Post-traumatic elbow stiffness: Pathogenesis and current treatments

Relaxin as a treatment for musculoskeletal fibrosis: What we know and future directions

Fibrotic changes in musculoskeletal diseases arise from the abnormal buildup of fibrotic tissue around the joints, leading to limited mobility, compromised joint function, and diminished quality of life. Relaxin (RLX) attenuates fibrosis by accelerating collagen degradation and inhibiting excessive extracellular matrix (ECM) production. Further, RLX disrupts myofibroblast activation by modulating the TGF-β/Smads signaling pathways, which reduces connective tissue fibrosis. However, the mechanisms and effects of RLX in musculoskeletal pathologies are emerging as increasing research focuses on relaxin's impact on skin, ligaments, tendons, cartilage, joint capsules, connective tissues, and muscles. This review delineates the actions of relaxin within the musculoskeletal system and the challenges to its clinical application. Relaxin shows significant potential in both in vivo and in vitro studies for broadly managing musculoskeletal fibrosis; however, challenges such as short biological half-life and sex-specific responses may pose hurdles for clinical use.

Comparing internal and external stabilization for traumatic elbow instability: a systematic review

Background

Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS.

Methods

A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment.

Results

The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals.

Discussion

The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.

Arthrofibrosis of the knee in pediatric orthopedic surgery

Arthrofibrosis is a challenging complication associated with knee injuries in both children and adults. While much is known about managing arthrofibrosis in adults, it is necessary to understand its unique aspects and management strategies in the pediatric population. This paper provides an overview of arthrofibrosis in pediatric orthopedic surgery, focusing on its causes, implications, classifications, and management. This paper is a comprehensive review of the literature and existing research on arthrofibrosis in pediatric patients. Arthrofibrosis is characterized by excessive collagen production and adhesions, leading to restricted joint motion and pain. It is associated with an immune response and fibrosis within and around the joint. Arthrofibrosis can result from various knee injuries in pediatric patients, including tibial spine fractures, ACL and PCL injuries, and extra-articular procedures. Technical factors at the time of surgery play a role in the development of motion loss and should be addressed to minimize complications. Preventing arthrofibrosis through early physical therapy is recommended. Non-operative management, including dynamic splinting and serial casting, has shown some benefits. New pharmacologic approaches to lysis of adhesions have shown promise. Surgical interventions, consisting of arthroscopic lysis of adhesions (LOA) and manipulation under anesthesia (MUA), can significantly improve motion and functional outcomes. Arthrofibrosis poses unique challenges in pediatric patients, demanding a nuanced approach that includes prevention, early intervention with non-operative means, and improvements in surgical techniques. Modern pharmacological interventions offer promise for the future. Customized interventions and research focused on pediatric patients are critical for optimal outcomes.

Management of Capitellar Osteochondritis Dissecans: A Critical Analysis Review

» Osteochondritis dissecans of the capitellum is a localized compromise of bone that may lead to subchondral collapse with articular cartilage damage and loose body formation.» The etiology is multifactorial; proposed mechanisms include repetitive microtrauma, vascular insufficiency, and genetic predisposition.» Diagnosis is based on patient presentation, clinical examination, diagnostic imaging, and intraoperative findings.» Management is dependent on lesion characteristics, with stable lesions amenable to nonoperative treatment and unstable lesions managed with surgical intervention.» Adolescent athletes can expect a return to their preinjury level of activity or competition following indicated surgical intervention.

Management of Lateral Condyle Humeral Fracture Associated With Elbow Dislocation in Children. A Retrospective International Multicenter Cohort Study

OBJECTIVES

Lateral humeral condyle fractures account for 12% to 17% of all distal humerus fractures in children, and usually occur as an isolated injury or are associated with radial neck and/or proximal ulna fractures. The presentation with a concomitant dislocation of the elbow is rare. Therefore, literature on young patients with this uncommon combination is sparse and mostly limited to case reports and small case series. The aim of the present study is to identify the best treatment strategy for this injury, recognize potential risk factors for the development of complications, and identify predictors of outcome.

METHODS

This is a multicenter retrospective review of electronic and written medical records for skeletally immature patients who were diagnosed with a lateral condyle fracture of the humerus associated with elbow dislocation (ED). Data recorded included patient demographics, fracture classification, direction of the dislocation, treatment strategy, time to union, elbow range of motion, complications, and additional procedures. The modified Flynn criteria were used to determine the outcomes.

RESULTS

We identified 23 patients who presented to 3 institutions with a concomitant lateral humeral condyle fractures and an ED. The mean age at the time of injury was 8.7 years (range: 6 to 13 y). The median time from injury to surgery was 1 day (interquartile range: 0.5, minimum to maximum: 0 to 29 d). The median follow-up was 24 weeks (interquartile range: 16, minimum to maximum: 4 to 120 wk). The injury occurred more commonly in males (79%) with Weiss type 3 fractures. The direction of the dislocation was posterior or posteromedial in most cases. Open reduction through a modified Kocher lateral approach and fixation with either Kirschner wires (N = 12) or cannulated screws (N = 9) was the preferred method of treatment. Eight patients (34.8%) developed complications, including persistent elbow stiffness (N = 5), elbow instability (N = 1), and avascular necrosis (N = 2). There were no cases of delayed union, nonunion, malunion, heterotopic ossification, neurological injury, or hardware failure. Patients treated with casting or Kirschner wire fixation had a significantly increased rate of elbow stiffness compared with screw fixation (50%, 25%, and 11%, respectively, P = 0.015). According to Flynn's criteria, 65% of the patients had good or excellent outcomes, and 35% had poor.

CONCLUSION

The findings of this study demonstrate a higher than previously described rate of complications in children with lateral condyle humerus fracture associated with ED, including persistent elbow stiffness, avascular necrosis, and chronic elbow instability, leading to unsatisfactory clinical outcomes in over one-third of the cases. Our findings suggest that the internal fixation with screws, combined with a shorter postoperative immobilization period (2 wk) may lead to improved clinical outcomes.

LEVEL OF EVIDENCE

Level III-therapeutic, case series.

The Internal Joint Stabilizer of the Elbow: A Systematic Review of the Clinical and Biomechanical Evidence

Purpose

The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow.

Methods

A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed.

Results

A total of nine retrospective reports on the IJS (N = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports.

Conclusions

The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles.

Clinical relevance

Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear.

3D-printing of the elbow in complex posttraumatic elbow-stiffness for preoperative planning, surgery-simulation and postoperative control

BACKGROUND

Restoration of mobility of the elbow after post-traumatic elbow stiffening due to osteophytes is often a problem.

METHODS

The anatomical structures were segmented within the CT-scan. Afterwards, the Multi Jet Fusion 3D-printing was applied to create the model made of biocompatible and steam-sterilizable plastic. Preoperative simulation of osteophyte resection at the 3D-model was performed as well as the direct comparison with the patient anatomy intraoperatively.

RESULTS

The patient-specific was very helpful for the preoperative simulation of the resection of elbow osteophytes. The 3D anatomical representation improved the preoperative plan its implementation. A high degree of fidelity was found between the 3D Printed Anatomical representation and the actual joint pathology.

CONCLUSIONS

Arthrolysis of complex post-traumatic bony changes is an important indication for the use of 3D models for preoperative planning. Due to the use of 3D printing and software simulation, accurate resection planning is feasible and residual bony stiffening can be avoided. 3D printing models can lead to an improvement in surgical quality.

The role of leukotriene inhibition using a 5-lipoxygenase (5-LO) inhibitor in a joint contracture model

PURPOSE

Arthrofibrosis is a common inflammatory complication of joint trauma and surgery. 5lipoxygenase (5-LO) is a key enzyme involved in inflammation. Inhibition of 5-LO has been shown to reduce inflammation in heart and lung models but has not been examined in a joint contracture model.

METHODS

Twenty-six rats underwent joint contracture. Six rats served as non-surgical controls. A 5-LO inhibitor, caffeic acid (CA), suspended in 10% ethanol was orally administered to 14 rats and ethanol without CA to the remaining 12 rats daily for 21 days. Leukotriene B4 (LTB4) levels were measured, both systemically and locally. 5-LO levels in the posterior capsule were quantified by measuring the ratio of the length of the posterior capsule demonstrating 5-LO immunostaining to the total length of the capsule.

RESULTS

Joint contracture was successfully achieved in all rats who underwent manipulation. Levels of 5- LO measured in the posterior capsule were significantly increased in the animals who underwent surgery (56%/44-64) compared to the non-surgical control animals (7%/4-9). LTB4 levels were found to be significantly lower in the non-surgical control animals (107.79 ± 34.08 pg/ml) compared to all surgical animals (157.6 ± 55.3 pg/ml).

CONCLUSION

Surgical intervention resulted in increased 5-LO activity of the synovial surface of the posterior capsule and increased LTB4 levels in the patellar tendon-fat pad. Oral administration of the 5LO inhibitor, CA, was ineffective at reducing systemic and local LTB4 levels and preventing knee joint contracture. Inhibiting 5-LO activity may still be effective in preventing arthrofibrosis and warrants further investigation.

Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness

INTRODUCTION

Elbow stiffness significantly affects the patient's quality of life. This joint must have at least 30°/130° extension/flexion and 50°/50° pronation/supination to function normally according to Morrey.

HYPOTHESIS

The objective of this study was to evaluate functional outcome of arthroscopic arthrolysis by comparing stiffness of post-traumatic and degenerative origin. The hypothesis was that this surgical technique allows functional improvement in any indication but with a faster result in degenerative pathology.

MATERIAL AND METHODS

This was a retrospective study including all patients who underwent elbow arthrolysis under arthroscopy, operated on by a single operator, between 2013 and 2020. Thirty-four patients were included, with a mean age of 45years (range, 18-78years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33years (range, 18-64years) and group B (degenerative) of 16 patients with a mean age of 59years (range, 42-78years). All patients were clinically assessed at a mean 27months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected.

RESULTS

In the overall series, preoperative range of motion was 81° and significantly improved postoperatively to 122° (p<0.001). The preoperative data of the 2 groups were comparable except for age (p<0.001) and MEPS (p=0.044). Postoperatively, range of motion improved significantly in both groups but with greater gain in group A (p=0.003). MEPS improved significantly in both groups, but the postoperative score was poorer in group B (p=0.001). Recovery of range of motion was faster in group B (2.4months) than in group A (3.7months) (p=0.021). There were 5 complications: 4 secondary decompensations of ulnar tunnel syndrome, and 1 postoperative radial nerve paresis. 94% of patients were satisfied or very satisfied with the result of surgery.

CONCLUSION

Arthroscopic arthrolysis is an effective option for post-traumatic and non-traumatic elbow stiffness. Improvement was significant in terms of both function and range of motion, with, however, better results in the post-traumatic group but results achieved more rapidly in the degenerative pathology group.

LEVEL OF EVIDENCE

IV, retrospective study.

Early Joint Use Following Elbow Dislocation Limits Range-of-Motion Loss and Tissue Pathology in Posttraumatic Joint Contracture

BACKGROUND

Simple elbow dislocation occurs at an incidence of 2.9 to 5.21 dislocations per 100,000 person-years, with as many as 62% of these patients experiencing long-term elbow joint contracture, stiffness, and/or pain. Poor outcomes and the need for secondary surgical intervention can often be prevented nonoperatively with early or immediate active mobilization and physical therapy. However, immobilization or limited mobilization may be necessary following trauma, and it is unknown how different periods of immobilization affect pathological changes in elbow joint tissue and how these changes relate to range of motion (ROM). The purpose of this study was to investigate the effects of varying the initiation of free mobilization on elbow ROM and histological features in an animal model of elbow posttraumatic joint contracture.

METHODS

Traumatic elbow dislocation was surgically induced unilaterally in rats. Injured forelimbs were immobilized in bandages for 3, 7, 14, or 21 days; free mobilization was then allowed until 42 days after injury. Post-mortem joint ROM testing and histological analysis were performed. One-way analysis of variance was used to compare ROM data between control and injured groups, and Pearson correlations were performed between ROM parameters and histological outcomes.

RESULTS

Longer immobilization periods resulted in greater ROM reductions. The anterior and posterior capsule showed increases in cellularity, fibroblasts, adhesions, fibrosis, and thickness, whereas the measured outcomes in cartilage were mostly unaffected. All measured histological characteristics of the capsule were negatively correlated with ROM, indicating that higher degrees of pathology corresponded with less ROM.

CONCLUSIONS

Longer immobilization periods resulted in greater ROM reductions, which correlated with worse histological outcomes in the capsule in an animal model of posttraumatic elbow contracture. The subtle differences in the timing of ROM and capsule tissue changes revealed in the present study provide new insight into the distinct timelines of biomechanical changes as well as regional tissue pathology.

CLINICAL RELEVANCE

This study showed that beginning active mobilization 3 days after injury minimized posttraumatic joint contracture, thereby supporting an immediate-motion clinical treatment strategy (when possible). Furthermore, uninjured but pathologically altered periarticular tissues near the injury location may contribute to more severe contracture during longer immobilization periods as the disease state progresses.

Features of the Rehabilitation of Patients with Fractures of the Humeral Diaphysis after Osteosynthesis

Aim: Determination of the target criteria of physical rehabilitation and the optimal time of their implementation depending on the methods of fixation of fractures of the humeral diaphysis. Materials and methods: The results of treatment of 59 patients with diaphyseal humeral fractures have been studied. All patients underwent extra- or intramedullary osteosynthesis. Results: In the absence of satisfactory stability of fracture fixation (Group A), passive movements and no active movements are recommended, especially in the presence of free bone fragments that serve as a site for muscle insertion (Group A1). The presence of free fragments with stable fixation (Groups B1 and B2) determined the possibility of active adduction and abduction movements of the shoulder. Complexes of physical rehabilitation exercises with the exclusion or prohibition of active rotational movements have been chosen for patients of Groups C1 and C2. Conclusions: The proposed system of distribution of physical load during the rehabilitation period according to the “ABC” type provides a biomechanically based approach to the rehabilitation process.

The efficacy of graded motor imagery in post-traumatic stiffness of elbow: a randomized controlled trial

BACKGROUND

Physiotherapy improves the movement range after the onset of post-traumatic elbow stiffness and reduces the pain, which is a factor limiting elbow range of motion. However, no results have been reported for motor-cognitive intervention programs in post-traumatic elbow stiffness management. The objective was to investigate the efficacy of graded motor imagery (GMI) in post-traumatic elbow stiffness.

METHODS

Fifty patients with post-traumatic elbow stiffness (18 female; mean age, 41.9 ± 10.9 years) were divided into 2 groups. The GMI group (n = 25) received a program consisting of left-right discrimination, motor imagery, and mirror therapy (twice a week for 6 weeks); the structured exercise (SE) group (n = 25) received a program consisting of range-of-motion, stretching, and strengthening exercises (twice a week for 6 weeks). Both groups received a 6-week home exercise program. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The secondary outcomes were the active range of motion (AROM), visual analog scale (VAS), Tampa Scale for Kinesiophobia (TSK), muscle strength of elbow flexors and extensors, grip strength, left-right discrimination, and Global Rating of Change. Patients were assessed at baseline, at the end of treatment (12 sessions), and a 6-week follow-up.

RESULTS

The results indicated that both GMI and SE interventions significantly improved outcomes (P < .05). After a 6-week intervention, the DASH score was significantly improved with a medium effect size in the GMI group compared with the SE group, and improvement continued at the 6-week follow-up (F_1,45 = 3.10, P = .01). The results with a medium to large effect size were also significant for elbow flexion AROM (P = .02), elbow extension AROM (P = .03), VAS-activity (P = .001), TSK (P = .01), and muscle strength of elbow flexors and elbow extensors (P = .03) in favor of the GMI group.

CONCLUSION

The GMI is an effective motor-cognitive intervention program that might be applied to the rehabilitation of post-traumatic elbow stiffness to improve function, elbow AROM, pain, fear of movement-related pain, and muscle strength.

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

STUDY DESIGN

Web-based modified Delphi study.

BACKGROUND

Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow.

PURPOSE

The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus.

METHODS

This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed.

RESULTS

Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule.

CONCLUSIONS

The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

Posttreatment Changes of the Elbow

Radiologists should be familiar with the typical surgical procedures applied at the elbow and aware of the spectrum of normal and pathologic appearances of posttreatment situations throughout all radiologic modalities. Most important in the case of posttraumatic surgical elbow procedures is correct postoperative elbow joint alignment, appropriate fixation of joint-forming fragments, and proper insertion of screws, plates, and anchor devices that do not conflict with intra-articular or bony structures. To report soft tissue repair procedures correctly, radiologists need to know the broad spectrum of different techniques applied and their appearance on magnetic resonance imaging.

Role of Tranexamic Acid in Arthroscopic Osteocapsular Release of the Elbow for Degenerative Arthritis

Background

Minimizing intra-articular bleeding and swelling is crucial in preventing the development of stiffness around the elbow. Tranexamic acid (TXA) has been shown to be an effective adjunct in reducing perioperative bleeding after surgery.

Purpose:

To determine the effect of intravenous (IV) TXA on postoperative drain tube output in arthroscopic osteocapsular release of the elbow for primary degenerative arthritis.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors performed a retrospective cohort study of 83 consecutive patients with primary degenerative elbow arthritis who underwent an arthroscopic osteocapsular release between 2015 and 2018. They organized patients into a no-TXA group (control) and a group that was given 1.0 g of IV TXA before tourniquet release. The primary outcome measure was drain tube output, and secondary outcome measures included postoperative day 1 pain levels on a visual analog scale and early range of motion at 8 weeks. Differences between groups were analyzed using 1-way analysis of variance, the Mann-Whitney U test, or the Fisher exact test.

Results:

There were 43 patients in the no-TXA group and 40 patients in the TXA group. Administration of IV TXA resulted in a 51% decrease in mean intra-articular bleeding for the TXA group, as measured via drain tube output (88.8 ± 80.5 mL [no-TXA] vs 43.4 ± 52.4 mL [TXA]; P = .0016). In both groups, there were significant increases in elbow arc of motion when compared with preoperative measurements. There were no between-group differences in early range of motion (129.7° ± 12.4° [no-TXA] vs 131.7° ± 9.2° [TXA]; P = .549) or postoperative pain (1.9 ± 2.2 [no-TXA] vs 1.5 ± 1.7 [TXA]; P = .89).

Conclusion:

In this study, IV TXA significantly reduced postoperative intra-articular bleeding in patients who underwent arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. However, there were no differences in postoperative range of motion or pain between patients who received TXA and controls.

Arthrofibrosis Nightmares: Prevention and Management Strategies

Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.

Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook

* Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.

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.

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.