Stiff elbow release at Cambridge Hospital

What conditions does it treat?

Elbow release may be considered for stiffness caused by:

• a stiff elbow after a broken bone, dislocation or other injury
• a stiff elbow following previous elbow surgery
• osteoarthritis (wear-and-tear arthritis) in the elbow
• heterotopic ossification, where extra bone grows in the soft tissue around the joint
• burns around the elbow
• an elbow kept still in a cast or splint for several weeks, which on its own can lead to long-term stiffness
• pressure on the ulnar nerve, which runs past the inner elbow, adding to stiffness and sometimes causing tingling or numbness
• some conditions present from birth, or nerve conditions such as cerebral palsy.

What are the benefits of having an elbow release?

Regaining even a modest amount of elbow movement can make a real difference. Most everyday tasks, such as washing, dressing or eating, need around 100 degrees of combined bending and straightening, so restoring movement towards that range can restore a good deal of independence.

Are there different types of surgical approaches?

There are two broad ways to perform this operation: open surgery, through a cut at the side, front or back of the elbow, or arthroscopic (keyhole) surgery, using a camera and instruments through small incisions. Keyhole surgery can work well for some patients, but it isn't suitable for everyone, particularly where there's dense scarring after a significant injury.

Which approach your surgeon uses depends on exactly what's restricting your movement. If you've mainly lost the ability to straighten your arm, a technique working from the outer side of the elbow, sometimes called the column procedure, removes thickened front joint lining, bone spurs and any loose fragments, and improves the arc of movement by around 30 degrees on average. If you've mainly lost the ability to bend your arm, your surgeon may need to work from the inner side instead, releasing tightened ligament and clearing any structures blocking the front of the joint. Some people need both approaches.

If pressure on the ulnar nerve is part of the problem, your surgeon may also free this nerve during the same operation, and sometimes moves it to a new position so it isn't caught up in scar tissue.

What happens before the operation?

Before considering surgery, your team will usually want to see that other options have been tried first, and will run some tests to plan your operation precisely.

• Most people are asked to try physiotherapy and stretching exercises first, often for six months or more, since this alone can successfully ease many contractures
• You may be asked about any previous elbow injuries or operations, since old scars and previous incisions affect where new cuts can be made
• X-rays are usually taken from a few different angles to look at the joint
• A CT scan may be used to pinpoint any loose bone fragments, healed-but-misaligned fractures, or areas where bone has grown somewhere it shouldn't
• Your team will check the nerves in your arm, particularly the ulnar nerve, since compression here can add to stiffness and needs treating at the same time
• Tell your surgeon about any medications you take and whether you smoke, since smoking can slow healing.

What happens during the procedure?

The exact steps depend on which approach you need, but a typical open elbow release follows this pattern:

1. You're given a general anaesthetic, so you're asleep throughout, and a tight cuff (tourniquet) is placed on your upper arm to limit bleeding and improve the view
2. Your surgeon makes a cut over the side, front or back of your elbow, depending on what's causing your stiffness
3. Working carefully between muscles rather than cutting through them, your surgeon reaches the elbow joint, protecting the nerves along the way
4. Bone spurs, areas of extra bone growth, scar tissue and thickened joint lining that are blocking movement are removed, along with any loose fragments
5. If needed, the ulnar nerve is freed and sometimes repositioned to keep it safe from scar tissue
6. Your surgeon gently bends and straightens your elbow to check the improvement in movement, then closes the muscle layers and skin.

What does recovery look like?

After open elbow release, you'll usually stay in hospital for around 48 hours. During this time, a continuous passive motion machine gently moves your arm through its range for you, and a small tube, a nerve block catheter, delivers ongoing local anaesthetic to keep you comfortable. You'll also have a bulky, padded bandage, and your team may show you how to elevate your arm on a pillow and use ice packs to help with swelling.

Once home, doing your prescribed stretching and movement exercises regularly is one of the most important parts of your recovery, since motion gained during surgery can be lost again without consistent, active exercise. You may be fitted with a splint to wear between exercise sessions, and physiotherapy typically continues for some weeks. Keep your wound clean and dry, and you can usually shower once your dressings are removed, unless your surgeon tells you otherwise.

On average, people keep around two-thirds of the movement gained during the operation once healing is complete. Even when a surgeon achieves a full range of motion on the operating table, some residual stiffness is common, so realistic expectations and continued exercise both matter.

What are the risks and complications?

As with any elbow surgery, there are some risks to be aware of, including:

• infection
• damage to the ulnar nerve, causing numbness, tingling or weakness, which is usually temporary but can occasionally be longer-lasting
• extra bone regrowing in the soft tissue around the joint, which your team may try to prevent with medication or a low dose of radiotherapy
• stiffness returning over time, even after a successful operation
• a small risk of fracture during the operation, since removing bone or old metalwork can weaken the area temporarily
• swelling and bruising around the elbow, which usually settles with rest, ice and elevation.