The contracted elbow: is ulnar nerve release necessary?

Functional and subjective outcomes after surgical management of complex elbow dislocations: a retrospective study

INTRODUCTION

Dislocations of the elbow are the second most frequent upper-body injury after shoulder dislocations, comprising 11-28% of all elbow injuries. Complex elbow dislocations pose challenging management due to the involvement of critical stabilizing structures. This study aimed to investigate functional and subjective outcomes (MEPS, DASH, Oxford score) in 44 patients with complex elbow dislocations who underwent surgery between 2018 and 2020, with subgroup analysis focusing on gender and age differences.

MATERIAL AND METHODS

A retrospective analysis was conducted on patients treated at C.T.O. Hospital, Turin, for complex elbow dislocations between January 2018 and December 2020. Surgical approaches included radial head synthesis, coronoid fixation, ligamentous repair, and ulnar nerve management. Postoperatively, patients followed a standardized or individualized program. Data analysis involved t-tests to assess score differences between subgroups.

RESULTS

Among the 44 analyzed patients, the mean age was 48 years, and the mean follow-up time was 29 months. Various types of complex dislocations were identified, with radial head and coronoid fractures classified accordingly. Surgical approaches included multiple methods of reduction and synthesis. While most patients adhered to postoperative programs, subsequent reoperations were conducted in 11% of cases. Scores did not significantly differ between genders, although a trend toward better DASH scores in males was observed. Younger patients showed better, though not statistically significant, outcomes in mobility and functional measures.

CONCLUSION

This study underscores the importance of pre-operative assessment for positive surgical outcomes in complex elbow dislocations. Additionally, findings suggest that younger age may correlate with slightly better functional outcomes. Despite limitations such as retrospective design and sample size, the study enhances our understanding of complex dislocation outcomes and provides valuable insights for future interventions.

Is anterior transposition of the ulnar nerve necessary for post-traumatic elbow stiffness? A retrospective study

OBJECTIVE

To explore whether anterior transposition of the ulnar nerve is necessary in patients with post-traumatic elbow stiffness.

METHOD

This was a retrospective study of 177 patients with post-traumatic elbow stiffness treated at Shandong Provincial Hospital from 1 January 2012 to 31 October 2022. Sixty-one patients presented with ulnar nerve symptoms, and 116 patients had no nerve symptoms. Outcomes between patients with and without symptoms were compared using a range of clinical measures, namely range of motion (ROM), ulnar nerve symptoms, and various standardized scoring systems, namely, the Mayo Elbow Performance Score (MEPS), visual analog scale (VAS), improved Broberg and Morrey Score (BMS), Quick disabilities of the Arm, Shoulder, and Hand (DASH) score, Oxford Elbow Score (OES), and Amadio score.

RESULTS

Open elbow release surgery significantly improved elbow joint function in patients with post-traumatic elbow stiffness, regardless of the presence of ulnar nerve symptoms. Patients with ulnar nerve symptoms showed significant improvement after anterior transposition compared with in situ release. For patients without ulnar nerve symptoms, there was no significant difference in outcomes between the two types of ulnar nerve surgery.

CONCLUSION

Anterior transposition of the ulnar nerve is preferable for patients with ulnar nerve symptoms, while the choice between anterior transposition and in situ release can be individualized for patients without symptoms, based on intraoperative findings.

Arthroscopic Capsular Release for Post-traumatic Elbow Stiffness

BACKGROUND

Post-traumatic elbow stiffness (PTES) may substantially affect the patient's functional range of motion and quality of life. Open elbow release has been extensively studied, but arthroscopic techniques are limited, particularly in differentiating between post-traumatic and non-traumatic stiffness. The purpose of this study is to assess the clinical outcomes after arthroscopic release of PTES regarding the range of motion (ROM), pain, functional assessment, and complications.

METHODS

A prospective cohort was conducted on adult patients who underwent arthroscopic arthrolysis for PTES, with 32 patients included in the final analysis. The ROM was measured using the orthopedic goniometer. Grip strength was measured using the Camry digital hand dynamometer (Camry, CA, USA) and compared to their contralateral side. The functional status of the patients was evaluated using the American Shoulder and Elbow Surgeons Score (ASES)andthe Mayo Elbow Performance Index (MEPI). All measurements were done before surgery and at the last follow-up visit. Pre-operative and post-operative changes in MEPI, ASES, and visual analog (VAS) scores were compared with the paired t-test.

RESULTS

After surgery, the ROM significantly improved from 74 ± 11 to 110 ± 15 degrees (p<0.001). Additionally, the ASES score and MEPI index both significantly improved from 69 ± 3.4 to 79 ± 6.3 and from 64 ± 5.7 to 82 ± 8, respectively (p<0.001). VAS scores also significantly improved from 1.1 ± 0.87 to 0.31 ± 0.53 at rest (p<0.001). The complication rate was 12%, including three transient ulnar nerve paresthesia and one superficial infection. Post-traumatic elbow release was more offered in distal humerus fractures (53%), followed by proximal ulna fracture/dislocations (25%).

CONCLUSION

We believe that arthroscopic arthrolysis is a safe and reliable treatment of PTES, which improves joint visibility and reduces pain. Patients can be counseled regarding the risk of a secondary surgery following distal humerus or proximal ulna fractures, including the expected recovery and complication rate.

Incidence of Repeat Elbow Capsular Release After Arthroscopic Elbow Capsular Release

Background

Elbow capsular release can be performed arthroscopically or through an open method to improve range of motion (ROM). However, it is unclear how frequently patients require an open capsular release after unsatisfactory results from an arthroscopic release.

Purpose/Hypothesis

The purpose of this study was to determine the percentage of patients who underwent an arthroscopic elbow release for loss of motion who then required a repeat elbow capsular release or other subsequent surgery on the same elbow. It was hypothesized that patients who underwent arthroscopic elbow release would rarely (<5%) require a subsequent elbow release.

Study Design

Case series; Level of evidence, 4.

Methods

Patients who underwent arthroscopic elbow capsular release from January 1, 2010, to December 31, 2019, were identified by chart review and procedure code. Demographic parameters, pre- and postoperative ROM, and surgical history were collected by chart review. Follow-up data included patient satisfaction and the Timmerman-Andrews (TA) elbow score. Data were compared between patients who did and those who did not require subsequent elbow surgery.

Results

Overall, of 140 study patients (116 male, 24 female; mean age, 49.6 years), 18 (12.9%) required subsequent surgery, including 6 capsular releases (4.3%; 1 open and 5 arthroscopic). The most common follow-up procedure was ulnar nerve releases/transpositions (n = 7). Total arc of elbow motion (flexion to extension) improved by a mean of 51.4°. The mean TA score was 76.5 ± 20.4 at a mean of 5.25 years postoperatively. Mean satisfaction score was 77.6 ± 26.3. In this study, 82.4% of patients stated that their symptoms either improved or resolved completely. Patients who required subsequent surgery had a significantly lower preoperative total arc of elbow motion versus those who did not require subsequent surgery (P = .046). There was no difference between the groups in symptom resolution, satisfaction, ROM, or TA score (P ≥ .279 for all).

Conclusion

After arthroscopic elbow release, <5% of patients required a repeat elbow capsular release, 12.9% required some form of follow-up elbow surgery, and 4.3% had a new injury of the elbow. Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release.

Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness

INTRODUCTION

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.

HYPOTHESIS

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.

MATERIAL AND METHODS

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 45years (range, 18-78years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33years (range, 18-64years) and group B (degenerative) of 16 patients with a mean age of 59years (range, 42-78years). All patients were clinically assessed at a mean 27months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected.

RESULTS

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 (2.4months) than in group A (3.7months) (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.

CONCLUSION

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.

LEVEL OF EVIDENCE

IV, retrospective study.

Surgical management of osteoarthritis in the shoulder and elbow

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Ulnar nerve decompression with osteocapsular arthroplasty for primary elbow osteoarthritis

PURPOSE

The aim of this study was to suggest treatment guidline for primary elbow OA with ulnar nerve neuropathy or high-grade stiffness by evaluating the effect of ulnar nerve decompression on the outcome of osteocapsular arthroplasty.

METHODS

A total of 30 patients who underwent primary osteocapsular arthroplasty for elbow OA were retrospectively reviewed. The surgical outcomes were evaluated for pain score (visual analog scale; VAS), range of motion (ROM), and Mayo Elbow Performance Score (MEPS). The ulnar nerve decompression was performed for (1) ulnar nerve neuropathy, and (2) high-grade stiffness of flexion, defined as the flexion angle, is <90°. Patients were categorized into the two groups: ulnar nerve decompression group (UD group, n = 11) and the non-decompression group (Non-UD group, n = 19). The surgical outcome was compared between the groups.

RESULTS

Primary elbow OA with cubital tunnel syndrome or high-grade stiffness showed comparable improvement in MEPS, VAS, and ROM arc at final follow-up in the UD group compared with the non-UD group (UD group vs. non-UD group: MEPS 85.91 vs 86.84, p-value = 0.824, VAS 1.46 vs 1.16, p-value = 0.588, ROM arc 108 vs 109, p-value = 0.949). Improvement in ROM arc at 2 years follow-up was significantly higher in UD group (UD group vs. non-UD group: ROM arc difference, 42 vs 14, p = 0.002).

CONCLUSION

Osteocapsular arthroplasty with ulnar nerve decompression for primary elbow OA with ulnar nerve neuropathy or high-grade stiffness provided improved motion arc and compatible clinical results.

LEVEL OF EVIDENCE

Level III, Retrospective comparative study.

Arthroscopic management of elbow stiffness

The elbow is particularly prone to stiffness. Loss of elbow motion is very limiting, and can be the result of trauma, primary osteoarthritis, heterotopic ossification and other conditions. Several exposures have been described for open elbow contracture release. Although a few decades ago elbow arthroscopy was considered only for diagnosis and removal of loose bodies, contemporary arthroscopic techniques allow successful management of the majority of conditions leading to elbow stiffness. Careful patient evaluation, use of advanced imaging studies, and acquisition of appropriate surgical skills are essential for the successful arthroscopic management of the stiff elbow. This expert opinion reviews some fundamentals of elbow stiffness as well as principles for the evaluation and arthroscopic management of the stiff elbow.

Surgical management for primary osteoarthritis of the elbow

The objective of this review is to summarize the surgical options for primary osteoarthritis of the elbow, reported clinical outcomes, and suggested indications in previous literatures. The surgical management of primary elbow arthritis has evolved because of an improved understanding of pathologic mechanisms and manifestations as well as the development of novel surgical techniques and devices. Osteocapsular arthroplasty (OCA), elbow debridement, distraction arthroplasty, and total elbow arthroplasty (TEA) have been employed for managing elbow osteoarthritis. Elbow debridement and OCA can be helpful in most cases of symptomatic elbow arthritis. TEA is usually recommended for end-stage arthritis in elderly patients after prosthetic implants have been in place for long periods or after complications. Distraction arthroplasty might find a place in the treatment of younger, active patients with end-stage arthritis.

Primary Elbow Osteoarthritis: Evaluation and Management

Most patients with primary osteoarthritis of the elbow report a history of heavy lifting with the affected upper extremity . Conservative treatment, including activity modifications, nonsteroidal anti-inflammatory drugs and the occasional intraarticular corticosteroid injection, may provide adequate pain relief in earlier stages . When surgery is required, and despite the presence of cartilage wear, many patients with primary elbow osteoarthritis experience substantial pain improvement with joint preserving procedures . The ulnar nerve needs to be carefully assessed and addressed at the time of surgery . Although open debridement procedures are effective, arthroscopic osteocapsular arthroplasty has emerged as the surgical procedure of choice . Total elbow arthroplasty is very successful in terms of pain relief and function, but it is reserved for patients with end-stage osteoarthritis who are relatively older and have failed joint preserving procedures.

Elbow Fracture-Dislocations: Determining Treatment Strategies

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

The column procedure preserves elbow stability on biomechanical testing

PURPOSE

The effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers.

METHODS

We assessed elbow joint laxity in 39 patients who underwent an open contracture release via the 'column procedure' described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints.

RESULTS

Mean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°-4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable.

CONCLUSIONS

Our experiment confirmed that the 'column procedure' is a safe procedure which does not compromise the stability of the elbow joint.

Arthroscopic arthrolysis of posttraumatic and non-traumatic elbow stiffness offers comparable clinical outcomes

Background

Primary purpose of this study is to compare the clinical outcomes of patients undergoing arthroscopic arthrolysis in posttraumatic and non-traumatic elbow stiffness. Secondary aims are to compare the level of satisfaction and complications.

Methods

We retrospectively evaluated the patients undergoing arthroscopic elbow arthrolysis between January 2008 and September 2015 and have completed a minimum 2-year follow-up. Total of 141 patients (male = 90; female = 51) with 143 elbows (posttraumatic, n = 75; non-traumatic, n = 68) with an average age of 33 years were available for final evaluation. The average follow-up period was 44 months. We used the Mayo Elbow Performance Index (MEPI) score, range of motion (ROM), Visual Analogue Scale (VAS) to measure clinical outcomes. The level of satisfaction was measured by a self-constructed questionnaire.

Results

All parameters were significantly improved postoperatively (P < 0.01). However, statistically significant differences were not present in the rate of postoperative improvement of elbow ROM (P = 0.08) and MEPI (P = 0.21) in both groups. According to MEPI, 72(96%) elbows in posttraumatic and 60(88%) elbows in non-traumatic group were rated as good to excellent. No statistically significant differences were observed in the level of satisfaction (P = 0.76) and rate of complications (P = 0.91).

Conclusions

Arthroscopic arthrolysis is an effective tool and a good option for the treatment of patients with posttraumatic and non-traumatic elbow stiffness. The rate of elbow ROM and MEPI score improvements were significant and comparable postoperatively with a high level of patient’s satisfaction. However, postoperative rehabilitation is equally essential to maintain intraoperative elbow ROM, to attain optimal outcome and to prevent complications.

Prospective outcome assessment of arthroscopic arthrolysis for traumatic and degenerative elbow contracture

BACKGROUND

The purpose of this study was to evaluate the efficacy of arthroscopic elbow release for both traumatic and degenerative contractures from intraoperative recording through the recovery time until final follow-up.

METHODS

The study is based on 54 consecutive patients with extrinsic elbow contracture (traumatic in 31 and degenerative in 23) treated with arthroscopic arthrolysis by a single surgeon in 2011-2015. Range of motion (ROM) and the Mayo Elbow Performance Score (MEPS) were recorded preoperatively; intraoperatively; following release; and in the 1st, 3rd, 8th, 12th, and 26th weeks and at 2 years postoperatively.

RESULTS

Significant improvements were noted in extension, flexion, and range of motion, measured both intraoperatively and at all follow-up visits. The greatest improvement in the range of motion was achieved at the time of surgery (from 89° ± 28° to 131° ± 14°, P < .001); it then decreased at 1 week to 103° ± 22° (P < .001) and slowly recovered to reach 124° ± 22° after 2 years. This was better than the preoperative value (P < .001) but worse than the intraoperative value (P = .002). A similar pattern was observed in both traumatic and degenerative contractures. The MEPS improved from 73 ± 12 preoperatively to 93 ± 14 at the final evaluation (P < .001). The ROM and MEPS results at every follow-up were comparable for both traumatic and degenerative contractures. ROM improved regardless of the severity of contracture.

CONCLUSIONS

Arthroscopic elbow arthrolysis was similarly efficient in ROM restoration in both traumatic and degenerative contractures and regardless of the severity of contracture. After early deterioration, the achieved gain slowly recovers over a period of 6 months but may not recover to the ranges achieved during arthroscopy.

Open surgical elbow contracture release after trauma: results and recommendations

BACKGROUND

Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture.

METHODS

A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded.

RESULTS

The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion.

CONCLUSION

Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.

Arthroscopic arthrolysis provides good clinical outcome in post-traumatic and degenerative elbow stiffness

PURPOSE AND HYPOTHESIS

The purpose of this retrospective study was to report on the functional outcome after arthroscopic arthrolysis in patients with post-traumatic or degenerative elbow stiffness. It was hypothesized that this operative procedure leads to improved range of motion (ROM) and improved functional outcome in both groups.

METHODS

Patients who underwent arthroscopic arthrolysis of the elbow between 2010 and 2015 were included in this study. Forty-two patients with an average age of 41.0 ± 13.5 years were available for evaluation. The mean follow-up was 28.3 ± 14.9 months. With regard to aetiology of elbow contractures, patients were divided into post-traumatic (group A) and degenerative (group B) cohort. General patients' data, previous surgical treatment and ROM were recorded. At follow-up evaluation, the clinical outcome was assessed by the ROM, visual analogue scale (VAS) for pain assessment and the Elbow Self-Assessment Score (ESAS).

RESULTS

The mean arc of motion of group A (n = 20) increased from preoperatively 74.3° to 120.5° postoperatively (p < 0.001); group B (n = 22) showed an improvement of 104.6° preoperatively to 123.4° after surgery (p = 0.002). Mean improvement was 46.3° ± 27.5° in group A and 16.4° ± 19.4° in group B. Mean post-operative VAS was 0.9 ± 1.5 in group A and 1.3 ± 2.2 in group B. 92.9% of patients achieved a functional arc of elbow motion >100°. The ESAS indicated good to excellent clinical outcome showing 88.8 ± 10.0 points in group A and 84.1 ± 21.4 points in group B. Thirty-six patients (85.7%) returned to their previous work level after surgery.

CONCLUSIONS

Arthroscopic arthrolysis is an effective treatment option for patients with restriction in elbow motion reasoned by post-traumatic or degenerative changes. Both groups showed a significant improvement of ROM and comparable outcome scores.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

Primary elbow arthroplasty: problems and solutions

Prosthetic replacement of the elbow joint has continued to improve over time. Widespread implantation of certain designs has led to identification a few successful elements of elbow arthroplasty, as well as several opportunities for improvement. Current hot topics in elbow arthroplasty include triceps-preserving exposures, implantation of components with better-expected wear performance, management of the ulnar nerve, prevention of infection, and the development of successful cementless components. Total elbow arthroplasty has the potential to improve pain, function and quality of life for many patients with articular destruction secondary to inflammatory arthropathy or as a consequence of trauma. Continued advances in this field are key to make this operation as reliable and lasting as hip or knee arthroplasty.

Ulnar neuritis after open elbow arthrolysis combined with ulnar nerve subcutaneous transposition for post-traumatic elbow stiffness: outcome and risk factors

BACKGROUND

Ulnar neuritis (UN) is a common complication of open elbow arthrolysis for elbow stiffness. The purpose of this study was to evaluate the outcome of subcutaneous anterior transposition of the ulnar nerve during open elbow arthrolysis and to describe the risk factors for UN.

METHODS

We retrospectively studied 260 patients with post-traumatic elbow stiffness who underwent routine ulnar nerve transposition during open elbow arthrolysis. Patient demographics, clinical characteristics, and incidence and reoperation rate of UN were recorded. UN was defined as new-onset ulnar nerve symptoms and no relief or worsening of pre-existing ulnar nerve symptoms during the period of postoperative rehabilitation. Factors affecting the development of UN were analyzed by univariate and multivariate analyses.

RESULTS

A total of 9.2% of the patients had UN, 25% of whom required reoperation for progressive neuropathy. The Dellon grade of patients associated with UN at last follow-up improved significantly compared with that preoperatively. The mean arc of motion in patients with UN decreased during follow-up in a time-dependent manner. Univariate analysis showed that male sex, limited preoperative flexion and arc of motion, preoperative heterotopic ossification (HO), and preoperative ulnar nerve symptoms were significantly associated with the development of UN. Multivariate regression analysis revealed that preoperative HO was the only independent risk factor for the development of UN.

CONCLUSIONS

UN is still an important complication, although ulnar nerve subcutaneous transposition was performed during open arthrolysis for post-traumatic elbow stiffness. Identified risk factors for UN, especially preoperative HO, should be taken into consideration before surgery.

Release of the stiff elbow with mini-open technique

BACKGROUND

Currently, there are many techniques used in the surgical release of elbow contracture, but no single technique has gained widespread acceptance. The purpose of this study was to report the outcomes of a lateral-column approach combined with a mini-open triceps-splitting technique for elbow contracture release.

METHODS

Thirty-six patients with a mean age of 39 years were included in the study. All patients underwent a combined lateral and minimal posterior triceps-splitting open elbow contracture release. Elbow range of motion and visual analog scale pain scores were recorded. The Mayo Elbow Performance Score was used to assess functional outcome.

RESULTS

The mean follow-up period was 38 months. Mean pain levels decreased from 7.59 preoperatively to 0.44 postoperatively (P < .05). The total arc of elbow motion increased from 52° preoperatively to 109° postoperatively, with an improvement of 57° (P < .05). The Mayo Elbow Performance Score improved from 44.17 preoperatively to 90.83 postoperatively (P < .05).

CONCLUSION

This study shows that a combined lateral and mini-open triceps-splitting approach is a safe and effective alternative technique for the treatment of elbow contractures.

Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty

PURPOSE

Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated.

METHODS

Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms.

RESULTS

Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition.

CONCLUSIONS

A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise

BACKGROUND

Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary.

METHODS

We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated.

RESULTS

Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively.

CONCLUSIONS

Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Significant improvement in nerve conduction, arm length, and upper extremity function after intraoperative electrical stimulation, neurolysis, and biceps tendon lengthening in obstetric brachial plexus patients

Background

Progressive loss of extension and concomitant bony deformity of the elbow are results of persistent biceps contracture in obstetric brachial plexus injury (OBPI) patients, if they do not fully recover. This adversely affects the growth and development and functions of the upper extremity.

Patients and method

We have performed biceps tendon lengthening (BTL) using a Z-plasty technique on OBPI patients aged 4 years to adulthood, who had been diagnosed with biceps tendon fixed flexion contractures. Ulnar, radial, and median nerve decompression was also performed at the same sitting. Somatosensory evoked potential (SSEP) monitoring was performed by stimulating the median and ulnar nerves at the wrist and the radial nerve over the dorsum of the hand and recording the peripheral, cervical, and cortical responses.

Seven children with obstetric brachial plexus palsy with an average age of 11 years (8.7–14.2 years) were included in this report. Mean follow-up time was 7.4 months (4–11 months). All the patients in this report had the elbow flexion contractures greater than 30°.

Results

Mean flexion contracture was 35° (30°–45°) preoperatively, which was improved to 0°–10° postoperatively with an average follow-up of 7 (4–11) months. This surgical procedure corrected the elbow flexion contractures, about an average of 25° and an improved length almost to normal, and improved the upper extremity functions. Neurophysiological data showed significant improvement in conduction of all three nerves tested after neurolysis. Further, median and radial nerve amplitude increase was statistically significant.

Conclusion

Statistically significant improvement in biceps length as well as nerve conduction was observed after the surgery. None of the children in our study lost biceps function, although weakness of the biceps is both a short- and long-term risk associated with biceps lengthening.

Delayed-onset ulnar neuritis after release of elbow contractures: clinical presentation, pathological findings, and treatment

BACKGROUND

Little information exists regarding delayed-onset ulnar neuritis (DOUN) after arthroscopic release of elbow contractures.

PURPOSE

To describe, in a large cohort of patients, the clinical presentation of and risk factors for developing DOUN after arthroscopic release of elbow contractures.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A retrospective study of 565 consecutive arthroscopic releases of elbow contractures was conducted. Essentially, DOUN was defined as ulnar neuritis or neuropathy, or worsening of pre-existing ulnar nerve symptoms, that developed postoperatively in patients with normal neurological examination findings immediately after surgery. After inclusion and exclusion criteria were met, 235 contracture releases in patients who had not undergone any ulnar nerve surgery remained and were used for the analysis of risk factors with a multivariate logistic regression analysis.

RESULTS

Twenty-six patients (11%) developed DOUN. The patients fell into 1 of 3 distinct groups. Fifteen (58%) presented with rapidly progressive DOUN, characterized by rapidly progressive sensorimotor ulnar neuropathy, increasing pain at the cubital tunnel during end-range flexion and/or extension, and rapidly deteriorating range of motion within the first week after surgery. Urgent ulnar subcutaneous nerve transposition was performed within 1 or 2 days of diagnosis. Eight (31%) presented with nonprogressive DOUN, characterized by mild sensory ulnar neuropathy, neither motor weakness nor substantial pain at the cubital tunnel, or loss of motion. Three (12%) presented with slowly progressive DOUN, characterized by the insidious onset of mild ulnar neuropathy. Significant risk factors for DOUN included a diagnosis of heterotopic ossification (odds ratio, 31; 95% CI, 5-191; P < .001), preoperative neurological symptoms (odds ratio, 6; 95% CI, 2-19; P = .001), and preoperative arc of motion (odds ratio, 0.97 per degree of motion; 95% CI, 0.96-0.99; P = .02).

CONCLUSION

Delayed-onset ulnar neuritis is an important complication of arthroscopic release of elbow contractures. We recommend a high index of suspicion and monitoring patients with progressive loss of elbow motion and end-range pain for evidence of subclinical ulnar neuritis.

Is routine ulnar nerve transposition necessary in open release of stiff elbows? Our experience and a literature review

PURPOSE

Prophylactic release of the ulnar nerve to reduce the incidence of postoperative nerve symptoms in stiff elbows has been recommended. However, the necessity for routine anterior transposition remains unclear. In this study, we aim to gain an insight into the value of routine transposition in open release of stiff elbows.

METHODS

We retrospectively reviewed 94 patients suffering from elbow stiffness with no pre-operative ulnar nerve symptoms. Simple decompression (with in situ decompression or epicondylectomy) and subcutaneous anterior transposition were chronologically performed in 53 and 37 patients, respectively. Another four patients were treated by a single lateral approach with no intervention of the ulnar nerve. Pre- and postoperative range of motion and incidence of ulnar nerve symptoms were recorded. The function of ulnar nerve was measured by Amadio rating scale.

RESULTS

The incidence of ulnar nerve dysfuction was 18.9% (ten of 53) and 8.1% (three of 37) in the simple decompression and transposition groups, respectively. The mean Amadio scores were 7.62 and 8.22, respectively. All these data showed a statistically significant difference (P < 0.05). In the lateral approach group, 50 % (two of four) of patients developed nerve symptoms with a mean Amadio score of 6.50.

CONCLUSIONS

The transposition group exhibited a superior nervous outcomes compared with the simple decompression group. No comparison was conducted between the transposition and lateral approach groups because of too few patients in the latter. According to related literature and our experience, we conclude that routine transposition is necessary to prevent postoperative nerve symptoms.

Delayed-onset ulnar neuritis after release of elbow contracture: preventive strategies derived from a study of 563 cases

PURPOSE

The purposes of this study were to determine whether delayed-onset ulnar neuritis (DOUN) after elbow contracture release can be prevented and to compare the efficacy of ulnar nerve decompression versus subcutaneous transposition.

METHODS

A retrospective study of 563 consecutive arthroscopic elbow contracture releases was conducted. The prophylactic efficacy of (1) subcutaneous transposition, (2) ulnar nerve decompression, (3) limited ulnar nerve decompression (7 to 8 cm), and (4) mini-decompression (4 to 6 cm) was assessed prospectively. The efficacy of prophylactic strategies (transposition, decompression, limited decompression, or mini-decompression) in preventing DOUN was compared by univariate survival analysis. Patients who underwent a subcutaneous transposition were matched with patients who underwent a standard open decompression or a limited decompression, according to gender, age (±10 years), diagnosis, and preoperative motion. This analysis was repeated after we excluded the patients who underwent associated open procedures (e.g., hardware removal).

RESULTS

DOUN occurred in 26 of 235 patients (11%) who did not undergo any prophylactic procedure versus 8 of 295 patients (3%) who underwent a prophylactic ulnar nerve decompression or transposition at the time of contracture release (P < .001). The neurologic impairment was significantly less severe after prophylactic decompression compared with patients without any prophylactic intervention (grade on Neuropathy Grading Scale, 2 vs. 4; P = .03). Ulnar nerve transposition and decompression were equally protective. The decompression length was the only factor significantly related to the failure of the prophylactic intervention (odds ratio, 0.19; P = .02). A mini-decompression was not as effective as a prophylactic procedure, whereas a limited decompression was equal to a standard decompression. The case-control analysis showed that the decompression and transposition had equal preventive effects but the transposition was associated with a higher rate of wound complications (19% vs. 4%, P = .03).

CONCLUSIONS

DOUN is a complication of arthroscopic elbow contracture release. Its incidence and severity can be reduced by limited open ulnar nerve decompression or transposition.

LEVEL OF EVIDENCE

Level II, prospective comparative study with retrospective analysis.

Outcomes of the mini-open Outerbridge-Kashiwagi procedure according to preoperative radiocapitellar joint status

PURPOSE

To compare the clinical and radiological outcomes in patients treated with the mini-open Outerbridge-Kashiwagi procedure according to radiological grading of the radiocapitellar joint.

METHODS

Sixty-three patients with primary elbow arthritis diagnosed between March 2004 and February 2010 were enrolled. Patients without and with radiocapitellar arthrosis were assigned to groups 1 (n = 34) and 2 (n = 29), respectively. The mean follow-up period was 51 months. Clinical outcomes were compared between groups using the presence of resting elbow pain; Morrey pain score; the Mayo Elbow Performance Score; the Disabilities of the Arm, Shoulder and Hand score; and active range of motion. Radiological outcomes, including the presence of loose bodies and re-ossification of fenestration, were evaluated.

RESULTS

No patient in group 1 and 4 patients in group 2 reported resting elbow pain at the final follow-up examination. All pain was on the radial side, and it was aggravated in 2 patients. The Mayo Elbow Performance Score and Disabilities of the Arm, Shoulder and Hand score and active motion improved in both groups. No significant difference in the Morrey pain score, Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score, or active range of motion was observed between groups. Postoperative deterioration of radiological joint status was similar in the ulnohumeral and radiocapitellar joints of both groups. Re-ossification of the fossa fenestration did not differ significantly between groups.

CONCLUSIONS

We compared the outcomes of the mini-open Outerbridge-Kashiwagi procedure according to radiocapitellar joint status. Short-term results were satisfactory in both groups, but resting pain associated with newly developed anterior loose bodies led to a poor outcome in group 2.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

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.

Prevention and treatment of elbow stiffness: a 5-year update

Elbow stiffness is a challenging and common problem faced by upper extremity surgeons. Although functional improvements can be made with both nonsurgical and surgical management strategies, physicians must remain vigilant with efforts to prevent stiffness before it starts. Recent advancements in the biology and pathology of elbow contracture have led to improved understanding of this difficult problem, and they may lead to future breakthroughs in the prevention and treatment of elbow stiffness. This article serves as an update to our previous review of elbow stiffness, focusing on recent advancements in the past 5 years, as well as updating our current algorithm for treatment.

Elbow arthroscopic surgery update for sports medicine conditions

Elbow arthroscopic surgery can now effectively treat a variety of conditions that affect athletes. Advances in instrumentation, increased surgeon familiarity, and expanded indications have led to significant growth in elbow arthroscopic surgery in the past few decades. While positioning, portal placement, and specific instruments may vary among surgeons, anatomic considerations guide surgical approaches to minimize neurovascular compromise. Arthroscopic procedures vary in difficulty, and surgeons should follow stepwise advancement with experience. Removal of loose bodies, debridement of synovial plicae, and debridement of the extensor carpi radialis brevis for lateral epicondylitis are considered simple procedures for novice elbow arthroscopic surgeons. More advanced procedures include management of osteochondritis dissecans, valgus extension overload in the throwing athlete, and capsular release. With proper technique, a variety of athletic elbow conditions can be treated arthroscopically with predictable results and minimal morbidity.

Elbow arthritis: current concepts

Elbow arthritis is a debilitating condition manifesting as a painful, stiff elbow. The purpose of this article is to provide an update and analyze current management, treatment options, and outcomes of treatment for elbow arthritis. This article focuses on recent developments in the treatment for elbow arthritis. Nonsurgical management may provide symptomatic relief in the majority of patients in the early stages of the disease process. Surgical treatment is guided by disease etiology and severity, patient age, and functional demands. Arthroscopic or open synovectomy, debridement arthroplasty, and interposition arthroplasty are generally recommended for the young and active patient population, whereas for low-demand and elderly patients with end-stage painful arthritis, total elbow arthroplasty is considered a more suitable surgical option. Advances in arthroscopic techniques and implant design have led to substantial improvements in the treatment of elbow arthritis.