Upper limb

Open arthrolysis for post-traumatic stiffness

of the elbow
RESULTS ARE DURABLE OVER THE MEDIUM TERM

S. Sharma, We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for
L. A. Rymaszewski post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of
movement of the elbow, pain scores and functional outcomes were recorded pre- and post-
From Glasgow Royal operatively. An improvement in the mean range of movement from 55˚ (0˚ to 95˚) to 105˚
Infirmary, Glasgow, (55˚ to 135˚) was obtained in our patients at one year. This improvement was maintained
Scotland over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and
patient satisfaction was recorded in 23 of the 25 patients at final follow-up.
On the basis of this study, we believe that the results of open arthrolysis for post-
traumatic stiffness of the elbow are durable over the medium term.

Post-traumatic stiffness is common following was 7.8 years (5 to 10.8). We excluded patients
injury to the elbow joint. The presence of three with an associated head injury, rheumatoid
articulations with a single synovial tissue-lined arthritis or primary osteoarthritis. According
capsule, the close proximity of the joint cap- to the classification of Mansat and Morrey10
sule to the ligaments and extracapsular muscle, 23 patients had an intrinsic injury to the elbow
and the intrinsic congruity of the humeroulnar and two an extrinsic injury.
articulation have all been suggested as pre- Open arthrolysis was performed under a
disposing factors.1-3 Fortunately, most activi- combination of regional anaesthesia (continu-
ties of daily living are performed within a 100˚ ous brachial plexus block) and general anaes-
arc of movement between 30˚ and 130˚.4 How- thesia. A lateral approach was used in six
ever, if the patient has an extension deformity patients, a posterior approach in 16, and a
of more than 30˚ and flexion of less than 130˚ combination of lateral and medial approaches
six months after the injury which is not in three. The surgical technique in all patients
improving, elbow arthrolysis should be consid- included releasing the contracted capsule, lat-
ered. A number of papers over the last decade eral collateral ligament and posterior band of
have reported the early benefit of elbow medial collateral ligament. A triceps and bra-
arthrolysis for post-traumatic stiffness with a chialis tenolysis was performed using a peri-
mean follow-up of 3.5 years (1 to 4).1-3,5-16 The osteal elevator. Any bony sources of
aim of this study was to assess the medium- impingement affecting flexion and extension

S. Sharma, FRCS(Tr & Orth), term results of open elbow arthrolysis in were removed. This included excision of the tip
Specialist Registrar
Orthopaedics patients with a minimum follow-up of five of the coronoid and olecranon and burring out

L. A. Rymaszewski, FRCS, years. the radial and olecranon fossae if necessary. If
Consultant Orthopaedic
Surgeon a satisfactory range of movement could not be
Glasgow Royal Infirmary, Patients and Methods obtained despite these measures, the elbow
Castle Street, Glasgow G4 0SF,
UK. A retrospective review of 25 patients who had joint was subluxed, any intra-articular adhe-
Correspondence should be sent
an open elbow arthrolysis for post-traumatic sions cleared, and the articular surfaces of the
to Mr S. Sharma; e-mail: stiffness between October 1991 and May incongruous humeroulnar joint were ‘sculpted’
sssharma2@[Link]
1997 was undertaken (Table I). All patients with a burr. Resection of the radial head was
©2007 British Editorial Society had an extension deformity of > 30˚ and flex- performed in five patients. Continuous passive
of Bone and Joint Surgery
doi:10.1302/0301-620X.89B6.
ion of < 130˚. All had a congruous humeroul- movement of the elbow under brachial plexus
18772 $2.00 nar joint at the time of arthrolysis. There were block was used post-operatively for a mean of
J Bone Joint Surg [Br]
19 men and six women, with a mean age of 34 three days (2 to 3.5). A fine catheter was
2007;89-B:778-81. years (15 to 62) at the time of operation. The threaded into the brachial sheath through
Received 11 October 2006;
Accepted after revision 2 March
median interval between injury and arthrolysis which a low dose of bupivacaine (0.125%)
2007 was 13 months (5 to 420). The mean follow-up was infused, the dosage being titrated against

778 THE JOURNAL OF BONE AND JOINT SURGERY

 OPEN ARTHROLYSIS FOR POST-TRAUMATIC STIFFNESS OF THE ELBOW 779

Table I. Details of the 25 patients who had an open elbow arthrolysis

Mean age (yrs) 34 (15 to 62)

Gender
M:F 19:6

Median interval between injury and open elbow arthrolysis (mths) 13 (5 to 420)
Mean follow-up (mths) 7.8 (5 to 10.8)

Elbow injury (Morrey grade18)

Intrinsic:extrinsic 23:2

Initial injury
Fracture distal humerus 12
Fracture radial head 4
Fracture olecranon/proximal ulna 2
Fracture radial head + proximal ulna 3
Posteror dislocation elbow 2
Fracture-dislocation elbow 2

the patient’s pain. In addition, patients also had the use of a improvement was maintained over a mean follow-up of 7.8
continuous morphine pump in the post-operative period. years (5 to 10.8), to 110˚ (45˚ to 140˚; p = 0.12). The ROM
Patients were discharged after three days and advised to remained within 10˚ of the ROM obtained one year after
actively mobilise their elbow. None received physiotherapy arthrolysis in 15 patients, eight showed a subsequent
after discharge, and none received any prophylaxis against increase in the ROM of more than 10˚ (10˚ to 30˚), and two
heterotopic ossification. deteriorated by 20˚ (15˚ to 25˚). Mean elbow flexion
At follow-up the range of movement (ROM) was mea- improved from 115˚ to 135˚ (improvement of flexion, 0˚ to
sured using a goniometer, pain by a visual analogue score 85˚), and mean extension improved from 60˚ to 30˚ (range
(VAS),17 and function by the Mayo Elbow Performance of improvement of extension 0˚ to 60˚; p < 0.001) over the
Index.18 Physical examination recorded the presence of mean follow-up of 7.8 years.
crepitus on movement, pain over the humeroulnar and Peak pain and the general level of pain decreased from a
capitellar-radial joints, medial and lateral instability, and mean of 4.5 (1 to 9) on the VAS to a mean of 2.0 (0 to 8) at
motor and sensory function in the limbs. Anteroposterior the one-year post-operative assessment (p < 0.001). There
and lateral radiographs of the elbow were taken and com- was a marginal increase in pain, with a mean score of 2.5
pared with previous radiographs for the appearance of (0 to 8) at the latest post-operative assessment (p = 0.08).
osteophytes, changes in joint degeneration, and the pres- Of the 25 patients, 23 had some relief of pain following
ence of heterotopic bone. arthrolysis. One pat ient had no relief of pain and one
The pre-operative ROM, VAS and Mayo Elbow Perfor- reported an increase in pain at the one-year post-operative
mance scores were compared with those at one year after assessment. This pain, however, improved following ulnar
arthrolysis. The Mayo score considers the variables of pain nerve decompression and she was free from pain at her lat-
(45 points), ROM (20 points), stability (10 points), and est follow-up.
function (25 points) with a maximum score of 100. A score The mean Mayo score improved from a pre-operative
of 60 to 74 was considered a fair result, 75 to 89 good, and level of 65 (5 to 70) to 90 (50 to 100) at the one-year assess-
90 to 100 excellent.12 We chose the results one year after ment (p < 0.001) and to 85 (50 to 100; p = 0.12) at the lat-
operation as a reference point for comparison with the lat- est follow-up.
est follow-up results because the ROM, VAS and Mayo Of the 25 patients, 22 were satisfied with the outcome.
scores continued to improve up to one year after arthroly- One patient had an improvement in ROM but increased
sis. pain which resolved following ulnar nerve decompression
The results were analysed using Student’s two-tailed t-test 18 months after her arthrolysis. She was satisfied at her last
for ROM and Wilcoxon’s rank-sum test for the VAS and assessment. Two patients were dissatisfied both at their
the Mayo score. A p-value of 0.05 was regarded as signifi- one-year post-operative assessment, and at final follow-up.
cant. On examination, no patient had crepitus during active
flexion and extension of the elbow. None had instability of
Results the elbow, but five had some local tenderness. Three com-
The total range of elbow movement improved in 23 of 25 plained of paraesthesia in the ulnar nerve distribution,
patients. Improvement in the arc of movement increased although none had motor weakness. Radiological evidence
from a mean of 55˚ (0˚ to 95˚) pre-operatively to 105˚ (55˚ of progressive humeroulnar degeneration was seen in four
to 135˚) one year after arthrolysis (p < 0.001). This patients, but three did not notice any increase in pain.

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780 S. SHARMA, L. A. RYMASZEWSKI

Post-operative triceps avulsion occurred in one patient, reported in the literature.1-3,5-16 However, the results at a
in whom arthrolysis was performed 35 years after an intra- mean follow-up of 7.8 years show no significant change in
articular fracture of the distal humerus with residual exten- either ROM or the Mayo score compared with those one
sion of 70˚ and flexion of 100˚. There was no improvement year after surgery.
in the ROM and he refused further surgery. One patient, in All except two patients were satisfied with the result at
whom we performed a revision arthrolysis for post- final follow-up. One, who developed a triceps avulsion
operative stiffness following an intra-articular fracture of post-operatively, refused further surgery and continued to
the humerus with an associated type I18 open fracture of the have only 70˚ of extension. In this patient arthrolysis was
mid-shaft of the radius and ulna, required a further revision performed 35 years after an intra-articular fracture of the
arthrolysis 18 months later, as the improvement in exten- distal humerus. The long period of pre-operative stiffness
sion from 70˚ to 50˚ was lost in the post-operative period. may have been a contributing factor to the failure of the
Following revision arthrolysis, there was no improvement procedure. Cikes et al,12 in a recent paper, reported that the
in extension, although her flexion improved from 100˚ to best results following open elbow arthrolysis were achieved
130˚. No patient developed an infection or had any prob- when the procedure was performed within one year of the
lems with their wound in the post-operative period. initial injury. The other dissatisfied patient had three
attempts at arthrolysis, two of which were performed by us.
Discussion Her range of flexion improved from 100˚ to 135˚, but
Established loss of movement following elbow injury can extension did not improve from the pre-operative value of
occasionally be treated by conservative measures such as 70˚. Injuries to the ipsilateral radius and ulna sustained at
braces or dynamic splints. Gausepohl, Mader and the time of injury may have contributed to her poor out-
Pennig19 recently reported satisfactory results in 14 cases come.
of post-traumatic elbow stiffness in children and adoles- The main weakness of this study is the limited number of
cents treated by mechanical distraction, but the results of patients available with a minimum five-year follow-up.
other studies have been unpredictable.20-22 However, all the surgical procedures were carried out by a
Recent papers on arthroscopic arthrolysis of the elbow single surgeon (LAR) and all patients followed the same
for post-traumatic stiffness report an improvement in post-operative regimen. A standard method of data collec-
movement ranging between 18˚ and 50˚.23-27 However, tion was used both pre-operatively and during the follow-
this procedure is not without risk. Transection of the up period. We have shown that open arthrolysis of the
median and radial nerves during the procedure has been elbow combined with continuous brachial plexus block
reported.28 Arthroscopic arthrolysis may have a role in and continuous passive movement in the post-operative
the treatment of primary osteoarthritis of the elbow,29,30 period can improve ROM and function in patients suffering
but its role in post-traumatic elbow stiffness remains from post-traumatic stiffness of the elbow, and that this
debatable. Many patients who have post-traumatic improvement can be maintained over a mean follow-up of
elbow stiffness following fixation of an intra-articular 7.8 years.
fracture require removal of the metalwork, which may be No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
a source of impingement, and open elbow arthrolysis can
easily be performed at the same time.
Open arthrolysis has been the gold standard for the References
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