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Operative Release of Complete Ankylosis of the Elbow Due to Heterotopic Bone in Patients without Severe Injury of the Central Nervous System

Investigation performed at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

David Ring, MD
Jesse B. Jupiter, MD
Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 11 Hancock Street, Unit 4, Boston, MA 02114. E-mail address for D. Ring: dring{at}partners.org E-mail address for J.B. Jupiter: jjupiter1@partners.org

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear.

Methods: A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47° of flexion) compared with those in the trauma cohort (66° of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand.

Results: Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80° of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81° in the burn cohort and 94° in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort.

Conclusions: Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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