Open Contracture Release Research Articles

Complex Fracture-Dislocations of the Elbow in the Pediatric Population.

Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries. This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications. A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of "excellent" (n=20, 76.9%) or "good" (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release. The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications. Therapeutic Level IV-case series.

Extension Contracture Post Total Knee Replacement: A Case Report

BACKGROUND: Stiffness is a common problem after knee arthroplasty and need for further procedure. Patients who experience this problem usually have poor outcome. Flexion contracture is the most reported case in most case reports; however, we reported a rare case of patient with extension contracture after total knee arthroplasty (TKA).
 CASE REPORT: A 62-year-old woman was presented with a 3-month history of right TKA. After 3 month she came to the hospital and complained that she could not flex the knee. Nevertheless, she could still walk. On the right knee, there was quadriceps hypotrophy. There was no active and passive range of motion (ROM), because it was fixed at 0°. We performed medial parapatellar approach for knee arthrotomy and we added lateral parapatellar arthrotomy to release the contracture. The fibrotic tissues were removed. The flexion and extension of the knee were evaluated and we managed to get 0–130° of flexion-extension ROM. In the ward, the patient was treated using continuous passive motion (CPM) for 1 week and the CPM was maintained within the range of 0–130°. Six months after surgery, the patient could walk normal with ROM range between 0 and 100°.
 CONCLUSION: Stiff knee is a common problem after TKA. Close observation and proper rehabilitation can prevent stiff knee. Close manipulation, manipulation under anesthesia, arthroscopy debridement, and open contracture release are the option of this problem.

The column procedure preserves elbow stability on biomechanical testing

PurposeThe effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers.MethodsWe assessed elbow joint laxity in 39 patients who underwent an open contracture release via the ‘column procedure’ described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints.ResultsMean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°–4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable.ConclusionsOur experiment confirmed that the ‘column procedure’ is a safe procedure which does not compromise the stability of the elbow joint.

Arthroscopic Elbow Contracture Release in the Pediatric Patient.

Elbow contracture is a sequelae of elbow trauma in pediatric patients. Arthroscopic contracture release has been shown to provide equivalent results to open contracture release with less associated morbidity and complications in the adult population. However, open contracture release is still commonly utilized in pediatric patients. The goal of this study is to determine the clinical results and safety profile of arthroscopic elbow contracture release in the pediatric population. A retrospective review of all patients 18 years of age and younger who underwent arthroscopic elbow contracture release was performed. Demographic statistics, indication for surgery, preoperative and postoperative flexion-extension and pronation-supination range of motion, and all complications were recorded and analyzed. Twenty-five patients were identified as having undergone 29 arthroscopic elbow contracture releases. The most common index injury was elbow contracture after radial head fracture. The flexion-extension arc of motion improved from 93.0±39.9 degrees to 128.0±19.2 degrees for a total improvement of 35.2 degrees (P=0.0002), whereas the pronation-supination arc of motion improved from 141.0±58.6 degrees to 153±49.3 degrees for a total improvement of 12.2 degrees (P=0.097). There were 7 total complications. Arthroscopic elbow contracture release allows for restoration of range of motion with an acceptable safety profile and can be considered as a less invasive alternative to open contracture release in the pediatric population. Level IV.

Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents.

Posttraumatic elbow contractures in children and adolescents are challenging to manage, and studies investigating surgical treatment are limited by the rarity of this condition. Small case series have shown variable gains in immediate and long-term elbow arc of motion after open surgical release. We reviewed our experience with open surgical release of posttraumatic elbow contracture in patients <21 years old at 2 institutions. A retrospective chart review identified patients who underwent posttraumatic open elbow contracture release by 2 surgeons at 2 institutions between 2006 and 2013. Nontraumatic contractures and arthroscopic releases were excluded. Twenty-six patients were included in this study. Mean age at the time of injury was 12 years (5 to 19 y) and at the time of surgery was 14 years (7 to 20 y). Capsulotomy, osteoplasty, removal of hardware, ulnar nerve release or transposition, and ligament reconstruction were performed through medial and lateral approaches as indicated by the pathology. Ten patients had ligament repair or stabilization, and 16 patients used a continuous passive motion (CPM) postoperatively. Outcomes included active range of motion and complications. Mean time from injury to surgical release was 29 months. Mean postoperative follow-up was 42 months. Elbow active flexion-extension and forearm rotation arcs both increased significantly by a mean of 49 and 70 degrees, respectively, at final follow-up. A mean 85% of intraoperative flexion-extension arc was maintained at final follow-up. Ligament repair or reconstruction and the use of a postoperative CPM did not significantly change these outcomes. Outcomes were not significantly different if our contracture release was performed within a year from injury. Patients who had surgery before our contracture release had decreased restoration of forearm rotation after release. Complications included 2 recurrent contractures (1 used a CPM and 1 did not), and 2 postoperative ulnar neuropathies (1 used a CPM and 1 did not). Open contracture release for posttraumatic elbow contracture in an adolescent population can significantly improve active range of motion. Level 3-therapeutic.

Open Elbow Contracture Release: Postoperative Management With and Without Continuous Passive Motion

Surgical contracture release can restore motion to stiff elbows. Some authors suggest that use of continuous passive motion (CPM) in postoperative management can increase ultimate mobility. This study tests the null hypothesis that there is no difference in the arc of flexion and extension between patients who used CPM and those who did not use CPM after open elbow contracture release. Sixteen patients who had an arc of flexion and extension of less than 80 degrees and used CPM after open contracture release were matched based on age, gender, diagnosis, preoperative arc of flexion and extension, and radiographic appearance (joint congruity, heterotopic bone, and arthritis) to 16 control patients who did not use CPM. Stiffness was of posttraumatic origin in 24 patients, related to primary osteoarthrosis in 4 patients, and related to heterotopic ossification after central nervous system injury or burns in 4 patients. The preoperative arc of flexion and extension averaged 38 degrees in the CPM cohort and 42 degrees in the no-CPM cohort. Subsequent surgeries included procedures to address residual stiffness in 1 patient in the CPM cohort and in 3 patients in the no-CPM cohort. At an average 6 months of follow-up, there was no difference in improvement in the arc of flexion and extension (58 degrees vs 61 degrees ) between the CPM and no-CPM cohorts. At the final evaluation, the improvement in arc of flexion and extension (59 degrees in both cohorts) and the final arc of flexion and extension (96 degrees vs 101 degrees ) were comparable between cohorts. These matched retrospective data do not demonstrate a benefit of CPM in the postoperative management of elbow contracture release.

Adolescent elbow injuries

Purpose of review The most common causes of adolescent elbow disorders are either secondary to overuse, most often associated with athletics, or trauma. In this review, we describe the most recent developments in treatment of several of these disorders. Recent findings Osteochondral allografting has been shown to be a reasonable alternative for patients with large, displaced osteochondritic lesions of the capitellum. Ulnar collateral ligament reconstruction, utilizing a docking technique, produces a high rate of return to overhead sport in male baseball players. Ulnar collateral ligatment repair should be considered in female athletes with ulnar collateral ligament insufficiency. Open contracture release and dynamic elbow external fixation with distraction have been shown to provide predictable outcomes in adolescent elbow contractures. Elbow injury prevention in youth baseball should be a high priority, as part of minimizing overuse and fatigue in youth pitchers. Summary Several recent studies have introduced innovations in the treatment of difficult adolescent elbow disorders, including large osteochondritic capitellar lesions and resistant elbow contractures. Recent data have also supported the continued use of ulnar collateral ligament reconstruction, medial epicondyle fixation and open contracture release in the adolescent patient.

Managing the Stiff Elbow: Operative, Nonoperative, and Postoperative Techniques

Elbow contracture may be caused by intrinsic or extrinsic limitations or a combination of both. Evaluation of the specific structures guides the development of an effective therapy treatment program. Intrinsic contractures are by definition due to joint/intra-articular incongruency, and therefore therapy and splinting cannot provide increase in joint motion. Nonoperative therapy treatment options include heat modalities, myofascial soft tissue mobilization, joint mobilization, muscle energy techniques, passive range of motion, active range of motion, extensive use of corrective splinting, and strengthening exercise. All operative candidates must participate in a preoperative therapy program of six to eight weeks to reduce extrinsic contractures as feasible and to assess patient compliance with an intensive postoperative therapy program. Corrective splinting may be needed for as long as six months to maintain gains made in surgery. The therapy following manipulation under anesthesia and open contracture release is similar. The therapist must know the details of the procedure. Operative treatment for the stiff elbow progresses in a sequential fashion to progressively release tissue structures limiting motion and reconstruct any structures as needed to provide joint stability. Postoperative therapy consists of continuous passive motion , corrective splinting, modalities, and specific exercise techniques to maintain passive gains achieved in surgery. The therapy is extensive and requires full participation from the patient to maximize motion and function. Complications of elbow contracture release include nerve palsy or nerve injury, seroma, joint instability, heterotopic ossification, and recurrence of elbow contracture.