Total resection and reconstruction of collateral ligaments in severe elbow stiffness induced by heterotopic ossification: a novel approach and review of the literature.

Background: Post-traumatic elbow stiffness poses a complex challenge, often attributed to intrinsic and extrinsic factors. Heterotopic ossification (HO) is a significant extrinsic contributor, leading to contracture and entrapment syndromes. This study explores the pioneering strategy of total resection and reconstruction of the ossified and contracted collateral ligament in managing extensive HO-induced elbow stiffness. Our goal was to show that complete collateral ligament excision and reconstruction result in a wide range of motion and no long-term HO or elbow instability. Methods: Six patients with severe elbow stiffness underwent HO resection and extensive soft tissue release. Two of them underwent a single fraction of radiotherapy, receiving a dose of 7 gray within the 24 hours preceding the surgery. Five patients with extensive medial HO underwent medial collateral ligament reconstruction using palmaris longus autografts in four of them and tensor fascia lata autograft in one of them, and one patient underwent lateral collateral ligament reconstruction with palmaris longus autograft after lateral collateral ligament sacrifice. Anterior transposition of the ulnar nerve was carried out for all patients to prevent postoperative ulnar nerve symptoms. Evaluations included preoperative and postoperative elbow flexion/extension arcs and Mayo Elbow Performance Score. Results: The study included six patients with stiff elbows (five males, 1 female), aged 17- 45 years (mean age: 30 years). Injury patterns included three nonvehicle traffic accidents and three trauma-related injuries. The trauma-to-surgery interval ranged from 6 to 288 months, with a mean of 79.17. Three patients required intensive care unit stays before surgery, while the other three did not, suggesting varying causes of HO development. After an average follow-up of 3 years, patients exhibited improved flexion/extension arcs (122.5°) from a mean preoperative 20°. The mean Mayo Elbow Performance Score improved from 21.67 preoperatively to 98.33 postoperatively. None of the patients reported varus or valgus instability. Conclusion: Our study demonstrates that excision and reconstruction of the ligament with HO can be a viable and reliable solution for elbow joint stiffness, particularly when the wide HO involves collateral ligaments and loosening procedures are deemed insufficient. Our approach proves cost-effectiveness compared to alternatives involving suture anchors or external fixators, with the added advantage of facilitating more flexion and extension postoperatively to preserve the achieved range of motion.