Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness

We retrospectively collected the data of patients with severe elbow stiffness at our institution between January 2018 and January 2019. We obtained institutional review board approval for this retrospective investigation, and informed consent was obtained from each patient. The inclusion criteria were (1) 18 to 60 years old; (2) severe elbow stiffness (extension-flexion arc ≤60°); and (3) treated by combined medial-lateral approach arthrolysis. The exclusion criteria were (1) concomitant burn or central nervous system injury; (2) elbows with rheumatoid arthritis or bone tumors; (3) follow-up time less than 2 years; or (4) incomplete clinical data.

A total of 128 patients underwent arthrolysis at our institution. After applying the inclusion and exclusion criteria, 49 patients were included in the study (Fig. 1), with a mean follow-up time of 28.4 ± 3.7 months (24–35 months). We measured the ROM of the elbow [11]. To objectively evaluate the elbow function, the Mayo Elbow Performance Score (MEPS) was used with regard to 4 aspects: pain (45 points), ROM (20 points), stability (10 points), and the ability to accomplish daily activities (25 points) [12]. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to subjectively evaluate elbow-related symptoms and disability [13]. The decision of whether using the hinged external fixation was made according to the preferences of the surgeons and the patients’ consent. The patients were then categorized into two groups: with hinged external fixation (group A) or without hinged external fixation (group B). All surgeries were performed by the same two surgeons, who were both well-trained and experienced in elbow arthrolysis. Group A consisted of 20 patients (16 males and 4 females), with an average age of 34.1 ± 10.8. Group B consisted of 29 patients (19 males and 10 females), with an average age of 37.6 ± 11.2 years. There were no significant differences in average age, sex, surgical side, body mass index (BMI) or incision type between the two groups (Table 1, P>0.05). The original types of injury of patients in the two groups are shown in Table 1.

Patients were placed in the standard supine position under general anesthesia or brachial plexus block. Sterile air tourniquets were applied.

A posterior midline incision or lateral and medial incisions were selected according to the previous surgical scar, location of heterotopic ossification (HO), and cause of stiffness. There was no significant difference in the choice of surgical incision between the two groups. (P>0.05, Table 1).

For the combined medial-lateral approach, the elbow was accessed medially first (Fig. 2). The ulnar nerve was exposed and protected. The triceps was reflected to the lateral side to exposed the medial and posterior aspect of the joint, and then the surgeons excised the HO on the posteromedial side of the joint, the posterior capsule and transverse and posterior bundle of the medial collateral ligament (MCL) while the anterior bundle was preserved. If there was still blockage posteriorly, the surgeons would perform olecranon fossa osteoplasty and olecranon tip excision in a consecutive manner.

On the lateral side, the lateral column procedure was done with partial extensor digitorum communis (EDC) split (Fig. 3) to expose the anterolateral part of the joint while preserving the lateral ulnar collateral ligament (LUCL). Surgeons then performed radial head fossa, coronoid fossa and coronoid process osteoplasty, and released the anterior capsule. If there was bony blockage on the posterolateral side, the surgeons would incise along the lateral margin of the triceps to expose the lateral ulnohumeral joint, excise the HO and release the posterolateral joint capsule.

The surgery was only considered complete when a satisfactory passive (moderate force) ROM was achieved under direct vision (0° - 130° of extension-flexion. Figure 4). Lateral stress test and lateral pivot shift test were performed to assess elbow stability [14]. Then, the ulnar nerve was transposed anteriorly to reduce post-operative ulnar nerve palsy. The fascia and subcutaneous tissue were closed layer by layer, and the incision was closed after the placement of drainage. Finally, a Stryker DJD II hinged external fixator was applied to the elbow based on the surgeon’s preference and patient’s consent.

All patients received analgesia pumps for 3 days after surgery to alleviate postoperative pain and help postoperative exercise. Closed negative pressure drainage was left in place until the 24-h drainage volume was less than 30 ml. The patients received oral indomethacin 25 mg/time, 3 times/day, for 6 weeks. On the second post-operative day, patients began to exercises by continuously flexing and extensing elbow and pronating and supinating the forearm with the assistance of the other arm. The external fixation was removed 6–8 weeks after surgery.

Patients were routinely followed up at 1, 3, 6 and 12 months postoperatively, and the last follow-up was performed for all patients 2 year after the operation. We measured the ROM of the elbow, MEPS, DASH, visual analogue scale (VAS) and documented the complications. Postoperative standard anteroposterior and lateral X-rays of the elbows were taken, and examined to find the signs of joint degeneration and the evidence of newly formed HO (Fig. 5).