Olecranon Osteotomy-Facilitated Elbow Release (OFER)

Overview

Introduction

Olecranon osteotomy-facilitated elbow release (OFER) provides excellent exposure of the joint with relatively minimal soft-tissue dissection and allows the surgeon to address all intrinsic and extrinsic causes of contracture in a safe and efficient manner with similar or better results compared with more traditional open or arthroscopic techniques.

Step 1: Incision and Dissection (Video 1)

Position the incision on the posterior aspect of the elbow.

Step 2: Ulnar Nerve Identification and Decompression (Video 2)

Locate, decompress, and mobilize the ulnar nerve.

Step 3: Olecranon Osteotomy (Video 3)

Perform a chevron or transverse osteotomy.

Step 4: Elevation of Olecranon (Video 4)

Unlike an osteotomy performed for acute fractures, the olecranon will be adherent because of intra-articular adhesions.

Step 5: Removing the Posterior Tether (Video 5)

Removing the soft-tissue posterior tether will facilitate flexion.

Step 6: Removing the Posterior Block (Video 6)

Removing the posterior soft tissue and osseous block will facilitate extension.

Step 7: Removing the Anterior Tether (Video 7)

Removing the anterior soft-tissue tether will facilitate extension.

Step 8: Removing the Anterior Block

Removing the anterior soft tissue and osseous block will facilitate flexion.

Step 9: Provisional Repair of Osteotomy Site (Video 8)

Provisional repair of the osteotomy site will allow for intraoperative assessment of the contracture release, and any adjustments can be performed as necessary.

Step 10: Assessment of Motion (Video 9)

If gravity alone does not achieve acceptable elbow extension and flexion, reassess the adequacy of your release.

Step 11: Definitive Repair of Osteotomy Site and Closure (Video 10)

Replace the pins with the definitive rigid implant, repair the MCL, and replace the retracted ulnar nerve.

Step 12: Postoperative Protocols (Video 11)

Using a perioperative regional block allows patients to participate in physical therapy immediately, which has psychological benefits.

Results

Thirty-five patients with an average age of 39.5 years (range, 18 to 63 years) underwent an OFER procedure¹.

Abstract

Background:

The olecranon osteotomy-facilitated elbow release (OFER) is a safe and effective method for releasing severe posttraumatic elbow contractures. The OFER procedure is easier, faster, and relatively less invasive, and appears to offer superior outcomes, compared with more traditional techniques.

Description:

An olecranon osteotomy provides a trapdoor through which the surgeon will have circumferential access to the joint and will be able to address all intrinsic and extrinsic causes of contracture. Access from the posterior to the anterior compartment is achieved by detaching the origin of the medial collateral ligament (MCL) and hinging the joint from medially to laterally, pivoting around the intact lateral collateral ligament. Once the olecranon and MCL are repaired, the elbow is stable enough for the patient to participate in intensive rehabilitation protocols.

Alternatives:

The first line of treatment for elbow contracture is physical therapy, focusing on range of motion and using modalities such as static-progressive and dynamic splinting protocols. In some select cases, there is also a role for manipulation under anesthesia. When nonoperative methods fail, elbow contractures may be treated surgically, using either open or arthroscopic techniques. Authors have described open release involving medial, lateral, and anterior approaches. The first outcome report of a posterior approach to treat elbow contractures has recently been published¹.

Rationale:

An open approach usually utilizes 1 or possibly 2 large incisions and involves invasive dissection through muscle and nerve mobilization. This may result in a postoperative hematoma and usually substantial pain, posing a challenge for rehabilitation. Arthroscopic techniques are less invasive, with potentially fewer complications, but are far more technically challenging. Also, most extrinsic and some intrinsic causes cannot be adequately addressed through the arthroscope. The outcomes of OFER have been found to be superior to those reported after either arthroscopic or more conventional open procedures. In addition, we believe that the OFER procedure is substantially faster and technically easier than either other open or arthroscopic releases, although we are not aware of any studies addressing this topic.

Introductory Statement

Olecranon osteotomy-facilitated elbow release (OFER) provides excellent exposure of the joint with relatively minimal soft-tissue dissection and allows the surgeon to address all intrinsic and extrinsic causes of contracture in a safe and efficient manner with similar or better results compared with more traditional open or arthroscopic techniques.

Indications & Contraindications

Indications

• Posttraumatic elbow contracture.

• Heterotopic ossification of the elbow.

• Spastic contractures of the elbow, in which case the procedure should be combined with appropriate tendon release and/or lengthening as indicated.

Contraindications

• Minimal elbow contractures that would otherwise be well tolerated.

• End-stage arthritis.

• Posttraumatic malunion or nonunion compromising normal articular congruity not otherwise addressed concomitantly or in a staged procedure.

• Extensive heterotopic ossification anteriorly (relative contraindication that may require modification of the technique).

Step 1: Incision and Dissection (Video 1)

Position the incision on the posterior aspect of the elbow.

• Position the patient in lateral decubitus (our preference) or supine.

• Make a longitudinal posterior incision, 10 cm in length, curving medially or laterally around the olecranon apex, an approach similar to what is used for an olecranon fracture (Fig. 1).

• Elevate full-thickness subcutaneous flaps medially and laterally directly off of the peritenon, ulnar periosteum, and muscle fascia (Fig. 2).

Fig. 1.

Skin incision.

Fig. 2.

Elevation of full-thickness flaps.

Video 1.

Download video file ^{(15.6MB, mp4)}

DOI: 10.2106/JBJS.ST.17.00067.vid1

Incision and dissection.

Step 2: Ulnar Nerve Identification and Decompression (Video 2)

Locate, decompress, and mobilize the ulnar nerve.

• Locate the ulnar nerve medially in the cubital tunnel, if it has not already been transposed (Fig. 3).

• Decompress the nerve in situ.

• Mobilize the nerve away from the cubital tunnel.

Fig. 3.

Identification and mobilization of the ulnar nerve.

Video 2.

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DOI: 10.2106/JBJS.ST.17.00067.vid2

Ulnar nerve identification and decompression.

Step 3: Olecranon Osteotomy (Video 3)

Perform a chevron or transverse osteotomy.

• Before performing the osteotomy, decide which implant will be used to repair the osteotomy site. We strongly recommend a rigid implant to resist a rigorous postoperative rehabilitation protocol. A plate or locking intramedullary nail is preferable. Avoid tension banding techniques or intramedullary partially threaded 6.5-mm screws.

• If an intramedullary nail is to be used, predrill the medullary canal.

• Perform a chevron or transverse osteotomy freehand or using commercially available guides (Fig. 4). Aim to cut through the “bare area” of the articulating surface of the ulna. The “bare area” refers to a transverse ridge located midway between the tip of the olecranon and coronoid process that is devoid of articular cartilage.

• Break through the anterior cortex using an osteotome to allow it to “key in” better during repair.

Fig. 4.

Chevron osteotomy of the olecranon.

Video 3.

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DOI: 10.2106/JBJS.ST.17.00067.vid3

Olecranon osteotomy.

Step 4: Elevation of Olecranon (Video 4)

Unlike an osteotomy performed for acute fractures, the olecranon will be adherent because of intra-articular adhesions.

• Elevate the olecranon from the humeral trochlea by lysing adhesions sharply with a scalpel. Take care not to injure the articular cartilage.

• To further mobilize the olecranon, release the capsule and any remaining soft tissues encountered medially and laterally in line with your chevron osteotomy by using a knife or dissecting scissors directed proximally.

• Avoid straying further medially, laterally, or distally in order to preserve the collateral ligaments.

Video 4.

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DOI: 10.2106/JBJS.ST.17.00067.vid4

Elevation of the olecranon.

Step 5: Removing the Posterior Tether (Video 5)

Removing the soft-tissue posterior tether will facilitate flexion.

• Sharply detach the posterior aspect of the capsule from the humerus using a scalpel.

• Sharply remove the posterior aspect of the capsule completely until only triceps muscle fibers are visible (Fig. 5).

• Elevate the triceps from the posterior cortex of the humerus using a wide elevator instrument to disrupt possible adhesions that may have formed between the triceps and the humerus, but be mindful of the radial nerve crossing over the humeral shaft approximately 15 cm proximal to the joint.

Fig. 5.

Exposure and release the posterior aspect of the capsule.

Video 5.

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DOI: 10.2106/JBJS.ST.17.00067.vid5

Removing the posterior tether.

Step 6: Removing the Posterior Block (Video 6)

Removing the posterior soft tissue and osseous block will facilitate extension.

• Using a rongeur, excise any osteophytes or reactive bone along the periphery of the olecranon.

• Remove any soft-tissue debris from the olecranon fossa.

• If needed, the olecranon fossa may be deepened and/or widened using a 5.0-mm burr. We routinely widen the olecranon fossa as most posterior impingement tends to occur medially and laterally (Fig. 6).

Fig. 6.

Deepening of the olecranon fossa.

Video 6.

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DOI: 10.2106/JBJS.ST.17.00067.vid6

Removing the posterior block.

Step 7: Removing the Anterior Tether (Video 7)

Removing the anterior soft-tissue tether will facilitate extension.

• With the ulnar nerve retracted, sharply detach the medial collateral ligament (MCL) directly off its origin on the medial epicondyle using a scalpel, and retract it distally (Fig. 7).

• Do not remove the attachment of the flexor-pronator mass.

• Elevate the anterior aspect of the capsule from the humerus, working medially to laterally and alternating between a scalpel and a wide osteotome.

• Stay directly on the anterior cortex of the humerus, keeping the brachialis anterior to the dissection. The neurovascular bundles are well protected from the dissection by the brachialis muscle.

• Avoid dissecting into the brachialis muscle anteriorly or dissecting distal to the coronoid and disrupting the brachialis tendon attachment.

• Place a Hohmann retractor around the coronoid and begin to lever the joint open, hinging around the intact lateral collateral ligament (LCL) complex (Fig. 8). As the joint opens and the anterior capsule is visualized, excise the capsule.

• Continue the dissection until the LCL complex is reached. Avoid disrupting the LCL complex. This is best accomplished by staying directly on the anterior cortex of the humerus as the joint is hinged open from medial to lateral. In fact, the intact LCL complex itself will restrict access to the lateral part of the joint and make it quite difficult to injure. Stability of the elbow during the early phases of rehabilitation depends on the integrity of the LCL complex. If the LCL complex is inadvertently compromised, it may need to be repaired well or reconstructed.

• It is important to note that, as the dissection continues laterally, the joint will open medially but the most lateral aspect of the joint may never be visualized. This is because the LCL remains intact and closes the lateral aspect of the joint. Given the restricted space in which to work laterally, it may not be possible to excise the capsule. In this case, elevating the capsule from the humerus with a wide osteotome is adequate.

Fig. 7.

Taking down the MCL.

Fig. 8.

Hinging the joint open and release of the anterior aspect of the capsule.

Video 7.

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DOI: 10.2106/JBJS.ST.17.00067.vid7

Removing the anterior tether.

Step 8: Removing the Anterior Block

Removing the anterior soft tissue and osseous block will facilitate flexion.

• Once the anterior tether is released and access to the anterior compartment is accomplished, remove any residual heterotopic bone (Fig. 9).

• If needed, remove hypertrophic spurs from the coronoid with a burr.

• In most cases, contouring the coronoid with a burr will remove most impingement issues, but in some cases widening of the anterior coronoid or radial fossae may be necessary. If so, access to these fossae or removing extensive heterotopic bone may be challenging without an adjuvant approach through the flexor-pronator mass or through the olecranon fenestration, similar to an Outerbridge-Kashiwagi procedure.

Fig. 9.

Release of the anterior tether and mechanical block.

Step 9: Provisional Repair of Osteotomy Site (Video 8)

Provisional repair of the osteotomy site will allow for intraoperative assessment of the contracture release, and any adjustments can be performed as necessary.

• Reduce the olecranon and use two 0.062-in (1.6-mm) pins for provisional fixation. Two pins are preferable to 1 because of the forces on the olecranon fragment while the elbow is taken through a range of motion.

Video 8.

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DOI: 10.2106/JBJS.ST.17.00067.vid8

Provisional repair of the osteotomy site.

Step 10: Assessment of Motion (Video 9)

If gravity alone does not achieve acceptable elbow extension and flexion, reassess the adequacy of your release.

• Bring the elbow into full extension. Allow gravity alone to passively extend the elbow. If gravity cannot bring the elbow into an acceptable degree of extension, reassess the adequacy of your release by addressing the posterior block and/or anterior tether.

• Bring the elbow into full flexion. Allow gravity alone to passively flex the elbow. If gravity cannot bring the elbow into an acceptable degree of flexion, reassess the adequacy of your release by addressing the anterior block and/or posterior tether.

Video 9.

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DOI: 10.2106/JBJS.ST.17.00067.vid9

Assessment of motion.

Step 11: Definitive Repair of Osteotomy Site and Closure (Video 10)

Replace the pins with the definitive rigid implant, repair the MCL, and replace the retracted ulnar nerve.

• Replace the pins with the definitive rigid implant of your choice; either a plate or a locking nail is recommended (Fig. 10).

• Repair the MCL with a single suture anchor at its site of detachment from the medial epicondyle (Fig. 11).

• If repairing the MCL reduces flexion, you may need to release the posterior bundle of the MCL.

• Replace the retracted ulnar nerve into its groove at the cubital tunnel. If the nerve subluxates with elbow range of motion, consider extending the incision and transposing the nerve anteriorly.

• The tourniquet is deflated, and adequate hemostasis is achieved. If there is any concern, then a drain may be used; however, it should not be necessary. Close the skin with your preferred technique.

• Apply a splint in full extension. This will be removed by the physical therapist later that day to initiate a range of motion.

Fig. 10.

Repair of the osteotomy site.

Fig. 11.

Repair of the MCL.

Video 10.

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DOI: 10.2106/JBJS.ST.17.00067.vid10

Definitive repair of the osteotomy site and closure.

Step 12: Postoperative Protocols (Video 11)

Using a perioperative regional block allows patients to participate in physical therapy immediately, which has psychological benefits.

• We prefer using a perioperative regional block to allow patients to participate in physical therapy immediately following surgery. This block allows relatively pain-free rehabilitation. Not only is this a temporary convenience for the patient, but it has psychological benefits as well. Often, patients have not moved the elbow for months or years. Without the obstacle of pain, they can regain hope that they can achieve motion again. When pain eventually returns, the patients still have the psychological advantage of having seen the elbow move and knowing that it is possible.

• We recommend that patients with preoperative radiographic evidence of heterotopic ossification take 75 mg of sustained-release oral indomethacin daily for 4 weeks postoperatively. No other adjuvant treatments, such as an intra-articular corticosteroid injection, radiation therapy, or use of a continuous passive motion device, are utilized.

Video 11.

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DOI: 10.2106/JBJS.ST.17.00067.vid11

Postoperative protocols.

Results

Thirty-five patients with an average age of 39.5 years (range, 18 to 63 years) underwent an OFER procedure¹. The mean duration of follow-up was 37.2 months (range, 24 to 72 months). The mean preoperative elbow motion arc was 33° (51° to 84° of flexion). Postoperatively, the motion arc improved significantly (p < 0.001) to 110° (16° to 126° of flexion). The mean visual analog scale pain score improved from 6.3 preoperatively to 1.4 at the time of follow-up (p < 0.001). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score improved from 57.5 preoperatively to 10.9 postoperatively (p < 0.001). The maximal improvement in the motion arc occurred at a mean of 8.7 weeks. There was 1 postoperative ulnar neurapraxia, which resolved spontaneously. The intraoperative tourniquet time averaged 27 minutes (range, 18 to 45 minutes). The average time until radiographic evidence of union of the olecranon osteotomy site was 6.6 weeks (range, 5.7 to 7.7 weeks). At last follow-up, there were no cases of nonunion, malunion, implant removal or soft-tissue irritation related to the implant, triceps insertion pain, symptoms of joint instability, or other complications.

The OFER procedure achieved superior postoperative arcs of motion, as compared with the majority of published results of other arthroscopic and open approaches (Table I), and there were minimal short-term and no long-term complications. These results occurred in a cohort that presented with more severe contractures than reported in previous studies. As previously noted, it has been our experience that the olecranon osteotomy approach offers unparalleled exposure of the elbow joint surface (Fig. 12). However, we are unaware of any head-to-head comparison studies that address this issue. The OFER procedure allows both intrinsic and extrinsic contracture etiologies to be addressed, whereas anterior, medial, lateral, and arthroscopic approaches may not provide sufficient exposure. Although this is a new technique, and we are not aware of any studies addressing the issue, we believe that the OFER procedure is substantially faster and technically easier than either other open or arthroscopic releases.

Fig. 12.

Intraoperative photograph showing 360° joint exposure.

TABLE I.

Outcomes of Elbow Contracture Release Surgery Reported in Literature

Study	Approach	No. of Patients	Mean Follow-up (mo)	Mean Increase in Arc of Motion (°)
Aldridge et al., 20042	Anterior	77	33	38
Cefo and Eygendaal, 20113	Arthroscopic	27	24	27
Wu et al., 20154	Arthroscopic	34	12	65
Kruse et al., 20165	Combined	36	38	57
Brinsden et al., 20086	Lateral	23	43	23
Ruch et al., 20087	Medial	14	25	55
Edwards et al., 20171	OFER	35	37	77

Pitfalls & Challenges

• When lysing the intra-articular adhesions, be mindful not to injure the articular cartilage.

• When removing the anterior aspect of the capsule, slide a wide osteotome along the anterior cortex of the humerus from distal to proximal, and do not stray into the brachialis anteriorly. To do otherwise would jeopardize neurovascular structures.

• The capsule anterior to the LCL complex must be detached from the humerus as well, but it is not readily visualized and must be detached blindly without injury to the LCL complex.

• Avoid detaching the LCL complex. If this is done inadvertently, the LCL complex may need to be repaired well or reconstructed. As long as the surgeon stays directly on the anterior cortex of the humerus and the joint is hinged open from medial to lateral, the intact LCL itself will restrict access to the lateral joint space, thereby making it very difficult to detach.

• If optimal flexion is not achieved, reevaluate the anterior block and posterior tether.

• If optimal extension is not achieved, reevaluate the anterior tether and posterior block.

• If, after the ulnar nerve is returned to the cubital tunnel, any subluxation occurs when the elbow is moved through a range motion, consider an anterior transposition.