Posterior Extensile Approach to Release a Post-traumatic Stiffness of the Elbow

Abstract

PURPOSE OF THE STUDY: Restriction of joint motion is a frequent complication in the treatment of elbow injury. Grade 4 elbow stiffness up to its ankylosis is a strong limiting factor in the patient's daily activities. The surgical release of a stiff elbow has been a rare procedure. It can be done using either isolated or combined approaches. The aim of the study is to present our experience with and the results of elbow arthrolysis using a posterior extensile approach to the joint.MATERIAL AND METHODS: Seven patients aged between 17 and 38 years with post-traumatic post-operative ankylosis, or grade 4 elbow stiffness were operated on. The average range of motion before surgery was 12.9° (range, 0° - 20°). The average interval between primary injury and arthrolysis was 21 months (range, 8 - 70 months). Clinical assessment before and after surgery was based on the Mayo Elbow Performance Score (MEPS). The average follow-up was 26 months (12 - 47). Arthrolysis was completed by application of an external fixator in four patients, by interposition arthroplasty in two patients, ulnar nerve transposition in five patients and radial head replacement in one patient. RESULTS The average MEPS score increased from 45.0 points (range, 30 - 65 points) to 87.9 points (range, 75 - 100 points). The average range of motion at the final follow-up was 99.3° (range, 65° - 135°). Most patients reported pain relief. There was no iatrogenic instability following surgery. Improvement was most marked in relation to joint function, as demonstrated by increase from an average score of 6.4 points (range, 0 - 15 points) before surgery to 24.3 points (range, 20 - 25 points) after surgery in the MEPS.DISCUSSION: Surgical treatment of an ankylosed elbow is not a common procedure in the majority of hospitals. The use of a posterior extensile approach, which preserves the extensor mechanism, to release the elbow joint has been reported only occasionally in the international literature. The results, however, seem to be good. On the other hand, removal of the olecranon is associated with a high complication rate. Operative release of the elbow with total joint replacement is an extreme option. CONCLUSIONS In grade 4 stiff elbow release, the posterior extensile approach to the elbow joint as described here allows us to have a good view of all articular compartments. It maintains continuity of the extensor apparatus of the elbow, which is the essential requirement for effective post-operative rehabilitation and therefore its great advantage. This approach is not associated with serious complications.