Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents

Abstract

Background: Post-traumatic elbow contractures in children and adolescents are challenging to manage, and studies investigating surgical treatment are limited by the rarity of this condition. Small case series have shown variable gains in immediate and long-term elbow arc of motion after open surgical release. We reviewed our experience with open surgical release of post-traumatic elbow contracture in patients less than 21 years old at two institutions. Methods: A retrospective chart review identified patients who underwent post-traumatic open elbow contracture release by two surgeons at two institutions between 2006 and 2013. Non-traumatic contractures and arthroscopic releases were excluded. 26 patients were included in this study. Mean age at the time of injury was 12 years (5–19 years) and at the time of surgery was 14 years (7–20 years). Capsulotomy, osteoplasty, removal of hardware, ulnar nerve release or transposition, and ligament reconstruction were performed through medial and lateral approaches as indicated by the pathology. 10 patients had ligament repair or stabilization, and 16 patients used a CPM post-operatively. Outcomes included active range of motion and complications. Results: Mean time from injury to surgical release was 29 months. Mean post-operative follow-up was 42 months. Elbow active flexion-extension and forearm rotation arcs both increased significantly by a mean of 49° and 70°, respectively, at final follow-up. A mean 85% of intra-operative flexion-extension arc was maintained at final follow-up. Ligament repair or reconstruction and the use of a postoperative CPM did not significantly change these outcomes. Outcomes were not significantly different if our contracture release was performed within a year from injury. Patients who had surgery prior to our contracture release had decreased restoration of forearm rotation after release. Complications included two recurrent contractures (one used a CPM and one did not), and two post-operative ulnar neuropathies (one used a CPM and one did not). Conclusions: Open contracture release for post-traumatic elbow contracture in an adolescent population can significantly improve active range of motion. Level of Evidence: Therapeutic 3

Midterm Outcomes After Open Arthrolysis for Posttraumatic Elbow Stiffness in Children and Adolescents

“…This finding was consistent with the outcomes of the latest literature. Piper et al 9 studied 26 young patients and reported a similar increase of 49 degrees. Though the difference in pathologic condition and surgical solution makes the improvement different, here we used different approaches as a whole adapting to pathologic conditions and study the relationship between surgical methods and improvement according to the postoperative baseline in treating the stiff elbow.…”

“… 20 A decreased ROM in the elbow has significantly interfered with qualities of daily living in children and adolescents. 9 , 12 Several studies have investigated the management of adult posttraumatic elbow contractures, with satisfactory outcomes of open elbow release. 1 , 6 …”

“…However, the instructive literature on pediatric and adolescent elbow stiffness is insufficient, with varying outcomes. 9 , 11 – 13 , 21 – 23 Recently, some studies have specifically reported equivocal outcomes of open surgical release in children and adolescents with stiff elbows. Stans et al 11 studied 37 patients and showed an average improvement in the arc of motion of 28 degrees, with 2 patients losing motion and 1 patient developing total ankylosis.…”

“… 4 , 5 In previous studies, open arthrolysis and hinged external fixation have been reported as an effective procedure for adult patients with elbow stiffness; similar good outcomes have also been reported in other studies. 6 – 9 Meanwhile the application of hinged external fixator after ligament repair is necessary for unstable elbows to maintain elbow stability, resist shearing and varus-valgus force, recover the ligament, and to improve the efficacy of daily rehabilitation. 10 However, the literature reporting posttraumatic stiffness in the elbows of pediatric and adolescent patients is limited and controversial.…”

“… 10 However, the literature reporting posttraumatic stiffness in the elbows of pediatric and adolescent patients is limited and controversial. 9 , 11 , 12 Stans et al 11 found that the outcomes of open surgery for elbow stiffness in young patients were less favorable and less predictable than those in adult patients, whereas Ek et al 13 demonstrated that the significant improvement in elbow motion was as good as that in adults. Although some factors had been found to affect the final outcomes of open release, such as type of injury, comatose condition, and radial head replacement, there have been contradicting findings on the age at surgery and the impact of serum alkaline phosphatase (AKP) levels in children and adolescents with posttraumatic elbow stiffness.…”