POST-TRAUMATIC STIFFNESS OF THE ELBOW

COMPLICATIONS AFTER SURGICAL TREATMENT OF JUPITER'S MONTEGGIA TYPE II FRACTURES

Monteggia fracture-dislocations are rare injuries, affecting about 2-5% of the population. Jesse Jupiter subdivided Bado's Type II fractures into four types, all of which presented an associated radial head fracture. Associated chondral and ligament injuries can evolve with postoperative complications.

Objective

To evaluate the incidence of complications and risk factors that may influence the postoperative outcomes of Jupiter lesions.

Methods

This retrospective study was conducted with surgically treated patients. The characteristics related to fractures and surgical approaches were evaluated and these variables were correlated with radiographic and functional postoperative complications.

Results

A total of 15 patients were evaluated, mostly men and with a higher prevalence of Types IIA and IID. The most frequent complications were heterotopic ossification and osteolysis around the radial head prosthesis. Postoperative instability occurred only in the lateral collateral ligament. According to MEPS functional score, 53% of the patients evolved with unfavorable outcomes.

Conclusion

The studied cases evolved with high rates of postoperative complications, mainly in Jupiter's Type IID fractures and associated coronoid fractures. Level of Evidence III, Therapeutic Study.

Design of a Smart Elbow Brace as a Home-Based Rehabilitation Device

Poststroke and traumatic elbow injuries are the most common cause of elbow stiffness, which results in loss of functional range of motion (ROM). Various studies support early mobilization of the elbow joint after injury or after surgery to reduce risks of elbow stiffness development. After hospitalization, patients are required to follow a long-term rehabilitation program during home recovery. Still, most patients do not adhere to their clinical therapy schedule due to either rehabilitation cost, social obligations, negligence, or lack of inspiration. Moreover, the numbers of therapists and assessment equipment are insufficient. This study introduces a smart elbow brace (SEB) as a home-based rehabilitation device that reduces regular in-patient rehabilitation costs and therapist workload and motivates patients to comply with the rehabilitation program that enhances the achievement of rehabilitation goals. Our device has two active degrees of freedom (2-DoF) that allow extension, flexion, pronation, and supination elbow motions. An extra sliding joint between forearm and wrist is added, which helps dump forces concentration at the elbow joint during extension-flexion movement. Mechanical design requirements, motion-tracking systems, and serious game development are described. The feasibility of a proposed SEB device is tested with five healthy subjects playing developed serious games with the device. The results show that subjects can attain maximum and minimum angles of flexion-extension and pronation-supination motion designed for elbow stiffness rehabilitation. The SEB device will be beneficial and be used at home as a complementary tool to support elbow stiffness rehabilitation during long-term home recovery.

Macrophage migration inhibitory factor regulates joint capsule fibrosis by promoting TGF-β1 production in fibroblasts

Joint capsule fibrosis caused by excessive inflammation results in post-traumatic joint contracture (PTJC). Transforming growth factor (TGF)-β1 plays a key role in PTJC by regulating fibroblast functions, however, cytokine-induced TGF-β1 expression in specific cell types remains poorly characterized. Macrophage migration inhibitory factor (MIF) is a proinflammatory cytokine involved in inflammation- and fibrosis-associated pathophysiology. In this study, we investigated whether MIF can facilitate TGF-β1 production from fibroblasts and regulate joint capsule fibrosis following PTJC. Our data demonstrated that MIF and TGF-β1 significantly increased in fibroblasts of injured rat posterior joint capsules. Treatment the lesion sites with MIF inhibitor 4-Iodo-6-phenylpyrimidine (4-IPP) reduced TGF-β1 production and relieved joint capsule inflammation and fibrosis. In vitro, MIF facilitated TGF-β1 expression in primary joint capsule fibroblasts by activating mitogen-activated protein kinase (MAPK) (P38, ERK) signaling through coupling with membrane surface receptor CD74, which in turn affected fibroblast functions and promoted MIF production. Our results reveal a novel function of trauma-induced MIF in the occurrence and development of joint capsule fibrosis. Further investigation of the underlying mechanism may provide potential therapeutic targets for PTJC.

Macrophage migration inhibitory factor activates the inflammatory response in joint capsule fibroblasts following post-traumatic joint contracture

Objectives: Joint capsule fibrosis caused by excessive inflammation leading to post-traumatic joint contracture (PTJC). Fibroblasts trigger inflammation under the challenge of various proinflammatory cytokines. Macrophage migration inhibitory factor (MIF) is a prominent proinflammatory cytokine involved in inflammation- and fibrosis-associated pathophysiology, we investigated the role of MIF in PTJC.

Methods: Using rat PTJC model and fibroblast inflammation model, we detected MIF expression in posterior joint capsule. Primary joint capsule fibroblasts (JFs) were used to investigate the effects of MIF on cell proliferation, migration and proinflammatory cytokines production. The mechanism of JF-mediated events was evaluated by qRT-PCR, western blot and immunoprecipitation. We screened the mRNA expression profile to identify gene candidates that mediate the effect of MIF on JFs.

Results: MIF increased in posterior joint capsule following PTJC and co-localized with fibroblasts. Injection of MIF inhibitor significantly suppressed joint capsule inflammation and fibrosis. In vitro, MIF promoted JF proliferation, migration, and inflammation by regulating mitogen-activated protein kinase/nuclear factor-κB pathway through coupling with CD74. Transcriptome analysis revealed that lipid metabolism-related factors Pla2g2a, Angptl4, and Sgpp2, downstream of MIF/CD74, were potentially implicated in JF inflammation.

Conclusion: MIF/CD74 axis elicited JF inflammation and may provide new therapeutic targets for joint capsule fibrosis in PTJC.

The use of bioabsorbable compression screws & polyethylene tension band for fixation of displaced olecranon fractures

INTRODUCTION

Transverse fractures of the olecranon are commonly fixed using tension-band wiring techniques. However the superficial nature of this area leads to high complication rates requiring removal of metalwork. The purpose of this retrospective study is to report and evaluate functional outcomes of polyethylene tension-band and bioabsorbable Magnesium alloy screw fixation of olecranon fractures.

METHODS

A retrospective case-control study was undertaken. Demographics, injury type and post-operative details were collected. All patients were treated in the same institution by a single surgeon. Primary outcomes included radiographic healing and post-operative range of motion. Secondary outcome was post-operative complications.

RESULTS

A total of five cases were identified. Mean age was 52.4. The control group was made up of six patients treated with a traditional tension band wire fixation. One patient in study group was lost to follow up. 80% of fractures in study group demonstrated anatomic post-operative radiographic union, compared with 83% of control group. All patients had range of motion above 100°, with full protonation and supination. One patient did have an extension lag of 15°.

CONCLUSION

Surgical repair of olecranon fractures is often complicated by the need for re-operation. This method provides both intramedullary fixation and conversion of distraction forces to compression forces with bioabsorbable materials, and aims to reduce the high re-operation rates commonly seen by avoiding the use of permanent indwelling metal hardware.

The stiff elbow: Current concepts

Elbow stiffness is defined as any loss of movement that is greater than 30° in extension and less than 120° in flexion. Causes of elbow stiffness can be classified as traumatic or atraumatic and as congenital or acquired. Any alteration affecting the stability elements of the elbow can lead to a reduction in the arc of movement. The classification is based on the specific structures involved (Kay’s classification), anatomical location (Morrey’s classification), or on the degree of severity of rigidity (Vidal’s classification). Diagnosis is the result of a combination of medical history, physical examination (evaluating both active and passive movements), and imaging. The loss of soft tissue elasticity could be the result of bleeding, edema, granulation tissue formation, and fibrosis. Preventive measures include immobilization in extension, use of post-surgical drain, elastic compression bandage and continuous passive motion. Conservative treatment is used when elbow stiffness has been present for less than six months and consists of the use of serial casts, static or dynamic splints, CPM, physical therapy, manipulations and functional re-education. If conservative treatment fails or is not indicated, surgery is performed. Extrinsic rigidity cases are usually managed with an open or arthroscopic release, while those that are due to intrinsic causes can be managed with arthroplasties. The elbow is a joint that is particularly prone to developing stiffness due to its anatomical and biomechanical complexity, therefore the treatment of this pathology represents a challenge for the physiotherapist and the surgeon alike.

Functional elbow range of motion 6 months after contracture release and ORIF K-wire in elbow stiffness with malunion capitellum and neglected radial head and ulnar dislocation: a case report

INTRODUCTION

Elbow stiffness is the most common complication following trauma of the elbow. This is because the elbow joint is susceptible to effusion, hemarthrosis, scarring, and capsule thickening due to its small intracapsular volume. Surgical treatment is therefore necessary to release soft tissue contracture.

CASE

A male teenager was unable to flex his elbow since 1 year prior to admission after falling down during football practice. He didn't seek any medical treatment and had his elbow massaged since 5 months ago. On physical examination, his right elbow was extended, with flexion-extension range of motion (ROM) of 30⁰ - 0⁰. On the radiograph, there was malunion fracture of left capitellum and neglected posterosuperior dislocation of radial head and ulna. Surgery was performed to release contracture and correct the malunion. Normal activity with functional elbow flexion-extension ROM of 110⁰ - 30⁰ was achieved in 6 months after operation.

DISCUSSION

Elbow stiffness is a challenging case for surgeon, especially in regards of developing good perioperative plan. The aim of treatment for elbow stiffness is to achieve a pain-free and functional elbow ROM.

CONCLUSION

To achieve functional elbow ROM, surgical treatment was necessary to release the contracture. In addition, the etiology of trauma must be thoroughly investigated and a good rehabilitation program must be integrative to the treatment.