The Stiff Elbow: Arthrofibrosis

CHAPTER 7 The Stiff Elbow: Arthrofibrosis

The elbow is particularly prone to stiffness following trauma. This propensity has been attributed to several factors, including the congruous nature of the joint, the presence of three articulations within a synovium-lined cavity, and the close relationship of the joint capsule to the intracapsular ligaments and surrounding muscles.1 Because of these factors, post-traumatic loss of motion is the most common complication after injury to the elbow joint. Arthroscopic techniques can improve motion and function in selected cases that fail conservative measures.


The capsule of the elbow is normally thin and transparent and has a high degree of elasticity (Fig. 7-1). However, after even relatively minor trauma, the capsule can undergo structural and biochemical alterations, leading to thickening, decreased compliance, and loss of motion.2 Prolonged immobilization after trauma may be a separate risk factor for the development of stiffness. In addition to capsular changes, the concavities of the humerus above the trochlea—the olecranon and coronoid fossae—can become filled with scar and fibrous tissue after injury. These fossae must be clear to accept the coronoid and olecranon processes at terminal elbow flexion and extension, respectively. In long-standing cases, secondary contracture of the brachialis and triceps muscles can limit motion.



Indications and Contraindications

Patients are candidates for contracture release if they have restricted elbow motion, with a flexion contracture of at least 25 to 30 degrees or less than 110 to 115 degrees of flexion, or both. Patients typically should have failed a course of supervised therapy, including proper splinting. A congruous ulnohumeral joint is required, as is adequate soft tissue coverage of the operative site. An interval from injury to operation of at least 3 to 4 months allows for resolution of post-traumatic inflammation.

Relative contraindications to arthroscopic elbow release include severe elbow contractures with minimal joint motion, prior ulnar nerve transposition surgery, and the presence of significant heterotopic bone. Surgical release of a contracted elbow is also contraindicated if a patient is deemed unable or unwilling to comply with the extensive program of postoperative therapy. Operative results depend on participation in a structured rehabilitation program. This is especially true for adolescents, who may not be dedicated to improving their elbow motion. If the ulnohumeral joint is incongruous, a simple release of the joint may not lead to improved motion and may worsen pain. Although pain at the extremes is common, patients who are candidates for elbow release surgery typically are pain free within their allowable arc of motion. If advanced post-traumatic arthritis exists in the ulnohumeral articulation, salvage-type procedures are required if surgery is undertaken.3

Arthroscopic Technique

Arthroscopic release of a post-traumatic elbow is much more difficult and complicated than arthroscopy for simpler conditions, such as loose bodies. The technique requires experience and knowledge of elbow stiffness surgery and demands advanced skills in elbow arthroscopy. Multiple portals are required, fluid management is essential, and arthroscopic joint retractors are helpful to aid in visualization. This is especially true after capsulectomy, when joint distention is more difficult.

Specialized instruments can be helpful, such as cannulas that do not have any holes near the tip (Fig. 7-3). Because the elbow is smaller than, for example, the knee, and has less intra-articular space, standard cannulas can lead to fluid inadvertently entering the soft tissues while visualizing the joint.

In very experienced hands, the procedure appears equivalent to more traditional open methods. However, there is clearly a learning curve, and potential complications must be appreciated. They include nerve injury, excessive fluid extravasation, and iatrogenic chondral damage.49 If there is a question regarding visualization or safely, the surgeon must be prepared to convert the procedure to an open approach.1013

From a purely mechanical standpoint, to improve elbow extension, posterior impingement must be removed between the olecranon tip and the olecranon fossa. Anteriorly, tethering soft tissues, such as the anterior joint capsule and any adhesions between the brachialis and the humerus, must be released (Fig. 7-4

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Jun 19, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on The Stiff Elbow: Arthrofibrosis

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