Post traumatic and post operative stiff elbow is a surgical challenge for even experienced orthopaedic surgeons.dr mohamed ashraf govt TD medical college alleppey kerala india is presenting systematically how to approach surgically to a case of stiff elbow to get back the functional movements.

1. STIFF ELBOW-SURGICAL OPTIONS
Dr MOHAMED ASHRAF,
Professor and head
Govt TD medical college ,alleppey,kerala,india
drashraf369@gmail.com

2.  Problem often ignored or
undertreated
 Poorly tolerated due to
lack of compensatory mech.
 Complex nature makes
treatment difficult
 conservative modalities got
limited role

3.  ULNO HUMERAL - ginglymus or hinge joint
 RADIO CAPITELLAR - enarthrosis or ball and
socket.
 PRUJ - trochoid or pivot
 more complexity more chance of stiffness
 High degree of articular congruity needed
3 in 1 joint

4. normal range
Flexion 0---145 degree
Pronation 80 degree
Supination 80 degree
Functional range
Flexion 30—130 (arc 100 deg]
Rotation 50—50 deg ( arc 100 deg)

5.  History
 Physical examination
 Radiograph
 Surgical approaches
 Addressing associated problems

6.  Scar and soft tissue
compromise
 Infection
 3 joints ROM
 Instability—valgus stress
and pivot shift
 Nerve dysfunction
 Examine entire extremity

7. RADIOLOGY
• Compare with previous xrays and
opp.Elbow
• Identify and asses malunion and
nonunion
• Hardware,OA, HO
• Stress xray for instability
• CT / MRI --asses ligaments and cartilage
pri.stabilisers- MCL[ ant.band]
lateral UCL

8.  Post.capsular contracture
 Triceps scarring
 Coronoid fossa bone or soft tissue block
 Coronoid tip osteophyte
 Radial head osteophyte
 post. MCL scarring
 HO
 Adhesions ,malunions

9.  Ant.capsular contracture
 Brachialis scarring
 Olecranon fossa bone or soft tissue block
 Olecranon tip osteophyte
 Radial head osteophyte
 Ant. MCL scarring
 Post. HO
 Adhesions, malunion

10.  Intrinsic-- joint surface involved
 IA adhesion,avn,IA steps,post tr OA,bone
blocks
 Extrinsic—joint surface not involved
 soft tissue,capsuloligamentous,EA
malunion,MUSCULAR,HO
 combined

11. “Simple stiff elbow”
jupiter
 No or min. prior surgery
 Mild to mod. Contracture <80 deg.
 No prior ulnar nerve transposition
 No or min. hardware
 No or min. HO
 Normal bony anatomy preserved
 better prognosis after capsular release

12.  Heat modalities
 Myofascial mobilisation
 Joint mobilisation
 Active rom
 Passive rom
 Corrective splinting-dynamic &static
progressive
 Strenghthening exercise
………………………BUT

13. CAPSULAR RELEASE
CAPSULECTOMY
ARTHROLYSIS
DISTRACTION
HO EXCISION
ARTHROSCOPY
SYNOVECTOMY
M U A
REPLACEMENT

14.  Kim sj seoul ,korea
 average ROM improvement 40 degree
 Timmermen L A alabama
 complete return of preinjury motion never returned
 Linzel D S boston
 open release more effective in stiffness with HO

 Scopy may be difficult in severely
contracted capsule-normal volume
14ml,stiff elbow 6ml
 Difficult in malunion,non union, in situ
implants

15.  only for stiff elbow with OA
 only in physiologically older
 only in low demand elbow
Bruno r j boston, j of aaos

16.  …removal of offending structures while
maintaining elbow stability and integrity of
crossing neurovascular structures…

17. CONSISTENT feature of post traumatic elbow contracture is capsular
contracture
Jupiter j.b,,acta orthop scand 1996
more myofibroblast in ant.capsule leading to ant.
Contracture
Hiderbrand et al
open elbow capsulectomy of post traumatic stiff elbow restores average
100 deg
Ring D,JupiterJB, Boston
Best result if done within 1 year of trauma.Severe the stiffness better
the result
Cikesa a,jolles dm
lussanne switzerland

Success in arthrolysis depends on surgeons experience in a given
method
Tan v ,et al ,outcome of open release for posttraumatic stiff elbow,j trauma 2006

18.  1. ulnar neurolysis and
transposition if preop dysfunction
 2. all contracted soft tissue
released, capsule excised .
 3.Brachialis released by
subperiosteal elevation
 4 bonyimpingement,outgrowths,
osteophytes,HO excised

19.  IF extension limited clear off
olecranon fossa or release triceps
tendon or excise tip of olecranon

20.  For ulnar transposition
 For posteromedial capsular release
 For MCL post. Band release
 For HO resection

21.  Posterolateral incision
 Between anconeus and ECU
 Common extensor origin stripped off
ant.capsule
 Laterally based capsule wedge excised
 If flexion limitation post.capsule released
between ECRL andTRICEPS

22.  SYNOSTOSIS EXCISEDTHRU BOYDS
APPROACH
 NON UNION DEBRIDED,GRAFTED AND FIXED
 LOOSE AND FAILED HARDWARE REMOVED
 RADIAL HEAD EXCISED IF RADIOCAPITELLAR
IMPINGMENT PRESENT
 IF EARLY ARTHRITIS DO DEBRIDEMENT
ARTHROPLASTY
 IF LARGE CARTILAGE DEFECT PRESENT
RELEASE MAYWORSENTHE PAIN

23.  Ant. Slab[3dys 10 deg flexion ,then full extn]
 Drain removal[hematoma avoided]
 C P M optional[ we never use]
 ROM started as the patient tolerate it
 Continue splinting and ROM -1 month
 Night splinting- 3 months

24.  Pain
 Movement
 Stability
 Function
 >90 excellent
 75—89 good
 60—74 fair
 <60 poor

25.  MCL injury– valgus instability in 90 deg.
 usually heal by itself
 LCL injury– rotary instability
 may be reattached by drill hole
 Neurovascular injury
 HO
 Wound breakdown
 infection

26.  8 years-average follow up 4.4 yrs[2007-2015]
 32 elbows-25 dominant
 Mean age-34 years
 Preop arc-average flexion deformity 40degr
average flexion 120 degree
 Post op correction-average ffd 10 degree
average flexion 150 degree

27. Prolonged immobilization in dislocation 5
Fracture dislocation 8
Radial head fracture[3 cases previous excision] 5
Lower humerus #[4 implant,6 explant] 10
Medial epicondyle fracture[previous surgery] 3
Head injury 1

28.  Reduced flexion only-4
 Reduced extension only-8
 Combined-20
 Total ankylosis-0

29. SCORING NO OF CASES
EXCELLENT[>130 flexion- very
very happy]
24
VERY GOOD [20-130 flexion- very
happy]
6
POOR [HO,persistent pain-
unhappy]
2

30.  Non-compliant
 Often fails
 May aggravate the problem
Vardakas DG et al ,evaluating and treatinf stiff
elbow,hand clinic 2002
Viola RW,treatment of stiff elbow,CORR 2000

31.  Average loss of correction at 1 year-10 degree
 Recurrence of 50% deformity with HO-1 case
 Ulnar nerve dysfunction-2 cases[transposed]
 Superficial infection-2 cases[previous implant]

42.  Careful use of the angled
retractor will neurovascular
bundle along with brachialis
 Dissection must be directed
posteriorly on humerus

48. POST –OP EXTENSION

50.  No concensus on most appropriate treatment
 Bhavuk garg,Aman dug,Vijay sharma AIIMS
 But our experience shows limited lateral peri-
columnar release is the best option

52. MBBS [GMC CALICUT]
D ORTHO [GMCTRIVANDRUM]
MS ORTHO [MMC MADRAS]
DNB ,MNAMS [NEW DELHI]
drashraf369@gmail.com