Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion

Regional distribution prevalence of heterotopic ossification in the elbow joint: a 3D study of patients after surgery for traumatic elbow injury

BACKGROUND

Heterotopic ossification (HO) is a common complication after elbow fracture surgery and can lead to severe upper extremity disability. The radiographic localization of postoperative HO has been reported previously. However, there is no literature examining the distribution of postoperative HO at the three-dimensional (3D) level. This study aimed to investigate 1) the distribution characteristics of postoperative HO and 2) the possible risk factors affecting the severity of postoperative HO at a 3D level.

METHODS

A retrospective review was conducted of patients who presented to our institution with HO secondary to elbow fracture between 13 January 2020 and 16 February 2023. Computed tomography scans of 56 elbows before elbow release surgery were reconstructed in 3D. HO was identified using density thresholds combined with manual identification and segmentation. The elbow joint and HO were divided into six regions according to three planes: the transepicondylar plane, the lateral ridge of the trochlear plane, and the radiocapitellar joint and coronoid facet plane. The differences in the volume of regional HO associated with different initial injuries were analyzed.

RESULTS

Postoperative HO was predominantly present in the medial aspect of the capsule in 52 patients (93%), in the lateral aspect of the capsule in 45 patients (80%), in the medial supracondylar in 32 patients (57%), and in the lateral supracondylar, radial head, and ulnar region in the same number of 28 patients (50%). The median and interquartile range volume of total postoperative HO was 1683 (777-4894) mm3. The median and interquartile range volume of regional postoperative HO were: 584 (121-1454) mm3 at medial aspect of capsule, 207 (5-568) mm3 at lateral aspect of capsule, 25 (0-449) mm3 at medial supracondylar, 1 (0-288) at lateral supracondylar, 2 (0-478) at proximal radius and 7 (0-203) mm3 at the proximal ulna. In the subgroups with Injury Severity Score > or = 16, Gustilo-Anderson II, normal uric acid levels, elevated alkaline phosphatase, and body mass index > or = 24, the median HO volume exceeds that of the respective control groups.

CONCLUSION

The medial aspect of the capsule was the area with the highest frequency and median volume of postoperative HO among all initial elbow injury types. Patients with higher Gustilo-Anderson grade, Injury Severity Score, alkaline phosphatase or Body Mass Index had higher median volume of postoperative HO.

Effect of electroacupuncture combined with rehabilitation training on hypertension: A systematic review and meta-analysis

To evaluate the clinical effects of electroacupuncture combined with rehabilitation training (EART) versus conventional rehabilitation training (CRT) on hypertension. Multiple databases like PubMed, Embase, Web of Science and Wanfang database, China National Knowledge Internet database, and Chinese Biological Medical database were used to search for the relevant studies and full-text articles involved in evaluating EART versus CRT with hypertension. Review Manager 5.4 was used to estimate the effects of the results among included articles. Forest plots, sensitivity analysis, and funnel plots were also conducted on the included articles. In this meta-analysis study, there were 9 relevant studies were eventually satisfied the included criteria. There were significant differences between EART group and CRT group in systolic blood pressure after treatment (MD -16.62, 95 %CI = -21.84 to -11.39; P < 0.00001), diastolic blood pressure after treatment (MD = -16.03, 95 % CI = -21.55 to -10.50; P < 0.00001), and effective rate (MD = 1.22, 95 % CI = 1.13 to 1.32; P < 0.00001). Sensitivity analysis and funnel chart demonstrated that the study was robust and limited publication bias was observed. Our data showed that EART was clinically more significant than CRT in hypertension. Further studies need to be performed using large relevance references to verify the effectiveness of EART in the treatment of hypertension.

Heterotopic Ossification in Burn Patients

ABSTRACT

Heterotopic ossification (HO) is a known complication of burns. The incidence of this complication is low. The etiology is unclear, but experiment conducted about HO can be significant. Currently, there are still no targeted, effective preventive and therapeutic measures against it. In this study, the relevant literature is summarized to demonstrate the potential pathogenic mechanisms, diagnosis, prophylaxis, and treatment measures of HO in burn patients. Early diagnosis and treatment can be effective in improving the prognosis of patients.

Skin Graft Versus Local Flaps in Management of Post-burn Elbow Contracture

Introduction

Contracture is a pathological scar tissue resulting from local skin tissue damage, secondary to different local factors. It can restrict joint mobility, resulting in deformity and disability. This study aimed to investigate the outcomes of skin grafts compared to local flaps to reconstruct post-burn elbow contractures. These parameters included regaining function, range of movement, recurrence, and local wound complications.

Methodology

A retrospective study reviewed 21 patients for elbow reconstruction over 12 months. Only patients with post-burn elbow contracture were included. Other causes, including previous corrective surgery, associated elbow stiffness, and patients who opted out of post-operative physiotherapy, were excluded. Patients were categorized according to the method of coverage into three groups: graft alone (G1), local flap (G2), or combined approach (G3). 

Results

Females were three times at higher risk to suffer a burn injury, while almost half of the cases were children. Scald injury represented 81% of burn causes. G1,2,3 were used in 47.6%, 42.9% and 9.5% of cases retrospectively. The overall rate of infection was 28.6%. Hundred percent graft taken was recorded in 83.3 % of cases; however, flap take was 91.1%. After 12 months of follow-up, re-contracture was 60% and 22.8% in G1 and G2; however, the satisfaction rate was 70% and 100% in both groups retrospectively. The overall satisfaction was 85.7% in all groups.

Conclusion

Grafts and local flaps are reasonable options for post contracture release; however, flaps are superior. Coverage selection depends on the lost tissue area and exposure of underlying deep structures. Physiotherapy and patient satisfaction are crucial in the outcomes. 

Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness

BACKGROUND

To evaluate and compare the functional outcomes of combined medial-lateral approach open arthrolysis with and without hinged external fixation.

METHODS

We retrospectively collected and analyzed the clinical data of patients with severe elbow stiffness who were treated in our institution from January 2018 to January 2019. All of them were treated with combined medial-lateral approach arthrolysis. There were 20 patients who had the hinged external fixation placed and 29 patients without the placement of the external fixation. Their baseline characteristics and functional outcomes were evaluated and compared.

RESULTS

The average follow-up time was 28.4 ± 3.7 months. There were no significant differences in the ROM of the elbow, MEPS, VAS, DASH, or complications between the two groups. The operation time and treatment cost of the patients without external fixation were significantly lower than patients with external fixation.

CONCLUSION

Combined medial-lateral approach open elbow arthrolysis without external fixation is a safe and effective way to treat elbow stiffness.

LEVEL OF EVIDENCE

Therapeutic Level III; Retrospective Cohort Comparison; Treatment Study.

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.

Heterotopic ossification formation after fractures about the elbow

INTRODUCTION

Heterotopic ossification (HO) is a well-known sequela after an elbow injury and is widely studied given the associated morbidity. The anatomic location of HO development for specific elbow injuries has not been reported. The purpose of this study was to describe the precise, anatomic location of HO development after different peri-articular elbow injuries.

METHODS

A retrospective chart review was performed for patients with peri-articular elbow fracture and/or dislocation who underwent an elbow contracture release. The injuries were grouped into coronal shear distal humerus/AO 13.B3 (CSDH), distal humerus/AO 13.A, 13.B1, B2 or 13.C (DH), olecranon/AO 21.B1 (OL), radial head/AO 21.B2 (RH), extra-articular proximal radius and ulna/AO 21.A (EAPRU) fractures and elbow dislocations (DL). The HO location was determined by reviewing elbow radiographs and CT scans and were classified as anterior capsule, medial or lateral collateral ligaments, and posterior capsule/triceps insertion.

RESULTS

The study consisted of 49 patients, such as 6 CSDH, 13 DH, 6 OL, 21 RH, 4 EAPRU fractures and 20 elbow DL. All CSDH and RH fractures and 19/20 elbow DL developed HO in the collateral ligaments, while 12/13 DH fractures developed an anterior capsule HO. All 6 OL fractures developed HO posteriorly, and 3/4 EAPRU fractures developed a proximal radioulnar synostosis.

CONCLUSIONS

Our findings suggest that the location of HO development is specific to the injury type and is influenced by the soft tissues involved. This is consistent with the understanding that HO is the abnormal ossification of normal structures.

Prolonged dislocation and delay to surgery are associated with higher rates of heterotopic ossification in operatively treated terrible triad injuries

Background

Heterotopic ossification (HO) formation after complex elbow injuries can significantly impact function. Prior studies have reported a 3%-45% incidence of HO following elbow trauma in a heterogeneous cohort of fracture patterns. The purpose of our study was to evaluate the prevalence of and identify risk factors for HO specifically in patients with terrible triad injuries.

Methods

A total of 61 patients (64 elbows) underwent operative treatment for terrible triad injuries with an average follow-up period of 19.8 months (range, 3-138 months). The medical records were reviewed for demographic data, duration of dislocation, number of reduction attempts, time to surgery, presence of radiographic HO, elbow motion at final follow-up, functional limitations, and need for secondary procedures.

Results

Radiographic HO developed in 77% of patients, and 63% had some level of functional restriction. Thirteen patients (26%) underwent a secondary procedure for HO excision. Patients with HO had a longer time to surgery (4.9 days vs. 2.8 days, P = .02), longer duration of dislocation (21 hours vs. 6 hours, P = .04), and reduced flexion-extension (94° vs. 112°, P = .04) and pronation-supination (109° vs. 163°, P = .002) arcs of motion compared with patients without HO. HO was also more likely to develop in patients who required closed reduction than in those with spontaneous reduction prior to presentation.

Conclusion

The prevalence of radiographic and clinically relevant HO after terrible triad injuries was higher than previously reported. Persistent dislocation necessitating a closed reduction, a longer duration of dislocation, and a delay to surgery were associated with the development of HO. Providers should consider earlier surgical stabilization or urgent referral to a specialist for patients with unstable injuries.

Post-traumatic elbow stiffness: Pathogenesis and current treatments

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

Use of a modified Outerbridge-Kashiwagi procedure for the treatment of posttraumatic elbow sequelae

BACKGROUND

To review our 10-year experience treating posttraumatic sequelae of the elbow using a modified Outerbridge-Kashiwagi (O-K) procedure.

METHODS

Twenty-one patients with posttraumatic sequelae of the elbow treated using the technique were evaluated clinically using the Mayo Elbow Performance Score, range of motion testing, and pain level. We noted the presence of preoperative and postoperative ulnar nerve symptoms, complications, and reoperations. Open contracture release was selected to address either removal of hardware or ulnar nerve pathology.

RESULTS

At a mean of 39 months (range, 12-116 months), the Mayo Elbow Performance Score improved from 52 to 84 (P < .0001) and the mean arc of motion improved from 44° to 98° (P < .0001). At the final follow-up, 90% of patients reported no pain or mild pain, and 81% of patients had a satisfactory objective result. In 15 of 21 cases (71%), it was necessary to mobilize the ulnar nerve. After contracture release, 1 patient developed new onset ulnar nerve symptoms. Three patients underwent reoperation: 2 for recalcitrant contracture and 1 for new onset ulnar nerve symptoms.

CONCLUSIONS

The mini-open O-K procedure is safe and effective in restoring function in patients with retained hardware and posttraumatic contracture. Posttraumatic arthritic patients often require both removal of hardware and neurolysis of the ulnar nerve. The mini-open O-K procedure allows complete access to the elbow joint, which facilitates release for both intrinsic and extrinsic contracture.

Complications of open reduction and internal fixation of distal humerus fractures

Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution.

Fixation with two precontoured anatomical locking plates at 90^o:90^o orthogonal or 180^o parallel is the optimal treatment.

The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness.

Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common.

Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009

Posttraumatic Elbow Stiffness: A Critical Analysis Review

Open and arthroscopic release are both effective surgical treatments for posttraumatic elbow stiffness. Both static and dynamic bracing are effective for increasing elbow range of motion when heterotopic ossification is not present. Some loss of immediate postoperative range of motion is expected. Recurrence of heterotopic ossification around the elbow is rare. The occurrence of ulnar nerve palsy is rare and often requires transposition.

Open surgical elbow contracture release after trauma: results and recommendations

BACKGROUND

Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture.

METHODS

A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded.

RESULTS

The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion.

CONCLUSION

Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.

Appropriate excision time of heterotopic ossification in elbow caused by trauma

OBJECTIVE

The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow.

METHODS

We retrospectively reviewed 42 patients who were treated operatively for heterotopic ossification of the elbow from March 2010 to December 2014 at our institution. The patients were divided into early (before 12 months) and late (after 12 months) excision groups. In the early excision group (17 patients), the average time from the initial injury to HO excision was 7.4 (3-11) months, and in the late excision group (25 patients), the average time was 33.5 (12-240) months. Every patient was evaluated by range of motion (ROM), the Mayo Elbow Performance Score (MEPS), postoperative complications and HO recurrence.

RESULTS

The preoperative mean ROM in the late excision group was greater than that of the early excision group, suggesting that the ROM is expected to increase even without surgery. Both early and late surgery increased ROM and MEPS, but early surgery improved ROM and MEPS more than late surgery did (p < .05).

CONCLUSIONS

Early excision of HO can provide better elbow function, as indicated by ROM and MEPS. Considering that there were no notable differences in postoperative ROM and MEPS, HO recurrence, or postoperative complications, we concluded that early excision is safe and that the time from an elbow injury to surgery may be shortened.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The timing of open surgical release of post-traumatic elbow stiffness: A systematic review

BACKGROUND

Open release of post-traumatic elbow stiffness is effective in restoring elbow function, but there is no guideline on the optimal time point of surgical release so far. The purpose of this article was to summarize the current available literature reporting on the timing of open release of post-traumatic elbow stiffness.

METHODS

The PubMed, Cochrane Library, and EMBASE were searched with a set of predefined inclusion and exclusion criteria. Manual searches for references were performed to find potential relevant studies. Two authors separately extracted data from all the articles selected.

RESULTS

27 articles published between 1989 and 2017 were included with an overall enrollment of 836 patients. We divided all included studies into 3 groups according to the timing of surgical release: group 1 (6-10 months after injury), group 2 (11-20 months after injury), and group 3(>20 months after injury). The mean postoperative Mayo Elbow Performance Score (MEPS) and recurrence rate were similar among the 3 groups; however, the mean gain in arc of motion in group 1 was the highest with the lowest complication rate among the 3 groups.

CONCLUSION

There was a trend toward a shorter waiting time from injury to open arthrolysis from 12 months to 6 months. The shorter waiting period of 6 to 10 months yielded better results. Therefore, early surgical release of stiff elbows is recommended for a shorter rehabilitation time and earlier return to work.

LEVEL OF EVIDENCE

Level IV, Systematic Review.

Heterotopic Ossification and Hypertrophic Scars

Burns and trauma cause superficial and deep soft tissue wounds that cannot heal to the preinjury state. Healing requires cell proliferation and differentiation into the injured tissue type, laying down extracellular matrix, often as collagens. Heterotopic ossification causes severe pain, nonhealing wounds, and restricted range of motion. Treatment includes radiation therapy, nonsteroidal anti-inflammatory drugs, bisphosphonates, and possibly surgical excision and prophylactic measures. Hypertrophic scars, nonosseous lesions caused by excessive collagen deposition, are often painful, functionally limiting, and aesthetically displeasing. Treatment includes CO2 laser application, steroid injections, and excision with skin grafting. This article reviews the management of these pathologic wounds.

Heterotopic Ossification Following Upper Extremity Injury

Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.

Restoring independency with an osteochondral graft of the navicular for coronoid process reconstruction

INTRODUCTION

The coronoid is a crucial element for elbow stability. In case of posttraumatic instability or reduced range of motion, a complex reconstruction might be necessary.

CASE

We present the case of a polytraumatized patient with complex upper extremity injury and initial poor outcome. Subluxation after initial surgery was treated by sublime tubercle reconstruction with a corticocancellous iliac crest graft. Due to massive ossification, the elbow remained stiff and the paraplegic patient was unable to use a manually propelled wheelchair. After arthrolysis, the unstable elbow was treated with an osteocartilaginous graft from the navicular of the foot as well as ulnar and radial collateral ligamentoplasties. At the time of follow-up, the patient had a stable joint and was able to independently perform activities of daily living.

CONCLUSION

An autologous navicular graft seems to be an excellent option for our paraplegic patient as the shape matches the sublime tubercle of the ulna.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

The clinical implications of heterotopic ossification in patients treated with radial head replacement for trauma: A case series and review of the literature

Radial head arthroplasty (RHA) is an acceptable treatment for comminuted radial head fractures (RHF). Fourteen patients with no postop HO prophylaxis were treated with RHA for comminuted RHF. A 50% incidence in HO was seen following RHA with a statistically increased risk (p ≤ 0.05) of reoperation compared to those without HO. Decreased ROM was seen on the affected side (p ≤ 0.05); patients without HO showed no statistical difference (p ≥ 0.05) in ROM or grip strength. HO following RHA increases patient risk for reoperation and decreases ROM. We recommend HO prophylaxis with NSAIDs and/or radiotherapy if no direct patient contraindications are found.

Articular osteotomy of the distal humerus and excision of extensive heterotopic ossification

Prior case series of corrective osteotomy of substantial intra-articular malunion after a fracture of the distal humerus described concomitant heterotopic ossification in a subset of patient, but only in mild forms. We present our experience in treating two patients with malunited articular fractures of the distal humerus with extensive heterotopic ossification and near ankylosis where the lateral articular fragments were encased in heterotopic bone. Although osteotomy of articular malunion after distal humeral fracture along with excision of extensive HO is challenging and risky due to potential devitalization of the fragments, articular deterioration during the delay to osteotomy, and recurrence of heterotopic bone among other concerns, restoring articular congruity in these patients using articular fracture fragments extracted from heterotopic ossification can lead to improved function of the elbow.

POST-TRAUMATIC STIFFNESS OF THE ELBOW

Elbow stiffness is a common problem after joint trauma, causing functional impairment of the upper limb. The severity of the dysfunction depends on the nature of the initial trauma and the treatment used. Appropriate clinical evaluation and complementary examinations are essential for therapeutic planning. Several surgical techniques are now available and the recommendation must be made in accordance with patient characteristics, degree of joint limitation and the surgeon's skill. Joint incongruence and degeneration have negative effects on the prognosis, but heterotrophic ossification alone has been correlated with a favorable surgical prognosis.

Distal Humerus Fractures: Open Reduction Internal Fixation

Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results.

Complications of Open Elbow Arthrolysis in Post-Traumatic Elbow Stiffness: A Systematic Review

Objective

The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients with post-traumatic elbow stiffness and provide a reference for better prevention and treatment of them.

Methods

The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for therapeutic studies with a set of inclusion and exclusion criteria. Data were extracted from selected articles, and a statistical analysis was performed to evaluate related factors and management of the complications.

Results

Twenty-eight articles published between 1989 and 2013, involving 810 patients, were included. Most of the complications included in the selected articles were nerve complications, heterotopic ossification, elbow instability, infection, pin-related complications and repeat elbow contracture. The total complication rate was 24.3% ± 3.0%, and the reoperation rate was 34.0%. Furthermore, the statistical analysis revealed that preoperative range of motion (β = -0.004, P = 0.01) and proportion of female (β = 0.336, P = 0.04) were the independent factors affecting the total complication rate.

Conclusions

Various risk factors are related to each of the complications, and we found that patients with less preoperative ROM and a higher proportion of female gender may point to a higher total complication rate. Therefore, to further improve the overall outcomes of this procedure, more and larger prospective studies should be performed to further elucidate the effects of prophylactic interventions targeting the risk factors, thus improving the methods of prevention and treatment of complications.

Open surgical release for contractures of the elbow

Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.

Limited Medial and Lateral Approaches to Treat Stiff Elbows

Open arthrolysis is an effective way to treat elbow stiffness. However, previous approaches led to significant surgical trauma. The goal of the current study was to evaluate the outcome of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation to treat elbow stiffness. A total of 18 patients (18 elbows) with elbow stiffness were retrospectively reviewed. The same inclusion and exclusion criteria were used for all patients. Preoperatively, the mean flexion arc was 43°±28° and the mean Mayo Elbow Performance Score was 62 points. Limited medial and lateral approaches were used to provide safe and complete arthrolysis. The other protocols included ulnar nerve transposition, medial epicondyle osteotomy, radial head resection, ligament repair, and hinged external fixation. Patients were encouraged to begin early rehabilitation 24 hours after surgery. At a mean follow-up of 20 months, the flexion arc improved to 130°±11° and the mean Mayo Elbow Performance Score was 97 points (15 excellent, 3 good). One patient had elbow instability, but function met the requirements of his daily life. Transient ulnar nerve palsy without infection occurred in 4 patients. With limited medial and lateral approaches, elbow stiffness can be treated effectively with open arthrolysis. This method is trauma controlled. Furthermore, a hinged external fixator can provide sufficient and safe rehabilitation. The use of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation is an effective and safe method to treat elbow stiffness.

Nonacute Treatment of Elbow Fracture with Persistent Ulnohumeral Dislocation or Subluxation

➤ There are patterns of traumatic elbow instability that help a surgeon to anticipate which structures are injured.➤ Patients treated for persistent subluxation or dislocation of the elbow more than two weeks after injury regain less motion and experience more adverse events.➤ The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion.➤ Motion and pain are affected by contracture and scarring of the soft tissues, malalignment of the joint, fracture malunion, damage to the articular surface, and ulnar neuropathy.➤ Biomechanical and clinical studies support treatment with radial head arthroplasty and/or coronoid reconstruction for patients who have osseous insufficiency.

Improvements in elbow motion after resection of heterotopic bone: a systematic review

Complex elbow trauma, severe burn, or a closed head injury render patients at risk for developing heterotopic ossification around the elbow. When heterotopic ossification restricts elbow motion, some patients request surgical resection. We performed a systematic review of the literature to analyze improvement in elbow motion after resection of heterotopic ossification around the elbow. We found that, on average, etiology had little impact on outcome after resection of heterotopic ossification. Resection of heterotopic bone generally leads to improvement of elbow function.

Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention

INTRODUCTION

The treatment of terrible triad injury with a poor outcome after intervention has not been successful thus far. The purpose of this study was to evaluate the efficacy of arthrolysis and reconstruction in the treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention.

MATERIALS AND METHODS

Twelve patients (12 elbows) with the diagnosis of terrible triad injury were respectively reviewed. All the 12 patients had elbow dysfunction after conservative and surgical treatment of the terrible triad injury. Preoperatively, the flexion arc and forearm rotation were 36.7° ± 28.5° and 51.3° ± 43.4°, respectively, and the Mayo Elbow Performance Score was 56.3 points. The mean interval between the primary injury and our surgical treatment was 6.6 months. Our surgical intervention included elbow arthrolysis, ulnar nerve transposition, radial head replacement, coronoid process and ligament repair, and hinged external fixation. Patients were encouraged to participate in rehabilitation training 24 h after surgery.

RESULTS

The mean follow-up duration was 20.1 months; the flexion arc and forearm rotation were 122° ± 18° and 140° ± 20°, respectively, and the mean Mayo Elbow Performance Score was 94.6 points (9 excellent, 3 good). Concentric stability was restored in all elbows. Complications included superficial pin tract infection (1), heterotopic ossification (3), and ulnar nerve palsy (1); the ulnar nerve symptoms had improved at the last follow-up.

CONCLUSIONS

The combination of open arthrolysis and reconstruction performed at a mean interval of 6-month posttrauma can restore functional mobility in cases of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Thus, it may be an effective alternative for the treatment of the poor outcome terrible triad injury. We recommend early functional rehabilitation with adherence to the guidelines for hinged external fixation.

Prevention and treatment of elbow stiffness: a 5-year update

Elbow stiffness is a challenging and common problem faced by upper extremity surgeons. Although functional improvements can be made with both nonsurgical and surgical management strategies, physicians must remain vigilant with efforts to prevent stiffness before it starts. Recent advancements in the biology and pathology of elbow contracture have led to improved understanding of this difficult problem, and they may lead to future breakthroughs in the prevention and treatment of elbow stiffness. This article serves as an update to our previous review of elbow stiffness, focusing on recent advancements in the past 5 years, as well as updating our current algorithm for treatment.

Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification

BACKGROUND

Heterotopic ossification (HO) is considered as a common extrinsic cause of elbow stiffness. The purpose of this study was to show the results of surgical treatment for post-traumatic elbow stiffness caused by HO in a large, consecutive series of patients in a single unit.

METHODS

We retrospectively reviewed 77 surgically treated patients with post-traumatic elbow stiffness caused by HO. Final motion arc and Mayo Elbow Performance Index (MEPI) were assessed as final results. Univariable and multivariable analyses were done to determine which factors had an effect on the final motion arc.

RESULTS

The average arc of elbow motion increased from 45° preoperatively to 112°, with an improvement of 67° at the final follow-up evaluation. The mean MEPI score was 91.9. At the final evaluation, 65 patients (84.4%) obtained a total motion arc of ≥100°. Recurrent HO was observed in 16 patients postoperatively, and 6 underwent repeated surgical release. The time from the initial injury to surgical release with a cutoff value of 19 months was the only independent factor affecting the final range of motion (ROM) in multivariable median regression analysis. With the numbers studied, no significant association was found between the final ROM and other clinical variables except for the recurrence of HO (93° vs 117°).

CONCLUSIONS

From the results of our study, we can support the surgical treatment of elbow stiffness caused by post-traumatic HO regardless of preoperative ROM. However, recurrence of heterotopic bone and delay in surgery of more than 19 months are associated with less favorable results.

Clinical results of the excision of heterotopic bone around the elbow: a systematic review

BACKGROUND

Heterotopic ossification (HO) of the elbow can occur following direct trauma, brain injury, or burns. Development of elbow HO is sporadic, making levels 1-3 clinical evidence difficult to establish. We systematically reviewed literature regarding management and outcomes of surgically treated elbow HO.

METHODS

A systematic review of the literature regarding elbow HO was performed to compare imaging modalities, surgical timing, surgical approaches, and methods of prophylaxis in outcomes of patients treated with excision.

RESULTS

Our systematic review included 24 level 3 or 4 studies investigating 384 post-trauma (158), brain injury (105), or burn (94) patients with elbows complicated by HO that were treated with surgical excision. Average patient age was 36.9 years and there was a 65/35 M/F ratio. For all etiologies, preoperatively elbow flexion/extension averaged 53/83; postoperatively elbow flexion/extension significantly improved to 22/123. Regardless of the etiology, surgical excision of elbow HO significantly improved functional range of motion. Neither total body surface area (TBSA) burned for burn patients or Garland classification for brain-injured patients correlated with outcome. Overall complication rate was 22.6% and included HO recurrence (11.9%), ulnar nerve injury, infection, and delayed wound healing.

CONCLUSION

Surgical treatment of elbow HO leads to improved functional outcome, whether the etiology of bone formation was direct elbow trauma, brain injury, or thermal injury.

Surgical treatment of post-traumatic elbow stiffness: a systematic review

BACKGROUND

Trauma to the elbow is a common cause of joint stiffness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. There is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiffness. The objective of this article was to review current available literature of studies reporting on open or arthroscopic release of post-traumatic elbow stiffness.

METHODS

A comprehensive literature search was performed. All titles and abstracts of potentially relevant studies were reviewed, with a set of predefined inclusion and exclusion criteria. After the initial assessment for inclusion, 2 authors extracted data independently from the included articles.

RESULTS

Thirty articles were included, with an overall enrolment of 798 patients. No randomized controlled trials were retrieved. The first article was published in 1989 and the most recent in 2012. There were 4 different kinds of treatment modalities identified from the included studies: 1) open arthrolysis; 2) arthroscopic arthrolysis; 3) open arthrolysis with external fixation; and 4) open arthrolysis with distraction arthroplasty. The gain in range of motion was 51°, 40°, 88°, and 56° for groups 1-4, respectively. The average percentage of complications was 23, 5, 73, and 58 for groups 1-4, respectively.

CONCLUSION

Current literature is not sufficient enough to draw firm statistically based conclusions. However, as the amount of complications seems to rise with the extent of the surgical procedure, we would advise to treat as less invasive as possible (grade C).

Surgical release of elbow stiffness after internal fixation of intercondylar fracture of the distal humerus

BACKGROUND

Loss of motion is common after intercondylar fracture of the distal humerus despite proper management. The purpose of the current study was to report the results of contracture release for stiffness that developed after open reduction and internal fixation (ORIF) of distal humeral intercondylar fractures.

METHODS

Twenty-four consecutive patients with a stiff elbow after ORIF of intercondylar fractures (20 AO type C2 and 4 type C3 fractures) were managed with contracture release at a median of 13 months. The surgical indication was total arc of motion of less than 100° despite physical therapy for more than 6 months. Plates and screws for ORIF were removed concomitantly in 16 patients. Each patient was evaluated by final arc of motion and Mayo Elbow Performance Score (MEPS).

RESULTS

The main lesions causing stiffness were heterotopic ossification or excessive callus in 13 patients and capsular fibrosis in 11. The mean total range of motion (ROM) was improved from 60.2° preoperatively to 104.8° postoperatively. At the final follow-up, 17 of the 24 elbows (71.8%) obtained a total ROM of more than 100°. The mean MEPS improved from 69 points preoperatively to 87 points at the final follow-up (P < .05). Refracture occurred during ROM exercise in 4 patients who had undergone concomitant implant removal during the contracture release.

CONCLUSION

Surgical release of a stiff elbow that develops after ORIF of intercondylar fractures can result in satisfactory restoration of ROM in most patients. However, potential risk of refracture after release should be considered when implants are concomitantly removed.

Operative Treatment of Elbow Stiffness

Introduction

Open elbow contracture release is the mainstay for the operative treatment of posttraumatic elbow stiffness.

Step 1 Skin Incision

Use either a posterior skin incision and raise medial and lateral skin flaps or use more direct individual medial and lateral skin incisions.

Step 2 Protect or Release Peripheral Nerves

Release the ulnar nerve using a small incision and in situ release when a lateral muscle interval (between the extensor carpi radialis brevis and extensor digitorum communis muscles) is preferred for the contracture release; use a larger incision with subcutaneous anterior transposition when a medial muscle interval (50:50 split of the flexor pronator mass) is used.

Step 3 Develop Muscle Intervals for Exposure of the Joint

Choose a lateral (extensor carpi radialis brevis/extensor digitorum communis) or medial (50:50 split of the flexor pronator mass) muscle interval to expose the elbow capsule.

Step 4 Resect Bone Contracted Capsule and Implants Restricting Motion

Remove the structures that hinder motion: implants, heterotopic bone, and contracted capsule.

Step 5 Tenolysis/Muscle Elevation

When the triceps and the brachialis muscles are adherent to the distal third of the humerus, release them using an elevator.

Step 6 Manipulate Elbow Consider Implant Removal

Take care not to push so hard that you fracture the bone at a stress riser created by removal of bone or implants.

Step 7 Wound Closure

Close the muscle intervals and skin.

Step 8 Postoperative Management

The key after surgery is frequent, active, patient-assisted elbow flexion, extension, and forearm rotation stretches.

Results

A case series of patients with elbow contracture release documented an average improvement in the arc of elbow flexion of between 21° and 66°.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Surgical release for posttraumatic loss of elbow flexion

BACKGROUND

Several surgical approaches have been suggested for the treatment of posttraumatic elbow stiffness; however, the optimal approach to elbows with considerable loss of flexion has not been well described. We investigated the pathologic lesions causing posttraumatic loss of elbow flexion and analyzed the results of surgical release.

METHODS

Forty-two patients with <100° of elbow flexion due to an extrinsic contracture following trauma underwent surgical release at a median of ten months after injury. To achieve maximum flexion, release of the posterior band of the medial collateral ligament was mandatory in all patients, and only four patients required additional anterior procedures. The ulnar nerve was transposed anteriorly in forty patients, including three who had had a previous transposition. To evaluate the results, we compared preoperative and postoperative elbow motion, Mayo Elbow Performance Index (MEPI) scores, and radiographs.

RESULTS

Intraoperatively, heterotopic ossification was observed in forty patients. It was located predominantly in the posteromedial aspect of the capsule. Heterotopic bone was more commonly found during surgery than it was identified preoperatively on radiographs. Mean flexion increased significantly from 89° preoperatively to 124° (range, 90° to 140°) at a mean of thirty-nine months postoperatively. The mean size of the flexion contracture decreased from 34° preoperatively to 9° (range, 0° to 30°) postoperatively. Overall, ≥120° of final flexion and a total arc of ≥100° were regained by 88% of the patients. The mean MEPI score improved significantly from 73 points preoperatively to 94 points (range, 72 to 100 points) postoperatively, with the result rated as excellent in thirty-two patients, good in eight, and fair in two. Two patients had clinical recurrence of heterotopic ossification associated with a failure to obtain an increase in flexion.

CONCLUSIONS

This study demonstrates that posttraumatic heterotopic ossification, particularly in the posteromedial aspect of the capsule, is closely associated with loss of elbow flexion. Satisfactory restoration of elbow flexion can be obtained in the majority of patients by surgical release of the posterior band of the medial collateral ligament and excision of heterotopic bone.

Health status after open elbow contracture release

BACKGROUND

Operative contracture release may improve motion of a posttraumatic stiff elbow. In this study, we tested the hypothesis that improvement in ulnohumeral motion after elbow contracture release leads to improvement in general health status and decreases upper-extremity-specific disability.

METHODS

Twenty-three patients with posttraumatic loss of ≥30° of elbow flexion or extension who elected to have an open elbow capsulectomy completed the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Short Form-36 (SF-36) preoperatively and at least one year postoperatively. Pain was measured with use of the American Shoulder and Elbow Surgeons (ASES) Elbow Evaluation instrument. Four patients underwent additional, subsequent procedures to address residual elbow stiffness.

RESULTS

One patient who needed several additional procedures, including a total elbow arthroplasty, was considered to have had a failure of the operative contracture release and was excluded from the analysis; this left twenty-two patients in the study. On the average, the arc of flexion and extension improved from 51° preoperatively to 106° postoperatively; the DASH score, from 38 points to 18 points; the SF-36 Physical Component Summary (PCS) score, from 39 points to 49 points (all p < 0.05); and the SF-36 Mental Component Summary (MCS) score, from 49 points to 54 points (p < 0.05). There was no significant correlation between the improvement in the arc of flexion and extension and the improvement in the DASH (p = 0.53), PCS (p = 0.73), or MCS (p = 0.41) score. There also was no correlation between the final arc of flexion and extension and the final DASH score (p = 0.39 for the total score, p = 0.52 for the PCS score, and p = 0.42 for the MCS score).

CONCLUSIONS

Health status and disability scores improve after open elbow contracture release, but the improvements do not correlate with the improvement in elbow motion. Among multiple objective and subjective factors, pain was a strong predictor of the final general health status and arm-specific disability.

Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction

PURPOSE

This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension.

METHODS

Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system.

RESULTS

An average of 22 months after surgery (range, 10 to 62 mo), the arc of flexion and extension averaged 95 degrees in the ankylosis cohort and 93 degrees in the partial HO cohort. Forearm rotation averaged 131 degrees versus 134 degrees ; the mean Disabilities of the Arm, Shoulder, and Hand score was 28 versus 30 points; and the mean Broberg and Morrey score was 81 versus 84 points, respectively.

CONCLUSIONS

After controlling for other factors, patients with elbow stiffness related to HO can recover comparable motion after surgical release at short-term follow-up whether they have complete ankylosis or only partial restriction of motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Total elbow replacement for the management of the ankylosed or fused elbow

This study reports our experience with total elbow replacement for fused elbows.

Between 1982 and 2004, 13 patients with spontaneously ankylosed elbows were treated with a linked semi-constrained non-custom total elbow implant. The mean age at operation was 54 years (24 to 80). The stiffness was a result of trauma in ten elbows, juvenile rheumatoid arthritis in one, and rheumatoid arthritis in two. The patients were followed for a mean of 12 years (2 to 26) and were evaluated clinically using the Mayo Elbow Performance Score, as well as radiologically.

A mean arc from 37° of extension to 118° of flexion was achieved. Outcomes were good or excellent for seven elbows at final review. Ten patients felt better or much better after total elbow replacement. However, there was a high complication rate and re-operation was required in over half of patients. Two developed peri-operative soft-tissue breakdown requiring debridement. A muscle flap with skin grafting was used for soft-tissue cover in one. Revision was undertaken in one elbow following fracture of the ulnar component. Three patients developed a deep infection. Three elbows were manipulated under anaesthesia for post-operative stiffness. Prophylactic measures for heterotopic ossification were unsuccessful.

Total elbow replacement for the ankylosed elbow should be performed with caution. However, the outcome can be reliable in the long term and have a markedly positive impact on patient function and satisfaction. The high potential for complications must be considered. We consider total elbow replacement to be an acceptable procedure in selected patients with reasonable expectations.

Analysis of results of surgical treatment of posttraumatic stiff elbow

BACKGROUND

Surgical management of posttraumatic elbow stiffness has been reported with poor outcome following treatment. Sequential release in earlier stages of stiffness yielded much better results. The goal of our study was to assess the outcome in improvement of the range of motion of the elbow after surgical release and to analyze a tailor-made approach according to individual needs to yield good result.

MATERIALS AND METHODS

A prospective study was conducted in 47 cases of elbow stiffness due to various types of injuries. All the cases were treated with sequential release if there was no progress after adequate supervised conservative management except in unreduced dislocations. All the cases were followed up for a minimum period of 24 months. Overall outcome was rated with the functional scoring system by Mayo Clinic Performance Index.

RESULTS

Twenty-five (44.68%) out of 47 patients had excellent results with a mean preoperative range of motion of 33.9 degrees and postoperative range of motion of 105 degrees with net gain in range of motion of 71.1 degrees ('t' test value is 19.27, P < 0.01). None of the patients had elbow instability. Patients not having heterotopic ossification, who underwent surgery from three to six months post injury had a mean gain of 73.5 degrees. In patients who waited for more than six months had mean gain of 66.8 degrees. However, the results in cases having heterotopic ossification followed a slightly different pattern. In cases where release was performed from three months to six months had mean gain of 77.5 degrees. Cases in which release was performed after six months had gain of 57.1 degrees.

CONCLUSIONS

In cases of posttraumatic elbow stiffness after a failed initial conservative treatment, early arthrolysis with sequential surgical soft tissue release yields good result than delayed surgery.