Treatment by Open Surgical Techniques

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Chapter 29 Treatment by Open Surgical Techniques

Odhrán Murray, Tom Nunn, Jane McEachan, Lech Rymaszewski

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 literature¹²^–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).

Table 29.1 Summary of the literature 2000–2010

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

Box 29.1 Indications for open arthrolysis

• Contracture static, usually at least 6–9 months after injury

• Significant stiffness – <30/–130° of flexion

• Significant loss of function

• Impingement pain – in extension, flexion or on forearm rotation (‘grip and grind’)

Age

The average age at which arthrolysis was undertaken over the past decade was 36 years, ranging from 8 to 76 years.^12,^13,^{16–23,26–31} Arthrolysis in the skeletally immature elbow has been successful,^14,¹⁵ although Stans et al²⁴ reported a tendency towards less favourable outcomes compared with adults. Caution should be exercised when considering arthrolysis in children, especially when the parents are anxious and keen on surgery. A child usually has little problem coping with a stiff elbow, and the potential for improvement with time and use is considerable. The adolescent may request intervention on cosmetic as well as functional grounds, and it is again important to address any unrealistic expectations.

Time from injury

The timing of arthrolysis is controversial as the natural history of posttraumatic elbow stiffness is of gradual improvement with use, up to at least 6 months after injury, although some individuals continue to improve significantly for up to and even beyond 1 year. Some surgeons believe that a shorter interval from trauma to arthrolysis, usually within 1 year, is associated with superior outcomes, both in terms of ROM and functional scores.^13,^17,^18,³⁴ Others^12,^15,³³ have found no correlation, and therefore, arthrolysis should be considered only when the patient’s ROM on serial goniometric measurements and function has plateaued. In the presence of heterotopic ossification, surgery should be postponed until it is radiologically mature.

Severity of stiffness

Paradoxically, the greatest improvement in motion may be achieved in elbows with the greatest restriction, despite significantly damaged articular surfaces;^4,^21,³³ for example Morrey⁴ reported six elbows whose movement improved by 80° (27–107°) following release, interposition and distraction. We found a similar improvement in seven patients with severe stiffness (mean 21° arc of motion), who achieved a mean gain of 79° following open arthrolysis, but without interposition or distraction.³¹ Clearly overall, a greater gain in the arc of movement results in better functional outcome and patient satisfaction. Patients are usually happy to exchange a painless, ankylosed joint for a mobile elbow even if this results in a degree of discomfort or pain. In the subgroup of patients whose main complaint is of generalized pain rather than stiffness, arthrolysis is still likely to result in a modest improvement in motion, although there is a risk that pain remains unaffected.

History

A careful history is essential to establish an accurate diagnosis, and understand the patient’s problems and expectations. The patient’s age, occupation, and hand dominance are recorded. The initial injury, subsequent management, degree of elbow stiffness and impact on the patient’s activities of daily living and recreational pursuits are determined. A visual analogue score (VAS) is useful to quantify the patients’ levels of pain at rest and night, after heavy lifting and on performing tasks with repetitive movements. Functional deficit can be estimated using systems such as the DASH or Oxford scores, which help in the overall assessment and facilitate planning.

Posttraumatic stiffness is not usually painful.³⁸ If pain is present, it tends to occur only at the extremes of flexion/extension due to impingement, with repeated movements or on loading, for example when lifting a heavy weight. Pain due to rotational movements, for example turning a stiff door knob or using a screwdriver, is indicative of radiocapitellar pathology. Less commonly, pain is experienced throughout the arc of elbow motion due to intra-articular incongruity or degeneration. Serious pathology including infection, inflammatory disease or tumour should be considered if severe pain is experienced at rest or at night, especially if the patient is systemically unwell. Occasionally but rarely, severe elbow pain and spasm can occur as a result of a regional pain syndrome, which will also affect the shoulder, wrist and hand. It is especially important to enquire if ulnar paraesthesia, sensory loss, weakness and/or clumsiness are present, as decompression or transposition of the ulnar nerve is essential to avoid disappointing results.²² Mechanical symptoms, such as catching and locking, may also be present, indicating the presence of loose bodies (Box 29.2).

Box 29.2 Assessment for surgically correctable pathology

• Restriction in ROM – measured with goniometer

• Impingement pain – terminal flexion/extension

• ‘Grip and grind’ pain – loading/rotation radiocapitellar joint

• Ulnar neuropathy

• Locking/mechanical symptoms – due to loose bodies

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

Imaging

Routine anteroposterior (AP) and lateral X-rays are the only imaging techniques required in the majority of cases, with osteophytes, loose bodies and heterotopic ossification easily identified on plain X-ray. Although computed tomography (CT) is increasingly being used to investigate complex contractures, management is unlikely to be altered as the exact pathology is defined and addressed at operation using an extensile approach (see below). Exceptions include identifying the course of a nerve passing within a mass of heterotopic bone, or to confirm fracture healing.

Other

Neurophysiological testing may be used to confirm and document ulnar neuropathy. If serious pathology such as infection, inflammatory disease or tumour is suspected, routine blood tests including full blood count, erythrocyte sedimentation rate and C-reactive protein are indicated.

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.

Interpositional arthroplasty and mechanical distraction

Interpositional arthroplasty has been advocated in the younger patient with arthritis, particularly when there is more than 50% loss of the articular surface. Interposition with tissue such as autologous fascia lata or allogenic Achilles tendon can be used to resurface the joint and a dynamic external fixator applied for protection of the repaired or reconstructed ligaments. Morrey ⁴ demonstrated an average flexion arc increase of 67° in 14 patients treated with distraction arthroplasty and 80° in six treated with distraction arthroplasty and interpositional grafting, although there was a significant complication rate. Overall, there is little evidence that interpositional arthroplasty adds value to arthrolysis alone with regard to ROM, pain relief or functional scores at a mean follow-up between 4 and 5 years.^15,^27,⁴⁰ In addition, there is a significant risk of instability, presumably due to the greater release required to secure the interposed material.^27,⁴⁰

Distraction arthroplasty has also been described for the treatment of posttraumatic stiffness of the elbow in children and adolescents.²⁴ This technique involves intraoperative distraction with an external fixator, a relaxation phase of less than 1 week, followed by mobilization of the elbow in a dynamic external fixator for several weeks. The authors have demonstrated that mechanical distraction results in statistical significant improvements in elbow ROM but not other outcome measures.²⁴