This study is a retrospective review of 37 pediatric patients who underwent an open elbow contracture release with a mean follow-up of 15 months (range, 6-44 months). The mean age at the time of surgery was 16 years (range, 10-20 years). The etiologies included post-traumatic in 28 patients in addition to arthrogyposis, brachial plexopathy, osteochondritis dissecans, and spondyloepiphyseal dysplasia. Surgery was performed at an average of 18 months (range, 6-108 months) following the onset of symptoms. A standard open procedure was performed through varied incisions but included an anterior capsulectomy in all patients and a posterior capsulotomy and ostectomy when indicated. Six patients were treated with an external fixator and three of those patients also had a fascial interpositional arthroplasty. The pre-operative arc of motion was 66 degrees and improved to a mean of 94 degrees post-operatively. Only 76 percent had an improvement greater than 10 degrees and only 46 percent achieved the “functional” arc of motion of 100 degrees (from 30-130 degrees). Two patients lost 10 and 30 degrees of elbow motion, respectively. Final follow-up motion was significantly less than intra-operative motion. Factors that correlated with ultimate poor outcome included intra-articular fractures or fracture dislocations, previous surgery, and younger age. Excision of the radial head was associated with poor post-operative forearm rotation. Elbow contractures resulting from simple elbow dislocations, extra-articular fractures, or those with identified loose bodies at the time of surgical intervention resulted in greatest improvement after surgery. Three complications were identified in two patients that included a deep infection, transient radial nerve palsy and a hematoma. These two patients had an arc of motion of 15 degrees and 20 degrees respectively and were both managed with interpositional arthroplasty and external fixation.
The results of surgical elbow release in this series of pediatric patients were overall less favorable and less predictable than those previously reported both in the pediatric literature as well as in the adult population. Previous series of pediatric elbow contractures reported much improved results, but these were generally performed in elbows less than 1 year prior to onset of symptoms. This study also included a mixed bag of diagnoses, conditions and surgical procedures. It does, however, highlight the difficulty of performing elbow release surgery in younger individuals. The reasons for this are not entirely clear. Compliance in therapy may be important, although there may be biologic and healing factors involved as well. The best results were found when loose bodies were removed at the time of contracture release or when the stiffness resulted from a simple elbow dislocation or extra-articular fracture. Contractures secondary to an intra-articular fracture or in patients with previous surgery did more poorly.
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Journal of Bone and Joint Surgery