Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification

Classification and Incidence of Heterotopic Ossifications in Relation to NSAID Prophylaxis after Elbow Trauma

Heterotopic ossification (HO) after elbow trauma can be responsible for significant motion restrictions. The study's primary aim was to develop a new X-ray-based classification for HO of the elbow. This retrospective study analyzed elbow injury radiographs from 138 patients aged 6-85 years (mean 45.9 ± 18) who underwent operative treatment. The new classification was applied at 6 weeks, 12 weeks, and 6 months postoperatively. The severity of HO was graded from 0 to 4 and localization was defined as r (radial), p (posterior), u (ulnar) or a (anterior) by two observers. The patients were categorized based on injury location and use of non-steroidal anti-inflammatory drugs (NSAIDs) for HO prophylaxis. The correlations between the generated data sets were analyzed using Chi-square tests (χ2) with a significance level of p < 0.05. The inter- and intraobserver reliability was assessed using Cohen's Kappa. In 50.7% of the evaluated X-rays, the formation of HO could be detected after 12 weeks, and in 60% after 6 months. The analysis showed a significant correlation between the injury's location and the HO's location after 12 weeks (p = 0.003). The use of an NSAID prophylaxis did not show a significant correlation with the severity of HO. The classification showed nearly perfect inter- (κ = 0.951, p < 0.001) and intrareliability (κ = 0.946, p < 0.001) according to the criteria of Landis and Koch. Based on the presented classification, the dimension and localization of HO in the X-ray image can be described in more detail compared to previously established classifications and, thus, can increase the comparability of results across studies.

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

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.

Heterotopic Ossification around the Elbow Revisited

Heterotopic ossification (HO) is the process of ectopic bone formation in the periarticular soft tissues and is usually formed in the elbow, hip and knee joint as a complication of trauma, burns, brain injury or surgical procedures. The development of HO around the elbow joint can cause a severe limitation of range of motion (ROM) and may affect daily activities of the patient. Treatment of ectopic bone formation around the elbow is a challenge for many surgeons. Non-operative treatment usually fails to restore the ROM of the elbow joint; thus, surgery is necessary to restore the function of the joint. In the past, many surgeons suggested that a delayed excision of HO, until maturation of the ectopic bone, is the best option in order to avoid any possible recurrence. However, many authors now suggest that this delay may lead to complications such as muscular atrophy and formation of soft tissue contractures that can cause a greater impairment of elbow function; thus, early excision is a better option and can better restore the elbow ROM. We performed a literature research of articles that investigated which is the best time of HO excision and we also evaluated if the tethering effect of HO can lead to a greater impairment of the elbow function. We found numerous studies suggesting that a limitation in ROM of the elbow can appear from the tethering of the ectopic bone formation and not only from primary HO. Concerning the HO excision, there were no significant differences between patients who underwent delayed and early excision, concerning the recurrence rate of HO around the elbow. Patients who underwent early excision had better restoration of elbow ROM; thus, early excision, combined with a rehabilitation program, is reported to be the best option for these patients.

Surgical arthrolysis of the stiff elbow: a systematic review

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY DESIGN

Level IV; Systematic review.

Integration of Task-Based Exoskeleton with an Assist-as-Needed Algorithm for Patient-Centered Elbow Rehabilitation

This research presents an Assist-as-Needed (AAN) Algorithm for controlling a bio-inspired exoskeleton, specifically designed to aid in elbow-rehabilitation exercises. The algorithm is based on a Force Sensitive Resistor (FSR) Sensor and utilizes machine-learning algorithms that are personalized to each patient, allowing them to complete the exercise by themselves whenever possible. The system was tested on five participants, including four with Spinal Cord Injury and one with Duchenne Muscular Dystrophy, with an accuracy of 91.22%. In addition to monitoring the elbow range of motion, the system uses Electromyography signals from the biceps to provide patients with real-time feedback on their progress, which can serve as a motivator to complete the therapy sessions. The study has two main contributions: (1) providing patients with real-time, visual feedback on their progress by combining range of motion and FSR data to quantify disability levels, and (2) developing an assist-as-needed algorithm for rehabilitative support of robotic/exoskeleton devices.

Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness

BACKGROUND

To evaluate and compare the functional outcomes of combined medial-lateral approach open arthrolysis with and without hinged external fixation.

METHODS

We retrospectively collected and analyzed the clinical data of patients with severe elbow stiffness who were treated in our institution from January 2018 to January 2019. All of them were treated with combined medial-lateral approach arthrolysis. There were 20 patients who had the hinged external fixation placed and 29 patients without the placement of the external fixation. Their baseline characteristics and functional outcomes were evaluated and compared.

RESULTS

The average follow-up time was 28.4 ± 3.7 months. There were no significant differences in the ROM of the elbow, MEPS, VAS, DASH, or complications between the two groups. The operation time and treatment cost of the patients without external fixation were significantly lower than patients with external fixation.

CONCLUSION

Combined medial-lateral approach open elbow arthrolysis without external fixation is a safe and effective way to treat elbow stiffness.

LEVEL OF EVIDENCE

Therapeutic Level III; Retrospective Cohort Comparison; Treatment Study.

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.

Heterotopic Ossification after Arthroscopic Elbow Release

Objectives

To evaluate the incidence and risk factors of heterotopic ossification (HO) after arthroscopic elbow release.

Methods

The present study included 101 elbows, with arthroscopic release performed on 98 patients over the 5‐year period from November 2011 to December 2015. Patients were divided into three groups: group 1, with elbow arthritis, including 46 elbows in 43 patients; group 2, with posttraumatic extrinsic elbow stiffness (without intraarticular adhesion), including 23 elbows in 23 patients; and group 3, with intrinsic contractures (with intraarticular adhesion), including 32 elbows in 32 patients. Arthroscopic elbow release was performed under general anesthesia. For intrinsic stiffness, a radiofrequency device was applied to release intraarticular scar tissue and create work space, which was rarely necessary in groups 1 and 2. In the postoperative period, X‐rays and CT scans were assessed at follow up to determine if there was HO formation, which was diagnosed when new calcifications were identified. The functional recovery was evaluated by comparing the range of motion (ROM) and pain relief preoperativley and postoperatively in each group. Other complications were also assessed postoperatively.

Results

The patients’ mean age was 38.6 years (range, 12–66), with 57 males and 41 females. Mean follow‐up was 21 months (range, 4–56). The active ROM and Mayo elbow performance index (MEPS) were improved from 93° ± 8.3° to 126° ± 12.4° (P < 0.05) and 71.4 ± 7.6 to 91.3 ± 8.7 (P < 0.001) in group 1, 66° ± 10.3° to 121° ± 10.7° (P < 0.005) and 65.6 ± 9.2 to 93.5 ± 11.2 (P < 0.05) in group 2, and 46° ± 6.7° to 91° ± 11.1° (P < 0.001) and 52.3 ± 6.4 to 80.6 ± 9.4 (P < 0.005) in group 3. HO developed in 25/101 cases (25%) and 4 patients with severe cases underwent repeat surgery. Those in group 1 were primarily arthritis patients; there were 3 out 46 cases with minor HO evident on X‐ray. In group 2, 1/23 had minor HO. In group 3, 21/32 patients had HO; 4 cases were considered severe, 4 were considered moderate, and 13 were considered minor. The average flexion–extension arc was improved by 47° at the last follow up. Other postoperative complications included 8 cases of prolonged drainage from portal sites, 17 transient nerve palsies, 1 permanent radial nerve injury, and 1 patient who developed delayed‐onset ulnar neuritis. This patient was fully recovered 5 months after surgery.

Conclusions

The high incidence of HO formation after arthroscopic elbow release may relate to improper application of a radiofrequency device. Minimizing thermal injury from these radiofrequency devices could reduce HO formation and improve postoperative functional recovery.

Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy

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.

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.

Treatment methods for post-traumatic elbow stiffness caused by heterotopic ossification

HYPOTHESIS

Heterotopic ossification (HO) is a common complication of surgically treated elbow fractures that can inhibit range of motion and impair quality of life. Although there are many treatment methods for HO, there is a lack of consensus as to the best option. We hypothesized that contracture release combined with Botox injection would lead to improved functional outcome scores when compared with current treatment methods.

METHODS

A retrospective review was conducted of patients who presented to a single surgeon with HO secondary to elbow fracture between 2005 and 2018. A total of 59 patients were identified who met inclusion criteria. Data were classified into 3 groups: contracture release (control - CR), Botox injection with CR (Botox + CR), and radiation therapy with CR (CR + RT). Range of motion measurements were obtained, including flexion, extension, pronation, and supination.

RESULTS

A total of 30 patients (30 of 59, 50.8%) received CR, 6 (6 of 59, 9.2%) were treated with CR + RT, and 23 (23 of 59, 40.0%) had CR + Botox. There was a significant difference between pre- and postoperative arc of motion for both CR + RT (P < .01) and CR + Botox (P < .01). In addition, there was a significant difference in pre- and postoperative extension for patients who received intraoperative Botox injections (P < .05). There was no significant difference between pre- and postoperative motion nor extension in the CR group.

CONCLUSION

Intraoperative Botox injection with CR is an effective method in the treatment of post-traumatic elbow stiffness caused by HO.

Prolonged dislocation and delay to surgery are associated with higher rates of heterotopic ossification in operatively treated terrible triad injuries

Background

Heterotopic ossification (HO) formation after complex elbow injuries can significantly impact function. Prior studies have reported a 3%-45% incidence of HO following elbow trauma in a heterogeneous cohort of fracture patterns. The purpose of our study was to evaluate the prevalence of and identify risk factors for HO specifically in patients with terrible triad injuries.

Methods

A total of 61 patients (64 elbows) underwent operative treatment for terrible triad injuries with an average follow-up period of 19.8 months (range, 3-138 months). The medical records were reviewed for demographic data, duration of dislocation, number of reduction attempts, time to surgery, presence of radiographic HO, elbow motion at final follow-up, functional limitations, and need for secondary procedures.

Results

Radiographic HO developed in 77% of patients, and 63% had some level of functional restriction. Thirteen patients (26%) underwent a secondary procedure for HO excision. Patients with HO had a longer time to surgery (4.9 days vs. 2.8 days, P = .02), longer duration of dislocation (21 hours vs. 6 hours, P = .04), and reduced flexion-extension (94° vs. 112°, P = .04) and pronation-supination (109° vs. 163°, P = .002) arcs of motion compared with patients without HO. HO was also more likely to develop in patients who required closed reduction than in those with spontaneous reduction prior to presentation.

Conclusion

The prevalence of radiographic and clinically relevant HO after terrible triad injuries was higher than previously reported. Persistent dislocation necessitating a closed reduction, a longer duration of dislocation, and a delay to surgery were associated with the development of HO. Providers should consider earlier surgical stabilization or urgent referral to a specialist for patients with unstable injuries.

The Survey of Cells Responsible for Heterotopic Ossification Development in Skeletal Muscles-Human and Mouse Models

Heterotopic ossification (HO) manifests as bone development in the skeletal muscles and surrounding soft tissues. It can be caused by injury, surgery, or may have a genetic background. In each case, its development might differ, and depending on the age, sex, and patient's conditions, it could lead to a more or a less severe outcome. In the case of the injury or surgery provoked ossification development, it could be, to some extent, prevented by treatments. As far as genetic disorders are concerned, such prevention approaches are highly limited. Many lines of evidence point to the inflammatory process and abnormalities in the bone morphogenetic factor signaling pathway as the molecular and cellular backgrounds for HO development. However, the clear targets allowing the design of treatments preventing or lowering HO have not been identified yet. In this review, we summarize current knowledge on HO types, its symptoms, and possible ways of prevention and treatment. We also describe the molecules and cells in which abnormal function could lead to HO development. We emphasize the studies involving animal models of HO as being of great importance for understanding and future designing of the tools to counteract this pathology.

The column procedure preserves elbow stability on biomechanical testing

PURPOSE

The effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers.

METHODS

We assessed elbow joint laxity in 39 patients who underwent an open contracture release via the 'column procedure' described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints.

RESULTS

Mean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°-4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable.

CONCLUSIONS

Our experiment confirmed that the 'column procedure' is a safe procedure which does not compromise the stability of the elbow joint.

[Mid-term effectiveness of arthrolysis and hinged external fixation for treatment of stiff elbow caused by heterotrophic ossification]

Objective

To evaluate the mid-term effectiveness of arthrolysis and hinged external fixation for the treatment of stiff elbow caused by heterotrophic ossification.

Methods

Between January 2014 and December 2017, 11 patients with stiff elbow caused by heterotrophic ossification were admitted. There were 9 males and 2 females with an average age of 32 years (range, 14-48 years), and left side in 6 cases and right side in 5 cases. The cause of stiff elbow included humerus fracture in 5 cases, ulna fracture in 2 cases, fracture of capitulum radii in 1 case, dislocation of capitulum radii in 1 case, terrible triad of the elbow in 1 case, and soft tissue injury in 1 case. The disease duration ranged from 7 to 18 months (mean, 11 months). Preoperative active range of motion of elbow was (19.6±17.5)° and Mayo score was 34.1±9.7. All patients received the treatment of arthrolysis and debridement of heterotrophic ossification lesion combining hinged external fixator, and active and passive rehabilitation with the help of hinged external fixator. The hinged external fixators were removed after 2 months.

Results

All patients were followed up 13-36 months (mean, 19.1 months). All incisions healed by first intention, and no complication of infection or nerve lesion occurred postoperatively. At last follow-up, the results of X-ray films showed that no heterotrophic ossification recurred. The active range of motion of elbow was (116.4±16.6)° and Mayo score was 93.2±7.8, showing significant differences when compared with preoperative ones ( t=17.508, P=0.000; t=16.618, P=0.000).

Conclusion

The application of arthrolysis and debridement of heterotrophic ossification lesion combining hinged external fixator can improve the elbow's range of motion significantly and obtain a good mid-term effectiveness.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation

PURPOSE

Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability.

METHODS

Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3 days.

RESULTS

At 10 month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity.

CONCLUSION

Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion.

LEVEL OF EVIDENCE

IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSION

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

Determining the effective timing of an open arthrolysis for post-traumatic elbow stiffness: a retrospective cohort study

Background

Following trauma, the elbow is the most susceptible to restricted motion among all joints. Open arthrolysis is often performed for post-traumatic elbow stiffness if that stiffness does not improve with non-operative management. However, the optimal timing for performing an open arthrolysis remains controversial. The purpose of this study was to compare the outcome (elbow motion and function) and the rate of complications among patients who had undergone early, median and late release procedures to establish an optimal time interval following the injury, after which, an effective open arthrolysis can be performed.

Methods

In this retrospective cohort study, we included total 133 patients, who had undergone open arthrolysis for post-traumatic elbow stiffness. The subjects were divided into 3 groups, with 31 patients in the early release group (arthrolysis performed at 6–10 months after injury), 78 patients in the median release group (at 11–20 months), and 24 patients in the late release group (at > 20 months). The release procedure in all patients was performed by the same surgeon, using the same technique. The general data, functional performance, and complications, if any, were retrospectively documented for all patients and statistically analysed.

Results

The demographic data and disease characteristics of all patients were comparable at baseline. Postoperatively, no significant differences were found among the three groups with respect to the range of motion (p = 0.067), Mayo Elbow Performance Score (p = 0.350) and its ratings (p = 0.329), visual analog scale score for pain (p = 0.227), Dellon classification for ulnar nerve symptoms (p = 0.497), and each discrete complication (all p values > 0.05).

Conclusions

At the final follow-up, our results showed no significant difference in the postoperative elbow motion capacities, functional scores and the rates of complications among patients who had undergone an early, median, and late release. Therefore, we have recommended that an early arthrolysis would be preferable due to its multiple advantages, and the conventionally observed interval of > 1 year after the injury, could be shortened.

Level of evidence

Level III; Retrospective Cohort Design; Therapeutic Study.

Posttraumatic Elbow Stiffness: A Critical Analysis Review

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

Prospective outcome assessment of arthroscopic arthrolysis for traumatic and degenerative elbow contracture

BACKGROUND

The purpose of this study was to evaluate the efficacy of arthroscopic elbow release for both traumatic and degenerative contractures from intraoperative recording through the recovery time until final follow-up.

METHODS

The study is based on 54 consecutive patients with extrinsic elbow contracture (traumatic in 31 and degenerative in 23) treated with arthroscopic arthrolysis by a single surgeon in 2011-2015. Range of motion (ROM) and the Mayo Elbow Performance Score (MEPS) were recorded preoperatively; intraoperatively; following release; and in the 1st, 3rd, 8th, 12th, and 26th weeks and at 2 years postoperatively.

RESULTS

Significant improvements were noted in extension, flexion, and range of motion, measured both intraoperatively and at all follow-up visits. The greatest improvement in the range of motion was achieved at the time of surgery (from 89° ± 28° to 131° ± 14°, P < .001); it then decreased at 1 week to 103° ± 22° (P < .001) and slowly recovered to reach 124° ± 22° after 2 years. This was better than the preoperative value (P < .001) but worse than the intraoperative value (P = .002). A similar pattern was observed in both traumatic and degenerative contractures. The MEPS improved from 73 ± 12 preoperatively to 93 ± 14 at the final evaluation (P < .001). The ROM and MEPS results at every follow-up were comparable for both traumatic and degenerative contractures. ROM improved regardless of the severity of contracture.

CONCLUSIONS

Arthroscopic elbow arthrolysis was similarly efficient in ROM restoration in both traumatic and degenerative contractures and regardless of the severity of contracture. After early deterioration, the achieved gain slowly recovers over a period of 6 months but may not recover to the ranges achieved during arthroscopy.

Open surgical elbow contracture release after trauma: results and recommendations

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Results of non-operative treatment of olecranon fracture in over 75-year-olds

INTRODUCTION

Surgery is the gold-standard treatment of displaced olecranon fracture, but is associated with numerous complications, especially in the elderly. Functional results of non-operative treatment in this population have never been analyzed in a prospective study.

STUDY HYPOTHESIS

Non-operative treatment of isolated olecranon fracture with stable elbow-joint in over 75-year-olds gives functional results comparable to those of surgery as reported in the literature, with fewer complications.

MATERIAL AND METHODS

A prospective study analyzed functional results of non-operative treatment of isolated closed Mayo I and II olecranon fracture with stable elbow, in patients aged ≥75 years. The principal assessment criterion was functional recovery on the Mayo Elbow Performance Score (MEPS) and QuickDASH at 6 months.

RESULTS

Twenty-two fractures in 21 patients were included. Mean MEPS was 95.26/100 (range, 85-100), and mean QuickDASH 4.3 (range, 0-29.55). Eighteen fractures showed osteoarthritis of the olecranon. There were no cases of elbow instability. There were no complications.

DISCUSSION

Non-operative treatment of olecranon fracture in patients aged ≥75 years provided excellent functional results at 6 months, without associated complications.

TYPE OF STUDY

Single-center prospective observation cohort study.

LEVEL OF EVIDENCE

4.

Appropriate excision time of heterotopic ossification in elbow caused by trauma

OBJECTIVE

The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow.

METHODS

We retrospectively reviewed 42 patients who were treated operatively for heterotopic ossification of the elbow from March 2010 to December 2014 at our institution. The patients were divided into early (before 12 months) and late (after 12 months) excision groups. In the early excision group (17 patients), the average time from the initial injury to HO excision was 7.4 (3-11) months, and in the late excision group (25 patients), the average time was 33.5 (12-240) months. Every patient was evaluated by range of motion (ROM), the Mayo Elbow Performance Score (MEPS), postoperative complications and HO recurrence.

RESULTS

The preoperative mean ROM in the late excision group was greater than that of the early excision group, suggesting that the ROM is expected to increase even without surgery. Both early and late surgery increased ROM and MEPS, but early surgery improved ROM and MEPS more than late surgery did (p < .05).

CONCLUSIONS

Early excision of HO can provide better elbow function, as indicated by ROM and MEPS. Considering that there were no notable differences in postoperative ROM and MEPS, HO recurrence, or postoperative complications, we concluded that early excision is safe and that the time from an elbow injury to surgery may be shortened.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The timing of open surgical release of post-traumatic elbow stiffness: A systematic review

BACKGROUND

Open release of post-traumatic elbow stiffness is effective in restoring elbow function, but there is no guideline on the optimal time point of surgical release so far. The purpose of this article was to summarize the current available literature reporting on the timing of open release of post-traumatic elbow stiffness.

METHODS

The PubMed, Cochrane Library, and EMBASE were searched with a set of predefined inclusion and exclusion criteria. Manual searches for references were performed to find potential relevant studies. Two authors separately extracted data from all the articles selected.

RESULTS

27 articles published between 1989 and 2017 were included with an overall enrollment of 836 patients. We divided all included studies into 3 groups according to the timing of surgical release: group 1 (6-10 months after injury), group 2 (11-20 months after injury), and group 3(>20 months after injury). The mean postoperative Mayo Elbow Performance Score (MEPS) and recurrence rate were similar among the 3 groups; however, the mean gain in arc of motion in group 1 was the highest with the lowest complication rate among the 3 groups.

CONCLUSION

There was a trend toward a shorter waiting time from injury to open arthrolysis from 12 months to 6 months. The shorter waiting period of 6 to 10 months yielded better results. Therefore, early surgical release of stiff elbows is recommended for a shorter rehabilitation time and earlier return to work.

LEVEL OF EVIDENCE

Level IV, Systematic Review.

Effect on muscle strength of the upper extremities after open elbow arthrolysis

Background

Open elbow arthrolysis manipulates tendons and soft tissues surrounding the elbow and may lead to strength decline after the operation. We hypothesized that strength of elbow and wrist motions and handgrip could be compromised after the procedure and that the strength recovery pattern may differ between men and women and between the dominant and nondominant side.

Methods

This was a prospective cohort study. We monitored 32 patients with post-traumatic elbow stiffness who underwent open arthrolysis between June 2014 and December 2014. All patients underwent standardized postoperative physical therapy. Preoperative and postoperative isometric strength were measured by a handheld dynamometer. Mayo Elbow Performance Score (MEPS) and arc of motion (AOM) were also analyzed.

Results

Mean follow-up was 26.13 months. Significant improvement was noticed in mean AOM (from 46° to 127°) and MEPS (from 67.97 to 96.86). No significant decline was noted in isometric strength at the last follow-up day. The strength ratios between men and women showed no significant difference from postoperative day 7 to the last follow-up day. At all follow-up assessments, isometric strength showed no significant difference between the dominant and nondominant side.

Conclusions

AOM and MEPS achieved significant enhancement after open elbow arthrolysis. The procedure did not lead to isometric strength decline. Postoperative gain of strength was proportional to the baseline strength level of each muscle group, and men had a more prominent gain of strength than women during the entire follow-up. Dominance had no effect on postoperative strength recovery.

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.

Osificación heterotópica en codo: resultados tras tratamiento quirúrgico

Introducción y objetivos: Se entiende osificación heterotópica (OH) como la formación ectópica de hueso maduro en los tejidos blandos adyacentes a zonas previamente lesionadas. La OH es una de las causas de rigidez articular del codo postraumática, con una prevalencia que oscila según series entre el 3 y el 45%. En su patogénesis se postula la diferenciación de células mesenquimales pluripotenciales en osteoblastos, siendo estos los causantes de la formación de hueso ectópico; sin embargo, se desconocen las causas que provocan esta reacción. Recientemente, diversos estudios de series de casos retrospectivos mediante análisis uni y multivariante han intentado encontrar factores de riesgo (FR) y parámetros predictores de la formación de OH, así como de su repercusión clínica.

Material y métodos: Presentamos un análisis retrospectivo de los casos de OH en codo tratados quirúrgicamente en nuestro centro entre los años 2005 y 2015. Se recogieron variables demográficas, antecedentes personales, evento traumático inicial, clínica, tiempo desde el traumatismo hasta el diagnóstico de la OH, tiempo desde el diagnóstico de OH hasta la cirugía escisional, seguimiento, recurrencia, y grados de movilidad en precirugía escisional y al final del seguimiento. Con ello pretendemos mostrar nuestra experiencia en el tratamiento quirúrgico de esta patología.

Resultados: Obtuvimos 4 casos con un tiempo medio de seguimiento de 40 meses. En 2 casos el evento traumático fue la luxación de codo, y en los otros 2, la ruptura del tendón del bíceps en su inserció n distal. Tres de ellos debutaron clínicamente con limitación en la movilidad articular, y uno con déficit motor a nivel radial. Todos los casos fueron varones con una edad media de 48 años. El tiempo medio transcurrido desde el evento traumático hasta el diagnóstico de OH fue de 4 meses, realizándose el tratamiento quirúrgico escisional tras el diagnóstico igualmente a los 4 meses aproximadamente como media. Tres de los 4 casos recidivaron, apareciendo nuevas calcificaciones con repercusión clínica y funcional.

Conclusión: Nuestros resultados convergen con los de la literatura en cuanto a FR y resultados funcionales; sin embargo, llama la atención el alto índice de recidiva en nuestra serie, con una tasa del 75% frente al 10-24% descrito en la literatura.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Open arthrolysis with pie-crusting release of the triceps tendon for treating post-traumatic contracture of the elbow

BACKGROUND

Extensive loss of elbow flexion compromises the performance of daily activities. We examined the clinical outcomes of patients with post-traumatic extension contracture of the elbow treated with open arthrolysis and pie-crusting release of the triceps tendon.

METHODS

We retrospectively reviewed the records of 7 patients (5 men and 2 women; mean age, 35 years) who underwent open arthrolysis via a combined lateral and medial approach with pie-crusting release of the triceps tendon for the treatment of post-traumatic elbow stiffness. All the patients had heterotopic ossification that restricted elbow motion and underwent removal of the ossified tissue and capsular release. The triceps tendon was gradually stretched by making multiple stab incisions on the tendon by using a No. 11 surgical blade. The range of motion of the elbow was recorded both preoperatively and at the final postoperative follow-up. Elbow function was assessed with the Mayo Elbow Performance Score.

RESULTS

The patients were followed up for a mean of 24 months. After treatment, significant improvement was noted in the total arc of motion (from 44° to 116°, P <.001), mean flexion (from 80° to 124°, P < .001), and mean extension (from 31° to 8°, P = .004). The mean Mayo Elbow Performance Score improved significantly from 59 points preoperatively to 92 points at the final evaluation. No major postoperative complications developed in any of the patients.

CONCLUSION

Our findings indicate that open arthrolysis with pie-crusting release of the triceps tendon is an effective and safe treatment approach for post-traumatic extension contracture of the elbow.

Articular osteotomy of the distal humerus and excision of extensive heterotopic ossification

Prior case series of corrective osteotomy of substantial intra-articular malunion after a fracture of the distal humerus described concomitant heterotopic ossification in a subset of patient, but only in mild forms. We present our experience in treating two patients with malunited articular fractures of the distal humerus with extensive heterotopic ossification and near ankylosis where the lateral articular fragments were encased in heterotopic bone. Although osteotomy of articular malunion after distal humeral fracture along with excision of extensive HO is challenging and risky due to potential devitalization of the fragments, articular deterioration during the delay to osteotomy, and recurrence of heterotopic bone among other concerns, restoring articular congruity in these patients using articular fracture fragments extracted from heterotopic ossification can lead to improved function of the elbow.

Management of Adult Elbow Fracture Dislocations

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Olecranon Fractures

Olecranon fractures are common upper extremity injuries, with all but nondisplaced fractures treated surgically. There has been a recent shift in the surgical management of these fractures from tension band wiring to locking plate fixation and intramedullary nailing; however, this comes with increased implant cost. Although most patients can expect good outcomes after these various techniques, there is little information to guide a surgeon's treatment plan. This article reviews the epidemiology, classification, treatment, and outcomes of olecranon fractures.

The efficacy of celecoxib in preventing heterotopic ossification recurrence after open arthrolysis for post-traumatic elbow stiffness in adults

BACKGROUND

Heterotopic ossification (HO) recurrence after joint surgery is always a disturbing problem for patients and surgeons. Our study was performed to assess the efficacy and safety of celecoxib in preventing the recurrence of HO after open arthrolysis for post-traumatic elbow stiffness.

METHODS

We retrospectively studied 152 patients with stiff elbows caused by post-traumatic HO. After surgery, 77 patients received celecoxib (200 mg once daily) for 28 days, whereas 75 did not. Radiographic evaluation was performed at 3, 6, and 9 months postoperatively. Univariate and multivariate analyses were performed to determine which factors affected HO recurrence.

RESULTS

HO was both more common and more severe in the no-celecoxib group than in the celecoxib group at 3, 6, and 9 months after surgery. A significant difference was observed between the 2 groups in terms of postoperative extension (P = .030), flexion (P = .008), and pronation (P = .005); however, no significant difference in postoperative supination was noted (P = .622). Logistic regression analysis showed that taking celecoxib was the protective factor for HO recurrence, whereas overweight (body mass index > 25) and male gender were the risk factors.

CONCLUSIONS

A short course of celecoxib aids in the prevention of HO recurrence after open arthrolysis for elbow stiffness in adults and could be an effective and safe option.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Limited extension after linked total elbow arthroplasty in patients with rheumatoid arthritis

OBJECTIVE

Total elbow arthroplasty (TEA) has become an established procedure to relieve pain and to increase the range of motion of the destructed elbow in patients with rheumatoid arthritis (RA). However, some patients still have limited extension after TEA, and the causes of limited extension after TEA have yet to be elucidated.

METHODS

To examine whether widening of the joint space can cause such limited extension, we retrospectively analyzed 55 cases of linked TEA in patients with RA. There were seven male and 40 female with a mean age of 63.8 years (range, 30-80 years) and a mean follow-up of 7.5 ± 4.2 years (range, 2.5-15.6 years). The Mayo Elbow Performance Score (MEPS) and radiological measurements were recorded. Widening of the joint space was calculated by subtracting the length measured on postoperative radiograph from preoperative radiograph.

RESULTS

MEPS and range of motion were significantly improved after surgery except for extension. The degree of extension was significantly correlated with radiological widening of the joint space in the limited extension group. Correlation analyses showed that postoperative limited extension was correlated with lower MEPS daily function.

CONCLUSIONS

Limited extension after linked TEA is partly derived from perioperative widening of the joint space and potentially limits daily function in patients with RA.

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.

Open surgical release for contractures of the elbow

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

Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator

BACKGROUND

Instability is a crucial issue in severe post-traumatic elbow stiffness during complete-release surgery. This study aimed to evaluate the efficacy of ligament repair using a suture anchor in the operative treatment of severely stiff elbows for which a hinged external fixator was indicated.

METHODS

We retrospectively reviewed 46 cases of severely stiff elbows (flexion arc <60°) undergoing open release. During the operation, all 46 elbows were noted to have instability. Suture anchors were applied to restore the ligament if it was impossible to repair the ligament directly, and a hinged external fixator was simultaneously applied to protect the vulnerable ligament and facilitate rehabilitation. No allograft or autograft was used in any of our cases. The stability, arc of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, and radiographs were evaluated.

RESULTS

At a mean follow-up of 24.3 months, the postoperative Mayo Elbow Performance Score was 91 points, as compared with 63 points preoperatively. The mean flexion arc improved from 25° to 126°. Three patients presented with moderate elbow instability when the hinged external fixator was removed; however, all of them regained stability by the last follow-up. Furthermore, 7 cases of new-onset nerve palsy were noted; however, all of them resolved with conservative management. None of the patients required secondary surgery for any reason.

CONCLUSIONS

Repair of an avulsed collateral ligament with suture anchors and hinged external fixation was effective in restoring functional mobility in patients with severe post-traumatic elbow stiffness after complete release. This could be an option for treating ankylosed, severely or very severely stiff elbows.

Is routine ulnar nerve transposition necessary in open release of stiff elbows? Our experience and a literature review

PURPOSE

Prophylactic release of the ulnar nerve to reduce the incidence of postoperative nerve symptoms in stiff elbows has been recommended. However, the necessity for routine anterior transposition remains unclear. In this study, we aim to gain an insight into the value of routine transposition in open release of stiff elbows.

METHODS

We retrospectively reviewed 94 patients suffering from elbow stiffness with no pre-operative ulnar nerve symptoms. Simple decompression (with in situ decompression or epicondylectomy) and subcutaneous anterior transposition were chronologically performed in 53 and 37 patients, respectively. Another four patients were treated by a single lateral approach with no intervention of the ulnar nerve. Pre- and postoperative range of motion and incidence of ulnar nerve symptoms were recorded. The function of ulnar nerve was measured by Amadio rating scale.

RESULTS

The incidence of ulnar nerve dysfuction was 18.9% (ten of 53) and 8.1% (three of 37) in the simple decompression and transposition groups, respectively. The mean Amadio scores were 7.62 and 8.22, respectively. All these data showed a statistically significant difference (P < 0.05). In the lateral approach group, 50 % (two of four) of patients developed nerve symptoms with a mean Amadio score of 6.50.

CONCLUSIONS

The transposition group exhibited a superior nervous outcomes compared with the simple decompression group. No comparison was conducted between the transposition and lateral approach groups because of too few patients in the latter. According to related literature and our experience, we conclude that routine transposition is necessary to prevent postoperative nerve symptoms.

Heterotopic ossification of the elbow treated with surgical resection: risk factors, bony ankylosis, and complications

BACKGROUND

Heterotopic ossification is the most common extrinsic cause of elbow contracture and may lead to clinically important stiffness, and rarely, complete bony ankylosis. Surgery sometimes is performed to treat this problem, and published reports differ regarding the factors that are associated with success or failure after this operation and whether the procedure is effective for patients with elbow ankylosis.

QUESTIONS/PURPOSES

We wished (1) to identify potential patient characteristics and modifiable risk factors that are associated with improvements in ROM after surgery for heterotopic ossification of the elbow; (2) to compare ROM gains between patients with complete ankylosis and partially restricted ROM; and (3) to characterize the complications of elbows treated by surgical release and excision of heterotopic ossification followed by a standardized rehabilitation program.

METHODS

We reviewed the records of all patients treated operatively for heterotopic ossification of the elbow from September 1999 to February 2012 at one institution by one surgeon. General indications for the surgery were clinically symptomatic or debilitating heterotopic ossification of the elbow. Each patient received prophylaxis postoperatively consisting of indomethacin (or single-shot radiation for patients with sensitivity to antiinflammatory medications). All patients received a physical therapy regimen and used a continuous passive motion machine for 6 weeks. Patient demographics, mechanism of injury, time between injury and surgery, and medical history were reviewed for comparison. Followup was at a mean of 13 months (range, 3-106 months); no patients were lost to followup. Thirty-nine patients (46 elbows) with heterotopic ossification treated with excision were identified: 10 patients (16 elbows) had burns, 28 patients (29 elbows) had trauma, and one patient (one elbow) had a closed head injury. Eight of the 39 patients (12 of 46 elbows [26%]) had complete ankylosis at the time of surgery.

RESULTS

Hypertension, obesity, and absence of intraoperative anterior ulnar nerve transposition were associated with an adverse effect on change from preoperative to final arc of motion. The group with ankylosis had greater preoperative to postoperative gain in arc compared with the group with partial restriction (96°, 95% CI, 84°-107° and 59°, 95% CI, 46°-72°, respectively). For the entire cohort there was an overall improvement in mean flexion-extension arc of motion from 35° to 103° at final followup (p < 0.001; 95% CI, 57°-80°), with a 17% rate of complications (three patients [three elbows] with heterotopic ossification, three patients [three elbows] with nerve palsies, one patient [one elbow] with deep wound infection, and one patient [one elbow] with an unstable elbow).

CONCLUSIONS

Patients with partially and completely restricted ROM showed substantial improvement in postoperative ROM. Hypertension, obesity, and absence of intraoperative anterior ulnar nerve transposition were negative predictors of outcome in our series. Surgery combined with postoperative prophylaxis and a regimented rehabilitation program are feasible modalities to treat patients with heterotopic ossification of the elbow.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study

BACKGROUND

With the improvements in wound healing through the use of intravenous prophylactic antibiotics and technical refinements, postoperative elbow infections have become less common but still occur in certain elective elbow surgeries. The objective of this study was to evaluate the safety and efficacy of prophylactic application of vancomycin into the operative site to reduce the incidence of infection after the open release of post-traumatic stiff elbows.

METHODS

A retrospective review of 272 such patients during a 4-year period was performed. In the control group (93 patients), simple prophylaxis with standard intravenous antibiotics was performed; in the vancomycin group (179 patients), vancomycin powder was applied directly into the wound before closure along with standard intravenous prophylaxis.

RESULTS

After a follow-up of at least 6 months, the control group was found to have 6 infections (6.45%; confidence interval: 2.40%-13.52%) compared with none (0%; confidence interval: 0-2%.04%) in the vancomycin group, which was a statistically significant difference (P = .0027). No adverse effects were documented from the direct use of the vancomycin powder.

CONCLUSIONS

The local application of vancomycin powder may be a promising means of preventing postoperative elbow infections after elbow release in patients with post-traumatic elbow stiffness.

Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention

INTRODUCTION

The treatment of terrible triad injury with a poor outcome after intervention has not been successful thus far. The purpose of this study was to evaluate the efficacy of arthrolysis and reconstruction in the treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention.

MATERIALS AND METHODS

Twelve patients (12 elbows) with the diagnosis of terrible triad injury were respectively reviewed. All the 12 patients had elbow dysfunction after conservative and surgical treatment of the terrible triad injury. Preoperatively, the flexion arc and forearm rotation were 36.7° ± 28.5° and 51.3° ± 43.4°, respectively, and the Mayo Elbow Performance Score was 56.3 points. The mean interval between the primary injury and our surgical treatment was 6.6 months. Our surgical intervention included elbow arthrolysis, ulnar nerve transposition, radial head replacement, coronoid process and ligament repair, and hinged external fixation. Patients were encouraged to participate in rehabilitation training 24 h after surgery.

RESULTS

The mean follow-up duration was 20.1 months; the flexion arc and forearm rotation were 122° ± 18° and 140° ± 20°, respectively, and the mean Mayo Elbow Performance Score was 94.6 points (9 excellent, 3 good). Concentric stability was restored in all elbows. Complications included superficial pin tract infection (1), heterotopic ossification (3), and ulnar nerve palsy (1); the ulnar nerve symptoms had improved at the last follow-up.

CONCLUSIONS

The combination of open arthrolysis and reconstruction performed at a mean interval of 6-month posttrauma can restore functional mobility in cases of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Thus, it may be an effective alternative for the treatment of the poor outcome terrible triad injury. We recommend early functional rehabilitation with adherence to the guidelines for hinged external fixation.