Prevention and treatment of elbow stiffness: a 5-year update

Olecranon Fossa Fenestration Approach to the Coronoid and Anterior Elbow: The Way OFF

Hypertrophic osteoarthritis of the elbow is a challenging condition that can vary from mild to severe, affecting patients' quality of life due to pain and loss of range of motion. A consensus about its treatment does not exist. Open arthrolysis with capsular release, synovectomy, Outerbridge-Kashiwagi fenestration, and removal of loose bodies and osteophytes demonstrated good results. In more recent times, an arthroscopic procedure has been shown to have the same efficacy as the open one. The aim of this Technical Note is to describe an all-arthroscopic procedure to reach the coronoid tip, in a safe and reproducible manner, through an olecranon fossa fenestration with a direct transtricipital posterior portal and an anterior cruciate ligament guide.

Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults

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.

A modified-delphi study establishing consensus in the therapeutic management of posttrauamtic elbow stiffness

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.

Effects of Different Static Progressive Stretching Durations on Range of Motion, Myofibroblasts, and Collagen in a Posttraumatic Knee Contracture Rat Model

OBJECTIVE

The purpose of this study was to investigate the effects of different durations of static progressive stretching (SPS) on posttraumatic knee contracture in rats, including range of motion (ROM), gait analysis, myofibroblast proliferation, and collagen regulation.

METHODS

The posttraumatic knee contracture model was established, and male Wistar rats were randomly divided into the 20-minute SPS treatment, 30-minute SPS treatment (S30), 40-minute SPS treatment, untreated, immobilization, and control groups. At Week 1, 2, and 4 of treatment intervention, joint ROM and gait were measured and compared. Knee joint samples stained with hematoxylin and eosin and Masson trichrome were used to observe alterations in pathological structures. Collagen density and cell numbers in the posterior joint capsule were used to assess joint capsule fibrosis and inflammation. Immunohistochemistry was used to detect type I collagen and α-smooth muscle actin expression.

RESULTS

The S30 group improved the most; ROM, stance, mean intensity, print area, and stride length were 115 (SD = 5) degrees, 0.423 (SD = 0.074) seconds, 156.020 (SD = 7.952), 2.116 (SD = 0.078) cm2, and 11.758 (SD = 0.548) cm, respectively. The numbers of myofibroblasts, fibroblasts, and inflammatory cells decreased, and collagen proliferation was significantly suppressed in the S30 group compared with the other groups.

CONCLUSION

S30 significantly improved posttraumatic knee contracture in rats, with reduced type I collagen and α-smooth muscle actin expression, decreased the numbers of myofibroblasts and inflammatory cells, suppressed fibrotic and inflammatory changes in the joint capsule, and increased joint mobility. This study provided basic evidence for an optimal standard-of-care treatment approach for posttraumatic knee joint contracture in rats, which may have significance for humans.

Elbow Stiffness Imaging: A Practical Diagnostic and Pretherapeutic Approach

Loss of elbow motion can lead to disability in everyday gestures, recreational activities, and work. Unfortunately, the elbow joint is particularly prone to stiffness because of its complex anatomy and biomechanics. The etiology of elbow stiffness is varied and must be diagnosed accurately in order to allow optimal treatment, which may be challenging for surgeons and physiotherapists. Its treatment can be either conservative, arthroscopic or surgical, with a trend for arthroscopic procedures when conservative treatment fails. There is no consensus on the optimal imaging workup for elbow joint stiffness, which may have an impact on patient management. This article reviews the current classification systems of elbow stiffness and the various imaging techniques used for diagnosis. Report checklists and clarifications on the role of each imaging method, as well as the imaging findings of normal and stiff elbows, are presented, leading to a proposed diagnostic algorithm. The main concern in imaging is to determine the cause of elbow stiffness, as many concomitant abnormalities might be present depending on the clinical scenario.

Increased volume and collagen crosslinks drive soft tissue contribution to post-traumatic elbow contracture in an animal model

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.

The Efficacy of Tele-Rehabilitation Program for Improving Upper Limb Function among Adults Following Elbow Fractures: A Pilot Study

Background: Active mobilization post-elbow fractures reduces the incidence of complications. Occupational therapists use tele-rehabilitation, incorporating technology into their practices. There is a lack of evidence-based trials regarding the integration of tele-rehabilitation during treatment. We therefore aimed to compare tele-rehabilitation treatment outcomes with conventional rehabilitation in improving the upper limb function post-elbow fractures. Methods: Eighteen participants post-elbow surgery due to fracture were divided into two groups according to age and fracture type. The groups received one month of treatment: the tele-rehabilitation group (N = 9, median age 33.0 ± 27.9 years, range 18.5–61.0) received 1–2 tele-rehabilitation treatments per week via a biofeedback system of elbow motion (the ArmTutor and 3D Tutor systems, MediTouch Ltd., Netanya, Israel) and 1–2 treatments in an outpatient clinic, and the control group (N = 9, median age 60.0 ± 37.0 years, range 20.5–73.0) received 3–4 treatments per week in the clinic. Both groups were instructed to self-practice at home. Four evaluations were performed: before and after the intervention, and 3 months and 1 year from surgery. The outcome measures included the Jebsen–Taylor hand function test; the disabilities of the arm, shoulder, and hand questionnaire; the patient-rated elbow evaluation; satisfaction; passive and active range of motion (ROM); and strength measurements. Results: Findings demonstrated a significant improvement in the ROM and in functional assessments in both groups. No statistically significant differences were found between the groups. The subjects in the tele-rehabilitation group reported a higher level of satisfaction and needed less help from a family member during practice. Conclusions: Tele-rehabilitation programs could be incorporated in the framework of treatment following elbow fractures. Tele-rehabilitation is a cost-effective treatment, suitable for patients with accessibility difficulties or who have difficulty arriving at the clinic.

Risk Factors for the Occurrence and Progression of Posttraumatic Elbow Stiffness: A Case-Control Study of 688 Cases

Background: Elbow stiffness is a severe complication after trauma. Surgical or conservative treatments may be ineffective for restoring functional elbow motion. We aim to evaluate intrinsic and extrinsic factors for the occurrence and severity of elbow stiffness.

Methods: This retrospective case–control study included mild/moderate stiffness, severe stiffness, and non-stiffness groups between January 2011 and December 2017 at a single orthopedic center. Multivariable logistic regression analysis and subgroup analysis were used to evaluate age, gender, body mass index, muscle strength, fracture type and site, injury mechanism, immobilization time, elbow dysfunction time, multiple surgeries, nerve symptoms, physical therapy, smoking and alcohol abuse, and dominant hand of stiff elbow as potential risk factors for the occurrence and severity of elbow stiffness.

Results: There were 461 patients in the stiffness group and 227 patients in the non-stiffness group. The odds ratios (ORs) of the age, muscle strength, and injury mechanism were 0.960, 0.333, and 0.216 for the occurrence of elbow stiffness. In subgroup evaluation, increased cast immobilization time might be a risk factor for patients receiving conservative therapies (OR = 2.02; p = 0.014). In the evaluation on factors for progression of elbow stiffness, “multiple surgeries” might be a risk factor in surgical treatment by subgroup analysis (OR = 1.943; p = 0.026). Nevertheless, alcohol abuse might increase severity of elbow stiffness in conservatively treated patients (OR = 3.082; p = 0.025).

Conclusion: Increased cast immobilization time in the conservative therapy might be a risk factor for stiffness occurrence. Multiple surgeries might be risk factors for stiffness progression. Alcohol abuse potentially increased stiffness severity after conservative treatment.

Effect of hyperuricemia on functional outcomes and complications in patients with elbow stiffness after open arthrolysis combined with hinged external fixation: a retrospective study

BACKGROUND

Hyperuricemia is considered a risk factor for increased postoperative complications and adverse functional outcomes in a variety of orthopedic surgeries. The purpose of this retrospective study was to investigate the clinical efficacy of patients with different uric acid levels after elbow arthrolysis.

METHODS

The study included 131 patients with post-traumatic elbow stiffness who underwent arthrolysis between March 2014 and March 2016. All patients were divided into 4 groups based on the preoperative serum level of uric acid (UA). The quartile method was used for grouping patients, including 33 in Q1 (UA <293 μmol/L), 34 in Q2 (293-348 μmol/L), 32 in Q3 (348-441 μmol/L), and 32 in Q4 (441-710 μmol/L). At baseline and each time point of follow-up, functional performance, Mayo Elbow Performance Score, visual analog scale for pain, and complications were evaluated.

RESULTS

Preoperative data were not significantly different among the 4 groups (Q1, Q2, Q3, and Q4). At the final follow-up, the following data showed significant differences among the 4 groups: extension (P = .031), flexion (P = .008), range of motion (P = .003), Mayo Elbow Performance Score (P = .011), and visual analog scale (P = .032). Interestingly, patients in the Q4 group had the poorest clinical outcomes. However, no significant differences were found among the 4 groups in new onset or exacerbation of nerve symptoms (P = .919), reduced muscle strength (P = .536), instability (P = .567), or infection (P = .374) at the last follow-up.

CONCLUSION

This study confirms that in patients with post-traumatic elbow stiffness, abnormal serum uric acid metabolism was a risk factor for poor performance and postoperative pain after arthrolysis. Therefore, detecting the preoperative serum uric acid levels of the patients would be helpful for evaluating the postoperative outcomes.

The stiff elbow: Current concepts

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.

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Posttraumatic stiff elbow

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

Combined treatment with paraffin, manual therapy, pegboard and splinting in a patient with post-traumatic stiff hand

Background

The stiff hand is a still common, severe complication of hand injuries.

Case presentation

We report here the case of a 56 year-old woman, professional goldsmith, who suffered a distal radius fracture of her right hand. The patient was treated with surgery followed by four weeks of immobilization, and developed a stiff hand. Physical examination showed mild inflammatory signs, pain and a major limitation in the extension and supination of the wrist, and in the mobility of the II, III, IV and V metacarpophalangeal (-5° and 32° of average passive extension and flexion, respectively) and interphalangeal (-35° and 73° of average passive extension and flexion, respectively) joints. There was a lack of slip of the flexor tendons. The diagnosis of complex regional pain syndrome was considered although it could not be definitely established. After five months of adverse evolution the patient was referred to our center where a combined intervention with paraffin, manual therapy, prolonged active and passive stretch on a pegboard, and splinting was applied. After initiation of this therapy, a marked change in the evolution of the pain, the mobility and functionality of the hand was observed. At the end of the rehabilitation program the patient was able to fully resume her job.

Conclusion

The present case illustrates the need of intensive treatment for post-traumatic hand stiffness, and describes, as an original contribution, a combined intervention therapy including paraffin, manual therapy, pegboard and splinting.

Open arthrolysis for elbow stiffness increases carrying angle but has no impact on functional recovery

BACKGROUND

With the exception of normal anatomic changes in the medial collateral ligament and radial head, other factors related to carrying angle changes have not been systematically studied. We reviewed patients who underwent open arthrolysis of the elbow, and evaluated if open arthrolysis could change carrying angle. We then identified factors associated with carrying angle changes.

METHODS

Fifty patients with a minimum of 24 months of follow-up after open arthrolysis were evaluated retrospectively. Preoperative and postoperative carrying angles were compared.

RESULTS

The carrying angles of 36 elbows in 36 patients were unchanged after surgery (Group A), while the carrying angles of 14 elbows in 14 patients increased postoperatively (Group B). In Group A, mean postoperative extension and flexion were 7° (range 0-24°) and 125° (range 10-135°) respectively, while mean postoperative pronation and supination were 60° (range 50-80°) and 65° (range 30-85°), respectively. In Group B, mean postoperative extension and flexion were 25° (range 0-40°) and 128° (range 60-138°), while mean postoperative pronation and supination were 65° (range 45-85°) and 60° (range 45-75°), respectively. No significant difference in range of motion and Mayo Elbow Performance Score was observed between the two groups.

CONCLUSIONS

During open arthrolysis, humeral trochlea debridement and techniques for improving forearm rotation could increase carrying angle. However, this had no impact on elbow functional recovery.

[Primary radial head arthroplasty in trauma : Complications]

Radial head fractures are common injuries in elbow trauma. Non-displaced fractures are best treated conservatively. Simple but displaced fractures require anatomic reduction and fixation, typically using screws. The treatment course for complex fractures with multiple fragments is still being debated, as results are less predictable. Radial head resection is not advised if concomitant injuries of the coronoid process or the collateral ligaments with instability are present. Favorable outcomes following open reduction and fixation using plates were reported recently. However, complication rates are very high. Radial head replacement is a valuable tool in treating complex fractures of the radial head with predominantly good and excellent results. Patients who suffer radial head fractures are typically of a younger age, resulting in high functional demands. Certainly, unspecific and specific complications related to radial head arthroplasty were reported in up to 40 % of cases in an acute fracture setting. This article highlights common complications in radial head arthroplasty and aims to present strategies to avoid them.

Arthrofibrosis After Periarticular Fracture Fixation

Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.

Complications of Elbow Trauma

The elbow is a highly congruent trochoginglymoid joint allowing motion in both flexion-extension and pronosupination across 3 articulations. Therefore, treatment of fractures of the elbow can be technically challenging to manage, even after initial surgery. The posttraumatic elbow is prone to complications such as stiffness associated with heterotopic ossification, instability or subluxation (posterolateral rotatory instability and varus posteromedial instability patterns), and wound complications. This article discusses the pathoanatomy, prevention, and treatment of these complications.

The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise

BACKGROUND

Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary.

METHODS

We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated.

RESULTS

Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively.

CONCLUSIONS

Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients

INTRODUCTION

The elbow is prone to stiffness after trauma. To regain functional elbow motion, several conservative and surgical treatment options are available. Nonoperative treatment includes physical therapy, intra-articular injections with corticosteroids, and a static progressive or dynamic splinting program. The objective of this study was to perform a comprehensive review of the literature to evaluate the best current evidence for nonoperative treatment options for posttraumatic elbow stiffness.

METHODS

We performed a search of all studies on nonoperative treatment for elbow stiffness in human adults. All articles describing nonoperative treatment of elbow stiffness, written in the English, German, French or Dutch language, including human adult patients and with the functional outcome reported were included in this study.

RESULTS

Eight studies (including 232 patients) met our eligibility criteria and were included for data analysis and pooling. These studies included one randomized controlled trial and seven retrospective cohort studies. Static progressive splinting was evaluated in 160 patients. The average pre-splinting range of motion of all elbows was 72°, which improved by 36° after splinting to an average post-splinting arc of motion of 108°. Dynamic splinting was evaluated in 72 patients with an average pre-splinting range of motion of 63°. The average improvement was 37° to an average post-splinting arc of motion of 100°.

CONCLUSIONS

Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. The choice for one treatment over the other is based on the preference of the surgeon and patient. We recommend to continue nonoperative treatment with dynamic or static bracing for 12 months or until patients stop making progression in range of elbow motion.