Dual mediolateral mini-open technique for the release of elbow contracture

Abstract

Background

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Traditional surgical options for releasing stiff elbows include open and arthroscopic techniques. The former involves long incisions and significant surgical trauma, while the latter is technique-demanding and carries a higher risk of nerve complications. This study was designed to (1) introduce a novel dual mediolateral mini-open releasing technique for elbow stiffness, (2) analyze the clinical outcomes of our proposed technique, and (3) investigate its advantages and limitations for surgical release of elbow contracture.

Methods

Patients who underwent dual medial and lateral mini-open surgeries for elbow stiffness performed by our surgical team between January 2017 and May 2022, with a minimum follow-up of 24 months, were recruited. We recorded the maximum flexion and extension angles, range of motion (ROM), Mayo Elbow Performance scores, visual analogue scale (VAS) scores, presence of heterotopic ossification, and ulnar neuropathy at each visit. Differences at pre-operative, post-operative, and last follow-up were analyzed. The lengths of surgical incisions and complications were also recorded.

Results

A total of 21 patients (11 males and 10 females) with an average age of 36.47 ± 9.81 years at surgery were enrolled. The average follow-up period was 29.76 ± 7.31 months. Lateral and medial incisions averaged 4.1 ± 0.3 cm and 3.0 ± 0.2 cm, respectively. Preoperatively, the maximum extension, flexion angle, and ROM were 37.14 ± 13.24°, 99.05 ± 19.25°, and 61.90 ± 21.07°, respectively. By the latest follow-up, extension and flexion angles were 6.81 ± 6.78° and 138.33 ± 6.78°, and the ROM was 131.52 ± 10.77°. Significant improvement was also observed in Mayo Elbow Performance and VAS scores. Preoperatively, 13 patients exhibited sensory or motor deficits secondary to ulnar nerve entrapment. At discharge, 5 patients demonstrated persistent neuropathy, with one new-onset case. By final follow-up, 3 cases with pre-existing entrapment maintained residual symptoms. No revision surgeries were needed in our cohort by the latest follow-up.

Conclusion

The dual mediolateral mini-open technique allows for a safe and effective release of stiff elbows through small incisions of 3–5 cm in length. With comparable improvements to those reported in traditional surgical approaches, this technique could serve as a reliable alternative to arthroscopic release procedures, aiming for smaller incisions and reduced surgical trauma. However, it is not indicated for patients with severe elbow joint deformities.

Introduction

Elbow contracture is a disabling condition commonly observed following trauma, burns, osteoarthritis, inflammatory arthritis, and infections in the elbow joint. This condition can be anatomically categorized into intrinsic, extrinsic, and mixed intrinsic and extrinsic stiffness. Intrinsic stiffness were contractures due to intra-articular injuries including adhesions, articular malalignment, and cartilage loss [2, 8, 15]. Extrinsic stiffness is caused by the contracture of the joint capsule, ligaments, or the formation of heterotopic ossification (HO). Co-existence of intrinsic and extrinsic factors is also frequently seen in clinical practice. Limited elbow joint motion can cause significant functional impairment, with reports indicating that a 50% decrease in elbow joint range of motion (ROM) can result in up to 80% loss of upper extremity function [2, 8, 15]. According to Morrey et al., a flexion–extension arc of 30° to 130° and a forearm rotation arc of 50° pronation to 50° supination are necessary for basic daily activities, while 140° of flexion and 65° of pronation are required for using keyboards and cellphones. Surgical release of the elbow joint is warranted when conservative treatments fail to restore the necessary joint motion.

Both open and arthroscopic techniques are commonly used for the surgical release of a stiff elbow. Arthroscopic release has been proven effective, offering minimal incisions, decreased blood loss, and reduced post-operative pain, which contribute to easier post-operative rehabilitation [2, 8, 15]. However, it also presents potential disadvantages, including an increased risk of nerve and ligament injury, and requiring significant surgical skill and experience. Open release techniques encompass various procedures tailored to the specific etiology and morphology of elbow anomalies. These techniques provide increased surgical visibility and are adaptable to a wider range of situations, making them more accessible for beginner surgeons. However, the increased surgical trauma associated with open release can result in greater blood loss and post-operative pain, which may compromise post-operative rehabilitation and cause cosmetic issues due to longer incisions [2, 11, 12, 14, 16].

While the reported various surgical techniques have their respective advantages and disadvantages, the key to successfully releasing a stiff elbow lies in adequate vision and access to pathology. In our experience, it is possible to release a stiff elbow with reduced surgical trauma through 3–5 cm incisions. Therefore, the purposes of the current study are to (1) introduce the dual mediolateral mini-open technique for the release of elbow contracture, (2) analyze the clinical outcomes of this technique, and (3) investigate advantages and limitations for our proposed technique.

Materials and method

Data collection

Clinical and radiographic data from patients who underwent dual mediolateral mini-open technique for the surgical release of elbow stiffness by our surgical team between January 2017 and May 2022, with a minimum follow-up of 24 months, were retrospectively analyzed. Patients with prior history of surgical release for elbow stiffness were excluded from the study.

Demographic information including age, gender, and dominant hand side were collected. Preoperatively, the etiology and duration of elbow stiffness, as well as the presence of neurogenic symptoms in the affected arm, were documented. The lengths of incisions on both the medial and lateral sides were measured immediately after surgery. Antero-posterior (AP) and lateral X-rays, along with CT scans, were obtained for each patient before ang after surgery. During follow-up, X-rays were utilized to assess the status of the operated elbow. Maximum flexion and extension angles, elbow range of motion (ROM), nerve symptoms, presence of HO, and Mayo Elbow Performance and VAS scores were recorded and compared at pre-operation, post-operation, and the latest follow-up.

Treatment

Surgical procedure

All patients underwent general anesthesia combined with regional nerve block. As is demonstrated in Fig. 1, after anesthesia induction, the patient is positioned laterally with the affected elbow facing upwards, placed on a hand table at a 90° flexion angle. The procedure begins by rotating the elbow laterally to expose the inner side. A longitudinal incision, approximately 3 cm in length, is made extending proximally from the midpoint of a line connecting the medial epicondyle of the humerus to the tip of the olecranon. Hooks are used to lift the skin and subcutaneous tissue to enhance visibility for the release of the ulnar nerve. Adhesions and scar tissue are meticulously dissected and released from the ulnar nerve. With necessary tractions of the medial incision and the assistance of headlight and surgical lopes, the ulnar nerve can be released beyond the proximal and distal ends of medial incision proximally and caudally. To anteriorly transpose the ulnar nerve, a subcutaneous tunnel should be created by trimming the fat tissue. Then, the released ulnar nerve is transposed anteriorly and anchored with sutures and facial slings. A longitudinal incision, approximately 4 cm in length, is made extending proximally from the humeroradial joint space along the lateral supracondylar ridge of the humerus. The extensor carpi radialis longus and its tendon are carefully dissected to access the coronoid fossa. Contracture scar tissue from the joint capsule and the inner surface of the brachialis muscle is removed until normal muscle or tendon is exposed. If present, heterotopic ossification tissue, including osteophytes and loose bodies, is removed simultaneously.

Fig. 1

A 44 years old man developed left elbow stiffness after a fall-induced sprain, he experienced six months of conservative care to restore elbow movement but with limited improvement. Surgical release was conducted to improve the range of motion. A, B Significant limitation in both flexion and extension of the elbow joint before operation. C After anesthesia induction, the patient is positioned laterally with the affected elbow facing upwards and placed on a hand table. D, E The medial and lateral incisions measure 3 and 4 cm, respectively. F The procedure begins by rotating the elbow laterally to expose the inner side. A longitudinal incision, approximately 3 cm in length, is made extending proximally from the midpoint of a line connecting the medial epicondyle of the humerus to the tip of the olecranon. Adhesions and scar tissue are meticulously dissected and released from the ulnar nerve, which is then repositioned anteriorly to prevent further compression. G The posterior bundle of the ulnar collateral ligament is cut to access the olecranon fossa from the medial side of the triceps brachii. Scar tissue in the olecranon fossa, posterior joint capsule, and the inner surface of the triceps brachii is cleaned until normal muscle tissue is exposed. Heterotopic ossification tissue is removed simultaneously if present. The ulnar nerve is then transposed between the deep fascia and muscle, and the deep fascia is fixed to the medial epicondyle of the humerus using an anchor. H The elbow is then rotated medially to expose the lateral side. A longitudinal incision, approximately 4 cm in length, is made extending proximally from the humeroradial joint space along the lateral supracondylar ridge of the humerus. The extensor carpi radialis longus and its tendon are carefully dissected to access the coronoid fossa. Contracture scar tissue from the joint capsule and the inner surface of the brachialis muscle is removed until normal muscle or tendon is exposed. I, J After the removal of visible contracture tissue from both medial and lateral incisions, the elbow joint is slowly flexed and extended, and the forearm is rotated to the maximum angle to check for any residual adhesion tissue that still limits motion

It is recommended to use surgical loupes and a headlight to improve vision through the limited incisions and minimize the risk of iatrogenic injury to tendons, nerves, and blood vessels.

After the removal of visible contracture tissue from both medial and lateral incisions, the elbow joint is slowly flexed and extended, and the forearm is rotated to the maximum angle to check for any residual adhesion tissue that still limits motion. Drainage tubes are placed in both medial and lateral sides, and the wound is sutured layer by layer after confirming the complete release of the elbow joint.

Post-operative management

X-rays are taken within 24 h post-surgery to confirm the status of the operated elbow joint. From the second day post-operation, patients are instructed to flex and extend the elbow joint and rotate the forearm to the maximum angle both passively and actively with the assistance of rehabilitators. The rehabilitation process usually lasts 3 to 6 months, according to the individualized advice of both surgeons and rehabilitation doctors.

Statistical treatment

The paired t-test was used to compare the extension, flexion angle, and ROM of the elbow, as well as the Mayo Elbow Performance score and VAS score, between pre-operative and post-operative measurements. Pearson chi-square test and Fisher exact test were utilized to evaluate differences in ulnar nerve compression symptoms before and after surgery. Statistical analysis was conducted using SPSS software (version 23.0, USA). Differences were considered statistically significant when p < 0.05.

Results

A total of 21 patients including 11 males and 10 females were eventually enrolled in our study. The average age at surgery was 36.47 ± 9.81 years. Patients were followed up for 29.76 ± 7.31 months. The mean length of lateral incision was 4.1 ± 0.3 cm, and the medial incisions averaged 3.0 ± 0.2 cm. Preoperatively, the maximum extension, flexion angle, and ROM were 37.14 ± 13.24°, 99.05 ± 19.25°, and 61.90 ± 21.07°, respectively. By the latest follow-up, extension and flexion angles were 6.81 ± 6.78° (p < 0.001) and 138.33 ± 6.78° (p < 0.001), and the ROM was 131.52 ± 10.77° (p < 0.001), which are all significantly improved compared to the pre-operative measurements.

Mayo Elbow Performance score and VAS were 71.33 ± 6.94 and 3.90 ± 1.41 before operation, which were 91.05 ± 5.06 (p < 0.001) and 0.90 ± 0.97 (p < 0.001) at the latest follow-up.

Thirteen patients demonstrated ulnar nerve associated sensory or motor deficit before surgery. At discharge, 5 patients presented with ulnar nerve symptoms, including 1 new onset case who demonstrated transient numbness of forearm that relieved at 6 months follow-up. By the latest follow-up, 3 patients with pre-operative ulnar neuropathy continued to exhibit motor deficit of hand. No major complication was observed in this cohort, and no revision surgery was conducted till the last follow-up.

Discussion

To achieve optimal improvement in elbow motion, it is crucial to balance adequate surgical release of contracture tissue with effective post-operative rehabilitation [9, 10, 15]. Minimizing surgical invasiveness in all releasing procedures is essential to reduce the incidence of complications and recurrence of contracture, and thereby facilitate better post-operative rehabilitation [17]. While arthroscopic release techniques can significantly reduce surgical trauma and improve rehabilitation outcomes compared to traditional open procedures, they present several limitations in clinical practice [10, 15]: (1) the incidences of blood vessel, nerve, and ligament injuries are higher compared to traditional open release techniques[4]; (2) the learning curve for acquiring the necessary endoscopic skills is steep for most surgeons; (3) additional medial incisions are often required to release and anteriorly transpose the ulnar nerve to manage pre-operative neuropathy or for prophylactic purpose, which can still cause considerable surgical trauma [7, 20]. Our study introduced a novel mini-open technique for surgical release of elbow contracture. With medial and lateral incisions averaging 3.0 ± 0.2 cm and 4.1 ± 0.3 cm respectively, patients in our cohort demonstrated similar improvements in elbow range of motion compared to previous reports of release techniques, without an increased incidence of complications during a minimum follow-up period of 24 months.

Although the choice of surgical approach can be tailored to the surgeon’s preference and their understanding of each case, it is undeniable that different approaches can significantly impact post-operative rehabilitation and long-term outcomes for patients undergoing elbow release surgery. While anterior and posterior approaches have been reported to provide satisfying improvements in ROM immediately after surgery, these approaches come with significant drawbacks [1, 3, 17]. The posterior approach is more frequently used for open release of elbow contracture due to its ability to provide extensive surgical exposure through a single incision with elevated broad medial and lateral skin flaps. However, this approach involves extensive surgical trauma, leading to prolonged surgical time and increased blood loss. After operation, the elevated inflammation and pain at the surgical site can compromise rehabilitation efforts. Additionally, post-operative hematoma or seroma may develop due to the space under the flaps. Another major drawback of both anterior and posterior approaches is the location of the incisions. Anteriorly and posteriorly located incisions are inevitably compressed and stretched during the rehabilitation process, leading to considerable pain and an increased risk of wound-related complications. This can further exacerbate the loss of ROM during follow-up. The combined medial and lateral approaches have been increasingly gained the preference of surgeons [3, 17,18,19]. First, the lateral approach could provide access for anterior tethers and blocks, and medial approach for posterior adhesion and obstructions [17]. Therefore, the combined medial and lateral approach allows releasing procedure in most cases of elbow stiffness. However, in traditional open releasing procedures, the lengths of medial and lateral incisions range from 8 ~ 10 cm to 8 ~ 12 cm, respectively [2, 6, 8, 15]. Although these long incisions provides adequate access for surgical release, they can still lead to increased pain and potential wound complications, which can negatively impact the overall recovery and restoration of elbow function [5, 13].

Recent studies have demonstrated that open releasing procedure from a limited incision could achieve similar or better improvement of flexion–extension motion for elbow stiffness. Kruse et al. [11] reported the clinical outcome of “mini-open” technique for surgical release of stiff elbow in 36 patients via combined lateral and posterior approach, reporting a mean increase of 57° in the flexion–extension arc was during an average of 38 months follow-up. Our dual mediolateral mini-open technique via combined medial and lateral approach reported 69.62° of increase in ROM from pre-operation to the latest follow-up in 21 patients. The relatively higher improvement of flexion–extension arc indicated that mini-open releasing procedure via medial and lateral approaches could allow similar or better clinical outcome. Additionally, Kruse et al. did not provide the length of incisions in his cohort. The incisions in our proposed technique measured approximately 3 ~ 5 cm. By minimizing incision lengths, patients experience less pain and fewer wound-related complications, which contributed to a more effective and less hindered rehabilitation process.

Although the dual mediolateral approach enables comprehensive release of all aspects of the stiff elbow joint, the limited incision size inevitably restricts the surgeon’s vision and lighting of the surgical field. The reported incidence of ulnar nerve injury during surgical release of elbow stiffness ranges between 2.4 and 13.6% [1, 9, 17, 18]. Severe pre-operative contracture, acute recovery of flexion angle, and open release from medial approach are more frequently correlated with onset of ulnar nerve deficits after surgery. The development of transient numbness of forearm in one of the cases (patient No.2) was potentially related to the insufficient vision and lighting during the releasing procedure from limited medial incision. To address this challenge, we implemented two key improvements in dual mediolateral mini-open technique. First, we utilized a headlight to provide additional illumination to the surgical area, and surgical loupes were employed to enhance the surgeon’s visualization of the operating field. Second, unlike the supine position typically used in traditional open releasing surgeries, the patient was placed in a side-lying position with the affected arm supported and draped over a padded support. During the initial releasing procedure through the limited incisions, the surgeon may encounter insufficient release of the contracture tissue. In such cases, re-evaluation of residual adhesion sites is necessary, involving repeated switches between the medial and lateral approaches until maximum release is achieved. The side lying position allows quick and convenient adjustments to the position of the elbow joint, ensuring that the operating incision can always face upwards for optimal access.

Despite the above strengths of our proposed release technique, this procedure may not be suitable for certain cases, such as those involving retained surgical instruments, joint deformities requiring osteotomy to achieve the desired ROM, complex ulnar nerve contractures necessitating extensive release procedures, or extensive HO. In our experience, the mini-open technique is contraindicated in the following scenarios: (1) HO masses involving the articular surface, which require complex osteotomy procedures; (2) multiple HO lesions affecting both anterior and posterior elbow regions, which increase surgical time, technical complexity, and risk of iatrogenic neurovascular injury; or (3) HO masses with a maximum diameter exceeding 2 cm, which are unresectable through limited incisions due to poor visualization and restricted instrument maneuverability (Tables 1 and 2).

Table 1 Demographic data

Table 2 Clinical data at pre-operation, post-operation and/or the latest follow-up

For patients requiring ulnar nerve release and anterior transposition, a mini-open incision permits up to 8–10 cm of nerve mobilization under adequate traction and with the aid of surgical loupes and headlights. Given the risk of iatrogenic nerve injury, extending the medial incision is acceptable when exposure is inadequate for complete nerve release. In our study, an average incision length of 3.0 ± 0.2 cm was sufficient for ulnar nerve release. In our cohort, four patients had persistent preoperative ulnar nerve symptoms, while 3 of them showed partial improvement at the final follow-up. Although preoperative nerve deficits were deemed irreversible, we emphasize that insufficient ulnar nerve release via a mini-open approach remains a risk in patients with preexisting neuropathy. We recommend thorough preoperative assessment of ulnar nerve compression to assess the possibility to release through mini-open incision, and counseling patients about the potential need for incision extension to achieve complete release. Therefore, surgeons should be proficient in traditional open release techniques to ensure safe and efficient conversion when necessary.

Conclusion

In conclusion, the dual medial and lateral small-incision release technique combines the advantages of traditional lateral open surgery and foramen magnum surgery, realizes full release of the elbow joint in a relatively small field of view, and minimizes the pain of the patient during rehabilitation exercises, which is conducive to the patient’s recovery.