CHAPTER 39 – Open Elbow Contracture Release

Elbow motion can be restricted by contracture of the skin, capsule, and muscles; heterotopic ossification, osteophytes, or implants; articular incongruity or damage; and malunion or nonunion.^[21] Ulnar neuropathy is commonly associated with elbow contracture and can be precipitated or exacerbated by surgeries that increase mobility.^[2] The best candidate for an arthroscopic elbow contracture release is a patient with capsular contracture with or without osteophytes. Most patients with pure capsular contractures after trauma can achieve functional motion with time and exercises (including static progressive or dynamic elbow splinting). ^{[5] [8]} Primary elbow arthritis is uncommon. Patients with less than 100 degrees of flexion or preexisting ulnar neuropathy merit ulnar nerve decompression.^[2] Once the ulnar nerve is released, it is straightforward to perform a capsular excision from the medial side.^[13] Arthroscopic elbow contracture release is more difficult and more dangerous than open contracture release, particularly because elbow arthroscopy is an uncommon procedure at which most of us are not well practiced. ^{[3] [9] [14] [16] [24]} For all of these reasons, operative treatment of elbow stiffness is best performed with an open procedure in most patients.

Preoperative Considerations

History

It is helpful to be aware of the details of prior trauma, burn, or central nervous system injury, prior surgeries in particular. In patients with prior central nervous system injury, one must determine the ability of the patient to participate in a postoperative rehabilitation protocol.^[34] A painful contracture suggests arthritis or ulnar neuropathy. Numbness and dexterity problems suggest ulnar neuropathy.

Physical Examination

The quality of the skin is important, particularly in post-burn contractures.^[28] The status of the skin with respect to prior injury and operative treatment will influence the operative tactics. When planning operative treatment of a posttraumatic contracture, we prefer to wait until the skin and scar are mobile and soft and no longer edematous or adherent. A complete motor and sensory examination of the ulnar nerve is performed along with evaluation for Tinel sign and an elbow flexion test.

Imaging

Standard anteroposterior and lateral radiographs of the elbow are usually sufficient to identify and to characterize arthritis, heterotopic ossification, and nonunions, but computed tomography is occasionally of use. In more complex cases, the computed tomographic scan can help with preoperative planning.^[34] Three-dimensional reconstructions are particularly easy to interpret. Computed tomographic scans may be particularly useful for characterizing malunion of the articular surface of the distal humerus.^[20]

Neurophysiologic testing should be considered when there is any possibility of preoperative ulnar neuropathy.

Indications and Contraindications

Morrey et al^[23] found that 15 daily activities could be accomplished with an arc of ulnohumeral motion between 30 and 130 degrees of flexion and an arc of forearm rotation from 50 degrees of pronation to 50 degrees of supination. However, these numbers should not be used to decide when to operate on elbow stiffness. Patients can adapt to and function well with much less motion,^[6] perhaps more so when the stiffness is in the nondominant elbow. Therefore, the indication for operative contracture release is a combination of diminished elbow motion and disability directly related to stiffness.

Simple capsular contracture (no heterotopic bone, no malunion or nonunion, no implants blocking motion, no ulnar neuropathy) usually responds to reassurance and encouragement of exercises, time, and static progressive or dynamic elbow splinting.^[5] Therefore, one should never rush into operative treatment of capsular contracture; patience and frequent visits for reassurance and encouragement are worthwhile.

Obvious hindrances to motion, including heterotopic bone, malunion, nonunion, prominent implants, and ulnar neuropathy, merit immediate operative treatment. Heterotopic ossification can be resected within 4 months of injury (when it is radiographically mature and the skin is mobile with little or no edema) regardless of activity on bone scans. ^{[15] [28] [33] [34]} Stiffness associated with advanced arthrosis or unsalvageable nonunion or malunion should be treated by interpositional or prosthetic elbow arthroplasty. ^{[21] [22]}

Surgical Planning

Elbow capsulectomy can be performed simultaneously with débridement of a deep infection. It also forms an integral part of the treatment of malunion,^[20] nonunion,^[11] and instability.^[26] Unstable skin can be treated with either prior or concomitant procedures to improve soft tissue coverage.^[28]

Patients with capsular contracture who desire extension can be treated with lateral capsulectomy (
Fig. 39-1

). ^{[4] [19]} Patients with concomitant ulnar neuropathy or limitation of elbow flexion are best treated with medial capsulectomy (
Fig. 39-2

). ^{[13] [36]} Patients with heterotopic bone, prominent implants, or complex contracture that cannot be adequately released from medial or lateral alone may benefit from a combined release. ^{[13] [28]} Preoperative (within 24 hours) radiation therapy (a single 7-Gy dose) is administered to patients with heterotopic bone to be excised.

Direct anterior release^[32] is rarely necessary because the anterior capsule can be more safely excised from medial or lateral. A posterior release with splitting of the triceps and fenestration of the olecranon fossa for access to the anterior elbow is used primarily for débridement of primary elbow arthrosis.^[2]

This chapter describes elbow capsulectomy through lateral (
Fig. 39-1

) and medial (
Fig. 39-2

) intervals.

Surgical Technique

Open elbow contracture release can be performed under general anesthesia or brachial plexus block. The patient is supine, and the arm is supported on a hand table. A sterile tourniquet is applied to the upper arm.

The skin incision can be straight and directly over the muscle interval to be used or posterior with a skin flap elevated to expose the muscle interval (
Fig. 39-1C

). If both medial and lateral intervals are to be used, a single posterior incision or both medial and lateral incisions can be made. In the unusual case of a direct anterior release, a direct anterior skin incision that crosses the flexion creases obliquely is made.

Specific Steps

Lateral Elbow Capsulectomy (
Box 39-1

)

1. Lateral Approach and Posterior Dissection

Release of elbow stiffness from the lateral side preserves the common wrist and digit extensors overlying the lateral collateral ligament. The skin is mobilized off the fascia to help identify the appropriate deep muscle interval (
Fig. 39-1D

). Deep dissection begins by identification of the supracondylar ridge, dividing the overlying fascia and exposing the ridge (
Fig. 39-1E

). The triceps is elevated off the posterior humerus and elbow capsule (
Fig. 39-1F

). The posterior dissection continues distally in the interval between the anconeus and extensor carpi ulnaris. The anconeus is elevated off the capsule, the humerus, and the ulna (
Fig. 39-1G

). Care is taken to preserve the lateral collateral ligament complex while the posterior elbow capsule is excised. The olecranon fossa is cleared out and even burred to deepen it if necessary (
Fig. 39-1H

). Loose bodies are identified and removed (
Fig. 39-1I

). The tip of the olecranon can also be excised (
Fig. 39-1J and K

).

Box 39-1 

Surgical Steps for Lateral Capsulectomy

1.    Lateral approach and posterior dissection    2.    Anterior dissection    3.    Medial dissection

2. Anterior Dissection

The origin of the extensor carpi radialis and part of the origin of the brachioradialis are released and elevated along with the brachialis off the anterior humerus and elbow capsule (
Fig. 39-1L and M

). Distally, an interval is developed just anterior to the midportion of the capitellum, roughly corresponding to the split between the extensor carpi radialis brevis and the extensor digitorum communis, although in practice the interval is not precise (
Fig. 39-1L, N, and O

). Keeping the dissection over the anterior half of the radiocapitellar joint will protect the lateral collateral ligament complex. The anterior elbow capsule is excised (
Fig. 39-1N

).

3. Medial Dissection

At the medial side of the elbow, the capsulectomy may transition to a capsulotomy for safety, depending on visualization (
Fig. 39-1O

). The radial and coronoid fossae can be cleared out and deepened as needed (
Fig. 39-1P

). The tip of the coronoid can be excised (
Fig. 39-1Q and R

). Resection of a deformed radial head may also be helpful in some patients.

Both the anterior and the posterior muscle intervals are sutured (
Fig. 39-1S and T

). Drains are used at the discretion of the surgeon. The skin is closed according to the surgeon’s preference.

Medial Elbow Capsulectomy

After skin incision, the ulnar nerve is identified on the medial border of the triceps. A complete release of the nerve through the arcade of Struthers, Osborne ligament, and flexor-pronator aponeurosis is then performed, along with neurolysis of the ulnar nerve if there is extensive scarring (
Fig. 39-2C

). Skin flaps can be safely elevated once the ulnar nerve is identified and protected.

The flexor-pronator mass is identified and split in half between the interval where the ulnar nerve runs and the anterior margin of the muscle mass. The anterior half of the flexor-pronator mass and the brachialis muscle are elevated off the anterior humerus and elbow capsule (
Fig. 39-2D to F

). The triceps is elevated off the distal humerus and the posterior elbow capsule (
Fig. 39-2G

). Capsular excision, fossae deepening, and coronoid and olecranon tip excision are as described for lateral capsulectomy.

Heterotopic Bone Excision and Other Factors

Heterotopic bone is excised piecemeal, with care taken to identify and to protect native bone and articulation. Bleeding bone surfaces are covered with bone wax. Implants are removed after capsulectomy and elbow manipulation to limit the risk of fracture. Malunion and nonunion are addressed as necessary.

Postoperative Considerations

Rehabilitation

Gravity-assisted and active-assisted range of motion exercises are initiated the morning after surgery. Static progressive or dynamic splints are used in patients who have trouble maintaining motion obtained in surgery. These splints are initiated as soon as the wound is stable.

Complications

Complications include recurrent stiffness and ulnar neuropathy (due to restoration of flexion or to handling of the nerve).

PEARLS AND PITFALLS

•    Release of a flexion contracture, especially in patients with primary osteoarthritis, can result in ulnar neuropathy.    •    The lateral collateral ligament can be protected by limiting the dissection to the anterior half of the radiocapitellar joint.

Results

The majority of published case series reporting the results of open elbow contracture release describe a single technique used to treat patients with a variety of diagnoses (
Table 39-1

). The results of various techniques seem comparable, although few data are available about the use of a medial exposure for posttraumatic contractures. ^{[25] [36]} In general, about 75% regain at least an 80-degree arc of flexion.^[25] Patients with limited flexion—particularly due to primary osteoarthritis—may be susceptible to ulnar neuropathy after release.^[2] The results of excision of subtotal heterotopic ossification may be superior to the results of capsular contracture release alone,^[18] but the results of excision of complete bone ankylosis, although generally rewarding, are less predictable.^[28]

Author	No. of Patients	Diagnosis	Operative Technique	Preoperative Arc (degrees)	Postoperative Arc (degrees)
Tosun et al[31] (2006)	22	Posttraumatic	Combined lateral and medial	35	86
Ring et al[25] (2006)	46	Posttraumatic	Patient-specific, variable	45	103
Tan et al[30] (2006)	52	Posttraumatic	Patient-specific, variable	57	116
Ring et al[27] (2005)	42	Posttraumatic	Patient-specific, variable; 23 had hinged external fixation	21	105
Aldridge et al[1] (2004)	77	Posttraumatic	Anterior; most with continuous passive motion postoperatively	59	97
Gosling et al[7] (2004; Epub May 30, 2003)	59	Posttraumatic	Patient-specific, variable	68	101
Wu[37] (2003)	20	Posttraumatic	Patient-specific, variable	47	118
Heirweg and De Smet[10] (2003)	16	Posttraumatic	Patient-specific, variable	47	87
Stans et al[29] (2002)	37	Mixed; age younger than 21 years	Patient-specific, variable	66	94
Wada et al[35] (2000)	13	Posttraumatic	Medial	46	110
Kraushaar et al[17] (1999)	12	Posttraumatic	Lateral	70	117
Mansat and Morrey[19] (1998)	37	Mixed	Lateral	49	94
Cohen and Hastings[4] (1998)	22	Posttraumatic	Lateral	74	129
Hertel et al[12] (1997)	26	Mixed	Patient-specific, variable	66	100