Open Arthrolysis for Severe Elbow Stiffness Secondary to Primary Elbow Osteoarthritis: A Retrospective Case Series of 60 Patients

Technical Summary: Open Arthrolysis for Severe Elbow Stiffness Secondary to Primary Osteoarthritis

Problem Statement
Primary elbow osteoarthritis frequently leads to severe functional impairment characterized by pain, osteophyte formation, and capsular contracture. While elbow arthroscopy has gained popularity for mild to moderate stiffness due to faster recovery and less soft-tissue disruption, it presents significant challenges in cases of severe stiffness (defined here as a flexion-extension arc of 31°–60°). In these severe cases, distorted intra-articular anatomy, extensive osteophytes, and tight capsular contractures create a narrow working space that makes adequate arthroscopic release technically demanding and less predictable. Consequently, there is a need to evaluate the efficacy and safety of open arthrolysis specifically for this selected population of patients with severe stiffness secondary to primary osteoarthritis.

Methodology
This study is a retrospective case series involving 60 patients treated between May 2022 and August 2025.

• Patient Selection: Inclusion criteria required patients over 16 years old with primary elbow osteoarthritis and severe stiffness (flexion-extension arc 31°–60°). Exclusion criteria included severe joint space narrowing requiring arthroplasty, inflammatory arthritis, post-traumatic stiffness, or prior elbow surgery.
• Surgical Technique: All patients underwent open arthrolysis with osteocapsular debridement and concomitant anterior transposition of the ulnar nerve.
  • Approach: A medial incision was used to identify, decompress, and anteriorly transpose the ulnar nerve. The posterior capsule was excised, and impinging osteophytes around the olecranon fossa and tip were removed.
  • Lateral Approach: A lateral incision allowed access to the anterior compartment via a split in the common extensor origin. The anterior capsule was excised, and osteophytes around the coronoid tip and fossa were removed.
  • Refinement: A high-speed burr was used to reshape the radial, coronoid, and olecranon fossae to eliminate bony impingement.
  • Closure: The ulnar nerve was transposed into a subcutaneous bed anterior to the medial epicondyle. Two drains were placed (medial posterior, lateral anterior).
• Postoperative Protocol: Rehabilitation began on the first postoperative day with active and passive flexion-extension exercises under analgesic support.
• Outcome Measures: Data collected included operative time, blood loss, drainage, hospital stay, and complications. Functional outcomes (Range of Motion, Mayo Elbow Performance Score [MEPS], Visual Analogue Scale [VAS] for pain) and ulnar nerve symptom resolution were assessed preoperatively and at a median follow-up of 8.5 months.

Key Results
The study reported successful completion of surgery and follow-up for all 60 patients.

• Operative Metrics: The median operative time was 106 minutes, with a median blood loss of 100 mL. The median hospital stay was 7 days.
• Functional Improvement: Significant improvements were observed at the final follow-up (P < .01):
  • Extension Deficit: Improved from 31.8° to 6.7°.
  • Flexion: Increased from 83.5° to 112.6°.
  • Flexion-Extension Arc: Increased from 51.7° to 105.9° (a mean gain of 54.2°).
  • MEPS: Improved from 44.8 to 86.8 points.
  • Pain (VAS): Decreased from a median of 3 to 1.
• Ulnar Nerve Outcomes: Among the 46 patients (77%) with preoperative ulnar nerve symptoms, 28 achieved complete resolution, 13 achieved partial resolution, and 5 showed no change. Crucially, no patients experienced worsening of symptoms, and no secondary surgery was required for nerve issues.
• Complications: The complication rate was low. Two patients (3.3%) experienced subcutaneous fluid collection, which resolved with conservative management. There were no cases of deep infection or revision surgery.

Key Contributions
This study provides specific evidence regarding the management of severe elbow stiffness secondary to primary osteoarthritis, a subgroup where arthroscopic evidence is limited.

1. Validation of Open Arthrolysis: It demonstrates that open arthrolysis with osteocapsular debridement is an effective method for restoring motion in severe cases where arthroscopic visualization may be insufficient.
2. Safety of Concomitant Nerve Transposition: The study supports the strategy of performing concomitant anterior transposition of the ulnar nerve in this cohort. It suggests that this approach effectively addresses pre-existing nerve symptoms and mitigates the risk of postoperative nerve irritation caused by the sudden increase in joint motion.
3. Procedural Efficiency: The median operative time of 106 minutes suggests that the open technique offers acceptable efficiency compared to reported arthroscopic times for similar severe cases (which have been reported as high as 222 minutes in other literature).

Significance and Claims
The authors conclude that open arthrolysis with osteocapsular debridement represents a reliable surgical option for patients with severe elbow stiffness secondary to primary osteoarthritis. The procedure offers favorable short-term outcomes by allowing direct visualization for the thorough removal of impinging osteophytes and contracted capsules, which are difficult to address arthroscopically in severe cases. Furthermore, the concomitant anterior transposition of the ulnar nerve is presented as a feasible and safe strategy that improves or maintains nerve function without increasing complication rates.

The paper maintains a modest tone regarding its conclusions, acknowledging limitations such as the lack of a randomized control group, the single-center retrospective nature of the study, and the relatively short follow-up period (median 8.5 months). The authors explicitly state that while the short-term results are promising, future multicenter, prospective comparative studies with longer follow-up are necessary to fully validate long-term outcomes, including the recurrence of stiffness and the progression of heterotopic ossification.