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Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction

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DOI: 10.1007/978-3-642-34746-7_78

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 Post-Traumatic Elbow Stiffness -
Arthrolysis and Mechanical
Distraction

Konrad Mader and Dietmar Pennig

Contents The Evolution of Mechanical Distraction

in Post-Traumatic Elbow Stiffness . . . . . . . . . . . . . 1494
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1480 Surgical Protocol of the Arthrodiatasis
Applied Anatomy, Pathology Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1496
and Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1482 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1506
Biomechanics of Elbow Stiffness . . . . . . . . . . . . . . . . . . 1482 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1507
The Biology of Joint Contracture . . . . . . . . . . . . . . . . . . 1482
The Role of Heterotopic Ossification . . . . . . . . . . . . . . 1484
Diagnosis, Indications for Surgery . . . . . . . . . . . . . . 1485
Pre-Operative Preparation and Planning . . . . . . . . . . . 1485
Timing of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
Non-Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1487
Surgical Release Operations in Post-Traumatic
Elbow Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1487
Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1487
Medial Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1487
Limited Lateral Approach: The Column Procedure 1488
Posterior Extensile Approach . . . . . . . . . . . . . . . . . . . . . . 1488
Arthroscopic Release in Post-Traumatic Elbow
Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1488
The Role of Arthroplasty in Elbow
Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1489
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1491
Open Arthrolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1491
Operative Technique- “Column Procedure” . . . . . . . 1491
Post-Operative Management . . . . . . . . . . . . . . . . . . . . . . . 1492
Critical Evaluation of Open Arthrolysis in Elbow
Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1494

K. Mader (*)
Section Trauma Surgery, Hand and Upper Extremity
Reconstructive Surgery, Department of Orthopaedic
Surgery, Førde Sentralsjukehus, Førde, Norway
e-mail: [email protected]
D. Pennig
Klinik f€ur Unfallchirurgie/Orthop€adie, Hand- und
Wiederherstellungschirurgie, St. Vinzenz- Hospital Köln,
Köln, Germany

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 1479

DOI 10.1007/978-3-642-34746-7_78, # EFORT 2014
1480 K. Mader and D. Pennig

of factors have been implicated to explain the

Abstract
elbow’s propensity to stiffness. These include
A stiff elbow is usually defined as having less
the intrinsic congruity of the humero-ulnar artic-
than 30 in extension or flexion of less than
ulation, the presence of three articulations within
130 . Most activities of daily living are
one synovial-lined cavity, and/or the close inter-
possible if the elbow has a range of motion
relationship of the joint capsule to both the
of 100 (30–130 of flexion, Morreys “arc of
intracapsular ligaments and surrounding muscles.
motion”). Loss of motion of the elbow is not
Morrey et al. studied 33 normal volunteers using
uncommon after trauma, burns, or coma and
an electrogoniometer designed to measure
severely impairs upper limb function. Loss of
three-dimensional motion of the elbow in daily
motion may be difficult to avoid and is
activities [4]. Their work demonstrated that most
challenging to treat. Detailed analysis
activities could be done within a functional arc
of the aetiology and diagnostic evaluation
of 100 (30–130 ) of flexion and extension
is of utmost importance for planning
(so- called “functional arc” of Morrey) and 100
any surgical intervention for elbow
of rotation of the forearm (50 of pronation and
stiffness. Current operative techniques, such
supination for each, Fig. 2). Yet certain func-
as open arthrolysis and closed distraction
tional tasks may demand greater motion in one
with external fixation (arthrodiatasis), are
direction or another [1, 3, 5]. As the upper limb
presented and evaluated. Elbow arthrolysis
represents an integration of several articulations,
is a technically-demanding procedure, but if
the combined loss of elbow extension and supi-
indication and techniques are used correctly
nation of the forearm, for example, will have an
and surgeon, physiotherapist, and patient are
additive effect on the performance of activities
familiar with the procedure, good long-term
requiring power for total use.
results may be achieved.
Irrespective of the underlying aetiologies,
elbow stiffness is a threat to the integrated func-
Keywords tion of the entire limb, thus making the restora-
Aetiology, pathology and biomechanics  tion of motion a basic goal of most reconstructive
Arthrolysis  Arthroplasty  Diagnosis  Dis- efforts following traumatic injury to the elbow.
traction  Elbow  Post-Traumatic  Rehabili- Post-traumatic elbow stiffness can be classified
tation  Stiffness  Surgical indications  according to the position of the contracture, as
Surgical treatment  Techniques-arthroscopy, extension or flexion stiffness, and an assessment
athrodiatasis of the function of adjacent joints is required
as well [1]. The causes can be divided into
intra-and extra-articular, but a mixed pathology
Introduction is often the reason for limitation of elbow function.
Extra-articular causes include muscular and
Post-traumatic stiffness after elbow trauma is skin retraction, fibrosis of ligaments and capsule,
common, affecting approximately 5 % of elbows and heterotopic bone formation with bony bridg-
after injury and causes substantial disability, lim- ing of the joint.
iting the ability to put the hand in the volume of Intra- articular causes include joint oblitera-
a sphere in space (Fig. 1). Post-traumatic condi- tion with the formation of fibro-fatty tissue and
tions that adversely affect the function of the articular incongruence with secondary degenera-
elbow joint represent a wide spectrum of patho- tive arthritis. Minor degrees of stiffness can be
logical processes. The injury pattern itself is only managed by physiotherapy and static or dynamic
one aspect in the development of post-traumatic splinting [6, 32].
stiffness, and prolonged immobilization seems to During the last 30 years, three operative treat-
be an important factor [1–3]. Loss of mobility ment protocols have emerged for the treatment of
represents the most common sequel. A number post-traumatic stiffness of the elbow:
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1481

30° 0 30 45 60 90°

Motion Loss Function (volume) Loss

30° 28%

45° 39%
60° 60%

Function • Volume
V • 4/3 πr3

Fig. 1 The “sphere” influence of the hand in space is reach in space. This non-linear function of ability is
highly dependent on shoulder and elbow motion. With represented by the exponential function loss seen with
restricted elbow motion, there is a rapid loss of ability to elbow flexion contractures >30 (drawing by Janssen [4])

145°
130° 0°

50° 50°

75°
85°

30° Supination Pronation

0°

Fig. 2 “Functional arc” after (Morrey [4])

Open surgical release operations have been operations have been proven to be an effective
described widely in the literature with reasonable treatment option in mild and moderate elbow
short-and mid-term results in several retrospec- stiffness. [9–11] The third treatment method
tive case studies [7, 8] and arthroscopic release uses closed mechanical distraction of the
1482 K. Mader and D. Pennig

elbow in order to restore a physiological joint connective tissue did not change, or at most was
space and elbow motion [12–15]. It was first reduced by 10 %, they suggested that there is an
described by Volkov and Oganesian [16] in increase in collagen cross-links expressed both
1975 and has been reported in limited series, per unit weight of collagen and on the basis of
which were combined with traditional operative collagen mass per knee due to the lack of physical
procedures. Mechanical distraction, which was stress and motion. Frank et al. extended this rab-
also termed “arthrodiatasis”, applied on its own bit model to study in detail the molecular biology
without major operative release of the joint cap- and biomechanics of both normal and healing
sule and ligaments has not been previously used ligaments. Their data was derived from light
in the treatment of elbow stiffness [15]. microscopy, transmission electron microscopy,
molecular biology (RT-PCR), and biomechanical
measurements (laxity, stress at failure, modulus,
Applied Anatomy, Pathology and static creep) of medial collateral ligaments in
and Biomechanics normal, pregnant rabbits and healing ligaments.
‘Flaws’ in the scar matrix, smaller-than-normal
Biomechanics of Elbow Stiffness diameter collagen fibrils, and failure of collagen
cross-link maturation were the most important
There are virtually no data on the biomechanics deficiencies which appeared to be related to liga-
of elbow stiffness in humans. Several investiga- ment scar weakness and inferior biomechanical
tors developed in vitro and in vivo testing’s sys- performance. The mechanical behaviour of both
tems to control elbow motion and to test the normal and healing ligaments was significantly
compliance and stiffness patterns during motion altered by relative states of joint motion. They
and Lin et al. showed that, in healthy subjects, the concluded that molecular analysis of ligaments
mechanical properties of the elbow joints were and ligament scars, combined with ongoing mor-
similar in men and women of comparable body phological and biomechanical studies of ligament
weights and did not deteriorate significantly until structure and function, will ultimately reveal
subjects reached the age of 70 years. However, no which factors can be manipulated clinically to
reliable testing systems exist to evaluate the bio- optimize the restoration of normal ligament prop-
mechanical changes in elbow stiffness. erties after ligament injuries.
Behrens et al. evaluated the effect of different
modes of immobilization on joint cartilage: Dogs
The Biology of Joint Contracture were immobilized for 6 weeks by long-leg casts
allowing 8–15 of motion, or with rigid external
In the recent years, the biologic response to fixators, a more severe model that kept the joints
trauma and immobilization has been increasingly rigid with no motion. Articular cartilage was
recognized and has been an on-going topic of examined histologically and biochemically.
basic investigations [1, 17]. In the late 1980s After 6 weeks of immobilization, water content
and through the 1990s, Akeson and his group increased by 7 % in both casted and fixator-
studied the effects of immobilization on the soft immobilized joints compared with normal knee
tissue envelope in the knee: Cast immobilization cartilage, while hexuronic acid was 23 % and
of the knee joint in rabbits for 9 weeks resulted in 28 % lower, respectively. The limited motion
a reduction of the mechanical properties in the permitted by the casts resulted in a smaller
lateral collateral ligament. Specifically, ligament depression of proteoglycan synthesis and less
stiffness was reduced in this tissue. In addition, proteoglycan loss during immobilization than
a significant increase in the intermolecular occurred in the rigid external fixator group. The
cross-links in 9-week immobilized rabbit peri- protective effect of limited motion was shown
articular connective tissue was found. Since the clearly during the recovery period: as measured
collagen mass in the immobilized peri-articular by hexuronic acid content, cartilage from the
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1483

casted joints had almost recovered within 1 week, joint capsules from patients with contractures
whereas the external fixator group experienced (326 +/ 61 cells per field, 36 % +/ 4 % total
little or no recovery during the week after treat- cells) when compared with similar tissues of the
ment. More insight into the pathobiology of joint organ donors (69 +/ 41 cells per field, 9 % +/
contracture was discovered by Bunker et al. in 4 % total cells). They hypothesized that specific
(clinical) forms of joint contracture (namely the growth factors are increased in the elbow cap-
frozen shoulder and Dupuytren´s disease). They sules of patients with post-traumatic elbow con-
showed that the predominant cells involved in tractures and a model of surgically-induced joint
joint capsule samples in frozen shoulder patients contracture in rabbit knees was developed to
were fibroblasts and myofibroblasts which lay study the growth factor expression in joint
down a dense matrix of type-I and type-III colla- contractures. The rabbit knee model correlated
gen within the capsule. They examined whether well with the human post-traumatic elbow
there was an abnormal expression or secretion of contractures.
cytokines, growth factors and MMPs in tissue Cohen and co- workers examined the struc-
samples from 14 patients with frozen shoulder tural and biochemical alterations of the elbow
using the reverse transcription/polymerase chain capsule after trauma by comparing capsules
reaction (RT/PCR) technique and compared the from 37 patients undergoing surgery for elbow
findings with those in tissue from four normal contracture with normal capsules from 7 donors.
control shoulders and from five patients with Contracture capsules were significantly thicker
Dupuytren’s contracture. Tissue from frozen than control capsules (P < .05) and exhibited
shoulders demonstrated the presence of mRNA extensive disorganization of collagen fibre bun-
for a large number of cytokines and growth fac- dle arrangement. The levels of cytokines matrix
tors although the frequency was only slightly metalloproteinase (MMP) 1, MMP-2, and MMP-
higher than in the control tissue. The frequency 3 were greater as compared with control capsules
of a positive signal for the pro-inflammatory (P < .05). This was associated with collagen
cytokines Il-beta and TNF-alpha and TNF-beta, disorganization, fibroblast infiltration, and in
was not as great as in Dupuytren’s tissue. The some specimens, lymphocytic infiltration in the
presence of mRNA for fibrogenic growth factors capsular tissue. In contracture specimens, there
was, however, more similar to that obtained in the was a localization of tissue inhibitor of matrix
control and Dupuytren’s tissue. This correlated metalloproteinase to staining only in the vicinity
with the histological findings which in most spec- of the synovial membrane and in blood vessels.
imens showed a dense fibrous tissue response Immunohistochemistry for type III collagen
with few cells other than mature fibroblasts and showed a greater presence in the control capsules
with very little evidence of any active inflamma- compared with contracture capsules. Their study
tory cell process. Positive expressions of the demonstrated pathological thickening, disorgani-
mRNA for the MMPs were also increased, zation of the collagen fibre arrangement, and
together with their natural inhibitor TIMP. The involvement of cytokines in the pathology of
notable exception compared with control and post-traumatic contracture of the elbow. They
Dupuytren’s tissue was the absence of MMP-14, were the first to characterize the histological pro-
which is known to be a membrane-type file in post-traumatic contracture of the elbow
MMP required for the activation of MMP-2 capsule and associate this with the presence of
(gelatinase A). MMPs and their inhibitors. Type III collagen was
Hildebrand and his co-workers concentrated present in the normal elbow capsule, but by com-
on the myofibroblast behaviour in post-traumatic parison, its immunohistochemical staining was
contracture of the elbow. First they demonstrated consistently diminished in the contracture capsule.
by immunohistochemical studies that myofibroblast Further characterization was recommended to
numbers and percentage of total cells that were identify elbow-specific processes and to propose
myofibroblasts were significantly elevated in the treatment strategies to decrease this pathologic
1484 K. Mader and D. Pennig

Fig. 3 CT scans of a 42 year-old female patient with post- (b) transverse scan showing a plate with screws in the
traumatic elbow stiffness after fracture- dislocation of the proximal radius leading to compromise in the motion of
elbow with radial head fracture, coronoid fracture and the proximal radio-ulnar joint. (c) sagittal reconstruction
ulnar ligament complex disruption: the extension/flexion showing involvement of the radial proximal ulna
is 0–30–65 and pronation supination is 20–0–0 , (a) (coronoid region) and slight subluxation of the humero-
transverse scan demonstrating ossification of the ulnar ulnar joint
ligament complex and an narrow humero-ulnar joint.

alteration of capsular tissue. They concluded that of HO around the elbow. Other causes include
though difficult to obtain, the evaluation of elbow neural axis trauma, thermal injury, and a genetic
capsules from individuals after trauma without disorder, termed fibrodysplasia ossificans
a subsequent joint contracture might be very help- progressiva. The incidence of HO seems to be
ful in understanding the normal and pathological directly correlated to the magnitude of the injury.
processes involved. In a series of isolated elbow dislocations a 3 %
Very recently, Rommens and his group in incidence of HO was reported. When the dislo-
Germany developed a 3-dimensional cell culture cation was combined with a fracture in proximity
model in order to study the role of myofibroblasts to the elbow or of the radial head, the incidence
(MF) from contracted elbow and shoulder joint rose to 16 % and 20 % respectively. Therefore,
capsules with respect to various factors. Aside the incidence of HO is five-times greater if there
from an elevation of the number and activation is an associated fracture along with the elbow
of myofibroblasts in the contracted capsule they dislocation. No laboratory value has been consis-
showed that TGF-ß1 and PDGF induced a cell tently correlated with HO activity or with HO
proliferation of MFs and increased the contrac- recurrence after resection [18]. The radiological
tion of extracellular matrices (ECM). assessment for HO consists of standard
anteroposterior and lateral plain films of the
elbow. Most HO will be evident on plain films
The Role of Heterotopic Ossification by 6 weeks after injury. Early radiographic HO
has indistinct margins and lacks trabeculations.
Heterotopic ossification (HO) is the most com- Mature HO has sharply defined margins on plain
mon extrinsic cause of elbow contracture. It is films with visible trabeculae. Computed tomog-
defined as the formation of mature cellular bone raphy (CT) is helpful to better evaluate the posi-
in non-osseous tissues. Myositis ossificans is tion and peri-articular geometry. Axial scans
defined as the formation of HO in inflamed mus- provide a good view of both the ulnotrochlear
cle. Peri-articular calcification is defined as col- and the proximal radio-ulnar joint and a clear
lections of calcium pyrophophates within soft relationship of HO to either/or both joints
tissues. Peri-articular calcification lacks trabecu- (Fig. 3). Hastings and Graham developed a clas-
lar organization and occurs in distinct structures, sification system of HO, based on functional
such as the collateral ligaments and the capsule. limitation: Class I includes radiographically
Direct elbow trauma is the most common cause evident HO but without functional limitation.
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1485

a
Grade I: <30 degrees Grade II: 30-60 degrees b c

Grade III: <60 degrees Grade IV: Bony Ankylosis

Fig. 4 Classification and evaluation of heterotopic ossi- stiffness after fracture-dislocation of the elbow with
fication (HO). (a) schematic drawing of the classification Grade IV HO. (c) CT scan of the same patient demon-
of HO after (Ilahi et al. 2001 [5]). (b) lateral X-ray of strating bony ankylosis (Ilahi grade IV)
a 40 year-old patient with severe post-traumatic elbow

Class II includes limited, yet functional, range of Radiotherapy is a local measure that acts by
elbow motion. Class II can be subdivided into inhiting osteoblastic precursor cells. Radiotherapy
IIA, IIB, and IIC. Limitation in the flexion- exten- has been shown to inhibit HO formation after total
sion plane is IIA, limitation in pronation- hip arthroplasty. Studies are now being performed
supination plane is IIB, and limitation in both is to evaluate the use of pre-operative or post-
IIC. Class III includes ankylosis of the particular operative radiation therapy combined with exci-
articulation. Class III can be sub-divided into A, sion of elbow HO. The standard radiation dose has
B, and C, in the same manner as Class II [19]. been a single dose of 600–700 cGy, administered
A concise and practical classification of HO at the within 72 h of elbow trauma, but 1,000 cGy in five
elbow was proposed by Ilahi in 2001, which uses 200 cGy fractions have also been used.
the degrees of heterotopic bone formation in the Functionally-limiting HO is removed surgi-
ventral (and dorsal) joint space (Fig. 4a) [20]. cally [12, 15, 18]. The goal is to resect all clini-
There are several risk factors that may predis- cally impinging HO. Safe contracture release and
pose a patient to form HO. These include signif- excision of HO can be performed as early as 3–6
icant elbow trauma (Fig. 4b), head injuries, burns, months after injury. The notion of waiting for HO
genetic predisposition, history of diffuse idio- to mature before excision has been challenged
pathic skeletal hyperostosis, ankylosing spondy- recently by Viola and others [18, 21]. They
litis, Paget´s disease, hypertrophic osteoarthritis showed that early HO excision is effective with
in males, and a history of previous HO. Prophy- no recurrence when medical prophylaxis with
laxis of HO includes medical therapy and radio- Indomethacin is performed.
therapy. The most commonly-used group of
medical agents are the nonsteroidal anti-
inflammatory drugs (NSAID’s) represented by Diagnosis, Indications for Surgery
indomethacin. NSAID’s are thought to act by
preventing precursor cells from differentiating Pre-Operative Preparation and
into osteoblasts. Their efficacy has been Planning
documented in surgery about the hip; however,
the role of indomethacin relative to the elbow is Pre-operative evaluation of elbow stiffness com-
still unkown. Low-dose external beam radiation prises a full general medical history with
has also been used as prophylaxis against HO. a detailed aetiology of the disability, including
1486 K. Mader and D. Pennig

Table 1 Post-traumatic elbow stiffness: preoperative Table 2 Diagnostic measures in elbow stiffness
evaluation
Investigation Key factors
Measures Trauma X-rays Initial amount of damage to
Patient history the joint
Radiologic history Trauma X-rays, previous Operative treatment Quality of initial reduction,
operations, actual situation Operation protocol, joint incongruency,
Diagnostic measures Clinical examination X-rays damage to cartilage?
Conventional X-rays Conventional X-rays Actual joint congruency,
Arthrogram bone quality
CT Implants and quality of
Nerve function tests/ Pain previous fixation
(VAS- score) Osteophytes at olecranon/
Documentation of joint coronoid process
movement of the upper CT (1 mm slices) Humero-ulnar subluxation
extremity Intraarticular malunion
Postoperative measures Osteophytes at olecranon/
Physiotherapy/ Patient coronoid process
contact Material in olecranon
Indomethacin 2  50 mg fossa/coronoid fossa
Position and classification
of heterotopic bone
Arthrography/Arthro-CT Fibrosis of joint capsule
full details of any professional and sporting activ- Scarring of proximal radio-
ulnar joint
ities. To understand the underlying pathology in
MR Thickness of cartilage
a case of elbow stiffness all x-rays, including
Position of nerves
trauma x-rays and documentation of previous
Nerve function tests Evaluation of previous
operations are of utmost importance (Table 1). ulnar, radial and median nerve damage
The history of previous manipulations under nerve
anaesthesia is recorded. These manoeuvres may
cause intra-articular damage by avulsion of car-
tilaginous fragments with subsequent damage to operative procedures are carried out. Prior and
the residual cartilage. We do not advocate this subsequent physiotherapy should be evaluated
method of treatment. After thorough clinical by a specialized physiotherapist. Only after reg-
examination has been carried out plain radio- ular physiotherapy has failed to produce
graphs are taken; an arthrogram is useful to eval- improvement in function should an operative
uate the remaining joint space, especially of the intervention be planned (Table 3).
proximal radio-ulnar joint for existing fibrosis. Indications for operative therapy are young
Arthrograms are best performed in conjunction and active patients, lack of motion in the domi-
with a CT scan (without contrast and as an arthro- nant extremity and a total range of movement less
CT scan). Pre-operative ulnar, radial and median than 100 , which includes a flexion deficit. The
nerve function tests are performed as a routine timing of the procedure depends on the previous
procedure. The ulnar nerve is especially vulnera- treatment history. When stiffness is persistent in
ble in cases where a lack of flexion has persisted spite of adequate physiotherapy early interven-
for a prolonged period [15]. tion is advisable. In the presence of heterotopic
ossification with limitation of the joint gliding
spaces, the notion of waiting for HO to mature
Timing of Surgery before excision has been challenged recently by
Viola and others [21–23]. They showed that
All conservative methods of treating restricted early HO excision is effective with no recurrence
elbow mobility should be attempted before when medial prophylaxis with Indomethacin
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1487

is performed. In our experience heterotopic bone been written about non-surgical treatment of
at the elbow joint may be removed as early as elbow contractures, but there was little in the
after 4 months. We also performed surgery in literature until 1978, when Green and McCoy
longstanding cases of elbow stiffness (more than reported on 15 patients with flexion contractures
10 years), but selection criteria are stricter when using a turnbuckle splint. They used a turnbuckle
there is such a long interval between the original splint (daily intermittent static-progressive
injury and presentation of the patient. The patient splinting) similar to that introduced by Steindler
must be able to follow all post-operative in 1947, and were able to achieve an average
physiotherapeutic measures, and only compliant reduction in deformity of about 37 after an aver-
and motivated patients are selected, particularly age treatment period of 20 weeks. In 1984, Salter
for fixator-assisted distraction in post-traumatic et al. demonstrated the application of basic
elbow stiffness. General contra-indications research on continuous passive motion of syno-
comprise uncontrolled diabetes, the presesence vial joints in a feasibility study, which was
of infection and poor compliance. In cases of repeated and reproduce-d by Laupattarakesem
associated hand-shoulder syndrome Sudeck´s in 1988. Since then continuous passive motion
dystrophy should be excluded [5]. has been used in the treatment of posttraumatic
limitation of elbow motion [25].

Non-Surgical Treatment

The prevention of the development of post- Surgical Release Operations in

traumatic elbow contractures begins with early Post-Traumatic Elbow Stiffness
stable internal fixation of fractures about the
elbow joint chaper (▶ Fracture Dislocations of Open surgical techniques are performed by four
the Elbow - the Elbow Fixator Concept). The basic approaches: limited anterior approach, lat-
goal is to obtain a stable construct that can with- eral, medial, and extensile posterior approach [1].
stand early range of motion exercises by all
means, even with the use of a supplementary
fixator with motion capacity. Simple elbow dis- Anterior Approach
locations (without associated fractures) should be
immobilized for no more than 1 week and Urbaniak et al. popularized an anterior approach to
then the patient can begin active assisted the elbow principally for the loss of elbow exten-
range of motion exercises. Nonsteroidal anti- sion in 1985. This approach does not address dis-
inflammatory medications, ice, muscle strength- orders that limit flexion and requires the identity
ening, and gentle physical therapy will help and protection of the neurovascular structures.
patients increase their active range of motion. Nonetheless, it does provide direct exposure of
Forced passive manipulation can result in trauma the anterior capsule and heterotopic bone that
to the brachialis and anterior capsule with subse- may also be present anteriorly. The authors noted
quent inflammation, haemarthrosis, heterotopic that the improvement was greater in patients with
ossification, and worsening of elbow contrac- a healthy joint compared with those patients who
tures. Historically and until recently manipula- have articular (intrinsic) involvement.
tion under anaesthesia (MUA) has been widely
used in combination with peripheral anaesthesia
(mainly plexus catherization) and is still in use in Medial Exposure
some major centres [6, 24]. Once contractures
have become fixed and patients have failed the The indication for addressing the post-traumatic
above modes of treatment, static-progressive stiff elbow via a medial approach is medial
splinting can be started. Recently much has pathology, particularly when the ulnar nerve
1488 K. Mader and D. Pennig

is involved [1]. The landmark for this approach is Extensive heterotopic bone also may be removed
the medial epicondyle and the ulnar nerve and with this extensile approach. The importance of a
the medial intermuscular septum. The key point sequential release of tissues for patients having
in the exposure is the recognition that the capsule post-traumatic contracture has been emphasized
is covered by the pronator teres; therefore the pro- based on experience with 44–46 patients, who
nator is separated from the common flexor mass were satisfied with such an approach [27].
and elevated from the anterior capsule. By mobi-
lizing the ulnar nerve and elevating the medial
aspect of the triceps, the posterior joint also can Arthroscopic Release in Post-Traumatic
be identified and impinging capsule osteophytes Elbow Stiffness
and heterotopic bone addressed. As it is a limited
exposure, it is not effective when the disorder The proposed advantages of arthroscopic surgery
involves the radiohumeral joint or more lateral over open surgery of the elbow include decreased
structures including the lateral collateral ligament. scarring, decreased risk of infection, less post-
operative pain, and possibly a more thorough visu-
alization of the elbow joint than is possible with an
Limited Lateral Approach: The Column arthrotomy during some procedures. There are
Procedure data indicating that elbow arthroscopy can
be used successfully to remove osteophytes
Extrinsic contracture of the anterior and/or pos- due to impingement or osteoarthritis, to perform
terior capsule can be released with the so-called synovectomy in patients with inflammatory arthri-
“column” procedure, which addresses the ante- tis, to remove adhesions and to release the capsule
rior and posterior part of the joint by exposing in patients with contractures, to resect symptom-
the anterior interval consisting of the distal fibres atic plicae, to remove loose bodies, and to evaluate
of brachioradialis and extensor carpi radialis patients with chronic elbow pain. Elbow arthros-
longus. The posterior interval simply consists of copy has been used to treat patients with
elevating the lateral margin of the triceps from osteochondritis dissecans, septic arthritis,
the posterior aspect of the lateral column. The epicondylitis, and elbow fracture. Arthroscopy
common extensor muscle mass is left intact can be used in selected cases to perform capsular
(Fig. 5a–c) [8]. releases, debride synovium and osteophytes.
The diminished capsular volume and reduced
compliance in the arthrofibrotic elbow may
Posterior Extensile Approach increase the incidence of neurovascular injury
during arthroscopy. Furthermore, the post-
This approach is selected if medial and lateral traumatic elbow may have altered bony
exposures are indicated or if the articular surface landmarks, which makes safe portal placement
is involved. The initial step consist of a posterior difficult. However, arthroscopic techniques
skin incision with dissection laterally, elevating have improved through the years. One experience
the common extensor muscle mass from the from Asia documents an improved pre-operative
scarred anterior capsule and collateral ligament flexion arc from 21 to 113 (which documents
complex. The triceps is elevated along with the moderate nature of stiffness) before to
anconeus. In some instances the triceps and 14–130 after arthroscopic surgery. The authors
anconeus are reflected from their attachment on subsequently reported improving the post-operative
the humerus and the ulna to gain access to the arc by 50 as greater experience with the technique
articular surface. Through this incision the ulnar was realized [11]. In one of the most developed
nerve also is identified and decompressed and to practices reporting 24 patients, the mean pre-
the extent necessary the posterior component of operative arc was 40–90 and improved to
the medial collateral ligament is resected [1]. 8–139 [29]. Recently Kamineni et al. and
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1489

Thoreux et al. have reported extensively on the The Role of Arthroplasty in Elbow
anatomic basis of arthroscopic capsulectomy Contracture
and endoscopic extracapsular capsulectomy in
high-grade contractures [10, 30]. Arthroscopic Prosthetic total elbow arthroplasty (TEA) is
treatment of the elbow stiffness is illustrated in a recognized treatment for the painful arthritic
detail in the chapter ▶ “Arthroscopic Techniques elbow with or without loss of elbow motion.
in the Elbow” [6]. The available implants can be broadly grouped

Biceps brachii

Anterior Interval

Brachioradialis
Triceps brachii
Extensor carpi radialis longus

Posterior Interval Extensor carpi radialis brevis

Extensor digitorum

Anconeus

b Joint capsule

Posterior Interval

Joint space

Fig. 5 (continued)
1490 K. Mader and D. Pennig

c
Joint capsule

Lateral ulnar collateral ligament

Anconeus

d
Joint capsule

Lateral ulnar collateral ligament

Fig. 5 Modified drawings of the “column procedure” posterior release [33]. (d) modified drawing of the situs
after Mansat and Morrey [8]. (a) the anterior and after anterior and posterior release; the lateral ligament
posterior interval. (b) Modified drawing of the anterior complex remains intact [33]
capsular release [33]. (c) Modified drawing of the

into linked, where the humeral and ulnar varus-valgus play between the humeral and
components are physically connected, and ulnar components (sloppy hinge) or there is no
unlinked. The former group can be sub-divided play (fixed hinge). A minority of implants incor-
further depending on whether there is porate a replacement for the head of the radius.
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1491

Severe flexion deficit Limited extensjon Salvage procedure

Mild to severe chronic dislocation deficit
loose bodies in the low demand
stiffness with complex cases PRUJ stiffness
mild stiffness patient in the
capsular fibrosis Cologne protocol Ventral release of
unclear elbow pain elderly age group
and HO +/- limited open capsule
arthrolysis Neocoronoid-
operation

Local TEA
Arthroscopy Open Mechanical measures
procedures distraction (Olecranon,
PRUJ)

Fig. 6 The different treatment options in post-traumatic elbow stiffness

The results reported for TEA are not as good as

those for hip and knee replacement, although the Operative Techniques
number of published studies has tended to be
comparatively small. Open Arthrolysis
Only a few reports in the literature describe
the results of total elbow arthroplasty for the Open arthrolysis of the elbow may be used in
treatment of ankylosed or stiff elbows. Also, patients with extrinsic pathology and a loss of
patients with post-traumatic arthritis are usually total range of motion of more of 30 (mainly
more active than patients with rheumatoid loss of flexion). [1, 5, 7, 8] Mansat and Morrey
arthritis, so the components are exposed to described in 1998 the “column procedure”,
more stress. In a recent series of patients with which is the standard open arthrolysis technique
post-traumatic arthritis, the rates of complica- from the radial (lateral) side. This technique
tions have ranged from 27 % to 38 % [31]. comprises arthrotomy, resection of the ventral
In ankylosed or severely contracted joints, and dorsal capsule with removal of existing
arthrolysis during the TEA may be necessary to osteophytes via a limited radial approach [8].
improve the arc of motion intra-operatively. This approach can be easily and safely combined
Usually, a circumferential capsular release and with a limited medial approach addressing medial
excision of the collateral ligaments is necessary. pathology (“medial column” procedure) [27]. We
This step cannot be performed without perform in nearly all cases of arthrolysis of the
compromising elbow stability, so the use of elbow (whether open, arthroscopic or with
a standard semi-constrained elbow prosthesis is mechanical distraction) a limited medial approach
recommended. The considerable forces acting in order to perform an in-situ neurolysis of the
on the prosthesis-bone interface in post- ulnar nerve (Fig. 7) [2, 3, 12, 15].
traumatic stiffness are of major concern and
are the reason for the reported high failure and
complication rate and therefore elbow replace- Operative Technique- “Column
ment is seen as a salvage procedure in the low- Procedure”
demand patient in the elderly age group.
(Figure 6 an overview of the surgical strate- The patient is placed in the supine position and
gies used in elbow stiffness). a hand-table is used. We routinely use a sterile
1492 K. Mader and D. Pennig

Fig. 7 Line drawing of the Biceps m.

medial aspect of the left Brachialis m.
elbow. The dotted lines
depict the curved incision,
which is performed for in-
situ neurolysis. All relevant
anatomical structures are
displayed (Modified after Lacertus
fibrosus
Mader et al. [2]) Flexor carpi
Arcade of Struthers
ulnaris m.
Triceps m.

Ulnar n.

Medial epicondyle

Cubital
tunnel
Osborne’s
fascia

tourniquet at the beginning of the operation. neurolysis of the ulnar nerve and identification of
A Kocher approach is used, if previous surgery the origin of the flexion muscles at the medial
will not make a modified incision possible (in epicondyle. The tendon flap is then dissected
cases of previous scars or avoiding soft tissue from the epicondyle anteriorly with the ulnar
comprise after e.g. previous plastic surgery). nerve kept posteriorly in the sulcus (Fig. 8b)
Next, anatomic landmarks of the “anterior and [26]. The remaining anterior joint capsule can
posterior interval” are the origin of the extensor now be exposed and excised leaving at least the
carpi radialis longus muscle and the distal lateral mid and posterior parts of the ulnar collateral
portion of the brachioradialis muscle (Fig. 5a). ligament intact (Fig. 8c). The approach also per-
After opening of the anterior interval and using mits inspection of the posterior part of the medial
appropriate Langebeck retractors the brachial joint along the triceps tendon, with the ulnar
muscle (providing shelter to the neurovascular nerve slightly deflected anteriorly (Fig. 8d).
structures) is elevated providing access to the
radial capsule and the coronoid (Fig. 5b). The
medial aspect of the joint capsule is not visual- Post-Operative Management
ized with the approach and, if medial pathology is
detected in the preoperative diagnostic pathway, Intraoperatively it is useful to prepare different
a medial approach is recommended in addition. casts: in maximum flexion, extension and an
If necessary the posterior interval is opened now intermediate angle resting cast [5]. Depending
with identification of the dorsal capsule, removal on a predominant extension or flexion deficit
of adhesions between the triceps, resection of the these casts are used as night splints. Commer-
capsule and debridement of the olecranon fossa cially available splints can also be used [6, 25].
thereby leaving the lateral ligament complex Post-operative analgesia is of special importance.
intact (Fig. 5c, d). The “medial column” proce- Both patient-controlled analgesia and regional
dure is executed via an arch-shaped approach plexus blockade are used [24, 25, 27]. Especially
over the medial epicondyle (Fig. 8a) with in-situ regional blockade removes proprioception in the
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1493

Fig. 8 Modified drawings

of the “medial” column a
Pronator teres
procedure after Marti et al.
[26]. (a) the situs before Brachialis
ulnar nerve neurolysis. (b)
Modified drawing of the
anterior medial capsular
release [33]. (c) Modified
drawing after opening of
the joint anterior [33]. (d)
modified drawing of the
situs during posterior
medial release, the anterior
portion of the medial
ligament complex remains
intact [33]

Common flexor tendon

Medial epicondyle Ulnar nerve

Common flexor tendon

Joint capsule
Medial cpicondyle Ulnar nerve

elbow and the “preventive” function of pain automated extension/flexion and supination/
response leading to removal of the monitor-effect pronation with programmable complex motion
of pain during physiotherapy: this may lead to patterns is a perfect tool both in the early post-
unacceptable pressure rising in the joint and operative and long-term out-patient use (our
repetitive micro-trauma to the cartilage and the patients have a minimum of 1 year physiother-
soft tissue. We therefore do not use plexus block- apy/ergotherapy after the index operation).
ade in our units and do not recommend it. We use Patience, a motivated patient and a realistic
a combination of peripheral and central pain- informed consent on success rate and possible
killer on a oral basis accompanied by oral outcome are the necessary ingredients for
indometacin (50 mg bid) as additional analgesic a positive outcome in these challenging patient
and as prophylaxis against heterotopic bone for- groups. It also important to state, that recent
mation. Continuous passive motion with studies demonstrated a strong difference between
1494 K. Mader and D. Pennig

the outcome of the physician-based outcome improvement in ulnohumeral motion after the
studies (e.g., Functional indexes) and patient- index surgery for capsular release was 53 (The
related outcome scores (e.g., the DASH): average flexion was 98  ). The nine patients who
Doornberg et al. have shown clearly, that pain had subsequent repeat elbow contracture release
has a very strong influence on both physician- gained an additional 24 , leading to a final aver-
rated (e.g., the MEPI) and patient-rated quantita- age flexion arc for the entire cohort of 103 . They
tive measures (e.g., DASH) of elbow function concluded that open elbow capsulectomy for
[28, 33]. Consequently, these measures are post-traumatic elbow stiffness restores a near-
strongly influenced by the psychosocial aspects 100 flexion arc on average. Second elbow
of illness that have a strong relationship with releases were needed in a high percentage of
pain, and objective measures of elbow function patients and provided limited additional motion
such as mobility may be undervalued. in most patients.

Critical Evaluation of Open Arthrolysis The Evolution of Mechanical

in Elbow Stiffness Distraction in Post-Traumatic Elbow
Stiffness
Looking critically at papers depicting a singular
surgical approach or operative strategies based on Restoration of function of the elbow (and the
case series, it is worth describing 2–5 year critical knee) with the use of mechanical distraction
analyses of open surgical release operations in dates from 1975, when Volkov and Oganesian
post-traumatic elbow stiffness [24, 28]. In described a hinged distraction device to mobilize
a paper by Tan and co- workers in 52 cases joint contractures [16]. They devised a new
open surgical release was performed for post- method for treating joints with a special hinged
traumatic elbow stiffness. Fourteen patients distractor apparatus which was fixed to bone by
(27 %) required manipulation under anaesthesia transosseous pins and provided an artificial exter-
(MUA) at 3.5 (average) weeks post-operatively nal articulating joint. The method was used in
and there was a loss of 50 % or greater of intra- a variety of joints: elbow, knee, radiocarpal,
operative motion in those patients; three of these metacarpophalangeal, interphalangeal, and
required further surgical contracture release, with ankle. The device was designed to permit accu-
two additional failed cases in this group. Consid- rate alignment of the joint surfaces, to relieve
ering the need for MUA as a failure of the index them of all static and dynamic loads once aligned
procedure, or a complication, there were 14 fail- and to maintain a constant pre-determined
ures of the index procedure or 14 additional com- amount of distance between the joint surfaces
plications. Additionally, five patients did not throughout the full range of motion. This,
reach a functional arc of motion, three patients according to Volkov and Oganesian, eliminated
had severe ulnar nerve problems, three had infec- excessive friction between the joint surfaces,
tions, two had post-operative instabilities; there prevented abnormal motion in the joint (includ-
were also two secondary releases and two ing instability) and permitted the newly-aligned
patients required hinged fixators. So, 20 of their joint surfaces to regenerate. The method also
patients required a total of 27 subsequent pro- allowed for gradual and controlled elimination
cedures (37 %) [28]. Ring et al. presented their of joint contractures. They stated correctly that
data on 46 adult patients with post-traumatic with their device, forces which are applied via the
elbow stiffness, evaluated an average of apparatus, are correctly distributed over the joint
48 months after open capsular excision. In order surfaces, leaving the biomechanics of the joint
to reach an improved range of motion, a second nearly normal and minimize abnormal stresses on
capsular excision was performed in nine patients soft tissues because correction was performed
(29 %) in their series [24]. The average gradually and distraction of the joint space was
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1495

a b c

Fig. 9 Schematic drawings of three genuine and original external fixators for mechanical distraction of the elbow. (a)
Volkov and Oganesian apparatus [16]. (b) Judet and Judet distractor [13]. (c) Morrey´s Mayo distraction device [14]

maintained during mobilisation. The apparatus 1990 (Fig. 9c) [14]. He provided a rationale for
for the elbow consisted of two Ilizarov half- application of distraction techniques for both
rings, which were connected by two distractor soft-tissue relapse and interposition arthroplasty
hinges (Fig. 9a). They used the distractor/fixator procedures. The Mayo distraction device, is
in 28 cases with heterogenous, severe pathology a bilateral distractor built on a 4 mm threaded
and found encouraging results after a follow-up pin through the axis of rotation and fixator pins in
of 1–6 years. The apparatus of Volkov and the distal humerus and proximal ulna, and is still
Oganesian appeared to have two main disadvan- in use (Howmedica, East. Rutherford, NJ, USA)
tages: first, no system was described for accurate and separates the ulnohumeral joint for 5 mm
alignment of the axial pin with the axis of rotation throughout the arc of flexion.
of the elbow joint. Second, the design was com- Since 1995 the department of the senior author
plex, cumbersome, and expensive. Drainage from has focussed on the treatment of complex elbow
the pin sites seemed to cause a great deal of trauma and its sequelae with special interest in
difficulty. post-traumatic elbow stiffness. One step was the
This discouraging conclusion was followed by development of an external fixator with motion
the description of a bilateral hinged distraction capacity, which is able to provide functional sta-
apparatus for ankylosed and stiff joints (elbow, bility in acute and chronic elbow dislocations in
knee, and ankle respectively) by Judet and Judet order to allow early mobilization of the elbow
in 1978 (Fig. 9b) [13]. After developing a sym- and thereby prevents post-traumatic stiffness.
metrical device with in-built distraction screws it The second step was the development of
was first tested in dogs to investigate joint a specific protocol for the treatment of post-
remodelling after removal of the joint cartilage traumatic elbow stiffness using mechanical dis-
in the knee with evidence of fibrous cartilage traction without major surgical soft tissue release
remodelling. The distractor apparatus was subse- [2, 3, 5, 12, 15]. This technique for joint
quently used in 11 cases of elbow pathology, arthrolysis differs from all other protocols for
mostly for reversing elbow arthrodesis, with mechanical distraction of the elbow, which
promising short-term results. merely use one fixator for mechanical distraction
The refinement and clinical use of mechanical and mobilisation of the elbow. The technique
distraction with the largest clinical experience from Cologne consists of two steps, the first
was based on the work of Morrey, who developed being distraction (two times 15 mm of joint
and tested a mechanical distractor evolved from space) of the peri-articular tissues (i.e., the joint
the original Brigham and Women’s device in capsule and scarred collateral ligaments) with
1496 K. Mader and D. Pennig

a strong distraction fixator and the second performed via a curved medial incision using
consisting of mobilization of the joint with dis- magnifying glasses and microsurgical instru-
tracted and separated joint surfaces using an ments (Fig. 7). The wound is covered with
elbow fixator with motion capacity. a moist swab and left open until the end of the
One hundred patients with post-traumatic operation to allow for monitoring of the ulnar
stiffness were treated prospectively according to nerve during distraction and flexion of the
this treatment concept with a mean follow- up of elbow [2]. The operative procedure of fixator
5 years [15]. application starts with identifying the centre of
rotation of the humero-ulnar joint. The tip of
a 2 mm K-wire is percutaneously placed at the
Surgical Protocol of the Arthrodiatasis base of the radial epicondyle. The arm is posi-
Procedure tioned on the operating table so as to obtain a true
lateral view with the image intensifier, the correct
The Devices aspect showing the circular shape of the radial
For intra-operative distraction a standard and ulnar epicondyles symmetrically overlapping
dynamic axial fixator (DAF; Orthofix Srl, Italy, each other. The tip of the K-wire is adjusted at the
U.K., USA) with standard clamp for the humeral proximal border of the ring of the humeral con-
pins and a T-clamp for the proximal ulnar pins is dyles visible on the image intensifier screen
used. In children and adolescents younger than (Fig. 9a–c) [2]. The pilot wire was then advanced
13 years a Pennig wrist fixator with in-built dis- into the condyles not penetrating the contralateral
traction unit was used [2, 12]. For relaxation and side to protect the ulnar nerve. After marking the
mobilisation under distraction a monolateral axis of humero-ulnar joint the cannulated central
external fixator with motion capacity is used unit is slid over the radial end of the K-wire using
(Orthofix Srl, Italy, U.K., USA). The fixator con- the fixator as template for screw insertion
sists of two slotted rails, which can each be (Fig. 10) and using the operative technique for
connected at the outer end via a ball-joint to the application of hinged external fixation of the
a fixator clamp. The inner ends of both rails elbow (See chapter ▶ “Fracture Dislocations of
overlap with a central connecting unit passing the Elbow - The Elbow Fixator Concept”).
through the slots of both bars allowing free move-
ment against each other in one plane. The central Mechanical Distraction
connecting unit consists of a central locking Mechanical distraction is performed with
screw and two additional link locking screws a standard dynamic axial fixator (DAF; Orthofix
that lock the position of the central unit on each Srl, Italy, UK, USA) which is applied for intra-
fixator rail independently. Locking of both link operative mechanical distraction prior to final
locking screws results in a hinged movement mounting of the elbow fixator [2]. The humeral
between both fixator rails corresponding to screws are used proximally and two additional
elbow flexion and extension; additional locking screws were inserted in the posterolateral aspect
of the central screw locks the hinge and serves to of the olecranon using a T-clamp. Standard
immobilize the humero-ulnar joint. distractors were used to distract the joint 15 mm
for two times (Fig. 11) over a minimum of 30 min
Operative Technique and fluoroscopy is performed in order to control
All operations are carried out under general symmetrical opening of the joint space. The dis-
anaesthesia without tourniquet (the first author traction fixator and olecranon screws are then
uses a sterile tourniquet for the in-situ removed and the elbow fixator with additional
neurolysis). All patients are in supine position small distractors was applied over the K-wire
with the flexed arm on a hand-table and image marking the elbow centre of motion before dis-
intensification is used. Each operation starts with traction. The ball joints and link locking screws
in-situ decompression of the ulnar nerve which is are locked into position and the pilot K-wire
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1497

Fig. 10 The elbow fixator

is used as a template for
application of the fixator
pins [2]

a b

Fig. 11 Schematic
drawing (a) and clinical
photograph (b) showing
intra-operative distraction
with the standard DAF
armed with a compression-
distraction unit with
a standard clamp for the c
humeral pins and a T-clamp
for the olecranon pins.
Insert (c): intra-operative
image intensifier image
demonstrating symmetric
distraction of the humero-
ulnar joint of 15 mm [2]

removed; distraction is carried out along the a concentric distraction. In cases with lack of
humeral and ulnar links (mean of 8 mm distrac- flexion, the locking position is between 100
tion), followed by movement of the joint under and 120 degrees of flexion. The status of the
radiographic control (Fig. 12). In all cases sym- ulnar nerve is again controlled at that point and
metrical distraction of the elbow joint with at flexion has to be released in case of increased
least double physiologic joint space is executed tension of the nerve. Soft tissue release is not
and documented fluoroscopically in the lateral routinely performed. Heterotopic ossification of
view, paying especially attention to maintaining bony fragments or appositions are removed via
1498 K. Mader and D. Pennig

Fig. 12 (a) and (b) Schematic drawing of the elbow fixator after mounting. The arrow shows the small distractor being
used for the third intraoperative distraction [2]

limited arthrotomy, while the surgical approach unit (mobilisation phase). Post-operative physio-
is indicated by evaluation of the conventional therapy is of utmost importance and is performed
x-rays and CT studies (Fig. 13c–d). Posterior or twice a day with cryotherapy prior to each ses-
rotational subluxation of the joint is reduced sion. Increased flexion is achieved with the com-
intra-operatively using the small distractors as pression-distraction unit by applying 2–4 mm
well as the capacity of the ball joints of the compression every 30 min between physiother-
elbow fixator. Elbow stiffness with chronic apy sessions (Fig. 14). This is a slow and contin-
dislocation of the joint is the real challenge to uous process that leads to a gradual gain in
face [34]. flexion. The second session of physiotherapy is
Sometimes additional procedures such as cor- scheduled as late possible in the day, after which
rective osteomies, partial hardware removal (we the fixator is locked for the night first in maxi-
do sometimes cut a plate peri-articularly in order mum flexion and then, on the following night
to avoid large compromise of the soft tissues). (after a focus on flexion during the day), in max-
Generally the surgical exposure is as minimal as imum extension. This night immobilisation alter-
possible. A overview over the surgical steps is nating between maximum flexion and maximum
given in Table 3. extension, is carried out for at least 3 weeks and
leads to step-wise gains in both flexion and exten-
Post-Operative Protocol sion, which of course is individualized according
The elbow joint is held in the desired position of to the patient’s needs and progress. This is
flexion for at least 6 days and for up to 10 days if followed by physiotherapy with the same proto-
the deficit has been longstanding (relaxation col but without locking the fixator overnight [2].
phase). Joint distraction is maintained by In order to avoid formation of heterotopic bone
the small distractor units, and elbow motion is and to reduce pain, indomethacin (50 mg twice
started by unlocking of the screw of the central a day with gastric protection) is prescribed for the
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1499

a b

Fig. 13 (continued)
1500 K. Mader and D. Pennig

Fig. 13 (continued)
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1501

Fig. 13 Clinical illustrative case of a 34 year-old manual of the incisions and on the right the ulnar nerve neurolysis.
worker sustaining polytrauma in a road traffic accident (g) Removal of the HO with the chisel using a triceps split
with dislocation of the both elbows, long-term ventilation approach with appropriate soft tissue bridge to the ulnar
after brain injury, 4 bilateral manipulations under analge- nerve approach; on the right the HO removed. (h) situs
sia on the intensive care unit with ankylosis of both elbows after removal of the dorsal HO and during insertion of
in 90 of flexion 6 referred 6 months after the initial injury. a strong bone anchor for re-inforcement of the thinned-out
The patient developed a severe psychotic aversion triceps. (i) intra-operative fluoroscopy printouts of posi-
towards hospital treatment during the 4 weeks stay in tion of the pilot k-wire for hinged fixation, mounting and
a university trauma unit. (a) and (b) clinical photographs placement of the olecranon pins, closed distraction and
of the upper extremities before operation of the left elbow: concentric distraction of the humero-ulnar joint. (j) intra-
note the severe atrophy McGowan type III of the operative images of the closed distraction procedure (with
interosseus musculature on the right side due to iatrogenic manual support of the assistant; left) and the fine tuning of
ulnar nerve injury during MUA session. (c) lateral radio- the distraction with the hinged fixator after removal of the
graphs showing bilateral complete ankylosis of the distraction fixator (right). (k) Anterioposterior radio-
humero-ulnar joint (Ilahi IV) and ankylosis of the proxi- graphs of the left elbow 6 months after the index operation
mal radio-ulnar joint on the right side. (d) CT scan of the and just before operation of the left right side with the
left side showing the extent and position of the humero- same protocol (plus revision of the proximal radio-ulnar
ulnar heterotopic bone. The main part of the HO lies joint via a Kocher approach). (l) clinical images at inter-
radial, not ulnar under the triceps. (e) Intra-operative mediate follow-up 8 weeks after operation on the right
fluoscope print-out showing the use of marking of the side: Satisfaction 10 of 10 possible points, MEPI 94 bilat-
position of the dorsal HO in the left side. (f) Clinical eral, DASH 20 bilateral, no regrown HO, pain 2 of 10
intra-operative image showing the limited approaches to possible points (VAS)
the ulnar nerve and the dorsal HO: on the left the marking
1502 K. Mader and D. Pennig

Table 3 Operative technique mechanical distraction Fig. 15a–h illustrate the clinical and radiological
Hand table, no tourniquet follow- up of the patient of Fig. 3.
Decompression of ulnar nerve
Removal of impinging osteophytes/ heterotopic bone Avoiding Elbow Stiffness
Central K-wire, humeral and ulnar screws Analysing our data on post-traumatic stiffness,
Olecranon pins and distraction fixator several factors can be identified which as single
Distraction 15 mm (2, under fluoroscopic control) factors or in combination lead to elbow contrac-
Removal of olecranon pins, elbow fixator ture and are worth noting as their avoidance or the
Redistraction humeral distractor (12 mm) correct treatment strategy will reduce the inci-
Ulnar distraction (when indicated) dence of post-traumatic stiffness.
Test-mobilisation (heterotopic bone)
The first is finding the correct diagnosis of the
Locking of fixator in 110 of flexion
elbow trauma present and detecting an inherent
Relaxation phase 6–10 days
instability or subluxation of the elbow joint;
hence this will decide the fate of the affected
elbow. The second is the duration of the
immobilisation in cast after any intervention for
an acute elbow injury, be it simple or unstable
dislocation, fracture-dislocation or gross instabil-
ity: [35] in our database of elbow stiffness, the time
in cast after the initial therapy is very high with
a mean of 5.7 weeks in cast (SD  1.5), which is in
sharp contrast to our protocol that begins early
active motion without the cast at 6 days post-oper-
atively. A fear of re-dislocation of the elbow, fail-
ure of internal fixation and persistent instability
leads to this prolonged casting which promotes
undirected stability, which clearly is elbow stiff-
ness. In our patient database, there were 14 cases
with simple elbow dislocation, in which casting
was more than 6 weeks in any individual patient.
A third important issue is the operative fixation
technique in simple and complex fracture-
dislocations of the elbow. There have recently
Fig. 14 Clinical image demonstrating the use of the been thoughtful publications on strategies in the
compression-distraction device to maintaining further treatment of simple and complex fracture-
increase flexion post-operatively [2] dislocations of the elbow. These are mostly based
on a general thought of adequately fixing and
total treatment period. X-ray controls are restoring the bony anatomy, followed by sutures
performed at 1, 7, 14, 28 days postoperatively of the ligament and physiotherapy. This strategy
and before removal of the fixator using dental lacks a principal key in avoiding early failure of
films for unobstructed lateral views. Pin-site the reconstruction by subluxation or pure instabil-
care is performed 2–3 times in the first weeks ity of the elbow joint, which is the maintenance of
with decreasing frequency using mild non- concentric reduction of the elbow with a hinged
coloured disinfectant and gauze dressing. The elbow fixator [35]. The failure of adequate use of
fixator remains in situ for 6–8 weeks, all fixator this important tool is reflected strongly in the clin-
pins are removed in the outpatient department ical cohort with a high percentage of persistent
without local anaesthesia. Physiotherapy is con- subluxation or re-dislocation of 28 % in the clini-
tinued for at least 1 year after fixator removal. cal case cohort in our material [15].
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1503

Heterotopic bone was resected via limited with a hinged fixator and medical prophylaxis
approaches according to conventional X-ray against heterotopic ossification.
and CT studies in 40 patients in our cohort.
This high incidence of heterotopic bone is Manipulation Under Anaesthesia
reflecting a high proportion of persistent insta- One very important iatrogenic problem is the
bility after the initial surgical treatment, hence use of manipulation under anaesthesia
heterotopic bone formation around the elbow (MUA) after open surgical release of elbow con-
joint is either due to severe head injury or tracture. In our series in 76 % percent of cases
a cause of the response of the soft tissues to there was no MUA, in 9 % one MUA and in 15
a on-going dislocating force. This is a clear patients more than 2 attempts to gain motion
sign that in the revision situation with with MUA (24 %). In the paper by Tan and
re-dislocation of the elbow, the management of co- workers in 52 cases open surgical release
recurrent complex instability should be treated was performed for post-traumatic elbow stiffness.

b c

Fig. 15 (continued)
1504 K. Mader and D. Pennig

Fig. 15 (continued)
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1505

Fig. 15 42 year-old female patient with post-traumatic forearm rotation only the first were addressed with closed
elbow stiffness after fracture-dislocation of the left elbow distraction (e) CT scan before revision of the radial head
with radial head fracture, coronoid fracture and ulnar lig- and the proximal radio-ulnar joint 6 months after closed
ament complex disruption: the extension/flexion is distraction depicting a concentric humero-ulnar joint. (f)
0–30–75 and pronation/supination is 20–0–0 . (a) Anterior posterior and lateral X-ray 6 months after closed
anteroposterior and lateral view of the trauma X-rays. (b) distraction and before revision of the radial head and the
lateral X-ray postoperatively in the casts 6 weeks after proximal radio-ulnar joint to restore forearm rotation: flex-
operation: plate and screw osteosynthesis of the radial ion/extension is 0–10–125 . (g) Anterior posterior and
head. (c) radial head view demonstrating translation of lateral X-ray 24 month’s hardware removal, re-shaping of
the radial head (iatrogen); the CT scan insert and schematic the radial head and limited arthrolysis of the proximal
drawing show the superposition of the radial shaft and radio-ulnar joint: flexion/extension is 0–10–125 and pro-
radial head. (d) Dental film X-ray after in-situ neurolysis nation/supination is 90–0–90 . (h) clinical picture at latest
and closed distraction of the left elbow showing a 6 mm follow-up 4 years after the index operation: MEPI is 96, the
concentric distraction of the joint space and a flexion of elbow is stable, the functional result is convincing and pain
120 . Due to stiffness in both flexion/extension arc and on the VAS score is 1

Fourteen patients (27 %) required manipulation three of these required further surgical contracture
under anaesthesia (MUA) at 3.5 (average) weeks release, with two additional failed cases in this
post-operatively and there was a loss of 50 % or group. If you now weigh the use of MUA in the
greater of intra-operative motion in those patients; right context, which is failure of the index
1506 K. Mader and D. Pennig

mean load deformation curve with

humeroulnar joint distraction
1200

1000
mean force [N]

800

600

400

200

0
0 2 4 6 8 10 12 14 16
distance of distraction [mm]

clinical patient elbows human cadaver elbows

Fig. 16 Forces in relation to distraction distance during sensor; the blue triangles display the peak forces during
closed elbow distraction in eight patients and eight distraction and the grey circles the constant forces
cadaver elbow specimens using a custom-made force

procedure or count it as complication, there were Complications

14 MUA procedures which are 14 failures of the
index procedure or 14 additional complications. It cannot be underlined more that elbow stiffness
In the cohort of Tan et al., five patients in addition is one of most challenging tasks the upper
did not reach a functional arc of motion, three extremity specialist is facing and that these
patients had severe ulnar nerve problems, three patients should be concentrated in centres of
had infections, two had post-operative instabil- excellence. The complication rate in our consec-
ities; in addition there were two second releases utive series of severe elbow contracture (mean
and two hinged fixators necessary. So 20 of pre-operative arc of motion (tROM) of of 31
their patients required a total of 27 subsequent (SD,  21 ) was reasonably low with seven com-
procedures (37 %). In conclusion, MUA is first plications (7 %) leading to five subsequent oper-
required in a high rate after open surgical release ative interventions in one hundred patients. This
and second does not help the function al outcome compares favourably with the complication rate
but causes severe iatrogenic complications after other treatment modalities with complica-
(Fig. 13a–l) [15, 24]. tion rates ranging from less than 5 % (in historical
papers) to over 30 % in the more recent critical
Other Fixators papers on open arthrolysis [23, 24]. The major
One important question in analyzing the treat- thread is the iatrogenic ulnar nerve injury: The
ment concept of using mechanical distraction in rate of pre-operative ulnar neuropathy in post-
the treatment of elbow stiffness remains, which traumatic elbow contracture in our data was
is, whether other fixators on the market may very high with a pre-operative ulnar neuropathy
provide comparable results. Recent data from (NCV > 50 m/s) of 43 patients (43 %), of which
Sekya et al., Kamineni et al. and Stavlas et al. 7 % were related to the initial injury (IRUN),
and the data from our own biomechanical 32 % where post-operative surgery-related ulnar
investigations clearly show that other fixators neuropathy (PSRUN) and 14 % were delayed
commercially available do not withstand the bio- compressive neuropathy (DCUN). These data
mechanical forces acting on the elbow and the are difficult to compare with previous studies,
fixator construct (Fig. 16). in which there is poor documentation of
Post-Traumatic Elbow Stiffness - Arthrolysis and Mechanical Distraction 1507

pre-operative ulnar neuropathy, especially of the 12. Gausepohl T, Mader K, Pennig D. Mechanical distrac-
aforementioned sub- groups [15]. In two more tion in post-traumatic stiffness of the elbow in children.
J Bone Joint Surg [Am]. 2006;88-A:211–21.
recent studies on open surgical release in elbow 13. Judet R, Judet T. Artholyse et arthroplastie sous
contracture Tan et al. reported on only three distracteur articulaire. Rev Chir Orthop. 1978;
patients with ulnar neuropathy in 52 patients 64:353–65.
(without sub grouping) and Ring et al. reported 14. Morrey BF. Post-traumatic contracture of the elbow:
operative treatment including distraction arthroplasty.
about “ulnar nerve problems” in 7 patients out of J Bone Joint Surg Am. 1990;72-A:601–18.
46, with four new (and iatrogenic) and three 15. Mader K, Pennig D. Posttraumatic stiffness of the
subsequent release operations for ulnar nerve elbow: results of mechanical distraction in 100
dysfunction at final follow-up. Hence our com- patients. J Bone Joint Surg Br. 2011;40(4):329–38.
16. Volkov MV, Oganesian OV. Restoration of function
plication rate regarding the ulnar nerve with four in the knee and elbow with a hinge-distractor appara-
subsequent ulnar neuropathies (4 %, PSRUN) tus. J Bone Joint Surg Am. 1975;57-A:591–60.
compared favourably with these results [15]. 17. Lin CC, Ju MS, Hang HW. Gender and age effects on
elbow joint stiffness in healthy subjects. Arch Phys
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18. Keschner MT, Paksima N. The stiff elbow. Bull NYU
Hosp Jt Dis. 2007;65:24–8.
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