Arthroscopic arthrolysis for posttraumatic elbow stiffness

doi:10.1016/j.jse.2010.11.018

Journal of Shoulder and Elbow Surgery

Volume 20, Issue 3, April 2011, Pages 434-439

https://doi.org/10.1016/j.jse.2010.11.018 Get rights and content

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.

Section snippets

Materials and methods

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

Evaluation

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 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

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

Results

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), Table II (C)). The mean EFA increased from 69 (SD, 4) preoperatively to 91 (SD, 4) 3 months postoperatively (Table II (A), Table II (E)). The postoperative ROM and EFA at 3, 12 and 24 months remained the same. The VAS score at rest 12 months

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 capsular release.1, 10, 22, 24, 25, 26, 31, 32 Several authors have reported their results after arthroscopic arthrolysis in the treatment of elbow joint contracture (Table III).2, 10, 12, 14, 15, 21, 23, 25,

Conclusion

In conclusion, loss of motion is a common complication after elbow trauma and can significantly interfere with the ability to perform activities in daily life. Nonsurgical treatment, including physiotherapy and static splinting, can restore a functional arc of motion in some patients. Traditionally, open release has good clinical outcomes. Arthroscopic capsular release with debridement and anterior capsulectomy is a safe and an effective treatment for posttraumatic elbow contracture with an

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

References (33)

C.M. Ball et al.
Arthroscopic treatment of post-traumatic elbow contracture
J Shoulder Elbow Surg
(2002)
S.H. Gallay et al.
Intra-articular capacity and compliance of stiff and normal elbows
Arthroscopy
(1993)
T. Haapaniemi et al.
Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture
Arthroscopy
(1999)
G.S. Jones et al.
Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow
Arthroscopy
(1993)
F. Kelberine et al.
[Elbow arthroscopy] Rev Chir Orthop Reparatrice Appar Mot
(2006)
E.W. Kelly et al.
Arthroscopic debridement without radial head excision of the osteoarthritic elbow
Arthroscopy
(2007)
A.L. Lindenhovius et al.
The posttraumatic stiff elbow: A review of the literature
J Hand Surg [Am]
(2007)
G.J. Lynch et al.
Neurovascular anatomy and elbow arthroscopy: inherent risks
Arthroscopy
(1986)
K.D. Nowicki et al.
Arthroscopic release of a posttraumatic flexion contracture in the elbow: A case report and review of the literature
Arthroscopy
(1992)
D. Nguyen et al.
Functional outcomes of arthroscopic capsular release of the elbow
Arthroscopy
(2006)

D.J. Ogilvie-Harris et al.

Arthroscopic treatment for posterior impingement in degenerative arthritis of the elbow

Arthroscopy

(1995)

B.B. Phillips et al.

Arthroscopic treatment of arthrofibrosis of the elbow joint

Arthroscopy

(1998)

J.F. Redden et al.

Arthroscopic fenestration for osteoarthritis

Arthroscopy

(1993)

D. Sahajpal et al.

Arthroscopic release of the stiff elbow

J Hand Surg [Am]

(2009)

F.H. Savoie et al.

Arthroscopic management of the arthritic elbow: Indications, technique, and results

J Shoulder Elbow Surg

(1999)

J.W.T. Byrd

Elbow arthroscopy for arthrofibrosis after type I radial head fractures

Arthroscopy

(1994)

Cited by (75)

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To perform a systematic review of complications associated with elbow arthroscopy in adults and children.
A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.
A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.
Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.
Level IV; systematic review of Level I-IV studies.
Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness
2023, Orthopaedics and Traumatology: Surgery and Research
Elbow stiffness significantly affects the patient's quality of life. This joint must have at least 30°/130° extension/flexion and 50°/50° pronation/supination to function normally according to Morrey.
The objective of this study was to evaluate functional outcome of arthroscopic arthrolysis by comparing stiffness of post-traumatic and degenerative origin. The hypothesis was that this surgical technique allows functional improvement in any indication but with a faster result in degenerative pathology.
This was a retrospective study including all patients who underwent elbow arthrolysis under arthroscopy, operated on by a single operator, between 2013 and 2020. Thirty-four patients were included, with a mean age of 45 years (range, 18–78 years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33 years (range, 18–64 years) and group B (degenerative) of 16 patients with a mean age of 59 years (range, 42–78 years). All patients were clinically assessed at a mean 27 months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected.
In the overall series, preoperative range of motion was 81° and significantly improved postoperatively to 122° (p < 0.001). The preoperative data of the 2 groups were comparable except for age (p < 0.001) and MEPS (p = 0.044). Postoperatively, range of motion improved significantly in both groups but with greater gain in group A (p = 0.003). MEPS improved significantly in both groups, but the postoperative score was poorer in group B (p = 0.001). Recovery of range of motion was faster in group B (2.4 months) than in group A (3.7 months) (p = 0.021). There were 5 complications: 4 secondary decompensations of ulnar tunnel syndrome, and 1 postoperative radial nerve paresis. 94% of patients were satisfied or very satisfied with the result of surgery.
Arthroscopic arthrolysis is an effective option for post-traumatic and non-traumatic elbow stiffness. Improvement was significant in terms of both function and range of motion, with, however, better results in the post-traumatic group but results achieved more rapidly in the degenerative pathology group.
IV, retrospective study.
Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness
2023, Revue de Chirurgie Orthopedique et Traumatologique
La raideur du coude affecte considérablement la qualité de vie d’un patient. Un secteur de mobilité de 30°/130° en extension/flexion et 50°/50° en pronation/supination a été considéré comme le secteur fonctionnel de mobilité par Morrey.
L’objectif de cette étude était de comparer les résultats fonctionnels des raideurs d’origines post-traumatique et dégénérative après arthrolyse arthroscopique. L’hypothèse était que cette technique chirurgicale permettait une amélioration fonctionnelle quelque-soit l’indication mais avec un résultat obtenu plus rapidement chez les patients présentant une pathologie dégénérative.
Il s’agissait d’une étude rétrospective, continue, mono-opérateur incluant tous les patients ayant été opéré d’une arthrolyse du coude sous arthroscopie entre 2013 et 2020, soit 34 patients, d’âge moyen 45 ans (18–78). Lors de l’analyse, les patients étaient répartis en deux groupes en fonction de l’étiologie de la raideur articulaire. Le groupe A (post-traumatique) était constitué de 18 patients de 33 ans d’âge moyen (18–64) et le groupe B (dégénératif) de 16 patients de 59 ans d’âge moyen (42–78). Les patients ont tous étaient évalué cliniquement à, en moyenne, 27 mois de recul. Les amplitudes articulaires, le niveau de satisfaction et le score Mayo Elbow Performance Score (MEPS) étaient recueillis.
Sur la série globale, l’arc de mobilité préopératoire était de 81° et a progressé significativement en post-opératoire à 122° (p < 0,001). Les données préopératoires des 2 groupes étaient comparables en dehors de l’âge (p < 0,001) et du MEPS (p = 0,044). En post opératoire, l’arc de mobilité a été significativement amélioré dans les 2 groupes mais avec un gain plus important pour le groupe A (p = 0,003). Le MEPS a progressé significativement dans les 2 groupes mais le score post-opératoire était moins bon pour le groupe B que pour le groupe A (p = 0,001), quant au gain sur la récupération des amplitudes articulaires, il a été plus rapide dans le groupe B (à 2,4 mois) que dans le groupe A (à 3,7 mois) (p = 0,021). Nous avons déploré 5 complications avec 4 syndromes irritatifs du nerf ulnaire au coude décompensés secondairement et une parésie post-opératoire du nerf radial. Enfin, 94 % des patients étaient satisfaits ou très satisfaits du résultat de leur intervention.
L’arthrolyse arthroscopique est un outil efficace et une bonne option pour le traitement des patients souffrant de raideurs du coude post-traumatiques et non-traumatiques. L’amélioration obtenue est significative tant sur la fonction que sur le gain en amplitude articulaire avec toutefois, un meilleur résultat obtenu dans le groupe post-traumatique mais un résultat acquis plus rapidement dans la pathologie dégénérative.
IV, Étude rétrospective.
Outcomes of Arthroscopic Elbow Contracture Release: Improvement for Severe Prosupination and Flexion Contracture
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Two patients presented with severe flexion contracture only. Reports in the literature demonstrate that patients typically reach a plateau in recovery 3 months postoperatively, and neither significantly increase or decrease their elbow ROM thereafter.6,15,28 Therefore, the authors recommend that the second stage of the planned two-stage release should occur at about 3 months after the first release.
The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies.
Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed.
Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n = 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n = 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases.
Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present.
IV, case series, treatment study
Midterm outcomes and survivorship of arthroscopic elbow debridement: a comparison of posttraumatic versus primary degenerative osteoarthritis
2022, JSES International
Arthroscopic debridement is an effective means of surgical management of both degenerative osteoarthritis (DOA) and posttraumatic arthritis (PTA) of the elbow. However, the difference in the efficacy and longevity of this procedure when performed for these two distinct pathologies remains in question. The purpose of this study was to identify and compare the midterm outcomes and survivorship of arthroscopic debridement of elbow PTA and DOA.
A retrospective analysis of patients undergoing arthroscopic debridement of DOA and PTA of the elbow was performed. A questionnaire containing the Oxford Elbow Score, as well as questions regarding the incidence of reoperation, additional nonoperative intervention, complications, pain, and satisfaction, was given at 5 years, minimum, after surgery. The midterm survivorship of arthroscopic debridement free of reoperation for any reason, as well as the remaining outcome measurements obtained via the questionnaire and in-office evaluation, was compared between PTA and DOA cohorts.
Eighty patients (DOA = 36, PTA = 44) were included in this study for analysis. All 36 patients with DOA were noted to be male. Follow-up time at the date of questionnaire response was 7.9 years (range, 5.6-11.8) in the DOA cohort and 8.6 years (range, 5.7-12.7) in the PTA cohort. Reoperation rates of 5.6% and 11.4% were identified in the DOA and PTA cohorts, respectively. No statistical difference was noted in reoperation rate, survivorship, or any measured patient-reported outcomes between cohorts at the final follow-up visit. Both cohorts demonstrated a significant improvement in Visual Analog Scale pain scores (P < .001) and ROM. Postoperative ROM was obtained at the final clinic visit at an average follow-up duration of 151 days and 255 days in the DOA and PTA cohorts, respectively. However, no difference in the degree of improvement in either outcome variable was identified after a comparison between cohorts.
Arthroscopic debridement is an equally efficacious treatment option for DOA and PTA of the elbow. Patients with either pathology can expect satisfactory elbow function and an improvement in pain with little chance of reoperation at the midterm of the follow-up duration.
The post-traumatic stiff elbow: A review
2021, Journal of Clinical Orthopaedics and Trauma
Upper extremity function is highly dependent on elbow motion in order to adequately position the hand in space. Loss of this motion due to stiffness following trauma can cause patients substantial disability, leading to difficulties with performing activities of daily living. Post-traumatic elbow stiffness is challenging to treat, and therefore prevention is of paramount importance. Key measures that can be used to prevent elbow stiffness are early surgical intervention for fracture or joint instability, as well as active mobilisation, which helps to prevent oedema and an increase in viscosity of inflammatory exudates. Other options include splinting and continuous passive mobilisation.
Once non-operative methods of addressing post-traumatic stiffness have been exhausted, arthrolysis of the stiff elbow can be performed via open or arthroscopic means depending on the type of pathology involved (intrinsic or extrinsic contracture) and experience of the surgeon with elbow arthroscopy. The particular open approach used depends on several factors, which include the formation and location of any heterotopic ossification present. Improvements in range of motion can be expected with both open and arthroscopic techniques, which can be effective and rewarding for patients. Post-operative rehabilitation, particularly early active mobilisation, should be considered essential in order to optimise patient outcomes following surgery.
This review aims to explore elbow stiffness following traumatic aetiology, assessing its pathogenesis and prevention, as well as reviewing surgical treatment options and post-operative rehabilitation.

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: 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.

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ElbowArthroscopic arthrolysis for posttraumatic elbow stiffness

Background

Materials and methods

Results

Discussion

Conclusion

Section snippets

Materials and methods

Evaluation

Surgical technique

Results

Discussion

Conclusion

Disclaimer

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Arthroscopy

[Elbow arthroscopy] Rev Chir Orthop Reparatrice Appar Mot

Arthroscopy

J Hand Surg [Am]

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

J Hand Surg [Am]

J Shoulder Elbow Surg

Elbow arthroscopy for arthrofibrosis after type I radial head fractures

Arthroscopy

Elbow
Arthroscopic arthrolysis for posttraumatic elbow stiffness