➢ The elbow is prone to the formation of heterotopic ossification after trauma. Elbow contracture due to heterotopic ossification leads to compromised range of motion and disabilities in performing daily activities.
➢ The treatment of elbow contracture is challenging and requires a multidisciplinary assessment.
➢ Nonoperative treatment is appropriate for patients within 6 months after the injury to counter the progressive loss of motion during the maturation of heterotopic bone.
➢ Operative intervention is indicated if the functional arc of motion cannot be maintained.
➢ Open arthrolysis combined with heterotopic excision, ulnar nerve decompression and transposition, and application of a hinged external fixator are effective interventions for improving elbow function.
➢ A prolonged and rigorous rehabilitation protocol after elbow release is important for preserving the arc of motion achieved during surgery.
Heterotopic ossification (HO) is defined as the formation of mature lamellar bone in nonosseous soft tissues1,2. The development of HO is associated with various local and systemic insults, including soft-tissue and osseous trauma, central nervous system injury or spinal cord injury, operative intervention, thermal burns, and congenital diseases3-6. The specific pathogenesis of HO is still incompletely understood.
The elbow is one of the most common joints for HO formation, usually following direct elbow trauma. HO around the elbow can be localized and asymptomatic, although extensive development of heterotopic bone can lead to compromised range of motion, elbow contracture, or even complete ankylosis3,5,7. According to Morrey et al., the functional arc of motion is defined as 100° of flexion (from 30° to 130°) and 100° of forearm rotation (from 50° of supination to 50° of pronation)8. Limited elbow motion prevents the patient from performing normal daily activities. In addition, the peripheral nerves of the upper extremity are susceptible to compression by heterotopic ossification, which may cause clinical symptoms and functional disability2,9-11.
The treatment of elbow stiffness is challenging because of the complicated anatomical manifestation, the involvement of both periarticular and intra-articular structures12, and a relatively high rate of recurrence and recontracture13-15. The objective of treating elbow contracture is to provide a pain-free, stable, and functional elbow16. A multidisciplinary assessment is necessary in the diagnosis and treatment of elbow contracture associated with HO.
A 42-year-old carpenter presented with a 12-month history of severely restricted movement of the right elbow. One year previously, he had sustained an open fracture of the right ulnar shaft in a motor-vehicle accident. Debridement and suturing were performed at the local hospital immediately after the injury, and open reduction and internal fixation (ORIF) of the ulna was performed 10 days after the injury. The right elbow and forearm were immobilized in a plaster cast for 2 weeks after surgery. After removal of the cast, the patient noticed difficulty when moving the right elbow. He tried to perform elbow exercises but found them difficult and noted pain when trying to improve the elbow motion with passive force. The restriction of elbow movement worsened and inhibited him from performing his work, so he came to our office for further treatment.
Physical examination revealed limited range of motion of the right elbow, with a flexion-extension arc of 5° (65° in flexion and 60° in extension) and a rotation arc of 150° (60° in pronation and 90° in supination) (Fig. 1). No instability of the elbow was detected. Neurological examination demonstrated paresthesias in the ulnar half of the ring and little fingers and on the ulnar side of the hand and forearm. The Tinel sign was negative. Weakness of abduction of the little finger was found but without claw-hand deformity. The grip strength of the right hand was normal compared with that of the left. The Mayo Elbow Performance Score (MEPS)17 was 50 points.
Radiographs and 3-dimensional computed tomography (CT) scans of the right elbow (Fig. 2) revealed arthrosis of the ulnohumeral joint. Osteophytes were observed around the elbow joint, especially the posterior part of the ulnohumeral joint. The ulna had osseous union. The internal fixation devices were in a satisfactory position. No bone malunion or nonunion was observed.
Preoperative Work-up and Treatments
A diagnosis of posttraumatic elbow contracture can be made easily on the basis of the history and physical examination. In cases of elbow contracture, establishing the exact injury mechanism and a thorough understanding of patient history are important. Relevant information pertaining to the initial traumatic event, previous treatment, previous operations, and medical intervention will influence the plan of treatment. A detailed physical examination of the elbow should be performed every time the patient visits the office. The active and passive ranges of motion of the elbow (including flexion-extension and pronation-supination), elbow stability, motor strength, skin condition, and the neurovascular status of the affected extremity should be carefully assessed. Inflammatory markers such as C-reactive protein and the erythrocyte sedimentation rate should be tested to exclude infection and inflammatory conditions18. Radiographic assessments, including standard anteroposterior and lateral radiographs and CT scans, are used to visualize potential lesions that might affect elbow motion, such as HO, malunion, and joint degeneration. Although radiographs are sufficient in most cases, CT scans with 3-dimensional reconstruction are helpful, particularly when HO is present19-21.
Delayed peripheral neuropathy is a common complication of elbow contracture. The ulnar nerve is most commonly involved, although the radial and median nerves also may be affected. Causes of neuropathy include osteoarthritic changes, deformities such as cubitus valgus or varus, elbow instability, and HO22. A detailed neurological evaluation should be performed for patients with elbow contracture. Although ulnar compression at the elbow can be diagnosed clinically, we recommend performing electroneurographic testing and ultrasonographic imaging preoperatively for patients with symptoms of ulnar neuropathy to confirm the diagnosis and to exclude the possibility of compression at other anatomical sites23,24. Ultrasonography is not a mandatory examination, but it is helpful for localizing and detecting the morphological changes and the extent of the ulnar nerve lesion at the elbow23,25.
Nonoperative treatment for elbow contracture associated with HO is most effective within 6 months after the injury to counter the progressive loss of motion that occurs during the maturation of heterotopic bone. Treatment options include mobilization of joint and myofascial soft tissue, active and passive elbow motion, static and dynamic splinting, and strengthening exercises2,26.
Soft-tissue mobilization, including massage, pressure, skin-rolling, twisting, and wringing applied to the contracted soft-tissue structures can increase tissue extensibility and decrease muscle tension. Although there are concerns that aggressive passive elbow exercises may lead to increased heterotopic bone formation27, there is little evidence to clarify the relationship between passive motion and HO formation. Passive range of motion should be performed progressively with a low load and within tissue tolerance. The patient should be relaxed and should not feel pain when passive stretching is applied to the elbow. Active exercises, usually performed following passive range of motion, are also helpful for improving elbow range of motion (especially elbow extension)28.
Corrective splinting devices can produce plastic elongation of contracted tissue by providing prolonged tension in the fibroblastic and remodeling phases of healing28. A static progressive splint applies a static stress-relaxation force to the elbow that dissipates as tissues stretch, whereas a dynamic splint provides constant pressure as additional elbow motion is achieved29. Both dynamic and static progressive splinting have been shown to be effective for improving elbow motion, and previous studies have demonstrated no significant differences between the 2 protocols with regard to improvement in motion30-33. We recommend that patients undergo dynamic or static progressive splinting for at least 6 months after the injury, until there is no progression in elbow motion.
Operative arthrolysis is considered when conservative treatment fails to restore a functional range of motion, especially when the remaining elbow motion is severely limited. Our criteria for operative release and HO resection are (1) function-limiting elbow stiffness due to heterotopic bone formation, with a flexion-extension arc of <100° and/or a rotation arc of <100°, (2) radiographic union of fractures, (3) radiographic manifestation of HO maturity or well-demarcated cortical margins, (4) elbow soft-tissue stability, and (5) patient competence to participate in the prolonged and rigorous postoperative rehabilitation program. For patients with a history of neurological injury, a detailed cognitive and physical function assessment should be performed before operative treatment. Patients with good neurological recovery and motor function have better outcomes and lower recurrence rates than those with serious cognitive and physical disabilities13,34,35. In our opinion, the presence of poor neurological recovery or serious cognitive dysfunction should be considered as a contraindication to contracture release.
Several approaches have been introduced for open release of elbow contracture2,36-40. The approach that is selected depends on various factors, including previous elbow incisions, the plane of elbow contracture, the location and extent of heterotopic bone, the need for nerve decompression, and the goals of treatment. The approach should provide an adequate exposure to the elbow with preservation of the neurovascular structures41. An isolated medial or anterior approach may be inadequate when extensive ectopic bone is present and requires exposure of both the medial and lateral parts of the elbow12,18. A combined medial and lateral approach or a single posterior approach is most often used. The posterior approach with elevation of broad medial and lateral skin flaps can provide extensive exposure to all aspects of the elbow joint through a single incision. The disadvantage of this approach is that hematoma or seroma may develop postoperatively because of the space under the flaps, which may require further treatment such as aspiration or operative resection42. Traction across the posterior wound with elbow flexion also may interfere with rehabilitation and may contribute to wound-healing complications43. The combined medial and lateral approach reduces the chance of hematoma formation and enables early postoperative exercises with fewer wound problems; however, it is associated with the potential risk of damaging the cutaneous nerves. The anterior aspect of the joint is released mainly through the lateral incision, and the posterior aspect is released through the medial incision. We favor this combined approach in most cases in which a patient has undergone previous surgery through a posterior incision. In most cases, the choice of operative approach depends on surgeon experience and preference.
The exposure procedure for the elbow joint is similar regardless of the incisions. From the lateral view, the extensor origins of the brachioradialis and extensor carpi radialis longus tendons are elevated off the anterior aspect of the humerus to release the anterior aspect of the joint. The anterior part of the capsule is excised, and intra-articular adhesions, loose bodies, and osteophytes in the coronoid fossa and the radiohumeral joint are removed. The medial approach is used to address the medial and posterior targets. The ulnar nerve should be identified, released from its tunnel, and protected during the medial procedure. The triceps muscle is elevated off the humerus to expose the olecranon fossa and the posterior part of the capsule for debridement. Release of medial soft tissues, resection of the posterior and transverse bundles of the medial collateral ligament, excision of HO, and clearance of the olecranon fossa are performed subsequently. The tip of the olecranon sometimes blocks elbow extension and can be shortened by 5 to 10 mm to increase the extension angle44.
The ulnar nerve is routinely exposed and released during the procedure of elbow arthrolysis as it is prone to elongation and increased intraneural pressure and is at high risk for dysfunction in association with increased elbow flexion after surgery16,22,45. The ulnar nerve is identified at the medial border of the triceps and is released from the ligament of Struthers or the intermuscular septum proximally to its entry under the flexor carpi ulnaris distally. Anterior transposition and medial epicondylectomy are also performed to treat nerve compression11,36,46. We suggest subcutaneous anterior transposition of the ulnar nerve to prevent postoperative neuropathy10, especially when preoperative ulnar nerve symptoms are present or preoperative elbow flexion is <100°.
The radial and posterior interosseous nerves should be identified and protected when there is extensive anterolateral heterotopic bone. The radial nerve can be identified in the superficial interval between the brachialis and brachioradialis muscles proximally and in the interval between the pronator teres and brachioradialis muscles distally. The posterior interosseous nerve can then be traced from the radial nerve at the radiohumeral joint line and traced through the supinator. Manipulation over the anterior radiocapitellar capsule and removal of the proximal radioulnar synostosis should be carefully performed in order to avoid harming the nerve. The median nerve courses along with the brachial artery between the biceps brachii and brachialis muscles on the medial side of the arm and enters the anterior compartment of the forearm via the cubital fossa. Care should be taken to protect the median nerve when elevating the brachialis tendon off the anterior aspect of the humerus41.
Heterotopic bone that blocks elbow motion should be removed. Anterior heterotopic bone usually forms beneath the brachialis muscle, blocking elbow flexion. After the heterotopic bone is carefully exposed and isolated, resection is performed with use of an osteotome or a rongeur. Care should be taken when removing heterotopic bone in the region of the proximal radioulnar joint, which usually interferes with forearm rotation, by defining the normal cortices of the proximal parts of the forearm bones. Posterior heterotopic bone beneath the triceps in continuity with the capsule and olecranon is difficult to distinguish from the normal anatomical structures, particularly when there is osseous ankylosis5. Sometimes the joint may be entirely encased in bone and the junction between the heterotopic bone and the original articular anatomy is not clear. It is necessary to resect heterotopic bone with an osteotome in layers until the joint is encountered and then administer quick and sharp blows to separate the heterotopic bone from the underlying host bone along anatomical planes41. Heterotopic bone within or around the medial or lateral collateral ligament should be removed carefully, and sometimes it is necessary to excise the ligament or to detach it from its humeral origin for further release. However, the anterior bundle of the medial collateral ligament and the lateral ulnar collateral ligament should be left intact to prevent instability2,46.
Following the resection of heterotopic bone and the release of contracted soft tissues, manipulation with gentle force is performed intraoperatively to check the elbow range of motion. Manipulation should be performed with great care, typically with 2 fingers, in order to avoid iatrogenic fracture or rupture. If substantial force is needed to mobilize the elbow, additional release should be performed to achieve a satisfactory range of motion. Intraoperative examination is necessary to detect the stability of the elbow. Although care should be taken to protect the collateral ligaments, injury is inevitable when an extensive contracture release is performed, especially when the elbow is severely stiff preoperatively (<50° of elbow flexion-extension range). In the case of injury, the injured collateral ligament is repaired via drill-holes or suture anchors47-49. A hinged external fixator can be used to provide additional stability and an ideal state for ligament recovery50,51. Limitation of forearm rotation can be treated with radial head resection or prosthetic replacement if there is proximal radioulnar synostosis52-54 or nonunion or malunion of the radial head55,56. We routinely remove metal implants that were inserted during previous procedures if the preoperative radiographs show solid union of fractures and the time interval between the previous fixation and the index procedure is long enough to allow for fracture union (>10 months).
If adequate release is completed and the elbow has reached a satisfactory range of motion, photographs should be made with the elbow in full flexion, extension, and rotation as a record of the operative result. These photographs will help physical therapists and patients in setting goals for rehabilitation and also will motivate patients to work on range of motion postoperatively with more confidence42. Indomethacin (25 mg, 3 times daily)57 or celecoxib (200 mg, 1 time daily)58 is administered over a period of 4 weeks after the operation to prevent the recurrence of HO, which could reduce the rate of recurrence of HO by 20% to 30%58-60. Some authors have suggested prophylactic radiation with a single dose of 700 cGy within 24 hours after the operation to prevent the development of HO28,46,61. However, others have reported that radiation therapy for the prevention of HO of the elbow is supported by weak evidence62-64. Thus, we do not routinely use radiation therapy as a postoperative intervention because of its uncertain efficacy and the possible adverse effects caused by radiation62,63,65,66.
The aims of postoperative management are to maintain the elbow motion that was achieved during surgery, to decrease pain and swelling, to increase muscle strength, and to regain the ability to perform daily activities. After the operation, the elbow is wrapped with a compression dressing and is elevated on several blankets or pillows to reduce swelling and hematoma formation. Local cooling helps to reduce blood flow through vasoconstriction and decreasing local nerve conduction. A compressive cryotherapy system is applied to the elbow for at least 3 sessions of 1 hour per day for 1 week, starting on the day of operation; this treatment is effective for relieving postoperative pain both at rest and in motion67. Plastic ice bags and refreezable silica gel packs are alternative options for the local application of cryotherapy, but, to avoid frostbite, care should be taken not to apply ice wraps directly to the skin.
Elbow mobilization performed at the early stage after elbow release is important for preserving the arc of motion. We routinely start the rehabilitation program on the first postoperative day. Postoperative exercises include active, active-assisted, and passive flexion and extension movements. Elbow rehabilitation should be performed at least 3 times a day and should be increased gradually from half an hour to 1 hour per session, depending on the tolerance of the patient. Manipulation with the patient under anesthesia is not routinely performed during the postoperative rehabilitation stage. Patients are expected to achieve at least 90% of the elbow range of motion that was attained during surgery within the first postoperative week and almost full motion in the subsequent week. Static progressive or dynamic splinting can be useful for postoperative rehabilitation, especially for patients who have difficulty maintaining the motion goals. Two types of splints, including one that focuses on elbow extension and one that focuses primarily on flexion, should be provided to the patient42. If a hinged external fixator was applied at the time of surgery, then it is locked at the extreme position of elbow extension or flexion after each session of exercise as well as when the patient is asleep overnight. The progressive exercise program continues with the help of the external fixator for 6 to 8 weeks until the fixator is removed during an outpatient procedure. The patient is encouraged to perform strength training and to use the elbow as much as possible after the removal of the fixator.
Some authors have reported on the application of a continuous passive motion (CPM) device immediately after surgery to restore a functional arc of motion36,68,69. However, the efficacy is controversial, and recent studies have demonstrated no significant benefits of CPM in the postoperative treatment of elbow contracture release70,71. A CPM device should not be applied to elbows that have been treated with ligament reconstruction.
Open elbow arthrolysis has been shown to be an effective method of treating posttraumatic elbow contracture with or without HO16,36,37,49,72-81. The mean improvement of the flexion-extension arc has ranged from 38°40 to 89°78. The effect of contracture release and HO excision is influenced by multiple factors, including the time from the injury to surgery, the condition of the soft tissues, the amount of HO, the preoperative arc of motion, the degree of arthritis, the experience of the surgeon, and patient compliance with postoperative rehabilitation. However, it is believed that operative intervention can provide a functional arc of elbow motion in most cases, regardless of whether the etiology of HO is direct elbow trauma, neurological injury, or thermal burns3-6.
The optimal time for operative excision of heterotopic bone is still controversial. Surgeons used to wait for 12 to 24 months after the initial trauma to perform intervention because of the high risk of recurrence of HO15,35,36,52. However, other factors may hinder elbow motion after long-standing dysfunction of the elbow, including progressive soft-tissue contracture, articular cartilage degeneration, and muscle atrophy. Recent studies have indicated that early excision of HO (<1 year after the injury) can safely proceed with no difference in the rate of recurrence as compared with delayed surgery3,6,9,57,82,83. Heterotopic bone formation begins 2 to 12 weeks after the inciting injury2,84. Radiographic evaluation should be performed to observe the progression of HO after the onset of contracture. The eventual maturity of HO generally takes approximately 3 to 6 months and is indicated by well-demarcated cortical margins and trabeculation on standard radiographs2,57. Operative release and HO resection can be performed as soon as the maturity of HO is confirmed radiographically5,52,57,85, although the indications for operative management may be influenced by other factors, including soft-tissue stability, union of involved fractures, the willingness of the patient to undergo operative intervention, and the competence of the patient with regard to the rigorous postoperative rehabilitation. We suggest that HO resection be performed at 6 to 10 months after the initial injury, and, if internal fixation has been used, the resection can be delayed up to 1 year to make sure that the fracture is completely healed.
The application of a hinged external fixator following elbow arthrolysis has several advantages: (1) it provides additional protection against rotatory and shearing forces and thus provides stability following extensive release78, (2) it keeps the elbow from valgus-varus displacement and provides a stable condition for ligament repair51, (3) it maintains concentric reduction of the elbow during mobilization, allowing for aggressive static and dynamic rehabilitation50, and (4) it provides an unloaded environment and helps cartilage recovery in complicated cases of elbow release combined with internal fixation of nonunited or malunited elbow fractures by mechanical distraction of the ulnohumeral joint using the fixator86-88. The drawbacks of using an external fixator include added costs, increased intraoperative risks, and pin-related complications (pin-track infection, pin breakage, ulnar nerve irritation, and pin-site fracture). However, the risk of related complications can be controlled under careful manipulation by surgeons and therapists, and a systematic review of the literature demonstrated no significant difference between patients managed with and without hinged external fixation with regard to the total complication rate89. On the basis of the good results that have been achieved previously44,50,78, we suggest that hinged external fixation should be used along with elbow contracture release if ligament repair has been performed, if potential instability is present, or if the arc of flexion and extension is <50° preoperatively.
Complications after open elbow arthrolysis include new-onset peripheral nerve symptoms or exacerbation of such symptoms (9%), recurrence of HO (6%), repeat soft-tissue contracture (4%), deep or superficial infection (2%), elbow instability (1%), and refracture (<0.5%)89,90. Poor preoperative elbow motion and female sex have been associated with a higher rate of complications89. Other potential risk factors are high body-mass index, diabetes, a longer time interval after the injury, and the duration of surgery90,91. Nerve complications are attributable to iatrogenic injury during surgery and increased nerve length and intraneural pressure associated with improved range of motion of the elbow postoperatively16,37,92. Delayed-onset ulnar neuropathy is the most common nerve complication after extensive release of elbow contracture89, leading to sensory or motor dysfunction. Most of the ulnar nerve complications are temporary, but some necessitate subsequent surgery to decompress the ulnar nerve. A decompression length of ≥7 cm and subcutaneous anterior transposition of the ulnar nerve during the contracture release can reduce the risk of ulnar neuropathy10,93. The risk of surgical site infection following elbow arthrolysis should not be underestimated; such an infection may lead to prolonged administration of antibiotics, delayed recovery, and poor or even disastrous outcomes. Regional delivery of antibiotic prophylaxis provides high tissue concentrations of antibiotic with limited systemic toxicity, which might be helpful for the prevention of infection90,94. Refracture after arthrolysis can be prevented by gentle manipulation of the elbow by the therapist or patient52. The occurrence of refracture also might be related to arthrolysis combined with implant removal77. Therefore, if complete radiographic union of a fracture is not confirmed preoperatively, surgical release should be postponed or performed with plate removal performed separately.
HO around the elbow is common and may limit functional mobility of the elbow. Open elbow arthrolysis and HO resection is an effective method for treating elbow contracture. A combined lateral and medial approach provides extensive exposure to all aspects of the elbow joint, with limited wound complications. Routine ulnar neurolysis and subcutaneous anterior transposition prevent postoperative neuropathy. Additionally, using a hinged external fixator in cases of severe stiffness has advantages for successful postoperative rehabilitation. A team-based cooperation between orthopaedic surgeons and physical therapists facilitates the achievement of satisfactory elbow function.
Investigation performed at the Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
Disclosure: The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of this article.
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