Session II - Upper Extremity

*Functional Outcome of Elbow Contracture Release

David Ring, MD; Alaina Kipps, BA; Jesse B Jupiter, MD (a-AO International); Massachusetts General Hospital; Boston, MA

Purpose: The ability of elbow contracture release to restore functional mobility is well documented, but the effect of this procedure on health status is less well studied. In particular, one would like to know if health status correlates directly with restoration of motion or if associated factors such as deformity, nonunion, instability, articular surface injury, and secondary gain are also important.

Methods: The health status of 69 patients with post-traumatic contracture of the elbow treated by a single surgeon with operative release was evaluated using four outcome instruments: 1) The Elbow Evaluation Form of the American Shoulder and Elbow Surgeons (ASES); 2) The Enforced Social Dependency Scale (ESDS); 3) The SF-36; and 4) The Disabilities of the Arm, Shoulder, and Hand Instrument (DASH). There were 35 women and 34 men women with an average age of 42 years (range 15 to 79). The original injury was a fracture of the distal humerus in 32 patients, a dislocation of the elbow with a fracture of the radial head, the coronoid process, or both in 16; a posterior Monteggia fracture in 9; an isolated radial head fracture in 5; a simple posterior dislocation of the elbow in 3; a fracture of the humeral diaphysis in 2; and a proximal both bone forearm fracture and a chronic anterior Monteggia lesion each in a single patient. Nineteen patients had an ununited fracture; 12 had ulnohumeral instability; 20 had heterotopic bone blocking motion (including 6 with complete ankylosis and 4 with proximal radioulnar synostosis; 24 patients had an ulnar neuropathy and one a radial neuropathy; and 3 patients had severe damage to the articular surface requiring fascial arthroplasty. Pre-operative elbow range of motion averaged 94 degrees of flexion (range 40 to 140 degrees), -53 degrees of extension (range -90 to -10), 51 degrees of pronation (range 0 to 90 degrees) and 43 degrees of supination (range 0 to 90 degrees).

Results: Patients were evaluated at an average of 54 months after elbow contracture release (range 12 to 130 months). Repeat contracture release was necessary in 11 patients, and 9 patients had subsequent procedures to address ulnar neuropathy. Motion at final follow-up averaged 126 degrees of flexion, -22 of extension; 70 of pronation and 70 of supination. Significant and marked improvements in health status were measured with all four instruments (P < 0.01). Subjective results correlated with functional motion except among patients with advanced articular surface injury, ulnohumeral instability, persistent nerve problems, or secondary gain. In the absence of these factors, outcome measures for patients with successful releases approached population norms.

Conclusions/Significance: Patients undergoing elbow contracture release experience marked improvements in health status. The subjective results are worse than the objective results in the presence of advanced articular surface injury, instability, recalcitrant nerve problems, and secondary gain. This type of evidence-based outcome study may help demonstrate the efficacy and importance of elbow contracture release to third party payors.