Elbow Contracture Release

Joaquin Sanchez-Sotelo, MD, PhD

Dr. Sanchez-Sotelo or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of Merck and Stryker; serves as a paid consultant to Tornier; has received research or institutional support from Stryker; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Elsevier and the Journal of Shoulder and Elbow Surgery; and serves as a board member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons and the Journal of Shoulder and Elbow Surgery.

Introduction

Among the major joints, the elbow is especially prone to stiffness and contracture. This is due, in part, to the constrained articular anatomy as well as the surrounding capsular and ligamentous structures. Contracture of varying degrees is very common after elbow trauma. Loss of motion and contracture also occurs in the setting of hypertrophic osteoarthritis, inflammatory arthritis, postoperative contracture, neuromuscular disease, and burns.

Although capsular fibrosis contributes to contracture in most elbows, motion may also be limited by bony impingement, heterotopic ossification, malunion, cartilage adhesions, prominent hardware, nonisometric ligaments, and other abnormalities of the articular surface. The term intrinsic stiffness refers involvement of the articular surfaces to such extent that motion cannot be reliably restored without addressing the articular surfaces surgically, whereas extrinsic stiffness refers to involvement of the periarticular soft tissues. In many cases, elbow stiffness is the result of combined involvement.

The normal elbow flexion arc is about 0° to 140°, and normal pronation and supination is about 80°. The majority of activities of daily living (ADLs) require a flexion arc of 30° to 130° and 50° of pronation and supination. A flexion arc of 30° to 130° reduces the space reached by the hand by about 20%. More recent work suggests that a greater range is required for certain activities, such as cell phone use.

Refractory elbow stiffness and contracture can be overcome by surgical removal of the contracted capsule and all sources of bony impingement, including areas of heterotopic ossification. Various surgical approaches have been described to remove a contracted capsule, loose bodies, osteophytes, and ectopic bone from the elbow joint. Arthroscopic contracture release, also known as arthroscopic osteocapsular arthroplasty, has gained popularity over the last few years, but open contracture release is also commonly performed.

Intraoperative restoration of a functional arc of motion can be achieved in the majority of elbows with extrinsic stiffness. However, maintenance of the range of motion (ROM) achieved in surgery is difficult, and the rehabilitation program after contracture release is paramount for the final outcome of any of these procedures. In general, improvements in flexion and extension are easier to obtain and maintain than improvements in pronation and supination.

This chapter reviews the surgical management and postoperative rehabilitation program typically recommended after surgical treatment of extrinsic stiffness.

Surgical Procedure

Indications and Contraindications

Release of elbow joints with extrinsic contracture is indicated when the degree of stiffness interferes with the patient’s function. Patients’ expectations vary based on their occupation and interests. Although it is traditionally accepted that most activities of daily living (ADLs) are possible when the elbow can be flexed from 30° to 130° degrees, and the arc of pronation and supination is of 50° in each direction, some patients may require greater mobility to perform their ADLs or more demanding athletic or artistic activities.

The main absolute contraindication for contracture release in our practice is active infection. Compromised skin and surrounding soft-tissue envelope is a relative contraindication, as these conditions can be managed in some cases with the incorporation of plastic surgical interventions. In addition, inability to comply with the postoperative rehabilitation program and severe neuromuscular dysfunction or paralysis are relative contraindications, although release of the hyperflexed elbow may be required in these circumstances to facilitate skin hygiene in the elbow flexion crease. In patients with intrinsic contracture, surgical release needs to be combined with other
procedures, such is interposition arthroplasty or total elbow arthroplasty.

Careful consideration should be given when considering arthroscopic capsular release in posttraumatic cases after open reduction and internal fixation. These cases may have extensive scarring related to the surgical procedure as well as the original injury, which may substantially increase the risk of the nerve injury.

The timing of contracture release needs to be carefully considered in some circumstances. Stiffness after fracture fixation is best addressed once fracture healing is confirmed. Resection of heterotopic ossification is considered typically 3 to 6 months after injury, substantially earlier than in the past. Controversy remains about the timing of contracture release for children and adolescents as well as patients with chronic regional pain syndrome (CRPS). Contracture release may be less reliable in older children and adolescents, attributed partly to increased fibrotic activity around growth spurts and partly to compliance issues. Early surgery may be considered in type II CRPS when ulnar neurolysis or release is considered, especially if a brachial plexus block will be used postoperatively.

Finally, the condition of the soft tissues needs to be assessed carefully to determine the need for soft-tissue coverage at the time of contracture release, especially in patients with previous open fractures, skin grafting, and/or soft-tissue flaps.

Surgical Technique

Preoperative evaluation is paramount for the success of surgical release of elbow contracture. Prior skin incisions and the condition of the elbow soft-tissue envelope should be noted. Motion should be accurately measured and recorded in flexion, extension, pronation, and supination. Neurovascular examination of the involved upper extremity is directed to identification of associated nerve deficits and is particularly directed to the ulnar nerve. Plain radiographs and computed tomography with three-dimensional reconstruction are the imaging modalities of choice to assess articular and bony anatomy, as well as ectopic ossification.

The principles of contracture release are the same for open and arthroscopic procedures and include (1) the removal of fibrotic anterior and posterior capsule, including the posterior band of the medial collateral ligament (MCL); and (2) elimination of bony impingement by removing osteophytes and bone from the olecranon, coronoid, radial head, and their respective fossae in the distal humerus.

The surgical procedure is typically performed with general anesthesia. A brachial plexus nerve block is performed once the neurovascular status of the affected extremity has been confirmed to be normal right after surgery, and provided there are no contraindications. An indwelling axillary catheter can be placed to provide pain relief for the first 2 to 3 days after surgery.

Open Contracture Release

In open contracture release, the capsule is first dissected free from the overlying muscle fibers and resected, and followed by bone removal. An effort is made to preserve the integrity of the collateral ligaments (lateral collateral ligament complex) and anterior band of the MCL. Table 13.1 lists the most common surgical exposures described for open contracture release. The decision to use the lateral or medial column approaches is based on the location of the associated pathology. In both approaches, the collateral ligaments are preserved whenever possible in order to avoid iatrogenic instability.

Table 13.1 COMMON PROCEDURES DESCRIBED FOR OPEN ELBOW CONTRACTURE RELEASE

Procedure	Posterior Compartment	Anterior Compartment
Lateral column	Raising triceps-anconeus laterally	ECRB–ECRL interval
Medial column	Raising triceps medially	Flexor–pronator interval
Ulnohumeral arthroplasty	Triceps split followed by oval fenestration at olecranon fossa	Through humeral oval fenestration
ECRB = extensor carpi radialis brevis, ECRL = Extensor carpi radialis longus.

In the lateral column procedure, a lateral incision is made and the interval between the extensor carpi radialis longus and brevis is developed to access the anterior compartment. The more anterior extensor muscles are detached and elevated with the brachialis muscle off of the anterior capsule, which is then resected across the anterior compartment of the elbow. The lateral approach is preferred if there is lateral pathology such as following a radial head fracture or if there is heterotopic bone more laterally based. The posterior compartment is accessed by elevating the anconeus and triceps off of the posterior capsule and posterior humerus (Figure 13.1).

In the medial column approach, a medial incision is made and the deeper dissection is carried through the common flexor pronator interval. These muscles are elevated with the brachialis muscle off of the anterior capsule, which is resected. The ulnar nerve can be exposed in the posterior compartment, and is accessed by elevating the triceps off of the posterior capsule and distal humerus. The medial approach is preferred if there is ulnar nerve involvement, after open reduction and internal fixation of distal humerus fractures that may have involved dissection of the ulnar nerve or heterotopic bone that is more medially located.

Open ulnohumeral arthroplasty, the Outerbridge-Kashiwagi procedure, is performed through a posterior incision and triceps-splitting approach to access the posterior compartment. The posterior capsule is released and excised, then the posterior osteophytes and spurring are removed. A complete fenestration of the distal humerus through the olecranon fossa is created to access the anterior compartment. This procedure is most commonly used to treat primary degenerative arthritis of the elbow.

Figure 13.1 Clinical photographs of open contracture release. A, The anterior and posterior compartment of the elbows can be exposed using ligament-preserving intervals. Restoration of motion usually requires capsulectomy (B) and bone removal (C). Illustrations of the lateral (D) and medial (E) column procedures. (Part D reproduced with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.)

Figure 13.2 Photographs of arthroscopic osteocapsular arthroplasty. Bone removal (A) and capsulectomy (B) may also be completed arthroscopically.

Arthroscopic Contracture Release

Advances in arthroscopy have led to the use for elbow contracture release. Arthroscopic capsular release is technically demanding, but has the advantage of being minimally invasive. In arthroscopic contracture release, the bony work is performed first, followed by capsulectomy (Figure 13.2). The anterior or posterior compartment may be addressed first based on surgeon’s preference. Bone removal is performed with arthroscopic burrs, whereas capsule resection is completed with a combination of arthroscopic bitters, shavers, and radiofrequency devices. Arthroscopic contracture release is thought to be more technically demanding and risky, especially as it relates to nerve injuries.

The Ulnar Nerve in Elbow Stiffness

The ulnar nerve is at risk of injury during elbow contracture release. Acute increases in elbow motion, especially flexion, may be poorly tolerated by the ulnar nerve secondary to perineural scarring and limited nerve mobility that results from previous injury and surgery, as well as a period of restricted elbow motion. In addition, the ulnar tunnel may be already compromised by bone spurs. In rare cases, heterotopic ossification can encase and surround the ulnar nerve.

Some patients may present with a subclinical or clinical ulnar neuropathy. Failure to address the ulnar nerve at the time of contracture release may lead to severe postoperative neuropathy or inability to maintain flexion motion secondary to pain on the medial side.

Controversy remains regarding the indications of in situ ulnar nerve release or subcutaneous transposition at the time of contracture release. In our practice, the ulnar nerve is addressed surgically in patients with preoperative symptoms of ulnar neuropathy, a positive Tinel sign at the ulnar tunnel, or flexion less than 90°. Some recommend routine in situ release in all elbows undergoing contracture release, and transposition for those with established motor neuropathy or a subluxating ulnar nerve.

The need to address the ulnar nerve is considered by some an indication to proceed to open surgery using the medial column procedure. However, in situ decompression of the ulnar nerve may be performed through a small incision and combined with either a lateral column procedure or arthroscopic contracture release (Figure 13.3). In situ decompression of the ulnar nerve also provides excellent exposure for resection of the posterior band of the MCL.

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