Chapter 39 Arthroscopic Debridement for Elbow Stiffness

Introduction

The primary function of the elbow joint is to enable free positioning of the hand in space. Good function of any extremity requires stable joints with normal pain-free motion of sufficient power to allow activities of daily living to be performed. Satisfactory hand function is dependent on the ability to position the hand in space and this ability is more dependent on elbow flexion, extension and forearm rotation than on any other single joint. In terms of overall upper extremity function it is very difficult to compensate for lost elbow motion.

Limitations in elbow motion restricts the extent of hand reach and, depending on the degree of loss of motion, can cause major functional limitations. Most activities of daily living and work can be accomplished with 100° of flexion–extension motion and 100° of rotation.¹ More severe restrictions of elbow motion are usually associated with significant loss of function.

Loss of elbow motion can be caused by a number of osseous or soft-tissue abnormalities located within or around the joint. Intra-articular causes include joint incongruity after fractures, articular adhesions and posttraumatic or degenerative arthritis. Diseases affecting the synovium such as rheumatoid arthritis and synovial chondromatosis (Fig. 39.1) may also result in limitation of motion. Posttraumatic capsular thickening and soft tissue contractures or heterotopic bone formation are typical extra-articular causes of loss of motion. Trauma is by far the most common cause of restriction of elbow motion.

Figure 39.1 Synovial chondromatosis.

Pain may or may not be a prominent feature of elbow stiffness. This may be related to the fact that patients may be less likely to seek advice for their elbow problem if the elbow is not painful. In patients with slight or moderate stiffness, pain is usually the main problem. In very stiff or ankylotic elbows it is the lack motion that causes the functional limitations. Very stiff elbows may actually be pain-free, but often have secondary pain related to the shoulder or neck region. Non-operative management consists of gentle, active physical therapy and dynamic or static progressive splinting, which is particularly useful in posttraumatic cases.^2,³ Surgical treatment may be indicated in patients with major functional limitations who have failed non-surgical management.

Advances in both open and in particular arthroscopic surgical approaches have led to a higher rate of clinically successful treatment of elbow stiffness and osteoarthritis of the elbow. In an recent state-of-the-art article, Bernhard Morrey stated that ‘without question, one of the greatest recent advances has been the application of techniques of elbow arthroscopy to the treatment of the stiff elbow’.⁴ The aim of this chapter is to discuss the role of arthroscopic release and debridement for elbow stiffness.

Background/aetiology

The most common cause of elbow stiffness is trauma. Posttraumatic contractures are related to the force of injury, the extent of soft tissue damage and severity of fractures. Contractures may be seen after simple soft tissue trauma or dislocations or the contracture may be secondary to severely comminuted fractures.

Intra-articular adhesions (Fig. 39.2), heterotopic ossification, scarring and contracture of the capsule all contribute to the stiffness. Scarring and shortening of the anterior capsule is usually the primary cause of the extension deficit and stiffness and shortening of the posterior oblique ligament medially and the posterior capsule result in flexion deficits.⁵ The degree of contracture is related to the severity of the initial trauma but other factors contribute including: non-anatomical reduction resulting in joint incongruency or inadequate fixation of the fractures not allowing early range of motion exercises. Prolonged immobilization can lead to capsular contracture and early active mobilization after injury is considered a significant factor in limiting residual stiffness.⁶^–⁸

Figure 39.2 Adhesions in the anterior compartment.

Summary Box 39.1 Factors leading to posttraumatic contracture

• Severity of initial injury

• Non-anatomical reduction of fractures

• Inadequate fracture fixation

• Prolonged immobilization

Heterotopic ossification may be caused by any type of trauma, including surgery, and is particularly common following elbow injuries when associated with head trauma. Heterotopic ossifications usually form in the flexor compartment of the elbow and can cause significant contractures. Resection should not be done until the ectopic bone exhibits a mature appearance on radiographs with trabeculations and well-defined cortical margins.⁷

Primary elbow osteoarthritis is relatively rare in comparison with osteoarthritis of the shoulder and the joints of the lower extremities (Fig. 39.3). Approximately 2% of the population is affected. Men are much more frequently affected than women and usually the dominant arm is involved. Because of the low prevalence, studies on larger number of patients are not possible, and our knowledge on factors associated with initiation of and progression of the condition is limited, as is the interplay and relative importance of risk factors. A multifactorial aetiology of elbow osteoarthritis is presumed. A number of factors, predisposing to or influencing the development and course of elbow osteoarthritis have been suggested: genetic predisposition, malalignment, ageing, joint loading and repetitive micro-trauma.⁹

Figure 39.3 Three-dimensional computed tomography (CT). Osteoarthrosis, lateral view.

Several reports have described an association between heavy manual labour and the development of elbow osteoarthritis. Two early reports noted a high incidence of elbow osteoarthritis in coal miners using pneumatic tools. In a study that examined 774 coal miners who used pneumatic tools Rostock found that 32.8% had degenerative arthritis of the elbow.¹⁰ Lawrence found a prevalence of osteoarthritis of 31% in miners who used pneumatic drills compared with only 16% in miners not using pneumatic tools.¹¹ In a more recent study Stanley found an association between strenuous manual work and the development of elbow osteoarthritis.¹² In most of the published series dealing with the management of elbow osteoarthritis there is an overrepresentation of patients engaged in strenuous manual labour or sports activities that induce comparative high loads or forces across the elbow. Even though the elbow is not a weight-bearing joint, forces across the joint are significant during normal activities of living. Using various simulation and mathematical models it has been estimated that resultant forces across the humeroulnar joint may reach one-half times body weight during normal daily activities and up to two to three times body weight during occupational activities such as lifting and moving heavy objects.¹³ Throwing or heavy pounding produce even higher forces of up to an estimated six times body weight.

Degenerative arthritis begins primarily at the radiocapitellar joint and at all stages changes tends to be more advanced radially than in the humeroulnar articulation.¹⁴ The early changes found are posteromedial defects on the radial head with a corresponding defect on the posterior part of the crest separating the trochlea from the capitellar area.

Contrary to osteoarthritis in most other joints, elbow osteoarthritis is characterized primarily by osteophyte formation, whereas loss of joint space occurs somewhat later. Osteophytes predispose to loose body formation as the osteophytes may break off during activity.

Loose bodies may remain loose, causing locking and pain, or they may become impacted in the coronoid or olecranon fossa increasing the thickness of the membrane. Some degree of capsular contracture is usually present and synovitis may or may not be a prominent feature.

Presentation, investigation and treatment options

Clinical presentation

Loss of elbow motion impairs hand reach and function and may cause significant functional impairment and pain. Motion loss after trauma depends on the type of injury and its treatment. After simple radial head fractures or dislocations without fracture the lost motion is usually in extension and caused by a combination of anterior capsular contracture and intra-articular adhesions. Prolonged immobilization is an important causative factor. Even though the extension deficit may be moderate, the patients often have high functional demands related to work or sport. Pain with activities involving extension is usually more the problem than the restriction of motion in itself.

Limitation of motion may also be related to a more severe trauma with joint incongruity, severe stiffness and pain causing significant impairment of function. A typical patient with elbow osteoarthritis is a manual worker in his mid-fifties, complaining of pain in the dominant arm on terminal elbow extension, flexion and forearm rotation. Usually the pain is elicited by more strenuous activities. Painful catching or locking sensations are common. The loss of motion is usually moderate with 20–30° of motion loss in both the flexion–extension and rotation arch.¹⁵ Between 25% and 50% of patients also have intermittent symptoms of ulnar neuropathy.¹⁶^–¹⁸

In primary osteoarthritis elbow motion may be compromised for several reasons. Flexion may be limited by osteophyte formation on the tip and on the medial facet of the coronoid (Fig. 39.4). In addition loose bodies or impacted loose bodies in the coronoid fossa may hinder flexion. Extension deficits or flexion contractures are usually caused by a combination of osteophytes along the olecranon process, loose bodies in the olecranon fossa and anterior capsular contracture (Figs 39.5, 39.6).

Figure 39.4 Three-dimensional CT. Osteoarthrosis, medial view. Prominent coronoid process. Osteophytes and loose bodies.

Figure 39.5 CT scan. Osteoarthritis. Loose bodies posteriorly.

Figure 39.6 Loose bodies and osteophytes in the posterior fossa.

Assessment (investigations)

To help determine the aetiology of elbow stiffness, a thorough history should be obtained. In posttraumatic contractures a detailed description of the initial injury is very important as well as the type of fracture and any associated soft tissue or neurovascular injuries. Any previous non-operative or surgical treatment, together with any complications, such as infection or nerve lesions, should be noted. In an osteoarthritic patient, details of workload and former elbow trauma should be clarified. Patients younger than 50 often have a history of a traumatic event. The degree of pain is variable and functional impairment depends largely on the individual requirements of each patient and is influenced by handedness as well as occupational and recreational demands. Future demands and expectations from the treatment should also be discussed.

At physical examination the elbow region is inspected, noting previous incisions, burns, scars and skin quality. Function of the radial, median and, in particular, the ulnar nerve is carefully evaluated and recorded. Position and mobility of the ulnar nerve is noted. A subluxating or transposed ulnar nerve should be identified. If nerve transposition or dislocation is suspected, preoperative ultrasonography may help determine the exact location if it is not readily located by palpation. Occasionally, minor or moderate elbow stiffness may be caused by an underlying instability. If this is suspected the elbow should be examined for instability under anaesthesia.

A goniometer is used to document active and passive motion in the extension–flexion plane (Fig. 39.7) as well as on rotation so that the response to treatment modalities can be documented. The presence of crepitus or pain in the motion arc is also noted. Standard anteroposterior and lateral radiographs are usually sufficient, but oblique and special projections may be helpful in evaluating possible intrinsic or extra-articular causes of restriction of motion: fracture deformity, joint incongruity, osteoarthritis, osteophytes, loose bodies, heterotopic ossifications and position of hardware. Computed tomography (CT) scans with three-dimensional reconstructions are very helpful in determining the extent and exact location of heterotopic ossification (Fig. 39.8), impinging osteophytes and the location of loose bodies in osteoarthritic elbows.¹⁹ CT scans are also routinely used if fracture deformity or joint incongruency is suspected.

Figure 39.7 Flexion deficit.

Figure 39.8 Heterotopic ossification anteriorly (CT scan).

Treatment options (indications)

Posttraumatic elbow stiffness

Trauma is by far the commonest cause of elbow contracture and prevention of stiffness is a primary goal in the rehabilitation after elbow trauma. Usually the main problem is an extension deficit as a result of a contracture of the anterior joint capsule. Less commonly, there is also heterotopic ossification present. Fracture deformity or joint incongruency can also cause flexion deficit. Finally, rotational deficit may be present after radial head fractures or in osteoarthritic elbows. In posttraumatic cases, physiotherapy, splinting, static or dynamic braces and other conservative treatment modalities should be tried to help improve range of motion. Some contractures, however, persist and do not improve over time in spite of therapy. A minimum of 6 months of non-operative treatment is recommended, but after 6 months there is usually only minimal additional gain in motion. There seems to be considerable individual clinical variation demonstrated by patients to similar degrees of trauma.²⁰

Osteoarthritis

Osteoarthritis is the second most common cause of elbow stiffness. Patients usually present with both pain and restriction of motion and often also locking or catching. Pain is often at the extremes of motion but there may also be mid-range pain with activity. Non-operative treatment options are: rest, activity modification and antiinflammatory medication.¹⁵ Temporary relief may also be achieved using intra-articular injections of steroid and local anaesthetics; however, they rarely provide pain relief of longer duration. Long-term activity modification is the most important component of conservative management. In patients engaged in strenuous work activities this may necessitate a job change. Physiotherapy with strengthening or range of motion exercises is rarely indicated and may actually increase pain.

Indications

Indications for surgical intervention in elbow stiffness should be based on the individual patient’s needs and the competence of the surgeon to fulfil these needs without undue risks for the patient.^1,^21,²² If there is considerable loss of motion or even ankylosis the potential benefits from surgery are of course very significant. Functional demands in occupation, personal needs, sports and other activities, however, differ considerably. Restriction of motion, even if moderate, will not necessarily be tolerated by all. Surgical benefits and risks should always be carefully explained and discussed with each patient.

Open surgical releases using various techniques are well established and successful in the treatment of posttraumatic elbow stiffness. Depending on the type and localization of the pathology, limited anterior, lateral, medial or extensile posterior exposures may be used.^6,²³^–²⁶ (The tendency over the last two decades has been to use less invasive techniques in an attempt to minimize soft tissue trauma, reduce pain to allow early aggressive rehabilitation and minimize the risk of recurrence because of scarring. The complication rate with open techniques has also been a concern. Limiting the exposure and extent of surgery has not negatively influenced the functional outcomes.

More recently arthroscopic techniques have evolved, further reducing soft tissue trauma. With only small arthroscopic scars and reduced pain postoperatively, rehabilitation can be accelerated and hospital stays shortened. Indeed, it can now be undertaken as an outpatient procedure. Clinical outcomes after arthroscopic release have been encouraging.²⁷^–²⁹ Arthroscopic elbow release is challenging because of the close proximity of neurovascular structures to portals and capsule, a limited working space within a stiff and non-compliant capsule and possibly joint incongruency. In addition it still is an uncommon procedure and only few surgeons perform a sufficient number of procedures to gain experience. Therefore, the indication for an arthroscopic procedure depends to a large extent on the surgeon’s ability and experience. Simple release of a moderate anterior capsular contracture in an otherwise intact joint with normal bony anatomy is not a technically demanding procedure, and an ideal case for an arthroscopic release. Very stiff joints with fracture sequelae or severely osteoarthritic joints with extensive osteophyte formation are more challenging and should be attempted only by the most experienced surgeons. Radial head resection is sometimes necessary as a part of the release procedure and again it may be performed arthroscopically. In patients with healed radial head fractures with deformity and radiocapitellar osteoarthritis with pain on forearm rotation and radiohumeral compression, resection is indicated. However, in osteoarthritis, there is still some controversy as to in which cases the procedure should be undertaken.³⁰^–³²

Relative contraindications for an arthroscopic approach include extremely stiff or ankylotic joints, some cases of heterotopic ossifications, and joint incongruity where joint surface correctional surgery is anticipated (Fig. 39.9). Unless the ulnar nerve can be clearly identified by palpation after a previous ulnar nerve transposition, localization may require either establishing the anteromedial portal through a mini-incision or identifying the ulnar nerve through a mini open approach before creating the portal.³³ Ultrasonography is usually very helpful in determining the exact location of nerves relative to ossification or the exact location of an anteposed ulnar nerve in different degrees of flexion. Heterotopic ossification is extracapsular and may be closely related to neurological structures.

Figure 39.9 Joint incongruency with severe restriction of range of motion following a distal humeral fracture. Not suited for an arthroscopic release.

Ulnar nerve intraneural pressure rises with increasing elbow flexion. Beyond 90° of flexion the intraneural pressure exceeds extraneural pressure and as a consequence it has been suggested that traction may be as important as compression in causing a cubital tunnel syndrome.³⁴ It has been suggested that in patients with flexion of less than 90–100° as well as undertaking a release, ulnar nerve decompression with resection of the posterior band of the medial collateral ligament should be undertaken.^1,³³ Arthroscopic release is not an effective procedure for patients with restriction of forearm motion. Only rotation loss caused by adhesions, fracture deformity or osteophytes around the radial head may be dealt with this way. Open release is usually indicated if there is a need for articular reconstruction, as after malunited intraarticular fractures.

Clinical Pearl 39.1