Pierre Mansat, Aymeric André, and Nicolas Bonnevialle
DEFINITION
Multiple techniques have been described for the release of elbow contractures. The medial approach has the advantages of direct access to both the anterior and posterior aspects of the ulnohumeral joint, and direct visualization of the ulnar nerve.
Medial-based releases were initially proposed by Wilner,24 whose technique involved medial epicondylectomy and wide dissection.
Weiss23 subsequently has described splitting the flexor pronator mass rather than complete release of the flexor pronator mass.
Hotchkiss12 popularized this approach to deal with extrinsic contracture of the elbow and ulnar nerve involvement.
Itoh et al10 and Wada et al22 underlined the importance of the posterior oblique band of the medial collateral ligament as a critical structure to identify and release if an extension contracture exists.
ANATOMY
The medial compartment of the elbow includes the medial side of the ulnohumeral joint, the medial collateral ligament, the flexor–pronator mass, the ulnar nerve, and the medial antebrachial cutaneous nerve (FIG 1A).
The medial ulnohumeral joint is composed of the medial column, the medial epicondyle, the medial side of the proximal aspect of the ulna, and the coronoid process.
The medial collateral ligament consists of three parts: anterior, posterior, and transverse segments (FIG 1B).
The anterior bundle is the most discrete component, the posterior portion being a thickening of the posterior capsule, and is well defined only in about 90 degrees of flexion.
The transverse component appears to contribute little or nothing to elbow stability.
The medial collateral ligament originates from a broad anteroinferior surface of the epicondyle but not from the condylar elements of the trochlea just inferior to the axis of rotation.18 The ulnar nerve rests on the posterior aspect of the medial epicondyle, but it is not intimately related to the fibers of the anterior bundle of the medial collateral ligament itself.
The flexor–pronator mass includes the pronator teres, the most proximal of the flexor pronator group; the flexor carpi radialis, which originates just inferior to the origin of the pronator teres at the anteroinferior aspect of the medial epicondyle; the palmaris longus muscle, which arises from the medial epicondyle and from the septa it shares with the flexor carpi radialis and flexor carpi ulnaris; the flexor carpi ulnaris, which is the most posterior of the common flexor tendons originating from the medial epicondyle and from the medial border of the coronoid and the proximal medial aspect of the ulna; and the flexor digitorum superficialis, which is the deepest from the common flexor tendon but superficial to the flexor digitorum profundus.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Diagnosis of the contracture is usually made by identifying a characteristic history and performing a physical examination.
Joint involvement is confirmed by plain radiographs. The anteroposterior (AP) view gives good visualization of the joint line, but the lateral view demonstrates osteophytes on the coronoid and at the tip of the olecranon, even when the joint space is preserved.
The details of the extent of the involvement are best observed on computed tomography.
Transverse imaging by magnetic resonance imaging (MRI) has little utility in our practice.
NONOPERATIVE MANAGEMENT
Several options have been proposed for the treatment of elbow contracture.
Nonoperative treatment with mobilization of the elbow through the use of alternating flexion and extension splints17 or dynamic splints8 sometimes provides a good result if it is begun soon after the contracture develops.
Manipulation with the patient under anesthesia has also been recommended, but loss of motion and ulnar nerve injury have been reported.6
Recently, botulinum toxin has been used to release muscle contracture in order to improve elbow rehabilitation.20
Nonoperative treatment usually is successful only for extrinsic stiffness that has been present for 6 months or less, however, and the results are unpredictable. With failure of nonoperative treatment, surgical release may be indicated. Some reports of this being done through an arthroscopic procedure recently appeared. Most surgeons employ an open procedure, and several have been described.
SURGICAL MANAGEMENT
Indications
Contracture release
Stiff elbow
Degenerative arthritis with anterior and posteromedial osteophytes
Ulnar nerve symptoms
Advantages
Allows exposure, protection, and transposition of the ulnar nerve
Preserves the anterior band of the medial collateral ligament
Affords access to the coronoid with intact radial head
FIG 1 • Superficial (A) and deep (B) anatomy of the medial side of the elbow.
Disadvantages
Difficulty in removing heterotopic bone on the lateral side of the joint
Affords poor access to radial head
Preoperative Planning
Before surgery, the decision must be made to approach the capsule from the lateral or medial aspect.
If the ulnar nerve is to be addressed or there is extensive medial or coronoid arthrosis, the medial approach is of value.
If the radiohumeral joint is involved or if a simple release is all that is required, the lateral “column” procedure is carried out.
Positioning
The patient is usually positioned supine, supported by an elbow or a hand table.
Two folded towels should be placed under the scapula.
A sterile tourniquet is positioned.
To expose the posterior joint, the patient’s shoulder should have fairly free external rotation; otherwise, the arm should be positioned over the chest.
Approach
The skin incision may be a posterior skin incision or a midline medial one (FIG 2).
The key to this exposure is identification of the medial supracondylar ridge of the humerus.
At this level, the surgeon can locate the medial intermuscular septum, the origin of the flexor–pronator muscle mass, and the ulnar nerve.
This site also serves as the starting point of the anterior and posterior subperiosteal extracapsular dissection of the joint.
FIG 2 • Skin incision.
TECHNIQUES
EXPOSING THE ULNAR NERVE AND THE MEDIAL FASCIA
Once the medial intermuscular septum is identified, the medial antebrachial cutaneous nerve is identified, traced distally, and protected.
The branching pattern varies, however, so it is occasionally necessary to divide the nerve to gain full exposure and to adequately mobilize the ulnar nerve, especially in revision surgery.
If this is necessary, the nerve is divided as proximally as the skin incision will allow, ensuring that the cut end lies in the subcutaneous fat (TECH FIG 1).
If previously anterior transposition was performed, the ulnar nerve should be fully identified and mobilized before proceeding.
The surgeon must be prepared to extend the previous incision proximally, as necessary.
In this setting, the nerve is often flattened over the medial flexor–pronator muscle mass, or it can “subluxate” to a posterior position.
This dissection requires patience and may take considerable time. Dissection of the nerve needs to be carried distally far enough to allow the nerve to sit in the anterior position without being kinked distal to the epicondyle.
The septum is excised from the insertion on the supracondylar ridge to the proximal extent of the wound, usually about 5 to 8 cm.
Many of the veins and perforating arteries at the most distal portion of the septum require cauterization.
TECH FIG 1 • Exposure of the ulnar nerve and medial fascia.
EXPOSING THE ANTERIOR CAPSULE FOR EXCISION AND INCISION
Once the septum has been excised, the flexor–pronator muscle mass should be divided parallel to the fibers, leaving roughly a 1.5-cm span of flexor carpi ulnaris tendon attached to the epicondyle (TECH FIG 2A,B).
The surgeon then returns the supracondylar ridge and begins elevating the anterior muscle with a Cobb elevator.
TECH FIG 2 • A,B. Exposure of the anterior capsule. C–E. After excision of the anterior capsule, visualization of the ulnohumeral joint down to the radiocapitellar joint.
Subperiosteally, the anterior structures of the distal humeral region proximal to the capsule are elevated to allow placement of a wide Bennett retractor. As the elevator moves from medial to lateral, the handle of the elevator is lifted carefully, keeping the blade of the elevator along the surface of the bone.
When heterotopic ossification along the lateral distal humerus is profuse, the radial nerve is at risk if it is entrapped in the scar on the surface of the bone.
A separate approach to the lateral side is sometimes needed.
The median nerve, brachial vein, and artery are superficial to the brachialis muscle.
A small cuff of tissue of the flexor–pronator origin can be left on the supracondylar ridge as the muscle is elevated. This facilitates reattachment during closing.
A proximal, transverse incision in the lacertus fibrosus may also be needed to adequately mobilize this layer of muscle.
Once the Bennett retractor is in place and the medial portion of the flexor–pronator has been incised, the plane between muscle and capsule should be carefully elevated.
As this plane is developed, the brachialis muscle is encountered from the underside. This muscle should be kept anterior and elevated from the capsule and anterior surface of the distal humerus.
Finding this plane requires careful attention.
The dissection of the capsule from the brachialis muscle proceeds both laterally and distally.
At this point, it is helpful to feel for the coronoid process by gently flexing and extending the elbow. The first few times that this approach is used, the coronoid seems quite deep and far distal.
A deep, narrow retractor is often helpful to allow the operator to see down to the level of the coronoid.
The extreme anteromedial corner of the exposure deserves special comment.
In a contracture release, the anteromedial portion often requires release.
To see this area, a small, narrow retractor can be inserted to retract the medial collateral ligament, pulling it medially and posteriorly.
This affords visualization of the medial capsule and protection of the anterior medial collateral ligament.
The anterior capsule should be excised (TECH FIG 2C–E) to the extent that that is practical and safe.
When first performing this procedure, it is helpful first to incise the capsule from the medial to the lateral aspect along the anterior surface of the joint.
Once this edge of the capsule is incised, it can be lifted and excised as far distally as is safe. From this vantage, and after capsule excision, the radial head and capitellum can be visualized and freed of scar, as needed.
In cases of primary osteoarthritis of the elbow, removing the large spur from the coronoid is crucial.
Using the Cobb elevator, the brachialis muscle can be elevated anteriorly for 2 cm from the coronoid process.
With the elevator held in position, protecting the brachialis but anterior to the coronoid, the large osteophyte can be removed with an osteotome.
The brachialis insertion is well distal to the tip of the coronoid.
EXPOSING AND EXCISING THE POSTERIOR CAPSULE AND BONE SPURS
The posterior capsule of the joint is exposed. The supracondylar ridge is again identified (TECH FIG 3).
Using the Cobb elevator, the triceps is elevated from the posterior distal surface of the humerus.
The exposure should extend far enough proximal to permit use of a Bennett retractor.
The posterior capsule can be separated from the triceps as the elevator sweeps from proximal to distal. The posterior medial joint line should also be identified, as it is often involved by osteophytes or heterotopic bone.
In contracture release, the posterior capsule and posterior band of the medial collateral ligament should be excised.
The medial joint line up to the anterior band of the medial collateral ligament should also be exposed and the capsule excised. This area is the floor of the cubital tunnel.
In contracture release and in primary osteoarthritis, the tip of the olecranon usually must be excised to achieve full extension.
The posteromedial joint line is easily visualized, but the posterolateral side must also be carefully palpated to ensure clearance.
TECH FIG 3 • Exposure of the posterior compartment.
ULNAR NERVE TRANSPOSITION
After being reattached to the medial supracondylar region, the ulnar nerve should be transposed and secured with a fascial sling to prevent posterior subluxation.
The sling can be fashioned by elevating two overlapping rectangular flaps of fascia or by using a medially based flap attached to the underlying subcutaneous tissue.
Once this maneuver is completed, the nerve must not be compressed or kinked.
The joint should be flexed and extended to ensure that the nerve is free to move.
CLOSURE
The flexor–pronator mass should be reattached to the supracondylar ridge with nonabsorbable braided 1-0 or 0 suture.
If a large enough cuff of tissue was left on the medial epicondyle, no holes need be drilled in bone.
Otherwise, drill holes in the edge of the supracondylar ridge can be made to secure the flexor–pronator mass (TECH FIG 4).
TECH FIG 4 • Closure.
PEARLS AND PITFALLS
POSTOPERATIVE CARE
If the neurologic examination findings in the recovery room are normal, a brachial plexus block is established and maintained with a continuous pump through a percutaneous catheter.
The arm is elevated as much as possible, and mechanical continuous passive motion exercise is begun the day of surgery and adjusted to provide as much motion as pain or the machine itself allows.
After 2 days the plexus block is discontinued, and, at day 3, the continuous passive motion machine is stopped.
Physical therapy is not used, but a detailed program of splint therapy is prescribed.
Adjustable splints are prescribed, depending on the motion before and after the procedure. The splints include a hyperextension or a hyperflexion brace, or both.
A detailed discussion regarding heat, ice, and antiinflammatory medication, along with a visual schedule for bracing, is provided.
During the first 3 months, the patient sleeps with the splint adjusted to maximize flexion or extension, whichever is more needed; it should not be so uncomfortable as to prevent sleeping for at least 6 hours.
Because the principal objective is to gain motion but to avoid pain, swelling, and inflammation, routine use of an anti-inflammatory medication is prescribed.
Therapy with splints is continued for about 3 months, during which time the patient is seen at 2to 4-week intervals, if possible.
After 4 weeks, an arc of about 80 degrees of motion is obtained, and the amount of time that each splint is worn is gradually decreased.
Splinting at night is continued for as long as 6 months if flexion contracture tends to recur when the splint is not used.
Patients are advised that it may take a year to realize full correction.
OUTCOMES
Recent reports on the results of surgical arthrolysis reveal an absolute gain in the flexion–extension arc between 30 and 60 degrees.1,3–5,7,9–11,14–16,19,21
A functional arc of motion between 30 and 130 degrees is obtained in more than 50% of cases, and some improvement in motion in more than 90% of the cases has been reported in the literature.1,3–5,7,9–11,14–16,19,21
In Europe, a combined lateral and medial approach has been used for many years, and gains in flexion arc have averaged between 40 and 72 degrees (in about 400 procedures).1,3,7,14 Some preferred a posterior extensile approach if medial and lateral exposures are anticipated.
The importance of sequential release of tissues has been emphasized, based on an experience with 44 of 46 patients (95%) who were satisfied with such an approach.13 The preoperative arc improved from 45 to 99 degrees.
The authors emphasize the need to release the exostosis and the collateral ligament when contracted, especially noting the need to release the posterior portion of the medial collateral ligament and decompress the ulnar nerve when ulnar nerve symptoms exist preoperatively.13
Using a medial approach, Wada et al22 obtained improvement of the mean arc of movement of 64 degrees. A functional arc of flexion–extension (30 to 130 degrees) was obtained in 7 of the 14 elbows. None of the patients developed symptoms related to the ulnar nerve. According to those authors, the medial approach has several advantages over both the anterior and lateral approaches:
Pathologic changes in the posterior oblique bundle of the medial collateral ligament can be observed and excised under direct vision.
Anterior and posterior exposure is possible through one medial incision, through which a complete soft tissue release and excision of part of the olecranon and coronoid process can be undertaken if necessary. Additional lateral exposure is indicated only if the medial approach has proved to be inadequate.
In the medial approach, the ulnar nerve is routinely released and protected under direct vision, which decreases the risk of damage.
COMPLICATIONS
A most important emerging consideration of the proper treatment of elbow stiffness is the vulnerability of the ulnar nerve.
The most common cause of failure of treatment has been in patients whose preoperative ulnar nerve symptoms were not appreciated or addressed, or patients in whom ulnar nerve symptoms developed postoperatively without adequate treatment. This is attributable to traction neuritis caused by the abrupt increase in elbow flexion or extension during the operation.
Even in the absence of preoperative neurologic symptoms, the nerve may be compromised subclinically and become symptomatic as elbow motion increases after surgery. Therefore, all patients who have stiff elbows must be evaluated for the presence or absence of ulnar nerve symptoms.
Antuna et al2 recommended that elbows with preoperative flexion limited to 90 to 100 degrees in which we expect to improve the motion by 30 or 40 degrees must be treated with inspection and often prophylactic decompression or translocation of the nerve, depending on the appearance of the nerve once the surgical procedure is finished.
Furthermore, all patients with preoperative ulnar nerve symptoms, even if they are mild, are treated with mobilization of the nerve.
These authors stated that manipulation of the elbow in the early postoperative period must be avoided if the nerve has not been decompressed or translocated.
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