Open elbow arthrolysis for post-traumatic elbow contracture

Rehabilitation after surgical release of the stiff elbow: A literature review

Background

Elbow stiffness poses a significant challenge for surgeons as well as physiotherapists during and after surgery. To date, there is no consensus regarding the subsequent rehabilitation after surgical release of the stiff elbow.

Objective

The aim is to evaluate the most important therapeutic strategies following open or arthroscopic release of the stiff elbow based on a comprehensive literature review, and to develop a consensus for or against specific therapeutic methods with the help of a survey among elbow experts of the D-A-CH Association for Shoulder and Elbow Surgery (DVSE).

Methods

Literature search was performed based on guidelines, the "health technology assessments", systematic reviews and clinical studies that examined rehabilitation after osteocapsular release of the stiff elbow. The databases of the "Guidelines International Network", various national guidelines, PubMed, the "Cochrane Central Register of Controlled Trials", the "Cochrane Database of Systematic Reviews", and the "Physiotherapy Evidence Database" were scanned, each for the period from January 1989 to December 2019. As part of an online survey, all active members of the DVSE were asked about their strategies in immediate aftercare and rehabilitation after elbow arthrolysis.

Results

A total of 5 reviews and 55 articles could be identified from 107 articles since 1989, which served as the basis for the preparation of an evidence-based aftercare recommendation. By reviewing all the mentioned paper and evaluation of the survery of DVSE members, a basic concept could be finalized.

Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review

Osteochondritis dissecans (OCD) of the elbow mainly occurs in overhead athletes (OHAs). This narrative review aimed to comprehensively analyze the epidemiological data, etiological factors, clinical and imaging features, treatment options, and outcomes of OHAs with the diagnosis of elbow OCD. A literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science. Individuals with elbow OCD were usually 10-17 years of age with incidence and prevalence varying between studies, depending on the sport activity of the patients. The etiology of OCD lesions is multifactorial, and the main causes are believed to be repetitive trauma, the biomechanical disproportion of the articular surfaces, poor capitellar vascular supply, and inflammatory and genetic factors. Athletes usually presented with elbow pain and mechanical symptoms. The mainstay for the diagnosis of elbow OCD is MRI. The treatment of elbow OCD lesions should be conservative in cases of stable lesions, while various types of surgical treatment are suggested in unstable lesions, depending mainly on the size and localization of the lesion. The awareness of medical practitioners and the timely diagnosis of OCD lesions in OHAs are key to favorable outcomes.

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.

Primary open elbow arthrolysis in post-traumatic elbow stiffness - A comparison of outcomes in severity of elbow injury

PURPOSE

Stiffness is a sequelae of elbow trauma. Arthrolysis may be considered to increase range of movement (ROM). Little is published on the outcomes/complications of elbow arthrolysis. We present our series of primary open arthrolysis in posttraumatic elbow stiffness.

METHODS

A consecutive series of patients that underwent primary open arthrolysis for posttraumatic elbow stiffness in our unit (2011-2018) were analysed. All procedures were performed by an elbow surgeon. Postoperative rehabilitation followed protocol with early motion; continuous passive motion (CPM) was utilised if requested. Data collected included patient demographics, traumatic injury type, arthrolysis technique, preoperative, intraoperative and postoperative elbow ROM, complications and postoperative Oxford Elbow Score (OES).

RESULTS

41 patients were included. 59% were male. Mean age at time of arthrolysis was 43 years (range 12-79 years). Mean duration of follow-up was 53 months (range 8-100 months). Median duration from time of injury to arthrolysis was 11 months (range 2-553 months). Mean preoperative flexion-extension arc (FEA) was 70°, improving to 104° postoperatively (p < 0.001). Mean preoperative pronosupination arc (PSA) was 125°, improving to 165° postoperatively (p < 0.001). Mean postoperative OES was 37 (n = 28). Complication rate was 24% with 7 recurrence requiring surgery, 2 nerve injuries and 1 infection. CPM, 10 patients, saw mean FEA improvement of 56°. Mean PSA improvement was 36°. Complication rate for these patients was 40%. Severe traumatic injury was associated with increased preoperative stiffness (FEA 61° vs 84°, PSA 111° vs 149°) but larger improvements in ROM (postoperative FEA 98° [p < 0.001], PSA 165° [p < 0.001]).

CONCLUSION

This series demonstrates improvement in elbow ROM following open arthrolysis with significantly higher gain in pronosupination for those withsevere injury. Moderate results were seen in a patient reported outcome measure. Patients considering arthrolysis should be counselled regarding expectations/complication rate.

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.

Effect on muscle strength of the upper extremities after open elbow arthrolysis

Background

Open elbow arthrolysis manipulates tendons and soft tissues surrounding the elbow and may lead to strength decline after the operation. We hypothesized that strength of elbow and wrist motions and handgrip could be compromised after the procedure and that the strength recovery pattern may differ between men and women and between the dominant and nondominant side.

Methods

This was a prospective cohort study. We monitored 32 patients with post-traumatic elbow stiffness who underwent open arthrolysis between June 2014 and December 2014. All patients underwent standardized postoperative physical therapy. Preoperative and postoperative isometric strength were measured by a handheld dynamometer. Mayo Elbow Performance Score (MEPS) and arc of motion (AOM) were also analyzed.

Results

Mean follow-up was 26.13 months. Significant improvement was noticed in mean AOM (from 46° to 127°) and MEPS (from 67.97 to 96.86). No significant decline was noted in isometric strength at the last follow-up day. The strength ratios between men and women showed no significant difference from postoperative day 7 to the last follow-up day. At all follow-up assessments, isometric strength showed no significant difference between the dominant and nondominant side.

Conclusions

AOM and MEPS achieved significant enhancement after open elbow arthrolysis. The procedure did not lead to isometric strength decline. Postoperative gain of strength was proportional to the baseline strength level of each muscle group, and men had a more prominent gain of strength than women during the entire follow-up. Dominance had no effect on postoperative strength recovery.

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.

Clinical outcomes after posterior open elbow arthrolysis for posttraumatic elbow stiffness

Background:

Loss of motion is a well-known complication after elbow trauma and in severe cases, arthrolysis of elbow is the procedure of choice. The posterior approach might have some advantages especially in post-traumatic patients who have undergone the same surgical approach in the past.

Objectives:

The aim of this study was to evaluate the short-term outcomes of elbow arthrolysis through posterior approach. Moreover, we assessed the effect of operation on the patients’ quality of life.

Patients and Methods:

During a retrospective-cohort study, the medical records of 14 patients (12 men, two women) whose range of movement had been limited post-traumatically and had undergone elbow arthrolysis with posterior approach were reviewed. Before intervention, the patients had a flexion less than 100 degrees or an extension lag of 30 degrees or more. For evaluation of the final outcomes, they were invited to participate in our study and the final range of motion, visual analogue score (VAS), disability of arm, shoulder and hand (DASH), Mayo elbow score (MES) and short form health survey (SF-36) scores were measured in the patients.

Results:

Mean age of the participants was 28.7 years. The interval from initial injury and arthrolysis was 16 months and the patients were followed for 14 months. The mean range of motion in patients before surgery was 35.8 degrees, which was increased to a mean of 108.9 after the surgery, indicating a 73.1 degrees improvement. The means of VAS, DASH, Mayo elbow and SF-36 scores in the patients were 1.6, 34, 68 and 43, respectively. A significant inverse correlation was found between the preoperative range of motion and final range of motion.

Conclusions:

According to our results, elbow arthrolysis through posterior approach could be an effective technique with low complications. Since the final range of motion improved significantly, it might be a valuable method in promoting the patients’ quality of life.

The outcome of open elbow arthrolysis: comparison of four different approaches based on one hundred cases

PURPOSE

The aim of this study was to evaluate the results of elbow arthrolysis according to the surgical approach, durability after arthrolysis and the severity of contracture.

METHODS

The study includes a cohort of 100 consecutive patients treated in our institution between 1986 and 2008. The indication for surgery was loss of mobility. This was the result of fractures, dislocation, simultaneous fracture/dislocation or other non-traumatic causes. All patients underwent open elbow release via one of four approaches (42 lateral, 44 medial, six combined medial-lateral and eight posterior). They were clinically evaluated at a minimum of 24 months after arthrolysis.

RESULTS

The average ranges of elbow extension, flexion and arc of motion had increased significantly at the follow up, respectively, by 20°, 16° and 36°. No significant difference was found with regard to surgical approach. However, we noticed significant deterioration of intra-operative average extension and arc of motion (AOM) over the follow up period, respectively, by 13° and 14°. The number of patients with AOM of 100° or more increased from three patients preoperatively to 28 postoperatively.

CONCLUSIONS

Open elbow arthrolysis is a successful method of treatment of elbow contracture. Results are durable, but there is some postoperative deterioration of extension gained during surgery. We may anticipate that at the final stage we shall obtain an average of 86% of intra-operative arc of motion. Patients with the most severe contractures have the best gains.

The contracted elbow: is ulnar nerve release necessary?

BACKGROUND

Prophylactic release of the ulnar nerve in patients undergoing capsular release for severe elbow contractures has been recommended, although there are limited data to support this recommendation. Our hypothesis was that more severely limited preoperative flexion and extension would be associated with a higher incidence of postoperative ulnar nerve symptoms in patients undergoing capsular release.

MATERIALS AND METHODS

We conducted a retrospective review of 164 consecutive patients who underwent open or arthroscopic elbow capsular release for stiffness between 2003 and 2010. The ulnar nerve was decompressed if the patient had preoperative ulnar nerve symptoms or a positive Tinel test. Preoperative and postoperative range of motion and incidence of ulnar nerve symptoms were recorded.

RESULTS

The mean improvement in the arc of motion of was 36.7°. New-onset postoperative ulnar nerve symptoms developed in 7 of 87 patients (8.1%) who did not undergo ulnar nerve decompression; eventually, 5 of these patients with persistent symptoms underwent ulnar nerve decompression. The rate of developing postoperative symptoms was higher if patients had preoperative flexion ≤ 100° (15.2%) compared with those with preoperative flexion >100° (3.7%). There was no association between preoperative extension or gain in motion arc and postoperative symptoms.

CONCLUSIONS

The overall rate of ulnar nerve symptoms after elbow contracture release was low if ulnar nerve decompression was performed in patients with preoperative symptoms or a positive Tinel test. There was a higher rate of ulnar nerve symptoms in patients with more severe contractures (≤ 100° of preoperative flexion), which did not reach statistical significance.

Posttraumatic elbow stiffness

Early posttraumatic elbow contractures may be treated with a combination of manipulation with the patient under anesthesia followed by bracing.Extrinsic contractures of the elbow may be treated with open or arthroscopic release, whereas intrinsic and combined contractures may require tissue release as well as partial or total arthroplasty.