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Journal of the American Academy of Orthopaedic Surgeons 106 Stiffness of the elbow can result from congenital abnormalities, paralytic deformities, degenerative arthrosis, burn contractures, se- quela of joint infections, and, most commonly, trauma to the elbow. Posttraumatic elbow stiffness can be classified as extrinsic (extra- articular), intrinsic (intra-articular), or mixed (Table 1). Extrinsic or extra-articular pathology includes that of the periarticular soft tissue and bone but excludes articular cartilage lesions. Skin contractures or subcutaneous scarring from incisions or burns can result in limited elbow motion. Direct capsular injury, or injury to the brachialis, biceps, or triceps muscles, can cause hemarthrosis, which may result in scarring and contracture with limitation of motion. Prolonged pain can produce both voluntary and involuntary guard- ing of the elbow during motion, eventually leading to contracture of the elbow capsule and, in some cases, the brachialis muscle. This pain mechanism is postulated as a possible explanation for stiffness occurring after relatively minor trauma to the elbow. Entrapment neuropathies, most commonly of the ulnar nerve, likewise can result in stiffness and loss of range of motion secondary to prolonged pain. Intrinsic causes of elbow stiffness are articular incongruity, loss of articular cartilage, hypertrophic callus on the articular surface, intra-articular adhesions, fibrosis, soft-tissue encroachment within the coronoid or olecranon fossa, or hypertrophic osteophytes that mechanically block motion. Evaluation Patient History Important elements of the patient history are the subjective description of motion deficits, degree of pain, duration of elbow stiffness, prior surgery of the elbow, and presence or absence of previous infection. Deficits in forearm pronation and supination are more likely caused by radiocapitellar joint pathology, although forearm and wrist pathology must be ruled out. Deficits in flexion and extension are most often caused by ulnohumeral joint pathology. Unless there is severe heterotopic ossification (HO) or complete ankylosis, the patient will usually experience loss in one functional motion arc, pronation- Dr. Bruno is Clinical Instructor, Department of Orthopaedics, Tufts University School of Medicine, New England Medical Center, Boston, MA. Dr. Lee is an Associate, University Sports Medicine, Corpus Christi, TX. Dr. Strauch is Assistant Professor, Department of Orthopaedic Surgery, Columbia University, New York, NY. Dr. Rosenwasser is Robert E. Carroll Professor of Hand Surgery, Department of Orthopaedic Surgery, Columbia University. Reprint requests: Dr. Rosenwasser, Columbia University, 622 West 168th Street, PH-11, New York NY 10032. Copyright 2002 by the American Academy of Orthopaedic Surgeons. Abstract Posttraumatic elbow stiffness is a common problem that is often difficult to manage. The goal of treatment is to restore a functional range of elbow motion (≥ 30° to 130°). Nonsurgical treatment includes physical therapy and splinting. If nonsurgical treatment has failed, the type of surgical treatment required depends on the extent of degenerative changes. When degenerative changes are absent or mild, soft-tissue release offers reliable increases in elbow motion. When moderate degenerative changes exist within the joint, débridement arthroplasty of osteophytes and soft tissue has shown some success with increase in joint motion. With advanced degenerative changes, the therapeutic options are more limited. Results from bio- logic resurfacing arthroplasty are unpredictable, and total elbow arthroplasty should be reserved for the lower-demand elbow in a physiologically older individual. J Am Acad Orthop Surg 2002;10:106-116 Posttraumatic Elbow Stiffness: Evaluation and Management Roderick J. Bruno, MD, Michael L. Lee, MD, Robert J. Strauch, MD, and Melvin P. Rosenwasser, MD Roderick J. Bruno, MD, et al Vol 10 No 2, March/April 2002 107 supination or flexion-extension. Posttraumatic elbow stiffness usually is not painful. Pain often implies arthrosis, impingement, entrapment neuropathy, or, less frequently, instability. Physical Examination The physical examination begins with inspection of the skin, noting scars, areas of skin loss, and areas of fibrosis. The nature of conditions such as skin loss, fibrosis, or scar adherence to underlying muscles and tendons and their contribution to stiffness should be assessed. Passive and active range of motion should be recorded to help determine current functional limitations and to be able to document the effi- cacy of subsequent treatment modalities. Morrey et al 3 determined that the functional range of motion required for activities of daily living is extension-flexion of 30° to 130° (an arc of motion of 100°) and pronation-supination of 50° to 50°. Terminal flexion is more important in performing activities of daily living than is terminal extension. The end point of restricted motion should be noted. A “soft” end point implies soft-tissue constraint; a “hard” end point may be attributed to bony impingement, although this distinction sometimes can be difficult to ascertain. A complete neurovascular assessment should be done, especially in the patient with previous trauma or surgery. Elec- trodiagnostic studies to help localize the lesion are indicated in the face of subjective complaints or document- ed deficits on examination. Imaging Studies Anteroposterior, lateral, and radiocapitellar oblique radiographs are used to evaluate the degree of degenerative changes, to rule out impingement from hardware, and to assess HO, fracture healing, and deformity. Stress radiographs can provide additional information when there is evidence of instability. In patients who have significant loss of pronation and supination, radiographs of the forearm and wrist should be obtained. When severe deformity or bridging HO is present, computed tomography, with both axial images and two- dimensional or three-dimensional reconstructions, may be necessary to assess the bony architecture of the joint. Computed tomography may also provide useful information in patients with lesser degrees of arthritic involvement, demon- strating whether an anterior or a posterior approach would provide a more direct exposure for osteophyte removal and débridement. Mag- netic resonance imaging may be useful in assessing medial and lateral collateral ligament integrity. Focal articular cartilage loss can be difficult to appreciate on preoperative imaging studies and may become apparent only during arthrot- omy. Nonsurgical Treatment The management of elbow stiffness begins with prevention, by institut- ing early motion after traumatic injuries and with other conditions that precipitate inflammation around the elbow joint. Nonsteroidal anti- inflammatory drugs combined with application of heat prior to exercise, application of ice, and physical therapy modalities (such as iontophoresis, ultrasound, massage, and electrical stimulation) can help increase and maintain motion. Muscle weakness or imbalance should be corrected with strengthening exercises. Fre- quent assessment and early interven- tion after elbow trauma are essential when motion milestones are not achieved. The first line of treatment appropriate for most patients with elbow stiffness is graduated active-assisted stretching exercises under the guidance of a physical therapist. For patients with mild to moderate contractures whose motion has not improved after several months of therapy, splinting is the next step. Dynamic hinged elbow splints with spring or rubber band tension may be useful to assist with deficits of elbow flexion. However, dynamic splints are often poorly tolerated by patients because they impart continuous stretch, which may cause cocon- traction and spasm of antagonistic muscles, leaving the patient with no respite other than splint removal. Static progressive (turnbuckle) splints are better tolerated for resistant flexion or extension deficits. If contracture is present in both direc- tions, the splint can be used in alter- nating positions. Green and McCoy 4 reported on 15 patients treated with aggressive physical therapy and turnbuckle splinting, with mean increases in flexion of 7° and in extension of 36°. A custom-molded elbow orthosis with articulated joints capable of full extension and flexion to 140° (Fig. 1) Table 1 Causes of Elbow Stiffness by Location of Pathology 1,2 Extrinsic Skin, subcutaneous tissue Capsule (posterior/anterior) Collateral ligament contracture Myostatic contracture (posterior/anterior) Heterotopic ossification Intrinsic Articular deformity Articular adhesions Impinging osteophytes Olecranon Coronoid Fibrosis that impinges on: Olecranon fossa Coronoid fossa Loose bodies Mixed Posttraumatic Elbow Stiffness Journal of the American Academy of Orthopaedic Surgeons 108 can be worn three to four times daily for 20-minute intervals to provide stretching, with or without static in- terval splinting. Progressive stretching allows for soft-tissue accommo- dation before progressing to the next level. Splints that maintain the max- imum extension achieved with static progressive splinting are recommended for use at night. Functional electrical stimulation has been inef- fective in treating established contractures and is not recommended. Continuous passive motion (CPM) machines have a limited role in treating established contractures and do not possess the mechanical ad- vantage or power to affect end-range mobility. If a notable motion deficit remains despite splinting, further nonsurgical treatment is unlikely to be of benefit. Closed manipulation under anesthesia may worsen elbow stiffness by producing swelling and inflammation with tearing of soft tis- sues, causing hemarthrosis and additional fibrosis. Forceful manipulation can also cause delamination or indentation of the articular cartilage. Surgical Treatment When nonsurgical treatment fails, the patient who has realistic expecta- tions of eventual outcome and who can comply with the arduous postoperative rehabilitation program may be a surgical candidate. The assessment of variables, including etiology of the stiffness and degree of functional impairment, dictates the surgical approach elected. For patients with little or no articular cartilage degeneration, soft-tissue releases, including anterior capsulectomy, brachialis muscle slide, and débridement of all encroaching soft tissue in the fossae of the distal humerus, are indicated. Patients with moderate degenerative changes can be treated with limited bony arthroplasties, which include dé- bridement arthroplasty or the Outerbridge-Kashiwagi ulnohumeral arthroplasty. Younger patients (aged <60 years) with severe degenerative changes can be treated with fascial interposition arthroplasty with or without application of a joint distractor. For older (aged ≥60 years) or low-demand patients with advanced elbow arthritis, total elbow arthroplasty with a semiconstrained design can restore comfort and mobility (Fig. 2). Minimal or No Articular Degenerative Changes For patients with minimal or no degenerative changes, soft-tissue release combined with removal of bony impingement can be helpful. This impingement is often charac- terized by overgrowth of cartilage or bone at the tip of the olecranon or coronoid. A patient with marked functional deficits who is motivated to participate in the extensive rehabilitation program is a candidate for surgical release. In most instances, surgery will improve motion when extension deficits are >30° and flexion is <100°. There are no absolute age limits for surgical release, although young children may be unable to participate in physical Figure 1 Progressive static orthotic device (adjustable static splint) used to help regain extension. Elbow stiffness Advanced degenerative changes Moderate degenerative changes No/mild degenerative changes Soft-tissue releases Supervised therapy, splinting ≥60 years <60 years Outerbridge- Kashiwagi ulnohumeral arthroplasty Total elbow arthroplasty Fascial interposition arthroplasty ± distraction Débridement arthroplasty Supervised therapy, splinting Débridement arthroplasty Figure 2 Algorithm for the management of posttraumatic elbow stiffness. The dashed line signifies an occasional indication for low- demand, younger patients. Roderick J. Bruno, MD, et al Vol 10 No 2, March/April 2002 109 therapy and the elderly may have confounding medical problems. A soft-tissue release after elbow trauma may be considered when the inflammatory phase of soft-tissue healing has resolved. The resolu- tion of inflammation usually occurs at 6 months but may be seen as early as 3 months after the traumatic injury. Moderate Articular Degenerative Changes Moderate articular degenerative change is defined as thinning of the cartilage in the absence of exposed subchondral bone or full-thickness lesions, with maintenance of some degree of joint motion. The articular damage is focal or is located in areas that can be excised without destabilizing the ulnohumeral joint. In contrast, severe degeneration is ascribed to those joints with complete cartilage eburnation or an ankylosed elbow. Patients with elbow stiffness and moderate articular degenerative changes may benefit from limited bony débridement or Outerbridge-Kashiwagi ulnohumeral arthroplasty. Advanced Articular Degenerative Changes Advanced articular degenerative change is defined as diffuse loss of full-thickness articular cartilage over a wide surface of the ulnotrochlear joint with intrusion of the humerus into the ulna. Surgical options for physiologically and chronologi- cally younger patients with elbow stiffness and severe degenerative changes are limited to interposition arthroplasty or arthrodesis. Because there is no ideal position for an elbow fusion (although 90° has been suggested), arthrodesis is not a viable option for most patients. The elbow’s function is to position the hand in space, both to the face and the environment; elbow fusion in midrange flexion thwarts these actions. Resection arthroplasty (arthrecto- my) alone is of historical interest because it results in intolerable instability and weakness. The procedure is rarely indicated except in patients with chronic infection with resistant organisms. In contrast, the limited resection (anatomic arthroplasty), which uses an interposition membrane (fascia lata, cutis, or Achilles tendon), may function well as an alternative in the noninfected younger patient with posttraumatic osteoarthritis. These interposition arthroplasties may be combined with either a static or dynamic span- ning external fixator during the early healing period. For older, low-demand patients, total elbow arthroplasty is a viable option. Total elbow arthroplasty also can be used as a salvage procedure for patients who have unsuccessfully undergone previous soft-tissue or limited bony débridement arthroplasties. Semiconstrained total joint arthroplasty has been a more reliable means of obtaining physiologic mobility while minimizing the stresses applied to the cemented humeral and ulnar stems. This type of total joint arthroplasty mimics the dynamic instant center of motion of the ulnohumeral joint and has led to increased durability of prostheses, providing reliable indications for use in advanced posttraumatic arthritis. Arthroscopy Elbow arthroscopy has become an increasingly useful tool in the acute and chronic posttraumatic setting. 5 Safe access to the joint must be established to undertake elbow arthroscopy without complications. Relative contraindications include previous ulnar nerve transposition, severe soft-tissue contractures, malunited fractures, or the presence of bridging heterotopic bone, which can impair visualization of anatomic landmarks and interfere with correct orientation. Elbow arthroscopy can be used for the treatment of joint synovitis, chondromalacia, osteochondral flaps, and loose bodies. 6 Mild impingement (particularly impingement secondary to coronoid or olecranon osteophytes) can improve with arthroscopic resection of osteophytes posteriorly, 7,8 or both anteri- orly and posteriorly through an arthroscopic modification of the Outerbridge-Kashiwagi procedure. 9,10 Newer soft-tissue release techniques that require identification and pro- tection of the major nerves about the elbow are being developed and refined, and they hold promise for the future. In addition, elbow arthroscopy can be used in the assessment and treatment of elbow pain and loss of motion after radial head fracture. 11 Arthroscopic resection of the radial head has also been successful in patients with radiocapitellar degenerative changes. 10,12,13 Elbow arthroscopy also may be beneficial when the status of the articular cartilage is uncertain. In these instances, arthroscopy allows staging of the degree of degenerative changes, thereby providing the surgeon with information needed to make decisions concerning the joint surface. 8 For example, elbow arthroscopy may help differentiate the patient who is a candidate for distraction arthroplasty from one with severe bony destruction requiring total elbow arthroplasty. Surgical Approaches In selecting the approach to the elbow, factors such as existing scars, suppleness of the skin, and location of intra-articular pathology help determine the primary incision site. If forearm rotation is limited, then the extensile lateral Kocher approach is most effective 1,14 because Posttraumatic Elbow Stiffness Journal of the American Academy of Orthopaedic Surgeons 110 it allows adequate visualization of the radiocapitellar joint as well as of the anterior and posterior ulnohumeral joints. The anterior compartment of the elbow joint can also be accessed from the lateral side using the lateral collateral ligament– sparing approach. 15 A medial approach is preferable if the ulnar nerve requires exploration or release. Access to the joint is through the posterior deltoid ligament, with preservation of the anterior oblique ligament. A combination of medial 16 and lateral 14 approaches also can be used if necessary. The anterior approach allows access to the anterior capsule, brachialis muscle, and biceps tendon. 17,18 However, this approach requires manipulation of the neurovascular structures. With the anterior approach, the olecranon fossa cannot be visualized; thus, one must be certain that no posterior pathology is present. The anterior approach is rarely required because the lateral approach usually permits anterior capsular release and muscle lengthening. The direct posterior triceps muscle–splitting approach allows limited access to the triceps muscle, posterior capsule, and olecranon fossa. In contrast, the triceps-sparing approach of Bryan and Morrey 19 provides extensive posterior exposure to the elbow joint. The triceps muscle is reflected as a sleeve from the medial side of its insertion on the proximal ulna, thereby eliminating the need for an olecranon osteotomy to mobi- lize the triceps. The Bryan-Morrey approach provides excellent visualization of the medial side of the joint, but it can be limiting in visual- izing the lateral aspect of the radiocapitellar joint. If necessary, a sepa- rate triceps split between the long and lateral heads will allow excellent postlateral joint exposure. Any ulnar nerve symptoms prior to elbow release obligate ulnar neurolysis and transposition. If the goal of surgery is an increase of joint mobility, then ulnar neurolysis and transposition is indicated to permit the increased excursion and gliding the ulnar nerve requires. The ulnar nerve is usually transposed subcuta- neously, but if the subcutaneous tissue bed is scarred, then submuscular transposition can be considered. Procedures done under tourniquet control should have meticulous hemostasis following release to minimize hematoma or be drained when appropriate. Soft-Tissue Release After exposing the elbow joint, the release must encompass all contract- ed structures. If the brachialis muscle is shortened, it should be released or recessed off the humerus. If the triceps or biceps muscle is shortened, a tendon lengthening is rarely required; more appropriately, a tenolysis or more proximal mobilization of the muscle from the underlying bone should be done. In most cases, the anterior and posterior capsules are involved, necessitating a capsulotomy or capsulectomy. Capsular contracture reduces the volume of the anterior and posterior joints and contributes to the soft- tissue encroachment of the humeral fossae, which can serve as a block to motion. Bridging or impinging HO should be excised. Displaced coronoid fragments often may block flexion. Within the joint, impinging marginal osteophytes or hypertrophic callus should be removed, as should osteochondral loose bodies, which can lead to synovitis. The collateral ligaments might be con- tracted, and the posteromedial collateral (deltoid) ligament may be routinely sacrificed. However, the anterior oblique band of the medial collateral ligament should not be resected unless it is enveloped in HO. If there is bridging ulnohumeral synostosis, it may be necessary to release both the medial and lateral collateral ligaments. If the elbow becomes unstable, ligament reconstruction or a hinged elbow fixator is indicated. 1 If the radial head has been frac- tured and is blocking pronation- supination or flexion secondary to malunion or global enlargement, it should be excised at the head-neck junction, with care taken to preserve the annular ligament. Resection arthroplasty is sufficient in most patients, with metallic radial head replacement reserved for instances of postrelease instability of the elbow joint. Mobilization is not necessary im- mediately after surgery. However, postoperative pain should be man- aged with a long-acting brachial plexus block (bupivacaine and epi- nephrine) either axillary or supra- clavicular. We do not routinely use CPM devices, although their use has been described. 2,14,18 Surgical incisions should be protected with a splint until incisions are well healed (10 to 14 days after surgery), at which time therapy is started. Range-of-motion exercises and in- terval progressive static splinting are initiated. Gentle passive and active-assisted range-of-motion exercises are used, under guidance of a physical therapist, with empha- sis on active triceps contraction using electrical stimulation as necessary. Progression of therapy is me- diated by patient factors including pain tolerance, compliance, ex- pectations, and physical limitations. Therapy milestones may be limited by the extent of surgical release, postoperative elbow stability (particularly if ligament reconstruction was necessary), and soft-tissue status. A final range of motion close to, but not necessarily equal to, motion achieved intraoperatively at the time of elbow release can be expected. Urbaniak et al 17 reported results of 15 patients with posttraumatic elbow stiffness who were treated Roderick J. Bruno, MD, et al Vol 10 No 2, March/April 2002 111 with anterior capsulectomy through an anterior approach. Elbow mobility increased an average of 32° at an average follow-up of 3.7 years. There were three transient neur- apraxias (two radial and one ulnar nerve). Gates et al 18 reported results of 18 patients treated with anterior capsulectomy and postoperative CPM whose arc of motion increased an average of 47° at average follow- up of 3 years. Transient neurapraxia (of the radial nerve) in two patients was observed. Morrey 2 reported the results of six patients with posttraumatic elbow stiffness who were treated with anterior and posterior capsulectomy through a lateral approach followed by CPM; these patients experienced an improvement in motion that averaged 42° at an average follow-up of 4.7 years. There was one persistent but not disabling ulnar nerve paresthesia. Fourteen patients treated with soft- tissue release plus a distraction device and CPM had an average increase in mobility of 62° at an average follow-up of 2.8 years. 2 Husband and Hastings 14 treated seven patients with posttraumatic elbow stiffness with anterior and posterior capsulotomy and tendo- lysis through a lateral approach with immediate CPM. At an average follow-up of 3.2 years, these patients maintained a 46° increased arc of motion. One transient ulnar nerve paresthesia was noted. Débridement Arthroplasty Débridement arthroplasty was originally described by Tsuge et al 20 and Tsuge and Mizuseki 21 as a treatment for advanced primary osteoarthritis of the elbow, but it may also be used to treat posttraumatic arthrosis with stiffness (Fig. 3). The olecranon and olecranon fossa are débrided of osteophytes and soft tissue. The coronoid, coronoid fossa, and radial head are likewise débrid- ed. Tsuge did not recommend rou- tine resection of the radial head. The lateral collateral ligament, if released during the operation, is repaired as necessary and the wound is closed over drains. In the initial study by Tsuge et al, 20 43 patients had improved motion, averaging 59°, biased toward flexion at an average of 9.2 years after release. Outerbridge-Kashiwagi Ulnohumeral Arthroplasty Kashiwagi 22 described another method of débridement arthroplasty, which allows exploration and débridement of the anterior and posterior compartments with less extensive soft-tissue dissection. Surgical indication for the majority of the patients was the elbow stiffness of primary osteoarthritis rather than a posttraumatic etiology. The elbow is approached through a posterior midline incision. The triceps muscle is split, and the posterior capsule is incised. The tip of the olecranon is excised. The olecranon fossa is fenestrated with a dental burr, creating a hole up to 1 cm in diameter. This hole allows for the removal of anterior compartment loose bodies and débridement of the coronoid and radial head. Morrey 23 modified this procedure, recom- mending elevation (rather than splitting) of the triceps and the use of a trephine to fenestrate the olecranon fossa to minimize bone dust. Morrey 23 reported on 15 patients who had undergone ulnohumeral débridement arthroplasty. These patients had improved elbow mobility of 21°, with equal gains in flexion and extension, and an 87% patient satisfaction rate at an average follow-up of 2.8 years. Distraction Fascial Arthroplasty Indications for interpositional arthroplasty include loss of more than half of the humeroulnar articular surface, adhesions that avulse or delaminate more than half of the articular surface (a finding usually noted at the time of surgical release), or malunion causing notable incongruity of the articular surface. 1 An extensile posterior approach to the elbow is made, again respecting existing scars. This approach permits broad exposure for global release of any restrictive capsule, ligaments, and muscles to obtain elbow motion. The radial head is excised if it is malunited and re- stricting forearm rotation at the proximal radioulnar joint. The humeral condyles and olecranon joint surfaces are then contoured to allow congruent surfaces for flexion and extension. This limited resection (anatomic) arthroplasty requires good bone stock, including length of humerus and ulna, and stable capsuloligamentous structures to provide an adequate ful- crum for muscle actions. A cutis or fascia lata graft may be used as the interpositional material to resurface the shaped distal humerus. 24 The graft is stretched over the distal humerus, interposing it from the proximal ulna, then secured with intraosseous sutures. The graft material, under protected loading conditions, may transform into fi- brocartilage; however, its durability and ability to provide pain relief are unpredictable. If bony and ligamentous stability are lost as a result of the resection, application of a dynamic joint-span- ning external fixation device, which reproduces the instant center of rotation of the ulnohumeral joint, may be necessary. The landmarks for the center of rotation of the elbow are the anteroinferior aspect of the medial epicondyle and the center of the lateral epicondyle. This is approximated by the center of the trochlea. The distraction device is then attached to the humerus and ulna and the joint is distracted ap- proximately 3 to 5 mm. Insufficient collateral ligaments should be re- constructed using tendon grafts if there is inadequate native material for reconstruction. Posttraumatic Elbow Stiffness Journal of the American Academy of Orthopaedic Surgeons 112 In an early study predating total elbow arthroplasty, Knight and Van Zandt 25 reported a series of 45 elbow fascial arthroplasties, 23 of which were done for posttraumatic etiologies. Their results showed 56% good outcomes and a 73% satisfaction rate at an average follow- up of 14 years. In a later study, Morrey 2 presented the results of six elbows treated with distraction/fascial arthroplasty followed for an average of 2.8 years, documenting an increase of 80° in the total arc of motion. In a subsequent study, 26 20 patients who underwent fascial arthroplasties had an 80% satisfaction rate. Total Elbow Arthroplasty In general, total elbow arthroplasty for posttraumatic arthrosis has been less successful than for rheumatoid arthritis and should be reserved for older, low-demand patients. Nonconstrained implants are not recommended because of difficulty ensuring stability after replacement. A recent study by Mansat and Morrey 27 reported the use of semiconstrained total elbow arthroplasty for individuals with stiff or ankylosed elbows. Although F G H A B C D E Figure 3 Attempted anteroposterior (A) and lateral (B) radiographs of a comminut- ed, intra-articular distal humerus fracture in a 68-year-old man. Because of the extensive comminution, the patient was treated with closed reduction and casting for 6 weeks. Postoperative anteroposterior (C) and lateral (D) radiographs show healing achieved in acceptable alignment but with limited extension (E). Extension-flexion range of motion was 40° to 120°. Nine months after the initial injury, the patient underwent a soft-tissue release and dé- bridement arthroplasty through a medial and lateral approach. After release of the intra-articular adhesions, the elbow was straightened intraoperatively to within 10° of full extension (F). At 5-year follow-up, the patient was pain free, with range of motion of 10° to 130°. Anteroposterior (G) and lateral (H) radiographs show some bony remodeling and preservation of the joint space. Roderick J. Bruno, MD, et al Vol 10 No 2, March/April 2002 113 their reported complication rate was high (infection, prosthetic loosening, and loss of motion were preva- lent), the authors concluded that replacement may be the only viable option for this difficult clinical problem, albeit not a long-term solution, particularly in younger, more active patients with higher functional de- mands. For total elbow arthroplasty, the Bryan-Morrey exposure is commonly used. 19 The distal humerus and proximal ulna are prepared with bone cuts specific to the implant, with care taken to preserve the medial and lateral humeral columns. Adequate soft-tissue releases are done to recreate the appropriate soft-tissue tension. The center of the hinge is placed at the previous center of the trochlear axis of motion. The implant is cemented, adequate hemostasis is achieved, and the wound is closed over drains. Mo- tion is begun after the wound has healed (Fig. 4). In a study of 53 Coonrad-Morrey total elbow arthroplasties for posttraumatic arthrosis, a 64% satisfaction rate at a mean follow-up of 6.3 years was reported. 28 The arc of motion improved from 72° to 94° after arthroplasty. Complications occurred in 21 of 55 patients (38%). There was loosening in 11 patients (20%), periprosthetic fracture in 4 (7.3%), and deep infection in 3 (5.4%). As the prosthetic design and technique were modified into the current design, the complication rate dropped to 16% and the patient satisfaction rate improved to 75%. Overall, 18% of the patients required revision surgery, mostly for loosening. For type I designs, revision occurred at an average of 40.6 months following surgery. For type II designs, time of revision was an average of 37.1 months following surgery. Figgie et al 29 studied 37 total elbow arthroplasties for posttraumatic arthrosis followed for an aver- D A B C Figure 4 Anterior (A) and lateral (B) radiographs of a Monteggia fracture-dislocation in a 59-year-old woman treated with open reduction and internal fixation of the ulna fracture. The radial head remained sub- luxated, even in an external fixator. Healing was achieved with painful, limited motion (range of motion, 45° to 90°). One year later, the patient underwent hardware removal, soft-tissue release, and radial head excision (C and D), with a temporary increase in motion. Because of continued disabling pain and stiffness, 5 months later the patient underwent a total elbow arthroplasty. Extensive degeneration of the distal humeral articular surface was noted (E). At 8-month follow-up (F and G), the patient was nearly pain free, with range of motion of 10° to 130°. E F G Posttraumatic Elbow Stiffness Journal of the American Academy of Orthopaedic Surgeons 114 age of 7 years, with 73% good and excellent results. Mobility increased from 50° to 90° following total elbow replacement. There was a high complication rate (36%), with an 11% rate of loosening; additional complications included fracture, infection, and ulnar nerve paresthe- sias. Fourteen percent of patients required revision surgery. Heterotopic Ossification Direct trauma, the most common cause of HO around the elbow, can cause intramuscular bleeding and displaced fracture fragments. This condition is often associated with elbow fracture-dislocation and residual subluxation or instability. Other causes of HO include neural axis trauma, thermal injury, and forceful passive manipulation of stiff joints in patients without pro- tective sensation. There appears to be a direct correlation between the frequency of HO and the magnitude of the injury. The incidence of HO in the elbow after elbow trauma ranges from 1.6% to 56%. The rate has varied depending on the type of injury and generally increases with fracture severity. 30 Rates of HO up to 89% have been reported in patients with concomitant neural axis trauma. 31 However, these reports do not indicate whether the HO is structurally significant and limiting to range of motion. Upper extremity HO has been classified by Hastings and Graham 30 into three types (Table 2). Radio- graphic visualization of heterotopic bone formation is possible within the first 4 to 6 weeks after the incit- ing event or injury. It is important to differentiate periarticular calcifi- cation, which is indicative of medial or lateral collateral ligament injury, from true HO. A technetium 99 methylene diphosphonate bone scan may demonstrate evidence of HO before it is able to be visualized on plain radiographs. Sensitivity is increased with the three-phase bone scan. Computed tomography can help determine the anatomic location, define the internal architecture, and assess the maturity of the heterotopic bone. Clinical symptoms include swelling, hyperemia, and diminished motion between 1 and 4 months after injury. The differential diag- nosis includes infection, thrombo- phlebitis, and reflex sympathetic dystrophy. In patients with spinal cord injuries, HO is found distal to the level of the lesion and thus occurs most commonly in the lower extremities. When the upper extremity is involved, it is usually on the side of spasticity, most commonly in the flexor muscles or the posterolateral elbow. HO is diffuse and does not necessarily follow anatomic structures or planes. When affected bone appears to be mature, marked by the presence of trabecu- lations, it may be excised. Often the extensive resection required to remove the heterotopic bone desta- bilizes the elbow, necessitating the application of a distraction fixator. In at-risk patients, the occurrence of HO can be decreased by pharma- cologic therapy. Diphosphonates (eg, etidronate disodium) inhibit the crystallization of hydroxyapatite, thus diminishing the mineralization of the osteoid. Indomethacin inter- rupts the synthesis of prostaglandin E 2 by inhibiting differentiation of precursor cells into active osteo- blasts. Indomethacin should be initiated in the early postinjury or postoperative period, usually within the first 24 hours. However, for progressive limitation of motion and functional impairment unresponsive to phar- macologic and physical therapy, surgery should be considered. The timing of surgery is critical. The HO should be metabolically quies- cent at the time of surgery, based on physical appearance of the limb (decreased swelling and erythema) and on mature appearance of the bone on radiographs. Bone scan was formerly considered the best predictor of the appropriate timing for surgical excision. However, a bone scan often remains active for 1 to 2 years during the remodeling phase, often causing an unneces- sary delay in surgical release. The surgeon must balance progressive soft-tissue contracture against the increased risk of recurrence if excision is done too early. To prevent recurrence of HO of the elbow, perioperative radiation may be administered in doses rang- ing from 1,000 cGy divided over five doses 32 to a single-dose treatment with 700 to 800 cGy delivered within 48 hours of surgery. 33 McAuliffe and Wolfson 32 reported a series of eight patients after HO excision who had been treated with 1,000 cGy in five divided doses. The patients achieved and maintained an increase in arc of motion of from 12° to 103° at a mean 4-year follow-up. Because the neurovascular structures about the antecubital space cannot be satisfactorily shielded during radiation therapy, the long- term risk for perineural or intra- neural fibrosis and nerve delayed injury is unknown. Table 2 Classification of Elbow Heterotopic Ossification 30 Class Description I Without functional limitation II Subtotal limitation IIA Limitation in flexion/ extension plane IIB Limitation in pronation/ supination axis IIC Limitation in both planes of motion III Complete bony ankylosis Roderick J. Bruno, MD, et al Vol 10 No 2, March/April 2002 115 Summary Posttraumatic elbow stiffness can be classified into intrinsic, extrinsic, or mixed causes. Preventing elbow stiffness with modalities aimed at early motion is crucial because treatment of established contracture is difficult. Treatment of posttraumatic elbow stiffness begins with supervised physical therapy, often combined with static progressive splinting. If nonsurgical treatment fails, patients with diminished motion (less than 30° to 130° in extension- flexion or less than 50° to 50° of pronation-supination) who can cooperate with the required rehabilitation program are candidates for surgical treatment. For patients with mild or no degenerative changes, soft-tissue releases are adequate. The direction of the greatest limitation of motion dictates the surgical approach and the capsular and tendinous structures to be released. The lateral approach can be used to gain adequate exposure for most anterior and/or posterior releases. Exposure of the anterior capsule and coronoid fossa is superior in the extended lateral or combined medial and lateral approaches and may be safer for the anterior neurovascular structures. Patients with preoperative ulnar nerve symptoms or those with marked chronic contracture require ulnar nerve exploration and neurolysis to prevent postrelease ulnar neuritis secondary to lack of gliding. Postoperative CPM is helpful in some patients but usually does not enhance end-range stretching as well as static progressive splinting does. Patients who have moderate degenerative changes may benefit from limited bony débridement or the Outerbridge-Kashiwagi ulnohumeral arthroplasty. Débridement arthroplasty has been associated with high patient satisfaction rates and reliable improvement in functional motion. In younger patients with advanced degenerative changes, interposition fascial arthroplasty with or without distraction can be done, although outcomes are often unpredictable. Total elbow arthroplasty in the older patient is usually a reliable option. However, for total elbow arthroplasty with a semiconstrained implant, loosening rates of up to 20% and revision rates of up to 18% have been reported. These results are improving with refine- ment of prosthetic design and im- plantation techniques. References 1. Morrey BF: Post-traumatic stiffness: Distraction arthroplasty, in Morrey BF (ed): The Elbow and its Disorders, ed 2. Philadelphia, PA: WB Saunders, 1993, pp 476-491. 2. Morrey BF: Post-traumatic contracture of the elbow: Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am 1990;72:601-618. 3. Morrey BF, Askew LJ, Chao EY: A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-877. 4. Green DP, McCoy H: Turnbuckle orthotic correction of elbow-flexion contractures after acute injuries. J Bone Joint Surg Am 1979;61:1092-1095. 5. Field LD, Savoie FH III: The arthroscopic evaluation and management of elbow trauma and instability. Op Tech Sports Med 1998;6:22-28. 6. Kim SJ, Kim HK, Lee JW: Arthroscopy for limitation of motion of the elbow. Arthroscopy 1995;11:680-683. 7. Ogilvie-Harris DJ, Gordon R, MacKay M: Arthroscopic treatment for posteri- or impingement in degenerative arthritis of the elbow. Arthroscopy 1995;11: 437-443. 8. O’Driscoll SW, Morrey BF: Arthroscopy of the elbow: Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg Am 1992;74:84-94. 9. Redden JF, Stanley D: Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16. 10. Savoie FH III, Nunley PD, Field LD: Arthroscopic management of the arthritic elbow: Indications, technique, and results. J Shoulder Elbow Surg 1999;8:214-219. 11. Byrd JW: Elbow arthroscopy for arthrofibrosis after type I radial head fractures. Arthroscopy 1994;10:162-165. 12. Lo IK, King GJ: Arthroscopic radial head excision. Arthroscopy 1994;10:689-692. 13. Menth-Chiari WA, Poehling GG, Ruch DS: Arthroscopic resection of the radial head. Arthroscopy 1999;15:226-230. 14. Husband JB, Hastings H II: The lateral approach for operative release of posttraumatic contracture of the elbow. J Bone Joint Surg Am 1990;72:1353-1358. 15. Cohen MS, Hastings H II: Post-traumatic contracture of the elbow: Opera- tive release using a lateral collateral ligament sparing approach. J Bone Joint Surg Br 1998;80:805-812. 16. Weiss AP, Sachar K: Soft tissue contractures about the elbow. Hand Clin 1994;10:439-451. 17. Urbaniak JR, Hansen PE, Beissinger SF, Aitken MS: Correction of posttraumatic flexion contracture of the elbow by anterior capsulotomy. J Bone Joint Surg Am 1985;67:1160-1164. 18. Gates HS III, Sullivan FL, Urbaniak JR: Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow: A prospective study. J Bone Joint Surg Am 1992;74:1229-1234. 19. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;166:188-192. 20. Tsuge K, Murakami T, Yasunaga Y, Kanaujia RR: Arthroplasty of the elbow: Twenty years’ experience of a new approach. J Bone Joint Surg Br 1987;69:116-120. 21. Tsuge K, Mizuseki T: Debridement arthroplasty for advanced primary osteoarthritis of the elbow: Results of a new technique used for 29 elbows. J Bone Joint Surg Br 1994;76:641-646. 22. Kashiwagi D: Osteoarthritis of the elbow joint: Intraarticular changes and the special operative procedure, Outerbridge-Kashiwagi Method (O-K Method), in Kashiwagi D (ed): Elbow Joint. Amsterdam: Elsevier Science . motion should be recorded to help determine current functional limitations and to be able to document the effi- cacy of subsequent treatment modalities. Morrey et al 3 determined that the. Elec- trodiagnostic studies to help localize the lesion are indicated in the face of subjective complaints or document- ed deficits on examination. Imaging Studies Anteroposterior, lateral, and radiocapitellar. six elbows treated with distraction/fascial arthroplasty followed for an average of 2.8 years, documenting an increase of 80° in the total arc of motion. In a subsequent study, 26 20 patients

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