Surgical release for posttraumatic loss of elbow flexion

Highly extensile approach for comminuted ulna coronoid process fractures with mini-plate fixation: a case series of 31 patients

BACKGROUND

For the treatment of coronoid process fractures, medial, lateral, anterior, anteromedial, and posterior approaches have been increasingly reported; however, there is no general consensus on the method of fixation of coronal fractures. Here, we present a highly-extensile minimally invasive approach to treat coronoid process fractures using a mini-plate that can achieve anatomic reduction, stable fixation, and anterior capsular repair. Further, the study aimed to determine the complication rate of the anterior minimally invasive approach and to evaluate functional and clinical patient-reported outcomes during follow-up.

METHODS

Thirty-one patients diagnosed with coronoid fractures accompanied with a "terrible triad" or posteromedial rotational instability between April 2012 and October 2018 were included in the analysis. Anatomical reduction and mini-plate fixation of coronoid fractures were performed using an anterior minimally invasive approach. Patient-reported outcomes were evaluated using the Mayo Elbow Performance Index (MEPI) score, range of motion (ROM), and the visual analog score (VAS). The time of fracture healing and complications were recorded.

RESULTS

The mean follow-up time was 26.7 months (range, 14-60 months). The average time to radiological union was 3.6 ± 1.3 months. During the follow-up period, the average elbow extension was 6.8 ± 2.9° while the average flexion was 129.6 ± 4.6°. According to Morrey's criteria, 26 (81%) elbows achieved a normal desired ROM. At the last follow-up, the mean MEPI score was 98 ± 3.3 points. There were no instances of elbow instability, elbow joint stiffness, subluxation or dislocation, infection, blood vessel complications, or nerve palsy. Overall, 10 elbows (31%) experienced heterotopic ossification.

CONCLUSION

An anterior minimally invasive approach allows satisfactory fixation of coronoid fractures while reducing incision complications due to over-dissection of soft tissue injuries. In addition, this incision does not compromise the soft tissue stability of the elbow joint and allows the patient a more rapid return to rehabilitation exercises.

Bony encasement of the ulnar nerve secondary to heterotopic ossification of the elbow: an evaluation of long-term outcomes

BACKGROUND

Ulnar neuropathy at the elbow caused by heterotopic ossification (HO) is a rare condition. This retrospective study aims to report on 32 consecutive cases of ulnar nerve encasement caused by elbow HO and evaluate long-term outcomes of operative management and a standardized postoperative rehabilitation regimen.

METHODS

A retrospective case series was conducted on 32 elbows (27 patients) that underwent operative management of bony ulnar nerve encasement. All procedures were performed in the inpatient setting at an Academic Level 1 Trauma Center from September 1999 to July 2021 by one of 3 fellowship-trained shoulder and elbow. Postoperatively, all patients received formal physical therapy, HO prophylaxis (30 received indomethacin, 2 received radiation), and a structured continuous passive motion machine regimen. Patient demographics, age, gender, type of injury, history of tobacco use, and medical comorbidities were obtained to include in the analysis. Long-term follow-up examinations were performed to evaluate elbow flexion-extension arc of motion, Mayo Elbow Performance Score, and visual analog scale pain scores.

RESULTS

Thirty-two elbows with complete bony ulnar nerve encasement secondary to HO were identified (14 from burns, 15 from trauma, 3 closed head injuries). Following surgery, the mean flexion-extension arc of motion improved significantly, increasing from 21° to 100° at long-term follow-up (average 8.7 years, range 2-17 years), with statistically significant improvements in preoperative vs. long-term postoperative elbow extension (P < .001), flexion (P < .001), and total arc of motion (P < .001). There was a statistically significant improvement in pre- vs. postprocedure ulnar nerve function, as demonstrated by a decrease in average McGowan grade (1.2-0.7; P = .002). Additionally, 63% of patients with preoperative ulnar neuropathy symptoms (20/32) had either complete resolution or subjective improvement after surgery. The mean time from injury to surgery was 518 days (range 65-943 days). Age, gender, time to surgery, and medical comorbidities were not associated with outcomes. The complication rate was 9% (3/32). Patients had an average flexion-extension arc of motion of 97° and average Mayo Elbow Performance Score of 80 ("good") at long-term follow-up.

CONCLUSIONS

The combination of operative management, postoperative HO prophylaxis, and a regimented rehabilitation program has proven to be a durable solution for treating and ensuring good long-term functional outcomes for patients with elbow HO and bony ulnar nerve encasement. This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes.

Regional distribution prevalence of heterotopic ossification in the elbow joint: a 3D study of patients after surgery for traumatic elbow injury

BACKGROUND

Heterotopic ossification (HO) is a common complication after elbow fracture surgery and can lead to severe upper extremity disability. The radiographic localization of postoperative HO has been reported previously. However, there is no literature examining the distribution of postoperative HO at the three-dimensional (3D) level. This study aimed to investigate 1) the distribution characteristics of postoperative HO and 2) the possible risk factors affecting the severity of postoperative HO at a 3D level.

METHODS

A retrospective review was conducted of patients who presented to our institution with HO secondary to elbow fracture between 13 January 2020 and 16 February 2023. Computed tomography scans of 56 elbows before elbow release surgery were reconstructed in 3D. HO was identified using density thresholds combined with manual identification and segmentation. The elbow joint and HO were divided into six regions according to three planes: the transepicondylar plane, the lateral ridge of the trochlear plane, and the radiocapitellar joint and coronoid facet plane. The differences in the volume of regional HO associated with different initial injuries were analyzed.

RESULTS

Postoperative HO was predominantly present in the medial aspect of the capsule in 52 patients (93%), in the lateral aspect of the capsule in 45 patients (80%), in the medial supracondylar in 32 patients (57%), and in the lateral supracondylar, radial head, and ulnar region in the same number of 28 patients (50%). The median and interquartile range volume of total postoperative HO was 1683 (777-4894) mm3. The median and interquartile range volume of regional postoperative HO were: 584 (121-1454) mm3 at medial aspect of capsule, 207 (5-568) mm3 at lateral aspect of capsule, 25 (0-449) mm3 at medial supracondylar, 1 (0-288) at lateral supracondylar, 2 (0-478) at proximal radius and 7 (0-203) mm3 at the proximal ulna. In the subgroups with Injury Severity Score > or = 16, Gustilo-Anderson II, normal uric acid levels, elevated alkaline phosphatase, and body mass index > or = 24, the median HO volume exceeds that of the respective control groups.

CONCLUSION

The medial aspect of the capsule was the area with the highest frequency and median volume of postoperative HO among all initial elbow injury types. Patients with higher Gustilo-Anderson grade, Injury Severity Score, alkaline phosphatase or Body Mass Index had higher median volume of postoperative HO.

Outcomes of Therapy and Ulnar Nerve Transposition for Elbow Stiffness After Pediatric Medial Epicondyle Fractures

Purpose

Following medial epicondyle fractures, a subset of pediatric patients has persistent limitations in elbow motion. This study soughted to understand the patient characteristics of this group and to assess the effectiveness of intensive therapy and ulnar nerve transposition in improving elbow range of motion and patient-reported outcomes.

Methods

A cohort of 31 pediatric patients with stiffness after elbow trauma was narrowed to 8 pediatric patients (7 female) ranging in age from 9 to 14 years, who were diagnosed with medial epicondyle fractures and underwent intensive therapy and ulnar nerve transposition with or without elbow joint release. We collected demographic and objective data as well as subjective data including Patient-Reported Outcome Measurement Information System (PROMIS) scores before and after ulnar nerve transposition.

Results

Following initial intensive therapy, elbow range of motion improved by an average of 56°, and 7 of the 8 patients reached a functional motion arc of 100°. Subsequently, following ulnar nerve surgery with or without elbow release, motion improved by an average of 22°, and 5 of the 8 patients demonstrated improvement from this intervention. Surgery led to improvements in subjective outcomes with an improvement in PROMIS mobility scores by an average of 9 points, pain interference by 6 points, and upper extremity scores by 3 points. Based on a previously determined minimally important difference of three points, these indicate significant clinical improvements.

Conclusions

A subset of pediatric patients with persistent stiffness following medial epicondyle fractures may benefit from additional interventions, including intensive therapy, transposition of the ulnar nerve, and open capsular release. However, not all patients were improved after ulnar nerve surgery, and the identification and treatment of ulnar nerve irritability may not fully resolve preoperative symptoms in all patients.

Type of study/level of evidence

Therapeutic IV.

Surgical arthrolysis of the stiff elbow: a systematic review

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY DESIGN

Level IV; Systematic review.

Effect of electroacupuncture combined with rehabilitation training on hypertension: A systematic review and meta-analysis

To evaluate the clinical effects of electroacupuncture combined with rehabilitation training (EART) versus conventional rehabilitation training (CRT) on hypertension. Multiple databases like PubMed, Embase, Web of Science and Wanfang database, China National Knowledge Internet database, and Chinese Biological Medical database were used to search for the relevant studies and full-text articles involved in evaluating EART versus CRT with hypertension. Review Manager 5.4 was used to estimate the effects of the results among included articles. Forest plots, sensitivity analysis, and funnel plots were also conducted on the included articles. In this meta-analysis study, there were 9 relevant studies were eventually satisfied the included criteria. There were significant differences between EART group and CRT group in systolic blood pressure after treatment (MD -16.62, 95 %CI = -21.84 to -11.39; P < 0.00001), diastolic blood pressure after treatment (MD = -16.03, 95 % CI = -21.55 to -10.50; P < 0.00001), and effective rate (MD = 1.22, 95 % CI = 1.13 to 1.32; P < 0.00001). Sensitivity analysis and funnel chart demonstrated that the study was robust and limited publication bias was observed. Our data showed that EART was clinically more significant than CRT in hypertension. Further studies need to be performed using large relevance references to verify the effectiveness of EART in the treatment of hypertension.

Complications associated with open reduction and internal fixation for adult distal humerus fractures: a multicenter retrospective study

Background

Open reduction and plate fixation are the preferred treatment options for most distal humerus fractures in adults. However, it is often challenging for orthopedic surgeons because of the complex anatomy and the difficulty in achieving stable fixation. This multicenter study aimed to analyze the complication types and rates of patients with distal humerus fractures treated with open reduction and plate fixation, and compare the results with those found in the literature. In addition, we describe the clinical outcomes.

Methods

This retrospective multicenter study was conducted between September 2001 and March 2021 and included data from four hospitals. In total, 349 elbows underwent surgical treatment at these hospitals during the study period. Patients > 17 years of age who were treated by plate fixation were included, and patients who were treated by other fixation methods were excluded. A total of 170 patients were included in the study. The following types of complications were investigated: (1) nerve related; (2) fixation and instrument related; (3) osteosynthesis related; (4) infection; and (5) others.

Results

The following complications were found: (1) 26 (15.3%) cases of postoperative ulnar nerve symptoms; 4 (2.4%) of postoperative radial nerve symptoms; (2) one (0.6%) case of screw joint penetration and screw loosening; and eight (4.7%) cases of hardware removal due to instrument skin irritation; (3) seven (4.1%) cases of nonunion; (4) two (1.2%) and four (2.2%) cases of superficial and deep infection, respectively, and seven (3.9%) cases of wound complication; and (5) 37 (21.8%) cases of heterotrophic ossification, 79 (46.5%) cases of elbow stiffness (did not achieve functional range of motion [ROM]), and 41 (24.1%) cases of osteoarthritis over Broberg and Morrey Grade I.

Paradoxically, the postoperative ulnar nerve symptoms were more frequent in the prophylactic ulnar nerve anterior transposition group. However, this difference was not statistically significant (p = 0.086). The mean ROM was 123.5° flexion to 9.5° extension. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 14.5 ± 15.6.

Conclusions

Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes. Surgeons must be vigilant about ulnar nerve complications.

Level of Evidence Therapeutic Level III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03292-1.

Does an Internal Joint Stabilizer and Standardized Protocol Prevent Recurrent Instability in Complex Persistent Elbow Instability?

BACKGROUND

The treatment of complex persistent elbow instability after trauma is challenging. Previous studies on treatments have reported varied surgical techniques, which makes it difficult to establish a therapeutic algorithm. Furthermore, the surgical procedures may not sufficiently restore elbow stability, even with an additional device, and a noted high rate of arthritis progression.While a recently developed internal joint stabilizer effectively treats elbow instability, its clinical application for complex persistent elbow instability is limited and the standardized protocol is not well described. Additionally, we want to know whether the arthritis progression will cause a negative impact on the functional outcomes of complex persistent elbow instability.

QUESTIONS/PURPOSES

(1) Does treatment of complex persistent elbow instability with a hinged internal joint stabilizer and a standardized protocol prevent recurrent instability and other complications? (2) What are the pre- to postoperative improvements in pain, disability, elbow performance, and ROM? (3) Is the development of post-traumatic arthritis associated with worse pain, disability, elbow performance, and ROM?

METHODS

Between September 2014 and October 2019, we treated 22 patients for persistent dislocation or subluxation after initial treatment of traumatic elbow fracture-dislocations. Of those, we considered patients who were at least 20 years of age, with an interval of 6 weeks or more between the injury (initial treatment) and the index reconstructive procedure, which had been performed at our institute, as potentially eligible. During that time, we used an internal joint stabilizer with a standardized protocol for posttraumatic complex persistent elbow instability. We performed total elbow replacements in patients older than 50 years who had advanced elbow arthritis. Based on that, 82% (18 of 22) of patients were eligible; 14% (3 of 22) were excluded because total elbow replacements was undertaken, and another 5% (1 of 22) were lost before the minimum study follow-up of 1 year (median 24 months [range 12 to 63]), leaving 64% (14 of 22) for analysis in this retrospective study. We treated 14 patients (14 elbows) with posttraumatic complex persistent elbow instability with an internal joint stabilizer and a standardized protocol that comprised debridement arthroplasty with ulnar neurolysis, restoration of bony and ligamentous (reattachment) structures, application of an internal joint stabilizer, and early rehabilitation. There were eight men and six women in this study, with a median (range) age of 44 years (21 to 68). The initial elbow fracture-dislocation injury pattern was a terrible triad injury in seven patients, a posterolateral rotatory injury in four patients, and a posterior Monteggia fracture in three patients. Preoperative and follow-up radiographs were reviewed for evidence of recurrent instability and arthritis. Complications such as wound infection, seroma, neurovascular injury, and hardware complications were ascertained through chart review. Preoperative and postoperative VAS score for pain, DASH, and Mayo Elbow Performance Scores (MEPS) were collected and compared. Furthermore, extension-flexion and supination-pronation arcs were collected by chart review. We divided the patients into two groups according to whether or not they developed posttraumatic arthritis. We then presented the differences between pain, disability, elbow performance, and ROM. The hinged internal joint stabilizer was removed using another open procedure under general anesthesia 6 to 8 weeks after surgery.

RESULTS

There were no recurrent instability during and after device removal. Seven patients developed complications, including wound infection, seroma, neurovascular injury, hardware complications, and heterotopic ossification. Two patients had complications related to internal joint stabilizers and three had complications linked to radial head prostheses. Median (range) preoperative to postoperative changes included decreased pain (VAS 5 [2 to 9] to 0 [0 to 3], difference of medians -5; p < 0.001), decreased disability (DASH 41 [16 to 66] to 7 [0 to 46], difference of medians -34; p < 0.001), improved function (MEPS 60 [25 to 70] to 95 [65 to 100], difference of medians 35; p < 0.001), improved extension-flexion arc (40° [10° to 70°] to 113° [75° to 140°], difference of medians 73°; p < 0.001), and supination-pronation arc (78° [30° to 165°] to 148° [70° to 175°], difference of medians 70°; p < 0.001). Between patients with and without development of post-traumatic arthritis, there were no differences in postoperative pain (VAS 0 [0 to 3] to 0 [0 to 1], difference of medians 0; p = 0.17), disability (DASH 7 [0 to 46] to 7 [0 to 18], difference of medians 0; p = 0.40), function (MEPS 80 [65 to 100] to 95 [75 to 100], difference of medians 15; p = 0.79), extension-flexion arc (105° [75° to 140°] to 115° [80° to 125°], difference of medians 10°; p = 0.40), and supination-pronation arc (155° [125° to 175°] to 135° [70° to 160°], difference of medians -20°; p < 0.18).

CONCLUSION

In this small, retrospective study, we found that an internal joint stabilizer with a standardized treatment protocol could maintain concentric reduction while allowing early functional motion, and that it could improve clinical outcomes for patients with complex persistent elbow instability. However, patients must be counseled that the complications related to the radial head prostheses may occur, and that the benefits of early motion must compensate for an additional removal procedure and the risk of seroma formation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Progression Patterns of Range of Motion Progression after Open Release for Posttraumatic Elbow Stiffness

Background & Hypothesis

Post-traumatic stiffness of the elbow may be treated surgically with open osteocapsular release. This study investigated postoperative range of motion (ROM) improvements after this procedure. We hypothesized that there would be predictable recovery patterns and significant progress up to 6 months after surgery.

Methods

A retrospective chart review of patients who underwent open elbow release for post-traumatic stiffness (PTS) was performed. Demographic information and surgical approach were recorded. Patients with ipsilateral primary elbow osteoarthritis were excluded. Range of motion (ROM) data were collected at preoperative, intraoperative, and postoperative intervals of 2 weeks, 6 weeks, 3 months, and 6 months. Growth mixture modeling (GMM) and latent class growth analysis (LCGA) were performed to identify motion recovery trajectory groups, and Student's t-tests were performed to compare ROM data between intervals.

Results

One hundred and eighty-seven patients who underwent open elbow release for PTS were included (112 with a medial approach, 50 lateral, and 25 both). The mean preoperative arc was 84° ± 31, and the arc of motion at final follow-up was 119° ± 19 (P < .05). The mean time to the final follow-up arc of motion was 16 weeks, with 56% of patients achieving their final arc by their 3-month follow-up visit. The largest improvement was seen with extension between 6 weeks and 3 months, where 26% of the extension at final follow-up was gained. Most of the recovery occurred within the first 3 months postoperatively, with small improvements thereafter. GMM and LCGA did not identify statistically significant groups for postoperative ROM progression trajectories. Arc of motion preoperatively, intraoperatively, and at 2 weeks postoperatively did not correlate with the final arc of motion. There were no demographic or historical characteristics, or thresholds of motion, which conferred a higher likelihood of achieving a better result postoperatively.

Conclusions

ROM recovery after surgical release for post-traumatic elbow stiffness did not depend on the preoperative, intraoperative, or 2-week postoperative arcs of motion. Most ROM recovery occurs early after surgery, and maximal arc of motion can be expected by approximately 16 weeks postoperatively. This knowledge may inform patients about their expected rehabilitation and splinting time and reduce the total costs of therapy.

Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach

Objective  To demonstrate the clinical outcomes and complication rates of the surgical release with a single posterior approach in the treatment of post-traumatic elbow stiffness.

Methods  A prospective study with patients submitted to surgery between May 2013 and June 2018 in a single center. The access to the elbow was made through the posterior approach. The patients were followed up by an occupational therapy team, and were submitted to a standardized rehabilitation protocol, with static progressive orthoses and dynamic orthoses. The primary outcome was the range of flexion-extension of the elbow after 6 months.

Results  A total of 26 patients completed the minimum follow-up of 6-months. The mean range of flexion-extension of the elbow at the end of 6 months was of 98.3 ± 22.0°, with an amplitude gain of 40.0 ± 14.0° in relation to the pre-operative period ( p  < 0.001). The average flexion-extension gain at the end of 6 months was of 51.7% ± 17.1% ( p  < 0.001). The mean pronosupination at the end of 6 months was of 129.0 ± 42.7° ( p  < 0.001). Half of the cases had moderate and severe stiffness in the pre-operative period, compared with 7.7% at 6 months post-operatively ( p  < 0.001). The mean score for the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) instruments was 74.4 ± 16.8 points and 31.7 ± 21.9 points respectively ( p  < 0.001 for both). The visual analogue scale (VAS) score presented no statistically significant difference compared to the pre-operative period ( p  = 0.096). Complications were observed in 6 (23%) patients, and no new surgical procedures were necessary.

Conclusions  The surgical release of the elbow associated with a rehabilitation protocol is a safe technique, with satisfactory results and low rate of complications.

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.

Identifying the Safe Zone in Arthroscopic Anterior Elbow Capsulectomy: A Cadaveric Study

The authors assessed the effects of forearm rotation on the proximity of the radial nerve and medial collateral ligament (MCL) to a proximal and a more distal arthroscopic anterior elbow capsulectomy. Arthroscopy was performed on 10 cadaveric specimens. Sutures were passed lateral to medial at the level of the radiocapitellar joint and at the proximal edge of the annular ligament. Dissection measured the distance to the radial nerve from the lateral starting point and to the MCL from the medial exit point in varying degrees of forearm rotation. The extent of brachialis muscle coverage of the radial nerve was documented. The distance from the starting point to the radial nerve increased in pronation at both levels. The medial extent of the capsulectomy remained a safe distance from the MCL. Brachialis muscle covered the radial nerve at both levels. Pronation increases the capsulectomy safe zone, including more distally, before encountering the radial nerve; the MCL is not at risk. [Orthopedics. 2020;43(5):e399-e403.].

Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy

Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.

Randomized trial for the treatment of post-traumatic elbow stiffness: surgical release vs. rehabilitation

BACKGROUND

There are no previous randomized trials comparing surgical to conservative treatment for post-traumatic elbow stiffness. The aim of our study was to compare elbow range of motion (ROM) and clinical outcomes among patients undergoing surgical treatment or a standardized rehabilitation for post-traumatic elbow stiffness.

METHODS

Randomized clinical trial of patients with post-traumatic elbow stiffness for more than 6 months who failed conventional physical therapy for 4 months. Patients were randomized into 2 treatment groups. The conservative group underwent the rehabilitation protocol associated with the use of orthoses (static progressive for extension and dynamic for flexion) and continuous passive motion. The surgical group underwent surgical release by a posterior approach without triceps detachment, followed by a rehabilitation protocol similar to the conservative group. The primary outcome of the study was flexion-extension ROM at 6 months of follow-up. Secondary outcomes included the visual analog scale for pain, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder, and Hand score, absolute and relative increase in flexion-extension ROM, and complication rates.

RESULTS

Thirty patients were analyzed in the study, 15 in each group. The mean elbow flexion-extension ROM at the end of 6 months of follow-up was 108° in the surgical group and 88° in the conservative group (P = .002). The mean absolute and the relative increase of elbow flexion-extension at 6 months were, respectively, 17° and 27% in the conservative group and 41° and 59% in the surgical group (P < .001).

CONCLUSION

Surgical elbow release associated with the rehabilitation protocol resulted in a greater flexion-extension ROM, as well as a greater absolute and relative increase compared with rehabilitation alone at 6 months of follow-up. The groups did not differ regarding clinical scores and complication rates.

Effect of hyperuricemia on functional outcomes and complications in patients with elbow stiffness after open arthrolysis combined with hinged external fixation: a retrospective study

BACKGROUND

Hyperuricemia is considered a risk factor for increased postoperative complications and adverse functional outcomes in a variety of orthopedic surgeries. The purpose of this retrospective study was to investigate the clinical efficacy of patients with different uric acid levels after elbow arthrolysis.

METHODS

The study included 131 patients with post-traumatic elbow stiffness who underwent arthrolysis between March 2014 and March 2016. All patients were divided into 4 groups based on the preoperative serum level of uric acid (UA). The quartile method was used for grouping patients, including 33 in Q1 (UA <293 μmol/L), 34 in Q2 (293-348 μmol/L), 32 in Q3 (348-441 μmol/L), and 32 in Q4 (441-710 μmol/L). At baseline and each time point of follow-up, functional performance, Mayo Elbow Performance Score, visual analog scale for pain, and complications were evaluated.

RESULTS

Preoperative data were not significantly different among the 4 groups (Q1, Q2, Q3, and Q4). At the final follow-up, the following data showed significant differences among the 4 groups: extension (P = .031), flexion (P = .008), range of motion (P = .003), Mayo Elbow Performance Score (P = .011), and visual analog scale (P = .032). Interestingly, patients in the Q4 group had the poorest clinical outcomes. However, no significant differences were found among the 4 groups in new onset or exacerbation of nerve symptoms (P = .919), reduced muscle strength (P = .536), instability (P = .567), or infection (P = .374) at the last follow-up.

CONCLUSION

This study confirms that in patients with post-traumatic elbow stiffness, abnormal serum uric acid metabolism was a risk factor for poor performance and postoperative pain after arthrolysis. Therefore, detecting the preoperative serum uric acid levels of the patients would be helpful for evaluating the postoperative outcomes.

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

Background

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

Methods

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

Results

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

Conclusion

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

ORIF of Distal Humerus Fractures with Modern Pre-contoured Implants is Still Associated with a High Rate of Complications

BACKGROUND

The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants.

MATERIALS AND METHODS

Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intra-operative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded.

RESULTS

Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), post-traumatic arthritis (9%), and heterotopic ossification (9%).

CONCLUSIONS

Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Predicting the risk of sarcopenia in elderly patients with patellar fracture: development and assessment of a new predictive nomogram

Purpose

To develop a risk prediction model for postoperative sarcopenia in elderly patients with patellar fractures in China.

Patients and methods

We conducted a community survey of patients aged ≥55 years who underwent surgery for patellar fractures between January 2013 and October 2018, through telephone interviews, community visits, and outpatient follow-up. We established a predictive model for assessing the risk of sarcopenia after patellar fractures. We developed the prediction model by combining multivariate logistic regression analysis with the least absolute shrinkage model and selection operator regression (lasso analysis) as well as the Support Vector Machine (SVM) algorithm. The predictive quality and clinical utility of the predictive model were determined using C-index, calibration plots, and decision curve analysis. We also conducted internal sampling methods for qualitative assessment.

Result

We recruited 137 participants (53 male; mean age, 65.7 years). Various risk factors were assessed, and low body mass index and advanced age were identified as the most important risk factor (P < 0.05). The prediction rate of the model was good (C-index: 0.88; 95% CI [0.80552–0.95448]), with a satisfactory correction effect. The C index is 0.97 in the validation queue and 0.894 in the entire cohort. Decision curve analysis suggested good clinical practicability.

Conclusion

Our prediction model shows promise as a cost-effective tool for predicting the risk of postoperative sarcopenia in elderly patients based on the following: advanced age, low body mass index, diabetes, less outdoor exercise, no postoperative rehabilitation, different surgical methods, diabetes, open fracture, and removal of internal fixation.

Arthroscopic visualization of the medial collateral ligament of the elbow

BACKGROUND

This study aimed to determine the extent to which the medial collateral ligament (MCL) can be visualized during a standard posterior arthroscopic view of the elbow.

METHODS

Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. Standard elbow arthroscopy was performed on each specimen using a standard posterior portal for visualization with a 30° arthroscope. The most distal borders of the visible part of the MCL were marked using a spinal needle and tagged using nylon sutures. Subsequently, the elbow was dissected. The overall surface area of the entire MCL and that defined by the suture tags were calculated for each specimen.

RESULTS

The mean area of the visible part of the MCL represented 48% of the mean overall area. The arthroscopically tagged part of the posterior band of the MCL represented <50% of the entire MCL. Arthroscopic visualization was not available for most of the posterior bands of the MCL.

CONCLUSIONS

Less than half of the MCL is visible with a 30° arthroscope from standard posterior portal. Thus, sole reliance on arthroscopic visualization with this manner is not enough to release of the MCL. The variable effort is required to improve the limited visualization during the procedure. Moreover, the individual attention is essential to protect the ulnar nerve because the ulnar nerve is very close to the MCL especially to the anterior band.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Open surgical elbow contracture release after trauma: results and recommendations

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Appropriate excision time of heterotopic ossification in elbow caused by trauma

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Arthroscopic arthrolysis provides good clinical outcome in post-traumatic and degenerative elbow stiffness

PURPOSE AND HYPOTHESIS

The purpose of this retrospective study was to report on the functional outcome after arthroscopic arthrolysis in patients with post-traumatic or degenerative elbow stiffness. It was hypothesized that this operative procedure leads to improved range of motion (ROM) and improved functional outcome in both groups.

METHODS

Patients who underwent arthroscopic arthrolysis of the elbow between 2010 and 2015 were included in this study. Forty-two patients with an average age of 41.0 ± 13.5 years were available for evaluation. The mean follow-up was 28.3 ± 14.9 months. With regard to aetiology of elbow contractures, patients were divided into post-traumatic (group A) and degenerative (group B) cohort. General patients' data, previous surgical treatment and ROM were recorded. At follow-up evaluation, the clinical outcome was assessed by the ROM, visual analogue scale (VAS) for pain assessment and the Elbow Self-Assessment Score (ESAS).

RESULTS

The mean arc of motion of group A (n = 20) increased from preoperatively 74.3° to 120.5° postoperatively (p < 0.001); group B (n = 22) showed an improvement of 104.6° preoperatively to 123.4° after surgery (p = 0.002). Mean improvement was 46.3° ± 27.5° in group A and 16.4° ± 19.4° in group B. Mean post-operative VAS was 0.9 ± 1.5 in group A and 1.3 ± 2.2 in group B. 92.9% of patients achieved a functional arc of elbow motion >100°. The ESAS indicated good to excellent clinical outcome showing 88.8 ± 10.0 points in group A and 84.1 ± 21.4 points in group B. Thirty-six patients (85.7%) returned to their previous work level after surgery.

CONCLUSIONS

Arthroscopic arthrolysis is an effective treatment option for patients with restriction in elbow motion reasoned by post-traumatic or degenerative changes. Both groups showed a significant improvement of ROM and comparable outcome scores.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, Systematic Review.

Retrospective Comparative Analysis of Elbow Arthroscopy Used to Treat Primary Osteoarthritis With and Without Release of the Posterior Band of the Medial Collateral Ligament

PURPOSE

To evaluate the clinical and functional outcomes of arthroscopic debridement arthroplasty with the release of the posterior band of the medial collateral ligament in patients with primary osteoarthritis.

METHODS

We evaluated 43 patients treated with arthroscopic debridement arthroplasty for elbow osteoarthritis from February 2006 to February 2014. In group A (n = 19), the posterior band of the medial collateral ligament was released, and in group B (n = 24), it was not released. The mean follow-up period in groups A and B was 55.4 months (range, 24-100 months) and 62.2 months (range, 24-103 months), respectively. Clinical results were evaluated by measuring the preoperative and postoperative range of motion (ROM) of the elbow, visual analog scale score, and Mayo Elbow Performance Score.

RESULTS

Both groups showed significant improvement in clinical outcome (visual analog scale and Mayo Elbow Performance Score) at the final follow-up compared with preoperative evaluation (group A, P = .009 and .013, respectively; group B, P = .015 and .008, respectively). Group A showed significant improvement in increased flexion at 6 months of follow-up (P = .043). However, there was no statistically significant difference in postoperative ROM and clinical results between the 2 groups at the final follow-up (P = .482).

CONCLUSIONS

Arthroscopic debridement arthroplasty with the release of the posterior band of the medial collateral ligament was associated with improved flexion at the 6-month postoperative follow-up, but no significant difference between the groups was observed at the final follow-up. Therefore, the additional release of the posterior band of the medial collateral ligament may be unnecessary for improving postoperative ROM.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Outcomes after operative treatment of elbow contractures in the pediatric and adolescent population

BACKGROUND

The role of elbow contracture release in the very young is unclear, with existing studies reporting conflicting results. This study evaluated the long-term results after open elbow contracture release in patients aged younger than 18 years.

METHODS

Between 1994 and 2012, 32 patients underwent open elbow contracture release at a mean age of 13.8 years (range, 5-18 years), and their outcomes were reviewed. The primary cause was traumatic in 30 patients (4 radial head/neck fractures, 5 intra-articular distal humeral fractures, 11 extra-articular distal humeral fractures, 10 complex fracture-dislocations), and the mean time from the index injury to contracture release was 16.3 months (range, 3-82 months). The cause in 2 patients was nontraumatic (1 osteochondritis dessicans, 1 congenital). The mean follow-up period was 66 months (range, 7-202 months).

RESULTS

At the latest follow-up, total arc of motion improved from 69° to 123° (P <.0001), with a mean increase of 54° (P <.0001). The function arc was >100° in 28 patients (88%), and 29 patients (91%) achieved >20° of improvement in their arc. Twelve patients (38%) underwent a gentle manipulation under anesthesia at a mean of 2.7 weeks (range, 1-5 weeks) for early recurrence of stiffness. There were 3 complications (1 deep infection, 1 hematoma, 1 humeral fracture through the external fixator pin site). No patients lost motion after surgery.

CONCLUSION

Elbow contracture release in the pediatric and adolescent population can provide significant improvements in range of motion similar to that achieved in adults. The improvements in motion are durable.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Arthrofibrosis After Periarticular Fracture Fixation

Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

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.

Arthroscopic débridement for primary osteoarthritis of the elbow: analysis of preoperative factors affecting outcome

BACKGROUND

The purposes of this study were to evaluate the clinical results of arthroscopic débridement and to identify preoperative factors that influence the outcome.

METHODS

Forty-three elbows with primary osteoarthritis in 43 patients treated with arthroscopic débridement were retrospectively evaluated. At a mean follow-up of 38 months (range, 18-77 months), the visual analog scale (VAS) score for pain, the arc of elbow motion, and the Mayo Elbow Performance Index (MEPI) score were assessed. The relationships between postoperative MEPI score and postoperative motion arc and preoperative factors including age, sex, involvement of the dominant arm, duration of symptoms, demand of elbow activity, VAS score, previous history of failed surgery, and arc of elbow motion were statistically evaluated.

RESULTS

The mean VAS score for pain, the mean arc of flexion-extension, and the mean MEPI score significantly improved after the operation (all P values < .001). Multivariate regression analysis revealed that among preoperative variables, arc of motion was found to be the only independent prognostic factor that affected both postoperative elbow function (P = .024) and final arc of motion (P < .001). The cutoff value of preoperative arc of motion for the final arc of motion was determined to be 80° (P < .001). Involvement of the dominant arm was found to be another independent factor that affected postoperative MEPI scores (P = .016).

CONCLUSIONS

Arthroscopic débridement for elbow osteoarthritis provides satisfactory pain relief, improvement of elbow motion, and good functional outcome. Based on the fact that preoperative motion arc is the independent factor that can predict clinical outcome, arthroscopic treatment is highly recommended for patients who have a motion arc of 80° or more as it yields reliable results.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Improvements in elbow motion after resection of heterotopic bone: a systematic review

Complex elbow trauma, severe burn, or a closed head injury render patients at risk for developing heterotopic ossification around the elbow. When heterotopic ossification restricts elbow motion, some patients request surgical resection. We performed a systematic review of the literature to analyze improvement in elbow motion after resection of heterotopic ossification around the elbow. We found that, on average, etiology had little impact on outcome after resection of heterotopic ossification. Resection of heterotopic bone generally leads to improvement of elbow function.

Temporary presence of myofibroblasts in human elbow capsule after trauma

BACKGROUND

Elbow stiffness is a common complication after elbow trauma. The elbow capsule is often thickened, fibrotic, and contracted at the time of surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast-to-myofibroblast differentiation. We hypothesize that myofibroblasts are absent in normal elbow capsules and in acute trauma and that they are subsequently elevated in patients with posttraumatic elbow contracture.

METHODS

We obtained twenty-one human elbow joint capsules within fourteen days after an elbow fracture and/or dislocation and thirty-four elbow joint capsules in thirty-four patients who had undergone operative release of posttraumatic contractures more than five months after injury. Myofibroblasts in the joint capsules were quantified with use of immunohistochemistry. Alpha-smooth muscle actin was used as a marker for myofibroblasts. Samples were characterized and were scored by an independent pathologist blinded for clinical data.

RESULTS

Eleven capsules were associated with the acute phase after trauma (hours to less than seven days), and staining for alpha-smooth muscle actin was negative in all but one capsule. Ten capsules were associated with a later posttraumatic phase with myofibroblasts staining positive for alpha-smooth muscle actin in all but two capsules. Thirty-two long-standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterized by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. Two joint capsules showed an earlier phase of fibrosis. Only two of the long-standing contractures had staining of alpha-smooth muscle actin in fibroblast-like cells; the lack of staining in the other contractures suggested an absence of myofibroblasts.

CONCLUSIONS

This study presents negative results on the hypothesis that myofibroblast numbers are elevated in long-standing (more than five months) human posttraumatic elbow capsules. The absence of myofibroblasts in long-standing elbow contracture capsules is in contrast to most other studies on human tissue in the literature to date.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Active Elbow Orthosis

This paper presents a novel approach to the design of a motorized rehabilitation device – active elbow orthosis (AEO) – inspired by the principles of robotic exoskeletons. The device is currently designed for the elbow joint, but can be easily modified for other joints as well. AEO determines the motion activity of the patient using a strain gauge and utilizes this measurement to control the actuator that drives the forearm part of the orthosis. Patient activity level is related to a free arm measurement obtained via a calibration procedure prior to the exercise. A high-level control module offers several types of exercises mimicking the physiotherapist. The device was successfully verified by tests on a number of patients, resulting in extended range of elbow-joint motion.

Prevention and treatment of elbow stiffness: a 5-year update

Elbow stiffness is a challenging and common problem faced by upper extremity surgeons. Although functional improvements can be made with both nonsurgical and surgical management strategies, physicians must remain vigilant with efforts to prevent stiffness before it starts. Recent advancements in the biology and pathology of elbow contracture have led to improved understanding of this difficult problem, and they may lead to future breakthroughs in the prevention and treatment of elbow stiffness. This article serves as an update to our previous review of elbow stiffness, focusing on recent advancements in the past 5 years, as well as updating our current algorithm for treatment.

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

BACKGROUND

Heterotopic ossification (HO) is considered as a common extrinsic cause of elbow stiffness. The purpose of this study was to show the results of surgical treatment for post-traumatic elbow stiffness caused by HO in a large, consecutive series of patients in a single unit.

METHODS

We retrospectively reviewed 77 surgically treated patients with post-traumatic elbow stiffness caused by HO. Final motion arc and Mayo Elbow Performance Index (MEPI) were assessed as final results. Univariable and multivariable analyses were done to determine which factors had an effect on the final motion arc.

RESULTS

The average arc of elbow motion increased from 45° preoperatively to 112°, with an improvement of 67° at the final follow-up evaluation. The mean MEPI score was 91.9. At the final evaluation, 65 patients (84.4%) obtained a total motion arc of ≥100°. Recurrent HO was observed in 16 patients postoperatively, and 6 underwent repeated surgical release. The time from the initial injury to surgical release with a cutoff value of 19 months was the only independent factor affecting the final range of motion (ROM) in multivariable median regression analysis. With the numbers studied, no significant association was found between the final ROM and other clinical variables except for the recurrence of HO (93° vs 117°).

CONCLUSIONS

From the results of our study, we can support the surgical treatment of elbow stiffness caused by post-traumatic HO regardless of preoperative ROM. However, recurrence of heterotopic bone and delay in surgery of more than 19 months are associated with less favorable results.