Arthroscopic arthrolysis leads to improved range of motion and health-related quality of life in post-traumatic elbow stiffness

Prevalence, Timing, Locational Distribution, and Risk Factors for Heterotopic Ossification After Elbow Arthroscopy

BACKGROUND

Arthroscopic techniques aim to reduce complications and accelerate recovery of the elbow after treatments for posttraumatic stiffness, arthritis diseases, lateral epicondylitis, ligament reconstruction, and elbow trauma. However, data on the true prevalence and characteristics of heterotopic ossification (HO) formation after elbow arthroscopy are limited.

PURPOSE

To investigate the prevalence, timing, locational distribution, and risk factors of HO after elbow arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 4.

METHODS

Data on 205 patients undergoing elbow arthroscopy by a single senior elbow surgeon at a single institution between May 2011 and January 2022 were retrospectively reviewed. The patients were evaluated at 2 weeks, 8 weeks, 6 months, and then annually after surgery or more frequently if HO developed, with a minimum of 1 year of postoperative follow-up. Postoperative anteroposterior and lateral elbow radiographs were taken at 2 weeks to rule out fracture and at 8 weeks to identify HO. The clinical outcomes were evaluated based on the pain visual analog scale; the shortened version of the Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and the Single Assessment Numeric Evaluation scores before and after surgery. Bivariate logistic regression analyses were used to determine factors affecting HO prevalence.

RESULTS

Thirteen (12 male, 1 female) of 205 (6.3%) patients developed HO, with 10 (76.9%) with HO that formed on the medial compartment of the elbow. Ten (76.9%) patients were diagnosed at 8 weeks after arthroscopic surgery, 1 (7.7%) at 6 months after surgery, and 2 (15.4%) at 12 months after surgery. HO was not found at 2 weeks after surgery in any patient. The mean follow-up time was 3.5 years (range, 1.0-11.8 years). Eleven asymptomatic patients were treated nonoperatively, and 2 symptomatic patients underwent HO excision arthroscopically or had a combination of open surgery and arthroscopy. Age was a protective factor for HO formation (odds ratio [OR], 0.953; 95% CI, 0.910-0.999; P = .047). The risk factors for HO formation were tourniquet time (OR, 1.042; 95% CI, 1.019-1.065; P < .001) and surgical time (OR, 1.026; 95% CI, 1.011-1.041; P < .001).

CONCLUSION

Among 205 patients who underwent elbow arthroscopy, HO was a minor complication of elbow arthroscopy, with a prevalence rate of 6.3%, and was usually located on the medial compartment of the elbow. Although the presence of HO may not affect the clinical outcomes in most patients, it should be carefully monitored for a minimum of 8 weeks postoperatively. Younger age, longer tourniquet time, and longer surgical time contributed to HO formation after elbow arthroscopy.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

Arthroscopic Capsular Release for Post-traumatic Elbow Stiffness

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incidence of Repeat Elbow Capsular Release After Arthroscopic Elbow Capsular Release

Background

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

Purpose/Hypothesis

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

Study Design

Case series; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

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

INTRODUCTION

Elbow stiffness significantly affects the patient's quality of life. This joint must have at least 30°/130° extension/flexion and 50°/50° pronation/supination to function normally according to Morrey.

HYPOTHESIS

The objective of this study was to evaluate functional outcome of arthroscopic arthrolysis by comparing stiffness of post-traumatic and degenerative origin. The hypothesis was that this surgical technique allows functional improvement in any indication but with a faster result in degenerative pathology.

MATERIAL AND METHODS

This was a retrospective study including all patients who underwent elbow arthrolysis under arthroscopy, operated on by a single operator, between 2013 and 2020. Thirty-four patients were included, with a mean age of 45years (range, 18-78years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33years (range, 18-64years) and group B (degenerative) of 16 patients with a mean age of 59years (range, 42-78years). All patients were clinically assessed at a mean 27months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected.

RESULTS

In the overall series, preoperative range of motion was 81° and significantly improved postoperatively to 122° (p<0.001). The preoperative data of the 2 groups were comparable except for age (p<0.001) and MEPS (p=0.044). Postoperatively, range of motion improved significantly in both groups but with greater gain in group A (p=0.003). MEPS improved significantly in both groups, but the postoperative score was poorer in group B (p=0.001). Recovery of range of motion was faster in group B (2.4months) than in group A (3.7months) (p=0.021). There were 5 complications: 4 secondary decompensations of ulnar tunnel syndrome, and 1 postoperative radial nerve paresis. 94% of patients were satisfied or very satisfied with the result of surgery.

CONCLUSION

Arthroscopic arthrolysis is an effective option for post-traumatic and non-traumatic elbow stiffness. Improvement was significant in terms of both function and range of motion, with, however, better results in the post-traumatic group but results achieved more rapidly in the degenerative pathology group.

LEVEL OF EVIDENCE

IV, retrospective study.

Application of ultrasound in avoiding radial nerve injury during elbow arthroscopy: a retrospective follow-up study

BACKGROUND

A safe and effective technique for anterolateral portal placement in elbow arthroscopy is significant. We compared the outcomes of patients who underwent elbow arthroscopy using different ultrasound-assisted techniques.

METHODS

From May 2016 to June 2021 a retrospective analysis on all patients who underwent elbow arthroscopy in our department was performed. Patients were separated into three groups: non-ultrasound; preoperative ultrasound; and intraoperative ultrasound. The minimum follow-up period was 1 year. Nerve injuries, visual analog scale (VAS), Mayo elbow-performance score (MEPS), Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), and range of motion (ROM) of the elbow were evaluated for comparison among the three groups pre- and post-operatively.

RESULTS

All 55 patients completed a 1-year follow-up: non-ultrasound (n = 20); preoperative ultrasound (n = 17); and intraoperative ultrasound (n = 18). There were 3 cases (15.0%) of transient radial nerve palsy in the non-ultrasound group. No nerve complications occurred in preoperative ultrasound and intraoperative ultrasound groups. The probability of postoperative radial nerve injury in the three groups was statistically different (P < 0.05). There was no significant difference in the VAS score, MEPS, DASH score, and ROM among the three groups at the follow-up evaluation (P > 0.05).

CONCLUSION

Performing anterolateral portal placement during elbow arthroscopy with ultrasound-assisted techniques successfully avoided radial nerve injury.

Complications of Elbow Arthroscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Elbow arthroscopic surgery has been popularized and has made significant progress during the past 3 decades. The elbow joint is relatively small and is in close proximity to many neurovascular structures. These factors make elbow arthroscopic surgery technically demanding and liable to complications.

PURPOSE

To evaluate the rate of complications after elbow arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis. PubMed, Web of Science, and Embase were searched up to July 2021. All clinical studies that reported complications after elbow arthroscopic surgery were included; a total of 1208 articles were initially found. Case reports, reviews, abstracts, imaging studies, technique studies, nonclinical studies, and those not reporting postoperative complications were excluded. Complication rates were pooled across studies and reported as percentages. Complications were expressed as weighted proportions with 95% CIs.

RESULTS

A total of 95 studies (14,289 elbows) were included in the meta-analysis. The overall weighted complication rate was 11.0% (95% CI, 8.8%-13.5%), with postoperative stiffness being the most commonly encountered complication (4.5% [95% CI, 2.1%-7.6%]; 158/8818 procedures). The second most encountered complication was the need for subsequent surgery with a weighted proportion of 4.1% (95% CI, 2.9%-5.6%; 177/8853 procedures) followed by nerve injury with a weighted proportion of 3.4% (95% CI, 2.6%-4.3%; 267/13,725 procedures). The ulnar nerve was the most commonly injured nerve (2.6% [95% CI, 1.9%-3.4%]; 123/6290 procedures).

CONCLUSION

The results of this study showed that elbow arthroscopic surgery is a relatively safe procedure with low complication rates.

Role of Tranexamic Acid in Arthroscopic Osteocapsular Release of the Elbow for Degenerative Arthritis

Background

Minimizing intra-articular bleeding and swelling is crucial in preventing the development of stiffness around the elbow. Tranexamic acid (TXA) has been shown to be an effective adjunct in reducing perioperative bleeding after surgery.

Purpose:

To determine the effect of intravenous (IV) TXA on postoperative drain tube output in arthroscopic osteocapsular release of the elbow for primary degenerative arthritis.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors performed a retrospective cohort study of 83 consecutive patients with primary degenerative elbow arthritis who underwent an arthroscopic osteocapsular release between 2015 and 2018. They organized patients into a no-TXA group (control) and a group that was given 1.0 g of IV TXA before tourniquet release. The primary outcome measure was drain tube output, and secondary outcome measures included postoperative day 1 pain levels on a visual analog scale and early range of motion at 8 weeks. Differences between groups were analyzed using 1-way analysis of variance, the Mann-Whitney U test, or the Fisher exact test.

Results:

There were 43 patients in the no-TXA group and 40 patients in the TXA group. Administration of IV TXA resulted in a 51% decrease in mean intra-articular bleeding for the TXA group, as measured via drain tube output (88.8 ± 80.5 mL [no-TXA] vs 43.4 ± 52.4 mL [TXA]; P = .0016). In both groups, there were significant increases in elbow arc of motion when compared with preoperative measurements. There were no between-group differences in early range of motion (129.7° ± 12.4° [no-TXA] vs 131.7° ± 9.2° [TXA]; P = .549) or postoperative pain (1.9 ± 2.2 [no-TXA] vs 1.5 ± 1.7 [TXA]; P = .89).

Conclusion:

In this study, IV TXA significantly reduced postoperative intra-articular bleeding in patients who underwent arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. However, there were no differences in postoperative range of motion or pain between patients who received TXA and controls.

Arthroscopic management of elbow stiffness

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