due to muscle weakness following a brachial plexus block. The aim is to prevent recurrence of the contractures – not to stretch and tear the remaining soft-tissues at the extremes of movement. No more movement can be obtained with the CPM than was achieved at surgery. There is little evidence that CPM provides additional value, although its usefulness may occur partly by reassuring patients after surgery that the operation was successful, as they can see that their arc of elbow movement is greater than that preoperatively.

Following discharge patients should be routinely encouraged to use their arm normally in the activities of daily living. The elbow can be mobilized safely within the limits of comfort, as pain and proprioception provide a feedback mechanism preventing inappropriate use. Post-arthrolysis, with the exception of interpositional arthroplasty,^27,40 instability is uncommon,^12–2931 even after extensive lateral release to allow subluxation (E3/F3), or even release of both collateral ligaments.^43,45

Physiotherapists are invaluable in providing advice and reassurance that improvement in motion and function will occur with use over the subsequent months. The temptation to passively stretch the joint should be resisted as inflammation, pain and spasm may ensue with further restriction of motion.

The senior author has never used passive stretching techniques, based on a belief that it adds no value and may result in unnecessary pain. In a personal series of 70 patients after open arthrolysis,³¹ CPM was used for approximately 48 hours postoperatively to maintain as much of the movement achieved at operation as possible. No further treatment was used after discharge, and in particular no passive stretching. The average ROM improved by and was maintained at 40° 1 year after surgery (from 69° to 109°). The conclusion was that there appears to be little evidence to support passive stretching after arthrolysis, as the results³¹ were similar to series reporting the routine use of this technique.^{16,19,22,23,46}

Static splints are frequently used to maintain the elbow in maximally flexed or extended positions, and can be used alternately during the rehabilitation period when resting, especially at night. In theory, the patient can then start to mobilize from the end of range position in the morning, although compliance may be an issue. Passive stretching techniques including manipulation by therapists or under anaesthesia,²³ and using dynamic or patient-adjusted static turnbuckle splints^19,22,46,47 remain controversial. These methods are based on a belief that stress relaxation of the soft tissues can be produced through plastic deformation. Advocates of these methods emphasize that the stretching should be ‘gentle’, i.e. very low forces applied within the limits of the patient’s symptoms. However, there must be considerable variation in the amount of force applied to the elbow in clinical practice, with the elbow often tolerating passive stretch poorly as detailed previously. In addition, elbow splints are uncomfortable as they tend to slip and require constant readjustment to allow them to act in the correct axis of rotation. If the splint is worn most of the time it will also interfere with daily activities, sleep and return to work. Gelinas et al⁴⁸ recommended turnbuckle splinting for 20 out of 24 hours, although many of their patients could not cope with this rigorous regimen.

Table 29.2 Illustrative case

58-year-old women with elbow stiffness 6 months after missed displaced intra-articular distal humeral fracture

Outcome and complications of treatment

Direct comparison between publications is difficult as the pathology and operative techniques, as well as methodology of reporting the results and complications, vary significantly. Outcomes from the recent literature are summarized in Table 29.1 and Box 29.3. Complications of open arthrolysis reported over the last 10 years range from 0 to 44% with an average of 15%.^{12–16,18–31} Although elbow movement improves in the vast majority of cases after open arthrolysis, some patients may be disappointed with the gain. Many series do not routinely report these cases as complications, while others state that a second release is sometimes necessary. Generally however, the results of revision surgery tend to be inferior.^22,23

Overall, ulnar neurapraxia/neuritis has emerged as the most common complication reported in the literature over the past decade.^12–31 Symptoms and signs of ulnar neuropathy due to compression and/or fibrosis in the posttraumatic elbow are not uncommon and may be subtle. Medial pain and mild intrinsic weakness can be easily overlooked preoperatively and then exacerbated by the arthrolysis, especially if only a lateral approach has been used. The ulnar nerve is particularly vulnerable if flexion is improved significantly,^19,21 as the cubital tunnel reduces in size as the retinaculum tightens with flexion. Other predisposing factors include subluxation of the nerve and callus formation, and in addition osteophytes or loose bodies can distort the floor of the tunnel. The nerve should then be decompressed, and indeed transposed if the bed is compromised. The latter, however, does not guarantee success due to perineural fibrosis.²² Prophylactic decompression/transposition is recommended by some surgeons if preoperative flexion is less than 120°.⁴¹

Wound problems, including haematoma, seroma, dehiscence and frank infection, will tend to be more common in complex cases, particularly when there is scarring due to previous surgery. Overall the incidence of significant problems requiring debridement is low.

Finally instability has rarely been reported,^27,40 partly as a good ROM can be obtained intraoperatively in the majority of patients without releasing the collateral ligaments. However, even if the lateral ligament complex/extensor origin is stripped from the distal humerus allowing elbow subluxation, only a few cases of instability have been reported – ‘it’s safe to sublux’.