Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach

Gracitelli, Mauro E.C.; Guglielmetti, César L.B.; Botelho, Caio A.S.; Malavolta, Eduardo A.; Assunção, Jorge H.; Ferreira Neto, Arnaldo A.

doi:10.1055/s-0039-1700827

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Original Article, Shoulder and Elbow • Rev. bras. ortop. 55 (5) • Sep-Oct 2020 • https://doi.org/10.1055/s-0039-1700827 copy

Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach^* * Study developed at Shoulder and Elbow Group, Instituto de Ortopedia e Traumatologia, Hospital Das Clínicas, Faculty of Medicine, Universidade de São (HCFMUSP), São Paulo, SP, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To demonstrate the clinical outcomes and complication rates of the surgical release with a single posterior approach in the treatment of post-traumatic elbow stiffness.

Methods

A prospective study with patients submitted to surgery between May 2013 and June 2018 in a single center. The access to the elbow was made through the posterior approach. The patients were followed up by an occupational therapy team, and were submitted to a standardized rehabilitation protocol, with static progressive orthoses and dynamic orthoses. The primary outcome was the range of flexion-extension of the elbow after 6 months.

Results

A total of 26 patients completed the minimum follow-up of 6-months. The mean range of flexion-extension of the elbow at the end of 6 months was of 98.3 ± 22.0°, with an amplitude gain of 40.0 ± 14.0° in relation to the pre-operative period (p < 0.001). The average flexion-extension gain at the end of 6 months was of 51.7% ± 17.1% (p < 0.001). The mean pronosupination at the end of 6 months was of 129.0 ± 42.7° (p < 0.001). Half of the cases had moderate and severe stiffness in the pre-operative period, compared with 7.7% at 6 months post-operatively (p < 0.001). The mean score for the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) instruments was 74.4 ± 16.8 points and 31.7 ± 21.9 points respectively (p < 0.001 for both). The visual analogue scale (VAS) score presented no statistically significant difference compared to the pre-operative period (p = 0.096). Complications were observed in 6 (23%) patients, and no new surgical procedures were necessary.

Conclusions

The surgical release of the elbow associated with a rehabilitation protocol is a safe technique, with satisfactory results and low rate of complications.

Keywords
elbow joint; contracture; post-traumatic stiffness; joint capsule release; treatment outcome

Clinical characteristics	Cases
Gender, n (%)
Male	17 (65.4)
Female	9 (34.6)
Age, years
Mean (standard deviation)	37.3 (11.3)
Smoking, n (%)
Yes	2 (7.7)
Former smoker	3 (11.5)
No	21 (80.8)
Diabetes, n (%)
Yes	2 (7.7)
No	24 (92.3)
Problems at work, n (%)
Yes	7 (26.9)
No	19 (73.1)
Affected side, n (%)
Right	14 (53.8)
Left	12 (46.2)
Dominant side affected, n (%)
Yes	14 (53.8)
No	12 (46.2)
Previous fracture, n (%)
Yes	19 (73.1)
No	7 (26.9)
Previous surgery, n (%)
Yes	8 (30.8)
No	18 (69.2)

Radiographic characteristics	Cases
Presence of synthesis material, n (%)
Yes	8 (30.8)
No	18 (69.2)
Radial head, n (%)
Without deformity	16 (61.5)
With deformity	7 (26.9)
Absent	2 (7.7)
Prosthesis	1 (3.8)
Loose bodies, n (%)
Yes	10 (38.5)
No	16 (61.5)
Osteophytes, n (%)
Yes	13 (50.0)
No	13 (50.0)

	Pre-operative	6 months	p-value
Degree of stiffness
I	1 (3.8)	18 (69.2)
II	12 (46.2)	6 (23.1)
III	9 (34.6)	2 (7.7)
IV	4 (15.4)	0 (0)	< 0.0001
Degree of arthrosis
0	5 (19.2)	4 (16.0)
1	8 (30.8)	8 (32.0)
2	11 (42.3)	9 (36.0)
3	2 (7.7)	4 (16.0)	0.811
Categorical Mayo Elbow Performance Score (MEPS)
Excellent	0 (0)	4 (15.4)
Good	5 (19.2)	11 (42.3)
Regular	8 (30.8)	7 (26.9)
Poor	13 (50.0)	4 (15.4)	0.011

	Cases		p-value
	Mean	Standard deviationn	p-value
Flexion-extension ROM (º)
Initial	58.4	22.7
6 weeks	78.0	22.5
3 months	89.4	26.0
6 months	98.3	22.0	< 0.001
ROM gain (º)
6 weeks	15.6	23.2
3 months	31.9	20.9
6 months	40.0	14.0	< 0.001
ROM relative gain (%)
6 weeks	16.4	28.9
3 months	39.5	24.0
6 months	51.7	17.1	< 0.001
Pronosupination ROM (º)
Initial	115.2	52.3
6 weeks	117.4	42.7
3 months	124.3	43.8
6 months	129.0	42.7	< 0.001

	Cases		p-value
	Mean	Standard deviation	p-value
Flexion (º)
Initial	99.3	24.8
6 weeks	101.7	20.3
3 months	108.8	21.0
6 months	116.0	17.6	< 0.001
Extension (º)
Initial	-40.9	20.9
6 weeks	-30.2	17.7
3 months	-19.4	11.1
6 months	-17.7	10.6	<0.001
Pronation (º)
Initial	58.1	27.6
6 weeks	55.4	24.7
3 months	59.0	24.0
6 months	62.5	24.1	0.017
Supination (º)
Initial	57.5	29.4
6 weeks	62.4	26.3
3 months	66.1	26.6
6 months	67.5	26.0	<0.001

	Cases		p-value
	Mean	Standard deviation	p-value
Mayo Elbow Performance Score (MEPS)
Initial	54.4	20.1
3 months	70.2	20.1
6 months	74.4	16.8	< 0.001
Disabilities of the Arm, Shoulder and Hand (DASH)
Initial	47.5	19.2
3 months	37.1	23.4
6 months	31.7	21.9	< 0.001
Visual Analogue Scale (VAS) for pain
Initial	5.1	3.1
6 weeks	4.4	3.0
3 months	4.0	2.9
6 months	4.1	2.5	0.096

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence Mauro E. C. Gracitelli, PhD, Rua Dr. Ovídio Pires de Campos, 333, 3° andar, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil (e-mail: mgracitelli@gmail.com).

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Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach* * Study developed at Shoulder and Elbow Group, Instituto de Ortopedia e Traumatologia, Hospital Das Clínicas, Faculty of Medicine, Universidade de São (HCFMUSP), São Paulo, SP, Brazil.

Abstract

Objective

Methods

Results

Conclusions

Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach^* * Study developed at Shoulder and Elbow Group, Instituto de Ortopedia e Traumatologia, Hospital Das Clínicas, Faculty of Medicine, Universidade de São (HCFMUSP), São Paulo, SP, Brazil.