Elbow capsulectomy for posttraumatic elbow stiffness

Open Arthrolysis for Chronic Elbow Dislocation with Extremely Severe Stiffness in Children

OBJECTIVE

Studies on extremely severe elbow stiffness after chronic dislocation in children are scarce. This study aims to investigate the choice of surgical treatment modalities and to analyze their treatment efficacy in children with chronic elbow dislocation with extremely severe periarticular stiffness.

METHODS

Data of 21 children with chronic elbow dislocation with extremely severe periarticular stiffness diagnosed and treated in our department between February 2015 and February 2021 were retrospectively analyzed. Twenty boys and one girl were included in the study, their mean age was 11 ± 2.5 years, and they had concomitant distal humerus fractures. For the treatment protocol, all children with extremely severe elbow stiffness were treated with open arthrolysis, and elbow joint stability was intraoperatively assessed. All children performed passive functional exercises the day after surgery. The elbow flexion and extension angles, range of motion (ROM), and Mayo score were evaluated preoperatively and at the final follow-up.

RESULTS

Of the 21 children, only one had recurrent severe stiffness of the elbow joint after surgery; nevertheless, the function was still improved compared with that before surgery. Preoperatively, the mean elbow extension and flexion angles were 72.2° ± 12.7° and 93.6° ± 11.1°, respectively, and the range of motion (ROM) of the elbow joint was 17.8° ± 8.3°. At the final follow-up, the mean elbow extension and flexion angles were 22.7° ± 18.6° and 118.8° ± 15.4°, respectively, and the elbow joint ROM was 96.1° ± 17.4°. The differences in the preoperative and postoperative ROMs, flexion angles, and extension angles of the elbow joint were significant (p < 0.01). The MEPS at the final follow-up was 78.57 ± 14.24, which was significantly higher than preoperative (29.76 ± 10.89), and the excellent rate was 81%.

CONCLUSION

Open arthrolysis and open reduction and internal fixation of the elbow joint are effective in treating chronic elbow dislocation with extremely severe stiffness in children.

Surgical arthrolysis of the stiff elbow: a systematic review

INTRODUCTION

Stiffness after elbow injuries can severely limit daily life. If adequate conservative treatment does not result in satisfactory improvement of elbow function, surgical intervention should be considered. Whether an open or arthroscopic procedure is preferable is still a topic of debate and a systematic review of functional outcomes is lacking.

MATERIALS AND METHODS

We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE, for studies published between 2013 and 2021. Primary objective was to compare open and arthroscopic arthrolysis' functional outcomes, respectively, especially ROM and MEPS, as well as the accompanied complications. The PRISMA guidelines were applied.

RESULTS

27 studies comprising 1666 patients were included. 1059 patients (63.6%) were treated with open arthrolysis, and 607 patients (36.4%) were treated with arthroscopic arthrolysis. The results presented indicate satisfactory outcomes in open and arthroscopic arthrolysis with regard to functional outcome parameters. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score, among the patients treated with an open procedure was 88.8%; 6.3% required revision whereas 18.1% had complications without the need for revision surgery. Within the cohort of arthroscopically treated patients, treatment success was 91.8%. Revisions and complications without further surgical intervention were significantly less frequent than in the open cohort, at 1.6% and 9.1%, respectively.

CONCLUSIONS

Both open and arthroscopic arthrolysis provide good to excellent functional outcomes. Since the number of complications and revision increases with the invasiveness of the treatment, an arthroscopic procedure might be favored if feasible by indication. The role of forearm rotation and the use of a hinged external fixator remains of interest.

STUDY DESIGN

Level IV; Systematic review.

Immunofluorescence analysis of sensory nerve endings in the periarticular tissue of the human elbow joint

INTRODUCTION

To investigate the dynamic aspects of elbow stability, we aimed to analyze sensory nerve endings in the ligaments and the capsule of elbow joints.

MATERIALS AND METHODS

The capsule with its anterior (AJC) and posterior (PJC) parts, the radial collateral ligament (RCL), the annular ligament (AL), and the ulnar collateral ligament with its posterior (PUCL), transverse (TUCL) and anterior parts (AUCL) were dissected from eleven human cadaver elbow joints. Sensory nerve endings were analyzed in two levels per specimen as total cell amount/ cm² after immunofluorescence staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, S-100 protein and 4',6-Diamidin-2-phenylindol, Carbonic anhydrase II and choline acetyltransferase on an Apotome microscope according to Freeman and Wyke's classification.

RESULTS

Free nerve endings were the predominant mechanoreceptor in all seven structures followed by Ruffini, unclassifiable, Golgi-like, and Pacini corpuscles (p ≤ 0.00001, respectively). Free nerve endings were observed significant more often in the AJC than in the RCL (p < 0.00002). A higher density of Ruffini endings than Golgi-like endings was observed in the PJC (p = 0.004). The RCL contained significant more Ruffini endings than Pacini corpuscles (p = 0.004). Carbonic anhydrase II was significantly more frequently positively immunoreactive than choline acetyltransferase in all sensory nerve endings (p < 0.05). Sensory nerve endings were significant more often epifascicular distributed in all structures (p < 0.006, respectively) except for the AJC, which had a pronounced equal distribution (p < 0.00005).

CONCLUSION

The high density of free nerve endings in the joint capsule indicates that it has pronounced nociceptive functions. Joint position sense is mainly detected by the RCL, AUCL, PUCL, and the PJC. Proprioceptive control of the elbow joint is mainly monitored by the joint capsule and the UCL, respectively. However, the extreme range of motion is primarily controlled by the RCL mediated by Golgi-like endings.

Progression Patterns of Range of Motion Progression after Open Release for Posttraumatic Elbow Stiffness

Background & Hypothesis

Post-traumatic stiffness of the elbow may be treated surgically with open osteocapsular release. This study investigated postoperative range of motion (ROM) improvements after this procedure. We hypothesized that there would be predictable recovery patterns and significant progress up to 6 months after surgery.

Methods

A retrospective chart review of patients who underwent open elbow release for post-traumatic stiffness (PTS) was performed. Demographic information and surgical approach were recorded. Patients with ipsilateral primary elbow osteoarthritis were excluded. Range of motion (ROM) data were collected at preoperative, intraoperative, and postoperative intervals of 2 weeks, 6 weeks, 3 months, and 6 months. Growth mixture modeling (GMM) and latent class growth analysis (LCGA) were performed to identify motion recovery trajectory groups, and Student's t-tests were performed to compare ROM data between intervals.

Results

One hundred and eighty-seven patients who underwent open elbow release for PTS were included (112 with a medial approach, 50 lateral, and 25 both). The mean preoperative arc was 84° ± 31, and the arc of motion at final follow-up was 119° ± 19 (P < .05). The mean time to the final follow-up arc of motion was 16 weeks, with 56% of patients achieving their final arc by their 3-month follow-up visit. The largest improvement was seen with extension between 6 weeks and 3 months, where 26% of the extension at final follow-up was gained. Most of the recovery occurred within the first 3 months postoperatively, with small improvements thereafter. GMM and LCGA did not identify statistically significant groups for postoperative ROM progression trajectories. Arc of motion preoperatively, intraoperatively, and at 2 weeks postoperatively did not correlate with the final arc of motion. There were no demographic or historical characteristics, or thresholds of motion, which conferred a higher likelihood of achieving a better result postoperatively.

Conclusions

ROM recovery after surgical release for post-traumatic elbow stiffness did not depend on the preoperative, intraoperative, or 2-week postoperative arcs of motion. Most ROM recovery occurs early after surgery, and maximal arc of motion can be expected by approximately 16 weeks postoperatively. This knowledge may inform patients about their expected rehabilitation and splinting time and reduce the total costs of therapy.

The post-traumatic stiff elbow: A review

Upper extremity function is highly dependent on elbow motion in order to adequately position the hand in space. Loss of this motion due to stiffness following trauma can cause patients substantial disability, leading to difficulties with performing activities of daily living. Post-traumatic elbow stiffness is challenging to treat, and therefore prevention is of paramount importance. Key measures that can be used to prevent elbow stiffness are early surgical intervention for fracture or joint instability, as well as active mobilisation, which helps to prevent oedema and an increase in viscosity of inflammatory exudates. Other options include splinting and continuous passive mobilisation. Once non-operative methods of addressing post-traumatic stiffness have been exhausted, arthrolysis of the stiff elbow can be performed via open or arthroscopic means depending on the type of pathology involved (intrinsic or extrinsic contracture) and experience of the surgeon with elbow arthroscopy. The particular open approach used depends on several factors, which include the formation and location of any heterotopic ossification present. Improvements in range of motion can be expected with both open and arthroscopic techniques, which can be effective and rewarding for patients. Post-operative rehabilitation, particularly early active mobilisation, should be considered essential in order to optimise patient outcomes following surgery. This review aims to explore elbow stiffness following traumatic aetiology, assessing its pathogenesis and prevention, as well as reviewing surgical treatment options and post-operative rehabilitation.

Identifying the Safe Zone in Arthroscopic Anterior Elbow Capsulectomy: A Cadaveric Study

The authors assessed the effects of forearm rotation on the proximity of the radial nerve and medial collateral ligament (MCL) to a proximal and a more distal arthroscopic anterior elbow capsulectomy. Arthroscopy was performed on 10 cadaveric specimens. Sutures were passed lateral to medial at the level of the radiocapitellar joint and at the proximal edge of the annular ligament. Dissection measured the distance to the radial nerve from the lateral starting point and to the MCL from the medial exit point in varying degrees of forearm rotation. The extent of brachialis muscle coverage of the radial nerve was documented. The distance from the starting point to the radial nerve increased in pronation at both levels. The medial extent of the capsulectomy remained a safe distance from the MCL. Brachialis muscle covered the radial nerve at both levels. Pronation increases the capsulectomy safe zone, including more distally, before encountering the radial nerve; the MCL is not at risk. [Orthopedics. 2020;43(5):e399-e403.].

Functional outcome following elbow release and hardware removal after bicolumnar fixation of distal humeral fractures

INTRODUCTION

Intra-articular fractures of the distal humerus are typically treated with bicolumnar plate fixation. Despite prompt and accurate reduction and fixation, there is a high rate of complications post-surgical fixation. The purpose of this study was to determine the indications, technique, and outcomes of patients who had undergone an elbow release and hardware removal following bicolumnar plate fixation for an intra-articular fracture of the distal humerus.

METHODS

Patients who had undergone an elbow release and hardware removal by a single surgeon following bicolumnar fixation of an intra-articular fracture of the distal humerus were identified. Patients were contacted to participate in a chart review and to return to clinic for a follow-up visit. Patients who returned for a follow-up visit completed the DASH (Disabilities of the Arm, Shoulder and Hand), the MEPS (Mayo Elbow Performance Score), and the SF-36.

RESULTS

Forty-two patients were included in the final analysis. The average time from the original injury to the elbow release procedure was 17.5 months. There was an improvement of 33° in the mean flexion-extension arc following the procedure (p<0.001). The mean DASH score was 21 (SD=19) and the mean MEPS score was 82 (SD=16). There was a high rate of post-traumatic osteoarthritis (n=30). Two patients underwent a total elbow arthroplasty (TEA). One patient sustained a re-fracture of the distal humerus, and subsequently underwent repeat bicolumnar fixation. There were four reoperations (10%): two patients had a revision release of contracture and two patients underwent a closed manipulation.

CONCLUSIONS

It appears safe to remove both plates and to re-intervene relatively early. There is a modest but consistent improvement in flexion-extension arc, and the re-operation rate is low. Although there is a high rate of post-traumatic arthritic change radiographically, TEA was rare, and elbow-based outcome scores were good, although not normal.

Inflammatory cytokines and matrix metalloproteinases in the synovial fluid after intra-articular elbow fracture

BACKGROUND AND HYPOTHESIS

Post-traumatic elbow contracture remains a common and challenging complication with often unsatisfactory outcomes. Although the etiology is unknown, elevated or abnormal post-fracture synovial fluid cytokine levels may result in the migration of fibroblasts to the capsule and contribute to capsular pathology. Thus, the purpose of this study was to characterize the cytokine composition in the synovial fluid fracture hematoma of patients with intra-articular elbow fractures.

METHODS

The elbow synovial fluid fracture hematoma of 11 patients with intra-articular elbow fractures was analyzed for CTXII (C-terminal telopeptides of type II collagen [a cartilage breakdown product]) as well as 15 cytokines and matrix metalloproteinases (MMPs) including interferon γ, interleukin (IL) 1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-10. The uninjured, contralateral elbow served as a matched control. Mean concentrations of each factor were compared between the fluid from fractured elbows and the fluid from control elbows.

RESULTS

The levels of 14 of 15 measured cytokines and MMPs-interferon γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-3, MMP-9, and MMP-10-were significantly higher in the fractured elbows. In addition, post hoc power analysis revealed that 10 of 14 significant differences were detected with greater than 90% power. The mean concentration of CTXII was not significantly different between groups.

CONCLUSIONS

These results demonstrate a proinflammatory environment after fracture that may be the catalyst to the development of post-traumatic elbow joint contracture. The cytokines with elevated levels were similar, although not identical, to the cytokines with elevated levels in studies of other weight-bearing joints, indicating the elbow responds uniquely to trauma.

Post-traumatic elbow stiffness: Pathogenesis and current treatments

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness?

BACKGROUND

The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied.

QUESTIONS/PURPOSES

We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure.

METHODS

Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62-83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery.

RESULTS

At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°-111°; p < 0.001), and 98% (48 of 49) of patients achieved a functional ROM of 30° to 130°. Improvements were also found in functional scores (MEPI: 54 ± 12 to 95 ± 7, mean difference, 41 points; DASH: 48 ± 17 to 8 ± 8, mean difference, 40 points; both p < 0.001), life quality (physical SF-36: 46 ± 11 to 81 ± 12, mean difference, 35 points; mental SF-36: 43 ± 14 to 80 ± 9, mean difference, 37 points; both p < .001), pain (VAS: 2.5 ± 2.4 to 0.4 ± 0.8; mean difference, 2.0 points; p < 0.001), and ulnar nerve function (Amadio score: 7.8 ± 1.9 to 8.4 ± 0.8; mean difference, 0.6 points; p = 0.004). A total of 18% (nine of 49 patients) developed complications, including new-onset or exacerbated nerve symptoms (four patients), recurrent heterotopic ossification (two patients), and pin-related infections (three patients). No patients underwent subsequent surgery for any of the above complications. Lastly, the medium-term ROM was divided into ROM ≤ 120° (n = 9) and ROM > 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2-47; p = 0.009) associated with recovery of ROM.

CONCLUSIONS

Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Use of a modified Outerbridge-Kashiwagi procedure for the treatment of posttraumatic elbow sequelae

BACKGROUND

To review our 10-year experience treating posttraumatic sequelae of the elbow using a modified Outerbridge-Kashiwagi (O-K) procedure.

METHODS

Twenty-one patients with posttraumatic sequelae of the elbow treated using the technique were evaluated clinically using the Mayo Elbow Performance Score, range of motion testing, and pain level. We noted the presence of preoperative and postoperative ulnar nerve symptoms, complications, and reoperations. Open contracture release was selected to address either removal of hardware or ulnar nerve pathology.

RESULTS

At a mean of 39 months (range, 12-116 months), the Mayo Elbow Performance Score improved from 52 to 84 (P < .0001) and the mean arc of motion improved from 44° to 98° (P < .0001). At the final follow-up, 90% of patients reported no pain or mild pain, and 81% of patients had a satisfactory objective result. In 15 of 21 cases (71%), it was necessary to mobilize the ulnar nerve. After contracture release, 1 patient developed new onset ulnar nerve symptoms. Three patients underwent reoperation: 2 for recalcitrant contracture and 1 for new onset ulnar nerve symptoms.

CONCLUSIONS

The mini-open O-K procedure is safe and effective in restoring function in patients with retained hardware and posttraumatic contracture. Posttraumatic arthritic patients often require both removal of hardware and neurolysis of the ulnar nerve. The mini-open O-K procedure allows complete access to the elbow joint, which facilitates release for both intrinsic and extrinsic contracture.

Multiple rare causes of post-traumatic elbow stiffness in an adolescent patient: A case report and review of literature

BACKGROUND

Joint stiffness after elbow surgery is not a rare complication, and is always accompanied by deformity. The causes of joint stiffness are multiple in different patients, and divided into intrinsic and extrinsic causes. Herein, we report an unusual case of posttraumatic elbow stiffness due to multiple and rare causes.

CASE SUMMARY

A 19-year-old male was hospitalized with the loss of motion of the left elbow for over ten years. Left limb computed tomography revealed left elbow stiffness with bony block and connection. The patient underwent surgery, and the etiology of joint stiffness was found to be a rare combination of common and uncommon causes. During an 18-mo follow-up period, the patient’s left elbow had normal motion and he was symptom-free.

CONCLUSION

However, this case combined with multiple and rare causes highlights that the patient with scar physique is likely to be accompanied with more severe soft tissue, nerve contracture, and heterotypic ossification, even during recurrence.

Surgical Management of the Posttraumatic Stiff Elbow: A Step-Wise Algorithm for Open Osteocapsular Release

Posttraumatic elbow stiffness is common with the primary indication for contracture release being limited motion that affects functional activities which has not adequately improved after intensive therapy and rehabilitation. Preoperative evaluation focuses on the history of previous nonoperative and/or operative treatment, physical exam with particular attention paid to the status of the ulnar nerve, and imaging consisting of radiographs and computed tomography. There are multiple intrinsic and extrinsic causes of posttraumatic contracture. In general, limitation of motion in one direction can be attributed to a mechanical block and/or opposing contracture or tightness. Open elbow contracture release has been shown to improve motion, patient health status and disability scores with the specific surgical approach based upon the contracture pathology and surgeon preference. A step-wise algorithm is presented for open osteocapsular release. An anterior and posterior release is performed first through a lateral approach with the addition of a medial approach if ulnar nerve dysfunction exists or inadequate release has been obtained from the lateral approach. A previous posterior incision can be utilized by raising full thickness flaps. After release, gentle manipulation is performed and intraoperative stability is assessed with stress testing under fluoroscopy. Postoperatively, pain is managed with an in-dwelling nerve catheter and rehabilitation commences immediately. Significant improvement in range of motion can be expected with adequate surgical release and postoperative rehabilitation.

[Performance control after arthroscopic arthrolysis with capsulectomy in fresh-frozen elbow joints]

BACKGROUND AND OBJECTIVE

Posttraumatic or postoperative movement restrictions in elbow joints can often occur (including capsular contracture) and can generate everyday limitations. In persistent elbow stiffness, arthroscopic arthrolysis with removal of the dorsal and ventral capsule portions can be carried out. The purpose of this study was to assess the efficacy of arthroscopic capsulectomy by means of an in vitro anatomical study.

METHODS

A standardized elbow arthroscopy with ventral and dorsal capsulectomy was performed and image-documented in five fresh-frozen elbow specimens. Subsequently, open dissection of the elbow joint was performed to analyze the amount of residual capsule by means of photodocumentation of the specimens.

RESULTS

Regardless of the surgeon and surgical experience, anterior and posterior remnants of the capsule remained in all specimens. Dorsal capsule strands around the standard arthroscopy portals were noticed particularly more often in the area of the high dorsolateral camera portal. An incomplete capsulectomy was seen on the ulnar side at the level of the posterior medial ligament (PML) in the immediate vicinity of the ulnar nerve. Ventrally, a capsulectomy was performed from the radial side and also the ulnar side until the brachialis muscle and additionally a complete capsulectomy as far as the anterior medial ligament (AML) and radial collateral ligament (RCL) was achieved. The capsule was completely resected in a proximal direction. Distally, irrelevant capsular remnants were found in the region of the annular ligament and distal of the tip of the coronoid process.

CONCLUSION

Arthroscopic arthrolysis can be performed with a high degree of radicality. The radicality must be self-critically taken into account in one's own action. The radicality of the portal change may even be higher ventrally than with an isolated column procedure. On the other hand, it must be critically considered that posteriorly, the PML cannot be adequately addressed by means of arthroscopy due to the risk of ulnar nerve injury. Portal changes might help to enable a more complete visualization of the joint capsule and may avoid leaving possibly relevant remnants of the capsule. If a release of the PML is required, this may have to be carried out in combination with an ulnar nerve release in a mini-open technique.

Arthroscopic Elbow Contracture Release in the Pediatric Patient

BACKGROUND

Elbow contracture is a sequelae of elbow trauma in pediatric patients. Arthroscopic contracture release has been shown to provide equivalent results to open contracture release with less associated morbidity and complications in the adult population. However, open contracture release is still commonly utilized in pediatric patients. The goal of this study is to determine the clinical results and safety profile of arthroscopic elbow contracture release in the pediatric population.

METHODS

A retrospective review of all patients 18 years of age and younger who underwent arthroscopic elbow contracture release was performed. Demographic statistics, indication for surgery, preoperative and postoperative flexion-extension and pronation-supination range of motion, and all complications were recorded and analyzed.

RESULTS

Twenty-five patients were identified as having undergone 29 arthroscopic elbow contracture releases. The most common index injury was elbow contracture after radial head fracture. The flexion-extension arc of motion improved from 93.0±39.9 degrees to 128.0±19.2 degrees for a total improvement of 35.2 degrees (P=0.0002), whereas the pronation-supination arc of motion improved from 141.0±58.6 degrees to 153±49.3 degrees for a total improvement of 12.2 degrees (P=0.097). There were 7 total complications.

CONCLUSIONS

Arthroscopic elbow contracture release allows for restoration of range of motion with an acceptable safety profile and can be considered as a less invasive alternative to open contracture release in the pediatric population.

LEVEL OF EVIDENCE

Level IV.

Posttraumatic Elbow Stiffness: A Critical Analysis Review

Open and arthroscopic release are both effective surgical treatments for posttraumatic elbow stiffness. Both static and dynamic bracing are effective for increasing elbow range of motion when heterotopic ossification is not present. Some loss of immediate postoperative range of motion is expected. Recurrence of heterotopic ossification around the elbow is rare. The occurrence of ulnar nerve palsy is rare and often requires transposition.

Arthroscopic debridement for primary elbow osteoarthritis with and without capsulectomy: a comparative cohort study

BACKGROUND

Arthroscopic elbow debridement for primary osteoarthritis may be performed with or without a joint capsulectomy. The purpose of this comparative cohort study was to compare range of motion (ROM) and early complications between patients with and without anterior capsulectomy.

METHODS

In total, 110 patients with primary osteoarthritis of the elbow who underwent an arthroscopic debridement for primary osteoarthritis were reviewed with a minimum of 3 months postoperative follow-up. The first group consisted of 51 patients who had a concomitant capsulectomy and the second group consisted of 59 patients who either had a capsulotomy or did not have the capsule addressed.

RESULTS

There was significantly greater pre-operative stiffness in the group who had an anterior capsulectomy versus those who did not. A greater improvement in arc of ROM occurred in patients who had a concomitant capsulectomy compared to patients without (24° versus 12°) (p < 0.003); however, there were no significant differences in final ROM between groups. There were no statistically significant differences in the incidence of complications between the groups (16% capsulectomy versus 18% no capsulectomy).

CONCLUSIONS

Elbow arthroscopy and debridement for primary elbow osteoarthritis yields satisfactory motion at short-term follow-up with or without a capsulectomy. The incidence of early complications was low at this tertiary referral centre, with no significant differences between groups.

Open surgical elbow contracture release after trauma: results and recommendations

BACKGROUND

Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture.

METHODS

A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded.

RESULTS

The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion.

CONCLUSION

Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.

Effect of disease duration on functional outcomes and complications after arthrolysis in patients with elbow stiffness

HYPOTHESIS

The purpose of this study was to determine the effect of a long duration of elbow stiffness on functional outcomes and complications after arthrolysis.

METHODS

Participants included consecutive patients with a long duration of elbow stiffness (≥5 years, n = 23) and control patients matched for age, sex, and initial injury type (n = 46). All patients underwent elbow arthrolysis combined with hinged external fixation between March 2014 and March 2016. At baseline and follow-up, we evaluated elbow motion (flexion, extension, supination, pronation, and range of motion) and patient-reported outcomes, including the Mayo Elbow Performance Score (MEPS) and visual analog scale for pain. Postoperative complications including infection, nerve dysfunction, and instability were recorded.

RESULTS

There were no significant differences in preoperative elbow pain, range of motion, or MEPS between groups. Postoperatively, pronation and the MEPS in patients with a long disease duration were inferior to those in control patients (P = .041 and P = .016, respectively). Patients with a long disease duration also had a significantly higher incidence of complications than control patients (P = .002). At final follow-up, 7 patients (30%) in the long disease duration group and 3 patients (7%) in the control group presented with nerve symptoms (P = .022).

CONCLUSIONS

A long duration of elbow stiffness may negatively influence functional outcomes and increase the risk of complications after arthrolysis.

The relation between elbow range of motion and patient satisfaction after open release of stiff elbow

Objective

The aim of this retrospective study was to find out whether a cut off value existed for elbow flexion and extension after open surgical release of elbow contracture that would correlate with subjective patient satisfaction.

Methods

The study enrolled 77 patients (53 males and 24 females with a mean age of 35.1 (18–77) years at the time of operation) with elbow contracture who attended regular follow-up appointments for more than 12 months. The mean follow up period was 44.2 months (12–186). The preoperative and postoperative modified MAYO elbow scores, objective parameters of increase in both flexion and extension end point measurements and improvement in total ROM were compared in order to determine the cut off degree of ROM in both flexion and extension that significantly correlated with patient satisfaction.

Results

Of the 77 participating patients, 26 patients had an extrinsic (33.8%) and 51 patients had an intrinsic elbow contracture (66.2%). Surgeries performed involved 40 cases of lateral release and 37 cases of both lateral and medial (progressive) release. The median preoperative total flexion-extension arch (ROM) was 45° (20°–65°). The median postoperative total flexion-extension arch (ROM) was 110° (97.5°–125°). The modified MAYO elbow score improved from 60 to 85 points postoperatively. The postoperative flexion cut off value was 115° for an excellent or good postoperative modified MAYO elbow score.

Conclusion

Post-operative flexion cut off value was 115° and had a positive effect on the postoperative patient satisfaction. The cut off value for postoperative extension was 20° but it was not a significant variable on patient satisfaction as was the total increase in ROM.

Level of significance

Level IV Therapeutic Study.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

The clinical implications of heterotopic ossification in patients treated with radial head replacement for trauma: A case series and review of the literature

Radial head arthroplasty (RHA) is an acceptable treatment for comminuted radial head fractures (RHF). Fourteen patients with no postop HO prophylaxis were treated with RHA for comminuted RHF. A 50% incidence in HO was seen following RHA with a statistically increased risk (p ≤ 0.05) of reoperation compared to those without HO. Decreased ROM was seen on the affected side (p ≤ 0.05); patients without HO showed no statistical difference (p ≥ 0.05) in ROM or grip strength. HO following RHA increases patient risk for reoperation and decreases ROM. We recommend HO prophylaxis with NSAIDs and/or radiotherapy if no direct patient contraindications are found.

The posttraumatic stiff elbow: an update

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Ulnar neuritis after open elbow arthrolysis combined with ulnar nerve subcutaneous transposition for post-traumatic elbow stiffness: outcome and risk factors

BACKGROUND

Ulnar neuritis (UN) is a common complication of open elbow arthrolysis for elbow stiffness. The purpose of this study was to evaluate the outcome of subcutaneous anterior transposition of the ulnar nerve during open elbow arthrolysis and to describe the risk factors for UN.

METHODS

We retrospectively studied 260 patients with post-traumatic elbow stiffness who underwent routine ulnar nerve transposition during open elbow arthrolysis. Patient demographics, clinical characteristics, and incidence and reoperation rate of UN were recorded. UN was defined as new-onset ulnar nerve symptoms and no relief or worsening of pre-existing ulnar nerve symptoms during the period of postoperative rehabilitation. Factors affecting the development of UN were analyzed by univariate and multivariate analyses.

RESULTS

A total of 9.2% of the patients had UN, 25% of whom required reoperation for progressive neuropathy. The Dellon grade of patients associated with UN at last follow-up improved significantly compared with that preoperatively. The mean arc of motion in patients with UN decreased during follow-up in a time-dependent manner. Univariate analysis showed that male sex, limited preoperative flexion and arc of motion, preoperative heterotopic ossification (HO), and preoperative ulnar nerve symptoms were significantly associated with the development of UN. Multivariate regression analysis revealed that preoperative HO was the only independent risk factor for the development of UN.

CONCLUSIONS

UN is still an important complication, although ulnar nerve subcutaneous transposition was performed during open arthrolysis for post-traumatic elbow stiffness. Identified risk factors for UN, especially preoperative HO, should be taken into consideration before surgery.

Complications of Open Elbow Arthrolysis in Post-Traumatic Elbow Stiffness: A Systematic Review

Objective

The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients with post-traumatic elbow stiffness and provide a reference for better prevention and treatment of them.

Methods

The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for therapeutic studies with a set of inclusion and exclusion criteria. Data were extracted from selected articles, and a statistical analysis was performed to evaluate related factors and management of the complications.

Results

Twenty-eight articles published between 1989 and 2013, involving 810 patients, were included. Most of the complications included in the selected articles were nerve complications, heterotopic ossification, elbow instability, infection, pin-related complications and repeat elbow contracture. The total complication rate was 24.3% ± 3.0%, and the reoperation rate was 34.0%. Furthermore, the statistical analysis revealed that preoperative range of motion (β = -0.004, P = 0.01) and proportion of female (β = 0.336, P = 0.04) were the independent factors affecting the total complication rate.

Conclusions

Various risk factors are related to each of the complications, and we found that patients with less preoperative ROM and a higher proportion of female gender may point to a higher total complication rate. Therefore, to further improve the overall outcomes of this procedure, more and larger prospective studies should be performed to further elucidate the effects of prophylactic interventions targeting the risk factors, thus improving the methods of prevention and treatment of complications.

Open surgical release for contractures of the elbow

Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.

Nonacute Treatment of Elbow Fracture with Persistent Ulnohumeral Dislocation or Subluxation

➤ There are patterns of traumatic elbow instability that help a surgeon to anticipate which structures are injured.➤ Patients treated for persistent subluxation or dislocation of the elbow more than two weeks after injury regain less motion and experience more adverse events.➤ The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion.➤ Motion and pain are affected by contracture and scarring of the soft tissues, malalignment of the joint, fracture malunion, damage to the articular surface, and ulnar neuropathy.➤ Biomechanical and clinical studies support treatment with radial head arthroplasty and/or coronoid reconstruction for patients who have osseous insufficiency.

Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury

BACKGROUND

Terrible triad injuries of the elbow, defined as elbow dislocation with associated fractures to the radial head and coronoid, are associated with stiffness, pain, and loss of motion. Studies to date have consisted of small sample sizes and used heterogeneous surgical techniques, which render comparisons difficult and unreliable.

QUESTIONS/PURPOSES

In a group of patients treated under a standard surgical protocol, we sought to determine the early dislocation rate, the range of motion in those not undergoing secondary procedures, the frequency and types of secondary surgical interventions required, the difference in motion between those undergoing secondary surgery and those who did not, and the frequency of heterotopic ossification and patient-reported stiffness.

METHODS

Patients underwent a surgical protocol that involved fixing the coronoid, fixing the radial head if possible, otherwise performing radial head arthroplasty, and repairing the lateral ligamentous structures. Patients were excluded if ipsilateral upper extremity fractures from the humerus to the distal forearm were present. Fifty-two patients had a minimum followup of 6 weeks and were included for the early dislocation rate, and 34 of these (65%) had a minimum of 6 months followup and were included for the rest of the data. Eighteen of the 52 (35%) were considered lost to followup because they were seen for less than 6 months postsurgically and were excluded from further analysis. Chart review was performed to determine the presence of early dislocation within the first 6 weeks after surgery, range of motion in patients not requiring a secondary procedure, the frequency and types of secondary procedures required, the range of motion before and after a secondary procedure if it was required, and postoperative stiffness. Postoperative radiographs were analyzed to determine the presence and severity of heterotopic ossification.

RESULTS

One of 52 patients sustained a dislocation within the first weeks of surgery (1.9%). Those not undergoing a secondary procedure were able to achieve a flexion arc of 110° and a supination-pronation arc of 148°. Nine of 34 patients (26%) underwent a secondary surgical procedure with stiffness, heterotopic ossification, and ulnar neuropathy being the most common surgical indications. Before secondary surgical procedures, patients had a flexion arc of 57° and a supination-pronation arc of 55°, which was less than those only requiring primary surgery alone (p < 0.001). After secondary surgery, patients were able to achieve a flexion arc of 96° and a supination-pronation arc of 124°, which was not different from those who did not undergo reoperation (p = 0.09 and p = 0.08, respectively). Twenty-eight of 34 patients demonstrated evidence of heterotopic ossification on radiographs, whereas 20 patients, including all nine undergoing secondary procedures, reported stiffness at the elbow.

CONCLUSIONS

Using a standardized surgical protocol, a low early dislocation rate was observed, although stiffness remains a challenge. Many patients who initially do not attain functional range of motion can usually attain this after secondary procedures aimed at removing the heterotopic ossification.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See guidelines for authors for a complete description of levels of evidence.

Medium-term results of arthroscopic debridement and capsulectomy for the treatment of elbow osteoarthritis

BACKGROUND

We retrospectively reviewed 20 patients (21 elbows) after arthroscopic debridement and capsulectomy of the elbow for primary osteoarthritis. We aimed to see if there was an improvement in pain, function, and range of movement in the medium-term.

MATERIALS AND METHODS

Outcomes of 20 patients (18 men, 2 women) with primary osteoarthritis of the elbow (21 elbows) operated on by the senior surgeon were reviewed at a mean of 5.5 years postoperatively. Inclusion criteria were patients with undergoing arthroscopic debridement and capsulectomy after failure of previous conservative treatment. Exclusion criteria were patients undergoing additional intra-articular procedures at surgery and patients with post-traumatic or inflammatory arthritis. Mean age was 42 years (range, 22-79 years). Preoperatively, osteoarthritis was classified based on plain x-ray images. Functional outcome was assessed using preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores, Mayo scores, and range of movement.

RESULTS

Radiographically, osteoarthritis was assessed as class I in 9 elbows, class II in 10 elbows, and class III in 3 elbows. There was a mean significant improvement in DASH score from 34.0 to 12.7 (P < .05). This was true for all grades of osteoarthritis and significant for classes II and III (P < .05). Mayo scores postoperatively were "excellent" in 11 elbows, "good" in 5, "fair" in 4, and "poor" in 1. Nineteen of the 20 patients said they would have had the surgery again.

CONCLUSION

Arthroscopic debridement and capsulectomy is an effective procedure for patients with primary osteoarthritis of the elbow. We propose this may work as a partial neurectomy to denervate pain sensation in the joint.

Surgical treatment of post-traumatic elbow stiffness: a systematic review

BACKGROUND

Trauma to the elbow is a common cause of joint stiffness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. There is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiffness. The objective of this article was to review current available literature of studies reporting on open or arthroscopic release of post-traumatic elbow stiffness.

METHODS

A comprehensive literature search was performed. All titles and abstracts of potentially relevant studies were reviewed, with a set of predefined inclusion and exclusion criteria. After the initial assessment for inclusion, 2 authors extracted data independently from the included articles.

RESULTS

Thirty articles were included, with an overall enrolment of 798 patients. No randomized controlled trials were retrieved. The first article was published in 1989 and the most recent in 2012. There were 4 different kinds of treatment modalities identified from the included studies: 1) open arthrolysis; 2) arthroscopic arthrolysis; 3) open arthrolysis with external fixation; and 4) open arthrolysis with distraction arthroplasty. The gain in range of motion was 51°, 40°, 88°, and 56° for groups 1-4, respectively. The average percentage of complications was 23, 5, 73, and 58 for groups 1-4, respectively.

CONCLUSION

Current literature is not sufficient enough to draw firm statistically based conclusions. However, as the amount of complications seems to rise with the extent of the surgical procedure, we would advise to treat as less invasive as possible (grade C).

Surgical release of elbow stiffness after internal fixation of intercondylar fracture of the distal humerus

BACKGROUND

Loss of motion is common after intercondylar fracture of the distal humerus despite proper management. The purpose of the current study was to report the results of contracture release for stiffness that developed after open reduction and internal fixation (ORIF) of distal humeral intercondylar fractures.

METHODS

Twenty-four consecutive patients with a stiff elbow after ORIF of intercondylar fractures (20 AO type C2 and 4 type C3 fractures) were managed with contracture release at a median of 13 months. The surgical indication was total arc of motion of less than 100° despite physical therapy for more than 6 months. Plates and screws for ORIF were removed concomitantly in 16 patients. Each patient was evaluated by final arc of motion and Mayo Elbow Performance Score (MEPS).

RESULTS

The main lesions causing stiffness were heterotopic ossification or excessive callus in 13 patients and capsular fibrosis in 11. The mean total range of motion (ROM) was improved from 60.2° preoperatively to 104.8° postoperatively. At the final follow-up, 17 of the 24 elbows (71.8%) obtained a total ROM of more than 100°. The mean MEPS improved from 69 points preoperatively to 87 points at the final follow-up (P < .05). Refracture occurred during ROM exercise in 4 patients who had undergone concomitant implant removal during the contracture release.

CONCLUSION

Surgical release of a stiff elbow that develops after ORIF of intercondylar fractures can result in satisfactory restoration of ROM in most patients. However, potential risk of refracture after release should be considered when implants are concomitantly removed.

The contracted elbow: is ulnar nerve release necessary?

BACKGROUND

Prophylactic release of the ulnar nerve in patients undergoing capsular release for severe elbow contractures has been recommended, although there are limited data to support this recommendation. Our hypothesis was that more severely limited preoperative flexion and extension would be associated with a higher incidence of postoperative ulnar nerve symptoms in patients undergoing capsular release.

MATERIALS AND METHODS

We conducted a retrospective review of 164 consecutive patients who underwent open or arthroscopic elbow capsular release for stiffness between 2003 and 2010. The ulnar nerve was decompressed if the patient had preoperative ulnar nerve symptoms or a positive Tinel test. Preoperative and postoperative range of motion and incidence of ulnar nerve symptoms were recorded.

RESULTS

The mean improvement in the arc of motion of was 36.7°. New-onset postoperative ulnar nerve symptoms developed in 7 of 87 patients (8.1%) who did not undergo ulnar nerve decompression; eventually, 5 of these patients with persistent symptoms underwent ulnar nerve decompression. The rate of developing postoperative symptoms was higher if patients had preoperative flexion ≤ 100° (15.2%) compared with those with preoperative flexion >100° (3.7%). There was no association between preoperative extension or gain in motion arc and postoperative symptoms.

CONCLUSIONS

The overall rate of ulnar nerve symptoms after elbow contracture release was low if ulnar nerve decompression was performed in patients with preoperative symptoms or a positive Tinel test. There was a higher rate of ulnar nerve symptoms in patients with more severe contractures (≤ 100° of preoperative flexion), which did not reach statistical significance.

Posttraumatic elbow stiffness

Early posttraumatic elbow contractures may be treated with a combination of manipulation with the patient under anesthesia followed by bracing.Extrinsic contractures of the elbow may be treated with open or arthroscopic release, whereas intrinsic and combined contractures may require tissue release as well as partial or total arthroplasty.

Outcomes of open arthrolysis of the elbow without post-operative passive stretching

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.

Ulnar collateral ligament reconstruction in posttraumatic elbow release

The purpose of this retrospective cohort comparison study was to determine the effect of ulnar collateral ligament reconstruction on postoperative range of motion (ROM) in patients undergoing posttraumatic elbow contracture release. Twenty-four consecutive patients underwent elbow arthrolysis. Six patients also underwent simultaneous collateral ligament excision and reconstruction, and 18 did not require ligament excision. All patients followed the same postoperative rehabilitation program. Minimum follow-up was 12 months. Final flexion/extension ROMs were similar in both groups. No subjective reports of postoperative elbow instability occurred in either group. Ligament reconstruction and early postoperative motion can be safely performed in the setting of posttraumatic elbow capsulectomy without sacrificing ROM gain or compromising stability provided by the ligament reconstruction.

EVALUATION OF THE RESULTS OF SURGICAL TREATMENT OF POSTTRAUMATIC STIFFNESS OF THE ELBOW IN SKELETALLY MATURE PATIENTS

Objective: To evaluate the results from surgical treatment of posttraumatic stiffness of the elbow in skeletally mature patients. Methods: Between October 2000 and October 2007, 45 elbows of 45 patients underwent surgical treatment performed by the Shoulder and Elbow Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. Ten patients were treated arthroscopically and the remainder by open surgery. The minimum follow-up was six months, with a mean of 22 months. Their ages ranged from 17 to 72 years, with a mean of 36 years and three months. Males predominated, accounting for 60% of the cases. The dominant limb was involved in 56.5% of the cases. The clinical evaluation of the results was done by using the criteria of the American Medical Association (AMA), as modified by Bruce; the Mayo Elbow Performance Score (MEPS); and measurements on the gain of flexion-extension arc and the final range of motion. Results: According to the AMA criteria, as modified by Bruce, 42.2% of our results were satisfactory, whereas 77.8% were satisfactory according to MEPS. The mean postoperative flexion-extension arc was 106°, and the main gain in range was 46°. The evaluation of the variables showed that patients with an initial flexion arc greater than 90° achieved a greater final flexion-extension arc, and those with an initial extension less than or equal to 60° gained greater range of motion. Conclusion: Surgical treatment of posttraumatic stiffness of the elbow in skeletally mature individuals was shown to be satisfactory according to MEPS, but unsatisfactory according to AMA. We observed that the patients with preoperative flexion greater than 90° evolved with a greater flexion-extension arc after surgical treatment, while those who had contracture with extension less than or equal to 60° gained a greater range of motion.

Health status after open elbow contracture release

BACKGROUND

Operative contracture release may improve motion of a posttraumatic stiff elbow. In this study, we tested the hypothesis that improvement in ulnohumeral motion after elbow contracture release leads to improvement in general health status and decreases upper-extremity-specific disability.

METHODS

Twenty-three patients with posttraumatic loss of ≥30° of elbow flexion or extension who elected to have an open elbow capsulectomy completed the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Short Form-36 (SF-36) preoperatively and at least one year postoperatively. Pain was measured with use of the American Shoulder and Elbow Surgeons (ASES) Elbow Evaluation instrument. Four patients underwent additional, subsequent procedures to address residual elbow stiffness.

RESULTS

One patient who needed several additional procedures, including a total elbow arthroplasty, was considered to have had a failure of the operative contracture release and was excluded from the analysis; this left twenty-two patients in the study. On the average, the arc of flexion and extension improved from 51° preoperatively to 106° postoperatively; the DASH score, from 38 points to 18 points; the SF-36 Physical Component Summary (PCS) score, from 39 points to 49 points (all p < 0.05); and the SF-36 Mental Component Summary (MCS) score, from 49 points to 54 points (p < 0.05). There was no significant correlation between the improvement in the arc of flexion and extension and the improvement in the DASH (p = 0.53), PCS (p = 0.73), or MCS (p = 0.41) score. There also was no correlation between the final arc of flexion and extension and the final DASH score (p = 0.39 for the total score, p = 0.52 for the PCS score, and p = 0.42 for the MCS score).

CONCLUSIONS

Health status and disability scores improve after open elbow contracture release, but the improvements do not correlate with the improvement in elbow motion. Among multiple objective and subjective factors, pain was a strong predictor of the final general health status and arm-specific disability.

Analysis of observational studies: a guide to understanding statistical methods

Observational studies provide an important source of information when randomized controlled trials cannot or should not be undertaken, provided that the data are analyzed and interpreted with special attention to bias. This article highlights the special analytic considerations required for proper reporting and interpretation of observational studies. We review statistical principles that are fundamental to understanding what observational data can offer. The concepts include the relationship between a study sample and the target population, and the two primary forms of statistical analysis: estimation and hypothesis testing. The concept of bias, and confounding in particular, is introduced as an obstacle to drawing valid conclusions from an observational study. The discussion will then focus on the techniques that are most useful in the analysis of the three most common types of observational studies (the case series, the therapeutic study, and the prognostic study). The goal of this review is to empower the reader to take a practical approach to and validly interpret the statistical analysis of these study types.

Terrible triad injury of the elbow: current concepts

Fracture-dislocations of the elbow remain among the most difficult injuries to manage. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. An elbow dislocation associated with a displaced fracture of the radial head and coronoid process almost always renders the elbow unstable, making surgical fixation necessary. The primary goal of surgical fixation is to stabilize the elbow to permit early motion. Recent literature has improved our understanding of elbow anatomy and biomechanics along with the pathoanatomy of this injury, thereby allowing the development of a systematic approach for treatment and rehabilitation. Advances in knowledge combined with improved implants and surgical techniques have contributed to better outcomes.

The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children

OBJECTIVES

To investigate the time required for elbow range of motion (ROM) recovery after supracondylar and lateral condylar fractures in children and to analyze the relationship between the ROM recovery and the related factors.

DESIGN

Retrospective study.

SETTING

Tertiary pediatric orthopaedic care unit at a general hospital.

PATIENTS/PARTICIPANTS

Forty-five children with distal humerus supracondylar fractures and 16 children with lateral condylar fractures were followed. Twenty-seven children with distal forearm fractures, which were immobilized with long arm casts, were used as a control group to study elbow flexion-extension recovery after immobilization without elbow fracture.

MAIN OUTCOME MEASUREMENTS

Elbow ROM was measured with a goniometer in a series of follow-up visits after cast removal until 90% ROM of the uninjured side had been reached. Morrey's definition was used to define ROM required for functional activity of daily living.

RESULTS

The supracondylar fracture group took 29.5, 39.0, 6.1, and 11.0 days to achieve 90% ROM in extension, flexion, supination, and pronation directions. The lateral condylar fracture group needed 30.2, 35.6, 2.3, and 8.9 days, respectively, in 4 directions. In the distal forearm fracture group, the elbow total flexion-extension angle required less than 2 weeks to reach a total arc of 135 degrees. The supination range was easier to recover than the pronation motion. The flexion recovered last among 4 directions in supra- and lateral condylar fractures.

CONCLUSIONS

In the uncomplicated distal humerus supracondylar and lateral condylar fractures, it takes 5 weeks to restore original elbow ROM after removal of long arm cast without physical therapy. This information could be applied in the education material to caregivers of children with elbow injuries.

The posttraumatic stiff elbow: a review of the literature

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.