The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 80, Issue 11

Articles | November 01, 1998

The Column Procedure: A Limited Lateral Approach for Extrinsic Contracture of the Elbow*

PIERRE MANSAT, M.D.†; B. F. MORREY, M.D.‡, ROCHESTER, MINNESOTA

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Investigation performed at the Mayo Clinic, Rochester

J Bone Joint Surg Am, 1998 Nov 01;80(11):1603-15

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Abstract

Thirty-eight elbows (thirty-seven patients) with an extrinsic contracture were treated operatively with a limited lateral approach to the anterior and posterior aspects of the capsule. Because the procedure elevates muscles from the anterior and posterior aspects of the lateral supracondylar osseous ridge, we called it the column procedure.The mean preoperative arc of flexion was 49 degrees (from 52 to 101 degrees). At a mean of forty-three months (range, twenty-four to seventy-four months) postoperatively, the mean arc of flexion was 94 degrees (from 27 to 121 degrees). The mean total gain in the arc of flexion-extension was 45 degrees; thirty-four elbows (89 percent) had an improved range of motion at the latest follow-up examination. Overall, thirty-one elbows (82 percent) had a satisfactory result. Greater improvement was obtained in elbows that had had severe stiffness (a total arc of 30 degrees or less) or that had had a combined flexion and extension contracture.A complication occurred in four elbows (11 percent). A hematoma developed in two elbows and impaired the final outcome in one of them. Two elbows had transient ulnar paresthesia, which resolved spontaneously. The arc of flexion obtained at the time of the operation was lost in ten elbows (26 percent) after an initial period of improvement; at the latest follow-up evaluation, four of these elbows had a mean decrease in the arc of flexion of 24 degrees compared with preoperatively.The column procedure is associated with a low rate of complications and is safe and effective for the treatment of a limitation in flexion or extension resulting from an extrinsic contracture of the elbow.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Stiffness, a rather common problem at the elbow that is often related to traumatic injury, may also result from osteoarthrosis, inflammatory arthritis, a burn, or head injury^{2,4,6,19,24,26,34,45,48,59}. Congenital stiffness is rare and is often associated with osseous malformation as well as soft-tissue dysplasia^8,13. Classification of the type and severity of the stiffness is important for the preoperative planning and for the estimation of the prognosis³⁸. In the broadest perspective, two types of contractures are recognized. Extra-articular, or extrinsic, contractures typically involve only the soft tissues (the capsule, ligaments, muscles, or a combination of these structures) but may also be the result of the formation of osteophytes. Heterotopic ossification in the soft tissues is also considered an extrinsic condition²³. Intra-articular, or intrinsic, contractures involve the intra-articular, or intrinsic, contractures involve the intra-articular elements, with a lesion of the surface of the cartilage or with intra-articular adhesions from a damaged or fractured joint. Gross distortion of the joint as a result of an inadequate or failed reduction of an intra-articular fracture is another cause of intrinsic contracture. The effect of the loss of motion on function depends on the extent and the specific position of the arc of motion that is affected^1,15,41

Several options have been proposed for the treatment of stiffness of the elbow. Nonoperative treatment with mobilization of the elbow through the use of alternating flexion and extension splints or dynamic splints sometimes provides a good result if it is begun soon after the contracture develops^{2,3,9,12,22,35,39}. Manipulation with the patient under anesthesia has also been recommended¹⁴. However, nonoperative treatment usually is successful only for extrinsic stiffness that has been present for six months or less, and the results are unpredictable. If nonoperative treatment fails, an operative release may be indicated. Arthroscopic release has been reported recently^{6,18,28,33,42,46,50}; however, most releases are performed as an open procedure. The many open approaches that have been described include anterior^{4,19,21,44,54,59}, posterior⁴⁹, lateral^26,32,47,57, medial³⁶, and combined medial and lateral releases^{1,7,15,27,29,31,36,52,53,56,58}. The release may involve only the anterior aspect of the capsule⁵⁴ or it may be more extensive and also involve the posterior aspect of the capsule^37,38. Lengthening of the biceps tendon^4,21,59, brachialis myotomy^4,21, release of collateral ligaments⁵², and resection of the radial head have all been performed in conjunction with the capsular release^32,47,57. Other authors have proposed distraction of the elbow^{10,11,30,38,55}, resection arthroplasty^{15,34,36,38,43,49,51}, or total elbow replacement^5,16,40 to treat stiff elbows that have an intrinsic contracture.

Since 1989, we have used a limited lateral approach, which we call the column procedure, for the treatment of extrinsic contracture of the elbow. The present report describes the indications, the operative technique, and the rationale for its use in thirty-eight consecutive elbows (thirty-seven patients). The principal indication for this procedure is an extrinsic contracture that causes a functional loss of flexion or extension, or both. Typically, a flexion-extension contracture of more than 30 degrees or flexion of less than 110 degrees, or both, warrants operative correction.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Hôpital de Purpan, Place du Docteur Baylor, 31 0659 Toulouse CEDEX, France.

‡Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Hôpital de Purpan, Place du Docteur Baylor, 31 0659 Toulouse CEDEX, France.

‡Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

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TABLE I DATA ON THE PATIENTS

*0 = no pain, 1 = mild paid, 2 = moderate pain, and 3 = severe pain. †Preoperatively/postoperatively. ‡Extension is expressed as degrees of flexion. §According to the Mayo elbow performance score⁴¹. A score of 90 points or more is excellent, a score of 75 to 89 points is good, a score of 60 to 74 points is fair, and a score of less than 60 points is poor. #Indicates the dominant extremity.

Case

Gender, Age, (yrs.)

Side

Initial Diagnosis

Duration of Contracture (mos.)

Pain*† (points)

Extension†‡ (degrees)

Flexion† (degrees)

Pronation† (degrees)

Supination† (degrees)

Mayo Elbow Performance Score⁴¹† (points)

Duration of Follow-up (mos.)

Complications

Result§

M, 67

Osteoarthrosis

1/1

30/20

130/130

90/90

85/85

Good

M, 36

Coma

1/1

80/30

90/140

60/60

70/70

47/85

Good

M, 52

Osteoarthrosis

1/0

35/15

110/140

80/80

65/100

Excellent

F, 5

Congenital

0/0

60/80

90/90

20/20

-15/0

64/70

Fair

M, 42

Fracture, olecranon

0/1

50/0

70/140

80/80

60/85

Good

M, 37

Coma

1/1

45/30

45/90

60/60

70/70

60/40

Hematoma

Poor

M, 36

Fracture-dislocation

1/1

50/45

100/140

0/50

0/20

69/80

Good

F, 36

Fracture-olecranon

1/2

25/45

95/90

50/90

90/90

73/45

Poor

M, 41

Burn

0/0

42/0

135/145

80/80

92/100

Excellent

F, 61

Fracture, distal end of humerus

2/0

45/0

110/100

45/75

45/80

52/95

Excellent

M, 33

Dislocation, elbow

2/0

40/15

110/140

80/80

55/100

Excellent

M, 36

Coma

180

1/0

55/40

130/145

80/60

69/95

Ulnar paresthesia

Excellent

M, 28

Fracture, distal end of humerus

240

0/1

90/45

110/125

70/70

80/80

69/80

Good

M, 39

Fracture, olecranon

1/1

35/30

105/140

80/80

60/60

72/80

Good

M, 16

Fracture, radial head

1/2

80/45

90/45

80/80

54/35

Poor

M, 35

Coma

1/0

60/0

90/140

80/80

60/100

Excellent

M, 17

Congenital

204

0/0

65/50

130/140

70/70

90/95

Excellent

M, 40

Fracture, distal end of humerus

1/1

0/0

95/140

85/80

90/80

64/85

Good

M, 38

Dislocation, elbow

0/0

45/0

140/145

75/75

60/60

92/100

Excellent

M, 33

Coma

2/0

70/50

90/110

0/0

30/80

Good

M, 32

Fracture, distal end of humerus

2/2

85/80

90/95

80/80

40/45

Poor

F, 54

Fracture-dislocation

1/0

50/30

95/140

15/60

5/40

59/100

Excellent

M, 40

Fracture-dislocation

120

2/3

30/20

90/40

75/70

70/70

55/29

Poor

M, 67

Osteoarthrosis

1/0

70/30

95/90

80/80

55/95

Excellent

M, 35

Fracture-dislocation

1/2

75/45

105/90

60/60

60/50

Poor

M, 47

Osteoarthrosis

1/1

50/20

90/120

80/80

56/85

Good

M, 44

Fracture-dislocation

2/1

30/20

135/140

80/80

61/85

Good

F, 19

Fracture-dislocation

1/1

45/10

90/145

80/80

60/60

59/85

Good

M, 43

Distal rupture, biceps

1/0

60/45

80/145

80/80

47/95

Excellent

M, 34

Dislocation, elbow

0/1

40/10

100/125

50/80

80/80

86/85

Good

M, 46

Burn

1/0

90/30

90/140

65/80

75/80

45/100

Excellent

Burn

1/0

75/30

85/70

75/80

85/80

45/80

Good

M, 60

Osteoarthrosis

120

1/0

50/30

70/110

0/60

20/60

45/95

Excellent

M, 68

Dislocation, elbow

180

2/0

50/30

135/145

80/80

62/100

Excellent

M, 54

Osteoarthrosis

120

1/0

45/10

125/140

80/80

75/60

72/100

Hematoma

Excellent

M, 51

Fracture-dislocation

1/1

50/30

90/100

20/40

0/20

51/75

Good

F, 33

Fracture-dislocation

2/1

50/20

90/130

80/80

41/85

Good

F, 63

Osteoarthrosis

1/0

20/10

135/140

80/80

77/100

Ulnar paresthesia

Excellent

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TABLE I DATA ON THE PATIENTS

Case

Gender, Age, (yrs.)

Side

Initial Diagnosis

Duration of Contracture (mos.)

Pain*† (points)

Extension†‡ (degrees)

Flexion† (degrees)

Pronation† (degrees)

Supination† (degrees)

Mayo Elbow Performance Score⁴¹† (points)

Duration of Follow-up (mos.)

Complications

Result§

M, 67

Osteoarthrosis

1/1

30/20

130/130

90/90

85/85

Good

M, 36

Coma

1/1

80/30

90/140

60/60

70/70

47/85

Good

M, 52

Osteoarthrosis

1/0

35/15

110/140

80/80

65/100

Excellent

F, 5

Congenital

0/0

60/80

90/90

20/20

-15/0

64/70

Fair

M, 42

Fracture, olecranon

0/1

50/0

70/140

80/80

60/85

Good

M, 37

Coma

1/1

45/30

45/90

60/60

70/70

60/40

Hematoma

Poor

M, 36

Fracture-dislocation

1/1

50/45

100/140

0/50

0/20

69/80

Good

F, 36

Fracture-olecranon

1/2

25/45

95/90

50/90

90/90

73/45

Poor

M, 41

Burn

0/0

42/0

135/145

80/80

92/100

Excellent

F, 61

Fracture, distal end of humerus

2/0

45/0

110/100

45/75

45/80

52/95

Excellent

M, 33

Dislocation, elbow

2/0

40/15

110/140

80/80

55/100

Excellent

M, 36

Coma

180

1/0

55/40

130/145

80/60

69/95

Ulnar paresthesia

Excellent

M, 28

Fracture, distal end of humerus

240

0/1

90/45

110/125

70/70

80/80

69/80

Good

M, 39

Fracture, olecranon

1/1

35/30

105/140

80/80

60/60

72/80

Good

M, 16

Fracture, radial head

1/2

80/45

90/45

80/80

54/35

Poor

M, 35

Coma

1/0

60/0

90/140

80/80

60/100

Excellent

M, 17

Congenital

204

0/0

65/50

130/140

70/70

90/95

Excellent

M, 40

Fracture, distal end of humerus

1/1

0/0

95/140

85/80

90/80

64/85

Good

M, 38

Dislocation, elbow

0/0

45/0

140/145

75/75

60/60

92/100

Excellent

M, 33

Coma

2/0

70/50

90/110

0/0

30/80

Good

M, 32

Fracture, distal end of humerus

2/2

85/80

90/95

80/80

40/45

Poor

F, 54

Fracture-dislocation

1/0

50/30

95/140

15/60

5/40

59/100

Excellent

M, 40

Fracture-dislocation

120

2/3

30/20

90/40

75/70

70/70

55/29

Poor

M, 67

Osteoarthrosis

1/0

70/30

95/90

80/80

55/95

Excellent

M, 35

Fracture-dislocation

1/2

75/45

105/90

60/60

60/50

Poor

M, 47

Osteoarthrosis

1/1

50/20

90/120

80/80

56/85

Good

M, 44

Fracture-dislocation

2/1

30/20

135/140

80/80

61/85

Good

F, 19

Fracture-dislocation

1/1

45/10

90/145

80/80

60/60

59/85

Good

M, 43

Distal rupture, biceps

1/0

60/45

80/145

80/80

47/95

Excellent

M, 34

Dislocation, elbow

0/1

40/10

100/125

50/80

80/80

86/85

Good

M, 46

Burn

1/0

90/30

90/140

65/80

75/80

45/100

Excellent

Burn

1/0

75/30

85/70

75/80

85/80

45/80

Good

M, 60

Osteoarthrosis

120

1/0

50/30

70/110

0/60

20/60

45/95

Excellent

M, 68

Dislocation, elbow

180

2/0

50/30

135/145

80/80

62/100

Excellent

M, 54

Osteoarthrosis

120

1/0

45/10

125/140

80/80

75/60

72/100

Hematoma

Excellent

M, 51

Fracture-dislocation

1/1

50/30

90/100

20/40

0/20

51/75

Good

F, 33

Fracture-dislocation

2/1

50/20

90/130

80/80

41/85

Good

F, 63

Osteoarthrosis

1/0

20/10

135/140

80/80

77/100

Ulnar paresthesia

Excellent

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TABLE II RELATIONSHIP BETWEEN PREOPERATIVE CHARACTERISTICS AND THE OUTCOME MEASURES AT THE LATEST FOLLOW-UP EVALUATION

*The numbers in the table represent the p values. NS = not significant. The level of significance is p < 0.05. †Traumatic or nontraumatic.

Preoperative Characteristic	Outcome Measure*
Pain	Flexion	Extension	Arc of Flexion- Extension	Mayo Elbow Performance Score⁴¹	Overall Result	Satisfaction of Patient
Age of patient	NS	NS	0.025	NS	0.017	0.009	0.046
Gender of patient	NS	NS	NS	NS	NS	NS	NS
Duration of contracture	0.013	NS	NS	NS	NS	NS	NS
Origin†	0.004	NS	NS	NS	NS	NS	NS
Flexion	NS	0.004	NS	0.008	0.008	0.012	NS
Extension	NS	NS	0.007	0.004	NS	NS	NS
Severity of stiffness	NS	0.004	0.004	0.0005	0.022	0.041	NS
Mayo elbow performance score⁴¹	NS	0.029	NS	0.014	NS	NS	NS
Intra-articular arthrosis	NS	NS	0.033	NS	NS	NS	0.014

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TABLE II RELATIONSHIP BETWEEN PREOPERATIVE CHARACTERISTICS AND THE OUTCOME MEASURES AT THE LATEST FOLLOW-UP EVALUATION

*The numbers in the table represent the p values. NS = not significant. The level of significance is p < 0.05. †Traumatic or nontraumatic.

Preoperative Characteristic	Outcome Measure*
Pain	Flexion	Extension	Arc of Flexion- Extension	Mayo Elbow Performance Score⁴¹	Overall Result	Satisfaction of Patient
Age of patient	NS	NS	0.025	NS	0.017	0.009	0.046
Gender of patient	NS	NS	NS	NS	NS	NS	NS
Duration of contracture	0.013	NS	NS	NS	NS	NS	NS
Origin†	0.004	NS	NS	NS	NS	NS	NS
Flexion	NS	0.004	NS	0.008	0.008	0.012	NS
Extension	NS	NS	0.007	0.004	NS	NS	NS
Severity of stiffness	NS	0.004	0.004	0.0005	0.022	0.041	NS
Mayo elbow performance score⁴¹	NS	0.029	NS	0.014	NS	NS	NS
Intra-articular arthrosis	NS	NS	0.033	NS	NS	NS	0.014

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Fig. 1 Illustration demonstrating the concept of the release, which is to identify the supracondylar ridge and to approach the anterior and posterior aspects of the capsule as necessary. Osteophytes are readily removed from the coronoid process or the olecranon.

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Fig. 2-A through 2-E: The operative technique. Fig. 2-A: Illustration demonstrating a limited Kocher skin incision over the lateral epicondyle (extending from six centimeters proximal to the epicondyle to three centimeters distal to the epicondyle). The anterior and posterior aspects of the lateral column are identified (dotted lines). ECRL = extensor carpi radialis longus, and ECRB = extensor carpi radialis brevis.

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Fig. 2-B Illustration demonstrating elevation of the extensor carpi radialis longus (ECRL) and the distal fibers of the brachioradialis. The anterior aspect of the capsule is isolated from the brachialis and is identified with an arthrotomy with an arthrotomy at the anterior aspect of the radiohumeral joint.

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Fig. 2-C Photograph of the special retractor (in two sizes) that facilitates exposure and protection of the anterior structures.

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Fig. 2-D Illustration demonstrating how the lateral half of the anterior aspect of the capsule is excised as widely as possible and the remaining medical half is incised (dotted line).

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Fig. 2-E Illustration demonstrating how the posterior aspect of the capsule is identified and excised, as necessary, by elevation of the triceps from the lateral osseous column. The posterior aspect of the ulnohumeral joint is exposed, and the capsule is incised. ECRL = extensor carpi radialis longus.

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Fig. 3-A Photographs of a reversible flexion-extension splint, which is used to improve flexion of less than 100 degrees (Fig. 3-A) as well as to improve extension (Fig. 3-B).

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Fig. 3-B Photographs of a reversible flexion-extension splint, which is used to improve flexion of less than 100 degrees (Fig. 3-A) as well as to improve extension (Fig. 3-B).

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Fig. 3-C Photograph of a hyperflexion splint with a shoulder harness and an adjustable Velcro strap. This splint is used if flexion is greater than 100 degrees.

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Fig. 4 Illustration of the overall gain in extension and flexion as well as the gain according to the etiology.

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Fig. 5 Illustration comparing the preoperative and postoperative flexion arcs according to the severity of the initial contracture.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Forty elbows (thirty-eight patients) were treated operatively, principally because of extrinsic stiffness, by the senior of us (B. F. M.), from January 1, 1989, through December 31, 1994, with a specific technique that has not been described previously. One patient (two elbows) was lost to follow-up. Thus, thirty-eight elbows (thirty-seven patients) were included in the present study. The mean age of the thirty male and seven female patients was forty-one years (range, five to sixty-eight years) (Table I). Twenty-one right elbows and seventeen left elbows were affected. One patient (Case 31) had bilateral involvement as the result of a burn injury. Twenty-one elbows were on the dominant side, and seventeen were on the nondominant side.

Twenty elbows (53 percent) had had a previous injury. The previous injuries included fracture-dislocation of the elbow (eight), isolated dislocation of the elbow (four), intra-articular fracture of the distal end of the humerus (four), fracture of the olecranon (three), and fracture of the radial head (one). The cause of the stiffness of the remaining eighteen elbows was primary osteoarthrosis (seven), heterotopic ossification around the elbow following a coma (five), a burn (three), a congenital etiology (two), and excessive immobilization after a distal biceps repair (one). Twenty-five elbows, including seventeen (85 percent) of the twenty that had a history of trauma, had had a previous operative procedure. Twenty-six (70 percent) of the thirty-seven patients had had some form of treatment previously. Before the index procedure, five patients had used a dynamic splint; three had had a manipulation under anesthesia; five had had an arthroscopic release; nineteen had had an open release, with removal of the hardware in thirteen; six had had simple removal of the hardware; and three had had a resection of the radial head. Fifteen patients had had more than one intervention. The mean duration of the contracture before the index procedure was fifty months (range, three to 240 months). Three elbows (8 percent) had been stiff for six months or less, thirteen elbows (34 percent) had been stiff for more than six months to one year, and twenty-two elbows (58 percent) had been stiff for more than one year.

Clinical Findings

Thirty patients (thirty-one shoulders) had pain preoperatively, which was mild in twenty-two patients (twenty-three shoulders) and moderate in eight patients (eight shoulders). No patient had severe pain.

Preoperatively, extension averaged 52 degrees (range, 0 to 90 degrees); the point of maximum flexion, 101 degrees (range, 45 to 140 degrees); pronation, 64 degrees (range, 0 to 90 degrees), and supination, 64 degrees (range, -15 to 90 degrees). The mean preoperative total arc of rotation was 128 degrees (range, 0 to 180 degrees). All of the elbows were stable. Two patients noted episodes of locking of the elbow. Seven patients had irritation of the ulnar nerve, but none of them had evidence of ulnar neuropathy. The symptoms persisted in two of the seven patients after the operation.

The stiffness was graded as very severe, severe, moderate, or minimum, according to data related to the importance of the arc of flexion^15,41. Fifteen elbows were very severely stiff (a total arc of 30 degrees or less), eight were severely stiff (a total arc of 31 to 60 degrees), nine were moderately stiff (a total arc of 61 to 90 degrees), and six were minimally stiff (a total arc of more than 90 degrees). Thus, twenty-three elbows (61 percent) were very severely or severely stiff.

On the basis of the functional arc of motion described by one of us (B. F. M.) and colleagues⁴¹, the contractures were classified into four groups¹. Three elbows had a functional arc of motion (extension of 30 degrees or less and flexion of 130 degrees or more), five had a flexion contracture (extension of more than 30 degrees and flexion of 130 degrees or more), three had an extension contracture (extension of 30 degrees or less and flexion of 130 degrees or more), and twenty-seven (71 percent) had a combined contracture (extension of more than 30 degrees and flexion of less than 130 degrees).

Radiographic Findings

Preoperative radiographs showed radiohumeral osteoarthrosis involving the radial head in eleven elbows and ulnohumeral osteoarthrosis involving the tip of the olecranon in twenty-three elbows and involving the coronoid process in one. Nine elbows also had loose bodies. Fourteen elbows had ectopic bone.

Evaluation of the Patients

The records and the preoperative and postoperative radiographs were available for all patients. The elbows were evaluated before the open release and at the time of the latest follow-up with the Mayo elbow performance score⁴¹. With this system, pain is rated as none, mild, moderate, or severe, with a maximum score of 45 points. Range of motion is measured with a handheld goniometer, with pronation and supination measured with the elbow at 90 degrees, and the maximum score for flexion is 20 points. Instability is recorded as none, modest, or severe. Modest instability is defined as more than 5 degrees but less than 20 degrees of varus-valgus excursion. The maximum score for stability is 10 points. The patient's ability to perform five specific activities of daily living and personal care, including combing the hair, feeding oneself, hygiene, buttoning a shirt, and tying shoelaces, is also assessed with the Mayo elbow performance score. A maximum score of 5 points is given for each activity, with a total maximum score of 25 points. The overall performance index was calculated by adding all of the scores together. A score of 90 points or more indicated an excellent result; a score of 75 to 89 points, a good result; a score of 60 to 74 points, a fair result; and a score of less than 60 points, a poor result. An excellent or good result was considered satisfactory.

All thirty-eight elbows were available for evaluation at a mean of forty-three months (range, twenty-four to seventy-four months) postoperatively. Information was obtained by means of a questionnaire and an interview regarding the patient's satisfaction with the result of the procedure, the activity level, the range of motion, and the status with regard to pain. Twenty patients were examined by one of us (P. M.), ten were examined by another orthopaedic surgeon, and seven were evaluated on the basis of tracings of the upper limb with the elbow in flexion and extension as well as on the basis of a questionnaire.

Statistical Analysis

The Wilcoxon rank-sum test was used to compare the preoperative and latest values for flexion and extension, pronation and supination, and the Mayo elbow performance score. A significant difference was defined as an observation that had less than a 5 percent probability of occurring by chance. We tested for a significant association between the result of the procedure and each preoperative criterion with use of the Fisher exact test, the Kruskal-Wallis test, or the Kendall tau correlation coefficient. The latter nonparametic measure of correlation is applied to the ranked data that may vary in one direction (increased motion) or the other (decreased motion). The various preoperative categories were the age and gender of the patient, the duration of the contracture, a traumatic or nontraumatic origin of the stiffness, flexion, extension, the severity of the stiffness, the Mayo elbow performance score, and radiographic evidence of intra-articular arthrosis. An association was sought between each of these variables and the latest outcome as represented by the postoperative level of pain, flexion, extension, arc of flexion-extension, Mayo elbow performance score, overall result, and satisfaction of the patient.

Operative Technique

General anesthesia was used for thirty-four of the thirty-seven patients. The column procedure consists of arthrotomy, release of the capsule, and excision of osteophytes through a limited lateral approach in order to release the anterior aspect of the capsule safely as well as to release the posterior aspect of the capsule if needed. The exposure is also adequate to remove osteophytes from the coronoid process or the olecranon if necessary (Fig. 1).

The patient is placed supine with a sandbag under the ipsilateral extremity and the arm draped free and brought across the chest. The proximal one-half of a Kocher incision, which extends six centimeters proximal to and three centimeters distal to the epicondyle, is used if there is no previous incision and if there are no symptoms related to the ulnar nerve. If there are symptoms related to the ulnar nerve, a midline posterior incision is made so that the nerve can be explored. If there is gross evidence of impingement before or after the capsular release, the nerve is decompressed as necessary.

In order to release the anterior aspect of the capsule with minimum disruption of normal tissue, the fleshy origin of the extensor carpi radialis longus and the distal fibers of the brachioradialis are identified (Fig. 2-A). Release of the origin of the extensor carpi radialis longus and the distal fibers of the brachioradialis from the humerus provides direct access to the superolateral aspect of the capsule (Fig. 2-B). The capsule is entered anteriorly at the radiohumeral joint to allow assessment of the thickness of the capsule. The brachialis is swept from the anterior aspect of the capsule with a periosteal elevator. A modified knee retractor with a blade-shaft angle of 130 degrees (Fig. 2-C) protects the brachialis, the radial nerve, and the brachial artery. The anterior aspect of the capsule is grasped, and the lateral half is excised to at least the level of the coronoid. The most medial aspect of the capsule, which can sometimes be difficult to visualize but can be palpated, is incised to complete the release (Fig. 2-D). The elbow is extended, and any remnant adhesion is gently lysed. At this time, if there is full extension or if extension is within 10 degrees of normal and there are no radiographically evident spurs on the olecranon, no additional release is needed. The capsule is left open, and the wound is closed.

If flexion is limited or if extension is not complete, it is probably the result of extensive scarring and adhesions involving the posterior aspect of the capsule. If this is the case, the triceps is elevated from the posterior aspect of the humerus, the posterior aspect of the capsule is released, and the olecranon fossa is cleaned of soft tissue (Fig. 2-E). The tip of the olecranon is excised if there are osteophytes. The amount of flexion and extension of the elbow is assessed. If there is at least 130 degrees of flexion, nothing more needs to be done posteriorly. If flexion is limited, the coronoid is inspected and any osteophytes are removed.

If there is evidence of irritation of the ulnar nerve, which is defined as a subjective alteration in sensation without objective sensory or motor changes or atrophy, a posterior incision is used to allow assessment of the lateral and medial aspects of the elbow through the same skin incision. The ulnar nerve is inspected, and occasionally it is translocated but more often it is simply decompressed in situ.

Postoperative Management

If the neurological examination in the recovery room reveals normal findings, a catheter is inserted percutaneously for a brachial plexus block, which is maintained with a continuous pump²⁰. The arm is elevated as much as possible, and continuous passive motion is begun on the day of the operation. The machine is adjusted to provide as much motion as pain or the machine itself allows. The block is discontinued two days postoperatively, and continuous passive motion is discontinued three days postoperatively.

Physical therapy is not used but a detailed program of therapy with adjustable splints³⁹, which depends on the motion before and after the procedure, is prescribed. The splints include a hyperextension or hyperflexion brace, or both (Figs. 3-A, 3-B, and 3-C).

During the first three weeks postoperatively, the patient sleeps with the splint adjusted to maximum flexion or extension, whichever is needed more, but not to an extent that prevents the patient from sleeping for at least six hours because of discomfort. When the patient gets up in the morning, he or she moves the elbow actively in a tub of hot water for fifteen minutes and then applies the other splint to hold the elbow at the opposite extreme of motion during the day. Between eight o'clock in the morning and noon, noon and six o'clock in the evening, and six o'clock in the evening and midnight, the splint is removed for one hour and the patient is encouraged to move the elbow through a full range of active motion frequently. At bedtime, ice is applied for ten to fifteen minutes if the elbow is sore from activity or heat is applied for ten to fifteen minutes if the elbow is stiff. The primary goal is to gain motion while avoiding pain, swelling, and inflammation. Therefore, the patient is instructed to use an anti-inflammatory medication regularly. Usually buffered aspirin is sufficient, but if there is ectopic bone seventy-five milligrams of indomethacin a day is prescribed instead. The postoperative program is explained in detail to the patient.

The splint therapy is altered depending on progress, but it is normally continued for about three months, during which time the patient is seen every two to four weeks if possible. If this is not feasible, which it often is not in our practice, the patient is asked to make tracings of the upper limb with the elbow in maximum flexion and maximum extension every month for three months and to submit these for review. The angles formed are measured with a goniometer to document the progress. After four weeks, an arc of about 80 degrees of motion is obtained and the amount of time that each splint is worn is gradually decreased. Nighttime use of the splints is continued for as long as six months if there is a tendency for the flexion contracture to recur when the splint is not being used. The patient is advised that it may take a year to establish maximum correction.

Results

Introduction | Materials and Methods | Results | Discussion | References

A modified Kocher skin incision was used in nineteen elbows; a posterior incision, in sixteen; and the previous skin incision, in three. An anterior capsular release, elevation of the triceps from the humerus, and a posterior capsular release was performed in all thirty-eight elbows. The tip of the olecranon was resected in twenty-three elbows, and the tip of the coronoid process was resected in thirteen. Ectopic bone was excised from eleven of the fourteen elbows in which it was present. A subcutaneous anterior translocation of the ulnar nerve was performed in nine elbows. The ulnar collateral ligament was repaired in three elbows in which the ligament had torn during the flexion maneuver. The brachialis tendon was released in one elbow.

The mean Mayo elbow performance score was 81 points (range, 29 to 100 points) at the latest follow-up evaluation compared with 62 points (range, 30 to 92 points) preoperatively (p < 0.0001). The result was excellent for sixteen elbows, good for fifteen, fair for one, and poor for six. Thus, thirty-one elbows (82 percent) had a satisfactory result and seven (18 percent) had an unsatisfactory result. Subjectively, seventeen patients said that they felt much better, thirteen felt better, five felt the same, and two felt worse postoperatively than they had preoperatively.

Pain

Preoperatively, eight (21 percent) of the thirty-eight elbows were moderately painful. At the latest follow-up evaluation, thirty-three elbows (87 percent) were not painful or were only mildly painful, four were moderately painful, and only one was severely painful and limited activities.

Stability

All of the elbows were stable both preoperatively and at the latest follow-up evaluation.

Arc of Motion

Flexion and Extension

Before the procedure, the mean arc of flexion was from 52 degrees of extension (range, 0 to 90 degrees) to 101 degrees of flexion (range, 45 to 140 degrees), with a mean total arc of 49 degrees (range, 0 to 115 degrees) (Fig. 4). At the least follow-up examination, the mean arc of flexion was from 27 degrees of extension (range, 0 to 80 degrees) to 121 degrees of flexion (range, 40 to 145 degrees), with a mean total arc of 94 degrees (range, 0 to 145 degrees). The mean gain in extension was 25 degrees (range, -20 to 60 degrees) (p < 0.0001), and the mean gain in flexion was 20 degrees (range, -50 to 70 degrees) (p = 0.0001). The overall mean gain in motion was 45 degrees (range, -40 to 120 degrees) (p < 0.0001). At the latest follow-up examination, thirty-four elbows (89 percent) had an improved range of motion, one (3 percent) had no change, and four (11 percent) had a decreased range of motion. The best results were obtained when the release had been performed for a contracture due to heterotopic ossification following a coma or for one due to a burn. The least predictable results were obtained when the release had been done because of congenital stiffness or in a patient who was less than twenty-one years old.

The greatest improvement in motion was found for the elbows that had been very severely stiff or severely stiff; these elbows gained an average of 53 degrees (range, -20 to 120 degrees) and 47 degrees (range, -40 to 90 degrees), respectively. The elbows that had been moderately or minimally stiff gained less motion; the average gains were 32 degrees (range, -25 to 55 degrees) and 31 degrees (range, 10 to 52 degrees), respectively (Fig. 5). Twenty (87 percent) of the twenty-three elbows that had been severely or very severely stiff had an improved arc of motion. A combined contracture persisted in severely elbows; an extension contracture, in nine; and a flexion contracture, in four. A functional arc of motion of 100 degrees or more was restored to ten (43 percent) of the twenty-three elbows that had been severely or very severely stiff preoperatively. Eight of the nine elbows that had been moderately stiff preoperatively had an improved arc of motion. Five of these nine elbows had a functional arc of flexion at the latest follow-up examination, but two still had a flexion contracture, one still had an extension contracture, and one still had a combined contracture. All of the elbows that had been minimally stiff preoperatively had an improved arc of flexion, and all had a functional arc of flexion.

The results were also influenced by the initial position of the flexion arc compared with the normal range. The greatest improvement in the arc of flexion-extension was obtained for the elbows that had had a combined contracture (mean, 54 degrees); these elbows had a mean of 29 degrees of improvement in extension and 25 degrees of improvement in flexion. Patients who had had stiffness in flexion or in extension sometimes had a gain in one type of motion associated with a slight loss in the other. A gain in extension was obtained more regularly and was greater (a mean of 24 degrees) than the gain in flexion (a mean of 7 degrees). The results for the elbows that had had only an extension contracture were inconsistent overall: one elbow had a gain in flexion and two had a loss of motion. The elbows that had had a flexion contracture regained a substantial amount of extension but sometimes had a small loss of flexion.

Thirty-two (84 percent) of the thirty-eight elbows had a functional arc of flexion-extension (30 to 130 degrees) at the end of the procedure, but only eighteen (47 percent) had a functional arc (or greater) at the time of the latest follow-up. Of the twenty elbows that did not have a functional arc, nine had a loss of extension, four had a loss of flexion, and seven had a combined loss. A mean of 28 percent of the motion that had been gained at the time of the operation was lost by the time of the latest follow-up. Loss of motion between the end of the procedure and the time of follow-up was particularly noted in the elbows that had had a combined contracture.

Pronation and Supination

Preoperatively, the elbows had a mean of 64 degrees of pronation (range, 0 to 90 degrees) and 64 degrees of supination (range, -15 to 90 degrees), with a mean arc of rotation of 128 degrees (range, 0 to 180 degrees). At the latest follow-up evaluation, they had a mean of 71 degrees of pronation (range, 0 to 90 degrees), and 67 degrees of supination (range, 0 to 90 degrees), with a mean arc of rotation of 138 degrees (range, 0 to 180 degrees). The mean gain in pronation was 7 degrees (range, -20 to 60 degrees) (p = 0.020), and the mean gain in supination was 3 degrees (range, -20 to 40 degrees). The mean overall gain in rotation was 10 degrees (range, -40 to 100 degrees) (p = 0.033). Nine elbows (24 percent) had an improved arc of motion, twenty-five (66 percent) had no change, and four (11 percent) had a decreased arc of motion.

Function

Preoperatively, the patients were able to perform a mean of 2.3 of the five daily activities assessed with the Mayo elbow performance score. Postoperatively, function returned to almost normal, with the patients able to perform a mean of 4.2 activities (p < 0.0001). Twenty-six (68 percent) of the thirty-eight elbows allowed the patient to perform all five daily activities normally; four (11 percent), four activities; two (5 percent), three activities; and six, two activities or fewer.

Complications

Four elbows (11 percent) had a complication. A hematoma developed in two elbows in the early postoperative period and had an adverse effect on the latest outcome for one of them. Two elbows had transient paresthesias of the ulnar nerve, which resolved spontaneously.

Ten elbows (26 percent) had a delayed loss of motion after a period of improvement postoperatively. However, six of these elbows still had improved motion at the latest follow-up examination compared with preoperatively. Four elbows had a decrease in motion (mean, 24 degrees) compared with preoperatively. Three of these elbows were manipulated with the patient under anesthesia; one elbow had an improved result, which remained stable over time, but the other two had a poor result with recurrence of the contracture.

Influence of Preoperative Factors on the Results

Each preoperative characteristic was tested with regard to its effect on the outcome at the latest follow-up examination in order to determine prognostic factors. The age of the patient, the severity of the stiffness, and the presence of intra-articular arthrosis were associated with the outcome as represented by the range of motion, the latest Mayo elbow performance score, the over-all result, the patient's satisfaction, or a combination of these measures (Table II).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Posttraumatic contracture of the elbow, the most common cause of stiffness of the elbow^1,15,36, usually affects young active patients who are around forty years old. Fracture of the distal aspect of the humerus, especially with intra-articular involvement, is the most common cause of intrinsic stiffness. The residua of dislocation, particularly fracture-dislocation, of the elbow are also major causes of stiffness. Fracture of the radial head and fracture of the olecranon are causes as well. Neurological osteopathy after head injury is the most common cause of nontraumatic stiffness. Usually, this stiffness is extrinsic, involving ossification of the periarticular soft tissues with conservation of the integrity of the joint. Other causes are burns and congenital factors. Osteoarthrosis may also result in considerable stiffness of the elbow. Usually the articular surface of the joint is intact but osteophytes at the tip of the olecranon fossa and the tip of the coronoid process limit motion, with pain at the extremes of motion due to impingement. In contrast, inflammatory arthritis often involves the joint, with diffuse narrowing of the joint space, and is not amenable to the procedure described in the present report.

The type and severity of the stiffness must be evaluated carefully before the operation. Extrinsic contracture may respond to release of the capsule and soft-tissue structures as well as resection of osteophytes, whereas intrinsic contracture with severe alteration of the surface of the joint may necessitate a distraction arthroplasty³⁸ or a total joint replacement in an older patient^16,43. Recent reports regarding the results of operative release have revealed gains in the flexion-extension arc of 30 to 60 degrees^{1,15,26,32,36-38,54}. A functional arc of motion from 30 to 130 degrees was obtained after about 50 percent of 516 procedures reported in the literature^{1,15,26,32,36-38,54}. Recent studies have demonstrated improvement resulting in a satisfactory outcome in 102 of 119 elbows^{26,32,38,51,54}. Most authors have reported an 80 percent⁵⁴ to 90 percent³⁸ rate of satisfactory results, with improvements ranging from 70 degrees⁵⁸ to 115 degrees²⁶. A satisfactory result has been defined as improved motion. Urbaniak et al. reported good results following anterior exposure to treat extrinsic stiffness, but the results were not as god for patients who had intrinsic stiffness and such patients were not considered ideal candidates for this procedure⁵⁴. Gates et al. pointed out the value of continuous passive motion after this procedure in order to increase or maintain the improvement gained at the time of the operation¹⁹.

A combined lateral and medial approach has been used in Europe for many years. A mean improvement of 51 degrees has been reported after 397 procedures^1,15,36. Husband and Hastings reported the results of a lateral approach in seven patients who had primarily extrinsic contracture²⁶. Extension improved from a mean of 45 degrees to a mean of 12 degrees, and flexion improved from a mean of 116 degrees to a mean of 129 degrees. The rate of complications was low (one patient). Weizenbluth et al., in a report from Scandinavia, reported that eleven of thirteen elbows had acceptable motion after five years⁵⁷. Kessler observed improvement in thirteen of fourteen elbows that had been treated with a lateral approach³². Schindler et al. reported a mean improvement of 35 degrees of flexion in thirty patients who had been managed with a lateral approach; 30 percent had a normal range of motion⁴⁷.

The result was satisfactory for thirty-one (82 percent) of the thirty-eight elbows in the present report, indicating that our procedure is a valuable limited operative technique. Thirty-four elbows (87 percent) had an increased range of motion, and the mean gain in the arc of flexion-extension was 45 degrees. The technique was more effective for elbows that had been severely or very severely stiff (a total arc of 60 degrees or less). Greater improvement in the arc of motion is expected for elbows with a combined flexion and extension contracture, and such elbows gain both flexion and extension.

The treatment of congenital stiffness is difficult. In the present report, one patient who had such stiffness was managed at the age of five years because of severely impaired function. The stiffness recurred after a postoperative period of improvement. The indications for the procedure and the potential for an unsatisfactory result in children must be fully discussed because of the high proportion of recurrence in this age-group¹³. In our series, the result was unsatisfactory for two of the three patients who were less than eighteen years old at the time of the operation.

In conclusion, release of the anterior aspect of the capsule through this limited lateral approach is safe and reliable. However, the etiology must be carefully considered and discussed before the operation is chosen. Stability is not lost with this technique, and the early return of function is related to the minimum operative trauma associated with this limited approach. The procedure provided a mean increase of 45 degrees in the arc of flexion, and thirty-four (80 percent) of the thirty-eight elbows had better motion at the time of follow-up. The rate of complications in the present study was low (11 percent). A hematoma adversely affected the result for one elbow. This finding emphasizes the need for careful hemostasis before closure of the wound. We do not typically drain these wounds, but drainage might be considered if ectopic bone is excised or if the dissection is more difficult or extensive than usual. This limited approach is very attractive for the treatment of stiffness of the elbow that is due to an extrinsic etiology. We recommend this procedure until the safety and efficacy of arthroscopic release of the elbow capsule is determined.

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Topics

contracture ; elbow region ; pain

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PIERRE MANSAT, B. F. MORREY; The Column Procedure: A Limited Lateral Approach for Extrinsic Contracture of the Elbow*. The Journal of Bone & Joint Surgery. 1998 Nov;80(11):1603-15.

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