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Zhang W, Wu X, Chen H, Bai J, Long L, Xue D. Regional distribution prevalence of heterotopic ossification in the elbow joint: a 3D study of patients after surgery for traumatic elbow injury. J Shoulder Elbow Surg 2024; 33:948-958. [PMID: 38182024 DOI: 10.1016/j.jse.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication after elbow fracture surgery and can lead to severe upper extremity disability. The radiographic localization of postoperative HO has been reported previously. However, there is no literature examining the distribution of postoperative HO at the three-dimensional (3D) level. This study aimed to investigate 1) the distribution characteristics of postoperative HO and 2) the possible risk factors affecting the severity of postoperative HO at a 3D level. METHODS A retrospective review was conducted of patients who presented to our institution with HO secondary to elbow fracture between 13 January 2020 and 16 February 2023. Computed tomography scans of 56 elbows before elbow release surgery were reconstructed in 3D. HO was identified using density thresholds combined with manual identification and segmentation. The elbow joint and HO were divided into six regions according to three planes: the transepicondylar plane, the lateral ridge of the trochlear plane, and the radiocapitellar joint and coronoid facet plane. The differences in the volume of regional HO associated with different initial injuries were analyzed. RESULTS Postoperative HO was predominantly present in the medial aspect of the capsule in 52 patients (93%), in the lateral aspect of the capsule in 45 patients (80%), in the medial supracondylar in 32 patients (57%), and in the lateral supracondylar, radial head, and ulnar region in the same number of 28 patients (50%). The median and interquartile range volume of total postoperative HO was 1683 (777-4894) mm3. The median and interquartile range volume of regional postoperative HO were: 584 (121-1454) mm3 at medial aspect of capsule, 207 (5-568) mm3 at lateral aspect of capsule, 25 (0-449) mm3 at medial supracondylar, 1 (0-288) at lateral supracondylar, 2 (0-478) at proximal radius and 7 (0-203) mm3 at the proximal ulna. In the subgroups with Injury Severity Score > or = 16, Gustilo-Anderson II, normal uric acid levels, elevated alkaline phosphatase, and body mass index > or = 24, the median HO volume exceeds that of the respective control groups. CONCLUSION The medial aspect of the capsule was the area with the highest frequency and median volume of postoperative HO among all initial elbow injury types. Patients with higher Gustilo-Anderson grade, Injury Severity Score, alkaline phosphatase or Body Mass Index had higher median volume of postoperative HO.
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Affiliation(s)
- Weijun Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Xiaoyong Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Hongyu Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Jinwu Bai
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Long Long
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Deting Xue
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
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Dunham CL, Steenbock H, Brinckmann J, Reiter AJ, Castile RM, Chamberlain AM, Lake SP. Increased volume and collagen crosslinks drive soft tissue contribution to post-traumatic elbow contracture in an animal model. J Orthop Res 2021; 39:1800-1810. [PMID: 33258516 PMCID: PMC7744303 DOI: 10.1002/jor.24781] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/29/2020] [Accepted: 06/12/2020] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint contracture (PTJC) in the elbow is a biological problem with functional consequences. Restoring elbow motion after injury is a complex challenge because contracture is a multi-tissue pathology. We previously developed an animal model of elbow PTJC using Long-Evans rats and showed that the capsule and ligaments/cartilage were the primary soft tissues that caused persistent joint motion loss. The objective of this study was to evaluate tissue-specific changes within the anterior capsule and lateral collateral ligament (LCL) that led to their contribution to elbow contracture. In our rat model of elbow PTJC, a unilateral surgery replicated damage that commonly occurs due to elbow dislocation. Following surgery, the injured limb was immobilized for 42 days. The capsule and LCL were evaluated after 42 days of immobilization or 42 days of immobilization followed by 42 days of free mobilization. We evaluated extracellular matrix protein biochemistry, non-enzymatic collagen crosslink content, tissue volume with contrast-enhanced micro-computed tomography, and tissue mechanical properties. Increased collagen content, but not collagen density, was observed in both injured limb capsules and LCLs, which was consistent with the increased tissue volume. Injured limb LCLs exhibited decreased normalized maximum force, and both tissues had increased immature collagen cross-links compared to control. Overall, increased tissue volume and immature collagen crosslinks in the capsule and LCL drive their contribution to elbow contracture in our rat model.
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Affiliation(s)
- Chelsey L. Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, MO
| | - Heiko Steenbock
- Institute of Virology and Cell Biology, University of Lübeck, Germany
| | - Jürgen Brinckmann
- Institute of Virology and Cell Biology, University of Lübeck, Germany;,Department of Dermatology, University of Lübeck, Germany
| | - Alex J. Reiter
- Department of Mechanical Engineering, Washington University in St. Louis, MO
| | - Ryan M. Castile
- Department of Mechanical Engineering, Washington University in St. Louis, MO
| | | | - Spencer P. Lake
- Department of Biomedical Engineering, Washington University in St. Louis, MO;,Department of Mechanical Engineering, Washington University in St. Louis, MO;,Department of Orthopaedic Surgery, Washington University in St. Louis, MO
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Ammerman BM, Updegrove G, Ponnuru P, Armstrong A. Analysis of Long-Term Outcomes Following Surgical Contracture Release of the Elbow: A Case Series. Cureus 2021; 13:e14691. [PMID: 34055535 PMCID: PMC8152451 DOI: 10.7759/cureus.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Elbow contracture is a debilitating condition with an incidence ranging from as low as almost 1% to as high as 20% and results in significant limiting consequences on a patient’s activities of daily living (ADLs). Postoperative rehabilitation is important in maintaining the range of motion and sustaining an improved range of motion. The purpose of this study was to evaluate the long-term results of elbow contracture release surgery and the effect of an occupational therapy/physical therapy (OT/PT)-guided, self-directed rehabilitation program following surgery, without the use of continuous passive motion (CPM) devices. Methods We enrolled patients who had undergone elbow contracture release surgery from 2005 to 2016 at a single institution under the senior author. The evaluation included objective measurements of range-of-motion, strength, and neurological sensory testing. Provocative testing of the elbow and hand was performed. American Shoulder and Elbow Surgeons-elbow (ASES-e), Simple Shoulder Test-elbow (SST-e), Disabilities of the Arm and Shoulder (DASH), Mayo Elbow Performance Index (MEPI), Short Form-36 (SF-36), and an investigator questionnaire were completed. Results We enrolled 19 patients, six female and 13 male, with an average follow-up of 58.9 months (SD± 39.8, Range 22-117). We showed improvement and sustained motion between preoperative and postoperative research visit flexion (p<0.001) and flexion extension-arc (p<0.01). The mean increase in flexion was 98° to 131° and the flexion-extension arc was 36°. Patients were satisfied with the decision to undergo surgery and had sustained ability to complete ADLs. Discussion This patient cohort demonstrated a statistically significant increase, as well as long-term maintenance in the flexion and flexion-extension arc. A self-directed, OT/PT-guided, therapy program without CPM was effective. Patients showed good outcomes and were satisfied with their ability to perform ADLs, decreased pain, and the decision to undergo surgery.
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Affiliation(s)
- Brittany M Ammerman
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Gary Updegrove
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Padmavathi Ponnuru
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - April Armstrong
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Abstract
Elbow stiffness is defined as an arc of flexion-extension motion of less than 100° and/or a contracture of more than 30° in flexion. Stiff elbow is common and can be very disabling, preventing individuals from carrying out the basic activities of daily living. The most common cause of stiff elbow is the sequela of an injury, but osteoarthritis can also produce limitations of mobility, which can benefit from surgical treatment The treatment of stiff elbow is initially orthopedic. If the patient still has functional limitations of the elbow after 6 months of suitable rehabilitation treatment , the option of surgical treatment must be considered. Surgical arthrolysis of the elbow can be performed with open surgery as well as with arthroscopic surgery. Good results can be obtained with both techniques achieving a functional arc of at least -30° extension to 130° of flexion. Arthroscopic surgery enables results comparable with those of open surgery but with a lower percentage of complications.
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Pan BQ, Huang J, Ni JD, Yan MM, Xia Q. Multiple rare causes of post-traumatic elbow stiffness in an adolescent patient: A case report and review of literature. World J Clin Cases 2019; 7:1191-1199. [PMID: 31183352 PMCID: PMC6547331 DOI: 10.12998/wjcc.v7.i10.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/26/2019] [Accepted: 04/19/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Joint stiffness after elbow surgery is not a rare complication, and is always accompanied by deformity. The causes of joint stiffness are multiple in different patients, and divided into intrinsic and extrinsic causes. Herein, we report an unusual case of posttraumatic elbow stiffness due to multiple and rare causes.
CASE SUMMARY A 19-year-old male was hospitalized with the loss of motion of the left elbow for over ten years. Left limb computed tomography revealed left elbow stiffness with bony block and connection. The patient underwent surgery, and the etiology of joint stiffness was found to be a rare combination of common and uncommon causes. During an 18-mo follow-up period, the patient’s left elbow had normal motion and he was symptom-free.
CONCLUSION However, this case combined with multiple and rare causes highlights that the patient with scar physique is likely to be accompanied with more severe soft tissue, nerve contracture, and heterotypic ossification, even during recurrence.
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Affiliation(s)
- Bai-Qi Pan
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jun Huang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jiang-Dong Ni
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Ming-Ming Yan
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Qin Xia
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
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Sun Z, Liu W, Wang W, Fan C. Development and validation of a new elbow-specific scoring system for patients with elbow stiffness: the Shanghai Elbow Dysfunction Score. J Shoulder Elbow Surg 2019; 28:296-303. [PMID: 30472055 DOI: 10.1016/j.jse.2018.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/30/2018] [Accepted: 08/05/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical scoring systems are increasingly important and popular for the evaluation of orthopedic patients. Elbow stiffness commonly causes functional impairment and upper-limb disability. The purpose of this study was to develop and validate a new elbow-specific assessment score to evaluate joint function in patients with elbow stiffness. METHODS The new system, the Shanghai Elbow Dysfunction Score (SHEDS), was developed in 3 portions: elbow motion capacities, elbow-related symptoms, and patient satisfaction level. A total of 73 patients with elbow stiffness were prospectively included. Intraclass correlation coefficients and Cronbach α values were calculated for test-retest reliability and internal consistency, respectively. Construct validity was assessed by correlating the SHEDS with previously validated scoring systems. Effect sizes (ES) and standardized response means (SRMs) were calculated for responsiveness. RESULTS Positive reliability with an intraclass correlation coefficient of 0.83 and adequate homogeneity with a Cronbach α value of 0.74 were found for the SHEDS. Good to excellent validity using Spearman correlation coefficients (SCCs) were determined for the total (0.51-0.82), motion (0.65-0.89), and symptom (0.35-0.53) scores. Responsiveness was large for the total ES, 3.48; SRM, 2.96), motion (ES, 2.54; SRM, 2.08), and symptom (ES, 1.26; SRM, 1.14) scores. There were no ceiling or floor effects. Significant positive correlations were found between patient satisfaction levels and the final scores (SCC, 0.62), as well as the score changes of the SHEDS (SCC, 0.42). CONCLUSION Our results suggest that the newly developed SHEDS is an excellent, comprehensive, valid scoring system to evaluate joint function in patients with elbow stiffness.
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Affiliation(s)
- Ziyang Sun
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wenjun Liu
- Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China; Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China.
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China; Department of Orthopedics, Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China.
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Attum B, Obremskey W. Posttraumatic Elbow Stiffness: A Critical Analysis Review. JBJS Rev 2018; 4:01874474-201609000-00001. [PMID: 27760073 DOI: 10.2106/jbjs.rvw.15.00084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Open and arthroscopic release are both effective surgical treatments for posttraumatic elbow stiffness. Both static and dynamic bracing are effective for increasing elbow range of motion when heterotopic ossification is not present. Some loss of immediate postoperative range of motion is expected. Recurrence of heterotopic ossification around the elbow is rare. The occurrence of ulnar nerve palsy is rare and often requires transposition.
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Affiliation(s)
- Basem Attum
- Vanderbilt University Medical Center, Nashville, Tennessee
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Haglin JM, Kugelman DN, Christiano A, Konda SR, Paksima N, Egol KA. Open surgical elbow contracture release after trauma: results and recommendations. J Shoulder Elbow Surg 2018; 27:418-426. [PMID: 29290605 DOI: 10.1016/j.jse.2017.10.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/08/2017] [Accepted: 10/18/2017] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Jack M Haglin
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA
| | - David N Kugelman
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Anthony Christiano
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Sanjit R Konda
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA; Trauma Division, Orthopaedic Department, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Nader Paksima
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA; Trauma Division, Orthopaedic Department, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth A Egol
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA; Trauma Division, Orthopaedic Department, Jamaica Hospital Medical Center, Queens, NY, USA.
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Appropriate excision time of heterotopic ossification in elbow caused by trauma. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:27-31. [PMID: 29290538 PMCID: PMC6136303 DOI: 10.1016/j.aott.2017.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow. METHODS We retrospectively reviewed 42 patients who were treated operatively for heterotopic ossification of the elbow from March 2010 to December 2014 at our institution. The patients were divided into early (before 12 months) and late (after 12 months) excision groups. In the early excision group (17 patients), the average time from the initial injury to HO excision was 7.4 (3-11) months, and in the late excision group (25 patients), the average time was 33.5 (12-240) months. Every patient was evaluated by range of motion (ROM), the Mayo Elbow Performance Score (MEPS), postoperative complications and HO recurrence. RESULTS The preoperative mean ROM in the late excision group was greater than that of the early excision group, suggesting that the ROM is expected to increase even without surgery. Both early and late surgery increased ROM and MEPS, but early surgery improved ROM and MEPS more than late surgery did (p < .05). CONCLUSIONS Early excision of HO can provide better elbow function, as indicated by ROM and MEPS. Considering that there were no notable differences in postoperative ROM and MEPS, HO recurrence, or postoperative complications, we concluded that early excision is safe and that the time from an elbow injury to surgery may be shortened. LEVEL OF EVIDENCE Level III, therapeutic study.
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10
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Chen W, Wang W, Li Z, Qian Y, Song J, Liu J, Cheng Y, Fan CY. Effect on muscle strength of the upper extremities after open elbow arthrolysis. JSES OPEN ACCESS 2017; 1:63-71. [PMID: 30675542 PMCID: PMC6340865 DOI: 10.1016/j.jses.2017.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Open elbow arthrolysis manipulates tendons and soft tissues surrounding the elbow and may lead to strength decline after the operation. We hypothesized that strength of elbow and wrist motions and handgrip could be compromised after the procedure and that the strength recovery pattern may differ between men and women and between the dominant and nondominant side. Methods This was a prospective cohort study. We monitored 32 patients with post-traumatic elbow stiffness who underwent open arthrolysis between June 2014 and December 2014. All patients underwent standardized postoperative physical therapy. Preoperative and postoperative isometric strength were measured by a handheld dynamometer. Mayo Elbow Performance Score (MEPS) and arc of motion (AOM) were also analyzed. Results Mean follow-up was 26.13 months. Significant improvement was noticed in mean AOM (from 46° to 127°) and MEPS (from 67.97 to 96.86). No significant decline was noted in isometric strength at the last follow-up day. The strength ratios between men and women showed no significant difference from postoperative day 7 to the last follow-up day. At all follow-up assessments, isometric strength showed no significant difference between the dominant and nondominant side. Conclusions AOM and MEPS achieved significant enhancement after open elbow arthrolysis. The procedure did not lead to isometric strength decline. Postoperative gain of strength was proportional to the baseline strength level of each muscle group, and men had a more prominent gain of strength than women during the entire follow-up. Dominance had no effect on postoperative strength recovery.
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Affiliation(s)
- Wei Chen
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Sixth People's Hospital East Branch, Shanghai, China
- Shanghai University of Medicine and Health Science, Shanghai, China
| | - Zhiwei Li
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Yun Qian
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Jialin Song
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiazhi Liu
- Department of Orthopaedics, Shanghai Sixth People's Hospital East Branch, Shanghai, China
| | - Yuan Cheng
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-yi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
- Department of Orthopaedics, Shanghai Sixth People's Hospital East Branch, Shanghai, China
- Corresponding author: Cun-yi Fan, MD, PhD, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Rd, Shanghai 200233, China. (C.-y. Fan).
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Nagura N, Kenmoku T, Onuma K, Fukushima K, Fujimaki H, Takahira N, Takaso M. Three-dimensional full-scale bone modeling for preoperative simulation of surgery in patients with elbow contractures due to bone deformities. Clin Case Rep 2017; 5:1401-1406. [PMID: 28781867 PMCID: PMC5538078 DOI: 10.1002/ccr3.1003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/26/2017] [Accepted: 04/16/2017] [Indexed: 11/22/2022] Open
Abstract
It is often difficult to treat for elbow contractures by malformation of bones. We planned a mobilization of elbow with using three‐dimensional full‐scale bone modeling. We found it was effective to use it in preoperative planning because we could recognize the elements of contractures in every deformity.
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Affiliation(s)
- Naoshige Nagura
- Department of Orthopaedic Surgery School of Medicine Kitasato University Sagamihara Kanagawa Japan
| | - Tomonori Kenmoku
- Department of Orthopaedic Surgery School of Medicine Kitasato University Sagamihara Kanagawa Japan
| | - Kenji Onuma
- Department of Orthopaedic Surgery School of Medicine Kitasato University Sagamihara Kanagawa Japan
| | - Kensuke Fukushima
- Department of Orthopaedic Surgery School of Medicine Kitasato University Sagamihara Kanagawa Japan
| | - Hisako Fujimaki
- Department of Orthopaedic Surgery School of Medicine Kitasato University Sagamihara Kanagawa Japan
| | - Naonobu Takahira
- Department of Biomedical Engineering and Rehabilitation Kitasato University School of Allied Health Sciences Sagamihara Kanagawa Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery School of Medicine Kitasato University Sagamihara Kanagawa Japan
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Abstract
Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.
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13
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Wang W, Zhan YL, Yu SY, Zheng XY, Liu S, Fan CY. Open arthrolysis with pie-crusting release of the triceps tendon for treating post-traumatic contracture of the elbow. J Shoulder Elbow Surg 2016; 25:816-22. [PMID: 27085297 DOI: 10.1016/j.jse.2016.01.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/18/2015] [Accepted: 01/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Extensive loss of elbow flexion compromises the performance of daily activities. We examined the clinical outcomes of patients with post-traumatic extension contracture of the elbow treated with open arthrolysis and pie-crusting release of the triceps tendon. METHODS We retrospectively reviewed the records of 7 patients (5 men and 2 women; mean age, 35 years) who underwent open arthrolysis via a combined lateral and medial approach with pie-crusting release of the triceps tendon for the treatment of post-traumatic elbow stiffness. All the patients had heterotopic ossification that restricted elbow motion and underwent removal of the ossified tissue and capsular release. The triceps tendon was gradually stretched by making multiple stab incisions on the tendon by using a No. 11 surgical blade. The range of motion of the elbow was recorded both preoperatively and at the final postoperative follow-up. Elbow function was assessed with the Mayo Elbow Performance Score. RESULTS The patients were followed up for a mean of 24 months. After treatment, significant improvement was noted in the total arc of motion (from 44° to 116°, P <.001), mean flexion (from 80° to 124°, P < .001), and mean extension (from 31° to 8°, P = .004). The mean Mayo Elbow Performance Score improved significantly from 59 points preoperatively to 92 points at the final evaluation. No major postoperative complications developed in any of the patients. CONCLUSION Our findings indicate that open arthrolysis with pie-crusting release of the triceps tendon is an effective and safe treatment approach for post-traumatic extension contracture of the elbow.
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Affiliation(s)
- Wei Wang
- Department of Orthopaedics, Shanghai Sixth People's Hospital East Branch, Shanghai, China
| | - Yu-lin Zhan
- Department of Orthopaedics, Shanghai Sixth People's Hospital East Branch, Shanghai, China
| | - Shi-yang Yu
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xian-you Zheng
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shen Liu
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-yi Fan
- Department of Orthopaedics, Shanghai Sixth People's Hospital East Branch, Shanghai, China; Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.
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14
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Lake SP, Castile RM, Borinsky S, Dunham CL, Havlioglu N, Galatz LM. Development and use of an animal model to study post-traumatic stiffness and contracture of the elbow. J Orthop Res 2016; 34:354-64. [PMID: 26177969 DOI: 10.1002/jor.22981] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 07/08/2015] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint stiffness (PTJS) of the elbow is a debilitating condition that poses unique treatment challenges. While previous research has implicated capsular tissue in PTJS, much regarding the development and progression of this condition remains unknown. The objective of this study was to develop an animal model of post-traumatic elbow contracture and evaluate its potential for studying the etiology of PTJS. The Long-Evans rat was identified as the most appropriate species/breed for development due to anatomical and functional similarities to the human elbow joint. Two surgical protocols of varying severity were utilized to replicate soft tissue damage seen in elbow subluxation/dislocation injuries, including anterior capsulotomy and lateral collateral ligament transection, followed by 6 weeks of unilateral joint immobilization. Following sacrifice, flexion-extension mechanical joint testing demonstrated decreased range-of-motion and increased stiffness for injured-immobilized limbs compared to control and sham animals, where functional impact correlated with severity of injury. Histological evaluation showed increased cellularity, adhesion, and thickness of capsule tissue in injured limbs, consistent with clinical evidence. To our knowledge, this is the first animal model capable of examining challenges unique to the anatomically and biomechanically complex elbow joint. Future studies will use this animal model to investigate mechanisms responsible for PTJS.
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Affiliation(s)
- Spencer P Lake
- Department of Mechanical Engineering & Materials Science, Washington University, 1 Brookings Hall, Campus Box 1185, St. Louis, 63130, Missouri.,Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Ryan M Castile
- Department of Mechanical Engineering & Materials Science, Washington University, 1 Brookings Hall, Campus Box 1185, St. Louis, 63130, Missouri
| | - Stephanie Borinsky
- Department of Mechanical Engineering & Materials Science, Washington University, 1 Brookings Hall, Campus Box 1185, St. Louis, 63130, Missouri.,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Chelsey L Dunham
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Necat Havlioglu
- Department of Pathology, John Cochran VA Medical Center, St Louis, Missouri
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
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Cai J, Wang W, Yan H, Sun Y, Chen W, Chen S, Fan C. Complications of Open Elbow Arthrolysis in Post-Traumatic Elbow Stiffness: A Systematic Review. PLoS One 2015; 10:e0138547. [PMID: 26383106 PMCID: PMC4575202 DOI: 10.1371/journal.pone.0138547] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 08/31/2015] [Indexed: 12/27/2022] Open
Abstract
Objective The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients with post-traumatic elbow stiffness and provide a reference for better prevention and treatment of them. Methods The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for therapeutic studies with a set of inclusion and exclusion criteria. Data were extracted from selected articles, and a statistical analysis was performed to evaluate related factors and management of the complications. Results Twenty-eight articles published between 1989 and 2013, involving 810 patients, were included. Most of the complications included in the selected articles were nerve complications, heterotopic ossification, elbow instability, infection, pin-related complications and repeat elbow contracture. The total complication rate was 24.3% ± 3.0%, and the reoperation rate was 34.0%. Furthermore, the statistical analysis revealed that preoperative range of motion (β = -0.004, P = 0.01) and proportion of female (β = 0.336, P = 0.04) were the independent factors affecting the total complication rate. Conclusions Various risk factors are related to each of the complications, and we found that patients with less preoperative ROM and a higher proportion of female gender may point to a higher total complication rate. Therefore, to further improve the overall outcomes of this procedure, more and larger prospective studies should be performed to further elucidate the effects of prophylactic interventions targeting the risk factors, thus improving the methods of prevention and treatment of complications.
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Affiliation(s)
- Jiangyu Cai
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, P. R. China, 200233
| | - Wei Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, P. R. China, 200233
| | - Hede Yan
- Division of Plastic and Hand Surgery, Department of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, P. R. China, 325027
| | - Yangbai Sun
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, P. R. China, 200233
| | - Wei Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, P. R. China, 200233
| | - Shuai Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, P. R. China, 200233
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, P. R. China, 200233
- * E-mail:
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16
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Outcomes of arthroscopic arthrolysis for the post-traumatic elbow stiffness. Knee Surg Sports Traumatol Arthrosc 2015; 23:2715-20. [PMID: 24832692 DOI: 10.1007/s00167-014-3032-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 04/19/2014] [Indexed: 01/28/2023]
Abstract
PURPOSE Post-traumatic contracture is a common complication after elbow trauma. If conservative therapy fails to restore adequate elbow motion, surgical release is recommended. Increase in arthroscopy knowledge and skills, as well as technological advances in the passed decade of years, has made arthroscopic arthrolysis a safe and reliable treatment for patients with a post-traumatic elbow contracture. The aim of this study was to report on the clinical outcome and improvement of ROM in post-traumatic stiff elbow treated by arthroscopic arthrolysis. METHODS Between 2008 and 2012, 34 consecutive patients with post-traumatic stiffness were treated with arthroscopic arthrolysis. Active and passive elbow movement is encouraged the day after operation with the effective pain management. Mayo Elbow Performance Index (MEPI) and visual analogue scale were measured. RESULTS At the final follow-up, the average arc of elbow motion increased from 48.6 ± 19.3 pre-operatively to 114.5 ± 25.7, with a mean improvement of 65.9°. The MEPI score improved from 68.2 ± 16.4 pre-operatively to 92.4 ± 21.6, with a mean improvement of 24.2 (p < 0.001). Results were good to excellent in 29 patients. CONCLUSION Injuries are the most common cause of elbow stiffness requiring surgical release. The procedure of arthroscopic arthrolysis is a good option for the treatment of post-traumatic elbow stiffness as it restores normal elbow function. Early passive/active post-operative rehabilitation is very important.
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Abstract
Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.
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Wang W, Jiang SC, Liu S, Ruan HJ, Fan CY. Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator. J Shoulder Elbow Surg 2014; 23:1537-44. [PMID: 24927881 DOI: 10.1016/j.jse.2014.03.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/20/2014] [Accepted: 03/29/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Instability is a crucial issue in severe post-traumatic elbow stiffness during complete-release surgery. This study aimed to evaluate the efficacy of ligament repair using a suture anchor in the operative treatment of severely stiff elbows for which a hinged external fixator was indicated. METHODS We retrospectively reviewed 46 cases of severely stiff elbows (flexion arc <60°) undergoing open release. During the operation, all 46 elbows were noted to have instability. Suture anchors were applied to restore the ligament if it was impossible to repair the ligament directly, and a hinged external fixator was simultaneously applied to protect the vulnerable ligament and facilitate rehabilitation. No allograft or autograft was used in any of our cases. The stability, arc of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, and radiographs were evaluated. RESULTS At a mean follow-up of 24.3 months, the postoperative Mayo Elbow Performance Score was 91 points, as compared with 63 points preoperatively. The mean flexion arc improved from 25° to 126°. Three patients presented with moderate elbow instability when the hinged external fixator was removed; however, all of them regained stability by the last follow-up. Furthermore, 7 cases of new-onset nerve palsy were noted; however, all of them resolved with conservative management. None of the patients required secondary surgery for any reason. CONCLUSIONS Repair of an avulsed collateral ligament with suture anchors and hinged external fixation was effective in restoring functional mobility in patients with severe post-traumatic elbow stiffness after complete release. This could be an option for treating ankylosed, severely or very severely stiff elbows.
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Affiliation(s)
- Wei Wang
- Department of Orthopaedics, Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shi-chao Jiang
- Department of Orthopaedics, Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shen Liu
- Department of Orthopaedics, Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hong-jiang Ruan
- Department of Orthopaedics, Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Cun-yi Fan
- Department of Orthopaedics, Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China.
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Yan H, He J, Chen S, Yu S, Fan C. Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study. J Shoulder Elbow Surg 2014; 23:686-92. [PMID: 24745317 DOI: 10.1016/j.jse.2014.01.049] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/22/2014] [Accepted: 01/27/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND With the improvements in wound healing through the use of intravenous prophylactic antibiotics and technical refinements, postoperative elbow infections have become less common but still occur in certain elective elbow surgeries. The objective of this study was to evaluate the safety and efficacy of prophylactic application of vancomycin into the operative site to reduce the incidence of infection after the open release of post-traumatic stiff elbows. METHODS A retrospective review of 272 such patients during a 4-year period was performed. In the control group (93 patients), simple prophylaxis with standard intravenous antibiotics was performed; in the vancomycin group (179 patients), vancomycin powder was applied directly into the wound before closure along with standard intravenous prophylaxis. RESULTS After a follow-up of at least 6 months, the control group was found to have 6 infections (6.45%; confidence interval: 2.40%-13.52%) compared with none (0%; confidence interval: 0-2%.04%) in the vancomycin group, which was a statistically significant difference (P = .0027). No adverse effects were documented from the direct use of the vancomycin powder. CONCLUSIONS The local application of vancomycin powder may be a promising means of preventing postoperative elbow infections after elbow release in patients with post-traumatic elbow stiffness.
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Affiliation(s)
- Hede Yan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China; Division of Plastic and Hand Surgery, Department of Orthopaedics, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jin He
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shiyang Yu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cunyi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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20
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Giannicola G, Bullitta G, Polimanti D, Gumina S. Factors affecting choice of open surgical techniques in elbow stiffness. Musculoskelet Surg 2014; 98 Suppl 1:77-85. [PMID: 24659203 DOI: 10.1007/s12306-014-0326-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 02/28/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND We analyzed the clinical outcomes of stiff elbow open treatment to assess factors affecting the choice of surgical procedures in a consecutive series of patients followed up prospectively. MATERIALS AND METHODS Forty-one patients, mean aged 48 years, were evaluated. Elbow stiffness was caused by post-traumatic osteoarthritis in 32 patients, primary osteoarthritis in seven and rheumatoid arthritis in two. Stiffness was classified as mixed and extrinsic in 28 and 13 cases, respectively. Seventeen ulno-humeral arthroplasties (UHA), seven UHA with radiocapitellar replacement, six UHA with radial head replacement, ten total elbow replacement and one UHA with anconeus interposition were performed. Mayo Elbow Performance Score (MEPS), modified-American Shoulder and Elbow Surgeons (m-ASES) and Q-DASH scores were used for the pre- and post-operative evaluation. RESULTS Mean follow-up was 25 months. The average increase in MEPS and m-ASES was 45 and 41, respectively. The average decrease in Q-DASH and the average increase in m-ASES pain were 43 and 21, respectively. The mean increase in flection, extension, pronation and supination was 29°, 25°, 18° and 17°, respectively. All the differences were statistically significant. CONCLUSIONS Strictly customized open surgery of elbow stiffness, by taking into account the clinical value of each patient's pathoanatomical conditions, yields satisfactory functional results in majority of cases. In particular, the degree and site of elbow cartilage wear proved to be the factors affecting the choice of treatment most. Treatment should be aimed at removing the causes of pain and at recovering range of motion.
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Affiliation(s)
- G Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Via Emilio Repossi 15, 00158, Rome, Italy.
| | - G Bullitta
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Via Emilio Repossi 15, 00158, Rome, Italy
| | - D Polimanti
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Via Emilio Repossi 15, 00158, Rome, Italy
| | - S Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Via Emilio Repossi 15, 00158, Rome, Italy
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Kuxhaus L, Zeng S, Robinson CJ. Dependence of elbow joint stiffness measurements on speed, angle, and muscle contraction level. J Biomech 2014; 47:1234-7. [PMID: 24433667 DOI: 10.1016/j.jbiomech.2013.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 12/12/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
Elbow joint stiffness is critical to positioning the hand. Abnormal elbow joint stiffness may affect a person's ability to participate in activities of daily living. In this work, elbow joint stiffness was measured in ten healthy young adults with a device adapted from one previously used to measure stiffness in other joints. Measurements of elbow stiffness involved applying a constant-velocity rotational movement to the elbow and measuring the resultant displacement, torque, and acceleration. Elbow stiffness was then computed using a previously-established model for joint stiffness. Measurements were made at two unique elbow joint angles, two speeds, and two forearm muscle contraction levels. The results indicate that the elbow joint stiffness is significantly affected by both rotational speed and forearm muscle contraction level.
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Affiliation(s)
- Laurel Kuxhaus
- Department of Mechanical & Aeronautical Engineering, Clarkson University, Potsdam, NY 13699, USA; Center for Rehabilitation Engineering Science and Technology, Clarkson University, Potsdam, NY 13699, USA.
| | - Sisi Zeng
- Department of Mechanical & Aeronautical Engineering, Clarkson University, Potsdam, NY 13699, USA
| | - Charles J Robinson
- Department of Electrical & Computer Engineering, Clarkson University, Potsdam, NY 13699, USA; Center for Rehabilitation Engineering Science and Technology, Clarkson University, Potsdam, NY 13699, USA
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Ploumis A, Belbasis L, Ntzani E, Tsekeris P, Xenakis T. Radiotherapy for prevention of heterotopic ossification of the elbow: a systematic review of the literature. J Shoulder Elbow Surg 2013; 22:1580-8. [PMID: 24138821 DOI: 10.1016/j.jse.2013.07.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 07/02/2013] [Accepted: 07/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification is a pathological process characterized by abnormal formation of bone in nonskeletal tissue. Radiotherapy for heterotopic ossification of the elbow is questionable because of possible adverse effects. METHODS A systematic review of the literature was conducted in MEDLINE, Scopus, ISI Web of Science, National Institute for Health and Clinical Excellence, National Guideline Clearinghouse, System for Information on Grey Literature in Europe, ClinicalTrials.gov, Cochrane Central Register of Clinical Trials, and Cochrane Database of Systematic Reviews up to April 2012. All published articles assessing interventions including radiotherapy for prevention of heterotopic ossification in the elbow of adult patients were considered. Information was recorded by the first two authors, and disagreements in interpretation were resolved by consensus. RESULTS In total, 27 studies using radiotherapy for elbow heterotopic ossification were identified (1 randomized clinical trial, 1 case-control study, and 25 case reports and case series) in the literature. Most of them used a single dose of 7.0 Gy. The randomized clinical trial was stopped early because of severe adverse effects (pseudarthrosis) caused by radiation. The case-control study showed that radiotherapy did not effectively prevent recurrence of heterotopic ossification. The case reports and case series mentioned only sparse adverse events. CONCLUSION The use of radiation therapy for prevention of heterotopic ossification of the elbow is supported by weak evidence.
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Affiliation(s)
- Avraam Ploumis
- Department of Orthopaedics and Rehabilitation, University of Ioannina Medical School, Ioannina, Greece.
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Koh KH, Lim TK, Lee HI, Park MJ. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification. J Shoulder Elbow Surg 2013; 22:1128-34. [PMID: 23796381 DOI: 10.1016/j.jse.2013.04.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/07/2013] [Accepted: 04/17/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is considered as a common extrinsic cause of elbow stiffness. The purpose of this study was to show the results of surgical treatment for post-traumatic elbow stiffness caused by HO in a large, consecutive series of patients in a single unit. METHODS We retrospectively reviewed 77 surgically treated patients with post-traumatic elbow stiffness caused by HO. Final motion arc and Mayo Elbow Performance Index (MEPI) were assessed as final results. Univariable and multivariable analyses were done to determine which factors had an effect on the final motion arc. RESULTS The average arc of elbow motion increased from 45° preoperatively to 112°, with an improvement of 67° at the final follow-up evaluation. The mean MEPI score was 91.9. At the final evaluation, 65 patients (84.4%) obtained a total motion arc of ≥100°. Recurrent HO was observed in 16 patients postoperatively, and 6 underwent repeated surgical release. The time from the initial injury to surgical release with a cutoff value of 19 months was the only independent factor affecting the final range of motion (ROM) in multivariable median regression analysis. With the numbers studied, no significant association was found between the final ROM and other clinical variables except for the recurrence of HO (93° vs 117°). CONCLUSIONS From the results of our study, we can support the surgical treatment of elbow stiffness caused by post-traumatic HO regardless of preoperative ROM. However, recurrence of heterotopic bone and delay in surgery of more than 19 months are associated with less favorable results.
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Affiliation(s)
- Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
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24
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Lee EK, Namdari S, Hosalkar HS, Keenan MA, Baldwin KD. Clinical results of the excision of heterotopic bone around the elbow: a systematic review. J Shoulder Elbow Surg 2013; 22:716-22. [PMID: 23380078 DOI: 10.1016/j.jse.2012.11.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/19/2012] [Accepted: 11/21/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) of the elbow can occur following direct trauma, brain injury, or burns. Development of elbow HO is sporadic, making levels 1-3 clinical evidence difficult to establish. We systematically reviewed literature regarding management and outcomes of surgically treated elbow HO. METHODS A systematic review of the literature regarding elbow HO was performed to compare imaging modalities, surgical timing, surgical approaches, and methods of prophylaxis in outcomes of patients treated with excision. RESULTS Our systematic review included 24 level 3 or 4 studies investigating 384 post-trauma (158), brain injury (105), or burn (94) patients with elbows complicated by HO that were treated with surgical excision. Average patient age was 36.9 years and there was a 65/35 M/F ratio. For all etiologies, preoperatively elbow flexion/extension averaged 53/83; postoperatively elbow flexion/extension significantly improved to 22/123. Regardless of the etiology, surgical excision of elbow HO significantly improved functional range of motion. Neither total body surface area (TBSA) burned for burn patients or Garland classification for brain-injured patients correlated with outcome. Overall complication rate was 22.6% and included HO recurrence (11.9%), ulnar nerve injury, infection, and delayed wound healing. CONCLUSION Surgical treatment of elbow HO leads to improved functional outcome, whether the etiology of bone formation was direct elbow trauma, brain injury, or thermal injury.
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Affiliation(s)
- Eric K Lee
- School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Kodde IF, van Rijn J, van den Bekerom MPJ, Eygendaal D. Surgical treatment of post-traumatic elbow stiffness: a systematic review. J Shoulder Elbow Surg 2013; 22:574-80. [PMID: 23375881 DOI: 10.1016/j.jse.2012.11.010] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/04/2012] [Accepted: 11/11/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trauma to the elbow is a common cause of joint stiffness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. There is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiffness. The objective of this article was to review current available literature of studies reporting on open or arthroscopic release of post-traumatic elbow stiffness. METHODS A comprehensive literature search was performed. All titles and abstracts of potentially relevant studies were reviewed, with a set of predefined inclusion and exclusion criteria. After the initial assessment for inclusion, 2 authors extracted data independently from the included articles. RESULTS Thirty articles were included, with an overall enrolment of 798 patients. No randomized controlled trials were retrieved. The first article was published in 1989 and the most recent in 2012. There were 4 different kinds of treatment modalities identified from the included studies: 1) open arthrolysis; 2) arthroscopic arthrolysis; 3) open arthrolysis with external fixation; and 4) open arthrolysis with distraction arthroplasty. The gain in range of motion was 51°, 40°, 88°, and 56° for groups 1-4, respectively. The average percentage of complications was 23, 5, 73, and 58 for groups 1-4, respectively. CONCLUSION Current literature is not sufficient enough to draw firm statistically based conclusions. However, as the amount of complications seems to rise with the extent of the surgical procedure, we would advise to treat as less invasive as possible (grade C).
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Affiliation(s)
- Izaäk F Kodde
- Department of Orthopaedics, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands.
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Mansat P, Bonnevialle N, Werner B. [Indications and technique of combined medial and lateral column procedures in severe extrinsic elbow contractures]. DER ORTHOPADE 2011; 40:307-15. [PMID: 21472425 DOI: 10.1007/s00132-010-1666-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Severe extrinsic elbow contracture can be treated effectively using elbow arthrolysis to obtain satisfactory results. Preoperative planing is of prime importance to evaluate joint involvement and to decide how to approach the capsule from the lateral or medial aspect of the elbow. Most of the time because of the extensive involvement of the periarticular tissue, a combined approach is usually preferred. It is a step-by-step procedure that must be adapted to the progressive gain of motion. The ulnar nerve must be identified systematically and often anteriorly transposed. Maximum gain of motion must be obtained at surgery because loss of elbow motion after surgery is common. Postoperative management must be closely followed static splint being preferable to active physiotherapy. Results of surgical arthrolysis for extrinsic stiffness is often satisfactory with an absolute gain in the flexion-extension arc between 30 and 60°.
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Affiliation(s)
- P Mansat
- Centre Hospitalier Universitaire PURPAN, Place du Dr. Baylac, F-31059, Toulouse, France.
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Blonna D, Lee GC, O'Driscoll SW. Arthroscopic restoration of terminal elbow extension in high-level athletes. Am J Sports Med 2010; 38:2509-15. [PMID: 20847224 DOI: 10.1177/0363546510376727] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although most people can lead near-normal lives with a limited but functional arc of elbow motion, athletes may find loss of terminal extension severely impairing. HYPOTHESIS Arthroscopic contracture release is effective in restoring full elbow extension in athletes whose loss of terminal extension impairs their intensities and/or levels of performance in sport. STUDY DESIGN Case series; Level of evidence, 4. METHODS Between 1997 and 2007, 24 athletes (26 elbows; mean age, 38 years [range, 12-58]) whose chief complaint was limited elbow extension (≤35°) underwent arthroscopic release of contractures (average follow-up, 33 months [range, 12-88]). All the patients were classified according to a sport-specific scoring system using the subjective patient outcome for return to sports score and the summary outcome determination score. RESULTS All 26 elbows improved subjectively and objectively with surgery. Of the 26 elbows, 25 were rated by the patients as normal (n = 15) or near-normal (n = 10) at final follow-up. Pain during intense sporting activities was absent in 17, mild and occasional without affecting performance in 6, and severe enough to affect performance in 1. Of the 24 patients (26 elbows), 22 patients (23 elbows) returned to the same sport at the same level of intensity and performance as before injury. Two patients (3 elbows) returned to the same sport but failed to reach their preinjury levels of performance. Extension improved in all patients, with the average flexion contracture decreasing from 27° ± 7° (range, 10°-35°) to 6° ± 9° (range, 10° of hyperextension to 25°; P < .001). Lack of extension was not a residual impairment factor in any patients. Three patients developed delayed-onset ulnar neuropathy after surgery, 2 of which were treated by subcutaneous transposition. All 3 resolved completely, 2 within the first 6 weeks; the other took longer than a year. CONCLUSION The arthroscopic release of contractures is a predictable technique to achieve a highly functional elbow in athletes.
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Affiliation(s)
- Davide Blonna
- Mayo Clinic, Sports Medicine Center, Rochester, MN 55905, USA
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28
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Park MJ, Chang MJ, Lee YB, Kang HJ. Surgical release for posttraumatic loss of elbow flexion. J Bone Joint Surg Am 2010; 92:2692-9. [PMID: 21084579 DOI: 10.2106/jbjs.i.01367] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several surgical approaches have been suggested for the treatment of posttraumatic elbow stiffness; however, the optimal approach to elbows with considerable loss of flexion has not been well described. We investigated the pathologic lesions causing posttraumatic loss of elbow flexion and analyzed the results of surgical release. METHODS Forty-two patients with <100° of elbow flexion due to an extrinsic contracture following trauma underwent surgical release at a median of ten months after injury. To achieve maximum flexion, release of the posterior band of the medial collateral ligament was mandatory in all patients, and only four patients required additional anterior procedures. The ulnar nerve was transposed anteriorly in forty patients, including three who had had a previous transposition. To evaluate the results, we compared preoperative and postoperative elbow motion, Mayo Elbow Performance Index (MEPI) scores, and radiographs. RESULTS Intraoperatively, heterotopic ossification was observed in forty patients. It was located predominantly in the posteromedial aspect of the capsule. Heterotopic bone was more commonly found during surgery than it was identified preoperatively on radiographs. Mean flexion increased significantly from 89° preoperatively to 124° (range, 90° to 140°) at a mean of thirty-nine months postoperatively. The mean size of the flexion contracture decreased from 34° preoperatively to 9° (range, 0° to 30°) postoperatively. Overall, ≥120° of final flexion and a total arc of ≥100° were regained by 88% of the patients. The mean MEPI score improved significantly from 73 points preoperatively to 94 points (range, 72 to 100 points) postoperatively, with the result rated as excellent in thirty-two patients, good in eight, and fair in two. Two patients had clinical recurrence of heterotopic ossification associated with a failure to obtain an increase in flexion. CONCLUSIONS This study demonstrates that posttraumatic heterotopic ossification, particularly in the posteromedial aspect of the capsule, is closely associated with loss of elbow flexion. Satisfactory restoration of elbow flexion can be obtained in the majority of patients by surgical release of the posterior band of the medial collateral ligament and excision of heterotopic bone.
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Affiliation(s)
- Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea.
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Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, Di Giunta G, Watanabe LN, Checchia SL. EVALUATION OF THE RESULTS OF SURGICAL TREATMENT OF POSTTRAUMATIC STIFFNESS OF THE ELBOW IN SKELETALLY MATURE PATIENTS. Rev Bras Ortop 2010; 45:529-37. [PMID: 27026959 PMCID: PMC4799211 DOI: 10.1016/s2255-4971(15)30298-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 03/09/2010] [Indexed: 11/21/2022] Open
Abstract
Objective: To evaluate the results from surgical treatment of posttraumatic stiffness of the elbow in skeletally mature patients. Methods: Between October 2000 and October 2007, 45 elbows of 45 patients underwent surgical treatment performed by the Shoulder and Elbow Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. Ten patients were treated arthroscopically and the remainder by open surgery. The minimum follow-up was six months, with a mean of 22 months. Their ages ranged from 17 to 72 years, with a mean of 36 years and three months. Males predominated, accounting for 60% of the cases. The dominant limb was involved in 56.5% of the cases. The clinical evaluation of the results was done by using the criteria of the American Medical Association (AMA), as modified by Bruce; the Mayo Elbow Performance Score (MEPS); and measurements on the gain of flexion-extension arc and the final range of motion. Results: According to the AMA criteria, as modified by Bruce, 42.2% of our results were satisfactory, whereas 77.8% were satisfactory according to MEPS. The mean postoperative flexion-extension arc was 106°, and the main gain in range was 46°. The evaluation of the variables showed that patients with an initial flexion arc greater than 90° achieved a greater final flexion-extension arc, and those with an initial extension less than or equal to 60° gained greater range of motion. Conclusion: Surgical treatment of posttraumatic stiffness of the elbow in skeletally mature individuals was shown to be satisfactory according to MEPS, but unsatisfactory according to AMA. We observed that the patients with preoperative flexion greater than 90° evolved with a greater flexion-extension arc after surgical treatment, while those who had contracture with extension less than or equal to 60° gained a greater range of motion.
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Affiliation(s)
- Alberto Naoki Miyazaki
- Assistant Professor and Head of the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo
| | - Marcelo Fregoneze
- Assistant Professor and Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo
| | - Pedro Doneux Santos
- Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo
| | - Luciana Andrade da Silva
- Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo
| | - Giovanni Di Giunta
- Trainee in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo
| | - Lucio Norio Watanabe
- Trainee in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo
| | - Sérgio Luiz Checchia
- Adjunct Professor and Clinical Head of the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo; Member and Academic Coordinator of the Shoulder and Elbow Group
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Brouwer KM, Lindenhovius ALC, de Witte PB, Jupiter JB, Ring D. Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction. J Hand Surg Am 2010; 35:1115-9. [PMID: 20541330 DOI: 10.1016/j.jhsa.2010.03.040] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Revised: 03/23/2010] [Accepted: 03/24/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension. METHODS Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system. RESULTS An average of 22 months after surgery (range, 10 to 62 mo), the arc of flexion and extension averaged 95 degrees in the ankylosis cohort and 93 degrees in the partial HO cohort. Forearm rotation averaged 131 degrees versus 134 degrees ; the mean Disabilities of the Arm, Shoulder, and Hand score was 28 versus 30 points; and the mean Broberg and Morrey score was 81 versus 84 points, respectively. CONCLUSIONS After controlling for other factors, patients with elbow stiffness related to HO can recover comparable motion after surgical release at short-term follow-up whether they have complete ankylosis or only partial restriction of motion. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Kim M Brouwer
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA 02114, USA
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Brinsden MD, Carr AJ, Rees JL. Post-traumatic flexion contractures of the elbow: Operative treatment via the limited lateral approach. J Orthop Surg Res 2008; 3:39. [PMID: 18783605 PMCID: PMC2546394 DOI: 10.1186/1749-799x-3-39] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 09/10/2008] [Indexed: 11/10/2022] Open
Abstract
Varying surgical techniques, patient groups and results have been described regards the surgical treatment of post traumatic flexion contracture of the elbow. We present our experience using the limited lateral approach on patients with carefully defined contracture types.Surgical release of post-traumatic flexion contracture of the elbow was performed in 23 patients via a limited lateral approach. All patients had an established flexion contracture with significant functional deficit. Contracture types were classified as either extrinsic if the contracture was not associated with damage to the joint surface or as intrinsic if it was.Overall, the mean pre-operative deformity was 55 degrees (95%CI 48-61) which was corrected at the time of surgery to 17 degrees (95%CI 12-22). At short-term follow-up (7.5 months) the mean residual deformity was 25 degrees (95%CI 19-30) and at medium-term follow-up (43 months) it was 32 degrees (95%CI 25-39). This deformity correction was significant (p < 0.01). One patient suffered a post-operative complication with transient dysaesthesia in the distribution of the ulnar nerve, which had resolved at six weeks. Sixteen patients had an extrinsic contracture and seven an intrinsic. Although all patients were satisfied with the results of their surgery, patients with an extrinsic contracture had significantly (p = 0.02) better results than those with an intrinsic contracture. (28 degrees compared to 48 degrees at medium term follow up). Surgical release of post-traumatic flexion contracture of the elbow via a limited lateral approach is a safe technique, which reliably improves extension especially for extrinsic contractures. In this series all patients with an extrinsic contracture regained a functional range of movement and were satisfied with their surgery.
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Affiliation(s)
- Mark D Brinsden
- The Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, UK
| | - Andrew J Carr
- The Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, UK
| | - Jonathan L Rees
- The Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, UK
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Open humerus shaft fracture with ipsilateral anterior shoulder fracture-dislocation and posterior elbow dislocation: a case report. THE JOURNAL OF TRAUMA 2008; 64:1383-6. [PMID: 18469665 DOI: 10.1097/01.ta.0000234736.66884.65] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gundlach U, Eygendaal D. Surgical treatment of posttraumatic stiffness of the elbow: 2-year outcome in 21 patients after a column procedure. Acta Orthop 2008; 79:74-7. [PMID: 18283576 DOI: 10.1080/17453670710014798] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Posttraumatic stiffness is a common complication of elbow injury and can result in considerable impairment in daily life. We assessed the outcome in 21 patients treated by a column procedure. PATIENTS AND METHODS We followed 21 patients (average age 40 (10-76) years, 11 women) for 2 years after surgery for a stiff elbow. Range of motion (ROM) and function (EFA score) were measured preoperatively and at 3,12, and 24 months postoperatively. RESULTS Before surgery, the mean ROM was 69 degrees (SD 24) and the mean EFA score was 74 (SD 13), which improved significantly to 104 degrees (17) and 91 (6), respectively, after release. There were no significant differences between the postoperative measurements at 3,12, and 24 months. No neurovascular complications were noted; 2 patients developed periarticular ossifications postoperatively. INTERPRETATION A column procedure results in an increase in motion and functional scores at 2-year follow-up. Outcome at 3 months after treatment is the same as after 2 years.
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Affiliation(s)
- Udo Gundlach
- Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, the Netherlands.
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Rex C, Suresh Kumar PM, Srimannarayana A, Chugh S, Ravichandran M, Harish DN. Analysis of results of surgical treatment of posttraumatic stiff elbow. Indian J Orthop 2008; 42:192-200. [PMID: 19826527 PMCID: PMC2759609 DOI: 10.4103/0019-5413.40257] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical management of posttraumatic elbow stiffness has been reported with poor outcome following treatment. Sequential release in earlier stages of stiffness yielded much better results. The goal of our study was to assess the outcome in improvement of the range of motion of the elbow after surgical release and to analyze a tailor-made approach according to individual needs to yield good result. MATERIALS AND METHODS A prospective study was conducted in 47 cases of elbow stiffness due to various types of injuries. All the cases were treated with sequential release if there was no progress after adequate supervised conservative management except in unreduced dislocations. All the cases were followed up for a minimum period of 24 months. Overall outcome was rated with the functional scoring system by Mayo Clinic Performance Index. RESULTS Twenty-five (44.68%) out of 47 patients had excellent results with a mean preoperative range of motion of 33.9 degrees and postoperative range of motion of 105 degrees with net gain in range of motion of 71.1 degrees ('t' test value is 19.27, P < 0.01). None of the patients had elbow instability. Patients not having heterotopic ossification, who underwent surgery from three to six months post injury had a mean gain of 73.5 degrees. In patients who waited for more than six months had mean gain of 66.8 degrees. However, the results in cases having heterotopic ossification followed a slightly different pattern. In cases where release was performed from three months to six months had mean gain of 77.5 degrees. Cases in which release was performed after six months had gain of 57.1 degrees. CONCLUSIONS In cases of posttraumatic elbow stiffness after a failed initial conservative treatment, early arthrolysis with sequential surgical soft tissue release yields good result than delayed surgery.
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Affiliation(s)
- Chandrabose Rex
- Rex Ortho Hospital, Poomarket, Mettupalayam Road, Coimbatore, Tamil Nadu, India,Correspondence: Dr. Chandrabose Rex, Rex Ortho Hospital, No.43, R.R. Layout, Behind Shanmuga Theatre, Poomarket, Mettupalayam Road, Coimbatore - 641 002, India. E-mail:
| | - PM Suresh Kumar
- Rex Ortho Hospital, Poomarket, Mettupalayam Road, Coimbatore, Tamil Nadu, India
| | | | - S Chugh
- Rex Ortho Hospital, Poomarket, Mettupalayam Road, Coimbatore, Tamil Nadu, India
| | - M Ravichandran
- Rex Ortho Hospital, Poomarket, Mettupalayam Road, Coimbatore, Tamil Nadu, India
| | - DN Harish
- Rex Ortho Hospital, Poomarket, Mettupalayam Road, Coimbatore, Tamil Nadu, India
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Lindenhovius ALC, Jupiter JB. The posttraumatic stiff elbow: a review of the literature. J Hand Surg Am 2007; 32:1605-23. [PMID: 18070653 DOI: 10.1016/j.jhsa.2007.09.015] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 09/12/2007] [Indexed: 02/02/2023]
Abstract
Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.
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Lindenhovius ALC, Linzel DS, Doornberg JN, Ring DC, Jupiter JB. Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion. J Shoulder Elbow Surg 2007; 16:621-5. [PMID: 17644008 DOI: 10.1016/j.jse.2007.01.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Revised: 10/06/2006] [Accepted: 01/16/2007] [Indexed: 02/01/2023]
Abstract
We compared 16 patients with post-traumatic heterotopic ossification (HO) restricting elbow motion (but not complete bony ankylosis) after elbow trauma with 21 patients with capsular contracture alone to test the hypothesis that HO is associated with diminished motion after release. Patients with burns or head injury were excluded. The preoperative flexion arc averaged 59 degrees in the HO cohort and 52 degrees in the capsular contracture cohort. The mean flexion arc after the index surgery improved by 54 degrees to a mean arc of 113 degrees in the HO cohort and by 35 degrees to a mean of 87 degrees in the capsular contracture cohort (P = .02). After all subsequent procedures (including procedures to address residual stiffness in 1 patient in the HO cohort and 4 patients in the capsular contracture cohort), the flexion arc averaged 116 degrees in the HO cohort and 98 degrees in the capsular contracture cohort (P = .19). Open release of post-traumatic elbow stiffness is more effective when HO hindering motion is removed than when there is capsular contracture alone.
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Kanakaris N, Tsoutseos N. Proximal Radio-Ulnar Synostosis at the Pin-Track Site after External Fixation of the Forearm. Eur J Trauma Emerg Surg 2007; 33:293-6. [PMID: 26814492 DOI: 10.1007/s00068-006-5136-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Accepted: 05/30/2006] [Indexed: 11/28/2022]
Abstract
Posttraumatic synostosis of the forearm bones is a rare but serious complication following fixation or even conservative treatment of adult forearm fractures. This is the second report in the English literature of such a complication at the pin-track site following external fixation of proximal forearm fractures. A 36-year-old male patient sustained an open fracture of his proximal right forearm after a road traffic accident. It was managed by external fixation of the ulna and plate fixation of the radius. At follow-up, a type 3 radio-ulnar synostosis at the pin-track site became evident, which was treated after 20 months with surgical resection of the bony bridge to regain the rotatory motion of his forearm.
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Affiliation(s)
| | - Nikolaos Tsoutseos
- Orthopedic Department of "Evangelismos", General Hospital, Athens, Greece
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Abstract
Repetitive overhead throwing exerts significant mechanical stress on the shoulder and elbow joint; this stress can lead to developmental anatomic changes in the young thrower. Asymptomatic pathology in the shoulder and elbow joint is prevalent and, with overuse, can progress to disabling injury. Joint injury occurs as a result of the body's inability to properly coordinate motion segments during the pitching delivery, leading to further structural damage. Identifying and preventing overuse is the key to avoiding injury, particularly in the young pitcher. Injury prevention and rehabilitation should center on optimizing pitching mechanics, core strength, scapular control, and joint range of motion.
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Tan V, Daluiski A, Simic P, Hotchkiss RN. Outcome of open release for post-traumatic elbow stiffness. ACTA ACUST UNITED AC 2006; 61:673-8. [PMID: 16967006 DOI: 10.1097/01.ta.0000196000.96056.51] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Post-traumatic elbow stiffness can be caused by a tether and/or a block, and these structures can exist both anteriorly and posteriorly about the joint to prevent motion. The purpose of this article is to report the outcome of elbow release performed for post-traumatic stiffness by a single surgeon. METHODS A retrospective review of charts and radiographs was performed on 52 case of patients who underwent open surgical treatment for post-traumatic elbow contracture by the senior author (RHN). The mean age of the group was 35.1 years. There were 32 men and 20 women. Contracture release surgery was performed at an average of 14 months from the time of injury. Indication for operative release was functional loss of elbow arc of motion that failed nonoperative therapy and splinting program. Follow-up was 18.7 months. Comparison of ranges of motion was performed with Student's paired t tests. RESULTS The average extension-flexion arc of motion improved from 57 to 116 degrees and forearm rotation improved from 119 to 145 degrees postoperatively. Fourteen patients (27%) required closed manipulation under anesthesia, in the early postoperative period. Five patients required a second contracture release at an average of 12 months after the index release. Four patients failed because of painful motion (n = 2) and elbow instability (n = 2). Other complications included wound infection (n = 3), cubital tunnel syndrome (n = 3) and reflex sympathetic dystrophy (n = 1). CONCLUSIONS Open elbow release with excision of tethers and blocks is a valuable procedure for post-traumatic stiffness. Recurrence in postoperative period is common but is responsive to manipulation under anesthesia and repeat releases.
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Affiliation(s)
- Virak Tan
- Division of Hand and Microsurgery, Department of Orthopaedics, University of Medicine and Dentistry of New Jersey-The New Jersey Medical School, Newark, New Jersey 07101-1709, USA.
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Mortazavi SMJ, Asadollahi S, Motamedi M. Operative treatment of anterior heterotopic bone formation of the elbow in a patient with severe haemophilia A. Haemophilia 2006; 12:444-7. [PMID: 16834750 DOI: 10.1111/j.1365-2516.2006.01295.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is no statistical data on the incidence of heterotopic ossification among patients with haemophilia, and a few reports documenting this entity in haemophilia are available. Although post-traumatic heterotopic ossification about the elbow is a well-recognized complication, we are not aware of any previously reported case in haemophiliacs. An 8-year-old boy with severe haemophilia A presented with fixed elbow in 80 degrees of flexion. Radiographs disclosed a mature anterior heterotopic ossification in the form of complete ulnohumeral bony bridge. Surgical excision of the heterotopic bone was performed. A full elbow range of motion was obtained after long-term physiotherapy. We conclude that this surgery is safe and successful in haemophilic patients, if performed at the right time under optimal situation.
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Affiliation(s)
- S M J Mortazavi
- Department of Orthopedic Sugery, Imam Hospital Haemophilia Centre, Tehran University of Medical Sciences, Tehran, Iran.
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