Postoperative rehabilitation in elbow surgery

Abstract

Postoperative rehabilitation plays a crucial role in the treatment of elbow pathology. Depending on the type of surgery, the elbow may need to be protected. As a general rule, the elbow should not be immobilized for a prolonged period after surgery. A removable splint can be used to protect the soft-tissues immediately postoperative and the patient is encouraged to remove the splint several times daily to mobilize the elbow. Dynamic articulated braces can be used to encourage movement while ligament or tendon repairs are being protected. Literature on postoperative elbow rehab is scarce. In this paper we provide practical guidelines for specific surgical procedures.

Introduction

Elbow pathology is diverse. It includes overuse syndromes, (post)traumatic conditions and nerve compression syndromes. Patients will often consult for pain, stiffness or decreased strength and function. Rehabilitation programs should be tailored to the patient and the pathology.

There is a clear distinction between preoperative (conservative treatment) or postoperative rehabilitation. There is a paucity of literature with regards to rehabilitation of the elbow following surgery and in most clinical studies the rehabilitation protocols are not well described. Most guidelines are based on ‘expert-opinion’. In this paper we will discuss our principles of postoperative rehabilitation and we will offer some suggestions on postoperative treatment following elbow surgery.

General principles

The postoperative treatment regimen consists of different phases. The first phase is the acute recovery phase or the inflammatory/proliferative phase in regards to connective tissue healing. In this phase focus lies on decreasing swelling, protecting the wound and allowing early mobilization of the elbow joint. In this phase we try to improve the articular homeostasis in order to reduce edema and hematoma and to acquire adequate range of motion, since the elbow joint is especially prone to contractures. Guidelines concerning the extent of the allowed mobilization are provided by the surgeon. Typically, this phase takes between two to four weeks. After three to four weeks collagen 3 fibers are being transformed into collagen 1 fibers. This process can take up to one year and the orientation of the collagen fibers is determined by the direction of the forces applied to the elbow. The change in collagen fibers announces the start of the remodulation phase. In this phase we concentrate on motion progression and onset of light isotonic exercises. Next is an advanced strengthening phase, this phase begins when the range of motion is complete and painless, typically between six weeks and three months. Lastly, patients roll into a phase focused on return to their preferred activity. Each phase must be tailored to the individual patient's needs and restrictions.1, 2, 3

Bandages, splints and braces

Mobilization braces can be used pre- or post operatively to increase range of motion (Fig. 1). They are custom made with either turnbuckle, static progressive stretch, or dynamic bracing that can stretch the elbow in flexion or extension.⁴

Fig. 1.

Custom made spring-loaded brace. The elastic spring extends the elbow, slowly stretching anterior structures. Intensity can be adjusted by the patient. (Courtesy of MoRe Foundation).

Braces can be a useful device in both the preoperative and postoperative rehabilitation of elbow. There is a difference in braces used to protect the elbow after surgery or braces that assist in improving elbow motion. The first category is used in the immediate postoperative period, up to two weeks, to protect surgical repairs, especially in case of tendon/ligament reconstruction (Fig. 2). Early motion is nearly always advocated and, depending on the indication, patients are encouraged to remove the splint several times daily, to allow early mobilization. If an articulated brace is used, the splint is removed on the first postoperative day and mobilization in the articulated brace is initiated.^3,5

Fig. 2.

Removable lightweight splint (eXo elbow splint by Jake Design, Belgium). (Courtesy of MoRe Foundation).

Specific rehabilitation guidelines

In the next section, specific treatment protocols are discussed. Postoperative instructions for open and arthroscopic surgery are nearly identical since rehabilitation depends mostly on the type of surgery. Therefore, we will not discuss open and arthroscopic techniques separately. The main difference is that after elbow arthroscopy an extension cast is applied for the first 24 h, to evacuate excess fluid after the arthroscopy.

Tendon injuries

Surgery for tendon injuries at the elbow is diverse, as it depends on the specific tendon and the quality of the injured tendon. Patients with lateral and medial epicondylitis rarely need surgery. However, as these are such common conditions, they are still the most commonly operated tendons in the elbow. Biceps and triceps tendon tears can be complete or partial and the type of surgery depends on the extent of the tear and surgeons’ preference.

As a general rule, a reattached tendon needs to be protected while it is healing. The risk of a retear is greatest at approximately 2 weeks after surgery. The type of surgery and strength of initial fixation will determine the postoperative guidelines. Hitchcock et al. mentioned that immobilization decreases the strength of tendon repair within the first three weeks of healing, therefore we try to promote early mobilization after all tendon repairs. Moreover, early passive and active mobilization prevent the initial weakening leading to increased repair strength.^6,7

Lateral and medial epicondylitis

Lateral epicondylitis or “tennis elbow” is the most common tendon problem of the elbow. It involves the common extensor tendon with the extensor carpi radialis brevis most commonly affected. The natural history is excellent and more than 90% of patients will heal without any intervention.⁸ Surgery becomes an option if conservative measures fail, and complaints have been present for over 12 months. Surgery can be done through arthroscopic, percutaneous or mini open technique. Because of the risk of iatrogenic ulnar nerve injury, arthroscopic or percutaneous techniques are currently not recommended as a surgical option for medial epicondylitis.⁹

The postoperative rehabilitation is identical for lateral and medial epicondylitis. The elbow will be protected with a removable static splint (Fig. 2). From the first postoperative day, the patient is encouraged to remove the splint five times daily for a minimum of 15 min, to mobilize the elbow. The splint is discontinued after two weeks, after which the elbow is mobilized further without physiotherapy. Functional exercises are started after six weeks and physiotherapy is prescribed if we notice any residual stiffness of the elbow. Patients can start all activities of daily life after 6 weeks. Full recovery is to be expected at three to six months but function is usually good before this time.10, 11, 12

Triceps tendon tears

Triceps tendon pathology is relatively rare. Tendinitis, partial or complete tears are possible. Surgery is usually reserved for symptomatic partial or complete tears. A debridement and reinsertion of the tendon is performed through a straight posterior incision.

A postoperative cast is applied in mild extension, which is changed for a dynamic brace on the first postoperative day. Extension is free but flexion is blocked at the tension-free range; 30° of extra flexion is permitted every 2 weeks. Full flexion is allowed after 6 weeks. Strengthening starts at 3 months.¹³

Biceps tendon tears

The incidence of distal biceps tendon rupture is 2,55 per 100,000 patient-years.¹⁴ Distal biceps tendon ruptures have a significant implication on supination and flexion power. In acute ruptures the tendon is surgically reinserted on the radial tuberosity. In chronic lesions an auto- or allograft may be necessary to augment the repair and to overcome retraction of the tendon. A single or two-incision technique can be used; both of which achieve comparable outcomes. We prefer a single-incision technique and use an endobutton to ensure a strong fixation with bony ingrowth of the tendon¹⁵ (Fig. 3). Postoperatively the elbow will be protected with a compressive bandage. The patient is encouraged to mobilize the elbow immediately. Full range of motion regarding extension/flexion and supination/protonation is allowed. Since the load to failure with the endobutton technique is 259 N, we allow patients to lift up to 20 kg (44lb) immediately postoperative.¹⁶ After 6 weeks, restrictions concerning weights are fully lifted.

Fig. 3.

The endobutton technique for distal biceps reinsertion through a single incision. (Courtesy of MoRe Foundation).

Ulnar nerve

Ulnar nerve compression is common. Patients complain of paraesthesia in the little finger and the ulnar side of the ring finger. Symptoms increase with prolonged flexion and local compression. For example, at night or while having a conversation on a mobile phone. In more severe cases a motor deficit may develop. One of the first signs is that the patient reports to have become ‘clumsy’ and often drop small objects. Atrophy of the first webspace and the intrinsic muscles of the hand can be seen. Nerve conduction studies will show compression at the cubital tunnel. A simple surgical decompression of the nerve is usually sufficient and leads to excellent results. The nerve is released and left in its groove posterior to the medial epicondyle (Fig. 4). Postoperatively a protective bandage is used for a minimum of 48 h. We prefer to leave the wound closed and the bandage is left in place for 2 weeks. The patient is allowed to mobilize the elbow immediately. Patients will often feel an almost immediate improvement of their symptoms but it can take up to three months for this to occur.

Fig. 4.

Decompression of the ulnar nerve. In this case compression was found between the two heads of the flexor carpi ulnaris muscle. (Courtesy of MoRe Foundation).

If the nerve is unstable, such as in snapping triceps syndrome, or if there is a hostile bed of the ulnar groove (e.g., calcification or callus after a fracture), an anterior transposition of the nerve may be necessary. A facial flap or sling is often used to stabilize the nerve and to prevent it from slipping posterior to the medial epicondyle in the early postoperative period. We protect the elbow with a lightweight removable splint for the first two weeks. The patient is encouraged to remove this splint up to five times a day for 10–15 min, to avoid elbow stiffness.

Formal physiotherapy is not indicated following ulnar nerve release or decompression. We prescribe Vitamin B complex to promote nerve healing and general principles of recovery apply.

Radial nerve

Radial nerve compression at the elbow is rare. Symptoms include vague pain in the anterolateral elbow and forearm and can include weakness. It can be associated to lateral epicondylitis and the diagnosis is easily missed. Compression can occur at different locations but most commonly occurs at the arcade of Frohse, the sharp tendinous proximal edge of the supinator and its muscle belly.¹⁷ Symptoms can be provoked by prolonged resisted supination of the forearm. We ask the patients to place both elbows in the side. Elbows are flexed ninety degrees and the examiner resists forearm rotation. After approximately 20–30 s, patients report a pain that they recognize. Resistance becomes weak and a tremor may occur. Nerve conduction studies (NCS) are difficult and may be false negative. Its sensitivity increases significantly if our clinical test is performed during or immediately before the NCS. Radial nerve decompression can be done through a lateral or an anterior incision. The nerve is released at the arcade of Frohse and in its intramuscular portion. Other areas of compression are identified and released if needed. Postoperatively a protective bandage is used for a minimum of 48 h. We prefer to leave the wound closed and the bandage is left in place for 2 weeks. The patient is allowed to mobilize the elbow immediately. Recovery of the radial nerve is slow and will take a minimum of three months. We prescribe Vitamin B complex to promote nerve healing and general principles of recovery apply.

Trauma

Fractures

Fractures of the elbow can include radial head, proximal ulna, distal humerus fractures or a combination. It is not uncommon that there is an associated ligamentous lesion and instability. Surgical treatment will focus on an anatomical reduction and stable fixation of the fracture fragments. This will allow for the elbow to be mobilized immediately after surgery. Early motion has been shown to lead to improved results in this patient group. Recommendations will usually follow the general principles outlined below:

Week 1–2: Decrease swelling, protect the wound. Passive and active range of motion are allowed. Hand and shoulder motion is encouraged.

Week 2: Clinic visit: Remove sutures or staples.

Week 2–6: Focus on mobility.

Week 6: Radiographic evaluation of healing and position of hardware.

Week 6–12: Increase intensity of ROM exercises. Improve function.

Week 12 to 6 months: Improve function.

Radial head/neck fractures

Radial head fractures are often treated conservatively. Immobilization is not needed in non- or minimally displaced fractures and the elbow can be mobilized immediately postoperative. A sling or removable splint can be used in the first few days to weeks, to provide comfort, decrease swelling and pain.

As with all fractures, stable fixation is key.¹⁸ When this is achieved, mobilization starts immediately after surgery, in absence of associated lesions. A protective bandage is used to protect the wound but there are usually no limitations of range of motion. In case of consolidation at 6 weeks, strengthening exercises are encouraged and return to sports is allowed. The speed of recovery depends on the reaction of the soft tissues but results are generally excellent.

Not only ligamentous injuries are associated with radial head and neck fractures, capitellar chondral defects, loose bodies and associated fractures of the coronoid are also common. These associated injuries should be treated simultaneously, and postoperative rehab is often dictated by these injuries.¹⁹

Radial head replacement

In comminuted, non-repairable radial head fractures, the radial head can be replaced with an implant. As in radial head repair, the postoperative rehabilitation must be tailored to the associated injuries. If at the end of the procedure, the elbow is stable, early mobilization is immediately allowed. In case of ligament injuries an articulated brace is applied for 6 weeks.²⁰ In case of concomitant LCL repair, the articulated brace is locked at 60° of extension, each 2 weeks an extra 30° of extension is allowed to achieve a full extension after 6 weeks. Postoperative treatment guidelines do not change if an associated MCL lesion is present.

Proximal ulna fractures

Proximal ulnar fractures include olecranon fractures, coronoid fractures or a combination of both. Most proximal ulna fractures are treated surgically, with sutures, pins and wires or with a plate and screw osteosynthesis.²¹ As with fixation of all elbow fractures, the surgeon should aim to achieve a stable fixation which allows immediate mobilization.

Wound complications are of concern after open reduction and internal fixation of the proximal ulna. Hardware is relatively prominent, and the skin of the posterior elbow can be quite fragile (Fig. 5). Therefore, extra care should be taken to protect the skin in the first weeks after surgery. Immediate mobilization is encouraged but care should be taken not to force flexion as this may jeopardize healing of the wound. Union is expected at around 6 weeks postoperatively. However, maximum weight bearing and return to sports are only allowed three to six months postoperatively.²²

Fig. 5.

Prominent hardware after olecranon osteosynthesis. (Courtesy of MoRe Foundation).

Distal humeral fractures

Distal humerus fractures are challenging²³, especially if there is an intra-articular component.

Stiffness is of particular concern after this injury. Early motion will be determined by the stability of the fixation and the integrity of the skin and the wound. This is different for every case; therefore, patient tailored rehabilitation guidelines are to be provided by the surgeon. As always early motion to prevent elbow stiffness is advocated. General guidelines as discussed above will be followed.

Total elbow arthroplasty

Postoperative rehabilitation after total elbow arthroplasty depends on the approach used. We prefer to use a lateral paratricipital approach.²⁴ This has the advantage that the triceps does not need to be protected after surgery and the elbow can be mobilized immediately. It has been shown that this can be done safely and early motion does not increase complication rate.²⁵ Unless there is increased risk for wound and skin problems, the elbow is not immobilized. If a ‘triceps-off’ approach is used full flexion may need to be restricted in the first few weeks. Patients are advised that there is a lifelong restriction on loading the prosthetic elbow. We advise patients to lift a maximum of 5 kg one off, and a maximum of 1.5 kg during repetitive tasks.²⁶

Ligament repair and reconstruction

Ligament repair can be indicated in certain elbow (fracture) dislocations that remain unstable after reduction. Most guidelines advice a closed reduction followed by an examination of the elbow. Acute repair is indicated if the elbow spontaneously dislocates before 30° of extension, when the elbow is moved from flexion to extension.²⁷ Other indications may depend on the profession, sports or hobbies of the patient.

Whilst a ligament repair is usually quite strong, its success depends on healing of the soft tissues. This means that the elbow needs to be protected for a period of time before all structures can be stressed without the risk of re-injury.

We immobilize the elbow in a removable splint immediately postoperatively. This avoids any adverse movements while the brachial plexus block is still active or when the patient wakes up from a general anesthesia. On the first postoperative day, the splint is removed and an articulated brace is used. The brace needs to be worn continuously for the first two weeks. Full flexion in the brace is allowed immediately. Extension is allowed up to 60°. Some surgeons prefer to restrict forearm rotation as well.²⁸ We have never done this and have found no problems with immediate active rotation. Bernas et al. described that extension up to 50° produces less than 3% strain in both bands of the reconstructed ulnar collateral ligament. Moreover, forearm rotation does not appear to affect strain in the anterior or posterior bands, nor do isometric muscle contractions. However, valgus and varus torque increased strain significantly.^29,30

After two weeks, sutures are removed and the brace is adjusted to allow up to 30° of extension. The patient is allowed to remove the brace regularly to shower or to exercise the elbow, with a physiotherapist or home exercise program. The patient is instructed not to place any varus- or valgus stress on the elbow, depending on which ligament was repaired. For example, in LCL repairs, we instruct the patient to hold the elbow by their side and not to abduct the shoulder when the brace is not worn. Full extension is allowed at four weeks postoperatively and the brace is discontinued after six weeks. Rehabilitation is then focused on function and strength. Unrestricted sporting activities are allowed from three months after surgery but it may take up to six months before an athlete can compete in full athletic activity.²⁸

Conclusion

Postoperative guidelines on rehabilitation after elbow surgery are usually based on expert opinion. In this paper we combined our personal experiences with the available published evidence. The emphasis is placed on early mobilization whenever possible. In the inflammatory phase a removable cast plays an important role in providing comfort and protection, whilst allowing early mobilization in the immediate postoperative period. If full range of motion is not allowed or if varus and valgus stresses need to be avoided, an articulated brace is used from the first postoperative day. After three to four weeks light isotonic exercises are started in order to align the transforming collagen 1 fibers in the right direction. In the third phase the focus lies on strengthening, and lastly the aim is returning to patient preferred activity.