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Does Age Contribute to Outcomes for Elbow Release in Arthrogryposis?
Christopher Richards, MD, MS1; Dan Zlotolow, MD2; Rey Natividad Ramirez, MD1;
1Cooper University Hospital, Camden, NJ; 2Shriners Hospital for Children Philadelphia, Philadelphia, PA

Introduction
Up to 25% of children with arthrogryposis have an elbow extension contracture that limits hand to mouth for functions such as eating. Posterior elbow release, triceps lengthening, and ulnar nerve transposition (posterior elbow release) has been shown to improve passive elbow flexion, with previous literature suggesting good results at an average of 3 years of age. No consensus exists regarding timing of surgery. This study looks at the effect of age at the time of surgery on the outcome of posterior elbow release.

Methods
This study is a retrospective chart review of consecutive patients with arthrogryposis who underwent a posterior elbow release for an elbow extension contracture between 2007 and 2014 at one institution. Out of 62 procedures in 44 patients, 20 procedures in 14 patients had a minimum follow-up longer than of 2 years and were included in the study. Of the six patients who had bilateral posterior elbow releases, all of them were done within 8 months of each other and within the same year of life. Patients were divided into 3 groups based on their age at the time of surgery: <2 years old, 2-3 years old and >3 years old. T-tests were used to compare the pre- and post-operative passive arcs of motion.

Results
The average pre-operative arc of motion was 16o (0o-30o) for the children younger than 2, 33.5o (5o-60o) for the children 2-3 and 45o (25o-80o) for the children older than 3. These differences were not statistically significant between cohorts. Children >3 years old also developed on average a 6.7o flexion contracture, shifting their pre-operative arc of motion into more flexion. The average post-operative arc of motion was 88.2o (70o-103o) for the children younger than 2, 60o (15o-85o) for the children 2-3 and 54.33o (23o-70o) for the children older than 3. There was a statistically significant difference in the post-operative arc of motion between the children less than 2 years old and both the children 2-3 years old and older than 3 years old. The difference between the 2-3 and >3 year old cohorts were not significant.

Conclusion
Children who underwent posterior elbow release prior to the age of 2 had a statistically significant increase in their post-operative passive arc of elbow motion compared to older children. The results were better and more predictable. Restoring passive elbow flexion should therefore be an early priority of the treatment plan for children with arthrogryposis.


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