1
|
Lanzerath F, Wegmann K, Hackl M, Uschok S, Ott N, Müller LP, Leschinger T. Surgical arthrolysis of the stiff elbow: a systematic review. Arch Orthop Trauma Surg 2023; 143:2383-2393. [PMID: 35482109 PMCID: PMC10110632 DOI: 10.1007/s00402-022-04442-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/05/2022] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Fabian Lanzerath
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany.
| | - Kilian Wegmann
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Michael Hackl
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Stephan Uschok
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Nadine Ott
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Lars P Müller
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Tim Leschinger
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| |
Collapse
|
2
|
Xiao D, Gong M, Chen C, Zha Y, Li T, Ji S, Hua K, Sun W, Jiang X. Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness. BMC Musculoskelet Disord 2021; 22:941. [PMID: 34758796 PMCID: PMC8582181 DOI: 10.1186/s12891-021-04796-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To evaluate and compare the functional outcomes of combined medial-lateral approach open arthrolysis with and without hinged external fixation. METHODS We retrospectively collected and analyzed the clinical data of patients with severe elbow stiffness who were treated in our institution from January 2018 to January 2019. All of them were treated with combined medial-lateral approach arthrolysis. There were 20 patients who had the hinged external fixation placed and 29 patients without the placement of the external fixation. Their baseline characteristics and functional outcomes were evaluated and compared. RESULTS The average follow-up time was 28.4 ± 3.7 months. There were no significant differences in the ROM of the elbow, MEPS, VAS, DASH, or complications between the two groups. The operation time and treatment cost of the patients without external fixation were significantly lower than patients with external fixation. CONCLUSION Combined medial-lateral approach open elbow arthrolysis without external fixation is a safe and effective way to treat elbow stiffness. LEVEL OF EVIDENCE Therapeutic Level III; Retrospective Cohort Comparison; Treatment Study.
Collapse
Affiliation(s)
- Dan Xiao
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Maoqi Gong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Chen Chen
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yejun Zha
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Shangwei Ji
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Kehan Hua
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Weitong Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
| |
Collapse
|
3
|
Sun Z, Li J, Cui H, Ruan H, Wang W, Fan C. A new pathologic classification for elbow stiffness based on our experience in 216 patients. J Shoulder Elbow Surg 2020; 29:e75-e86. [PMID: 31678024 DOI: 10.1016/j.jse.2019.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 07/27/2019] [Accepted: 08/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow stiffness commonly causes functional impairment and upper-limb disability. This study aimed to develop a new pathologic classification to further understand and standardize elbow arthrolysis from a new perspective, as well as to determine clinical outcomes. METHODS Extension-flexion dysfunction was classified into 4 types: EFI, tethers alone; EFII, tethers with blocks; EFIII, articular malformation; and EFIV, bony ankylosis. Forearm rotation dysfunction was classified into 3 types: FRI, contracture alone; FRII, radial head malunion or nonunion; and FRIII, proximal radioulnar bony ankylosis. A total of 216 patients with elbow stiffness were prospectively included and categorized preoperatively. All surgical procedures were performed by the same chief surgeon; different types underwent specific procedures. Patient data, elbow motion, and functional scores were analyzed. RESULTS Mean range of motion (ROM) increased from 40° preoperatively to 118° at final follow-up; 88% of patients regained ROM of 100° or greater. The forearm rotation arc (FRA) with forearm rotation dysfunction increased from a preoperative mean of 76° to 128°; 82% of patients regained an FRA of 100° or greater. The mean Mayo Elbow Performance Index (MEPI) increased from 63 to 91 points; the proportion of patients with good or excellent results was 95%. EFI patients had the best ROM (129°) and MEPI (93 points) and EFIV patients achieved the most-changed ROM (116°), whereas EFIII patients had the worst ROM (104°) and MEPI (84 points) and the least-changed ROM (64°). The FRA was best in FRI patients (142°), followed by FRII patients (118°), and worst in FRIII patients (82°); in contrast, the changed FRA was greatest in FRIII patients (82°), followed by FRII patients (64°), and least in FRI patients (37°). CONCLUSION This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes.
Collapse
Affiliation(s)
- Ziyang Sun
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Juehong Li
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haomin Cui
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hongjiang Ruan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China; Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China; Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai, China.
| |
Collapse
|
4
|
What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness? Clin Orthop Relat Res 2019; 477:2319-2328. [PMID: 31107330 PMCID: PMC6999955 DOI: 10.1097/corr.0000000000000726] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied. QUESTIONS/PURPOSES We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure. METHODS Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62-83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery. RESULTS At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°-111°; p < 0.001), and 98% (48 of 49) of patients achieved a functional ROM of 30° to 130°. Improvements were also found in functional scores (MEPI: 54 ± 12 to 95 ± 7, mean difference, 41 points; DASH: 48 ± 17 to 8 ± 8, mean difference, 40 points; both p < 0.001), life quality (physical SF-36: 46 ± 11 to 81 ± 12, mean difference, 35 points; mental SF-36: 43 ± 14 to 80 ± 9, mean difference, 37 points; both p < .001), pain (VAS: 2.5 ± 2.4 to 0.4 ± 0.8; mean difference, 2.0 points; p < 0.001), and ulnar nerve function (Amadio score: 7.8 ± 1.9 to 8.4 ± 0.8; mean difference, 0.6 points; p = 0.004). A total of 18% (nine of 49 patients) developed complications, including new-onset or exacerbated nerve symptoms (four patients), recurrent heterotopic ossification (two patients), and pin-related infections (three patients). No patients underwent subsequent surgery for any of the above complications. Lastly, the medium-term ROM was divided into ROM ≤ 120° (n = 9) and ROM > 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2-47; p = 0.009) associated with recovery of ROM. CONCLUSIONS Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
|
5
|
Third Place Award: Posttraumatic elbow arthrofibrosis incidence and risk factors: a retrospective review. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Zhou Y, Cai JY, Chen S, Liu S, Wang W, Fan CY. Application of distal radius-positioned hinged external fixator in complete open release for severe elbow stiffness. J Shoulder Elbow Surg 2017; 26:e44-e51. [PMID: 28104095 DOI: 10.1016/j.jse.2016.09.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/31/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radical release for severe stiff elbows may lead to instability. Hinged external fixation is used to treat unstable elbows. We hypothesized that extensive open release combined with a distal radius-positioned hinged external fixator would have good performance and low complications rate in treating severe elbow stiffness. Thus, the efficacy and security of this technique were assessed in this study. METHODS We retrospectively reviewed 38 post-traumatic elbows with severe stiffness that underwent arthrolysis between February 2011 and February 2014. All patients were assessed as having elbow instability after complete arthrolysis. Ligament repair was combined with implantation of a hinged external fixator (fixed to the humerus and distal radius) to maintain elbow stability. Flexion arc, forearm rotation, Mayo Elbow Performance Score, elbow stability, and radiographs were evaluated preoperatively and postoperatively, and complications were documented. RESULTS Mean follow-up was 31 months. Significant improvement was noted in flexion-extension arc (from 27° to 126°), forearm rotation (from 148° to 153°), and mean Mayo Elbow Performance Score (from 68 points to 96 points). Mean pronation arc decreased from 66° preoperatively to 6° at 1.5 months of follow-up and showed a transient reduction during first 6 months postoperatively. Pin-related infection occurred in 2 patients, which was cured with conservative treatment. Two patients had moderate instability after removal of the fixator and regained stability at the 12-month follow-up. At the last follow-up, complications included ulnar nerve paralysis in 3, recurrence of heterotopic ossification in 1, and moderate pain in 1. CONCLUSIONS Complete open release combined with a distal radius-positioned hinged external fixator is an effective treatment for severe stiff elbows. This technique had a low complication rate.
Collapse
Affiliation(s)
- Yi Zhou
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China; Department of Orthopaedics, Capital Medical University, Affiliated Beijing ChaoYang Hospital, Beijing, China
| | - Jiang-Yu Cai
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China; Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Shen Liu
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-Yi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China.
| |
Collapse
|