Stiff elbow is a complex reconstructive surgical problem characterized by persistent limitation of motion and function within the flexion-extension arc, resulting from combined fibrotic and osseous changes involving the capsule, periarticular soft tissues, and articular surfaces. The low joint volume of the elbow and its close anatomical relationship to the brachial artery as well as the median, ulnar, and radial nerves further narrow the surgical safety margin, particularly in cases associated with post-traumatic fibrosis and heterotopic ossification. Surgical planning is therefore based on accurately identifying the underlying cause of motion restriction and applying a targeted release strategy accordingly. Arthroscopic release can facilitate controlled capsular release and intra-articular debridement, thereby supporting early rehabilitation; however, careful portal planning, adequate joint distension, precise instrument control close to the bony surface, and meticulous fluid management are critical to ensure neural safety. In contrast, open release is preferred in cases of extensive fibrosis, advanced heterotopic ossification, deformity, or complex osseous blocks, as it provides wider visualization, enables comprehensive removal of bony impingement, and allows direct protection of neurovascular structures. Surgical success depends on the sequential removal of mechanical blocks followed by gradual capsular release, with continuous reassessment of the balance between motion and stability at each stage. Evaluation of the ulnar nerve, and selective decompression or transposition when indicated, represents an essential component of the surgical strategy. In appropriately selected patients, Outerbridge-Kashiwagi debridement and interposition arthroplasty in young and active individuals remain effective treatment options when applied under proper indications.