Surgical treatment of extraarticular elbow contracture

Preoperative simulated surgery on 3D model assists osteotomy feasibility verification and surgical guidance for patients with cubitus valgus/varus deformity: a retrospective observational study

BACKGROUND

As the common delayed complication of supracondylar fractures in children, cubitus valgus/varus deformity might lead to pain and loss of motion of the elbow. The current corrective treatment might not be accurate enough and even contribute to postoperative deformity. This study retrospectively analyzed the clinical value of preoperative simulated surgery on 3D model-assisted osteotomy feasibility verification and surgical guidance for cubitus valgus/varus deformity.

METHODS

Seventeen patients were selected from October 2016 to November 2019. Deformities were analyzed from imaging data and 3D models and corrected after the simulated operations. The radiographic evaluation comprised osseous union, carrying angle, and anteversion angle of the distal humerus. The clinical evaluation was performed according to the Hospital for Special Surgery (HSS) scoring system.

RESULTS

All patients underwent the operation successfully and had no postoperative deformity. The carrying angle was significantly improved postoperatively (P < 0.001). The anteversion angle of the distal humerus did not change significantly (P > 0.05). The HSS score rose after surgery (P < 0.001). The function of the elbow joint was excellent in seven cases and good in ten cases.

CONCLUSION

Simulated surgery on 3D model plays an important role in osteotomy plan and surgical guidance, contributing to good surgical efficacy.

Analysis of Long-Term Outcomes Following Surgical Contracture Release of the Elbow: A Case Series

Background

Elbow contracture is a debilitating condition with an incidence ranging from as low as almost 1% to as high as 20% and results in significant limiting consequences on a patient’s activities of daily living (ADLs). Postoperative rehabilitation is important in maintaining the range of motion and sustaining an improved range of motion. The purpose of this study was to evaluate the long-term results of elbow contracture release surgery and the effect of an occupational therapy/physical therapy (OT/PT)-guided, self-directed rehabilitation program following surgery, without the use of continuous passive motion (CPM) devices.

Methods

We enrolled patients who had undergone elbow contracture release surgery from 2005 to 2016 at a single institution under the senior author. The evaluation included objective measurements of range-of-motion, strength, and neurological sensory testing. Provocative testing of the elbow and hand was performed. American Shoulder and Elbow Surgeons-elbow (ASES-e), Simple Shoulder Test-elbow (SST-e), Disabilities of the Arm and Shoulder (DASH), Mayo Elbow Performance Index (MEPI), Short Form-36 (SF-36), and an investigator questionnaire were completed.

Results

We enrolled 19 patients, six female and 13 male, with an average follow-up of 58.9 months (SD± 39.8, Range 22-117). We showed improvement and sustained motion between preoperative and postoperative research visit flexion (p<0.001) and flexion extension-arc (p<0.01). The mean increase in flexion was 98° to 131° and the flexion-extension arc was 36°. Patients were satisfied with the decision to undergo surgery and had sustained ability to complete ADLs.

Discussion

This patient cohort demonstrated a statistically significant increase, as well as long-term maintenance in the flexion and flexion-extension arc. A self-directed, OT/PT-guided, therapy program without CPM was effective. Patients showed good outcomes and were satisfied with their ability to perform ADLs, decreased pain, and the decision to undergo surgery.

Arthroscopic Treatment of Posttraumatic Elbow Stiffness Due to Soft Tissue Problems

OBJECTIVES

To evaluate the effectiveness of arthroscopic management of posttraumatic elbow stiffness due to soft tissue problems.

METHODS

A retrospective review of 30 consecutive arthroscopic elbow releases for posttraumatic stiff elbow from November 2011 to December 2019 was conducted. Stiff elbows with bony problems, such as heterotopic ossification, intraarticular nonunion or malunion, and cartilage lesions were excluded from this study. Contracture and adhesion of soft tissue around the elbow were identified. Surgical treatments included arthroscopic capsulectomy, ligaments and muscle release, and ulnar nerve release. The results were evaluated using the Mayo elbow performance score (MEPS) and range of motion of the elbow. Surgery-related complications were assessed.

RESULTS

Patients who underwent arthroscopic release were followed up for between 6 and 35 months, with a mean follow-up time of 10.1 months. The postoperative elbow ROM was 123.2° ± 19°, which was significantly different compared to the preoperative value of 68° ± 32°. In addition, the MEPS score improved from 71.2 ± 10.3 preoperatively to 93.7 ± 6.6 at the final follow-up, a mean improvement of 22.5 (range, 0-55; P < 0.05). Postoperative complications included five cases of prolonged drainage from the portal site, three transient nerve palsies, and one hematoma in the medial elbow.

CONCLUSION

With full recognition by the surgeon of the pathologic changes of the soft tissue around the elbow, arthroscopic release is usually safe and effective for posttraumatic elbow stiffness without symptomatic bony problems.

Anterior elbow release for post-traumatic flexion contractures in patients 21 years or younger

HYPOTHESIS AND BACKGROUND

An elbow contracture in a young person can be a devastating problem. Significant contractures will lead to functional loss of the extremity. Appropriately performed contracture release can have profound implications on the overall well-being of the patient. The purpose of this study was to report improvements in sagittal-plane range of motion and the complication rate following an anterior elbow release for flexion contractures in patients 21 years or younger.

METHODS

We performed a retrospective review of 27 patients with a median age of 16.8 years who were treated surgically for elbow flexion contracture with an anterior approach. Follow-up was possible in 18 of these patients at an average of 31 months. An anterior approach was performed in all 18 patients, with 4 patients undergoing an additional posterior incision to address posterior structures limiting extension.

RESULTS

Elbow extension improved by an average of 35°, from -54° to -19°. The mean total arc of elbow motion improved by 37°, from 65° to 102°. Two complications occurred: traction-related neurapraxia of the lateral antebrachial cutaneous nerve and transient neurapraxia of the posterior interosseous nerve.

DISCUSSION AND CONCLUSION

Elbow contracture release through an anterior approach is an acceptable surgical option. Significant improvement is obtained with a low risk of complications.

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.

Joint contracture is reduced by intra-articular implantation of rosiglitazone-loaded hydrogels in a rabbit model of arthrofibrosis

Trauma, surgery, and other inflammatory conditions can lead to debilitating joint contractures. Adjunct pharmacologic modalities may permit clinical prevention and treatment of recalcitrant joint contractures. We investigated the therapeutic potential of rosiglitazone by intra-articular delivery via oligo[poly(ethylene glycol)fumarate] (OPF) hydrogels in an established rabbit model of arthrofibrosis. OPF hydrogels loaded with rosiglitazone were characterized for drug elution properties upon soaking in minimum essential media (MEM) with 10% fetal bovine serum and measurements of drug concentrations via High Performance Liquid Chromatography (HPLC). Drug-loaded scaffolds were surgically implanted into 24 skeletally mature female New Zealand White rabbits that were divided into equal groups receiving OPF hydrogels loaded with rosiglitazone (1.67 mg), or vehicle control (10 µl DMSO). After 8 weeks of joint immobilization, rabbits were allowed unrestricted cage activity for 16 weeks. Contracture angles of rabbit limbs treated with rosiglitazone showed statistically significant improvements in flexion compared to control animals (mean angles, respectively, 64.4° vs. 53.3°, p < 0.03). At time of sacrifice (week 24), animals in the rosiglitazone group continued to exhibit less joint contracture than controls (119.0° vs. 99.5°, p = 0.014). The intra-articular delivery of rosiglitazone using implanted OPF hydrogels decreases flexion contractures in a rabbit model of arthrofibrosis without causing adverse effects (e.g., gross inflammation or arthritis). Statement of Clinical Significance: Post-traumatic joint contractures are common and debilitating, with limited available treatment options. Pharmacologic interventions can potentially prevent and treat such contractures. This study is translational in that a commercially approved medication has been repurposed through a novel delivery device. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2949-2955, 2018.

Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis

BACKGROUND

In the treatment of lateral epicondylitis (LE), the role of a new dynamic wrist orthosis is unclear.

PATIENTS AND METHODS

Patients suffering from a LE longer than 3 months were multicentrically and prospectively randomized into a physiotherapeutic group (PT group) and in a physiotherapy group plus wrist orthosis (PT + O group). Physiotherapy consisted of daily eccentric strengthening exercises under initial professional supervision. Inclusion criteria were a Placzek score greater than 4. Exclusion criteria were previous surgery, rheumatic arthritis, elbow instability, radicular symptoms, higher-grade extensor tendon rupture, or cervical osteoarthritis. The clinical evaluation was performed after 12 weeks and 12 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, Placzek Score, the pain rating (VAS), range of motion and the Subjective Elbow Score were evaluated.

RESULTS

Of the initially 61 patients, 31 were followed up after 12 weeks and 22 after 12 months. Twenty-nine patients (43%) were male, the mean age was 46, and 44 patients (66%) had the right elbow involved. At 12 weeks, there was a pain reduction on the VAS in both groups (PT + O: 6.5-3.7 [p = .001]; PT: 4.7-4.1 [p = .468]), albeit it was only significant for the PT + O group. At 12 months, reduction was significant in both groups (PT + O: 1.1 [p = .000]; PT: 1.3 [p = .000]). The painless maximum hand strength in kg improved in both groups significant after 3 and 12 months. The Placzek score was reduced from 8.25 to 3.5 [p = .001] after 12 weeks for the PT + O group and from 8.1 to 3.8 [p = .000] in the PT group, as well as after 12 months in the PT + O group to 0 [p = .000] and in the PT group to 2.0 [p = .000]. The PRTEE improved in both groups after 12 weeks (PT + O: 52.8--31.3 [p = .002]; PT: 48.6-37.6 [p = .185]) and 12 months (PT + O: 16.15 [p = .000]; PT: 16.6 [p = .000]), although the reduction at 12 weeks was not significant for the PT group.

CONCLUSION

The elbow orthosis appears to accelerate the healing process with respect to the PRTEE and pain on the VAS (12 weeks follow-up), although there is an adjustment after 12 months in both groups and a significant improvement of symptoms is achieved in all endpoints.

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.

Safety of Intra-Articular Implantation of Oligo[Poly(ethylene glycol) Fumarate] Scaffolds into the Rabbit Knee

Implantable biomaterials supporting extended release of pharmacologic agents may permit localized intra-articular delivery of drugs that modulate the fibrotic response to injuries and surgery. Oligo[poly (ethylene glycol)] fumarate (OPF) is an attractive organic carrier, but its safety profile within synovial joints remains unclear. Here, we assessed the safety of OPF sponges using a validated in vivo model of knee arthrofibrosis. A cohort of 102 rabbits was divided into five groups: arthrotomy only (24), arthrotomy with OPF scaffold placement (24), surgically induced contracture (24), surgically induced contracture with OPF scaffold placement (24), and control without any surgical intervention (6). Six rabbits per surgical group were sacrificed at 72 h, 2, 8, and 24 weeks. Outcomes included biomechanical testing of range of motion, histologic analysis of synovial and cartilage tissues, and scaffold degradation. Cartilage histology and biomechanical measurements were comparable between groups with and without OPF. Synovial inflammation scores were similar among most groups with a minimally elevated score in the rabbits with arthrotomy and OPF versus those with arthrotomy alone. Scores for synovial tissues in rabbits with contracture and OPF were clinically equivalent to those with contractures alone. Most animals (92%) retained scaffold fragments at 24 weeks. Thus, OPF scaffolds implanted into native or arthrofibrotic rabbit knees neither induce nor aggravate cartilage damage, synovial inflammation, or contractures. The apparent safety of OPF scaffolds suggests that they are suitable carriers for the controlled delivery of reagents into the intra-articular joint space to treat arthrofibrosis.

Dynamic Splint for the Treatment of Stiff Elbow

Background

The purpose of this paper is to retrospectively evaluate the results of the treatment of elbow stiffness with the use of dynamic splints.

Methods

We included 17 patients with stable and congruent joints, with a range of motion of 100 degrees or less who had not responded to the rehabilitation program. Average previous mobility was 108–42 degrees, with a total arc of 66 degrees. The splints consist of an articulated brace with springs. On average their use began 94 days after surgery or trauma and continued for 86 days. Statistical analysis was performed. Average follow-up was 18 months.

Results

Postoperative mobility was 126–19 degrees, with a total arc of 107 degrees. Motion increased an average of 41 degrees. Six patients failed to recover a functional arc of motion.

Conclusion

Our results suggest that dynamic splints are useful in the treatment of elbow stiffness. We achieved an average improvement of 41° in the arc of motion, which in many cases has rendered arthrolysis unnecessary. Tailoring the splint to the individual patient is very important since its usage must be prolonged in order to achieve plastic deformity through the principle of progressive stretching.

The posttraumatic stiff elbow: an update

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Release of the stiff elbow with mini-open technique

BACKGROUND

Currently, there are many techniques used in the surgical release of elbow contracture, but no single technique has gained widespread acceptance. The purpose of this study was to report the outcomes of a lateral-column approach combined with a mini-open triceps-splitting technique for elbow contracture release.

METHODS

Thirty-six patients with a mean age of 39 years were included in the study. All patients underwent a combined lateral and minimal posterior triceps-splitting open elbow contracture release. Elbow range of motion and visual analog scale pain scores were recorded. The Mayo Elbow Performance Score was used to assess functional outcome.

RESULTS

The mean follow-up period was 38 months. Mean pain levels decreased from 7.59 preoperatively to 0.44 postoperatively (P < .05). The total arc of elbow motion increased from 52° preoperatively to 109° postoperatively, with an improvement of 57° (P < .05). The Mayo Elbow Performance Score improved from 44.17 preoperatively to 90.83 postoperatively (P < .05).

CONCLUSION

This study shows that a combined lateral and mini-open triceps-splitting approach is a safe and effective alternative technique for the treatment of elbow contractures.

Spastic Paralysis of the Elbow and Forearm

As the physiologic recovery period concludes, the patient is evaluated for surgical procedures that may rebalance muscle function and correct deformity. Upper extremity function is the product of complex and highly sophisticated mechanisms working in unison, and a careful, systematic preoperative evaluation is critical. A good function of the hand cannot be achieved without adequate position of the shoulder, elbow, forearm, and wrist. The goals of surgery must be practical and clearly understood by the patient and the family.

Effectiveness of rosiglitazone in reducing flexion contracture in a rabbit model of arthrofibrosis with surgical capsular release: A biomechanical, histological, and genetic analysis

AIMS

Animal models have been developed that allow simulation of post-traumatic joint contracture. One such model involves contracture-forming surgery followed by surgical capsular release. This model allows testing of antifibrotic agents, such as rosiglitazone.

METHODS

A total of 20 rabbits underwent contracture-forming surgery. Eight weeks later, the animals underwent a surgical capsular release. Ten animals received rosiglitazone (intramuscular initially, then orally). The animals were sacrificed following 16 weeks of free cage mobilisation. The joints were tested biomechanically, and the posterior capsule was assessed histologically and via genetic microarray analysis.

RESULTS

There was no significant difference in post-traumatic contracture between the rosiglitazone and control groups (33° (standard deviation (sd) 11) vs 37° (sd14), respectively; p = 0.4). There was no difference in number or percentage of myofibroblasts. Importantly, there were ten genes and 17 pathways that were significantly modulated by rosiglitazone in the posterior capsule.

DISCUSSION

Rosiglitazone significantly altered the genetic expression of the posterior capsular tissue in a rabbit model, with ten genes and 17 pathways demonstrating significant modulation. However, there was no significant effect on biomechanical or histological properties.Cite this article: M. P. Abdel. Effectiveness of rosiglitazone in reducing flexion contracture in a rabbit model of arthrofibrosis with surgical capsular release: A biomechanical, histological, and genetic analysis. Bone Joint Res 2016;5:11-17. doi: 10.1302/2046-3758.51.2000593.

Arthroscopic joint debridement and capsular release in primary and post-traumatic elbow osteoarthritis: a retrospective blinded cohort study with minimum 24-month follow-up

BACKGROUND

Elbow osteoarthritis (OA) is a degenerative condition which in the advanced stage can severely impair joint mobility. Conservative treatment remains the first choice; surgery should be considered in case of failure in patients prepared to adhere to a demanding rehabilitation protocol. We assess the effectiveness of arthroscopic joint debridement and capsular release in a series of patients with primary and post-traumatic elbow arthritis.

MATERIALS AND METHODS

Forty-eight subjects (40 males, eight females; mean age 48 years) with a preoperative diagnosis of primary (19, 40 %) or post-traumatic OA (29, 60 %) were evaluated at a mean follow-up of 44 months. Outcome measures were active range of motion (ROM), pain score, Oxford elbow score (OES), and Mayo elbow performance score (MEPS). OA severity was graded into three classes (I-III) based on X-ray findings. Statistical significance was set at 5 %.

RESULTS

At the final follow-up evaluation, active flexion/extension increased significantly (p < 0.01); pronation and supination improved, but the difference was not significant (p > 0.05). The pain score improved from 7.2 to 4.3 (p < 0.01). Both OES and MEPS improved significantly (p < 0.001). Patients with post-traumatic OA had better ROM (p = 0.0391) and clinical scores (OES, p = 0.011; MEPS, p = 0.010). ROM and clinical scores were lower but not significantly so in class II than in class I patients. A smooth coronoid and olecranon fossa was found in 38 (79 %) patients and a preserved ulnotrochlear joint space in 40 (80 %).

CONCLUSIONS

Elbow OA has become more common as a result of earlier diagnosis and an increased number of acute injuries involving the joint. Arthroscopy is an effective technique to treat OA which provides the best results with the correct indications. Prospective studies are needed to help develop guidelines enabling selection of the best treatment option.

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.

Posttraumatic elbow contractures: targeting neuroinflammatory fibrogenic mechanisms

Posttraumatic elbow stiffness remains a common and challenging clinical problem. In the setting of a congruent articular surface, the joint capsule is regarded as the major motion-limiting anatomic structure. The affected joint capsule is characterized by irreversible biomechanical and biochemical fibrogenic changes strikingly similar to those observed in many other fibroproliferative human conditions. Studies in humans and preclinical animal models are providing emergent evidence that neuroinflammatory mechanisms are critical upstream events in the pathogenesis of posttraumatic connective tissue fibrogenesis. Maladaptive recruitment and activation of mast cell infiltrates coupled with the aberrant expression of growth factors such as transforming growth factor-beta, nerve growth factor, and neuropeptides such as substance P are common observations in posttraumatic joint contractures and many other fibroproliferative disorders. Blockade of these factors is providing promising evidence that if treatment is timed correctly, the fibrogenic process can be interrupted or impeded. This review serves to highlight opportunities derived from these recent discoveries across many aberrant fibrogenic disorders as we strive to develop novel, targeted antifibrotic prevention and treatment strategies for posttraumatic elbow stiffness.

Surgical capsular release reduces flexion contracture in a rabbit model of arthrofibrosis

Animal models of joint contracture may be used to elucidate the mechanisms of arthrofibrosis. Patients with joint contracture commonly undergo surgical capsular release. Previous animal models of joint contracture do not simulate this aspect of arthrofibrosis. We hypothesize that a surgical capsular release will decrease the severity of arthrofibrosis in this rabbit model. A capsular contracture was surgically created in 20 skeletally mature rabbits. Eight weeks later, ten rabbits underwent capsular release, which consisted of elevation of the posterior capsule through a lateral incision and manipulation under anesthesia. Ten rabbits had a sham incision, without release (control group). Immediately after release or sham surgery, extension loss (calculated by subtracting the knee extension angle (degrees) of the operative limb from the nonoperative, contralateral limb) was measured using fluoroscopy. All animals were sacrificed following 16 weeks of postoperative free cage activity. At sacrifice, joint contracture was measured using a custom, calibrated device. The histology of the posterior joint capsule was assessed at sacrifice. All animals survived both operations without complications. Immediately after surgical release or sham surgery, the average extension loss was 129.2 ± 10.7° in the control group versus 29.6 ± 8.2° in the capsular release group (p = 0.0002). Following 16 weeks of remobilization, the average extension loss of the control and capsular release animals were 49.0 ± 12.7° and 36.5 ± 14.2°, respectively (p = 0.035). There were no histological differences between the two groups. In this animal model, a surgical capsular release decreased the extension loss (flexion contracture) immediately after surgery, as well as following sixteen weeks of remobilization. There were no histological changes detected in the posterior joint capsule.

Strength of ulnar fixation in ulnar collateral ligament reconstruction: a biomechanical comparison of traditional bone tunnels to the tension-slide technique

BACKGROUND

Surgical reconstruction of the ulnar collateral ligament after rupture has evolved substantially since the original description. Reconstruction techniques vary significantly at the ulnar and humeral interface. The purpose of this study was to develop a model to isolate, test, and compare the ulnar fixation of the traditional bone tunnel technique and a new technique, the tension slide.

MATERIALS AND METHODS

Six matched pairs of cadaveric arms were dissected to isolate the ulna. Pairs were randomized to the bone tunnel or tension-slide ulnar fixation technique, and consistent tendon grafts were used for each reconstruction. A specialized tendon clamp was used to grip the grafts. Specimens were preloaded with a valgus force to 1 N x m and tested to failure in torsion at 4.5°/s. Statistical analysis was performed with 1-way analysis of variance with the Tukey post hoc test (α = .05).

RESULTS

The bone tunnel technique exhibited higher initial and total stiffness, as well as higher torsional torque at 10° and 30° of valgus angulation and at ultimate failure. The tension-slide technique exhibited significantly higher angular displacement at 3 N x m but not at ultimate failure. The bone tunnel technique exhibited higher work at 10° and 30° of valgus angulation.

CONCLUSION

In this model, traditional bone tunnels performed superior to the tension-slide construction in terms of both strength and stiffness. Whether there is a kinematic benefit to the tension slide, which moves the ulnar fixation to within the native ulnar collateral ligament footprint, is yet to be determined. Further study is needed to assess the clinical benefit of a stronger ulnar fixation.

ARTHROSCOPIC TREATMENT OF ELBOW STIFFNESS

To present the arthroscopic surgical technique and the evaluation of the results from this technique for treating elbow stiffness.

METHODS

Between April 2007 and January 2010, ten elbows of ten patients with elbow stiffness underwent arthroscopic treatment to release the range of motion. The minimum follow-up was 11 months, with an average of 27 months. All the patients were male and their average age was 32.8 years (ranging from 22 to 48 years). After the arthroscopic treatment, they were followed up weekly in the first month and every three months thereafter. The clinical evaluation was made using the criteria of the University of California at Los Angeles (UCLA).

RESULTS

All the patients were satisfied with the results from the arthroscopic treatment. The average UCLA score was 33.8 points.

CONCLUSION

Arthroscopic treatment for elbow stiffness is a minimally invasive surgical technique that was shown to be efficient for treating this complication.

Arthroscopic restoration of terminal elbow extension in high-level athletes

BACKGROUND

Although most people can lead near-normal lives with a limited but functional arc of elbow motion, athletes may find loss of terminal extension severely impairing.

HYPOTHESIS

Arthroscopic contracture release is effective in restoring full elbow extension in athletes whose loss of terminal extension impairs their intensities and/or levels of performance in sport.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1997 and 2007, 24 athletes (26 elbows; mean age, 38 years [range, 12-58]) whose chief complaint was limited elbow extension (≤35°) underwent arthroscopic release of contractures (average follow-up, 33 months [range, 12-88]). All the patients were classified according to a sport-specific scoring system using the subjective patient outcome for return to sports score and the summary outcome determination score.

RESULTS

All 26 elbows improved subjectively and objectively with surgery. Of the 26 elbows, 25 were rated by the patients as normal (n = 15) or near-normal (n = 10) at final follow-up. Pain during intense sporting activities was absent in 17, mild and occasional without affecting performance in 6, and severe enough to affect performance in 1. Of the 24 patients (26 elbows), 22 patients (23 elbows) returned to the same sport at the same level of intensity and performance as before injury. Two patients (3 elbows) returned to the same sport but failed to reach their preinjury levels of performance. Extension improved in all patients, with the average flexion contracture decreasing from 27° ± 7° (range, 10°-35°) to 6° ± 9° (range, 10° of hyperextension to 25°; P < .001). Lack of extension was not a residual impairment factor in any patients. Three patients developed delayed-onset ulnar neuropathy after surgery, 2 of which were treated by subcutaneous transposition. All 3 resolved completely, 2 within the first 6 weeks; the other took longer than a year.

CONCLUSION

The arthroscopic release of contractures is a predictable technique to achieve a highly functional elbow in athletes.

EVALUATION OF THE RESULTS OF SURGICAL TREATMENT OF POSTTRAUMATIC STIFFNESS OF THE ELBOW IN SKELETALLY MATURE PATIENTS

Objective: To evaluate the results from surgical treatment of posttraumatic stiffness of the elbow in skeletally mature patients. Methods: Between October 2000 and October 2007, 45 elbows of 45 patients underwent surgical treatment performed by the Shoulder and Elbow Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. Ten patients were treated arthroscopically and the remainder by open surgery. The minimum follow-up was six months, with a mean of 22 months. Their ages ranged from 17 to 72 years, with a mean of 36 years and three months. Males predominated, accounting for 60% of the cases. The dominant limb was involved in 56.5% of the cases. The clinical evaluation of the results was done by using the criteria of the American Medical Association (AMA), as modified by Bruce; the Mayo Elbow Performance Score (MEPS); and measurements on the gain of flexion-extension arc and the final range of motion. Results: According to the AMA criteria, as modified by Bruce, 42.2% of our results were satisfactory, whereas 77.8% were satisfactory according to MEPS. The mean postoperative flexion-extension arc was 106°, and the main gain in range was 46°. The evaluation of the variables showed that patients with an initial flexion arc greater than 90° achieved a greater final flexion-extension arc, and those with an initial extension less than or equal to 60° gained greater range of motion. Conclusion: Surgical treatment of posttraumatic stiffness of the elbow in skeletally mature individuals was shown to be satisfactory according to MEPS, but unsatisfactory according to AMA. We observed that the patients with preoperative flexion greater than 90° evolved with a greater flexion-extension arc after surgical treatment, while those who had contracture with extension less than or equal to 60° gained a greater range of motion.

Open surgical treatment of posttraumatic elbow contractures in children

Posttraumatic elbow stiffness in children can be a severe obstacle to accomplishing basic activities of daily living, including dressing, and participating in recreational activities. The etiology of this stiffness is typically extrinsic or instrinsic pathology caused by an earlier supracondylar humerus fracture, elbow dislocation, or elbow fracture-dislocation. Children with functional limitations, typically associated with flexion contractures greater than 30 degrees or less than a functional arc (30 to 130 degrees) can benefit from surgical contracture release, which consistently improves range of motion.

Management of severe extra-articular contracture of the elbow by open arthrolysis and a monolateral hinged external fixator

Arthrolysis and dynamic splinting have been used in the treatment of elbow contractures, but there is no standardised protocol for treatment of severe contractures with an arc of flexion < 30 degrees . We present our results of radical arthrolysis with twin incisions with the use of a monolateral hinged fixator to treat very severe extra-articular contracture of the elbow. This retrospective study included 26 patients (15 males and 11 females) with a mean age of 30 years (12 to 60). The mean duration of stiffness was 9.1 months (5.4 to 18) with mean follow-up of 5.2 years (3.5 to 9.4). The mean pre-operative arc of movement was 15.6 degrees (0 degrees to 30 degrees ), with mean pre-operative flexion of 64.1 degrees (30 degrees to 120 degrees ) and mean pre-operative extension of 52.1 degrees (10 degrees to 90 degrees ). Post-operatively the mean arc improved to 102.4 degrees (60 degrees to 135 degrees ), the mean flexion improved to 119.1 degrees (90 degrees to 140 degrees ) and mean extension improved to 16.8 degrees (0 degrees to 30 degrees ) (p < 0.001). The Mayo elbow score improved from a mean of 45 (30 to 65) to 89 (75 to 100) points, and 13 had excellent, nine had good, three had fair and one had a poor result. We had one case of severe instability and one wound dehiscence which responded well to treatment. One case had deep infection with poor results which responded well to treatment. Our findings indicate that this method is very effective in the treatment of severe elbow contracture; however, a randomised controlled study is necessary for further evaluation.

Open elbow contracture release: postoperative management with and without continuous passive motion

PURPOSE

Surgical contracture release can restore motion to stiff elbows. Some authors suggest that use of continuous passive motion (CPM) in postoperative management can increase ultimate mobility. This study tests the null hypothesis that there is no difference in the arc of flexion and extension between patients who used CPM and those who did not use CPM after open elbow contracture release.

METHODS

Sixteen patients who had an arc of flexion and extension of less than 80 degrees and used CPM after open contracture release were matched based on age, gender, diagnosis, preoperative arc of flexion and extension, and radiographic appearance (joint congruity, heterotopic bone, and arthritis) to 16 control patients who did not use CPM. Stiffness was of posttraumatic origin in 24 patients, related to primary osteoarthrosis in 4 patients, and related to heterotopic ossification after central nervous system injury or burns in 4 patients. The preoperative arc of flexion and extension averaged 38 degrees in the CPM cohort and 42 degrees in the no-CPM cohort.

RESULTS

Subsequent surgeries included procedures to address residual stiffness in 1 patient in the CPM cohort and in 3 patients in the no-CPM cohort. At an average 6 months of follow-up, there was no difference in improvement in the arc of flexion and extension (58 degrees vs 61 degrees ) between the CPM and no-CPM cohorts. At the final evaluation, the improvement in arc of flexion and extension (59 degrees in both cohorts) and the final arc of flexion and extension (96 degrees vs 101 degrees ) were comparable between cohorts.

CONCLUSIONS

These matched retrospective data do not demonstrate a benefit of CPM in the postoperative management of elbow contracture release.

Anterior interosseous nerve palsy after open capsular release for elbow stiffness: report of 2 cases

Surgical release of elbow contracture has been associated with injury to structures traversing the elbow. Injury to ulnar and radial nerves has been reported, but this review describes 2 cases of anterior interosseous nerve palsy after open release of an established elbow contracture.

Elbow arthrolysis in severely stiff elbows

INTRODUCTION

This study involves the results of open elbow arthrolysis performed on a series of patients having fixed joint contracture.

PATIENTS AND METHODS

Eighteen patients were treated with open arthrolysis. Eleven patients had very severely stiff elbows (flexion arc less than 30 degrees ), five patients had severely stiff elbows (31 degrees -60 degrees ) and two patients had moderately stiff elbows (60 degrees -90 degrees ). Fixed flexion deformity was observed in nine patients preoperatively.The mean interval between the trauma and arthrolysis was 14.8 months. The mean age was 27 years. After radiological examination, lateral kocher incision was used on 13 patients, medial and lateral incision on 3 patients, transolecranon approach on 1 patient and anterior and posterior approach on 1 patient. External fixator was applied on four patients. Fasia lata interposition was performed in three patients. Additional procedures were as follows, bone fixation in five patients, bone grafting in two patients, nerve grafting in one patient, subcutaneous ulnar nerve transposition in three patients. The average follow-up time was 47 months.

RESULTS

At the final evaluation, the mean extension deficit had improved from 55 degrees to 32 degrees . The mean end flexion increased from 81 degrees to 124 degrees postoperatively. The flexion arc of three patients in whom heterotopic ossification was excised had increased to 65 degrees . Infection was diagnosed in two patients (11%).

CONCLUSION

The importance of this study is that the patients have fixed deformities and a long follow-up time. Severely stiff elbow is one of the main indications of open arthrolysis in the patients without muscle atrophy. We suggest sequential arthrolysis as an effective way to obtain good range of motion especially in severe stiff elbows as well as to maintain the ligamantous stability of the elbow joint.

Post-traumatic flexion contractures of the elbow: Operative treatment via the limited lateral approach

Varying surgical techniques, patient groups and results have been described regards the surgical treatment of post traumatic flexion contracture of the elbow. We present our experience using the limited lateral approach on patients with carefully defined contracture types.Surgical release of post-traumatic flexion contracture of the elbow was performed in 23 patients via a limited lateral approach. All patients had an established flexion contracture with significant functional deficit. Contracture types were classified as either extrinsic if the contracture was not associated with damage to the joint surface or as intrinsic if it was.Overall, the mean pre-operative deformity was 55 degrees (95%CI 48-61) which was corrected at the time of surgery to 17 degrees (95%CI 12-22). At short-term follow-up (7.5 months) the mean residual deformity was 25 degrees (95%CI 19-30) and at medium-term follow-up (43 months) it was 32 degrees (95%CI 25-39). This deformity correction was significant (p < 0.01). One patient suffered a post-operative complication with transient dysaesthesia in the distribution of the ulnar nerve, which had resolved at six weeks. Sixteen patients had an extrinsic contracture and seven an intrinsic. Although all patients were satisfied with the results of their surgery, patients with an extrinsic contracture had significantly (p = 0.02) better results than those with an intrinsic contracture. (28 degrees compared to 48 degrees at medium term follow up). Surgical release of post-traumatic flexion contracture of the elbow via a limited lateral approach is a safe technique, which reliably improves extension especially for extrinsic contractures. In this series all patients with an extrinsic contracture regained a functional range of movement and were satisfied with their surgery.

The posttraumatic stiff elbow: a review of the literature

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.

Structural and biochemical evaluation of the elbow capsule after trauma

This study evaluates the structural and biochemical alterations of the elbow capsule after trauma through microscopy and immunohistochemistry. We compared capsules from 37 patients undergoing surgery for elbow contracture with normal capsules from 7 donors. Contracture capsules were significantly thicker than control capsules (P < .05) and exhibited extensive disorganization of collagen fiber bundle arrangement. Levels of specific cytokines involved in connective tissue turnover were measured. The results showed that the levels of cytokines matrix metalloproteinase (MMP) 1, MMP-2, and MMP-3 were greater as compared with control capsules (P < .05). This was associated with collagen disorganization, fibroblast infiltration, and in some specimens, lymphocytic infiltration in the capsular tissue. In contracture specimens, there was a localization of tissue inhibitor of matrix metalloproteinase 2 staining only in the vicinity of the synovial membrane and in blood vessels. Immunohistochemistry for type III collagen showed a greater presence in the control capsules compared with contracture capsules. This study demonstrates pathologic thickening, disorganization of the collagen fiber arrangement, and involvement of cytokines in the pathology of post-traumatic contracture of the elbow.

Soft-Tissue Coverage of the Elbow: An Outcome Analysis and Reconstructive Algorithm

BACKGROUND

Soft-tissue defects surrounding the elbow can be a challenging problem for the reconstructive surgeon. Multiple reconstructive options are available, but there are few published outcome studies. The authors performed an outcome analysis of soft-tissue coverage for elbow defects to determine the benefits and limitations of various reconstructive options in this problematic area.

METHODS

A retrospective review was performed of all elbow defects requiring flap coverage from 1988 to 2005. Patient demographics, defect characteristics, type of flaps used, complications, and long-term outcomes were analyzed. The t test was used for statistical comparison.

RESULTS

A total of 99 flaps were performed in 96 patients. Forty-seven percent of the defects were secondary to trauma. Sixty-six percent of the flaps used were pedicled flaps and 19 percent were free flaps. The most common pedicled flap used was the radial forearm flap, whereas the most commonly used free flap was the latissimus dorsi muscle flap. Reconstructive failures occurred in 10 percent of patients; these 10 patients required a second flap for limb salvage. The pedicled latissimus dorsi muscle flap had the highest complication rate (57 percent), with distal necrosis being the most frequent complication. The pedicled latissimus dorsi flap was associated with a higher complication rate when compared with the radial forearm flap (p = 0.01).

CONCLUSIONS

The pedicled latissimus was associated with a high rate of distal necrosis when it was used to cover defects distal to the olecranon. The authors recommend the use of the radial forearm flap or a free flap for soft-tissue coverage of defects lying over the proximal ulna.

Genetic influences on joint contractures secondary to immobilization

The primary research question of this study queries whether, beyond environmental conditions, genetic factors affect the development of joint contractures. We hypothesized that intrinsic genetic factors influence the severity of joint contractures developing secondary to joint immobilization. Forty rats from four inbred rat strains had one leg immobilized in knee flexion for 4 weeks. The contracture was measured mechanically as the lack of range of motion to a standardized torque. Using the contralateral leg as a control, the average severity of the contracture could be calculated and compared between strains. All immobilized legs presented knee contractures after 4 weeks of immobilization. Two strains (Dark Agouti and Fisher 344) showed a larger mean knee contracture than those of the two other rat strains (Augustus Copenhagen Irish and Brown Norway). Environmental factors, such as immobility, are usually identified as a cause of a joint contracture. These results demonstrate that, in addition to mechanical factors in the environment of a joint, intrinsic genetic factors participate in the process leading to joint contracture. This demonstration has important consequences for directing future research and may lead to interventions to help patients at risk of developing joint contractures.

Outcome of open release for post-traumatic elbow stiffness

BACKGROUND

Post-traumatic elbow stiffness can be caused by a tether and/or a block, and these structures can exist both anteriorly and posteriorly about the joint to prevent motion. The purpose of this article is to report the outcome of elbow release performed for post-traumatic stiffness by a single surgeon.

METHODS

A retrospective review of charts and radiographs was performed on 52 case of patients who underwent open surgical treatment for post-traumatic elbow contracture by the senior author (RHN). The mean age of the group was 35.1 years. There were 32 men and 20 women. Contracture release surgery was performed at an average of 14 months from the time of injury. Indication for operative release was functional loss of elbow arc of motion that failed nonoperative therapy and splinting program. Follow-up was 18.7 months. Comparison of ranges of motion was performed with Student's paired t tests.

RESULTS

The average extension-flexion arc of motion improved from 57 to 116 degrees and forearm rotation improved from 119 to 145 degrees postoperatively. Fourteen patients (27%) required closed manipulation under anesthesia, in the early postoperative period. Five patients required a second contracture release at an average of 12 months after the index release. Four patients failed because of painful motion (n = 2) and elbow instability (n = 2). Other complications included wound infection (n = 3), cubital tunnel syndrome (n = 3) and reflex sympathetic dystrophy (n = 1).

CONCLUSIONS

Open elbow release with excision of tethers and blocks is a valuable procedure for post-traumatic stiffness. Recurrence in postoperative period is common but is responsive to manipulation under anesthesia and repeat releases.

Anatomical basis of arthroscopic capsulotomy for elbow stiffness

Stiffness is a frequent condition in elbow pathologies, both traumatic and non-traumatic, and usually requires an operative treatment including an anterior capsulotomy. Elbow arthroscopy is certainly an alternative to surgery, but the technique of arthroscopic capsulotomy remains controversial. Our aim was to study the anterior elbow capsule anatomy to recommend an efficient and safe arthroscopic capsulotomy. We dissected ten cadaveric elbows and analyzed the insertions of the anterior capsule, their variations and the relationships with the surrounding neurovascular structures (radial and median nerve, brachial artery). The influence of elbow flexion was studied on fresh elbows with radioscopic evaluation. The distances between the anterior capsule and the neurovascular structures were measured at four reference levels. The insertions of the anterior capsule were also studied on the embalmed elbows. The radial nerve is always the closest structure to the capsule, but in this study it was always protected by the brachialis muscle. The distance between the anterior capsule and the neurovascular structures is consistently higher on the proximal side, regardless of which structure is considered. The 90 degrees flexion position allows the best capsular distension and offers optimal security with regard to neurovascular structures. All arthroscopic surgeons are concerned about potential neurovascular complications (varying from 0 to 14% in the literature). Previous anatomical studies examined the relationships between the arthroscopic portals and the neurovascular structures. This study developed a precise description of the relationship between the anterior capsule and the surrounding neurovascular structures, which let us recommend technical parameters to conduct a safe arthroscopic capsulotomy.

Static progressive splinting for posttraumatic elbow stiffness

OBJECTIVES

To determine the value of static progressive splinting in helping patients with posttraumatic elbow stiffness regain functional motion and avoid operative treatment for stiffness.

DESIGN

Retrospective case series.

SETTING

Level I Trauma Center.

PATIENTS AND INTERVENTION

Over a 3-year period, 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees) were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. Three patients were treated after the injury alone; 14 were treated after operative treatment of the initial injury, and 12 after a secondary operative contracture release for posttraumatic stiffness. Splinting was initiated on an average of 55 days (range, 15 to 200 d) after injury or operative treatment.

MAIN OUTCOME MEASUREMENTS

Ulnohumeral range of motion before and after splint treatment.

RESULTS

The flexion arc improved from 71 degrees (range, 0 to 100 degrees) before splinting to 112 degrees (range, 20 to 150 degrees) after splinting. After splinting, 3 patients had a flexion contracture greater than 30 degrees and 10 patients (34%) had fewer than 130 degrees of flexion. Only 3 patients-2 with heterotopic bone and 1 with an associated ulnar neuropathy-requested an operation to address elbow stiffness. Patients who were splinted after the initial injury (n=17, average improvement (fl-ext)=51+/-37 degrees) regained greater motion during splint wear than patients treated after elbow capsulectomy (n=12, average improvement (fl-ext)=22+/-24 degrees).

CONCLUSIONS

Static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most patients.

Coronal shear fractures of the distal humerus: the capitellum and trochlea

Fractures of the capitellum and trochlea are uncommon and multiple options have been advocated for the treatment of this injury. A single management technique has not emerged as the superior technique, and a complement of interventions is necessary to manage the continuum of injuries that can be observed. In general, open reduction and internal fixation is advocated for healthy and active patients with satisfactory bone quality to allow for the insertion of stable fixation. In the geriatric population, total elbow arthroplasty may emerge as the treatment of choice particularly for the more comminuted fracture patterns. Postoperative rehabilitation is important and is guided by fracture stability, ligament integrity, and the ability of the patient to cooperate with the treatment protocol. Gratifying results can be achieved in most patients with even the most complex injuries.

Anterior release of the elbow for extension loss

BACKGROUND

There are many causes of elbow contracture. When nonoperative techniques fail to increase the arc of motion of the elbow, surgical intervention may be indicated. The purpose of this study was to report the outcomes of surgical correction, predominantly with an anterior release, of elbow flexion contractures. In addition, we evaluated the efficacy of continuous passive motion in the immediate postoperative period.

METHODS

We retrospectively reviewed the outcomes of 106 consecutive patients who had undergone anterior elbow release for the treatment of a flexion contracture between July 1975 and June 2001. Twenty-nine patients were excluded because they had been followed for less than twelve months, leaving a study group of seventy-seven patients. Postoperatively, fifty-four of the seventy-seven patients were treated with continuous passive motion and the other twenty-three patients were treated with extension splinting. The average duration of follow-up was thirty-three months. The average patient age was thirty-four years. The results were evaluated on the basis of both preoperative and postoperative radiographs as well as clinical measurements of elbow motion, all performed by the same examiner using the same large (47-cm-long) goniometer.

RESULTS

The mean preoperative extension in the seventy-seven patients was 52 degrees, which decreased to 20 degrees postoperatively. The mean flexion increased from 111 degrees preoperatively to 117 degrees postoperatively, and the mean total arc of motion increased from 59 degrees to 97 degrees. The total arc of motion in the patients treated with continuous passive motion increased 45 degrees, compared with an increase of 26 degrees in those treated with extension splinting. There were eleven complications in ten patients. The majority were traction neuropathies. There were two infections (one superficial and one deep), both of which resolved following treatment.

CONCLUSIONS

Release of a pathologically thickened anterior elbow capsule through a predominantly anterior approach to correct diminished elbow extension is a safe and effective technique. Furthermore, compared with splinting in extension alone, the utilization of continuous passive motion during the postoperative period increases the total arc of motion.

Evaluating and treating the stiff elbow

The evaluation and treatment of the stiff elbow are described, as well as the lateral, medial, anterior, and posterior approaches for release of elbow contractures. The results after surgical release in 48 patients that failed nonoperative treatment for elbow contractures in our institution are reported. A literature review is provided.