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Arthroscopic management of elbow stiffness and arthritis
OVERVIEW
Chapter synopsis
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Stiffness and contracture of the elbow are common after elbow injury, surgical interventions, and with arthritic conditions. Initial treatments are typically nonoperative and include static bracing and structured rehabilitation. For patients who experience suboptimal motion that severely limits their activities of daily living, surgical intervention is typically indicated. Arthroscopic techniques are a viable alternative to traditional open contracture release.
Important points
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Arthroscopic contracture release of the elbow is a technically demanding procedure that requires intimate knowledge of intracapsular elbow anatomy.
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A thorough evaluation of the entire extremity should be performed preoperatively, including meticulous evaluation of the ulnar nerve.
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A congruent ulnohumeral joint is necessary before pursuit of arthroscopic release; accordingly, severe contractures may be more reliably treated with an open surgical technique.
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Compliance with postoperative rehabilitation protocols is essential in ensuring recovery of elbow motion after surgical contracture release.
Clinical/surgical pearls
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The liberal use of retractors is highly recommended, especially after capsulectomy when fluid distention is difficult.
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The anterior release consists of debridement of the radial and coronoid fossae to remove impingement during elbow flexion.
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Anterior capsulectomy is technically easier from a medial-to-lateral direction and is performed more safely proximal to the trochlea to avoid injury to the radial nerve.
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Posterior release consists of debridement of the olecranon fossa as well as removal of osteophytes from the tip of the olecranon to allow for unimpeded elbow extension.
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We recommend ulnar nerve decompression in patients who demonstrate provocative ulnar neuropathic symptoms and in patients who experience a significant loss of flexion preoperatively.
Clinical/surgical pitfalls
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If visualization is compromised or if concern exists intraoperatively regarding the ability to safely perform an adequate release arthroscopically, the surgeon should be prepared to convert the procedure to an open approach.
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Anterior capsulectomy should be performed with extreme diligence, as the radial nerve lies directly anterior to the radiocapitellar joint; capsulectomy is most safely initiated proximal to the trochlea.
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Posteromedial capsulectomy places the ulnar nerve at risk of injury; we recommend identifying and decompressing the ulnar nerve through a limited open approach before proceeding with posteromedial capsulectomy.
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Risk to the ulnar nerve can be minimized by avoiding the use of suction or a bur in proximity to the nerve.
Introduction
Stiffness is one of the commonest complications and consequences of elbow trauma, elbow surgery , and arthritic conditions. The predisposition of the posttraumatic or arthritic elbow to develop contracture has been attributed to several factors, including the intrinsic congruity of the ulnohumeral articulation, the presence of three articulations within a synovium-lined cavity, and the intimate relationship of the capsule to the intracapsular ligaments and extracapsular muscles.
Several authors have evaluated the elbow motion necessary to complete daily activities; these studies have reported that a majority of activities could be reasonably performed within a functional arc of 100 degrees (30 to 130 degrees) of flexion and extension of the elbow and 100 degrees of rotation of the forearm (50 degrees each for pronation and supination). The inability of the posttraumatic or arthritic elbow to achieve this motion may result in substantial impairment of upper extremity function, especially with the loss of elbow flexion and forearm supination, which are difficult to compensate for.
Nonoperative management for stiffness remains the initial modality of treatment and typically includes static splinting as well as structured rehabilitation and physical therapy dedicated toward regaining functional range of motion. These modalities are particularly useful for the first 6 to 12 months post-injury but become less successful in cases of more remote trauma. For patients whose elbow contracture is refractory to conservative measures, surgical debridement and release of the elbow are offered in an effort to restore functional motion of the joint. Although open approaches have been classically described, arthroscopic techniques are less invasive alternatives for the treatment of elbow stiffness and demonstrate similar outcomes within the literature.
Pre-operative considerations
History
It is imperative for the practitioner to determine the extent to which the loss of elbow motion compromises a patient’s functional capabilities. The magnitude of functional impairment, rather than absolute loss of motion, ultimately directs management decisions when treating the patient with posttraumatic contracture of the elbow. In addition to posttraumatic arthritis, other degenerative conditions such as primary osteoarthritis and inflammatory arthritis can also lead to painful elbow range of motion, loss of motion, or mechanical symptoms. Activities such as involvement in heavy labor, competitive throwing, or weightlifting can predispose to the formation of elbow osteoarthritis. A careful review of the patient’s medical and social histories may provide insight into the etiology of the patient’s elbow complaints.
For the posttraumatic elbow, the details surrounding any index and subsequent injuries as well as mechanism of trauma are important aspects of the history. Many of these patients will have undergone previous surgical treatment, and it is critical to obtain and review previous operative documentation, especially when arthroscopic treatment is being considered. Prior ulnar nerve transposition is critical to assess. Complications related to initial treatments, including infection, neurologic deficits, or other ipsilateral limb injuries, all potentially influence future management. In addition, details regarding the patient’s progress or, more important, lack of progress with structured rehabilitation should be elicited during the history taking.
Physical examination
Physical examination begins with inspection of the entire upper extremity, specifically evaluating for deformity, swelling, and muscle atrophy while noting the location of any previous surgical incisions that would influence further surgical planning. Range-of-motion evaluation should include the hand, wrist, forearm, and elbow and should be compared with the contralateral, unaffected extremity. In the posttraumatic setting, loss of extension is more common than loss of flexion. Patients with other elbow arthritides, especially osteoarthritis, may complain of pain at terminal flexion and extension from osteophytosis and impingement.
A careful neurovascular examination is essential, especially during the evaluation of ulnar nerve function. If the ulnar nerve has not be previously transposed, the ulnar nerve may become entrapped in scar tissue along the medial elbow after trauma, which may result in posttraumatic ulnar neuropathy. Traction ulnar neuritis of the elbow may manifest as medial elbow pain, and patients may report sensory changes in an ulnar nerve distribution, particularly with elbow flexion. Patients with posttraumatic ulnar neuropathy may simply have loss of flexion and medial elbow pain in the absence of overt symptoms of ulnar neuropathy; thus, a meticulous neurovascular evaluation, including assessment of two-point discrimination, pinch strength, and intrinsic muscle function, are essential to document the preoperative function of the ulnar nerve. Elbow stability must also be assessed, in particular to rule out subtle posterolateral rotatory instability as a cause of the patient’s complaints of stiffness.
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