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Cui H, Luo G, Wang Y, Luan M, He K, Ruan J, Li J, Lou T, Sun Z, Chen S, Yu S, Wang W, Fan C. Tranexamic acid in patients with post-traumatic elbow stiffness: protocol for a randomised, double-blind, placebo-controlled trial investigating the effectiveness of tranexamic acid at reducing the recurrence of heterotopic ossification after open elbow arthrolysis. BMJ Open 2023; 13:e075502. [PMID: 38110382 DOI: 10.1136/bmjopen-2023-075502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Exaggerated inflammatory response is one of the main mechanisms underlying heterotopic ossification (HO). It has been suggested that the antifibrinolytic drug tranexamic acid (TXA) can exert a significant anti-inflammatory effect during orthopaedic surgery. However, no prospective studies have yet investigated the effects of TXA on HO recurrence in patients following open elbow arthrolysis (OEA). METHODS AND ANALYSIS Here, we present a protocol for a single-centre, randomised, double-blind, placebo-controlled trial to investigate the effectiveness of TXA on HO recurrence after OEA in a single hospital. A minimum sample size of 138 eligible and consenting participants randomised into treatment and control groups in a 1:1 manner will be included. Patients will receive 2 g of intravenous TXA (experimental group) or placebo (normal saline, control group) administered before skin incision. The primary outcome is HO recurrence rate within 12 months after surgery. The secondary outcomes are the serum immune-inflammatory cytokines including erythrocyte sedimentation rate, C reactive protein, interleukin (IL)-6, IL-1β, IL-13 at the first and third day postoperatively, and elbow range of motion and functional score at 1.5, 6, 9 and 12 months after surgery. After completion of the trial, the results will be reported in accordance with the extensions of the Consolidated Standards of Reporting Trials Statement for trials. The results of this study should determine whether TXA can reduce the rates of HO occurrence after OEA. ETHICS AND DISSEMINATION Ethical approval has been granted by the Medical Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (reference number 2022-123-(1)). The results of this study will be disseminated through presentations at academic conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2300068106.
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Affiliation(s)
- Haomin Cui
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Gang Luo
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Yin Wang
- Nursing Department, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Luan
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kuangyu He
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Jihao Ruan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Juehong Li
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Tengfei Lou
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Ziyang Sun
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Shuai Chen
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Shiyang Yu
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
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Wang F, Wang J, Li M, Hu J, Song K, Zhang J, Fan Y. Biomechanical study of the effect of traction on elbow joint capsule contracture. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:21451-21466. [PMID: 38124605 DOI: 10.3934/mbe.2023949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Dynamic orthoses have a significant effect on the treatment of elbow capsular contracture. Because of the lack of quantitative research on traction forces, determining the appropriate traction force to help stretch soft tissues and maintain the joint's range of motion is a challenge in the rehabilitation process. We developed a human elbow finite element (FE) model incorporating the activity behavior of the muscles and considering different capsular contracture locations, including total, anterior and posterior capsular contractures, to analyze the internal biomechanical responses of different capsular contracture models during flexion (30 to 80 degrees). Traction loads of 10, 20, 30 and 40 N were applied to the ulna and radius at the maximum flexion angle (80 degrees) to explore the appropriate traction loads at week 4 after a joint capsule injury. We observed a significant increase in posterior capsule stress with anterior capsular contracture (ACC), and the maximum peak stress was 1.3 times higher than that in the healthy model. During the fourth week after elbow capsule injury, the appropriate traction forces for total capsule contracture (TCC), ACC and posterior capsule contracture (PCC) were 20, 10 and 20 N, respectively; these forces maintained a stable biomechanical environment for the elbow joint and achieved a soft tissue pulling effect, thus increasing elbow mobility. The results can be used as a quantitative guide for the rehabilitation physicians to determine the traction load for a specific patient.
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Affiliation(s)
- Fang Wang
- College of Mechanical Engineering, The Key Laboratory of Integrated Design and On-Line Monitoring of Light Industrial and Food Engineering Machinery and Equipment in Tianjin, Tianjin University of Science & Technology, Tianjin 300222, China
- Key Laboratory of Rehabilitation Aids Technology and System of the Ministry of Civil Afairs, National Research Center for Rehabilitation Technical Aids, Beijing 100176, China
| | - Jiaming Wang
- College of Mechanical Engineering, The Key Laboratory of Integrated Design and On-Line Monitoring of Light Industrial and Food Engineering Machinery and Equipment in Tianjin, Tianjin University of Science & Technology, Tianjin 300222, China
| | - Mingxin Li
- Department of Traumatic Orthopaedics, Tianjin Hospital, Tianjin 300299, China
| | - Jun Hu
- College of Mechanical Engineering, The Key Laboratory of Integrated Design and On-Line Monitoring of Light Industrial and Food Engineering Machinery and Equipment in Tianjin, Tianjin University of Science & Technology, Tianjin 300222, China
| | - Kehua Song
- College of Mechanical Engineering, The Key Laboratory of Integrated Design and On-Line Monitoring of Light Industrial and Food Engineering Machinery and Equipment in Tianjin, Tianjin University of Science & Technology, Tianjin 300222, China
| | - Jianguo Zhang
- College of Mechanical Engineering, The Key Laboratory of Integrated Design and On-Line Monitoring of Light Industrial and Food Engineering Machinery and Equipment in Tianjin, Tianjin University of Science & Technology, Tianjin 300222, China
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Sciences and Medical Engineering, Beihang University, Beijing 100083, China
- Beijing Advanced Innovation Centre for Biomedical Engineering, Beihang University, Beijing 100083, China
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Ghayyad K, Ahmadi Z, Rajabi H, Alimohammadi MM, Kachooei AR. Arthroscopic Capsular Release for Post-traumatic Elbow Stiffness. Cureus 2023; 15:e47838. [PMID: 38021529 PMCID: PMC10676772 DOI: 10.7759/cureus.47838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Post-traumatic elbow stiffness (PTES) may substantially affect the patient's functional range of motion and quality of life. Open elbow release has been extensively studied, but arthroscopic techniques are limited, particularly in differentiating between post-traumatic and non-traumatic stiffness. The purpose of this study is to assess the clinical outcomes after arthroscopic release of PTES regarding the range of motion (ROM), pain, functional assessment, and complications. METHODS A prospective cohort was conducted on adult patients who underwent arthroscopic arthrolysis for PTES, with 32 patients included in the final analysis. The ROM was measured using the orthopedic goniometer. Grip strength was measured using the Camry digital hand dynamometer (Camry, CA, USA) and compared to their contralateral side. The functional status of the patients was evaluated using the American Shoulder and Elbow Surgeons Score (ASES)andthe Mayo Elbow Performance Index (MEPI). All measurements were done before surgery and at the last follow-up visit. Pre-operative and post-operative changes in MEPI, ASES, and visual analog (VAS) scores were compared with the paired t-test. RESULTS After surgery, the ROM significantly improved from 74 ± 11 to 110 ± 15 degrees (p<0.001). Additionally, the ASES score and MEPI index both significantly improved from 69 ± 3.4 to 79 ± 6.3 and from 64 ± 5.7 to 82 ± 8, respectively (p<0.001). VAS scores also significantly improved from 1.1 ± 0.87 to 0.31 ± 0.53 at rest (p<0.001). The complication rate was 12%, including three transient ulnar nerve paresthesia and one superficial infection. Post-traumatic elbow release was more offered in distal humerus fractures (53%), followed by proximal ulna fracture/dislocations (25%). CONCLUSION We believe that arthroscopic arthrolysis is a safe and reliable treatment of PTES, which improves joint visibility and reduces pain. Patients can be counseled regarding the risk of a secondary surgery following distal humerus or proximal ulna fractures, including the expected recovery and complication rate.
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Affiliation(s)
- Kassem Ghayyad
- Orthopedic Surgery, Rothman Orthopaedics Florida at AdventHealth, Orlando, USA
| | - Zahra Ahmadi
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, IRN
| | - Hadi Rajabi
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, IRN
| | | | - Amir R Kachooei
- Orthopedic Surgery, Rothman Orthopaedics Florida at AdventHealth, Orlando, USA
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, IRN
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Contreras ES, Lynch DJ, Hatef S, Speeckaert AL, Goyal KS. Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults. Hand (N Y) 2023; 18:1169-1176. [PMID: 35264046 PMCID: PMC10798208 DOI: 10.1177/15589447221075667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to determine whether any relevant patient, fracture, surgical, or postoperative characteristics are associated with loss of reduction after plate fixation of isolated olecranon fractures in adults. METHODS Patients who underwent open reduction and internal fixation of an olecranon fracture at our institution over an 11-year period were analyzed. Electronic patient charts and radiographic images were reviewed to gather patient, fracture, surgical, and postoperative data. Statistical analysis to explore the differences between groups was performed. RESULTS Seven of 96 patients experienced a loss of fracture reduction diagnosed at a median of 19 days after their initial surgery (range: 4-116 days). The radiographic mode of failure of all patients who lost reduction was proximal migration of the proximal fracture fragment with or without implant failure. The group that lost reduction had a significantly smaller proximal fragment (14.2 vs 18.6 mm), a higher incidence of malreduction with a persistent articular step-off greater than 2 mm (6/7 vs 14/89), a greater distance between the most proximal screw and the olecranon tip (19.8 vs 13.5 mm), a higher proportion of constructs with screws placed outside of the primary plate (4/7 vs 14/89), and a higher proportion of patients that were not immobilized postoperatively (3/7 vs 8/89). CONCLUSIONS Our results suggest anatomical reduction at the articular surface and adequate fixation of the proximal fragment are key factors in maintenance of reduction, with smaller proximal fragments being at higher risk for failure. A period of postoperative immobilization may decrease the risk of loss of reduction.
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Affiliation(s)
| | - Daniel J. Lynch
- The Ohio State University Wexner Medical Center, Columbus, USA
| | - Sarah Hatef
- The Ohio State University Wexner Medical Center, Columbus, USA
| | | | - Kanu S. Goyal
- The Ohio State University Wexner Medical Center, Columbus, USA
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Omodani T. Supine-Position Ultrasound-Assisted Arthroscopic Surgery for Elbow Joint Contracture: A Case Report. Cureus 2023; 15:e46921. [PMID: 37954817 PMCID: PMC10640385 DOI: 10.7759/cureus.46921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
A 16-year-old male had a right elbow contracture after dislocation. The patient underwent supine-position ultrasound-assisted arthroscopic surgery, combining open removal of the posterior oblique ligament with the medial collateral ligament. The elbow joint flexion angle improved from 120 degrees to 145 degrees, and the extension angle improved from -50 degrees to 0 degrees. The patient returned to sports without recurrence of elbow joint contracture three months after surgery. Supine-positioned ultrasound-assisted arthroscopic surgery for elbow joint contracture is a safe and effective technique that eliminates the need for intraoperative position changes and big skin incisions.
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Affiliation(s)
- Toru Omodani
- Orthopedics, Tokyo Advanced Orthopedics, Tokyo, JPN
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Tamartash H, Bahrpeyma F, Mokhtari Dizaji M. Ultrasound evidence of altered lumbar fascia in patients with low back pain. Clin Anat 2023; 36:36-41. [PMID: 36199243 DOI: 10.1002/ca.23964] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/14/2022] [Accepted: 10/01/2022] [Indexed: 12/14/2022]
Abstract
Different hypotheses have been proposed about the role of lumbar connective tissue in low back pain (LBP). However, none of the previous studies have examined the change in the elastic behavior of lumbar fascia in patients with LBP. The present study aimed to evaluate the changes in the elastic behavior of lumbar fascia in patients with chronic non-specific LBP based on ultrasound imaging. The sonographic strain imaging assessed the thoracolumbar fascia (TLF) of 131 human subjects (68 LBP and 63 non-LBP). Assessments were done at L2-L3 and L4-L5 levels bilaterally. The points were located 2 cm lateral to the midpoint of the interspinous ligament. There were no significant differences in age, sex, and BMI between LBP and healthy individuals. There is a strong inverse relationship between pain severity (r = -0.76, n = 68, p = 0.004) and the TLF elastic modulus coefficient. No significant relationship were observed between age (r = 0.053, n = 68, p = 0.600), BMI (r = -0.45, n = 68, p = 0.092), and gender (r = -0.09, n = 68, p = 0.231) with the TLF elasticity coefficient. The LBP group had a 25%-30% lower TLF elastic modulus coefficient than healthy individuals. The present study is the first to evaluate the elastic coefficient of TLF using the ultrasound imaging method. The study results showed that the TLF elastic coefficient in patients with LBP was reduced compared to healthy individuals and directly related to LBP severity.
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Affiliation(s)
- Hassan Tamartash
- Department of Physiotherapy, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Farid Bahrpeyma
- Department of Physiotherapy, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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7
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Moore LK, Lee CS, Agha O, Liu M, Zhang H, Dang ABC, Dang A, Liu X, Feeley BT. A novel mouse model of hindlimb joint contracture with 3D-printed casts. J Orthop Res 2022; 40:2865-2872. [PMID: 35266583 DOI: 10.1002/jor.25313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/21/2021] [Accepted: 03/01/2022] [Indexed: 02/04/2023]
Abstract
Stiff joints formed after trauma, surgery or immobilization are frustrating for surgeons, therapists and patients alike. Unfortunately, the study of contracture is limited by available animal model systems, which focus on the utilization of larger mammals and joint trauma. Here we describe a novel mouse-based model system for the generation of joint contracture using 3D-printed clamshell casts. With this model system we are able to generate both reversible and irreversible contractures of the knee and ankle. Four- or 8-month-old female mice were casted for either 2 or 3 weeks before liberation. All groups formed measurable contractures of the knee and ankle. Younger mice immobilized for less time formed reversible contractures of the knee and ankle. We were able to generate irreversible contracture with either longer immobilization time or the utilization of older mice. The contracture formation translated into differences in gait, which were detectable using the DigiGait® analysis system. This novel model system provides a higher throughput, lower cost and more powerful tool in studying the molecular and cellular mechanisms considering the large existing pool of transgenic/knockout murine strains.
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Affiliation(s)
- Laura K Moore
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Carlin S Lee
- Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA
| | - Obiajulu Agha
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Mengyao Liu
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA
| | - He Zhang
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA.,Department of Exercise Physiology, Beijing Sport University, Beijing, China
| | - Alan B C Dang
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA
| | - Alexis Dang
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA
| | - Xuhui Liu
- Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA
| | - Brian T Feeley
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Orthopedic Surgery, San Francisco VA Medical Center, San Francisco, California, USA
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Whitten M, Silfies SP, Grampurohit N, Fedorczyk JM. A modified-delphi study establishing consensus in the therapeutic management of posttrauamtic elbow stiffness. J Hand Ther 2022; 35:299-307. [PMID: 35033398 DOI: 10.1016/j.jht.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 10/30/2021] [Accepted: 11/13/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Web-based modified Delphi study. BACKGROUND Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow. PURPOSE The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus. METHODS This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed. RESULTS Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule. CONCLUSIONS The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.
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Affiliation(s)
- Mary Whitten
- Drexel University, Bay Path University, VA Connecticut Healthcare System, West Haven, CT, USA.
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Athanaselis ED, Komnos G, Deligeorgis D, Hantes M, Karachalios T, Malizos KN, Varitimidis S. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022; 17:7-13. [PMID: 35734034 PMCID: PMC9166263 DOI: 10.5005/jp-journals-10080-1546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options. Materials and methods Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus. Results The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively. Conclusion In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function. How to cite this article Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7–13.
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Affiliation(s)
- Efstratios D Athanaselis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Georgios Komnos
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Dimitrios Deligeorgis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Michael Hantes
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Theofilos Karachalios
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Konstantinos N Malizos
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Sokratis Varitimidis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
- Sokratis Varitimidis, Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece, e-mail:
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CAVALCANTI ALISSONMARTINSGRANJA, OLIVEIRA FILHO RENATOSANTOSDE, GOMES HEITORCARVALHO, MARTINS AMANDABEZERRADESOUZA, GARCIA ELVIOBUENO, FERREIRA LYDIAMASAKO. REVIEW OF ARTICULATED ELBOW ORTHOTICS FOR JOINT STIFFNESS REHABILITATION. ACTA ORTOPÉDICA BRASILEIRA 2022; 30:e254358. [DOI: 10.1590/1413-785220223005e254358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022]
Abstract
ABSTRACT Joint stiffness is the most common complication in elbow injuries, presenting several etiologies and pathophysiological mechanisms that hinder treatment and prognosis. Prevention and treatment of joint contracture depend on the cause of stiffness, and early intervention should modify its outcomes. The methods used may be conservative or surgical, alone or in combination, according to each individual situation. Objective: Review articles on articulated elbow orthosis for joint stiffness rehabilitation. Methods: A literature review was conducted in journals available at the PubMed, Medline and LILACS databases, using the following Health Science Descriptors (DeCS): orthotic devices; braces; elbow; elbow joint; contracture; joint disorders. It sought to retrieve and analyze studies with the highest level of evidence that have already been conducted on articulated elbow orthosis for joint stiffness rehabilitation. Results: After applying the inclusion and exclusion criteria, four articles were included from PubMed and none from Medline or LILACS. Of the four PubMed articles, two were systematic reviews and two were randomized clinical trials. Conclusion: Articulated elbow orthoses can benefit joint stiffness treatment, improving range of motion and pain, showing superior effect compared to non-articulated plaster orthotics. Level of Evidence III, Systematic Review of Level III Studies.
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Bäcker HC, Freibott CE, Swart E, Perka C, Jobin CM, Rosenwasser MP. A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness.
Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).
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12
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Sim G, Fleming J, Glasgow C. Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice. J Hand Ther 2021; 34:90-99. [PMID: 32156579 DOI: 10.1016/j.jht.2019.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/10/2019] [Accepted: 12/31/2019] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Mixed-methods survey. INTRODUCTION Elbow stiffness and contractures often develop after trauma. There is a lack of evidence on mobilizing orthoses and the factors guiding orthotic prescription. PURPOSE OF STUDY To investigate hand therapists' orthotic preferences for varying extension and flexion deficits, and describe the factors affecting orthotic choice for post-traumatic elbow contractures. METHODS 103 members responded to the electronic survey via the Australian Hand Therapy Association mailing list. Five post-surgical scenarios were used to gather information regarding orthotic preferences, reasons and orthotic protocol: (1) week 8 with 55° extension deficit; (2) week 12 with 30° extension deficit; (3) week 12 with 55° extension deficit; (4) week 8 with flexion limited to 100°; (5) week 12 with limited flexion. RESULTS Most responders (89.9%) used mobilizing orthoses, predominantly for extension (88.5%). Orthotic preferences for scenarios 1 to 5 were (1) serial static (78.3%); (2) custom-made three-point static progressive (38.8%); (3) custom-made turnbuckle static progressive (33.8%); (4) "no orthosis" (27.9%); and (5) custom-made hinged (27.1%) and nonhinged (27.1%) dynamic. Choices were based on "effectiveness," "ease for patients to apply and wear," and "ease of fabrication/previous experience/comfortable with design." The recommended daily dosage for extension was 6 to 12 hour. DISCUSSION This is the first known study that reflects on the use of mobilizing orthoses in post-traumatic elbows in Australia. CONCLUSIONS Mobilizing orthoses are used routinely for post-traumatic elbows in Australia. Extension deficits are managed with serial static and static progressive orthoses at weeks 8 and 12, respectively. Research is needed to assess whether orthotic intervention before 12 weeks is beneficial in reducing contractures.
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Affiliation(s)
- Germaine Sim
- EKCO Hand and Upper Limb Rehabilitation Unit, South Brisbane, QLD, Australia; The University of Queensland, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, Australia.
| | - Jennifer Fleming
- The University of Queensland, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Celeste Glasgow
- Royal Brisbane and Women's Hospital, Occupational Therapy, Herston, QLD, Australia
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Dunham CL, Steenbock H, Brinckmann J, Reiter AJ, Castile RM, Chamberlain AM, Lake SP. Increased volume and collagen crosslinks drive soft tissue contribution to post-traumatic elbow contracture in an animal model. J Orthop Res 2021; 39:1800-1810. [PMID: 33258516 PMCID: PMC7744303 DOI: 10.1002/jor.24781] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/29/2020] [Accepted: 06/12/2020] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint contracture (PTJC) in the elbow is a biological problem with functional consequences. Restoring elbow motion after injury is a complex challenge because contracture is a multi-tissue pathology. We previously developed an animal model of elbow PTJC using Long-Evans rats and showed that the capsule and ligaments/cartilage were the primary soft tissues that caused persistent joint motion loss. The objective of this study was to evaluate tissue-specific changes within the anterior capsule and lateral collateral ligament (LCL) that led to their contribution to elbow contracture. In our rat model of elbow PTJC, a unilateral surgery replicated damage that commonly occurs due to elbow dislocation. Following surgery, the injured limb was immobilized for 42 days. The capsule and LCL were evaluated after 42 days of immobilization or 42 days of immobilization followed by 42 days of free mobilization. We evaluated extracellular matrix protein biochemistry, non-enzymatic collagen crosslink content, tissue volume with contrast-enhanced micro-computed tomography, and tissue mechanical properties. Increased collagen content, but not collagen density, was observed in both injured limb capsules and LCLs, which was consistent with the increased tissue volume. Injured limb LCLs exhibited decreased normalized maximum force, and both tissues had increased immature collagen cross-links compared to control. Overall, increased tissue volume and immature collagen crosslinks in the capsule and LCL drive their contribution to elbow contracture in our rat model.
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Affiliation(s)
- Chelsey L. Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, MO
| | - Heiko Steenbock
- Institute of Virology and Cell Biology, University of Lübeck, Germany
| | - Jürgen Brinckmann
- Institute of Virology and Cell Biology, University of Lübeck, Germany;,Department of Dermatology, University of Lübeck, Germany
| | - Alex J. Reiter
- Department of Mechanical Engineering, Washington University in St. Louis, MO
| | - Ryan M. Castile
- Department of Mechanical Engineering, Washington University in St. Louis, MO
| | | | - Spencer P. Lake
- Department of Biomedical Engineering, Washington University in St. Louis, MO;,Department of Mechanical Engineering, Washington University in St. Louis, MO;,Department of Orthopaedic Surgery, Washington University in St. Louis, MO
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14
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Akhtar A, Hughes B, Watts AC. The post-traumatic stiff elbow: A review. J Clin Orthop Trauma 2021; 19:125-131. [PMID: 34277339 PMCID: PMC8261251 DOI: 10.1016/j.jcot.2021.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022] Open
Abstract
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.
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15
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Ammerman BM, Updegrove G, Ponnuru P, Armstrong A. Analysis of Long-Term Outcomes Following Surgical Contracture Release of the Elbow: A Case Series. Cureus 2021; 13:e14691. [PMID: 34055535 PMCID: PMC8152451 DOI: 10.7759/cureus.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Elbow contracture is a debilitating condition with an incidence ranging from as low as almost 1% to as high as 20% and results in significant limiting consequences on a patient’s activities of daily living (ADLs). Postoperative rehabilitation is important in maintaining the range of motion and sustaining an improved range of motion. The purpose of this study was to evaluate the long-term results of elbow contracture release surgery and the effect of an occupational therapy/physical therapy (OT/PT)-guided, self-directed rehabilitation program following surgery, without the use of continuous passive motion (CPM) devices. Methods We enrolled patients who had undergone elbow contracture release surgery from 2005 to 2016 at a single institution under the senior author. The evaluation included objective measurements of range-of-motion, strength, and neurological sensory testing. Provocative testing of the elbow and hand was performed. American Shoulder and Elbow Surgeons-elbow (ASES-e), Simple Shoulder Test-elbow (SST-e), Disabilities of the Arm and Shoulder (DASH), Mayo Elbow Performance Index (MEPI), Short Form-36 (SF-36), and an investigator questionnaire were completed. Results We enrolled 19 patients, six female and 13 male, with an average follow-up of 58.9 months (SD± 39.8, Range 22-117). We showed improvement and sustained motion between preoperative and postoperative research visit flexion (p<0.001) and flexion extension-arc (p<0.01). The mean increase in flexion was 98° to 131° and the flexion-extension arc was 36°. Patients were satisfied with the decision to undergo surgery and had sustained ability to complete ADLs. Discussion This patient cohort demonstrated a statistically significant increase, as well as long-term maintenance in the flexion and flexion-extension arc. A self-directed, OT/PT-guided, therapy program without CPM was effective. Patients showed good outcomes and were satisfied with their ability to perform ADLs, decreased pain, and the decision to undergo surgery.
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Affiliation(s)
- Brittany M Ammerman
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Gary Updegrove
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Padmavathi Ponnuru
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - April Armstrong
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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16
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Oh WT, Do WS, Oh JC, Koh IH, Kang HJ, Choi YR. Comparison of arthroscopy-assisted vs. open reduction and fixation of coronoid fractures of the ulna. J Shoulder Elbow Surg 2021; 30:469-478. [PMID: 32750532 DOI: 10.1016/j.jse.2020.06.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical and radiographic outcomes and complications for arthroscopy-assisted vs. open reduction and fixation of coronoid fractures in patients with complex elbow fracture-dislocations. METHODS This retrospective study analyzed patients with complex elbow fracture-dislocations who underwent surgical fixation for coronoid fractures of the ulna from March 2009 to January 2016. Subjects included those who received either arthroscopy-assisted (group A) or open surgery (group O) for coronoid fractures and concurrent reconstruction of the lateral column (radial head and/or lateral ulnar collateral ligament) with follow-up for at least 2 years. Clinical outcomes were assessed using the visual analog scale for pain, range of motion, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand score at 2 years after surgery. For radiographic assessment, union of the coronoid, development of heterotopic ossification, and arthritic changes were evaluated. We also reviewed surgery-related complications. RESULTS Twenty-five patients (mean age, 40.0 ± 12.4 years) were enrolled in this study (group A, 15 patients; group O, 10 patients), and there were no statistical differences in baseline data between the 2 groups. Clinical outcomes did not differ between the 2 groups. All fractures were united and that the prevalence of heterotopic ossification and arthritic changes were similar between the 2 groups. However, operation-related complications were more common in group O than in group A (group A, 13.3%; group O, 40.0%), including 1 patient who underwent ulnar nerve neurolysis and anterior transposition at 3 months after the initial operation. CONCLUSIONS Eliciting fewer complications, arthroscopy-assisted reduction and fixation of coronoid fractures shows union rates and clinical results comparable to open fixation in patients with complex elbow fracture-dislocation.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Woo-Sung Do
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Jin-Chul Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea.
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Tat AM, Can F, Tat NM, Sasmaz HI, Antmen AB. The effects of manual therapy and exercises on pain, muscle strength, joint health, functionality and quality of life in haemophilic arthropathy of the elbow joint: A randomized controlled pilot study. Haemophilia 2021; 27:e376-e384. [PMID: 33626198 DOI: 10.1111/hae.14281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Effective physiotherapy interventions are required for haemophilic arthropathy (HA) of the elbow due to its biomechanical differences and contribution to upper limb functionality. AIM To investigate the effects of manual therapy & exercises on bleeding frequency, pain, range of motion (ROM), strength, joint health, functionality and quality of life (QoL) in HA of the elbow. METHODS Seventeen participants with HA of the elbow were randomized as Manual Therapy & Exercises Group (MTEG = 9) and Home Exercises Group (HEG = 8). Soft tissue mobilization, joint traction (grade I-II) and Mulligan's mobilization with movement as manual therapy, and stretching/strengthening exercises were applied to MTEG, while HEG had only same exercises as home programme. The interventions lasted 3 days/weekly for 5 weeks. Bleeding frequency was evaluated with patients' records; pain with Numeric Pain Scale; ROM with goniometer; strength with digital dynamometer; joint health with HJHS; functionality with Quick-Disability of Arm, Shoulder and Hand questionnaire; and QoL with Oxford Elbow Score. RESULTS Bleeding frequency and activity pain were decreased, while elbow ROMs and flexor strength were increased in MTEG (P ˂ 0.05). Also significantly improvements were seen in joint health, functionality and QoL in MTEG. HEG showed improvements in activity pain, QoL and some ROMs. MTEG had better results in ROMs, joint health and functionality (P ˂ 0.05). CONCLUSION Manual therapy & exercises may be used without causing bleeding and pain to increase the functionality, joint health and QoL, and is superior to home exercise for joint health and functionality. Home exercises may be ameliorated in pain, QoL and some ROMs.
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Affiliation(s)
- Ayse Merve Tat
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Necmettin Erbakan University, Konya, Turkey
| | - Filiz Can
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Necati Muhammed Tat
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Necmettin Erbakan University, Konya, Turkey
| | - Hatice Ilgen Sasmaz
- Faculty of Medicine, Department of Pediatric Hematology and Oncology, Cukurova University, Adana, Turkey
| | - Ali Bulent Antmen
- Department of Pediatric Hematology and Oncology, Acıbadem Hospital, Adana, Turkey
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18
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PrEvention of Posttraumatic contractuRes with Ketotifen 1 (PERK 1): A Randomized Clinical Trial. J Orthop Trauma 2020; 34:e442-e448. [PMID: 32639394 DOI: 10.1097/bot.0000000000001878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the use of ketotifen fumarate (KF) to reduce posttraumatic contractures after elbow fractures and/or dislocations. DESIGN Randomized clinical trial. SETTING Three hospitals in Calgary, Canada, including one Level 1 trauma center. PARTICIPANTS Adults (n = 151) sustaining operative or nonoperatively managed isolated distal humerus or proximal radius ± ulna fractures or elbow dislocations within 7 days of injury. INTERVENTIONS KF 5 mg (n = 74) or lactose placebo (PL, n = 77) orally twice daily for 6 weeks. MAIN OUTCOMES Primary outcome elbow flexion-extension arc range of motion (ROM) at 12 weeks postrandomization. Safety measures including serious adverse events and radiographic fracture line disappearance from 2 to 52 weeks postrandomization. RESULTS The elbow ROM (mean, confidence interval) was not significantly different between KF (122 degrees, 118-127 degrees) and PL (124 degrees, 119-130 degrees) groups (P = 0.56). There was a significant difference in elbow ROM at 12 weeks postrandomization comparing operative (117 degrees, 112-122 degrees) versus nonoperative groups (128 degrees, 124-133 degrees) irrespective of intervention (P = 0.0011). There were 11 serious adverse events (KF = 6, PL = 5) that were those expected in an elbow fracture population potentially taking KF. There was no statistically significant difference in the rates of these events between the groups. The disappearance of fracture lines over the course of time was similar between groups. There was one nonunion in each group. CONCLUSIONS In a population of operative and nonoperatively managed elbow fractures and/or dislocations KF did not reduce posttraumatic contractures. The administration of KF in this population was not found to result in a significantly higher number of major adverse events when compared with placebo. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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19
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Liu CS, Ademola A, Zhang M, Garven A, Kopka M, Salo PT, Hart DA, Befus AD, Hildebrand KA. Human serum mast cell tryptase levels in elbow fractures or dislocations and its association with injury severity. J Orthop Res 2020; 38:2015-2019. [PMID: 32112583 DOI: 10.1002/jor.24642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/07/2020] [Accepted: 02/19/2020] [Indexed: 02/04/2023]
Abstract
Mast cells contain an abundance of tryptase, and preclinical models have shown elevated serum mast cell tryptase (SMCT) in the setting of posttraumatic joint contractures. Therefore, SMCT emerged as a potential biomarker to help recognize patients with more severe injuries and a higher likelihood of developing contractures. The objective of this study is to assess SMCT levels in participants with varying severity of elbow fractures and/or dislocations. A prospective cohort including 13 participants with more severe injuries that required an operation and 28 participants with less severe injuries managed nonoperatively were evaluated. A control group of eight individuals without elbow injuries was also evaluated. The SMCT levels were measured using an enzyme-linked immunosorbent assay kit specific for human mast cell tryptase. A one-way analysis of variance and Tukey's Honest Significance test was used to assess for statistical significance among and between the three groups. The average time from injury to the collection of the blood samples was 4 ± 2 days. Highly significant differences were identified between the operative, nonoperative, and control groups (P = .0005). In the operative group, SMCT levels were significantly higher than the nonoperative group (P = .0005) and the control group (P = .009), suggesting a correlation between SMCT levels and injury severity. There was no statistically significant difference in SMCT levels between the nonoperative and control groups. The SMCT levels were elevated in participants with acute elbow injuries requiring operative intervention, suggesting that SMCT levels were higher in injuries regarded as more severe.
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Affiliation(s)
- Crystal S Liu
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ayoola Ademola
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mei Zhang
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Garven
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michaela Kopka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Banff Sport Medicine, Banff, Alberta, Canada
| | - Paul T Salo
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David A Hart
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Bone and Joint Health Strategic Clinic Network, Edmonton, Alberta, Canada
| | - A Dean Befus
- Department of Medicine, Alberta Respiratory Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin A Hildebrand
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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20
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Roulet S, Charruau B, Mazaleyrat M, Ferembach B, Marteau E, Laulan J, Bacle G. Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy. Tech Hand Up Extrem Surg 2020; 25:84-88. [PMID: 32868694 DOI: 10.1097/bth.0000000000000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.
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Affiliation(s)
- Steven Roulet
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Bertille Charruau
- Department of Upper Limb and Hand Surgery, Clinique de l'Essonne, Cedex, France
| | - Matthieu Mazaleyrat
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Benjamin Ferembach
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Emilie Marteau
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Jacky Laulan
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Guillaume Bacle
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
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21
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Arthroscopic anterior capsular release for posttraumatic elbow flexion contracture in pediatric patients: a case report of two patients with treatment protocol. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Masci G, Cazzato G, Milano G, Ciolli G, Malerba G, Perisano C, Greco T, Osvaldo P, Maccauro G, Liuzza F. The stiff elbow: Current concepts. Orthop Rev (Pavia) 2020; 12:8661. [PMID: 32913596 PMCID: PMC7459370 DOI: 10.4081/or.2020.8661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 01/14/2023] Open
Abstract
Elbow stiffness is defined as any loss of movement that is greater than 30° in extension and less than 120° in flexion. Causes of elbow stiffness can be classified as traumatic or atraumatic and as congenital or acquired. Any alteration affecting the stability elements of the elbow can lead to a reduction in the arc of movement. The classification is based on the specific structures involved (Kay’s classification), anatomical location (Morrey’s classification), or on the degree of severity of rigidity (Vidal’s classification). Diagnosis is the result of a combination of medical history, physical examination (evaluating both active and passive movements), and imaging. The loss of soft tissue elasticity could be the result of bleeding, edema, granulation tissue formation, and fibrosis. Preventive measures include immobilization in extension, use of post-surgical drain, elastic compression bandage and continuous passive motion. Conservative treatment is used when elbow stiffness has been present for less than six months and consists of the use of serial casts, static or dynamic splints, CPM, physical therapy, manipulations and functional re-education. If conservative treatment fails or is not indicated, surgery is performed. Extrinsic rigidity cases are usually managed with an open or arthroscopic release, while those that are due to intrinsic causes can be managed with arthroplasties. The elbow is a joint that is particularly prone to developing stiffness due to its anatomical and biomechanical complexity, therefore the treatment of this pathology represents a challenge for the physiotherapist and the surgeon alike.
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Affiliation(s)
- Giulia Masci
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Gianpiero Cazzato
- Università Cattolica del Sacro Cuore, Rome.,Artrogruppo, Clinica San Feliciano, Rome
| | - Giuseppe Milano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia.,Department of Bone and Joint Surgery, Spedali Civili, Brescia, Italy
| | - Gianluca Ciolli
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Giuseppe Malerba
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Carlo Perisano
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Tommaso Greco
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Palmacci Osvaldo
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Giulio Maccauro
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Francesco Liuzza
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
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Wahl EP, Lampley AJ, Chen A, Adams SB, Nettles DL, Richard MJ. Inflammatory cytokines and matrix metalloproteinases in the synovial fluid after intra-articular elbow fracture. J Shoulder Elbow Surg 2020; 29:736-742. [PMID: 31784384 DOI: 10.1016/j.jse.2019.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/14/2019] [Accepted: 09/23/2019] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Elizabeth P Wahl
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Alexander J Lampley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Angel Chen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dana L Nettles
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marc J Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Ademola A, Hildebrand KA, Schneider PS, Mohtadi NGH, White NJ, Bosse MJ, Garven A, Walker REA, Sajobi TT. PrEvention of posttraumatic contractuRes with Ketotifen 2 (PERK 2) - protocol for a multicenter randomized clinical trial. BMC Musculoskelet Disord 2020; 21:123. [PMID: 32093652 PMCID: PMC7041204 DOI: 10.1186/s12891-020-3139-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Injuries and resulting stiffness around joints, especially the elbow, have huge psychological effects by reducing quality of life through interference with normal daily activities such as feeding, dressing, grooming, and reaching for objects. Over the last several years and through numerous research results, the myofibroblast-mast cell-neuropeptide axis of fibrosis had been implicated in post-traumatic joint contractures. Pre-clinical models and a pilot randomized clinical trial (RCT) demonstrated the feasibility and safety of using Ketotifen Fumarate (KF), a mast cell stabilizer to prevent elbow joint contractures. This study aims to evaluate the efficacy of KF in reducing joint contracture severity in adult participants with operately treated elbow fractures and/or dislocations. Methods/design A Phase III randomized, controlled, double-blinded multicentre trial with 3 parallel groups (KF 2 mg or 5 mg or lactose placebo twice daily orally for 6 weeks). The study population consist of adults who are at least 18 years old and within 7 days of injury. The types of injuries are distal humerus (AO/OTA type 13) and/or proximal ulna and/or proximal radius fractures (AO/OTA type 2 U1 and/or 2R1) and/or elbow dislocations (open fractures with or without nerve injury may be included). A stratified randomization scheme by hospital site will be used to assign eligible participants to the groups in a 1:1:1 ratio. The primary outcome is change in elbow flexion-extension range of motion (ROM) arc from baseline to 12 weeks post-randomization. The secondary outcomes are changes in ROM from baseline to 6, 24 & 52 weeks, PROMs at 2, 6, 12, 24 & 52 weeks and impact of KF on safety including serious adverse events and fracture healing. Descriptive analysis for all outcomes will be reported and ANCOVA be used to evaluate the efficacy KF over lactose placebo with respect to the improvement in ROM. Discussion The results of this study will provide evidence for the use of KF in reducing post-traumatic joint contractures and improving quality of life after joint injuries. Trial registration This study was prospectively registered (July 10, 2018) with ClinicalTrials.gov reference: NCT03582176.
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Affiliation(s)
- Ayoola Ademola
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Canada.
| | - Kevin A Hildebrand
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada.,Department of Surgery, University of Calgary, Calgary, Canada
| | - Prism S Schneider
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Department of Surgery, University of Calgary, Calgary, Canada
| | - Nicholas G H Mohtadi
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada.,Department of Surgery, University of Calgary, Calgary, Canada
| | - Neil J White
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, USA
| | | | - Richard E A Walker
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada.,Department of Radiology, University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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25
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Rotem G, Herman A, Lidar M, Eshed I. Post-traumatic arthritis of the sacroiliac joints mimicking inflammatory sacroiliitis: analysis of consecutive computed tomography examinations. Clin Radiol 2020; 75:433-440. [PMID: 32044095 DOI: 10.1016/j.crad.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 01/08/2020] [Indexed: 12/27/2022]
Abstract
AIM To assess the presence, prevalence and characteristics of post-traumatic, inflammatory-like changes of the sacroiliac joint (SIJ) on pelvic computed tomography (CT). MATERIALS AND METHODS Sequential CT examinations from the acute (index) and follow-up post-traumatic periods of 24 patients that underwent pelvic trauma with SIJ involvement were evaluated and compared to 32 control patients with pelvic fractures that did not involve the SIJs. Index CT was evaluated for the presence of fracture, intra-articular step, and diastasis, whereas follow-up CT was scored for periarticular sclerosis, erosions, ankylosis, and backfill. Clinical follow-up was performed by pain provocation SIJ tests and a questionnaire (study representative subgroup, n=11, 46%) and from clinical files (control group, n=26, 31%). Pearson correlation coefficient was assessed between the index and follow-up CT variables. Linear regression was used to predict the influence of trauma variables on the development of inflammatory-like structural changes. RESULTS Total "structural, arthritis-like lesions' score from the follow-up CT examination was significantly higher in the study compared to the control group (3.25 versus 0.05 respectively, p<0.001). The presence of intra-articular diastasis and fracture were significant risk factors for the development of structural inflammatory-like lesions in the SIJ (1.19 and 2.1 respectively, p<0.001). Painful SIJs by physical examination were found in 50% of the clinically evaluated subgroup which was mechanical by nature in 81.8%. CONCLUSION Traumatic SIJ fracture or diastasis is associated with the development of post-traumatic SIJ structural inflammatory-like lesions on pelvic CT, mimicking sacroiliitis. These findings may be the result of focal, post-traumatic joint inflammation, which leads to mechanical rather than inflammatory symptoms.
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Affiliation(s)
- G Rotem
- Department of Orthopedic Surgery, Sheba Medical Center, 52621, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Herman
- Department of Orthopedic Surgery, Assuta Ashdod Medical Center, 7747629, Affiliated to Ben Gurion University, Beer Sheva, Israel
| | - M Lidar
- Rheumatology Unit, Sheba Medical Center, 52621, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Eshed
- Department of Diagnostic Imaging, Sheba Medical Center, 52621, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Wessel LE, Gu A, Richardson SS, Fufa DT, Osei DA. Elbow contracture following operative fixation of fractures about the elbow. JSES OPEN ACCESS 2019; 3:261-265. [PMID: 31891023 PMCID: PMC6928310 DOI: 10.1016/j.jses.2019.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The rates of elbow contracture and contracture release after surgically treated elbow trauma are poorly defined. The purpose of this study was to define the incidence of elbow contracture diagnosis and release after surgical treatment for elbow trauma. METHODS The Humana insurance database was queried using the PearlDiver Patient Records Database between 2007 and 2017. Subjects were identified using International Classification of Diseases (ICD) codes in combination with Current Procedural Terminology codes and were included if they had a minimum of 1-year follow-up. Qualifying operative elbow trauma patients were queried for development of postoperative elbow contracture. Patient demographic characteristics, risk factors for elbow stiffness, and use of postoperative anticoagulation were recorded. Fracture severity was classified based on ICD-9 and ICD-10 codes. Logistic multivariate analysis was performed to determine independent risk factors for postoperative elbow contracture. RESULTS The study population included 10,672 patients who were surgically treated for elbow trauma. In total, 902 patients (8.4%) were diagnosed with a contracture following fracture. Of patients with a diagnosis of elbow contracture, 65 patients (7.2%) underwent contracture release. On average, time to contracture diagnosis was 3.6 months (SD 7 months) and time to contracture release was 8.4 months (SD 3.6 months). The use of postoperative anticoagulation, burn or head injury at the time of fracture, male sex, obesity, opioid use, and moderate or severe fracture severity were significantly associated with progression to elbow contracture. CONCLUSION The development of elbow contracture after surgical treatment of elbow trauma has a relatively high incidence of 8.4%.
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Affiliation(s)
- Lauren E. Wessel
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Jayakumar P, Teunis T, Vranceanu AM, Moore MG, Williams M, Lamb S, Ring D, Gwilym S. Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures. J Shoulder Elbow Surg 2019; 28:1431-1440. [PMID: 31327393 DOI: 10.1016/j.jse.2019.04.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury. METHODS We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R2, correlation matrices, and variable inflation factor assessment. RESULTS There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points. CONCLUSIONS Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.
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Affiliation(s)
- Prakash Jayakumar
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Teun Teunis
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Meredith Grogan Moore
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Mark Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Headington Campus, Oxford, UK
| | - Sarah Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Ring
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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D'Ambrosi R, Formiconi F, Ursino N, Rubino M. Treatment of complete ankylosed elbow with total arthroplasty. BMJ Case Rep 2019; 12:12/7/e231123. [PMID: 31331932 DOI: 10.1136/bcr-2019-231123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We reported the case of a 38-year-old patient who in 2017 presented to our institution after post-traumatic complete ankylosis of the elbow. He complained of stiffness and pain, and the radiographs revealed complete fusion of the humeroulnar joint. The Mayo Elbow Performance Score (MEPS) on admission was 31, and the elbow was fused at 90° flexed position. The patient underwent semiconstrained total elbow arthroplasty with Bryan-Morrey approach; after a 2.1 years follow-up, active arc of movement was 120°. The MEPS was excellent with a 100 points score, the patient was able to complete all activities of daily living. We did not report any complications. Total elbow arthroplasty has shown to be a good therapeutic option that make it possible to restore adequate functional range of motion and relieve pain in young patients with post-traumatic stiffness/arthritis of the elbow.
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Pan BQ, Huang J, Ni JD, Yan MM, Xia Q. Multiple rare causes of post-traumatic elbow stiffness in an adolescent patient: A case report and review of literature. World J Clin Cases 2019; 7:1191-1199. [PMID: 31183352 PMCID: PMC6547331 DOI: 10.12998/wjcc.v7.i10.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/26/2019] [Accepted: 04/19/2019] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Bai-Qi Pan
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jun Huang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jiang-Dong Ni
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Ming-Ming Yan
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Qin Xia
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
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Dunham CL, Castile RM, Chamberlain AM, Lake SP. The Role of Periarticular Soft Tissues in Persistent Motion Loss in a Rat Model of Posttraumatic Elbow Contracture. J Bone Joint Surg Am 2019; 101:e17. [PMID: 30845041 PMCID: PMC6738539 DOI: 10.2106/jbjs.18.00246] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow injuries disrupt the surrounding periarticular soft tissues, which include the muscles, tendons, capsule, ligaments, and cartilage. Damage to these tissues as a result of elbow trauma causes clinically significant contracture in 50% of patients. However, it is unclear which of these tissues is primarily responsible for the decreased range of motion. We hypothesized that all tissues would substantially contribute to elbow contracture after immobilization, but only the capsule, ligaments, and cartilage would contribute after free mobilization, with the capsule as the primary contributor at all time points. METHODS Utilizing a rat model of posttraumatic elbow contracture, a unilateral soft-tissue injury was surgically induced to replicate the damage that commonly occurs during elbow joint dislocation. After surgery, the injured limb was immobilized for 42 days. Animals were evaluated after either 42 days of immobilization (42 IM) or 42 days of immobilization with an additional 21 or 42 days of free mobilization (42/21 or 42/42 IM-FM). For each group of animals, elbow mechanical testing in flexion-extension was completed post-mortem with (1) all soft tissues intact, (2) muscles/tendons removed, and (3) muscle/tendons and anterior capsule removed. Total extension was assessed to determine the relative contributions of muscles/tendons, capsule, and the remaining intact tissues (i.e., ligaments and cartilage). RESULTS After immobilization, the muscles/tendons and anterior capsule contributed 10% and 90% to elbow contracture, respectively. After each free mobilization period, the muscles/tendons did not significantly contribute to contracture. The capsule and ligaments/cartilage were responsible for 47% and 52% of the motion lost at 42/21 IM-FM, respectively, and 26% and 74% at 42/42 IM-FM, respectively. CONCLUSIONS Overall, data demonstrated a time-dependent response of periarticular tissue contribution to elbow contracture, with the capsule, ligaments, and cartilage as the primary long-term contributors. CLINICAL RELEVANCE The capsule, ligaments, and cartilage were primarily responsible for persistent motion loss and should be considered during development of tissue-targeted treatment strategies to inhibit elbow contracture following injury.
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Affiliation(s)
- Chelsey L. Dunham
- Departments of Biomedical Engineering (C.L.D. and S.P.L.), Mechanical Engineering & Materials Science (R.M.C. and S.P.L.), and Orthopaedic Surgery (A.M.C. and S.P.L.), Washington University in St. Louis, St. Louis, Missouri
| | - Ryan M. Castile
- Departments of Biomedical Engineering (C.L.D. and S.P.L.), Mechanical Engineering & Materials Science (R.M.C. and S.P.L.), and Orthopaedic Surgery (A.M.C. and S.P.L.), Washington University in St. Louis, St. Louis, Missouri
| | - Aaron M. Chamberlain
- Departments of Biomedical Engineering (C.L.D. and S.P.L.), Mechanical Engineering & Materials Science (R.M.C. and S.P.L.), and Orthopaedic Surgery (A.M.C. and S.P.L.), Washington University in St. Louis, St. Louis, Missouri
| | - Spencer P. Lake
- Departments of Biomedical Engineering (C.L.D. and S.P.L.), Mechanical Engineering & Materials Science (R.M.C. and S.P.L.), and Orthopaedic Surgery (A.M.C. and S.P.L.), Washington University in St. Louis, St. Louis, Missouri
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Attum B, Obremskey W. Posttraumatic Elbow Stiffness: A Critical Analysis Review. JBJS Rev 2018; 4:01874474-201609000-00001. [PMID: 27760073 DOI: 10.2106/jbjs.rvw.15.00084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Basem Attum
- Vanderbilt University Medical Center, Nashville, Tennessee
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Temporal Patterns of Motion in Flexion-extension and Pronation-supination in a Rat Model of Posttraumatic Elbow Contracture. Clin Orthop Relat Res 2018; 476:1878-1889. [PMID: 30001292 PMCID: PMC6259801 DOI: 10.1097/corr.0000000000000388] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The elbow is highly susceptible to contracture, which affects up to 50% of patients who experience elbow trauma. Previously, we developed a rat model to study elbow contracture that exhibited features similar to the human condition, including persistently decreased ROM and increased capsule thickness/adhesions. However, elbow ROM was not quantitatively evaluated over time throughout contracture development and subsequent mobilization of the joint. QUESTIONS/PURPOSES The purposes of this study were (1) to quantify the time-dependent mechanics of contracture, including comparison of contracture after immobilization and free mobilization; and (2) to determine what changes occur in capsule and joint surface morphology that may support the altered joint mechanics. METHODS A total of 96 male Long-Evans rats were randomized into control and injury (unilateral soft tissue injury/immobilization) groups. Flexion-extension and pronation-supination joint mechanics (n = 8/group) were evaluated after 3, 7, 21, or 42 days of immobilization (IM) or after 42 days of IM with either 21 or 42 days of free mobilization (63 or 84 FM, respectively). After measuring joint mechanics, a subset of these limbs (n = 3/group) was prepared for histologic analysis and blinded sections were scored to evaluate capsule and joint surface morphology. Joint mechanics and capsule histology at 42 IM and 84 FM were reported previously but are included to demonstrate the full timeline of elbow contracture. RESULTS In flexion-extension, injured limb ROM was decreased compared with control (103° ± 11°) by 21 IM (70° ± 13°) (p = 0.001). Despite an increase in injured limb ROM from 42 IM (55° ± 14°) to 63 FM (83° ± 10°) (p < 0.001), injured limb ROM was still decreased compared with control (103° ± 11°) (p = 0.002). Interestingly, ROM recovery plateaued because there was no difference between injured limbs at 63 (83° ± 10°) and 84 FM (73° ± 19°) (p > 0.999). In pronation-supination, increased injured limb ROM occurred until 7 IM (202° ± 32°) compared with control (155° ± 22°) (p = 0.001), representative of joint instability. However, injured limb ROM decreased from 21 (182° ± 25°) to 42 IM (123° ± 47°) (p = 0.001), but was not different compared with control (155° ± 22°) (p = 0.108). Histologic evaluation showed morphologic changes in the anterior capsule (increased adhesions, myofibroblasts, thickness) and nonopposing joint surfaces (surface irregularities with tissue overgrowth, reduced matrix), but these changes did not increase with time. CONCLUSIONS Overall, flexion-extension and pronation-supination exhibited distinct time-dependent patterns during contracture development and joint mobilization. Histologic evaluation showed tissue changes, but did not fully explain the patterns in contracture mechanics. Future work will use this rat model to evaluate the periarticular soft tissues of the elbow to isolate tissue-specific contributions to contracture to ultimately develop strategies for tissue-targeted treatments. CLINICAL RELEVANCE A rat model of posttraumatic elbow contracture quantitatively described contracture development/progression and reiterates the need for rehabilitation strategies that consider both flexion-extension and pronation-supination elbow motion.
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Spitler CA, Doty DH, Johnson MD, Nowotarski PJ, Kiner DW, Swafford RE, Jemison DM. Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness. J Orthop Trauma 2018; 32:e304-e308. [PMID: 30028796 DOI: 10.1097/bot.0000000000001222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Evaluate the safety and efficacy of manipulation under anesthesia (MUA) for posttraumatic elbow stiffness. DESIGN Retrospective, case series. SETTING Single institution; level 1 trauma center. PATIENTS/PARTICIPANTS Chart review of 45 patients over a 10-year period treated with MUA for posttraumatic elbow stiffness after elbow injuries treated both operatively and nonoperatively. INTERVENTION None. MAIN OUTCOME MEASURES Change in total flexion arc pre- to postmanipulation; time to manipulation; complications. RESULTS Average time from most recent surgical procedure or date of injury to MUA was 115 days. Average premanipulation flexion arc was 57.9 degrees; average flexion arc at the final follow-up was 83.7 degrees. The improvement in elbow flexion arc of motion was statistically significant (P < 0.001). Post hoc analysis of the data revealed 2 distinct groups: 28 patients who underwent MUA within 3 months of their most recent surgical procedure (early manipulation), and 17 patients who underwent MUA after 3 months (late manipulation). Average improvement in elbow flexion arc in the early MUA group was 38.3 degrees (P < 0.001); improvement in the late MUA group was 3.1 degree. Comparison of improvement between the early and late MUA groups found a significant difference (P < 0.001) in mean flexion arc improvement from premanipulation to postmanipulation, favoring the early group. One patient had a complication directly attributable to MUA. Nineteen patients required additional procedures on the injured extremity after MUA. CONCLUSIONS MUA is a safe and effective adjunct to improving motion in posttraumatic elbow stiffness when used within 3 months from the original injury or time of surgical fixation. After 3 months, MUA does not reliably increase elbow motion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Daniel H Doty
- College of Medicine Chattanooga, University of Tennessee, Chattanooga, TN
| | - Michael D Johnson
- Department of Orthopaedics, University of Alabama-Birmingham, Birmingham, AL
| | - Peter J Nowotarski
- College of Medicine Chattanooga, University of Tennessee, Chattanooga, TN
| | - Dirk W Kiner
- College of Medicine Chattanooga, University of Tennessee, Chattanooga, TN
| | - Rachel E Swafford
- College of Medicine Chattanooga, University of Tennessee, Chattanooga, TN
| | - D Marshall Jemison
- College of Medicine Chattanooga, University of Tennessee, Chattanooga, TN
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The Waterfall Fascia Lata Interposition Arthroplasty "Grika Technique" as Treatment of Posttraumatic Osteoarthritis of the Elbow in a High-Demand Adult Patient: Validity and Reliability. Case Rep Orthop 2018; 2018:8253732. [PMID: 29850330 PMCID: PMC5937584 DOI: 10.1155/2018/8253732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/13/2018] [Accepted: 03/20/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction The elbow interposition arthroplasty is a very common procedure performed mainly on active young patients who need great functionality and for whom total joint replacement is contraindicated and arthrodesis is noncompliant. We are going to demonstrate a case of a 34-year-old male suffering from malunion of the distal humerus, elbow stiffness, and manifest signs of arthrosis of the dominant limb, treated with the IA Grika technique at a 5-year follow-up. Patients and Methods The chosen criteria to evaluate the injured side and the uninjured side during the clinical and radiological follow-up were the objective function and related quality of life, measured by the Mayo Elbow Performance Score (MEPS), and postoperative complications. To assess flexion and supination forces and elbow muscular strength, a hydraulic dynamometer was used. Results At a 5-year follow-up, the results were excellent as during the first year. Conclusions The Grika technique is a valid and feasible option in the treatment of elbow injuries.
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Posttraumatic Proximal Radioulnar Synostosis after Closed Reduction for a Radial Neck and Olecranon Fracture. Case Rep Orthop 2018; 2018:5131639. [PMID: 29805828 PMCID: PMC5899880 DOI: 10.1155/2018/5131639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 12/26/2017] [Accepted: 01/08/2018] [Indexed: 01/27/2023] Open
Abstract
Posttraumatic proximal radioulnar synostosis (PPRUS) is a severe complication of radial head and neck fractures known to occur after severe injury or operative fixation. Cases of PPRUS occurring after minimally displaced, nonoperatively treated radial neck injuries are, by contrast, extremely rare. Here, we present a pediatric case of PPRUS that developed after a nonoperatively treated minimally displaced radial neck fracture with concomitant olecranon fracture. While more cases are needed to establish the association between this pattern of injury and PPRUS, we recommend that when encountering patients with a minimally displaced radial neck fracture and a concomitant elbow injury, the rare possibility of developing proximal radioulnar synostosis should be considered.
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Morrey ME, Sanchez-Sotelo J, Lewallen EA, An KN, Grill DE, Steinmann SP, Yao JJ, Salib CG, Trousdale WH, Reina N, Kremers HM, Lewallen DG, van Wijnen AJ, Abdel MP. Intra-articular injection of a substance P inhibitor affects gene expression in a joint contracture model. J Cell Biochem 2018; 119:1326-1336. [PMID: 28671282 PMCID: PMC6388635 DOI: 10.1002/jcb.26256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 01/23/2023]
Abstract
Substance P (SP), a neurotransmitter released after injury, has been linked to deregulated tissue repair and fibrosis in musculoskeletal tissues and other organs. Although SP inhibition is an effective treatment for nausea, it has not been previously considered as an anti-fibrotic therapy. Although there are extensive medical records of individuals who have used SP antagonists, our analysis of human registry data revealed that patients receiving these antagonists and arthroplasty are exceedingly rare, thus precluding a clinical evaluation of their potential effects in the context of arthrofibrosis. Therefore, we pursued in vivo studies to assess the effect of SP inhibition early after injury on pro-fibrotic gene expression and contractures in an animal model of post-traumatic joint stiffening. Skeletally mature rabbits (n = 24) underwent surgically induced severe joint contracture, while injected with either fosaprepitant (a selective SP antagonist) or saline (control) early after surgery (3, 6, 12, and 24 h). Biomechanical testing revealed that differences in mean contracture angles between the groups were not statistically significant (P = 0.27), suggesting that the drug neither mitigates nor exacerbates joint contracture. However, microarray gene expression analysis revealed that mRNA levels for proteins related to cell signaling, pro-angiogenic, pro-inflammatory, and collagen matrix production were significantly different between control and fosaprepitant treated rabbits (P < 0.05). Hence, our study demonstrates that inhibition of SP alters expression of pro-fibrotic genes in vivo. This finding will motivate future studies to optimize interventions that target SP to reduce the formation of post-traumatic joint contractures.
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Affiliation(s)
- Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Kai-Nan An
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Diane E. Grill
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Jie J. Yao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Nicolas Reina
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Hilal M. Kremers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
- Health Sciences Research, Mayo Clinic, Rochester, MN
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Dunham CL, Castile RM, Chamberlain AM, Galatz LM, Lake SP. Pronation-Supination Motion Is Altered in a Rat Model of Post-Traumatic Elbow Contracture. J Biomech Eng 2018; 139:2621591. [PMID: 28418515 DOI: 10.1115/1.4036472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Indexed: 11/08/2022]
Abstract
The elbow joint is highly susceptible to joint contracture, and treating elbow contracture is a challenging clinical problem. Previously, we established an animal model to study elbow contracture that exhibited features similar to the human condition including persistent decreased range of motion (ROM) in flexion-extension and increased capsule thickness/adhesions. The objective of this study was to mechanically quantify pronation-supination in different injury models to determine if significant differences compared to control or contralateral persist long-term in our animal elbow contracture model. After surgically inducing soft tissue damage in the elbow, Injury I (anterior capsulotomy) and Injury II (anterior capsulotomy with lateral collateral ligament transection), limbs were immobilized for 6 weeks (immobilization (IM)). Animals were evaluated after the IM period or following an additional 6 weeks of free mobilization (FM). Total ROM for pronation-supination was significantly decreased compared to the uninjured contralateral limb for both IM and FM, although not different from control limbs. Specifically, for both IM and FM, total ROM for Injury I and Injury II was significantly decreased by ∼20% compared to contralateral. Correlations of measurements from flexion-extension and pronation-supination divulged that FM did not affect these motions in the same way, demonstrating that joint motions need to be studied/treated separately. Overall, injured limbs exhibited persistent motion loss in pronation-supination when comparing side-to-side differences, similar to human post-traumatic joint contracture. Future work will use this animal model to study how elbow periarticular soft tissues contribute to contracture.
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Affiliation(s)
- Chelsey L Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130 e-mail:
| | - Ryan M Castile
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO 63130 e-mail:
| | - Aaron M Chamberlain
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO 63130 e-mail:
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY 10029 e-mail:
| | - Spencer P Lake
- Mem. ASME Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO 63130;Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO 63130;Department of Biomedical Engineering, Washington University in St. Louis, 1 Brookings Drive, Campus Box 1185, St. Louis, MO 63130 e-mail:
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Viveen J, Doornberg JN, Kodde IF, Goossens P, Koenraadt KLM, The B, Eygendaal D. Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial. BMC Musculoskelet Disord 2017; 18:484. [PMID: 29166890 PMCID: PMC5700741 DOI: 10.1186/s12891-017-1854-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/15/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The elbow is prone to stiffness after trauma. To regain functional elbow motion several conservative- and surgical treatment options are available. Conservative treatment includes physical therapy, intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the posttraumatic stiff elbow is often performed. The best Evidence-Based rehabilitation protocol for patients after an operative release is unknown to date and differs per surgeon, hospital and country. Options include early- or delayed motion supervised by a physical therapist, immediate continuous passive motion (CPM), (night) splinting and a static progressive or dynamic splinting program. METHODS/DESIGN The SET-Study (Stiff Elbow Trial) is a single-centre, prospective, randomized controlled trial. The primary objective of this study is to compare the active Range of Motion (ROM) (flexion arc and rotational arc) twelve months after surgery between three groups. The first group will receive in-hospital CPM in combination with early motion Physical Therapy (PT) supervised by a physical therapist, the second group will receive only in-hospital early motion PT supervised by a physical therapist and the third group will receive outpatient supervised PT from postoperative day seven till ten. Secondary outcome measures will be Patient Reported Outcome Measures (PROMs) including the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), the quick Disabilities of Arm, Shoulder and Hand (qDASH) score, Visual Analogue pain Scale in rest and activity (VAS), Pain Catastrophizing Scale (PCS), the Short Form (SF)-36, the Centre for Epidemiological Studies Depression Scale Revised (CESD-R) and the Work Rehabilitation Questionnaire (WORQ) for the upper limb. DISCUSSION A successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow. TRIAL REGISTRATION The trial is registered at the Dutch Trial Register: NTR6067 , 31-8-2016.
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Affiliation(s)
- Jetske Viveen
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Flinders University, Bedford Park SA, Adelaide, 5042, Australia
| | - Izaak F Kodde
- Department of Orthopaedic Surgery, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam-Zuidoost, The Netherlands
| | - Pjotr Goossens
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands
| | - Koen L M Koenraadt
- , Foundation for Orthopaedic Research, Care & Education, Amphia Hospital, 4818 , CK, Breda, The Netherlands
| | - Bertram The
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands
| | - Denise Eygendaal
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands.,Department of Orthopaedic Surgery, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam-Zuidoost, The Netherlands
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Static Progressive Orthoses for Elbow Contracture: A Systematic Review. JOURNAL OF HEALTHCARE ENGINEERING 2017; 2017:7498094. [PMID: 29081938 PMCID: PMC5610839 DOI: 10.1155/2017/7498094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/07/2017] [Accepted: 08/03/2017] [Indexed: 12/04/2022]
Abstract
Background As one of the most common musculoskeletal complications following trauma, elbow contracture is a frequent source of disabled daily activities. Conventional interventions are inadequate to provide favorable outcome. The static progressive orthoses are getting popular in the treatment of this problem. Objective The purpose of this review was to assess the effectiveness of static progressive orthoses for elbow contracture. Methods Literatures when written in English published during 1 January 1997 and 31 January 2017 were searched in the following databases: Web of Science, Cochrane Library, PubMed, and EBSCOhost. Articles are quality-assessed by two assessors, each article was summarized in evidence tables, and a narrative synthesis was also performed. Results Ten clinical trials were included. The study design and outcome measures used varied. Significant immediate improvement in the range of motion was reported by all studies, and those effects were still significant at follow-up. No significant difference was shown between static progressive and dynamic orthoses for elbow contracture in one randomized control trial. Conclusions Current low-quality evidence suggested that static progressive orthoses provided assistance for elbow contracture through improving range of motion. Further research is recommended using high-quality randomized controlled trials.
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Third Place Award: Posttraumatic elbow arthrofibrosis incidence and risk factors: a retrospective review. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheah A, Harris A, Le W, Huang Y, Yao J. Relative ratios of collagen composition of periarticular tissue of joints of the upper limb. J Hand Surg Eur Vol 2017; 42:616-620. [PMID: 28486835 DOI: 10.1177/1753193416674324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We investigated the relative ratios of collagen composition of periarticular tissue of the elbow, wrist, metacarpophalangeal, proximal and distal interphalangeal joints. Periarticulat tissue, which we defined as the ligaments, palmar plate and capsule, was harvested from ten fresh-frozen cadaveric upper limbs, yielding 50 samples. The mean paired differences (95% confidence interval) of the relative ratios of collagen between the five different joints were estimated using mRNA expression of collagen in the periarticular tissue. We found that the relative collagen composition of the elbow was not significantly different to that of the proximal interphalangeal joint, nor between the proximal interphalangeal joint and distal interphalangeal joint, whereas the differences in collagen composition between all the other paired comparisons of the joints had confidence intervals that did not include zero.
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Affiliation(s)
- A Cheah
- 1 Robert A. Chase Hand & Upper Limb Center, Stanford University Medical Center, Redwood City, CA, USA.,2 Department of Hand & Reconstructive Microsurgery, National University Hospital, Singapore
| | - A Harris
- 1 Robert A. Chase Hand & Upper Limb Center, Stanford University Medical Center, Redwood City, CA, USA
| | - W Le
- 1 Robert A. Chase Hand & Upper Limb Center, Stanford University Medical Center, Redwood City, CA, USA
| | - Y Huang
- 3 Department of Orthopedics, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.,4 School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - J Yao
- 1 Robert A. Chase Hand & Upper Limb Center, Stanford University Medical Center, Redwood City, CA, USA
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Mattyasovszky SG, Mausbach S, Ritz U, Langendorf E, Wollstädter J, Baranowski A, Drees P, Rommens PM, Hofmann A. Influence of the anti-inflammatory cytokine interleukin-4 on human joint capsule myofibroblasts. J Orthop Res 2017; 35:1290-1298. [PMID: 27504740 DOI: 10.1002/jor.23386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/05/2016] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint contracture was reported to be associated with elevated numbers of contractile myofibroblasts (MFs) in the healing capsule. During the physiological healing process, the number of MFs declines; however, in fibroconnective disorders, MFs persist. The manifold interaction of the cytokines regulating the appearance and persistence of MFs in the pathogenesis of joint contracture remains to be elucidated. The objective of our current study was to analyze the impact of the anti-inflammatory cytokine interleukin (IL)-4 on functional behavior of MFs. Cells were isolated from human joint capsule specimens and challenged with three different concentrations of IL-4 with or without its neutralizing antibody. MF viability, contractile properties, and the gene expression of both alpha-smooth muscle actin (α-SMA) and collagen type I were examined. Immunofluorescence staining revealed the presence of IL-4 receptor (R)-alpha (α) on the membrane of cultured MFs. The cytokine IL-4 promoted MF viability and enhanced MF modulated contraction of collagen gels. Moreover, IL-4 intervened in gene expression by up-regulation of α-SMA and collagen type I mRNA. These effects could be specifically lowered by the neutralizing IL-4 antibody. On the basis of our findings we conclude that the anti-inflammatory cytokine IL-4 specifically regulates viability and the contractile properties of MFs via up-regulating the gene expression of α-SMA and collagen type I. IL-4 may be a helpful target in developing anti-fibrotic therapeutics for post-traumatic joint contracture in human. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1290-1298, 2017.
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Affiliation(s)
- Stefan G Mattyasovszky
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Stefan Mausbach
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Eva Langendorf
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jochen Wollstädter
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Phillipp Drees
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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Desai MJ, Ramalingam H, Ruch DS. Heterotopic Ossification After the Arthroscopic Treatment of Lateral Epicondylitis. Hand (N Y) 2017; 12:NP32-NP36. [PMID: 28453354 PMCID: PMC5480670 DOI: 10.1177/1558944716668844] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) is a well-known complication following the surgical treatment of fractures and dislocations about the elbow but it is not commonly discussed as a complication following arthroscopy. We present a case of a young athlete who developed HO after the arthroscopic treatment of lateral epicondylitis. METHODS This is a case report chart review of a 24 year old male with lateral epicondylitis. After failing conservative measures, arthroscopic debridement of the extensor carpi radialis brevis (ECRB) origin ensued. The treatment and patient's final disposition were reported. RESULTS The patient developed heterotopic ossification of the elbow follow arthroscopic debridement of the ECRB origin. Further surgery was required to excise the heterotopic ossification. Good recovery of motion was achieved. CONCLUSION To our knowledge, we present the first case of HO development after elbow arthroscopy for lateral epicondylitis. As the use of elbow arthroscopy continues to grow, there is a need for identification of the risk factors and primary prophylaxis for HO.
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Affiliation(s)
- Mihir J. Desai
- Vanderbilt University, Nashville, TN, USA,Mihir J. Desai, Department of Orthopaedics, Vanderbilt University, 1215 21st Avenue South, MCE. S. Tower Suite 3200, Nashville, TN 37232, USA.
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Dunham CL, Castile RM, Havlioglu N, Chamberlain AM, Galatz LM, Lake SP. Persistent motion loss after free joint mobilization in a rat model of post-traumatic elbow contracture. J Shoulder Elbow Surg 2017; 26:611-618. [PMID: 28081997 PMCID: PMC5502529 DOI: 10.1016/j.jse.2016.09.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/19/2016] [Accepted: 09/29/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Post-traumatic joint contracture (PTJC) in the elbow is a challenging clinical problem due to the anatomical and biomechanical complexity of the elbow joint. METHODS We previously established an animal model to study elbow PTJC, wherein surgically induced soft tissue damage, followed by 6 weeks of unilateral immobilization in Long-Evans rats, led to stiffened and contracted joints that exhibited features similar to the human condition. In this study, after 6 weeks of immobilization, we remobilized the animal (ie, external bandage removed and free cage activity) for an additional 6 weeks, after which the limbs were evaluated mechanically and histologically. The objective of this study was to evaluate whether this decreased joint motion would persist after 6 weeks of free mobilization (FM). RESULTS After FM, flexion-extension demonstrated decreased total range of motion (ROM) and neutral zone length, and increased ROM midpoint for injured limbs compared with control and contralateral limbs. Specifically, after FM total ROM demonstrated a significant decrease of approximately 22% and 26% compared with control and contralateral limbs for injury I (anterior capsulotomy) and injury II (anterior capsulotomy with lateral collateral ligament transection), respectively. Histologic evaluation showed increased adhesion, fibrosis, and thickness of the capsule tissue in the injured limbs after FM compared with control and contralateral limbs, which is consistent with patterns previously reported in human tissue. CONCLUSION Even with FM, injured limbs in this model demonstrate persistent joint motion loss and histologic results similar to the human condition. Future work will use this animal model to investigate the mechanisms responsible for PTJC and responses to therapeutic intervention.
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Affiliation(s)
- Chelsey L. Dunham
- Department of Biomedical Engineering, Washington University, St. Louis, MO
| | - Ryan M. Castile
- Department of Mechanical Engineering & Materials Science, Washington University, St. Louis, MO
| | - Necat Havlioglu
- Department of Pathology, John Cochran VA Medical Center, St. Louis, MO
| | | | - Leesa M. Galatz
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Spencer P. Lake
- Department of Biomedical Engineering, Washington University, St. Louis, MO,Department of Mechanical Engineering & Materials Science, Washington University, St. Louis, MO,Department of Orthopaedic Surgery, Washington University, St. Louis, MO,Corresponding Author: Spencer P. Lake, Ph.D., 1 Brookings Drive, Campus Box 1185, St. Louis, MO 63130,
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Zimmer ZR, Horneff JG, Taylor RM, Levin LS, Kovach S, Mehta S. Evaluation and Treatment of Open Distal Humeral Fractures. JBJS Rev 2017; 5:01874474-201701000-00005. [PMID: 28135232 DOI: 10.2106/jbjs.rvw.16.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Zachary R Zimmer
- 1Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania2Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania3Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas
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47
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Abstract
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.
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Affiliation(s)
- Ravi Mittal
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Prof. Ravi Mittal, Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail:
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Steplewski A, Fertala J, Beredjiklian PK, Abboud JA, Wang MLY, Namdari S, Barlow J, Rivlin M, Arnold WV, Kostas J, Hou C, Fertala A. Auxiliary proteins that facilitate formation of collagen-rich deposits in the posterior knee capsule in a rabbit-based joint contracture model. J Orthop Res 2016; 34:489-501. [PMID: 26241613 DOI: 10.1002/jor.23007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 07/31/2015] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint contracture is a debilitating consequence of trauma or surgical procedures. It is associated with fibrosis that develops regardless of the nature of initial trauma and results from complex biological processes associated with inflammation and cell activation. These processes accelerate production of structural elements of the extracellular matrix, particularly collagen fibrils. Although the increased production of collagenous proteins has been demonstrated in tissues of contracted joints, researchers have not yet determined the complex protein machinery needed for the biosynthesis of collagen molecules and for their assembly into fibrils. Consequently, the purpose of our study was to investigate key enzymes and protein chaperones needed to produce collagen-rich deposits. Using a rabbit model of joint contracture, our biochemical and histological assays indicated changes in the expression patterns of heat shock protein 47 and the α-subunit of prolyl 4-hydroxylase, key proteins in processing nascent collagen chains. Moreover, our study shows that the abnormal organization of collagen fibrils in the posterior capsules of injured knees, rather than excessive formation of fibril-stabilizing cross-links, may be a key reason for observed changes in the mechanical characteristics of injured joints. This result sheds new light on pathomechanisms of joint contraction, and identifies potentially attractive anti-fibrotic targets.
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Affiliation(s)
- Andrzej Steplewski
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jolanta Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pedro K Beredjiklian
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mark L Y Wang
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Surena Namdari
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jonathan Barlow
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael Rivlin
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - William V Arnold
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - James Kostas
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Cheryl Hou
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrzej Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Lake SP, Castile RM, Borinsky S, Dunham CL, Havlioglu N, Galatz LM. Development and use of an animal model to study post-traumatic stiffness and contracture of the elbow. J Orthop Res 2016; 34:354-64. [PMID: 26177969 DOI: 10.1002/jor.22981] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 07/08/2015] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint stiffness (PTJS) of the elbow is a debilitating condition that poses unique treatment challenges. While previous research has implicated capsular tissue in PTJS, much regarding the development and progression of this condition remains unknown. The objective of this study was to develop an animal model of post-traumatic elbow contracture and evaluate its potential for studying the etiology of PTJS. The Long-Evans rat was identified as the most appropriate species/breed for development due to anatomical and functional similarities to the human elbow joint. Two surgical protocols of varying severity were utilized to replicate soft tissue damage seen in elbow subluxation/dislocation injuries, including anterior capsulotomy and lateral collateral ligament transection, followed by 6 weeks of unilateral joint immobilization. Following sacrifice, flexion-extension mechanical joint testing demonstrated decreased range-of-motion and increased stiffness for injured-immobilized limbs compared to control and sham animals, where functional impact correlated with severity of injury. Histological evaluation showed increased cellularity, adhesion, and thickness of capsule tissue in injured limbs, consistent with clinical evidence. To our knowledge, this is the first animal model capable of examining challenges unique to the anatomically and biomechanically complex elbow joint. Future studies will use this animal model to investigate mechanisms responsible for PTJS.
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Affiliation(s)
- Spencer P Lake
- Department of Mechanical Engineering & Materials Science, Washington University, 1 Brookings Hall, Campus Box 1185, St. Louis, 63130, Missouri.,Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Ryan M Castile
- Department of Mechanical Engineering & Materials Science, Washington University, 1 Brookings Hall, Campus Box 1185, St. Louis, 63130, Missouri
| | - Stephanie Borinsky
- Department of Mechanical Engineering & Materials Science, Washington University, 1 Brookings Hall, Campus Box 1185, St. Louis, 63130, Missouri.,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Chelsey L Dunham
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Necat Havlioglu
- Department of Pathology, John Cochran VA Medical Center, St Louis, Missouri
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
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Mattyasovszky SG, Wollstädter J, Martin A, Ritz U, Baranowski A, Ossendorf C, Rommens PM, Hofmann A. Inhibition of Contractile Function in Human Joint Capsule Myofibroblasts by Targeting the TGF-β1 and PDGF Pathways. PLoS One 2016; 11:e0145948. [PMID: 26730954 PMCID: PMC4712129 DOI: 10.1371/journal.pone.0145948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/10/2015] [Indexed: 01/12/2023] Open
Abstract
Background Contractile myofibroblasts (MFs) accumulate in the joint capsules of patients suffering from posttraumatic joint stiffness. MF activation is controlled by a complex local network of growth factors and cytokines, ending in the increased production of extracellular matrix components followed by soft tissue contracture. Despite the tremendous growth of knowledge in this field, inconsistencies remain in practice and prevention. Methods and Findings In this in vitro study, we isolated and cultured alpha-smooth muscle actin (α-SMA) positive human joint capsule MFs from biopsy specimens and investigated the effect of profibrotic and antifibrotic agents on MF function. Both TGF-β1 and PDGF significantly induced proliferation and increased extracellular matrix contraction in an established 3D collagen gel contraction model. Furthermore, both growth factors induced α-SMA and collagen type I gene expression in MFs. TGF-β1 down-regulated TGF-β1 and TGF-β receptor (R) 1 and receptor (R) 2 gene expression, while PDGF selectively down-regulated TGF-β receptor 2 gene expression. These effects were blocked by suramin. Interestingly, the anti-oxidant agent superoxide dismutase (SOD) blocked TGF-β1 induced proliferation and collagen gel contraction without modulating the gene expression of α-SMA, collagen type I, TGF-β1, TGF-β R1 and TGF-β R2. Conclusions Our results provide evidence that targeting the TGF-β1 and PDGF pathways in human joint capsule MFs affects their contractile function. TGF-β1 may modulate MF function in the joint capsule not only via the receptor signalling pathway but also by regulating the production of profibrotic reactive oxygen species (ROS). In particular, anti-oxidant agents could offer promising options in developing strategies for the prevention and treatment of posttraumatic joint stiffness in humans.
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Affiliation(s)
- Stefan G. Mattyasovszky
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Jochen Wollstädter
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Anne Martin
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Christian Ossendorf
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Pol M. Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
- * E-mail:
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