Elbow stiffness is an uncommon condition that significantly impacting a patient's daily activities. Trauma is the most frequent cause of elbow stiffness. However, capitellum fractures are rare, accounting for approximately 1 % of elbow fractures. They are often misdiagnosed due to nonspecific symptoms and the complex anatomy of the elbow joint.

We report the case of a 54-year-old female who presented with left elbow stiffness eight months after a traumatic incident. On physical examination, her left elbow extension was +10°, and flexion was restricted to 65°, with no limitation in pronation or supination. Imaging studies revealed a malunited capitellum with osteophytes at the posterolateral site of the olecranon. A 3D-printed model of her elbow was created based on a CT scan to aid surgical planning. She underwent capsulectomy and osteotomy and was stabilized with two bioabsorbable P(L/DL)LA pins. Six months postoperatively, the patient's elbow range of motion was fully restored, and no complications were observed.

Elbow stiffness resulting from the malunion of a capitellum fracture typically necessitates surgical intervention to restore functional movement in the elbow.

Capitellum fractures are uncommon and frequently underdiagnosed, leading to complications such as elbow stiffness and reduced functionality. Early detection is crucial, as delayed diagnosis can result in complex management due to malunion. 3D printing from CT scans helps surgeons accurately evaluate malunions and plan precise surgical interventions.

Stiffness after elbow injuries can severely limit daily life. If adequate conservative treatment does not result in satisfactory improvement of elbow function, surgical intervention should be considered. Whether an open or arthroscopic procedure is preferable is still a topic of debate and a systematic review of functional outcomes is lacking.

We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE, for studies published between 2013 and 2021. Primary objective was to compare open and arthroscopic arthrolysis' functional outcomes, respectively, especially ROM and MEPS, as well as the accompanied complications. The PRISMA guidelines were applied.

27 studies comprising 1666 patients were included. 1059 patients (63.6%) were treated with open arthrolysis, and 607 patients (36.4%) were treated with arthroscopic arthrolysis. The results presented indicate satisfactory outcomes in open and arthroscopic arthrolysis with regard to functional outcome parameters. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score, among the patients treated with an open procedure was 88.8%; 6.3% required revision whereas 18.1% had complications without the need for revision surgery. Within the cohort of arthroscopically treated patients, treatment success was 91.8%. Revisions and complications without further surgical intervention were significantly less frequent than in the open cohort, at 1.6% and 9.1%, respectively.

Both open and arthroscopic arthrolysis provide good to excellent functional outcomes. Since the number of complications and revision increases with the invasiveness of the treatment, an arthroscopic procedure might be favored if feasible by indication. The role of forearm rotation and the use of a hinged external fixator remains of interest.

Level IV; Systematic review.

Post-trauma elbow stiffness (PTES) is a common complication after elbow trauma that causes severe upper limb disability. Open elbow arthrolysis (OEA) with radial head arthroplasty (RHA) is an effective method to treat PTES with rotation limitation, or persistent pain/instability after radial head resection. However, no long-term results have been reported for this technique. This study aimed to show the clinical and radiographic outcomes of OEA with RHA over 8 years and compare its efficacy at 3 years (short-term).

Patients with PTES treated by OEA with RHA between September 2010 and December 2012 were retrospectively reviewed. Seventeen patients were followed up over 8 years (range, 100-106 months). A bipolar prosthesis of RHA was performed during OEA. Preoperative, 3-year, and 8-year elbow and forearm motion, upper limb function, radiographic outcomes, and complications were recorded.

Clinically important improvements in elbow motion and forearm rotation were obtained, from 34° and 58° preoperatively, to 109° and 135° at 3 years, which were maintained over 8 years, to 113° (P = .262) and 134° (P = .489). The Mayo Elbow Performance Index had clinically important increases from the preoperative level of 58 to 94 points at 3 years, and was maintained over 8 years (95 points, P = .422), with 100% reporting excellent to good outcomes. Pain and nerve symptoms were also improved. Complications consisted of new-onset ulnar nerve symptoms in 1 patient, nonclinically significant heterotopic ossification recurrence in 3, humeroulnar arthritis exacerbation in 4, and periprosthetic lucency in 8.

OEA with RHA yielded satisfactory short-term outcomes for PTES at 3 years, with substantial improvements in elbow mobility and function, and the results were durable over the long term (8 years).

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576-584.

Elbow stiffness is defined as any loss of movement that is greater than 30° in extension and less than 120° in flexion. Causes of elbow stiffness can be classified as traumatic or atraumatic and as congenital or acquired. Any alteration affecting the stability elements of the elbow can lead to a reduction in the arc of movement. The classification is based on the specific structures involved (Kay's classification), anatomical location (Morrey's classification), or on the degree of severity of rigidity (Vidal's classification). Diagnosis is the result of a combination of medical history, physical examination (evaluating both active and passive movements), and imaging. The loss of soft tissue elasticity could be the result of bleeding, edema, granulation tissue formation, and fibrosis. Preventive measures include immobilization in extension, use of post-surgical drain, elastic compression bandage and continuous passive motion. Conservative treatment is used when elbow stiffness has been present for less than six months and consists of the use of serial casts, static or dynamic splints, CPM, physical therapy, manipulations and functional re-education. If conservative treatment fails or is not indicated, surgery is performed. Extrinsic rigidity cases are usually managed with an open or arthroscopic release, while those that are due to intrinsic causes can be managed with arthroplasties. The elbow is a joint that is particularly prone to developing stiffness due to its anatomical and biomechanical complexity, therefore the treatment of this pathology represents a challenge for the physiotherapist and the surgeon alike.

Primary elbow osteoarthritis (PEOA) is a debilitating disease that can be difficult to treat. Osteocapsular débridement (OD) has been described through various approaches, including arthroscopic and open approaches, with successful outcomes in treating PEOA. There is insufficient evidence in the literature to date to demonstrate the superiority of any approach. The purpose of this review was to compare the clinical results of arthroscopic vs. open OD for PEOA.

The online databases PubMed, Embase (Elsevier), and Scopus (Elsevier) were searched from inception through April 1, 2018, for clinical studies reporting on OD. Studies were stratified based on an arthroscopic vs. open approach. Weighted means were calculated for surgical and patient-reported outcomes.

We included 30 studies, reporting on 871 patients and 887 elbows, with a mean follow-up period of 44.3 ± 25.5 months. Of these studies, 15 (420 elbows) reported on open OD, 14 (456 elbows) reported arthroscopic OD, and 1 reported on a cohort of each approach (open in 5 elbows and arthroscopic in 6). The Mayo Elbow Performance Score improved by 28.6 ± 4.57 in the open group vs. 26.6 ± 7.24 in the arthroscopic group. Flexion improved by 19° ± 6° in the open group and 10° ± 6° in the arthroscopic group. Extension improved by 11° ± 5° in the open group and 11° ± 6° in the arthroscopic group.

Open OD and arthroscopic OD are effective surgical treatment options for patients with symptomatic PEOA, reliably improving flexion, extension, and functional outcome scores with low complication rates.

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

To review our 10-year experience treating posttraumatic sequelae of the elbow using a modified Outerbridge-Kashiwagi (O-K) procedure.

Twenty-one patients with posttraumatic sequelae of the elbow treated using the technique were evaluated clinically using the Mayo Elbow Performance Score, range of motion testing, and pain level. We noted the presence of preoperative and postoperative ulnar nerve symptoms, complications, and reoperations. Open contracture release was selected to address either removal of hardware or ulnar nerve pathology.

At a mean of 39 months (range, 12-116 months), the Mayo Elbow Performance Score improved from 52 to 84 (P < .0001) and the mean arc of motion improved from 44° to 98° (P < .0001). At the final follow-up, 90% of patients reported no pain or mild pain, and 81% of patients had a satisfactory objective result. In 15 of 21 cases (71%), it was necessary to mobilize the ulnar nerve. After contracture release, 1 patient developed new onset ulnar nerve symptoms. Three patients underwent reoperation: 2 for recalcitrant contracture and 1 for new onset ulnar nerve symptoms.

The mini-open O-K procedure is safe and effective in restoring function in patients with retained hardware and posttraumatic contracture. Posttraumatic arthritic patients often require both removal of hardware and neurolysis of the ulnar nerve. The mini-open O-K procedure allows complete access to the elbow joint, which facilitates release for both intrinsic and extrinsic contracture.

Posttraumatic elbow stiffness is common with the primary indication for contracture release being limited motion that affects functional activities which has not adequately improved after intensive therapy and rehabilitation. Preoperative evaluation focuses on the history of previous nonoperative and/or operative treatment, physical exam with particular attention paid to the status of the ulnar nerve, and imaging consisting of radiographs and computed tomography. There are multiple intrinsic and extrinsic causes of posttraumatic contracture. In general, limitation of motion in one direction can be attributed to a mechanical block and/or opposing contracture or tightness. Open elbow contracture release has been shown to improve motion, patient health status and disability scores with the specific surgical approach based upon the contracture pathology and surgeon preference. A step-wise algorithm is presented for open osteocapsular release. An anterior and posterior release is performed first through a lateral approach with the addition of a medial approach if ulnar nerve dysfunction exists or inadequate release has been obtained from the lateral approach. A previous posterior incision can be utilized by raising full thickness flaps. After release, gentle manipulation is performed and intraoperative stability is assessed with stress testing under fluoroscopy. Postoperatively, pain is managed with an in-dwelling nerve catheter and rehabilitation commences immediately. Significant improvement in range of motion can be expected with adequate surgical release and postoperative rehabilitation.

The olecranon osteotomy-facilitated elbow release (OFER) is a safe and effective method for releasing severe posttraumatic elbow contractures. The OFER procedure is easier, faster, and relatively less invasive, and appears to offer superior outcomes, compared with more traditional techniques.

An olecranon osteotomy provides a trapdoor through which the surgeon will have circumferential access to the joint and will be able to address all intrinsic and extrinsic causes of contracture. Access from the posterior to the anterior compartment is achieved by detaching the origin of the medial collateral ligament (MCL) and hinging the joint from medially to laterally, pivoting around the intact lateral collateral ligament. Once the olecranon and MCL are repaired, the elbow is stable enough for the patient to participate in intensive rehabilitation protocols.

The first line of treatment for elbow contracture is physical therapy, focusing on range of motion and using modalities such as static-progressive and dynamic splinting protocols. In some select cases, there is also a role for manipulation under anesthesia. When nonoperative methods fail, elbow contractures may be treated surgically, using either open or arthroscopic techniques. Authors have described open release involving medial, lateral, and anterior approaches. The first outcome report of a posterior approach to treat elbow contractures has recently been published¹.

An open approach usually utilizes 1 or possibly 2 large incisions and involves invasive dissection through muscle and nerve mobilization. This may result in a postoperative hematoma and usually substantial pain, posing a challenge for rehabilitation. Arthroscopic techniques are less invasive, with potentially fewer complications, but are far more technically challenging. Also, most extrinsic and some intrinsic causes cannot be adequately addressed through the arthroscope. The outcomes of OFER have been found to be superior to those reported after either arthroscopic or more conventional open procedures. In addition, we believe that the OFER procedure is substantially faster and technically easier than either other open or arthroscopic releases, although we are not aware of any studies addressing this topic.

Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062.

Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture.

A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded.

The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion.

Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.

Elbow contractures can cause functional limitation, and treatment can be challenging. The purpose of this article is to describe a novel technique that releases posttraumatic elbow contractures through an olecranon osteotomy and report the outcomes.

Thirty-five patients with refractory posttraumatic elbow contracture who underwent an olecranon osteotomy-facilitated elbow release (OFER) procedure were included in the study. The average patient age was 39.5 years (range, 18 to 63 years), and the mean duration of follow-up was 37.2 months (range, 24 to 72 months). Preoperative and postoperative data included age, sex, cause of contracture, previous surgical procedures, active elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, visual analog scale pain scores, and radiographs. Intraoperative tourniquet time and complications were recorded.

The mean preoperative elbow motion arc was 33° (51° to 84° of flexion). Postoperatively, the motion arc improved significantly (p < 0.001) to 110° (16° to 126° of flexion). The mean visual analog pain scale score improved from 6.3 preoperatively to 1.4 at the time of follow-up (p < 0.001). The mean DASH score improved from 57.5 preoperatively to 10.9 postoperatively (p < 0.001). The maximal improvement in the motion arc occurred at a mean of 8.7 weeks. There was 1 postoperative ulnar neurapraxia that resolved spontaneously. The intraoperative tourniquet time averaged 27 minutes (range, 18 to 45 minutes). The average time until radiographic evidence of union of the olecranon osteotomy site was 6.6 weeks (range, 5.7 to 7.7 weeks).

The OFER is a safe and effective means of treating posttraumatic elbow contractures, and is an alternative to traditional open or arthroscopic techniques.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.