A new pathologic classification for elbow stiffness based on our experience in 216 patients

Resection Outcomes of Posttraumatic Elbow Heterotopic Ossification: Multicenter Case Series at a Minimum 5-Year Follow-Up

BACKGROUND

Heterotopic ossification (HO), a common complication after elbow trauma, causes severe limb disability. Resection is usually performed for posttraumatic elbow HO (PTEHO) to regain mobility, and although heavily reported, there has been no long-term (minimum, 5-year) follow-up.

METHODS

A total of 173 patients who underwent PTEHO resection were followed up for a minimum of 5 years in 4 hospitals between January of 2015 and August of 2016. Demographics, disease characteristics, and preoperative and minimum 5-year assessments were collected. After controlling for potential variables when dividing long-term range of motion (ROM) into less than 120 degrees and greater than or equal to 120 degrees, risk factors for ROM recovery to modern functional arc were identified through multivariable regression analysis.

RESULTS

Clinically important improvements in ROM from 39 degrees to 124 degrees were obtained at final follow-up, and 74.6% achieved modern functional arc (≥120 degrees). Mayo Elbow Performance Index had clinically important increases from 69 to 93 points at final follow-up, and 96.5% reported excellent to good. Pain (numeric rating scale, from 1.9 to 0.6 points) and ulnar nerve symptoms were improved. The total complication rate was 15.6%, including new-onset ulnar nerve symptoms (5.8%), HO recurrence with clinical symptoms (6.9%), elbow instability (1.7%), and joint infection (1.2%). Previously reported high body mass index ( P = 0.002) and long disease duration ( P = 0.033) were equally identified as risk factors for not achieving modern functional arc; meanwhile, tobacco use ( P = 0.024) and ankylosed HO ( P < 0.001) were found to be new risk factors.

CONCLUSIONS

Resection yields satisfactory outcomes for PTEHO at long-term follow-up of a minimum of 5 years. High body mass index, tobacco use, long disease duration, and ankylosed HO would negatively affect ROM recovery to a modern functional arc (≥120 degrees).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Hinged External Fixation Combined with Open Debridement for Post-traumatic Elbow Stiffness: A Systematic Review and Meta-analysis

Background

Open debridement remains the gold standard for the clinical treatment of post-traumatic elbow stiffness. However, postoperative complications, such as re-contraction and heterotopic ossification of the elbow joint, are highly prevalent. Hinged external fixation appears to offer the potential for greater improvement of joint function and reduction of complications. The purpose of this article is to provide the latest evidence on the effectiveness and safety of hinged external fixation combined with open debridement for the treatment of post-traumatic elbow stiffness.

Methods

We searched for randomized controlled trials (RCTs) from the China National Knowledge Infrastructure, MEDLINE, PubMed, Web of Science, EMBASE, and Cochrane Library databases until December 31, 2022. STATA 15.1 software was used to analyze all the data for this article. The quality of the included articles was evaluated using the Cochrane Reviewer's Handbook 5.3.

Results

Finally, we selected 8 high-quality RCTs for our meta-analysis, which included 555 patients. The meta-analysis demonstrated that hinged external fixation combined with open debridement for post-traumatic elbow stiffness (treatment group) showed a significant increase in elbow flexion and extension mobility (WMD = 5.16, 95% CI 4.39-5.49, Z = 13.02, P = 0.000), Mayo elbow function scores (WMD = 5.25, 95% CI 4.33-6.17, Z = 11.15, P = 0.000), and Mayo excellent rate (RR = 1.25, 95% CI 1.14-1.37, Z = 4.87, P = 0.000). Additionally, there was a significant decrease in the complication rate (RR = 1.11, 95% CI 1.02-1.20, Z = 2.54, P = 0.011) compared to open debridement alone (control group). Furthermore, the results of the publication bias test showed no significant bias.

Conclusions

With the assistance of hinged external fixation, open debridement for post-traumatic elbow stiffness can lead to increased elbow mobility and a reduced complication rate. However, due to the small sample size, a multicenter randomized controlled trial with a larger sample size is still necessary to further confirm the effectiveness and safety of hinged external fixation combined with open debridement for post-traumatic elbow stiffness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-01087-y.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical arthrolysis of the stiff elbow: a systematic review

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY DESIGN

Level IV; Systematic review.

Study on the Mechanism of Pathological Recognition Based on Bioelectrical Impedance Spectrum to the Elbow Joint

The elbow joint is prone to stiffness and adhesion after trauma or surgery. High-energy trauma easily led to loss of mobility of the elbow joint. Mild trauma can also cause stiffness in the elbow joint. In order to investigate the pathogenesis of stiffness and adhesion in elbow joint, a feedback-type elbow joint control system based on network is proposed in this paper. The simulation results show that it has significant differences in elbow bioelectrical impedance in patients with elbow trauma, and this new method realizes the control strategy of converting the patient’s elbow joint pathological information into elbow joint orthosis control information.

Analysis of Bioelectrical Impedance Spectrum for Elbow Stiffness Based on Hilbert-Huang Transform

With the advent of posttraumatic elbow rehabilitation, prevention of elbow stiffness has become a key part of the development of sports medicine. In order to clarify the time point of joint movement after internal fixation to the elbow and to provide a mechanical model for individualized diagnosis. This paper uses electromagnetic wave detection technology to quickly detect the bioelectrical impedance signal of the patient's lesion location, then passes the message to the upper control system for processing, summarizes the improved Hilbert–Huang transform to deep learning, and deep learning algorithms and computer technology are used to mine the bioelectrical impedance signal of the elbow joint. The simulation and human experiment results show that bioelectrical impedance signals can clarify the pathogenesis of elbow joint stiffness and the relationship between rehabilitation treatment time and duration. It has the advantages of low cost, high fitting accuracy, strong robustness, and noninvasiveness.

Development and validation of a prognostic nomogram for open elbow arthrolysis : the Shanghai Prediction model for Elbow Stiffness Surgical Outcome

AIMS

The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.

METHODS

We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation.

RESULTS

BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome.

CONCLUSION

The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment. Cite this article: Bone Joint J 2022;104-B(4):486-494.

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.

Targeting repeatability of a less obtrusive surgical navigation procedure for total shoulder arthroplasty

PURPOSE

Surgical navigation systems have demonstrated improvements in alignment accuracy in a number of arthroplasty procedures, but they have not yet been widely adopted for use in total shoulder arthroplasty (TSA). We believe this is due in part to the obtrusiveness of conventional optical tracking systems, as well as the need for additional intraoperative steps such as calibration and registration. The purpose of this study is to evaluate the feasibility of adapting a less-intrusive dental navigation system for use in TSA.

METHODS

We developed a proof-of-concept system based on validated laser-engraved surgical tools recently introduced for use in dental surgery that are calibrated once when manufactured and not recalibrated at time of use. The design also features a notably smaller bone-mounted tracker that can be tracked from a wide range of viewing angles. To assess our system's performance, we modified the dental surgical software to support guidance of a TSA procedure. We then conducted a user study in which three participants with varying surgical experience used the system to drill 30 holes in a glenoid model. Using a coordinate measuring machine, we determined the resulting drilled trajectory and compared this to the pre-planned trajectory. Since we used a model glenoid rather than anatomical specimens, we report on targeting precision rather than overall procedure precision or accuracy.

RESULTS

We found targeting precision < 1 mm (standard deviation) for locating the entry hole and <  ~ 1° (SD) for both version and inclination. The latter value was markedly lower than the end-to-end angular precision achieved by previously reported TSA navigation systems (approximately 3°-5° SD).

CONCLUSION

We conclude that variability during the targeting phase represents a small fraction of the overall variability exhibited by existing systems, so a less obtrusive navigation system for TSA based on laser-engraved tooling is likely feasible, which could improve the uptake rates of surgical navigation for TSA, thereby potentially leading to improved overall surgical outcomes.

How effective is periarticular multimodal drug injection in open elbow arthrolysis? A prospective double-blind randomized controlled trial

BACKGROUND

Evidence on the efficacy and safety of periarticular multimodal drug injection (PMDI) in open elbow arthrolysis (OEA) is limited. This study aimed to investigate differences in postoperative pain, blood loss, and range of motion (ROM) between PMDI vs. no injection among patients undergoing OEA, and the presence of PMDI-related complications.

METHODS

This prospective, double-blind randomized controlled trial included 59 patients who underwent OEA. Patients randomly received PMDI (ropivacaine, epinephrine, ketoprofen) before wound closure or no injection. The primary outcomes were elbow pain over the first postoperative week at rest and during motion, measured using the visual analog scale (VAS). VAS scores were compared to attain the 20-mm threshold values for a minimum clinically important difference. Parecoxib consumption on OEA night and postoperative days (PODs) 1-3 and total consumption during the first postoperative week were recorded. Blood loss was recorded every 24 hours until POD 3. ROM during rehabilitation was measured daily from day 1 to day 7 after surgery, as well as at 3-month follow-up. Medication-related side effects were recorded prospectively.

RESULTS

The mean VAS score showed clinically important differences between PMDI and control groups at rest on OEA night (mean difference [MD], 25 mm; P < .001) and first 3 PODs with motion (POD 1: MD, 28 mm, P < .001; POD 2: MD, 21 mm, P < .001; POD 3: MD, 21 mm, P < .001) but not in other postoperative assessments. Parecoxib consumption was lower in the PMDI group on OEA night and PODs 1-3. Total parecoxib consumption during the first postoperative week was lower in the PMDI group vs. the control group (MD, 148 mg; P < .001). Blood drainage was less in the PMDI group vs. the control group on POD 1 (MD, 38 mL; P = .016) but not on POD 2 (P = .950), POD 3 (P = .259), or total (P = .184). The PMDI group exhibited significantly better ROM during the first 4 PODs than the control group, whereas there was no difference at 3-month follow-up. No medication-related side effects were noted in the PMDI group.

CONCLUSION

PMDI effectively relieves pain and reduces analgesic consumption for OEA patients, without an apparent increase in risks.

Open elbow arthrolysis for post-traumatic elbow stiffness: an update

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576-584.