Treatment of the Stiff Elbow

Although this text carries the title Operative Hand Surgery and was originally conceived as a compilation of techniques for surgery of the hand, attention to the problem of the stiff elbow is warranted for three reasons. First, loss of motion of the elbow directly restricts the ability to place the hand in space to and from the body, thereby disabling the function of the entire upper limb. Second, surgeons skilled in operations on the hand are increasingly called on to evaluate and treat stiff elbows following trauma or caused by arthritis. Surgical release of a contracted elbow requires meticulous dissection of neurovascular structures at the elbow, an area of anatomy that usually falls most comfortably under the purview of the hand surgeon. Finally, in the past 20 years, development of more dependable methods and techniques has made contracture release more reliable and clinically possible.

Before the 1990s, the published literature, including textbooks on orthopedics, reflected a general reluctance to treat the stiff elbow surgically. The condition was seldom discussed in textbooks; Wilson was one of the few who wrote about the subject in the 1940s. The terms that were applied in the literature, such as contracture, stiff elbow, posttraumatic elbow, and arthrolysis, were not precise enough for comparative purposes. Since then, operative treatment has become more common and results more predictable, although the lack of uniformity in reporting for evidence-based comparison persists. In general, reported results reflect a consensus that open capsulectomy, carefully performed on a willing patient, using a medial, lateral, or mediolateral approach to the elbow joint, results in a consistent and notable improvement in motion with only a small risk of serious complications. The need for hinged external fixation is limited. ^, Arthroscopic techniques continue to advance and can be used alone or in combination with open approaches but can be challenging if there is scarring around the ulnar or radial nerve. For further reading, I recommend the well-written summaries of King, Modabber and Jupiter, and Søjbjerg.

Causes and Prevention of the Stiff and Contracted Elbow

Our understanding of what creates a stiff joint is incomplete. We do know that an intraarticular effusion causes the joint to assume a position of flexion to maximize the volume of the capsule and minimize pressure. This may explain the position of flexion assumed for comfort immediately after injury. In addition, there are biologic factors that help explain this process. Once in a flexed position, the flexors and extensors tend to contract together, perhaps to minimize pain, leading to a cycle of increasing stiffness. More study is needed to understand the neuromuscular response to pain and trauma. The synovial capsule of the elbow is thin and usually transparent, and the joint surfaces have adequate clearance for full extension and flexion. After trauma, the capsule thickens, limiting flexion and extension as a “block” and a “tether,” respectively. The thickness of the capsule that requires excision, even after minimal trauma, may exceed 8 mm ( Fig. 24.1 ).

Fig. 24.1, The anterior capsule is being elevated, viewed from the lateral exposure. The capsule is approximately 5 mm thick.

It is important to institute active motion with gentle passive assistance as soon as is practical after injury, although there are times when rehabilitation must be tempered owing to tenuous fixation of intraarticular fractures. Sometimes, unfortunately, motion is not started until 6 weeks or longer after a simple fracture or dislocation, and by that time it is often too late. Even with attentive, supervised therapy that is initiated early, however, many patients will not regain optimal motion after trauma.

Our tools for minimizing contracture after injury are generally limited to physical therapy and splinting. Manipulation has been reported as useful but should be approached with caution after fracture or in the presence of internal fixation. Undoubtedly, as we begin to understand more about protective or overactive muscle reflexes and pain, as well as the molecular biology of scar formation, we will have better tools to minimize pathologic contractures.

It is helpful to remember a few guidelines when discussing a stiff elbow with a patient and the family, especially after trauma:

- 1.
  Unless evidence of gross malpractice exists, the contracture is seldom caused by the method of internal fixation or technical performance of the surgeon.
- 2.
  The therapist usually has not failed to improve the patient’s motion. Many therapists have little experience with stiff elbows following trauma and are appropriately reluctant. However, assigning blame to a therapist for using a dynamic splint for 9 months with little success (which can occur) serves no purpose. The therapist is often caught between the frustration of the patient and the hidden worry of the surgeon, both of whom see the failure to regain motion as a defeat.
- 3.
  The patient is usually not at fault, either. It is not uncommon for a patient to state that both the surgeon and the therapist have told the patient, “You didn’t work hard enough.” Patients respond to treatment differently, and those with a traumatized elbow demonstrate a wide range of responses. It is helpful to listen carefully to the patient and family. Most will tell of weeks and months of visits to the therapist, painful dynamic splints, and, finally, frustration. Any patient on whom one is considering operative treatment must be brought into the team and made to feel an integral part of the solution.

In summary, there is usually little value in spending time laying blame for a stiff or contracted elbow. A more productive use of time can be discussing your evaluation and plans to improve the situation and your rationale for treatment.

Preoperative Assessment

It is helpful to categorize the contracture as severe, moderate, or minimal ( Table 24.1 ). This somewhat vague, ordinal classification permits a starting point for assessment, operative planning, postoperative management, and setting expectations. As the surgeon gains experience, the arbitrary categories become a continuum and consequently less valuable.

TABLE 24.1

Categories of Posttraumatic Stiffness

Category	Range of Motion	Associated Findings and Characteristics	Likely Treatment	Likely Outcome
Minimal	Less than 30 degrees of motion loss (usually extension)	Single isolated injury Single previous surgery Near-normal joint Identifiable cause of motion loss	Open release with limited exposure Possible arthroscopic release Outpatient PT	Nearly complete recovery of motion
Moderate	40–100 degrees of total motion	Moderately severe injury More than one previous operation Ulnar nerve at risk Moderate HO present, both anteriorly and posteriorly Minor joint surface injury	Ulnar nerve release (transposition) Open release with medial and lateral exposure Coordinated PT Inpatient CPM with indwelling catheter	Seldom regain full extension
Severe	Less than 30 degrees total motion	Severe injury Several previous operative procedures “Enveloping fibrosis” Joint surface injury may be present Nerve entrapment or risk Often, all three of above findings Massive HO Potential joint surface incongruity Triceps may be adherent to midhumerus	Complete dissection/protection of all nerves Resection of HO from all blocking locations Triceps tenolysis Possible hinged external fixation Protection of posterolateral ligament Comprehensive-coordinated PT (indwelling catheter)	30–130 degrees of motion achieved Prolonged rehabilitation Strength and power often limited

CPM, Continuous passive motion; HO, heterotopic ossification; PT, physical therapy.

Operative treatment of a stiff elbow begins with an understanding of the probable cause of the patient’s contracture and the patient’s functional requirements, both vocationally and recreationally. Other factors such as the patient’s age and the time since injury must be considered (discussed in more detail later). These factors, taken together, determine not only the indications for surgery but also which surgical approach and type of postoperative treatment are likely to produce a successful result. The checklist in Table 24.1 is intended to help guide patient selection, operative approach, and regimen of postoperative rehabilitation. However, the need for midcourse corrections in the operating room and during the postoperative period is a constant and fundamental feature of operative treatment for a stiff elbow. To make these adjustments, the surgeon and therapist must have all of the resources for assessment and treatment available. Vigilance is paramount.

Patient History

Age of the Patient

The group of patients with the highest success rate in my practice is from 18 to 50 years old. These are generally people with high motivation who are capable of understanding their disability and seek to change it. The results reported in the pediatric population are more varied. ^, A child with joint injury and cartilage damage is still very challenging, and surgery should be contemplated with caution. This is especially true in adolescents who may be in a rebellious phase or who lack the maturity for cooperation. Occasionally, parents will bring an unwilling and uncooperative teenager for consideration of operative contracture release. Such patients will generally not participate in the postoperative therapy program and fail to regain motion. Some may even worsen after operative treatment. However, some individuals in this age group can also be quite rewarding to treat, especially those injured during participation in organized sports (such as gymnastics and wrestling) who are anxious to return to the team. They are usually highly motivated and will follow instructions to the letter.

Lower rates of success are generally achieved with the elderly. Elderly patients with a stiff elbow may have significant associated swelling of the hand and stiffness of the shoulder, both of which limit the possibility of success and the impact of improved elbow mobility. In addition, the quality of the joint may be so poor that the only reasonable option is total elbow replacement. In these cases, the long-standing dysfunction, usually caused by protracted immobilization of the entire limb, makes for prolonged and often incomplete restoration of function.

Duration of Contracture and Timing of Operative Release

There has been much speculation about the timing of contracture release, especially when considering excision of heterotopic ossification (HO) ( Fig. 24.2 ). Although the use of technetium bone scans was touted in the past for predicting the “activity” and, therefore, the probability of recurrence of HO, this test should be discarded as irrelevant because the scan sometimes remains “hot” for many years.

Fig. 24.2, A, Severe open injury caused by a motorboat propeller in a lake. B, The joint was pinned and immobilized in a reduced position. Plates were not used for fear of infection and soft tissue stripping. C, Three months after the injury, wispy immature heterotopic ossification can be seen forming along the anterior surface of the joint. D, At 8 months, both sides of the joint are enveloped by bone. The patient has no motion in the elbow. E and F, Two years after open release and hinged external fixation with a Compass Elbow Hinge, the patient has nearly full extension and flexion without pain or deterioration of the joint. This excellent result was possible because the initial treating surgeon kept the joint reduced. Despite the ensuing stiffness, the reduced joint protected cartilage and ligaments.

The optimal timing of intervention depends on the source of the contracture. If the loss of motion is due to a fracture that has fallen apart because of failed internal fixation or a persistently dislocated elbow, waiting serves no purpose. These patients should have the joint surfaces and congruity restored as soon as is practical in the hope of preserving some function. These cases are the most difficult and require both contracture release and restoration of the architecture, followed by protected motion intended to minimize strain on the repaired bone and ligaments. Often, external fixation, hinged or fixed, is required (see Chapter 22 ).

For patients who have a normal or nearly normal articulation, the timing of intervention should be based on documented failure of physical therapy and progressive splinting to improve motion. Although there is increased interest in earlier operative intervention, it is important to be certain that all nonoperative methods have been exhausted. In general, most patients do not improve beyond 4 to 6 months after injury (except children with supracondylar fractures). At the 6-month mark, unless there is significant brain injury, intervention can be considered. In cases with HO, the process has usually matured and can safely be removed at this time (see Fig. 24.2 ). Some have reported that contracture release after more than 1 year after injury has been associated with a lesser gain in motion. For patients who have had a significant loss of motion for more than 10 years, regaining substantial motion may be impossible without humeral shortening and ulnohumeral arthroplasty because of changes in length of the median nerve and brachial artery.

Pain and the Stiff Elbow

Most uncomplicated posttraumatic contractures are not very painful. There may be some discomfort at the end range of motion, but within the zone of limited motion, the patient is generally comfortable. If this is not the case, one should suspect posttraumatic arthrosis or joint incongruity. Patients who have had excessively forceful manipulations or passive mobilization in a misguided attempt to restore motion at a late date may have reactive pain and swelling. However, as the scar matures and tissue equilibrium is regained, this inflammatory response usually abates.

Ipsilateral shoulder pain is common with flexion contractures over 40 degrees as the patient attempts to position the hand at the side while walking or carrying, causing the shoulder to extend. In the patient with long-standing stiffness, an examination of the shoulder is helpful, because limited rotation or abduction may decrease access during surgery of the elbow.

Another source of pain may be ulnar nerve entrapment. Patients with a sensitive or trapped ulnar nerve after trauma may not exhibit the usual symptoms and signs of cubital tunnel syndrome. Instead of a definitive loss of sensibility in the distribution of the ulnar nerve, these patients may only exhibit resistance and reluctance to flexion in the first 2 months and tenderness along the medial elbow. In this way, the ulnar nerve itself may contribute to joint stiffness. Patients may describe “tightness” or “soreness” in the ulnar digits without frank sensory changes or weakness. As the contracture matures, the ulnar nerve is not under tension and therefore may not exhibit dysfunction.

In primary arthritis of the elbow associated with anterior and posterior osteophyte formation, pain is usually present at the end range of flexion and extension. That is where the osteophytes impinge. The middle range is usually comfortable and without crepitation. However, as the condition progresses and further deterioration of the trochlear surface of the humerus and other cartilage loss occur, the pain may be more constant, severe, and present in all positions.

Assessment of Motion Loss and the Effect on Function

What Degree of Motion Is Necessary?

Morrey and colleagues studied normal subjects by electrogoniometry and determined that most tasks of daily living could be performed in a range of 30 to 130 degrees of flexion and extension. This study was helpful in defining what most normal people use throughout the course of daily activity, but it did not ask the question, What is required for these tasks?

With the assistance of our therapy department, my colleagues and I studied 52 patients with decreased elbow motion and recorded the tasks that they could perform with and without specified adaptations. Twenty elbow-dependent tasks ranging from buttoning a collar to reaching for a lower drawer were evaluated. The goal was to examine which tasks could be performed and, of those performed, which required a significant postural or spatial adaptation. The study found that patients lacking flexion of more than 110 degrees were unlikely to be able to button a collar, shave the face, place an earring, or tie a scarf or necktie. Loss of elbow flexion limits using eating utensils and self-care of the hair, face, and neck. In our study, patients could not compensate for loss of flexion; the neck and wrist are limited in their capacity to flex to assist the hand in reaching the neck, face, head, or ears. Although loss of flexion is generally ignored in the published literature, every effort should be made to improve flexion, especially when there is less than 105 degrees present.

Patients with lack of extension, however, can much more easily accommodate for the loss. In our study, flexion contracture of greater than 40 degrees required positional adaptation, but the tasks could still be accomplished. Reaching the feet or toes was possible with increased knee, hip, and trunk flexion. For opening low drawers, the patient could kneel to pull them open bimanually. In other words, positioning the hand in space, away from the body or to the feet, is limited with loss of extension, but the patient can accommodate for this by moving the trunk (and hand) closer to the object of interest.

An important conclusion from our study was that if improved extension is sought, it should not be obtained at the expense of flexion. This is not a “trade” that patients will want to make.

In the preoperative assessment it is helpful for patients to detail what tasks they have difficulty performing because of limitation of motion. Patients may be functional with a 40-degree flexion contracture but simply not like the appearance. Given the complexity of the surgery and the postoperative effort usually required, I generally do not recommend contracture release for the improvement of appearance only.

Elbow motion must be carefully documented by goniometry and a standardized technique. I have found the interobserver error in trained personnel to be about ±10 degrees. My own intraobserver error is about 5 degrees when using a large goniometer. Given these numbers, I doubt the value of reporting elbow measurements in increments of less than 5 degrees. It is important for the surgeon to measure the angles personally and not merely rely on measurements recorded by others.

Indications for Contracture Release

It is impossible to set absolute indications for operative contracture release. Generally, any patient with a 40-degree loss of extension or with less than 105 degrees of flexion will benefit from improved motion and should be considered for contracture release. It is seldom possible to guarantee full extension, irrespective of the operative approach or postoperative management. This point is especially important to discuss with patients such as gymnasts, who require full extension, or even hyperextension, to “lock out” the arms during handstands or floor exercises. Occasionally, patients with posttraumatic contractures of 30 degrees or less, despite being very functional, seek nearly full extension for sports, especially for the throwing arm. If the contracture is simple and uncomplicated by joint incongruity, these patients can often be improved by either arthroscopic release or a release from the lateral approach alone.

Physical Examination of the Ulnar Nerve

The ulnar nerve is vulnerable to injury, scarring, and dysfunction after trauma, distal humeral internal fixation, and complex dislocations. Hence, careful preoperative assessment of the nerve is mandatory. In many cases it is not possible to be certain whether the nerve has been transposed. Even if the previous operative note is available and states that a transposition was performed, the nerve may have slipped back into a more posterior position.

If the ulnar nerve is entrapped or shows signs of significant dysfunction, neurolysis and transposition at the time of contracture release can restore sensibility and strength in the proximal muscles innervated by the ulnar nerve. The more distal intrinsic muscles of the hand are less likely to recover, although occasionally in younger patients, dramatic improvement may be seen.

Most patients with loss of flexion require ulnar nerve transposition at the time of surgery, and this point should be discussed with the patient. Patients with primary osteoarthritis of the elbow often demonstrate osteophytes extending into the cubital tunnel. These patients, usually middle-aged men, may have a subclinical, indolent course. When carefully examined, the intrinsic weakness may be subtle and the loss of sensibility discovered only with threshold measurements or two-point discrimination. If there is doubt, preoperative electrophysiologic testing, with special attention to electromyography, should be performed.

Patients may have temporary postoperative ulnar nerve dysfunction, especially if the nerve is already symptomatic. Most improve with neurolysis and transposition, but recovery is often slow if the dysfunction has been present for a long time.

When dissecting the ulnar nerve, there is seldom any reason to perform an internal neurolysis or intrafascicular or even epineural dissection. Instead, the goal is to free the nerve from the entrapment posterior to the axis of the joint and allow it to be transposed to the anterior position. Leaving a cuff of soft tissue, especially in a setting of reoperation, poses less threat to nerve function than trying to strip all soft tissue from the nerve.

Assessment of the Ulnohumeral Joint Surface After Trauma

The most challenging reconstructive problem is elbow stiffness with concomitant cartilage loss in the ulnohumeral joint. Hence, assessment of this surface by either computed tomography (CT) or magnetic resonance imaging (MRI) is paramount if the joint surface is suspected to be of poor quality. Ultimately, however, the articular surface must be inspected at the time of surgery to determine whether there is adequate cartilage in the functional zone of motion. The radiocapitellar surface can be sacrificed with radial head resection or excision of the capitellum. Not uncommonly, the end-bearing surface of the radial head is devoid of cartilage, but patients are not symptomatic during forearm rotation. In these patients, typically middle-aged men with osteoarthritis, the radial head does not need to be addressed. However, if incongruity or poor cartilage surfaces in the ulnohumeral joint are present, a contracture release alone is not likely to be beneficial. I have made the mistake of improving motion but inducing pain by performing a contracture release in degenerated joints.

In the older patient with limited demand, total elbow replacement may be the optimal choice (see Chapter 27 ). In the younger patient with severe incongruity, interposition arthroplasty is sufficiently unpredictable that I seldom perform this procedure following trauma.

Imaging the Stiff Elbow

Many radiologic features need to be assessed before surgery is considered:

- What is the quality of the joint and relative health of the cartilage?
- Where is the hardware, and is it impeding motion? (Is removal necessary?)
- Where is the HO or impingement located?
- Are the fractures healed?

A significant flexion contracture may preclude visualization of the distal humeral articular surface with standard radiographic techniques. Typically, the technician places the film plate perpendicular to the joint at midrange. An anteroposterior view with the distal humerus lying flat on the cassette is a helpful additional view. A true lateral view is also mandatory. In some cases I also obtain true lateral views in maximal active flexion and maximal active extension. Technicians find these difficult at first because the humerus tends to internally or externally rotate at the extremes of position and the “true lateral” view is lost. These additional views may show subtle shifts of the joint, as well as previously unseen projections of heterotopic bone.

As noted previously, the quality of the articular surfaces in a stiff posttraumatic elbow is of paramount importance. The ulnohumeral joint is probably more important than the radiocapitellar joint, although having both intact and functional is optimal. Assessing this joint and the quality of the cartilage is best done with plain radiographs. If this is insufficient, CT scans with thin slices in the sagittal and coronal planes are needed. I recommend 0.8-mm–thick contiguous slices with overlap. This acquisition method permits multiplanar reconstruction and other manipulations. Three-dimensional surface reconstructions can be helpful in preoperative planning.

For fracture cases, it is sometimes difficult to determine whether union has been achieved, especially when plates and screws overlie the area in question. CT is problematic because of “noise” from the metal; however, CT radiologists continue to improve their ability to suppress this effect, especially with titanium implants. MRI techniques are improving to better assess fragment healing, viability, and perfusion, even in the presence of metallic hardware. ^,

At no time have I used bone scans to assess a contracted elbow, finding them of no use in patients with posttraumatic contracture with or without heterotopic bone.

The Preoperative Discussion

Once you have determined that a surgical release could be performed, it is important to discuss expectations, the surgery, and the potential complications with the patient. From this discussion alone, the patient may shy away and appropriately conclude that it is possible to live quite well with the limitation of motion.

Much like rehabilitation after flexor tendon repair, without the full cooperation and dedication of the patient, surgery may not improve function. In fact, given the complexity of some cases, the attempted release may worsen motion.

As detailed later, each contracture requires at least two operative plans. If the first approach does not succeed in achieving the expected goal during surgery, the second option should be employed. If you believed that a medial approach to the joint would permit a complete capsulectomy but at surgery find the lateral structures both limiting and out of safe reach, then a concomitant lateral approach should be considered. Likewise, postoperative management varies greatly, depending on each patient’s individual response. It is important to explain the variability in response to operative release. Fortunately, most patients with contractures understand this because they have already been told that this was in some way their fault or the fault of their “muscles.” Some require very little supervised therapy, even little continuous passive motion (CPM); others need serial static progressive bracing (flexion and extension) and occasionally a carefully administered manipulation. For massive HO with long-standing contractures, I also explain the use of dynamic hinged external fixation. As a matter of disclosure, I helped design and patent the Compass Elbow Hinge (manufactured by Smith and Nephew, UK). However, for 15 years I have received no compensation in any form.

If during any of the discussion with the patient you detect unwillingness or wariness, waiting may be warranted. I also encourage patients to discuss their questions with other patients, and I keep a list of former patients willing to discuss their operative experience.

Patients should also be informed about the possibility of transient increased ulnar nerve symptoms.

Classifying the Contracture and Matching the Operative Plan

After deciding to proceed with contracture release, it is helpful to classify the contracture as minimal, moderate, or severe (see Table 24.1 ). This general guide may help in planning what is needed to succeed. The most common reason for a failed contracture release, in my opinion, is a failure on the part of the surgeon to abandon an orthodox method in favor of a less assured technique (arthroscopy) or to use a single anatomic approach to the joint when the potential gain in motion is not achieved at the time of surgery. The operative contracture release requires a progressive, adaptive surgical approach, and the surgeon must safely increase the exposure in order to excise the offending fibrosis on nearly all aspects of the joint, anteroposterior and mediolateral. ^, If an uncomplicated, simple dislocation has caused a 30-degree flexion contracture, arthroscopic capsular excision may be sufficient.

The operative tools needed for successful contracture release range from arthroscopy to hinged external fixation to total elbow arthroplasty. Deciding which one you need depends on the patient’s age, the cause of the stiffness, the quality of the joint, and, in some ways, the patient’s personality. As we have gained experience with both the different causes of contracture and different types of patients, we have also had access to new tools and methods of treatment. The best care for a given patient with a contracture is the most minimal necessary surgery, including minimal anatomic exposure, and rehabilitation to achieve the desired result. For instance, a patient with a range of 40 to 105 degrees and HO will usually require exposure of the capsule for complete excision from both the medial and lateral approaches but not necessarily hinged fixation. Although in this situation the use of hinged fixation may potentially improve extension (from 20 degrees achieved with capsulectomy alone to perhaps 5 additional degrees with hinged fixation), I do not believe that this is worth the cost, potential complications, or aggravation to the patient.

In a different circumstance with more massive HO, hinged external fixation may be necessary to stabilize the elbow postoperatively and permit immediate motion with intermittent passive stretch.

I set out to perform the operation most likely to achieve the goal, but I am always prepared to extend the exposure, or approach the joint from an additional direction, and I explain this to the patient preoperatively. In other words, if I think that an arthroscopic release is likely to be sufficient, I also plan for the possibility of an open release if full passive motion is not achieved on the operating table. I may plan for hinged fixation in case there is unexpected muscle–tendon tightness and failure to regain extension or flexion on the table or the joint is surprisingly or excessively worn and requires interposition. Having now performed 480 contracture releases, I have found the need for hinged fixation to be rare. ^, In older patients with suspected cartilage damage or avascular bone, total elbow replacement should be available and discussed before surgery.

Predicting what you need and what will succeed is an iterative process that comes from your own experience and the seasoned opinions of others. It is important to be prepared to change and not be wedded to any single approach. Orthodoxy here should only be a dedication to optimizing your patient’s motion and not to a single exposure, approach, or device.

Anesthesia for Contracture Release

Regional blocks are preferred and are in fact the only method I have used for contracture release over the past 20 years. At my institution, ultrasound-guided infraclavicular blocks have become standard for contracture release; an indwelling catheter is often used so that additional dosing can occur 24 to 72 hours postoperatively. Long-acting agents are the norm. Bupivacaine may leave the patient blocked for 24 to 48 hours. Although this may cause the surgeon concern, especially regarding the inability to check the status of the nerve, the pain relief and slow return of sensation are helpful as the patient begins motion the next day.

If the infraclavicular (or supraclavicular) technique or catheter is not available, axillary blocks may be used, but these may leave the upper end of the medial incision with sensibility. A small amount of local anesthetic in this area is usually all that is needed.

General anesthesia with endotracheal intubation may be used if regional blocks are unsuccessful or the anesthesia staff is unwilling to do regional blocks. More narcotics are likely to be needed in the immediate postoperative period.

In children, I use infraclavicular indwelling catheters combined with general anesthesia. This is the “best of both worlds” for this challenging age group.

Operative Techniques and Approaches

Arthroscopic Release

Arthroscopic elbow release is becoming more applicable as the techniques and instruments are improved and experience is gained. This method works best in a young athlete with a loose body or a history of a hyperextended elbow and a resultant minimal but annoying contracture. The anterior capsule can safely be released under direct arthroscopic visualization.

Two groups should be approached with great caution. The first group includes patients with a posttraumatic stiff elbow, in whom the capsule may be quite thick, sometimes 0.5 to 1 cm thick, and adherent to the anterior humerus. Because of this envelope of fibrotic tissue, arthroscopic release fails to excise the restraining tissue and puts the ulnar, median, and radial nerves at risk. ^, ^,

The other group “at risk” is typified by a 45- to 55-year-old with primary osteoarthritis and simple osteophytes projecting from the coronoid and the tip of the olecranon. In my opinion, arthroscopic release alone should not be performed if the patient requires ulnar nerve transposition or if there are large osteophytes in the posteromedial corner, which is the floor of the cubital tunnel. I have treated two patients in whom the ulnar nerve had accidentally been debrided with an arthroscopic shaver. Other injuries have also been reported. The surgeon should resist the temptation to use the shaver in this region unless the ulnar nerve is mobilized. Open techniques are safe and relatively simple, permitting visualization of the relevant neurovascular structures as needed. It is my firm belief that one should understand and be able to perform an open capsulectomy (described in the following) using both medial and lateral approaches before using the arthroscope as the primary tool of visualization and capsulectomy. Furthermore, adequate experience and skill in elbow arthroscopy is required because this is technically a difficult arthroscopic operation.

Open Release

When an open release is planned, the location of the potential pathologic condition and the nature of the contracture should determine the approach to the joint. One should not feel constrained to use one approach over another because of an unfounded allegiance to a given method. If the patient has a simple flexion contracture related to a radial head fracture, the lateral approach is usually sufficient and is relatively simple to perform. ^, In more complex cases in which the ulnar nerve requires exposure, I usually begin with the medial “over-the-top” exposure. ^, ^, I am always prepared to use a supplementary lateral approach in these cases if there is HO located on the lateral side, if I am concerned about the position and safety of the radial nerve, or if there is an impinging osteophyte behind the capitellum. It is therefore important to understand both the medial and lateral approaches and be able to use them as needed in the operating room. Both a transhumeral and a transolecranon approach have been described, but I have not used either. ^, I also no longer use the Outerbridge-Kashiwagi procedure (transhumeral trephination), which is designed to treat patients with primary arthritis of the elbow. If there is a significant lack of flexion (limited to <90 degrees), evidence of ulnar nerve dysfunction, or osteophytes in the posteromedial joint line, I prefer the medial “over-the-top” approach. As described in the next section, this approach permits exposure of the ulnar nerve and access to the anterior and posterior osteophytes. If flexion is minimally limited and the ulnar nerve is palpable and mobile, I prefer arthroscopic debridement and contracture release.

Only rarely can contracture be treated with anterior capsulectomy alone. Of the more than 480 contractures that I have treated operatively over the past 10 years, only a handful were adequately freed by incising the anterior capsule alone. In most instances, you should always plan to have access to the posterior joint surface, whether from the medial or lateral side of the joint. The olecranon fossa must be free of bone and soft tissue for full terminal extension to be achieved.

The advantage of knowing and using both the medial and lateral approaches is that you can protect the anterior medial ligament on the medial side by using the medial “over-the-top” approach. From the lateral exposure, the lateral ligaments described as noted by Husband and Hastings and others ^, can be protected.

Medial “Over-the-Top” Approach

The principal advantages of this approach are as follows:

- Allows exposure, protection, and transposition of the ulnar nerve
- Preserves the anterior medial collateral ligament
- Preserves the posterolateral ulnohumeral ligament complex
- Permits both anterior and posterior access to the joint
- Allows access to the coronoid and anterior osteophytes with an intact radial head
- Can be easily converted to the triceps-sparing exposure of Bryan-Morrey, which permits complete dislocation of the joint and a more extensile approach (for total elbow replacement)
- The disadvantages are as follows:
- Difficult to remove heterotopic bone or osteophytes on the lateral side of the joint
- Poor access to the radial head

Patient position and preparation

The patient is usually supine with the arm supported by a hand table ( Fig. 24.3A ). It is helpful to bring as much of the patient as possible onto the hand table. The patient’s head may require support with a small foam ring because a standard pillow projects too far toward the shoulder and impedes the skin preparation. Two folded towels should be placed under the ipsilateral scapula to lift the shoulder away from the surgical table. The preparation should include the axilla to allow a sterile tourniquet to be applied. For the surgeon to visualize the anterior and posterior surfaces of the distal humerus, the patient should have fairly free external rotation of the shoulder. In some cases, with a concomitant frozen or stiff shoulder, a proper manipulation the shoulder under anesthesia preceding the elbow release can help restore shoulder motion, especially external rotation.

Fig. 24.3, Medial “over-the-top” approach. A, The supine position is the most useful. Two folded towels should be placed under the ipsilateral scapula. B, The skin incision may vary according to previous incisions. If the incision is made along the posterior surface, larger flaps are needed. C, The intermuscular septum should be recognized as a landmark and excised for adequate mobilization of the ulnar nerve. D, The anterior capsule is first exposed by splitting fibers between the flexor carpi ulnaris and the pronator. The anterior portion of the medial collateral ligament is protected. E, Once exposed, the capsule is sharply excised. Anterior heterotopic ossification arising from the coronoid is usually excised at this point. F, The ulnar nerve is carefully mobilized and moved forward. G, The posterior surface is exposed for excision of the capsule and heterotopic ossification. H, The tip of the olecranon is removed to clear the posterior fossa. I, The ulnar nerve is left in the anteriorly transposed position. A fascial sling or subcutaneous fat sling can be fashioned to hold the nerve anteriorly transposed without constriction.

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