J Shoulder Elbow Surg (2011) 20, 434-439
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Arthroscopic arthrolysis for posttraumatic elbow stiffness Irma Cefo, MD*, Denise Eygendaal, MD, PhD Department of Orthopaedic Surgery, Upper-Limb Unit, Amphia Hospital, Breda, The Netherlands Background: Loss of motion of the elbow joint is a common finding after elbow trauma. Restoration of motion of the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. Arthroscopic capsular release of stiff elbows has recently been introduced as a safe but technically demanding technique. The outcome in 27 patients treated by arthroscopic capsular release was assessed. Materials and methods: We evaluated 27 patients (17 women) who were an average age of 42 years (range, 14-65) at 3, 12, and 24 months after arthroscopic capsular release of a posttraumatic stiff elbow. Range of motion (ROM) and Elbow Function Assessment (EFA) were measured. Results: Before the arthroscopic procedure, the mean flexion was 123 (SD 8 ), extension was 24 (SD 9 ), and total ROM was 99 (SD 11 ), and after surgery, flexion improved significantly to 133 (SD 5 ), extension to 7 (SD 6 ), and total ROM to 125 (SD 10 ). The mean (SD) EFA showed improvement from 69 (SD 4) preoperatively to 91 (SD 4) postoperatively. The postoperative outcomes at 3, 12 and 24 months were similar. One postoperative superficial infection of the lateral portal occurred and was successfully treated with oral antibiotics. No vascular or neurologic complications were noted. Discussion: Historical data underscore the fact that arthroscopic release of posttraumatic elbow contracture is technically demanding but can effective improve the elbow arc of motion. Conclusion: Arthroscopic capsular release of the elbow is a safe and reliable treatment for patients with a posttraumatic elbow contracture. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.
Loss of motion is a common complication after elbow trauma and can significantly interfere with the ability to perform the activities of daily life. Several different surgical procedures have been used to treat stiff elbow. Elbow contractures can be the result of intrinsic The study was approved by the Ethics Committee of our hospital, which stated that informed consent of each patient was not needed because this study is an anonymous, clinical evaluation of patients treated in a standardized way according to the current treatment protocol for stiff elbows in our institution. *Reprint requests: Irma Cefo, MD, Amphia Hospital, Dept. of Orthopaedic Surgery, Upper-Limb Unit, Molengracht 21, 4818 CK Breda, The Netherlands. E-mail address:
[email protected] (I. Cefo).
(intraarticular) or extrinsic (extraarticular) causes. In most posttraumatic contractures, intrinsic and extrinsic causes both play a role. Established contractures should be treated initially with physical therapy and static-progressive splinting. When a minimum of 6 to 12 months of nonsurgical management has failed, a patient who is motivated to comply with a strict postoperative rehabilitation program is a candidate for surgical release. For years the gold standard for surgical release of stiff elbows was the open lateral column procedure.7,16,18 The results were generally good, with low complication rates. Arthroscopic capsular release of stiff elbows has recently been introduced as a safe but technically demanding technique.28
1058-2746/$ - see front matter Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.11.018
Arthroscopic arthrolysis for posttraumatic elbow stiffness Table I Pt
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
435
Details of initial injury and elbow function preoperatively and postoperatively in the 27 patients Sex
F M M F F F F M M F F M M F F M M F F F M F M F F F F
Age (y)
Preoperative Flex,
Ext,
ROM,
Postoperative Flex,
Ext,
ROM,
33 63 33 51 53 59 62 49 52 45 35 36 39 38 37 65 39 36 52 41 39 57 20 38 37 22 14
130 130 130 135 140 120 120 120 130 120 120 120 120 110 110 130 120 110 120 110 130 120 130 120 120 130 120
e50 e40 e20 e30 e20 e20 e20 e20 e30 e15 e20 e20 e20 e15 e15 e30 e20 e40 e10 e30 e15 e30 e30 e20 e20 e20 e20
80 90 110 105 120 100 100 100 100 105 100 100 100 95 95 100 100 70 110 80 115 90 100 100 100 110 100
130 130 140 145 140 140 130 130 140 140 130 130 130 130 130 135 130 130 130 130 130 130 140 130 140 140 130
e5 e10 e5 e5 e5 e5 e5 e5 0 0 e5 e10 e5 e5 e5 e5 e10 e20 e5 e5 0 e5 0 e5 0 e10 e5
125 120 135 140 135 135 125 125 140 140 125 120 125 125 125 130 120 110 125 125 130 125 140 125 140 130 125
Injury
Year
Time between injury and arthroscopic arthrolysis (mon)
RHF Ms 2 RHF Ms 2 EL, RHF Ms RHF Ms 3 RHF Ms 3 RHF Ms 3 RHF Ms 2 RHF Ms 3 RHF Ms 2 EL, RHF Ms RHF Ms 2 RHF Ms 1 EL, RHF Ms RHF Ms 2 EL EL, RHF Ms DHF DHF RHF Ms 3 EL RHF Ms 1 EL EL RHF Ms 1 EL RHF Ms 3 CF
2005 2002 2005 2005 1979 2005 2001 2005 2006 1962 2005 2006 1997 1995 2004 2006 2003 1996 1994 2004 2003 1978 2007 2007 2005 2006 2006
15 70 33 24 339 32 63 26 13 180 20 13 116 84 30 8 43 123 144 25 33 333 12 13 26 6 12
2; CF
2; CF
3; CF
3
CF, capitellum fracture; DHF, distal humeral fracture; EL, elbow luxation; F, female; M, male; Ms, Mason; RHF, radial head fracture; ROM, range of motion.
The indications for surgery depend on the patient’s functional needs. Morrey et al20 stated that an elbow needs a minimum range of motion (ROM) of 100 flexion/extension and 100 pronation/supination to function adequately in the activities of daily living (ADL). In specific groups of patients, however, such as professional athletes, even a slight extension deficit of 20 can result in a dysfunctional elbow in ADL. The purpose of this study was to evaluate clinical outcome and improvement of ROM after arthroscopic treatment of posttraumatic elbow contractures.
adequate nonsurgical treatment. All patients received physical therapy for 6 months or more. Patients were excluded from the study if there was active infection around their elbow or if they were unable to cope with the postoperative rehabilitation program. Significant intrinsic disease of the joint with disruption of the bony architecture at preoperative radiographs was reason for exclusion. Also excluded were patients with Brooker 3 and more heterotopic ossification, diagnosed on radiographs, and patients with primary degenerative or inflammatory arthritis of the elbow. Patients who required hardware removal or had ulnar nerve decompression were excluded as well.
Materials and methods Evaluation Between June 2006 and December 2007, 27 consecutive patients (17 females) with a posttraumatic contracture of the elbow were treated with an arthroscopic release. Patients were an average age of 42 years (range, 14-65 years), The study included patients with posttraumatic contracture (for details of traumatic deformities, see Table I) if they had a symptomatic loss of flexion of more than 20 and/or a loss of extension of at least 20 . Arthroscopic surgery was indicated when restricted elbow motion interfered with ADL or sporting activities, despite
Evaluation took place preoperatively, after 3, 12 and 24 months, using the Elbow Function Assessment (EFA; Appendix 1).4,20 ROM and EFA are determined preoperatively after 3, 12, and 24 months. Pain at rest was evaluated on a visual analog scale (VAS) preoperatively and after 12 months. Plain radiographs and computed tomography (CT) were
I. Cefo, D. Eygendaal
436 performed to evaluate the osseous abnormalities in all patients preoperatively, and plain radiographs in 2 views were taken at 3 months and 1 year after surgery.
Surgical technique All patients were operated on by the same surgeon (D.E.). The time between surgical intervention and trauma varied from 6 to 339 months. Physical examination under anesthesia was routine. The patient was placed in the lateral decubitus position (Fig. 1). A tourniquet was used in all cases. The joint was distended with saline, and access was through a midposterior and a posterolateral portal. The posterior compartment was debrided using a 5.5-mm oscillating shaver and a 4-mm oval burr (Stryker Shaver System, Kalamazoo, MI). All osteophytes, loose bodies, and fibrotic tissue were removed. The anterior compartment was examined using an anteromedial portal after a careful palpation of the ulnar nerve and intermuscular septum; a second anterolateral portal was created outside-in. A synovectomy was performed with a 5.5mm oscillating shaver, if necessary, to establish a view. The coronoid process and the coronoid fossa and capitellum were debrided with a 4-mm burr. Finally, the anterior capsule was released using a punch from medial to lateral. Follow-up treatment consisted of continuous passive motion (CPM) device for the first 24 hours, continuously, followed by a standardized program under supervision of a physiotherapist (Appendix 2). Patients were discharged from the hospital on day 2.
Statistics Changes in baseline for flexion, extension, ROM and EFA, were tested using the paired t test. The mean change, its 95% confidence interval, and P value were calculated. The change in the VAS score was tested using the sign test; the observed distribution of the change in the VAS score is presented.
Figure 1 The patient is placed in a lateral decubitus position for arthroscopic capsular release.
Table II (A)
Scores before operation (n ¼ 27)
Variable
Mean
SD
Flexion Extension Range of motion EFA
122.8 e23.7 99.1 69.0
7.9 9.1 10.6 4.3
EFA, elbow function assessment; SD, standard deviation
Results
Table II (B) rest
The preoperative mean flexion and mean extension improved at at 3 months from 123 (SD, 8 ) to 133 (SD, 5 ) and 24 (SD, 9 ) to 7 (SD, 6 ), respectively (P < .0005). The mean total ROM improved from 99 (SD, 11 ) to 125 (SD, 10 ; P < .0005; Table II, A and C). The mean EFA increased from 69 (SD, 4) preoperatively to 91 (SD, 4) 3 months postoperatively (Table II, A and E). The postoperative ROM and EFA at 3, 12 and 24 months remained the same. The VAS score at rest 12 months postoperatively was still 0 in 8 patients, was still 1 in 14, had improved from 2 to 0 in 4, and from 3 to 1 in 1 patient. This change was significant (P ¼.008; sign test; Table II. B and D). One postoperative superficial infection occurred in the lateral portal and was successfully treated with oral antibiotics. No vascular or neurologic complications were noted.
VAS score
No.
0 1 2 3
8 14 4 1
Preoperative visual analog scale (VAS) score at
Discussion Open release has traditionally had good clinical outcomes.18 However, open release leaves large scars and causes increased soft tissue trauma, which may lead to contracture recurrence and can delay the progress of physiotherapy programs.30 Good outcomes have been reported with
Arthroscopic arthrolysis for posttraumatic elbow stiffness Table II (C) Mean changes from the preoperative baseline at the various intervals (n ¼ 27) Interval
Variable
Mean,
95% CI
P
3 mon
Flexion Extension ROM Flexion Extension ROM Flexion Extension ROM
9.8 16.5 26.3 10.9 18.3 29.3 10.9 18.3 29.3
7.1-12.5 12.5-20.4 21.8-30.8 8.4-13.5 14.9-21.8 25.7-32.8 8.4-13.5 14.9-21.8 25.7-32.8
