Wednesday, May 27, 2009

Operative interventions in stiff elbow- A mini review



Introduction:

Two intermediate joints i.e. the elbow and the knee are the most affected by myositis ossificans. Stretching to regain ROM in the post immobilization period is not out of danger of acquiring myositis. Contracted elbow poses difficulty to both operative and non-operative treatment (7).
In my more than a decade of carrier as a graduate & specialist physiotherapist I have hardly seen case non-responding to physiotherapy for stiff elbow except cases associated with bony block. The part of world where I live in orthopedic surgery is not common for elbow stiffness. Recently I saw a case presenting with post operative stiff elbow. To my assessment stiffness was due to capsule as the stiffness was bi-directional and characteristic end-feel. Despite 15 days of oscillatory mobilization, stretching & other rehabilitation exercises, there was o remarkable change. I have no provision of serial casting in my set up. So I tried to get in to reviewing operative interventions in elbow stiffness cases. The following is the summary of that review.

Posttraumatic stiffness in elbow (2): Patients may present with extrinsic, intrinsic contractures or mixed contractures (combined extrinsic and intrinsic contractures) in a stiff elbow.
1. Initial traumas may be isolated fractures or dislocation and complex fracture-dislocations.
2. Initial treatments may be nonoperative, radial head resection, and ORIF.

Operative procedures
Posttraumatic elbow stiffness can impose severe functional limitations on the performance of activities of daily living. Patients who have failed a minimum of six months of nonsurgical management and who are motivated to comply with postoperative rehabilitation are candidates for surgical release. Unlike earlier studies the current studies suggest that posttraumatic stiffness of the elbow, particularly when the articular surface is left intact, may be treated reliably (7). There are several effective surgical approaches and techniques available. The choice of surgical approach and technique is dictated by the location of the pathology, condition of the skin, and degree of arthritic changes (5).

A. Capsulectomy: Capsulectomy is employed many times for posttraumatic stiffness. According to reports (1) patients are operated twice where the first operation dictates it. In a study by Ring & colleagues, average improvement in ulnohumeral motion after surgery for capsular release was 53 degrees (The average flexion was 98 degrees). The patients who subsequent repeat elbow contracture release had gained an additional 24 degrees, leading to a final average flexion arc 103 degrees. How ever in postoperative period Ulnar neuropathy was reported.

B. Column procedure: This surgical approach is a limited surgical approach. Because the procedure elevates muscles from the anterior and posterior aspects of the lateral supracondylar osseous ridge, we called it the column procedure. It allows anterior capsular exposure through an interval in the brachioradialis and extensor carpi radialis longus. A static adjustable splint rather than physical therapy is used in postoperative period. According to Morrey Column procedure can be successful in the majority of patients undergoing surgical release for capsular & extrinsic contracture of the elbow. Similarly, Mansat & colleagues reported the same column procedure which can both approach anterior and posterior aspects of the capsule is associated with a low rate of complications and is safe and effective for the treatment of a limitation in flexion or extension resulting from an extrinsic contracture of the elbow.

C. Arthrolysis (2,3): Arthrolysis refers to operative loosening of adhesions in an ankylosed joint. Adhesive structures can exist both anteriorly and posteriorly about the joint to prevent motion (3). Arthrolysis can be open or arthroscopic. Severely stiff elbow is one of the main indications of open arthrolysis in the patients without muscle atrophy (14). Open elbow release with excision of tethers and blocks is a valuable procedure for post-traumatic stiffness (3). According to Kayalar & Colleagues, sequential open arthrolysis is an effective way to simultaneously to obtain good range of motion especially in severe stiff elbows and to maintain the ligamantous stability of the elbow joint.
Cikes & colleagues (2) evaluated the results of open arthrolysis for posttraumatic elbow stiffness. The findings are as follows:

1. The mean total increase in range of motion was 40 degrees (13 to 112 degrees), with a mean gain in flexion of 14 degrees (0 to 45 degrees) and 26 degrees in extension (5 to 67 degrees).
2. There is no correlation between the type of stiffness, the surgical approach used, and the results.
According to the findings of these authors there is no complication of open arthrolysis such as elbow instability or post operative osteoarthritis. Interestingly, patients with the greatest preoperative stiffness had significantly better improvement of mobility. The best results were obtained in patients who had arthrolysis done within 1 year after the initial trauma. However, according to Tan & colleagues recurrence in postoperative period is common but is responsive to manipulation under anesthesia and repeat releases.

D. Arthroscopic surgery for stiff elbow: The appreciable aspect of arthroscopic method is minimal invasive nature of arthroscopic techniques & it is an effective procedure for limitation of motion of the elbow with minimal morbidity (4). According to Kim & colleagues report (4):
1. The elbow ROM shows a progressive increase until 1 year after surgery.
2. Even after 1 year post op. ROM shows little additional increase.
3. ROM show more improvement in patients whose duration of symptoms is less than 1 year as compared to patients of symptoms more than 1 year.
4. Post op. arthroscopic ROM results for posttraumatic stiffness & degenerative stiffness are similar even though in posttraumatic stiffness cases extension is more limited.
5. In more than 90% patient significant improvement in ROM can be achieved after arthroscopic procedures.

Do releases after heterotopic ossification (but not complete bony ankylosis) & capsular contracture alone restricting elbow motion have different outcomes. It is commonly believed that in cases with heterotopic ossification is associated with diminished motion after release. Lindenhovius & colleagues in their comparative study consisting of cohorts of heterotopic ossification & capsular contracture found, open release of post-traumatic elbow stiffness is more effective when heterotopic ossification hindering motion is removed than when there is capsular contracture alone.
Reviewer’s Comment: However, from the above said study, it is clear the capsular fibrotic tissues are less amenable to that of bony blocks associated with heterotopic ossification.

Different approaches for elbow surgeries in stiff-elbow

1. Anterior capsular release for extension losses in elbow: According to Aldridge & colleagues release of a pathologically thickened anterior elbow capsule through a predominantly anterior approach to correct diminished elbow extension is a safe and effective technique. Furthermore, compared with splinting in extension alone, the utilization of continuous passive motion during the postoperative period increases the total arc of motion.

2. Modified lateral release for extension losses in elbow: This approach is a modification of the procedure described by Nirschl for resection and repair of lateral elbow tendinosis (tennis elbow). This modified approach allows visualization of the entire anterior elbow joint without disturbing the common extensor origin or the collateral ligaments. If necessary, a second, posterior triceps-splitting incision is used to access the olecranon fossa. Medial approach or transhumeral perforation is not at all required in this procedure.
Kraushaar & colleagues used this technique for 12 patients. According to Kraushaar & colleagues (9), all patients were treated after operation with the elbow splinted in extension for 3 days, after which they were started on an aggressive physical therapy regimen. There were no wound complications, no neurovascular injuries, and no formations of heterotopic bone.

3. Medial release in elbow for post traumatic contractures: A medial approach is useful to reveal and excise the pathological changes in the medial collateral ligament. This technique employs a single medial approach. The posterior oblique bundle of the medial collateral ligament is resected, followed by posterior and anterior capsulectomies. An additional lateral release through a separate incision is employed if required.
Wada & colleagues employed this release method on 14 elbows. Contrary to the expectation of elbow instability ala medial collateral ligament resection all 14 elbows showed scarring of the posterior oblique bundle of the medial collateral ligament. In this study neither the interval from injury to operative release nor the age of the patient affected the results. Hence Wada & colleagues consider this approach as a useful tool to reveal and excise the pathological changes in the medial collateral ligament and effective route through which to correct post-traumatic contracture of the elbow.

4. Lateral release in elbow for post traumatic contractures: Cohen & colleagues described & performed a modified lateral approach allows release of post-traumatic contracture without disruption of the lateral collateral ligament or the origins of the extensor tendon at the lateral epicondyle of the humerus. The advantages include a simplified surgical procedure, less operative morbidity, and unrestricted rehabilitation. Both pain and function in the elbow (humeroulnar joint) improved significantly in post-traumatic stiffness of the elbow in 22 patients using this modified technique.

5. Isolated release of the medial collateral ligament over elbow stiffness: Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. Ruch & colleagues found isolated release of the medial collateral ligament called partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain.
Ruch & colleagues performed the operation through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step.

Post surgical complications in operations for stiff elbow include:

1. Wound dehiscence
2. Wound infection
3. Cubital tunnel syndrome
4. Reflex sympathetic dystrophy
5. Instability
6. Operative failure

Reference(s):
1. Ring D et al; J Hand Surg [Am]. 2006 Oct;31(8):1264-71.
2. Cikes A et al; J Orthop Trauma. 2006 Jul;20(6):405-9.
3. Tan V et al; J Trauma. 2006 Sep;61(3):673-8.

4. Kim SJ et al; Clin Orthop Relat Res. 2000 Jun;(375):140-8.

5. Issack PS et al; Bull Hosp Jt Dis. 2006;63(3-4):129-36.

6. Lindenhovius AL et al; J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):621-5. Epub 2007 Jul 23.
7. Morrey BF; Clin Orthop Relat Res. 2000 Jan;(370):57-64.
8. Aldridge JM 3rd et al; J Bone Joint Surg Am. 2004 Sep;86-A(9):1955-60.

9. Kraushaar BS et al; J Shoulder Elbow Surg. 1999 Sep-Oct;8(5):476-80.

10. Wada T et al; J Bone Joint Surg Br. 2000 Jan;82(1):68-73.

11. Cohen MS et al ; J Bone Joint Surg Br. 1998 Sep;80(5):805-12.

12. Ruch DS et al; J Bone Joint Surg Br. 2008 May;90(5):614-8.

13. Mansat P et al; J Bone Joint Surg Am. 1998 Nov; 80(11):1603-15.

14. Kayalar M et al; Arch Orthop Trauma Surg. 2008 Oct;128(10):1055-63. Epub 2008 Apr16.

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