[Arthrolysis of the elbow in posttraumatic contracture]

Intra- and periarticular fractures about the elbow joint are treated with open reduction and internal fixation. This allows early functional after-treatment. Nevertheless, the range of motion remains more or less unsatisfactory. In these cases open arthrolysis provides a considerable improvement in joint function. We therefore recommend this operation when the hardware is removed about 9 months after the accident. The reasons for post-traumatic contracture of the elbow could be intrinsic such as interposed fragments, intra-articular adhesions, incongruity of the articular surfaces--or extrinsic--like contractures of the capsule and ligaments, adhesions of different layers, ectopic bone formations. In most cases a combination of both can be found. Important conditions for successful arthrolysis are mostly intact joint surfaces, failure of all conservative efforts to improve the arc of motion, a motivated patient who understands clearly the risks and benefits that could reasonably be expected by the operative procedure and rehabilitation and, last but not least, a skilled, experienced surgeon. The choice of the approach depends on the main location of the post-traumatic changes and on previous incisions. Osteotomy of the radial epicondyle gives a much better view of the joint and should be performed whenever necessary. The exact course of the operation may not be standardized. The main point is to remove scarred adhesions and bony irregularities. An individually modified rehabilitation program is as important as the operative procedure itself to achieve the best results possible. In general, the exercises should not cause pain. In the first few days plaster casts in flexion and extension are used. Physiotherapy is supported by CPM machines as early as possible. Patients must be prepared with the help of drugs and the application of ice bags. Even after months improvement of motion can be obtained. In a retrospective follow-up study, 125 out of 168 patients with arthrolysis of the elbow joint were reviewed. Most patients sustained a fracture of the distal humerus. In 77%, the results were graded as very good, good or satisfactory, i.e., the average relative improvement amounted to at least 40% according to the criteria of W. Blauth. Patients with very severe (preoperative ROM 0-30 degrees) and severe (preoperative ROM 30-60 degrees) contractures profited more (relative improvement 60%) than the others (relative improvement 45%). Overall, the average arc of total motion increased 49 degrees; the relative improvement of motion increased by 58%.