41
Treatment of Elbow Arthrofibrosis
Recent technological advances in elbow arthroscopy have expanded its indications for the management of elbow joint pathology. One of these expanded indications is the treatment of elbow joint contracture or arthrofibrosis from a variety of causes, including posttraumatic, congenital, and atraumatic. With recent emphasis on minimally invasive surgery, the ability to treat elbow joint stiffness arthroscopically becomes increasingly valuable. Considering recently published reports, it does not appear that open release for elbow arthrofibrosis is superior to arthroscopic release when appropriate techniques are implemented. Arthroscopy also allows for a more complete evaluation of the elbow joint, does not compromise collateral ligament stability, and minimizes surgical dissection and morbidity. It is important to remember, however, that arthroscopic capsular release is a technically demanding procedure and should be attempted only by surgeons with extensive experience with elbow arthroscopy. The techniques depicted in this chapter are primarily utilized for cases of posttraumatic or osteoarthritic elbow stiffness. The specific etiology must be identified preoperatively. Some conditions such as stiffness secondary to burns, neurological disorders (cerebral palsy), or heterotopic ossification will not respond favorably to these techniques.
Indications
1. The primary indication is a painful contracture of 30 degrees or more that is functionally limiting and refractory to conservative treatment.
2. Elbow contractures of less than 30 degrees that impair occupational functional demands.
3. Patients with a lesser degree of flexion contracture who have painful popping or locking secondary to intraarticular pathology may also be candidates for concomitant arthroscopic release at the time of surgery.
Contraindications
1. Altered neurovascular anatomy, such as a subluxating ulnar nerve or previous ulnar nerve transposition
2. Certain extraarticular deformities that might entrap neurovascular structures
3. Limited experience with elbow arthroscopy
Physical Examination
1. Determine whether the limitation of motion is painful as most people can function well with a 30-degree extension loss for activities of daily living.
2. During the physical examination, ulnar nerve subluxation must be identified preoperatively if contemplating elbow arthroscopy.
3. Assess the degree of capsular contracture by measuring elbow flexion, extension, pronation, and supination. A firm end point for elbow extension suggests more difficulty with nonoperative measures than a soft, “rubbery” endpoint.
4. Asses for ulnar nerve subluxation and irritation. A subluxating ulnar nerve is a relative contraindication for arthroscopic capsular release, and ulnar neuritis preoperatively suggests the need for concomitant ulnar nerve transposition at the time of surgery.
Diagnostic Tests
1. Standard radiographs are usually all that is required for preoperative planning.
2. Lateral tomograms may be helpful to identify unusual deformities of the olecranon and coronoid fossae.
3. Magnetic resonance imaging, computed tomography, and arthrography are rarely indicated and usually do not contribute significant information for surgical treatment.
Special Considerations
1. Nonoperative treatments include physical therapy and static and dynamic splinting, and should be considered for up to 1 year after the onset of the contracture.
2. Goals of nonoperative treatment are to regain elbow motion gradually without creating more inflammation, capsular tearing, and hemorrhage.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
