Arthroscopic Management of Stiff Elbow

Materials and Methods

Thirty-four patients with stiff elbow with varying underlying etiologies were treated with arthroscopic procedures at our institution between 2003 and 2009. During the study period, all patients presenting with elbow stiffness were put on a supervised program of physiotherapy. Various physiotherapy techniques including night splints, continuous passive motion, and active and active-assisted exercises were used. If the patient showed some improvement after 6 weeks of physiotherapy, the rehabilitation program was continued. Arthroscopic surgery was considered only in those patients showing no ROM improvement after 6 weeks, or those whose progress became stagnant for >6 weeks at any point in their course of physiotherapy, with their stiffness affecting the activities of daily living.

Preoperative evaluation included clinical measurement of ROM and Mayo Elbow Performance Score. Peripheral neurovascular status was carefully assessed with special attention given to the ulnar nerve function. Standard anteroposterior (AP), lateral, and oblique views of the elbow were taken. Computed tomography (CT) scan was used to delineate bony causes of ankylosis (Figure ), and preoperative magnetic resonance imaging (MRI) was performed for the patients in whom soft tissue pathology was suspected, eg, osteochondritis dessicans and rheumatoid arthritis.

Figure 1:. 3-D Reconstructed CT Image Showing Olecranon and Coronoid Osteophytes.

Surgical Technique

All surgeries were performed by the same surgeon (H.S.). The arm was placed in the lateral position, keeping the affected side up, as described by O’Driscoll and Morrey. ¹¹ The arm was supported on a well-padded bolster with the forearm hanging free and the elbow flexed at 90°. A pneumatic tourniquet was not used, as the pump pressure was found to be enough to provide a bloodless field. Prior to the arthroscopic procedure, passive mobilization of the joint in a safe ROM was done under anesthesia. A standard 4.5-mm arthroscope with 30° angulation was used to perform the arthroscopic procedure.

The joint was distended with 10 to 15 mL normal saline through the direct lateral portal (soft spot). For visualizing and working in the posterior compartment, direct posterior and posterolateral portals, respectively, were used. The arthroscope was introduced through the direct posterior portal, located 3 cm proximal to the olecranon tip. The posterolateral portal was established approximately 3 cm proximal to the olecranon tip near the lateral margin of the triceps. Using these portals, posterior capsulotomy and removal of olecranon process osteophytes and any posterior compartment loose bodies were performed.

The anterior compartment was visualized and worked through the proximal lateral and the proximal medial portals, as these portals have been found to be safer and provide better visualization than the standard anterolateral and anteromedial portals. ^12–16 The proximal lateral portal established at a point 2 cm proximal and anterior to the lateral epicondyle was used to visualize the medial capsule, trochlea, coronoid process, and coronoid fossa, while the proximal medial portal made 2 cm anterior and proximal to the medial epicondyle was used to visualize the radiocapitellar joint. These portals were used for anterior capsule release (along its proximal humeral attachment), removal of coronoid process osteophytes and any anterior compartment loose bodies, and debriding the damaged radial head.

The exact surgical procedure depended on the intra-articular findings. Posterior compartment procedures were performed first, followed by those of the anterior compartment. This allowed better anterior joint distension from the fluid in the posterior compartment. Posterior capsulotomy was performed in cases with decreased flexion and anterior capsulotomy in patients with restricted extension. Olecranon osteophytectomy and olecranon fossa deepening was performed in patients with kissing osteophytes, which restricted ROM. A similar indication was used for performing coronoid fossa deepening and coronoid process osteophytectomy. Resection of the medial collateral ligament to achieve greater flexion was not performed in any of the patients.

Gentle passive and active ROM exercises were begun as soon as the pain and swelling subsided. Clinical follow-up was done regularly at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and every subsequent year postoperatively. Average follow-up was 27.33 months (range, 12–90 months). At every follow-up visit, changes in ROM and Mayo Elbow Performance Score were assessed. A goniometer was used to measure ROM and the measurements were taken by an independent observer.

Patients were divided into 2 groups based on preoperative duration of symptoms. Group 1 comprised patients with a duration of symptoms <6 months, while Group 2 comprised patients with a duration of symptoms >6 months. The final results in the 2 groups were compared for differences. Statistical analysis was performed using SPSS 17 (SPSS, Inc, Chicago, Illinois). Paired t test (Wilcoxon test) and Mann-Whitney test were used to test statistical significance, which was set at P<.05.

Results

During the study period, 34 patients underwent arthroscopic surgery. Four patients were lost to follow-up. The remaining 30 patients (23 men, 7 women) were followed for a minimum of 12 months. Average patient age was 40.9 years (range, 14–60 years). The right elbow was involved in 19 cases and the left in 11 cases. Average interval between symptom onset and arthroscopic surgery was 41.45 months.

Osteoarthritis and posttraumatic stiffness were found to be the most common causes of elbow stiffness. Nineteen patients (63.3%) had osteoarthritis, including overuse injuries, and 7 (23.3%) had post-traumatic stiffness. Other causes included osteochondritis dessicans (3 patients) and rheumatoid arthritis (1 patient).

Posterior capsular release was the most common procedure performed (in all but 2 patients), followed by anterior capsular release (73.3%), loose body removal (70%), and olecranon process osteophytectomy (70%). Coronoid fossa deepening was the least commonly performed procedure, used in only 13.3% of patients ().

Table. Arthroscopic Procedures

At final follow-up, ROM had improved in all but 1 patient. A gain in flexion was seen in more patients (90%) than a gain in extension (76.7%). Final Mayo Elbow Performance Score had improved in 80% of patients.

Mean ROM increased from 74° (range, 10°–105°) preoperatively to 110.16° (range, 65°–140°) at final follow-up. Mean extension improved from 22.83° (range, 5°–50°) preoperatively to 10.83° (range, 0°–35°) postoperatively. Mean flexion increased from 96.83° (range, 30°–120°) preoperatively to 120.84° (range, 90°–145°) at final follow-up. Mean Mayo Elbow Performance Score also rose from 64.5 (range, 15–85) preoperatively to 83.17 (range, 65–95) at final follow-up. All of these differences in pre- and postoperative values were statistically significant ( P<.001). Final Mayo Elbow Performance Score was moderate or above in 100% of patients and good or above in 93.3% of patients. None of the patients had a poor Mayo Elbow Performance Score at final follow-up.

We also analyzed and compared the results of the 2 groups separately (Figure ). Group 1 patients had a statistically significant improvement in mean flexion (20°), extension (38.64°), ROM (58°), and Mayo Elbow Performance Score (32.7 points). Although Group 2 patients also showed improvement in all the parameters (7.37°, 16°, 23.76°, and 10.5 points, respectively), improvement was less compared to Group 1, and Mayo Elbow Performance Score improvement was not statistically significant. Thus, patients with a duration of symptoms <6 months had a statistically significant better outcome in all 4 parameters studied.

Figure 2:. Graph Illustrating Comparison of Functional Results at Final Follow Up. Group I Comprised Patients with a Duration of Symptoms <6 Months and Group II Comprised Patients with a Duration of Symptoms >6 Months. Abbreviation: MEPS, Mayo Elbow Performance Score.

No complication was seen in any case. Some patients who had had a gain in motion in the initial months postoperatively lost some of the motion on prolonged follow-up, although all but 1 had improved ROM at final follow-up. All patients who had some relapse of stiffness on prolonged follow-up had a diagnosis of degenerative elbow osteoarthritis and belonged to Group 2.

Discussion

The elbow joint is prone to stiffness because of its higher propensity to trauma, the close inter-relationship of the joint capsule with extra-articular muscles, and the unique response of the joint capsule to trauma. ¹⁷ Many different treatment options have been described in the literature for solving this difficult problem. Conservative measures are useful only in cases with a short history, and only to a limited extent. ^2,3 Surgical measures are indicated only after failure of a reasonably long trial of conservative measures.

Many open methods have been used for treating stiff elbow with mixed results. ^5–7 But open procedures have the disadvantage of causing additional soft tissue insult on already scarred tissue, and this may lead to a delayed and painful postoperative rehabilitation program.

With improvements in arthroscopic instruments and techniques, elbow arthroscopy has emerged as a popular choice for managing stiff elbow. Arthroscopy causes minimal soft tissue damage and thus an early and less painful start to the rehabilitation program. ^8,18–20 It has the added benefit of visualizing and addressing the exact intra-articular pathology. The only disadvantage of arthroscopy is the non-amenability of extra-articular causes of elbow ankylosis.

The main rationale behind our surgical technique was a sequential targeting of the offending structures. The posterior compartment structures were managed first because posterior capsule contracture is mainly responsible for the lack of complete flexion, which is more disabling than lack of extension.

In our study, posterior capsular release was the most common procedure performed (93.3%), followed by anterior capsular release (73.3%), loose body removal (70%), and olecranon process osteophytectomy (70%). Coronoid process osteophytectomy and coronoid fossa deepening were performed on the fewest patients (33.3% and 13.3%, respectively). This finding is in contrast to earlier studies in which coronoid process osteophytes were a more frequent finding than olecranon process osteophytes. ¹⁷ It can be explained by our strategy of removing the coronoid process osteophyte only if any impingement was seen during ROM.

Satisfactory results after arthroscopic management of stiff elbow have been reported by other authors. Ball et al ⁹ obtained satisfactory improvement in elbow ROM in 100% of patients, while Kim and Shin ¹⁷ showed satisfactory results in 92% of patients after arthroscopic procedures. Our study also showed an improvement in ROM in all but 1 patient (97%). Improvement in flexion was achieved in more patients (90%) than improvement in extension (76.7%). This is comparable to the findings of Kim and Shin. ¹⁷ Also, the improvement seen in flexion (24°) was greater than that seen in extension (12°). This is clinically important because loss of flexion is more disabling for the patient than loss of extension.

Our results varied according to the chronicity of the disease and the underlying disease process. The patients with a shorter duration of symptoms (<6 months) had a superior result than those with a longer duration of symptoms (>6 months). This was seen in all 4 aspects studied, ie, final flexion, extension, ROM, and Mayo Elbow Performance Score. Patients with a posttraumatic cause of ankylosis had a superior and long-lasting gain in ROM compared to patients with degenerative arthritis. Patients with degenerative arthritis were seen to have a relapse of stiffness over a prolonged follow-up. The cause of this relapse can be multifactorial. First, patients with degenerative arthritis return to the same occupation or activity postoperatively, which causes overuse or degenerative arthritis. Second, it is hypothesized that in degenerative arthritis, the surgeon removes the diseased tissue (cartilage, osteophyte, or capsule) but does not treat the underlying disease process. Thus, the natural history of the disease is only reversed a few years and not completely altered. We believe that arthroscopic surgery is justified in these patients because although the increase in ROM is not significant, the symptoms are dramatically reduced, and after regaining motion, many of these patients are willing to change their occupation or modify their lifestyle.

No intra- or postoperative complications were observed in our series. The complications that can occur after arthroscopic treatment of stiff elbow are usually neurovascular in nature. As reported by Galley et al, the compliance of the elbow capsule is reduced to 15% of normal in stiff elbow patients. Thus, capsular distension is difficult, and it increases the chances of neurological injury. To avoid these complications, the portals were made as close as possible to the elbow articulations and in 90° of elbow flexion. Careful preoperative neurological assessment of the limb was done, especially focusing on ulnar nerve function. Various series in the literature report only rare and usually transient complications. ^8,19,21–23

Our study had some limitations. There was no control group to compare the results of arthroscopic release with open methods, and our study group was not homogeneous and consisted of patients with various causes of stiffness.

Conclusion

Arthroscopic release is a safe and effective method for the treatment of stiff elbow. The minimally invasive nature of the surgery makes it an attractive option. The best results are seen in patients with posttraumatic etiology and in patients with a shorter duration of symptoms.