The criteria for inclusion in the study were a posttraumatic elbow
contracture, skeletal maturity, and =40° of elbow flexion and
extension. The exclusion criteria included substantial heterotopic
ossification that was a major block to motion, a severe burn injury, a severe
head injury with residual spasticity or cognitive deficits limiting the
patient's ability to participate in postoperative rehabilitation, fracture
nonunion, incongruency or instability of the ulnohumeral joint, and severe
articular injury necessitating fascial arthroplasty. Retrospective review of
medical records and selective invitation to return for an examination and
radiographic evaluation were approved by a human research committee.
Over an eight-year period, two surgeons operated on forty-two consecutive
patients who met the inclusion and exclusion criteria. During the early part
of the study, twenty-three patients were treated with a hinged external
fixator that incorporated a worm gear for applying static progressive stretch
postoperatively. These patients were compared with nineteen patients treated
without hinged external fixation during the later part of the study. This was
a nonrandomized study. Hinged external fixation was used routinely for severe
contractures during the initial part of the study, it was gradually used less
often over the course of the study, and it was used infrequently toward the
end of the study.
Entire Group of Patients
There were twenty-eight men and fourteen women with an average age of
thirty-nine years (range, eighteen to seventy-one years). Twenty-two right
limbs, twenty of which were dominant, and twenty left limbs, one of which was
dominant, were involved. Five of the original injuries were the result of a
fall from a standing height; seventeen, a fall from a greater height; fifteen,
a motor-vehicle accident; four, a sports-related injury; and one, a gunshot
wound.
Fifteen patients had a fracture of the distal part of the humerus, and
twenty-seven had a fracture-dislocation of the elbow. In three patients, the
original injury was open. The injury was initially treated operatively in
thirty-four patients. Thirty-nine patients had had at least one prior surgical
procedure before being referred to us, and fifteen of them had had multiple
prior surgical procedures.
The interval between the initial injury and the elbow contracture release
averaged fifteen months (range, four to forty-four months). Thirteen patients
had signs of arthrosis that were rated as Type 1, according to the system of
Broberg and Morrey6,
on preoperative radiographs.
Prior to the index capsular excision, the arc of ulnohumeral motion
averaged 21° (range, 0° to 40°), with an average elbow flexion of
79° (range, 0° to 110°) and an average flexion contracture of
57° (range, 0° to 90°).
Patients Treated Without Hinged External Fixation
There were thirteen men and six women with an average age of forty-three
years (range, eighteen to seventy-one years) (see Appendix). Ten right limbs,
nine of which were dominant, and nine left limbs, one of which was dominant,
were involved. Four of the original injuries were the result of a fall from a
standing height; seven, a fall from a greater height; four, a motor-vehicle
accident; and four, a sports-related injury.
Nine patients had a fracture of the distal part of the humerus, and ten had
a fracture-dislocation of the elbow. Seventeen patients were treated
operatively for the initial injury. Eighteen patients had had at least one
prior surgical procedure before being referred to us, and eight of those
patients had had multiple prior surgical procedures. The interval between the
initial injury and the elbow contracture release averaged ten months (range,
four to twenty months). Six patients had signs of Type-1 arthrosis on
preoperative radiographs. Prior to the index capsular excision, the arc of
ulnohumeral motion averaged 24° (range, 0° to 40°), with an
average elbow flexion of 87° (range, 40° to 110°) and an average
flexion contracture of 62° (range, 30° to 90°).
Patients Treated with Hinged External Fixation
There were fifteen men and eight women with an average age of thirty-six
years (range, twenty-three to sixty-four years) (see Appendix). Twelve right
limbs, eleven of which were dominant, and eleven left limbs, none of which
were dominant, were affected. Two of the original injuries were the result of
a fall from a standing height; ten, a fall from a greater height; and eleven,
a motor-vehicle accident.
Six patients had a fracture of the distal part of the humerus, and
seventeen had a fracture-dislocation of the elbow. Seventeen patients were
treated operatively for the initial injury. Twenty-one patients had had at
least one prior surgical procedure before being referred to us, and seven of
them had had multiple prior surgical procedures. The interval between the
initial injury and the elbow contracture release averaged nineteen months
(range, five to forty-four months). Seven patients had signs of Type-1
arthrosis on preoperative radiographs. Prior to the index capsular excision,
the arc of ulnohumeral motion averaged 18° (range, 0° to 40°),
with an average elbow flexion of 71° (range, 40° to 110°) and an
average flexion contracture of 53° (range, 30° to 90°).
Operative Technique
The specific operative technique for the elbow contracture release was
dictated by the presence of prior incisions, ulnar neuropathy, and implants. A
lateral
approach7-9
was used in seven patients (all treated without a hinge); a medial approach,
in twenty (five treated without a hinge and fifteen treated with a
hinge)2,4;
and a combined medial and lateral approach, in fifteen (seven treated without
a hinge and eight treated with a
hinge)10. An
isolated lateral approach was not possible for the patients who were to be
treated with a hinge because the temporary central axis wire and the
posteromedial screw of the hinge place the ulnar nerve at risk. Subcutaneous
anterior transposition of the ulnar nerve was performed in all patients
treated with a medial or combined medial and lateral approach. The Compass
Universal Hinge was applied with use of standard
techniques4.
Postoperative Management
Patients with hinged external fixation began gentle passive mobilization of
the elbow, using a dial on the fixator that connects to a gear mechanism that
propels the fixator through a range of elbow motion, on the morning after the
surgery, and they incorporated active-assisted exercises and functional use of
the limb as soon as pain allowed (usually within one
week)4. Patients
without hinged external fixation began gravity-assisted active-assisted elbow
exercises on the morning after the surgery. Passive manipulation was not
allowed. The hinge was removed between four and eight weeks (average, six
weeks) after the surgery. Static progressive
splinting3 was used
for patients who demonstrated slow progress at the four to eight-week
postoperative visit. Resistive exercises were initiated approximately eight
weeks after the surgery.
Evaluation
The final evaluation was performed at an average of thirty-nine months
(range, thirteen to ninety-four months) after the contracture release and
prior to any repeat surgery for contracture release. The primary outcome
measure was the improvement in the ulnohumeral flexion arc, which was compared
between groups with use of a Student t test (SPSS, Chicago, Illinois), with a
p value of <0.05 considered to be significant.
The average final improvement in the ulnohumeral arc of motion after
the index procedure was 89° (range, 50° to 145°) in the group
treated with a hinge and 78° (range, 35° to 110°) in the group
treated without a hinge. This difference was not significant with the numbers
available (p = 0.175).
The final postoperative arc of ulnohumeral motion averaged 107° (range,
70° to 145°) in the group treated with a hinge and 103° (range,
60° to 140°) in the group treated without a hinge. The postoperative
flexion averaged 129° (range, 110° to 145°) in the group treated
with a hinge and 126° (range, 95° to 145°) in the group treated
without a hinge. The postoperative flexion contracture averaged 22°
(range, 0° to 40°) in the group treated with a hinge and 23°
(range, 0° to 60°) in the group treated without a hinge.
No patient had symptoms or signs of elbow instability. All patients had
grade-5 strength according to the Medical Research Council grading system. The
final radiographs showed signs of Type-1 arthrosis in twenty-three patients
and Type-2 arthrosis in three patients. Of the patients treated without a
hinge, eleven had Type-1 and one had Type-2 arthrosis. Of the patients treated
with a hinge, twelve had Type-1 and two had Type-2 arthrosis.
Complications and Subsequent Operations
Five patients had pin-track infection treated with local pin care and oral
antibiotics. One patient had pin-track osteomyelitis requiring
débridement and parenteral antibiotics. There were two broken 5.0-mm
Schanz screws, both of which were managed nonoperatively. (The broken end of
the pin was retained within the bone.) Two other patients had ulnar nerve
irritation from the posteromedial pin, which resolved after removal of the
hinge. One patient sustained a fracture through a pin site during passive
manipulation by a therapist; this was treated with plate-and-screw
fixation.
Two (9%) of the twenty-three patients treated with a hinge and five (26%)
of the nineteen patients treated without a hinge requested a second operation
for contracture release. (The motion prior to the secondary
surgery—i.e., the final motion after the index procedure—was used
for the analysis in the study.) Two patients had subsequent surgery to remove
hardware.
Severe capsular contractures of the elbow have an element of
associated muscle contracture. Exercises, including static progressive and
dynamic splinting, can address this component of the contracture, but both can
be challenging in the immediate postoperative period. Incorporation of a worm
gear for static progressive splinting into a hinged external fixator can
potentially apply more direct and effective force to the elbow earlier in the
postoperative period to help maintain the motion obtained in the operating
room after the capsular
release2,4.
In our nonrandomized, retrospective comparison, the final increase in
ulnohumeral motion was slightly (11°) greater in the group treated with a
hinge than in the group treated without a hinge. This difference was not
significant, but might become so in a larger study. On the other hand, a
difference of 11° is probably not clinically relevant as such a small
amount most likely would not make a major difference in elbow function.
Furthermore, the average final arc of ulnohumeral motion differed by only
4° between the groups, reflecting the slightly worse mean initial arc of
motion in the group treated with a hinge.
The disadvantages of ancillary hinged external fixation include added costs
for both the apparatus itself and hospital expenses (e.g., operating room time
and the surgeon's fee), added risks, the need for close monitoring of the
hinge, and pin-related problems (infection, fracture, and nerve irritation).
It is notable that a second surgery for contracture release was more common in
patients treated without a hinge (26% compared with 9% of those treated with a
hinge), but this finding is difficult to interpret given the complexity of the
decision to undertake additional surgery.
In our opinion, the routine use of hinged external fixation as ancillary
treatment for a severe posttraumatic elbow contracture is not merited. We
continue to use hinged external fixation for the treatment of unstable elbows
and elbows requiring fascial arthroplasty, many of which are associated with
an elbow contracture.
Tables presenting the clinical data for both patient groups are available
with the electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
In support of their research or preparation of this manuscript, one or more
of the authors received grants or outside funding from the AO Foundation. R.N.
Hotchkiss received payments or other benefits or a commitment or agreement to
provide such benefits from a commercial entity (Smith and Nephew Richards,
Memphis, Tennessee). No commercial entity paid or directed, or agreed to pay
or direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.