Musculoskelet Surg (2014) 98 (Suppl 1):S77–S85 DOI 10.1007/s12306-014-0326-z
ORIGINAL ARTICLE
Factors affecting choice of open surgical techniques in elbow stiffness G. Giannicola • G. Bullitta • D. Polimanti S. Gumina
•
Received: 31 December 2013 / Accepted: 28 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
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 (mASES) 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
G. Giannicola (&) G. Bullitta D. Polimanti S. Gumina Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, ‘‘Sapienza’’ University of Rome, Via Emilio Repossi 15, 00158 Rome, Italy e-mail: [email protected]
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. Keywords Elbow stiffness Osteoarthritis Elbow arthroplasty Radiocapitellar replacement Radial head replacement Total elbow replacement
Introduction Elbow stiffness frequently leads to a significant functional limitation of the upper limb and, consequently, to a reduction in the quality of life [1–4]. Post-traumatic and inflammatory conditions are the most frequent causes of severe elbow stiffness [5–7]. According to Morrey, this condition may be classified as either extrinsic or intrinsic [8]; however, the most frequently observed type is mixed stiffness, which is characterized by both extrinsic and intrinsic alterations. Surgical treatment is often the only effective option for the stiff elbow, especially in intrinsic contractures [5–7]. Over the years, a number of surgical procedures have been proposed and have yielded satisfactory clinical results: these may be classified as either non-replacement or replacement procedures; these procedures are frequently performed together when intrinsic and extrinsic factors coexist in the same patient [9–15]. One issue that is currently debated is the choice of the most adequate surgical technique in each patient, since the pathoanatomy of the stiff elbow and the patient’s characteristics may vary markedly. This considerable variation makes it difficult to draw up a reliable classification based on shared therapeutic algorithms that may be consulted
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easily, forcing surgeons to select treatment on the basis of their own, personal experience. The aim of our prospective study was to investigate the factors involved most in the choice of surgical procedures by analyzing the clinical outcomes of open treatment in a group of consecutive patients with elbow stiffness. We hypothesized that the degree and site of elbow cartilage wear are the factors that affect the choice of treatment most.
Materials and methods Study population and clinical assessment In 3 years, 41 consecutive patients underwent surgery for elbow stiffness performed by the same surgeon (G.G.). The patients comprised 27 men and 14 women, with a mean age at surgery of 48 years (16–81). Elbow stiffness was caused by post-traumatic condition in 32 patients, primary osteoarthritis in seven and rheumatoid arthritis in two. The dominant elbow was involved in 21 patients; the right elbow was involved in 20 cases and the left elbow in the remaining 21 cases. The primary injury of patients with post-traumatic elbow stiffness was an intra-articular fracture of the distal humerus in 11 patients, the terrible triad in 8, a fracturedislocation of the proximal ulna and radius (Monteggia like-lesions) in 6, a radial fracture associated with dislocation in 4, an olecranon fracture in 2 and a simple elbow dislocation in 1 patient. The treatment of the initial injury in this group of patients was surgical in 18 cases and conservative in 14 cases, though with unsatisfactory clinical results in all the cases. Stiffness in all the patients was classified as mixed and extrinsic in 28 and 13 cases, respectively. According to the Este`ve classification, stiffness was rated as minimal in 8 cases, moderate in 13, severe in 13 and very severe in 7 [16]. Sixteen patients exhibited ulnar neuropathy at the preoperative clinical evaluation: 12 patients presented an isolated sensory dysfunction, while 4 patients presented an associated motor and sensory dysfunction. An electromyographic evaluation was performed to confirm the presence and the severity of the ulnar neuropathy in all 16 cases. Prior to surgery, all the patients underwent a clinical, radiographic and CT evaluation with 2D and 3D reconstructions. The pre- and post-operative clinical evaluations were accomplished according to the Mayo Elbow Performance Score and Index (MEPS and MEPI), the modifiedAmerican Shoulder and Elbow Surgeons (m-ASES) and the Q-DASH scores [17–19]. On the pre-operative radiographs, 27 patients had signs of osteoarthritis. These signs were classified as moderate in
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19 and severe in 8, according to Broberg and Morrey [20]. The two patients with rheumatoid arthritis were rated as type IIIa, according to the Morrey and Adams classification [21]. Heterotopic ossification (HO) was observed in 17 post-traumatic patients: there were 1 type I, 12 type IIA, 1 type IIB, 2 type IIC and 1 type IIIC, according to the Hastings and Graham classification [22]. Surgical treatment Before surgery, all of the patients had undergone medical therapy and physiotherapy sessions for an average period of 4 months (2–7), though without any benefit. Open surgery was performed on average 49 months (6–300) after the onset of elbow stiffness. Patient positioning and the surgical approaches were chosen depending on the type of procedure required. A prone position was used in 10 patients that underwent a total elbow replacement (TER), while the remaining 31 patients were placed supine with the arm supported on a table. The arm was exsanguinated, and a pneumatic tourniquet was applied for a maximum of 2 h. When possible, the incision was performed over the pre-existing scar. A posterior midline skin incision was performed in 39 patients, a posterolateral skin incision in one and a medial skin incision in one. Seventeen of the 41 patients, who had extrinsic or mixed stiffness and no relevant signs of cartilage degeneration, underwent an ulno-humeral arthroplasty (UHA), which consists in joint debridement with anterior and posterior capsulectomy, release of the triceps brachii and brachialis muscles from the bone surfaces of the distal humerus, removal of osteophytes and loose bodies. Deep dissection in these patients was carried out by means of the bilateral column procedure in 13 cases, the lateral column procedure in 3 and the medial column in 1 case [11, 23]. Neurolysis of the ulnar nerve was carried out in 7 of the 17 patients and was transposed anteriorly in four. The radial head was found to be degenerated or deformed in 7 of the 41 patients. A radial head prosthesis (Radial Head System, Tornier, Saint-Ismier, France) was implanted after the UHA in all these patients but one, in whom the radial neck presented a severe post-traumatic deformity that prevented the radial head prosthesis from being implanted; in this young patient, with an EssexLopresti lesion [24], a type I interposition of anconeus muscle was performed after radial head resection, as described by Morrey and Schneeberger [25]. In this group of seven patients, deep dissection was carried out in five patients by means of the lateral column procedure alone and in two by means of the bilateral column. Neurolysis of the ulnar nerve was performed in one of the seven patients.
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The articular surface of the radiohumeral joint was found to be degenerated in another seven patients, while the ulno-humeral compartment appeared to be preserved, with no or minimal signs of osteoarthritis. After UHA, radiocapitellar replacement was performed in six patients with the Lateral Resurfacing Elbow (Biomet Orthopedics, Warsaw, Indiana). One patient, in whom a radial head prosthesis had been implanted during a previous operation, exhibited elbow stiffness associated with mobilization of the radial implant and wear of the capitellum articular surface. The device was removed from this patient, and a new implant with the UNI-Elbow Radio Capitellum system (Small Bone Innovation, Morrisville, Pennsylvania) was inserted after UHA. Deep dissection was carried out by means of the lateral column procedure alone in four patients and the bilateral column procedure in three cases. In this group of seven patients, neurolysis of the ulnar nerve was performed in three cases. In 10 of the 41 patients, the radio-humeral and ulnohumeral joints surfaces were severely damaged and could not be saved. In these cases, a TER with a linked device (Discovery Elbow System, Biomet Orthopedics, Warsaw, Indiana) was performed. The TER was implanted using the triceps preserving approach in four cases, the New Castle approach in four and the Bryan Morrey approach in two [26–28]. The ulnar nerve was isolated and transposed anteriorly in all these cases. One articular drain and one subcutaneous drain were applied at the end of the surgery in all the patients.
6 weeks. No brace was used in any of the ten patients who underwent TER. Patients were discharged a mean of 3 days post-surgery (2–7). The resumption of most daily activities, including work activities, was allowed from the 8th week, while more demanding physical activities were allowed 3–6 months after surgery, depending on the procedures performed. Patients who underwent TER were instructed in the specific functional limitations related to the presence of the prosthesis, including avoidance of repetitive strain, lifting weights of over 2 kg and leaning completely on the operated limb while getting up from a sitting position and vice versa.
Post-operative treatment
Statistical analysis
The elbow was immobilized in extension with a brachial– antebrachial plaster cast for 48 h in a raised position in all the patients, and cryotherapy was applied. Prophylaxis for HO with 100 mg/day of indomethacin was administered from the second day post-surgery for the following 5 weeks. On the second day, after the removal of the drains and the plaster cast, patients were allowed to do selfmanaged active and passive flection–extension and supination–pronation exercises several times a day and to keep the limb extended and raised between the physiotherapy sessions. A hinged elbow brace was used in 30 patients to protect the elbow when one or both collateral ligaments had been detached during the surgical procedure and reinserted at the end of operation. Furthermore, the hinged brace was used to facilitate the recovery of range of motion; in particular, during the night, the brace was locked in maximal extended or flexed position to allow the maintenance of joint range of motion obtained by means of surgery and post-operative physiotherapy. In one patient who suffered from persistent joint instability despite ligament reattachment, a hinged elbow fixator was applied for
All computations were carried out using SPSS software 21.0 (IBM corporation, Armonk, NY, USA). Improvements in the average pre- and post-operative values of the flection, extension, supination, pronation, arc of movement, MEPS, m-ASES and Q-DASH were assessed using paired Student’s t tests. Differences were regarded as significant when p \ 0.05.
Table 1 Pre-operative and post-operative clinical outcomes in all cases Measurements
Pre-operative values average (range)
Post-operative values average (range)
p values
Flection
105° (60–140)
134° (100–150)
\0.0001
Extension
40° (5–85)
15° (0–70)
\0.0001
Arc of movement
66° (0–125)
118° (70–150)
\0.0001
Pronation
61° (0–90)
79° (20–85)
\0.0001
Supination
65° (0–85)
82° (50–90)
\0.0001
MEPS
48 (15–95)
93 (65–100)
\0.0001
Q-DASH
58 (5–96)
15 (0–71)
\0.0001
m-ASES
44 (0–98)
85 (51–99)
\0.0001
m-ASES pain
22 (0–48)
43 (21–50)
\0.0001
Results The average follow-up after the surgical procedures lasted 25 months (12–54). The pre- and post-operative clinical outcomes are reported in Table 1. A significant improvement was observed between pre- and post-operative range of motion and scores. At final follow-up, satisfactory outcomes were observed in 37 out of 41 patients; in particular, the post-operative MEPI was excellent in 27, good in 10 and fair in 4 patients. The pre- and post-operative clinical results divided by type of treatment and etiology are reported in Tables 2 and 3, respectively.
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Table 2 Pre-operative and post-operative results in each surgical procedures Measurements
UHA (17 cases)
UHA with radial head replacement (or 1 anconeus interposition) (7 cases)
UHA with radiocapitellar replacement (7 cases)
Total elbow replacement (10 cases)
Flection
(103.5°) 131°
(124°) 136°
(99°) 130°
(95.5°) 137°
Extension
(42°) 16°
(34°) 8,6°
(31°) 11°
(49°) 22,5°
Arc of movement E/F Pronation
(62°) 115° (70°) 78,5°
(90°) 128° (46°) 81°
(69°) 119° (59°) 82°
(46.5°) 114° (58°) 74,5°
Supination
(71°) 83°
(59°) 81°
(68°) 79°
(61.5°) 83°
MEPS
(49) 91
(59) 94
(48) 97
(33) 87.5
Q-DASH
(52) 11
(53) 13
(59) 13
(76) 25
m-ASES
(51) 86
(46) 86
(43) 90
(24) 77
In brackets pre-operative clinical results
Table 3 Pre-operative and post-operative results divided by etiology Measurements
Clinical results Post-traumatic (32 cases)
Primitive and rheumatoid arthritis (9 cases)
Flection
(105°) 134°
(105,5°) 131°
Extension
(40°) 16°
(38°) 13°
Arc of movement E/F
(65°) 118°
(67°) 118°
Pronation
(57°) 77°
(75,5°) 85°
Supination
(63°) 81°
(74°) 84°
MEPS
(48) 92
(48) 93
Q-DASH
(58) 15
(56) 25
m-ASES
(42.5) 85
(18) 68
In brackets pre-operative clinical results
The four patients with a fair outcome included one who was a heavy drinker with psychiatric disorders; this patient developed stiffness after a periprosthetic fracture caused by a new fall 7 months after TER. The fracture was treated conservatively as the patient demonstrated lack of compliance, with clinically unsatisfactory results. Another patient in this group developed an elbow extrinsic flection contracture after TER, despite the absence of any implantrelated causes of stiffness; he displayed a lack of compliance in the post-operative rehabilitation that probably led to a lower functional result. The last two patients with fair results developed a new ulnar sensory deficit in the postoperative period that affected the final outcomes. At the final follow-up, 13 of the 16 patients with a preoperative ulnar neuropathy displayed a complete recovery of their sensory and motors nerve dysfunctions; a mild lack of strength in the interosseous muscles persisted in the remaining three patients. Two patients had an elbow contracture relapse between surgery and the final follow-up. The first patient, who underwent an UHA associated with radiocapitellar
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replacement, developed a grade IIA posteromedial HO (Fig. 1); a second operation for debridement and HO excision performed 12 months after the first led to a satisfactory final outcome (Fig. 2). The second patient, who underwent an UHA associated with radial head replacement, developed radioulnar synostosis with forearm rotation ankylosis (Fig. 3). In the post-operative period, he discontinued indomethacin prophylaxis for HO because of gastrointestinal bleeding. A second operation performed on this patient 13 months after the first yielded a good final result (Fig. 4).
Discussion In this study, we analyzed the clinical outcomes of stiff elbow open treatment in a group of consecutive patients and assessed the factors that affect the choice of surgical procedures. Our results confirmed our initial hypothesis, according to which the degree and site of elbow cartilage wear are the factors affecting the choice of surgical treatment most. In recent decades, knowledge of the causes of elbow stiffness and its treatment has grown considerably. This has led to various classifications being proposed, some of which are based on the severity of ROM impairment and others on pathogenetic factors [7, 16, 22, 29]. The most frequently used classification is currently the Morrey classification, which divides elbow stiffness into three main types: extrinsic, intrinsic and mixed [7]. Various open or arthroscopic surgical procedures have also been described in recent decades and may be classified as either nonreplacement or replacement procedures [9–15, 30–33]. The only difference between many of the non-replacement surgical procedures, such as OK procedure, open debridement, bilateral column procedure, UHA and extensive release, lies in the type and extent of the deep dissection, the surgical steps all being similar [9–11, 13]. Several studies
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Fig. 1 Radiographs showing, in anteroposterior (a) and in lateral (b) view, the development of a posteromedial heterotopic ossification (white arrow) with elbow stiffness relapse after the first operation (c–f)
have reported good results for each of these surgical procedures in highly selected case series [34–36]. However, the current dilemma for each surgeon is not the lack of effective surgical treatments for elbow stiffness, but the choice of the most suitable surgical technique for each patient since detailed diagnostic and therapeutic guidelines do not yet exist. The lack of a comprehensive algorithm is due primarily to the fact that each patient has a different stiffness pattern, even though the pathoanatomical causes are the same in all patients; in particular, what makes the choice of treatment difficult is the fact that the clinical value of each pathoanatomical alteration differs in every patient and is often difficult to quantify pre-operatively. For these reasons, the surgeon, on the basis of his experience, needs to be able to understand the clinical importance of each pathoanatomical alteration in terms of the reduction in the arc of movement, of pain and, sometimes, of instability; in other words, the surgeon needs to be able ‘‘to understand each individual case of elbow stiffness.’’ The low correlation between pathoanatomical changes and symptoms clearly was highlighted in the study by Hasting and Graham;
indeed, they observed that the presence of HO was not clinically significant in the majority of the cases [22]. Another factor that hampers the birth of a comprehensive classification useful for treatment and complicates the choice of surgery is the lack of information on the causes and pathogenetic mechanisms underlying elbow pain [8]. Although the pain mechanism in osteoarthritis is multifaceted, it is well documented in other joints that denuded bone, periosteum irritation and bone marrow lesions are the main causes of pain [37, 38]. Hence, in patients with severe articular cartilage wear, the use of prosthesis it is recommended because with the implant several causes of pain are removed. The importance of pain relief is underlined by recent clinical studies that have shown that the improvement in quality of life in patients treated surgically for elbow stiffness is influenced to a greater extent by the reduction in pain than by the improvement in the arc of motion [4, 39]. Lastly, the patient’s general characteristics such as age, affected side, general state of health and specific functional requirements are other important factors that may affect the choice of treatment [8, 40].
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Fig. 2 Pictures showing the radiographs (a, b) and clinical evaluation (c–f) after second operation for debridement and HO excision
Fig. 3 Radiographs showing, in anteroposterior (a) and in lateral (b) view, the development of radioulnar synostosis (white arrows) with forearm rotation ankylosis (c)
In the light of these considerations, the aim of our study was to evaluate which factors most influence the choice of treatment and the final clinical outcome in a consecutive
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series of patients. In our case series, which included a high number of patients affected by post-traumatic conditions, patients with rheumatoid arthritis and patients with primary
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Fig. 4 Post-operative radiographs (a, b) and clinical evaluation (c–f) showing a satisfactory outcome 13 months after the second operation
osteoarthritis, we performed a wide range of non-replacement and replacement surgical procedures and, last but not least, neurolysis–transposition of the ulnar nerve. All these procedures were combined with one another in various combinations depending on the pathoanatomical conditions underlying the clinical symptoms of each patient. In particular, UHA was carried out in patients in whom extrinsic factors were present, such as HO, capsular and muscular retraction, as well as in those with osteophytosis. In our series, UHA was performed in all patients. The factor that most affected the choice of other surgical techniques, such as replacement procedures, was the presence of cartilage wear associated with pain; ultimately, an evaluation of the site and degree of osteoarthritis led to the surgical procedure being customized in each patient. In patients with lateral compartment degeneration, the UHA was associated with a partial or total radiocapitellar joint replacement. In particular, in subjects in whom prono-supination was limited by the deformity and wear of the radial head, we used a radial head prosthesis. In such cases, the release of the quadrate ligament and the reconstruction of the LCL were
often required to recover rotation and stability, respectively. In other cases with radiocapitellar joint wear, we adopted a lateral resurfacing implant when articular surface degeneration was not associated with deformity of the radial head circumference and capitellum; by contrast, in one case with stiff elbow and radial head prosthesis mobilization, we performed an UHA associated with radiocapitellar replacement, adopting the UNI-Elbow Radio Capitellum System since this type of implant allows radial head prosthesis revision. Only in one young patient, with severe rotatory stiffness and pain due to radial head degeneration and deformity of the proximal radius associated with a chronic Essex-Lopresti lesion, did we perform a radial head resection and interposition arthroplasty with the anconeus muscle because it was impossible to perform a radial head replacement. A TER was performed in patients with severe arthritis or/and deformity of the ulno-humeral joint. Before implantation of the prosthetic device, extensive debridement and neurolysis of the ulnar nerve were always performed in such patients. We adopted various approaches in
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the earlier cases in our patient series, preferring triceps detachment in patients with severe post-traumatic elbow stiffness, as recommended in several studies [27, 41]. However, in our department, we now perform TER using the triceps preserving approach in all cases; although this procedure significantly extends the surgical times, it reduces post-operative pain, accelerates the recovery of range of motion and prevents triceps weakness in our experience. Lastly, in keeping with the results of previous studies, our findings suggest that the patient compliance during the post-operative rehabilitation period is an important factor that may affect the final clinical outcome [39]. At the last follow-up evaluation, two patients who displayed a lack of compliance yielded unsatisfactory results and suffered from elbow stiffness relapse. These data highlight the need to carefully evaluate the patients’ psychological characteristics before surgery, particularly when a TER is planned. The main limitation of our study is the relatively low number of patients analyzed. Indeed, studies on larger consecutive patient series are warranted to gain an even better understanding of all factors that may influence the choice of treatment for elbow stiffness and clinical results. In conclusion, our study shows that elbow stiffness surgery needs to be carefully planned by taking into account the clinical value of each patient’s pathoanatomical conditions in order to guarantee the recovery of function and pain relief. In particular, the factor that affects the choice of open surgical techniques most is the presence of joint deformities and osteoarthritis. Indeed, debridement procedures are performed in all cases, whereas replacement procedures are selected according to each patient’s characteristics. The best final clinical results were achieved when surgical treatment significantly reduced pain and led to the recovery of elbow motion. Conflict of interest No financial or other relationships that might lead to a conflict of interest are present in this article. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. No funds were received in support of this study. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification. Human and Animal Studies The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.
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S85 30. Redden JF, Stanley D (1993) Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 9:14–16 31. Ogilvie-Harris DJ, Gordon R, MacKay M (1995) Arthroscopic treatment for posterior impingement in degenerative arthritis of the elbow. Arthroscopy 11:437–443 32. Savoie FH, Nunley PD, Field LD (1999) Arthroscopic management of the arthritic elbow: indications, technique, and results. J Shoulder Elb Surg 8:214–219 33. Marinelli M, Bettelli G, Guerra E, Nigrisoli M, Rotini R (2010) Mobilization brace in post traumatic elbow stiffness. Muskuloskelet Surg 94:37–45 34. Oka Y (2000) Debridement arthroplasty for osteoarthrosis of the elbow: 50 patients followed mean 5 years. Acta Orthop Scand 71(2):185–190 35. Park MJ, Kim HG, Lee JY (2004) Surgical treatment of posttraumatic stiffness of the elbow. J Bone Jt Surg Br 86(8): 1158–1162. doi:10.1302/0301-620X.86B8.14962 36. Sharma S, Rymaszewski LA (2007) Open arthrolysis for posttraumatic stiffness of the elbow: results are durable over the medium term. J Bone Jt Surg Br 89(6):778–781. doi:10.1302/ 0301-620X.89B6.18772 37. Felson DT, Chaisson CE, Hill CL, Totterman SM, Gale ME, Skinner KM et al (2001) The association of bone marrow lesions with pain in knee osteoarthritis. Ann Intern Med 134:541–549 38. Haviv B, Bronak S, Thein R (2013) The complexity of pain around the knee in patients with osteoarthritis. Isr Med Assoc J 15(4):178–181 39. Lindenhovius AL, Jupiter JB (2007) The post traumatic stiff elbow: a review of the literature. J Hand Surg Am 32(10): 1605–1623. doi:10.1016/j.jhsa.2007.09.015 40. Wysocki RW, Cohen MS (2011) Primary osteoarthritis and posttraumatic arthritis of the elbow. Hand Clin 27(2):131–137. doi:10.1016/j.hcl.2011.02.001 41. Morrey BF (2000) Surgical exposure of the elbow. In: Morrey BF (ed) The elbow and its disorders, 3rd edn. Saunders, Philadelphia, pp 109–134
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ORIGINAL ARTICLE
Factors affecting choice of open surgical techniques in elbow stiffness G. Giannicola • G. Bullitta • D. Polimanti S. Gumina
•
Received: 31 December 2013 / Accepted: 28 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
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 (mASES) 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
G. Giannicola (&) G. Bullitta D. Polimanti S. Gumina Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, ‘‘Sapienza’’ University of Rome, Via Emilio Repossi 15, 00158 Rome, Italy e-mail: [email protected]
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. Keywords Elbow stiffness Osteoarthritis Elbow arthroplasty Radiocapitellar replacement Radial head replacement Total elbow replacement
Introduction Elbow stiffness frequently leads to a significant functional limitation of the upper limb and, consequently, to a reduction in the quality of life [1–4]. Post-traumatic and inflammatory conditions are the most frequent causes of severe elbow stiffness [5–7]. According to Morrey, this condition may be classified as either extrinsic or intrinsic [8]; however, the most frequently observed type is mixed stiffness, which is characterized by both extrinsic and intrinsic alterations. Surgical treatment is often the only effective option for the stiff elbow, especially in intrinsic contractures [5–7]. Over the years, a number of surgical procedures have been proposed and have yielded satisfactory clinical results: these may be classified as either non-replacement or replacement procedures; these procedures are frequently performed together when intrinsic and extrinsic factors coexist in the same patient [9–15]. One issue that is currently debated is the choice of the most adequate surgical technique in each patient, since the pathoanatomy of the stiff elbow and the patient’s characteristics may vary markedly. This considerable variation makes it difficult to draw up a reliable classification based on shared therapeutic algorithms that may be consulted
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easily, forcing surgeons to select treatment on the basis of their own, personal experience. The aim of our prospective study was to investigate the factors involved most in the choice of surgical procedures by analyzing the clinical outcomes of open treatment in a group of consecutive patients with elbow stiffness. We hypothesized that the degree and site of elbow cartilage wear are the factors that affect the choice of treatment most.
Materials and methods Study population and clinical assessment In 3 years, 41 consecutive patients underwent surgery for elbow stiffness performed by the same surgeon (G.G.). The patients comprised 27 men and 14 women, with a mean age at surgery of 48 years (16–81). Elbow stiffness was caused by post-traumatic condition in 32 patients, primary osteoarthritis in seven and rheumatoid arthritis in two. The dominant elbow was involved in 21 patients; the right elbow was involved in 20 cases and the left elbow in the remaining 21 cases. The primary injury of patients with post-traumatic elbow stiffness was an intra-articular fracture of the distal humerus in 11 patients, the terrible triad in 8, a fracturedislocation of the proximal ulna and radius (Monteggia like-lesions) in 6, a radial fracture associated with dislocation in 4, an olecranon fracture in 2 and a simple elbow dislocation in 1 patient. The treatment of the initial injury in this group of patients was surgical in 18 cases and conservative in 14 cases, though with unsatisfactory clinical results in all the cases. Stiffness in all the patients was classified as mixed and extrinsic in 28 and 13 cases, respectively. According to the Este`ve classification, stiffness was rated as minimal in 8 cases, moderate in 13, severe in 13 and very severe in 7 [16]. Sixteen patients exhibited ulnar neuropathy at the preoperative clinical evaluation: 12 patients presented an isolated sensory dysfunction, while 4 patients presented an associated motor and sensory dysfunction. An electromyographic evaluation was performed to confirm the presence and the severity of the ulnar neuropathy in all 16 cases. Prior to surgery, all the patients underwent a clinical, radiographic and CT evaluation with 2D and 3D reconstructions. The pre- and post-operative clinical evaluations were accomplished according to the Mayo Elbow Performance Score and Index (MEPS and MEPI), the modifiedAmerican Shoulder and Elbow Surgeons (m-ASES) and the Q-DASH scores [17–19]. On the pre-operative radiographs, 27 patients had signs of osteoarthritis. These signs were classified as moderate in
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19 and severe in 8, according to Broberg and Morrey [20]. The two patients with rheumatoid arthritis were rated as type IIIa, according to the Morrey and Adams classification [21]. Heterotopic ossification (HO) was observed in 17 post-traumatic patients: there were 1 type I, 12 type IIA, 1 type IIB, 2 type IIC and 1 type IIIC, according to the Hastings and Graham classification [22]. Surgical treatment Before surgery, all of the patients had undergone medical therapy and physiotherapy sessions for an average period of 4 months (2–7), though without any benefit. Open surgery was performed on average 49 months (6–300) after the onset of elbow stiffness. Patient positioning and the surgical approaches were chosen depending on the type of procedure required. A prone position was used in 10 patients that underwent a total elbow replacement (TER), while the remaining 31 patients were placed supine with the arm supported on a table. The arm was exsanguinated, and a pneumatic tourniquet was applied for a maximum of 2 h. When possible, the incision was performed over the pre-existing scar. A posterior midline skin incision was performed in 39 patients, a posterolateral skin incision in one and a medial skin incision in one. Seventeen of the 41 patients, who had extrinsic or mixed stiffness and no relevant signs of cartilage degeneration, underwent an ulno-humeral arthroplasty (UHA), which consists in joint debridement with anterior and posterior capsulectomy, release of the triceps brachii and brachialis muscles from the bone surfaces of the distal humerus, removal of osteophytes and loose bodies. Deep dissection in these patients was carried out by means of the bilateral column procedure in 13 cases, the lateral column procedure in 3 and the medial column in 1 case [11, 23]. Neurolysis of the ulnar nerve was carried out in 7 of the 17 patients and was transposed anteriorly in four. The radial head was found to be degenerated or deformed in 7 of the 41 patients. A radial head prosthesis (Radial Head System, Tornier, Saint-Ismier, France) was implanted after the UHA in all these patients but one, in whom the radial neck presented a severe post-traumatic deformity that prevented the radial head prosthesis from being implanted; in this young patient, with an EssexLopresti lesion [24], a type I interposition of anconeus muscle was performed after radial head resection, as described by Morrey and Schneeberger [25]. In this group of seven patients, deep dissection was carried out in five patients by means of the lateral column procedure alone and in two by means of the bilateral column. Neurolysis of the ulnar nerve was performed in one of the seven patients.
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The articular surface of the radiohumeral joint was found to be degenerated in another seven patients, while the ulno-humeral compartment appeared to be preserved, with no or minimal signs of osteoarthritis. After UHA, radiocapitellar replacement was performed in six patients with the Lateral Resurfacing Elbow (Biomet Orthopedics, Warsaw, Indiana). One patient, in whom a radial head prosthesis had been implanted during a previous operation, exhibited elbow stiffness associated with mobilization of the radial implant and wear of the capitellum articular surface. The device was removed from this patient, and a new implant with the UNI-Elbow Radio Capitellum system (Small Bone Innovation, Morrisville, Pennsylvania) was inserted after UHA. Deep dissection was carried out by means of the lateral column procedure alone in four patients and the bilateral column procedure in three cases. In this group of seven patients, neurolysis of the ulnar nerve was performed in three cases. In 10 of the 41 patients, the radio-humeral and ulnohumeral joints surfaces were severely damaged and could not be saved. In these cases, a TER with a linked device (Discovery Elbow System, Biomet Orthopedics, Warsaw, Indiana) was performed. The TER was implanted using the triceps preserving approach in four cases, the New Castle approach in four and the Bryan Morrey approach in two [26–28]. The ulnar nerve was isolated and transposed anteriorly in all these cases. One articular drain and one subcutaneous drain were applied at the end of the surgery in all the patients.
6 weeks. No brace was used in any of the ten patients who underwent TER. Patients were discharged a mean of 3 days post-surgery (2–7). The resumption of most daily activities, including work activities, was allowed from the 8th week, while more demanding physical activities were allowed 3–6 months after surgery, depending on the procedures performed. Patients who underwent TER were instructed in the specific functional limitations related to the presence of the prosthesis, including avoidance of repetitive strain, lifting weights of over 2 kg and leaning completely on the operated limb while getting up from a sitting position and vice versa.
Post-operative treatment
Statistical analysis
The elbow was immobilized in extension with a brachial– antebrachial plaster cast for 48 h in a raised position in all the patients, and cryotherapy was applied. Prophylaxis for HO with 100 mg/day of indomethacin was administered from the second day post-surgery for the following 5 weeks. On the second day, after the removal of the drains and the plaster cast, patients were allowed to do selfmanaged active and passive flection–extension and supination–pronation exercises several times a day and to keep the limb extended and raised between the physiotherapy sessions. A hinged elbow brace was used in 30 patients to protect the elbow when one or both collateral ligaments had been detached during the surgical procedure and reinserted at the end of operation. Furthermore, the hinged brace was used to facilitate the recovery of range of motion; in particular, during the night, the brace was locked in maximal extended or flexed position to allow the maintenance of joint range of motion obtained by means of surgery and post-operative physiotherapy. In one patient who suffered from persistent joint instability despite ligament reattachment, a hinged elbow fixator was applied for
All computations were carried out using SPSS software 21.0 (IBM corporation, Armonk, NY, USA). Improvements in the average pre- and post-operative values of the flection, extension, supination, pronation, arc of movement, MEPS, m-ASES and Q-DASH were assessed using paired Student’s t tests. Differences were regarded as significant when p \ 0.05.
Table 1 Pre-operative and post-operative clinical outcomes in all cases Measurements
Pre-operative values average (range)
Post-operative values average (range)
p values
Flection
105° (60–140)
134° (100–150)
\0.0001
Extension
40° (5–85)
15° (0–70)
\0.0001
Arc of movement
66° (0–125)
118° (70–150)
\0.0001
Pronation
61° (0–90)
79° (20–85)
\0.0001
Supination
65° (0–85)
82° (50–90)
\0.0001
MEPS
48 (15–95)
93 (65–100)
\0.0001
Q-DASH
58 (5–96)
15 (0–71)
\0.0001
m-ASES
44 (0–98)
85 (51–99)
\0.0001
m-ASES pain
22 (0–48)
43 (21–50)
\0.0001
Results The average follow-up after the surgical procedures lasted 25 months (12–54). The pre- and post-operative clinical outcomes are reported in Table 1. A significant improvement was observed between pre- and post-operative range of motion and scores. At final follow-up, satisfactory outcomes were observed in 37 out of 41 patients; in particular, the post-operative MEPI was excellent in 27, good in 10 and fair in 4 patients. The pre- and post-operative clinical results divided by type of treatment and etiology are reported in Tables 2 and 3, respectively.
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Table 2 Pre-operative and post-operative results in each surgical procedures Measurements
UHA (17 cases)
UHA with radial head replacement (or 1 anconeus interposition) (7 cases)
UHA with radiocapitellar replacement (7 cases)
Total elbow replacement (10 cases)
Flection
(103.5°) 131°
(124°) 136°
(99°) 130°
(95.5°) 137°
Extension
(42°) 16°
(34°) 8,6°
(31°) 11°
(49°) 22,5°
Arc of movement E/F Pronation
(62°) 115° (70°) 78,5°
(90°) 128° (46°) 81°
(69°) 119° (59°) 82°
(46.5°) 114° (58°) 74,5°
Supination
(71°) 83°
(59°) 81°
(68°) 79°
(61.5°) 83°
MEPS
(49) 91
(59) 94
(48) 97
(33) 87.5
Q-DASH
(52) 11
(53) 13
(59) 13
(76) 25
m-ASES
(51) 86
(46) 86
(43) 90
(24) 77
In brackets pre-operative clinical results
Table 3 Pre-operative and post-operative results divided by etiology Measurements
Clinical results Post-traumatic (32 cases)
Primitive and rheumatoid arthritis (9 cases)
Flection
(105°) 134°
(105,5°) 131°
Extension
(40°) 16°
(38°) 13°
Arc of movement E/F
(65°) 118°
(67°) 118°
Pronation
(57°) 77°
(75,5°) 85°
Supination
(63°) 81°
(74°) 84°
MEPS
(48) 92
(48) 93
Q-DASH
(58) 15
(56) 25
m-ASES
(42.5) 85
(18) 68
In brackets pre-operative clinical results
The four patients with a fair outcome included one who was a heavy drinker with psychiatric disorders; this patient developed stiffness after a periprosthetic fracture caused by a new fall 7 months after TER. The fracture was treated conservatively as the patient demonstrated lack of compliance, with clinically unsatisfactory results. Another patient in this group developed an elbow extrinsic flection contracture after TER, despite the absence of any implantrelated causes of stiffness; he displayed a lack of compliance in the post-operative rehabilitation that probably led to a lower functional result. The last two patients with fair results developed a new ulnar sensory deficit in the postoperative period that affected the final outcomes. At the final follow-up, 13 of the 16 patients with a preoperative ulnar neuropathy displayed a complete recovery of their sensory and motors nerve dysfunctions; a mild lack of strength in the interosseous muscles persisted in the remaining three patients. Two patients had an elbow contracture relapse between surgery and the final follow-up. The first patient, who underwent an UHA associated with radiocapitellar
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replacement, developed a grade IIA posteromedial HO (Fig. 1); a second operation for debridement and HO excision performed 12 months after the first led to a satisfactory final outcome (Fig. 2). The second patient, who underwent an UHA associated with radial head replacement, developed radioulnar synostosis with forearm rotation ankylosis (Fig. 3). In the post-operative period, he discontinued indomethacin prophylaxis for HO because of gastrointestinal bleeding. A second operation performed on this patient 13 months after the first yielded a good final result (Fig. 4).
Discussion In this study, we analyzed the clinical outcomes of stiff elbow open treatment in a group of consecutive patients and assessed the factors that affect the choice of surgical procedures. Our results confirmed our initial hypothesis, according to which the degree and site of elbow cartilage wear are the factors affecting the choice of surgical treatment most. In recent decades, knowledge of the causes of elbow stiffness and its treatment has grown considerably. This has led to various classifications being proposed, some of which are based on the severity of ROM impairment and others on pathogenetic factors [7, 16, 22, 29]. The most frequently used classification is currently the Morrey classification, which divides elbow stiffness into three main types: extrinsic, intrinsic and mixed [7]. Various open or arthroscopic surgical procedures have also been described in recent decades and may be classified as either nonreplacement or replacement procedures [9–15, 30–33]. The only difference between many of the non-replacement surgical procedures, such as OK procedure, open debridement, bilateral column procedure, UHA and extensive release, lies in the type and extent of the deep dissection, the surgical steps all being similar [9–11, 13]. Several studies
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Fig. 1 Radiographs showing, in anteroposterior (a) and in lateral (b) view, the development of a posteromedial heterotopic ossification (white arrow) with elbow stiffness relapse after the first operation (c–f)
have reported good results for each of these surgical procedures in highly selected case series [34–36]. However, the current dilemma for each surgeon is not the lack of effective surgical treatments for elbow stiffness, but the choice of the most suitable surgical technique for each patient since detailed diagnostic and therapeutic guidelines do not yet exist. The lack of a comprehensive algorithm is due primarily to the fact that each patient has a different stiffness pattern, even though the pathoanatomical causes are the same in all patients; in particular, what makes the choice of treatment difficult is the fact that the clinical value of each pathoanatomical alteration differs in every patient and is often difficult to quantify pre-operatively. For these reasons, the surgeon, on the basis of his experience, needs to be able to understand the clinical importance of each pathoanatomical alteration in terms of the reduction in the arc of movement, of pain and, sometimes, of instability; in other words, the surgeon needs to be able ‘‘to understand each individual case of elbow stiffness.’’ The low correlation between pathoanatomical changes and symptoms clearly was highlighted in the study by Hasting and Graham;
indeed, they observed that the presence of HO was not clinically significant in the majority of the cases [22]. Another factor that hampers the birth of a comprehensive classification useful for treatment and complicates the choice of surgery is the lack of information on the causes and pathogenetic mechanisms underlying elbow pain [8]. Although the pain mechanism in osteoarthritis is multifaceted, it is well documented in other joints that denuded bone, periosteum irritation and bone marrow lesions are the main causes of pain [37, 38]. Hence, in patients with severe articular cartilage wear, the use of prosthesis it is recommended because with the implant several causes of pain are removed. The importance of pain relief is underlined by recent clinical studies that have shown that the improvement in quality of life in patients treated surgically for elbow stiffness is influenced to a greater extent by the reduction in pain than by the improvement in the arc of motion [4, 39]. Lastly, the patient’s general characteristics such as age, affected side, general state of health and specific functional requirements are other important factors that may affect the choice of treatment [8, 40].
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Fig. 2 Pictures showing the radiographs (a, b) and clinical evaluation (c–f) after second operation for debridement and HO excision
Fig. 3 Radiographs showing, in anteroposterior (a) and in lateral (b) view, the development of radioulnar synostosis (white arrows) with forearm rotation ankylosis (c)
In the light of these considerations, the aim of our study was to evaluate which factors most influence the choice of treatment and the final clinical outcome in a consecutive
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series of patients. In our case series, which included a high number of patients affected by post-traumatic conditions, patients with rheumatoid arthritis and patients with primary
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Fig. 4 Post-operative radiographs (a, b) and clinical evaluation (c–f) showing a satisfactory outcome 13 months after the second operation
osteoarthritis, we performed a wide range of non-replacement and replacement surgical procedures and, last but not least, neurolysis–transposition of the ulnar nerve. All these procedures were combined with one another in various combinations depending on the pathoanatomical conditions underlying the clinical symptoms of each patient. In particular, UHA was carried out in patients in whom extrinsic factors were present, such as HO, capsular and muscular retraction, as well as in those with osteophytosis. In our series, UHA was performed in all patients. The factor that most affected the choice of other surgical techniques, such as replacement procedures, was the presence of cartilage wear associated with pain; ultimately, an evaluation of the site and degree of osteoarthritis led to the surgical procedure being customized in each patient. In patients with lateral compartment degeneration, the UHA was associated with a partial or total radiocapitellar joint replacement. In particular, in subjects in whom prono-supination was limited by the deformity and wear of the radial head, we used a radial head prosthesis. In such cases, the release of the quadrate ligament and the reconstruction of the LCL were
often required to recover rotation and stability, respectively. In other cases with radiocapitellar joint wear, we adopted a lateral resurfacing implant when articular surface degeneration was not associated with deformity of the radial head circumference and capitellum; by contrast, in one case with stiff elbow and radial head prosthesis mobilization, we performed an UHA associated with radiocapitellar replacement, adopting the UNI-Elbow Radio Capitellum System since this type of implant allows radial head prosthesis revision. Only in one young patient, with severe rotatory stiffness and pain due to radial head degeneration and deformity of the proximal radius associated with a chronic Essex-Lopresti lesion, did we perform a radial head resection and interposition arthroplasty with the anconeus muscle because it was impossible to perform a radial head replacement. A TER was performed in patients with severe arthritis or/and deformity of the ulno-humeral joint. Before implantation of the prosthetic device, extensive debridement and neurolysis of the ulnar nerve were always performed in such patients. We adopted various approaches in
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the earlier cases in our patient series, preferring triceps detachment in patients with severe post-traumatic elbow stiffness, as recommended in several studies [27, 41]. However, in our department, we now perform TER using the triceps preserving approach in all cases; although this procedure significantly extends the surgical times, it reduces post-operative pain, accelerates the recovery of range of motion and prevents triceps weakness in our experience. Lastly, in keeping with the results of previous studies, our findings suggest that the patient compliance during the post-operative rehabilitation period is an important factor that may affect the final clinical outcome [39]. At the last follow-up evaluation, two patients who displayed a lack of compliance yielded unsatisfactory results and suffered from elbow stiffness relapse. These data highlight the need to carefully evaluate the patients’ psychological characteristics before surgery, particularly when a TER is planned. The main limitation of our study is the relatively low number of patients analyzed. Indeed, studies on larger consecutive patient series are warranted to gain an even better understanding of all factors that may influence the choice of treatment for elbow stiffness and clinical results. In conclusion, our study shows that elbow stiffness surgery needs to be carefully planned by taking into account the clinical value of each patient’s pathoanatomical conditions in order to guarantee the recovery of function and pain relief. In particular, the factor that affects the choice of open surgical techniques most is the presence of joint deformities and osteoarthritis. Indeed, debridement procedures are performed in all cases, whereas replacement procedures are selected according to each patient’s characteristics. The best final clinical results were achieved when surgical treatment significantly reduced pain and led to the recovery of elbow motion. Conflict of interest No financial or other relationships that might lead to a conflict of interest are present in this article. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. No funds were received in support of this study. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification. Human and Animal Studies The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.
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