Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow

Arthroscopy: The Journal of Arthroscopic and Related Surgery 9(3):277-283 Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America

Arthroscopic Capsular Release of Flexion Contractures (Arthrofibrosis) of the Elbow G. S c o t t J o n e s , M . D . , a n d F . H . S a v o i e I I I , M . D .

Summary: Twelve patients with flexion contractures of the elbow were managed by arthroscopic release of the proximal capsule and debridement of the olecranon fossa. Postoperatively the mean flexion contracture improved from 38 to 3° with supination improving from 45 to 84° and pronation improving from 80 to 88°. All patients reported a decrease in pain level as well as improvement in motion. There was one severe complication in this series, in which a patient sustained a permanent posterior interosseous nerve palsy. Arthroscopic limited capsular release appears to be satisfactory management modality for flexion contracture of the elbow. Key Words: Elbow--Contracture--Release-Capsule.

cle describes the indications, techniques and the resuits of these cases.

Flexion contracture of the elbow and the resulting loss of motion may cause significant morbidity (1,2). Posttraumatic and osteoarthritic contractures often result in contracture of the anterior joint capsule (3-5). Patients with capsular contracture have been managed by a number of surgical options. In the past, procedures ranged from capsulectomy to more extensive capsular'release, release combined with biceps tendon lengthening, brachialis myotomy, and release of the more anterior fibers of the collateral ligaments (1,2,6). More recently, anterior capsulotomy without tendon lengthening and anterior release with immediate continuous passive motion and the lateral approach for operative release have all been advocated in surgical treatment of these contractures (3,7-9). We have modified seve r n of the limited open techniques for use via arthroscopic management, performing a proximal capsular release and debridement of the olecranon fossa with removal of associated osteophyte formation using standard arthroscopic portals. This arti-

MATERIALS AND METHODS Twelve patients with flexion contracture of the elbow who failed a program of physical therapy and splinting lasting 4-18 months were managed by arthroscopic capsular release. There were seven men and five women. Age at surgery ranged from 12 to 72 years with an average age of 38 years. The dominant extremity was involved in eight cases, with the nondominant extremity being involved in four cases. The etiology of the contracture was posttraumatic loss of motion in six patients, degenerative arthritis in three, and rheumatoid arthritis in three. Of the six patients with trauma as the etiology of the contracture, there were four radial head fractures, one lateral epicondylar fracture, and one medial condyle fracture. Four of these six patients had undergone previous surgical procedures. In the remaining six patients no prior surgical procedures had been performed. The interval from injury to surgery ranged from 4 to 22 months, with each patient participating in a minimum of 3 months of intensive physical therapy before consideration for operative reconstruction. The preoperative flexion

From Mississippi Sports Medicine & Orthopaedic Center, and University of Mississippi Medical Center, Jackson, Mississippi. Address correspondence and reprint requests to Dr. Felix H. Savoie III, 1325 E. Fortification Street, Jackson, MS 39202, U.S.A.

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contracture ranged from 10 to 90 ° with a mean of 38 °. The preoperative point of maximum flexion ranged from 90 to 140° with a mean of 106°. Four patients lacked full pronation preoperatively and seven patients lacked full supination. The follow-up interval ranged from 15 to 32 months with an average of 22 months. All patients were evaluated for pain preoperatively and postoperatively using the following classification scale: no pain, 0 points; mild (patient had occasional pain during activities of daily living but took no medications), 1 point; moderate (patient had pain at night or occasionally took medication for pain), 2 points; severe (patient took medication for pain regularly, and activities of daily living were impaired), 3 points; complete disability (patient was unable to use the elbow whatsoever), 4 points. All patients were evaluated independently by a local physical therapist for flexion, extension, pronation, and supination range of motion, and for pain using the aforementioned scale. SURGICAL TECHNIQUE The patients are placed in the prone position as described by Poehling and Whipple (10), with a tourniquet placed on the upper arm to restrict blood flow. Motion is again tested with the patient asleep, and the elbow is gently manipulated to determine the extent of the contracture. A standard set up, preparation, and draping of the arm is accomplished. The elbow joint is distended using a standard posterior soft spot portal. An anterior superior

medial portal is established - 2 cm proximal to the tip of the medial epicondyle anterior to the intramuscular septum. The arthroscope is introduced through this portal, and the anterior aspect of the elbow joint is evaluated. In cases in which the entire capsule is adherent to the anterior structures, this portal can be used to visualize the anterior aspect of the elbow joint from above without danger of damage to the anterior neurovascular structure. A lateral portal is then established using an inside-out technique with a blunt switching stick to protect the posterior interosseous nerve and prevent injury to this structure. A second cannula is inserted over this switching stick, and as visualization became adequate the arthroscope is transferred to this portal. The shaver is then placed in the anterosuperomedial portal, and soft tissue and adhesions are released from the radial head and coronoid process. The full radius resector shaver blade is used to resect the anterior capsule off of the proximal humerus as the arm is gradually extended (Fig. 1A and B). Contact of the shaver to the bone of the humerus should be maintained at all times. The medial and lateral edges of the bone mark the limit of the resection. This extension should be accomplished in both pronation and supination. It is extremely important to be certain that both instruments are within the capsule of the elbow joint during this procedure and not into the anterior soft tissues. Once maximal extension has been achieved, the instruments are removed from the anterior portal, and a posterior lateral and posterior central portal are

1A,B

FIG. 1. Schematic (A) and photographic illustrations (B) of anterior capsular release, showing release of the anterior capsule from the humerus using a shaver blade. Arthroscopy, Vol. 9, No. 3, 1993

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established 3 cm proximal to the tip of the olecranon. In most cases there is significant scarring in the olecranon fossa; this is resected and the arm is again extended (Fig. 2A and B). Osteophytes at the tip of the olecranon are resected using a notchplasty shaver blade (Fig. 3A and B). The olecranon fossa is then debrided of remaining scar tissue and deepened if necessary. Any redundant posterior superior capsular scarring may be released with a blunt trochar or a shaver blade to further increase flexion. Lastly, the lateral and medial gutters are freed of adhesions (Fig. 4A and B). The blunt trochar is placed into each gutter from posterior and manipulated to break up the adhesions, which may then be resected with the shaver blade. Care must be taken in the medial gutter to protect the ulnar nerve. The elbow is splinted in full extension and supination for 24-72 h, and immediate passive and active motion is initiated. RESULTS All patients returned for follow-up 15 to 32 months post-surgery with the exception of the one patient who had a posterior interosseous nerve palsy, who was contacted by telephone. The mean preoperative flexion deformity of 38° was reduced to a mean postoperative flexion deformity of 3°. All patients postoperatively had at least 20-125 ° of motion. Flexion was increased from a preoperative average of 106° to an average of 138° postoperatively. All patients maintained postoperative flexion and extension at the follow-up examinations. Pronation and supination were also increased. Three patients

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who had preoperative decreased pronation improved postoperatively, one from 35 to 90° , one from 0 to 80°, and one from 60 to 90°. Of seven patients who had decreased supination preoperatively, this motion increased an average of 60°. Six of these patients regained full supination as compared with the opposite, normal elbow (Tables 1 and 2). Pain was decreased postoperatively in all patients. The pain scores diminished from a preoperative average score of 2 to a postoperative average score of 0.8. All patients followed up were satisfied with their improvement in both range of mot i o n and pain. One p a t i e n t was m a r k e d l y dissatisfied because of posterior interosseous nerve dysfunction. There are two complications in our study. One involves the aforementioned postoperative palsy of the posterior interosseous nerve that did not resolve and required surgical intervention. One patient underwent remanipulation under anesthesia 3 weeks postoperatively with continued physical therapy. This patient went on to regain range of motion equal to the opposite Side. There are no cases of postoperative infection or heterotopic ossification. DISCUSSION Flexion contracture of the elbow can be a serious problem both functionally and cosmetically. Loss of motion beyond the functional arc of 30-120 ° may significantly interfere with a person's ability to perform activities of daily living (11). Although some contractures of short duration may respond to phys-

2A,B

FIG. 2. Schematic (A) and photographic illustrations (B) showing posterior fossa debridement. Arthroscopy, Vol. 9, No. 3, 1993

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3A,B

FIG. 3. Schematic illustration (A) of debridement of the tip of the olecranon with photographic illustration (B) after debridement.

ical therapy and bracing, most long-standing contractures require surgical treatment (12-14). Wilson in 1944 reported on a small series in which he performed anterior capsulectomy and lengthening of the biceps tendon (6). Although his patients regained an average of 42 ° of extension, nerve palsy developed in four of seven patients postoperatively. Wilner in 1948 treated 10 elbow flexion contractures by osteotomy of the medial epicondyle and

reflecting the c()mmon flexor origin to allow complete anterior capsulectomy (2). Nine of 10 elbows showed improvement with an average increase in extension of 23°; one patient showed no improvement. Glynn and Niebauer reported on a small series of patients with elbow flexion contractures treated by lengthening the biceps tendon, transfering the brachialis muscle, and performing complete anterior

4A,B

/

/ FIG. 4. Schematic (A) and photographic illustrations (B) showing debridement of the radial gutter using the shaver blade. Arthroscopy, Vol. 9, No. 3, 1993

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T A B L E 1. Patient data~results of procedure (extension) Pain

Case no.

Sex

Age

Left/right

Initial disease or injury

1 2 3 4 5 6 7 8 9 10 11 12

M M F M M F F M M M F F

57 24 32 32 19 12 37 39 72 37 52 50

L L R R~ La R~ L R~ R~ Ra R~ R~

Rheumatoid arthritis Osteoarthritis Radial head fracture Radial head fracture Lateral epicondyle fracture Medial condyle fracture Radial head fracture Radial head fracture Osteoarthritis Osteoarthritis Rheumatoid arthritis Rheumatoid arthritis

Preop

Extension (°) Postop

1 2 1 2 2 1 3 2 3 2 3 2

Preop

Postop

Change

20 45 45 35 45 90 45 15 40 10 30 40

5 5 0 0 0 0 0 0 0 0 10 0

15 40 45 35 45 90 45 15 40 10 20 40

38

2

36

1 0 0 1 1 0 0 0 1 1 2 1

2.0

.6

Dominant

capsulectomy (1). Extension in their patients' elbows improved an average of 44° . In 1985 Urbaniak described a technique in which he used a limited anterior capsulotomy to treat 15 elbow flexion contractures (3). Results of his study showed the mean preoperative flexion contracture of 48 ° reduced to 19° postoperatively. However, his results showed less improvement in patients with significant posttraumatic arthrosis. Breen in 1987 treated three elbows with anterior release and immediate postoperative continuous passive motion (7). His results showed an average preoperative flexion contracture of 42° decreased to 5° 1 year postoperatively. However, Gates found continuous passive motion to be of no benefit in a series of 33 patients managed by anterior capsular release (9). The lateral approach for operative release of posttraumatic flexion contracture of the elbow was

described by Husband in 1990 (9). Extension improved from a mean of 45° preoperatively to 12° postoperatively. Also, the point of maximum flexion increased from 116° preoperatively to 129° postoperatively. Advantages of the lateral approach include anterior and posterior exposure for a more complete evaluation, and release and/or debridement of the elbow joint. The senior author's (F.H.S.) extensive experience with elbow arthroscopy led to the formulation of a technique to use this modality in the management of contractures of the elbow. To our knowledge, this study is the first series describing arthroscopic treatment of flexion contracture of the elbow. In treating flexion contractures of the elbow, intrinsic causes of contractures such as changes within the joint (usually the result of intra-articular fracture or arthritic processes), as well as extrinsic causes including contracture of the capsule, collat-

TABLE 2. Results of procedure~length of follow-up Case no. 1

2 3 4 5 6 7 8 9 10 11 12

Flexion (o)

Pronation (0)

Supination (o)

Preop

Postop

Change

Preop

Postop

Change

Preop

Postop

Change

Follow-up (months)

110 100 100 120 110 100 90 140 100 120 95 90

140 145 100 150 140 135 140 140 140 140 140 140

30 45 0 30 30 35 50 0 40 20 45 50

90 35 90 95 90 90 0 90 90 90 60 80

90 90 90 95 90 90 80 90 90 90 90 80

0 55 0 0 0 0 80 0 0 0 30 0

90 0 20 90 90 90 0 90 45 5 60 10

90 45 90 90 90 90 90 90 90 70 90 85

0 45 70 0 0 0 90 0 45 65 30 75

24 32 15 25 21 26 17 23 17 22 23 17

106

137

31

80

88

14

45

84

35

22

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eral ligaments, flexor muscles of the elbow, and heterotopic ossification must be considered (15). In properly selected patients, an arthroscopic approach to these contractures allows one to deal with the capsular contracture, as well as the intrinsic joint pathology. The ability to debride the joint and to treat the intra-articular pathology arthroscopically offers significant advantage to previously described procedures of releasing only the extrinsic pathology associated with the contracture. In contrast to Urbaniak's series, we found no difference in the results of those patients with posttraumatic arthrosis as compared with those with nontraumatic etiology of contracture (3). Also, the advantage of limited skin incision and soft tissue dissection offered by arthroscopy allows patients to begin aggressive postoperative physical therapy soon after surgery and may decrease the risk of anterior scarring and recurrent contracture. Although this is a difficult procedure, complications seem to be few. In our series there was one posterior interosseous nerve palsy, with no other significant complications. In another, open series, Richards (16) noted a single posterior interosseous nerve palsy using Urbaniak's technique. The patient in his series had previous operative intervention on the radial head, and he postulated this as a cause of the problem. The patient in our series had a displaced anterior radial head fracture that healed attached to the anterior capsule. During arthroscopic debridement and manipulation, the capsule separated in this area rather than near the humerus, severing the nerve. Richards postulated a similar mechanism in his patient, recommending that limited lateral approach capsular release not be used in multiply operated patients. We would agree with his recommendation for our procedure as well. These serious complications underscore the inherent difficulty in managing these problem cases. Injuries or surgery that produce excessive scarring in the vicinity of the posterior interosseus nerve should be considered a contraindication to an arthroscopic capsular release. Other series had limited complications. Urbaniak reported three transient nerve palsies in his initial series of 15 patients (3). Gates similarly reported three transient nerve palsies in his series of 33 patients (9). Breen reported no complications in his three patients (7). Husband reported one ulnar nerve paresthesia in his seven patients (8). In a series of extremely complicated patients requiring extensive release and external fixation, Morrey reported eight complications (occurring in Arthroscopy, Vol. 9, No. 3, 1993

seven patients) in his series of 26 patients (11). Four of these (two ulnar nerve paresthesias, one triceps avulsion, and one infection) responded to additional surgical procedures, whereas the other four were minor and resolved without further surgery. The complication rate reported in all these series is 11 of 65, or 17%, similar to our incidence of 16%. This is still a relatively high rate, and should be considered before attempting surgical management of these injuries. Arthroscopic release of capsular flexion contracture of the elbow has been shown to be an effective means of decreasing flexion contracture of the elbow in patients in whom capsular contracture is the primary pathology. However, complications do occur, and this procedure requires experience in both arthroscopy and open surgery. Arthroscopic release was equally as effective in patients with posttraumatic arthrosis as in patients with other causes of elbow contracture. We feel that the decreased soft tissue trauma, as well as the ability to evaluate and treat intra-articular pathology associated with contracture, makes arthroscopic release a valuable means of treating flexion contractures of the elbow.

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ARTHROFIBROSIS OF THE ELBOW 12. Dickson RA. Reversed dynamic slings: a new concept in the treatment of post-traumatic elbow flexion contractures. Injury 1976;8:35-8. 13. Volkov MV, Oganesian OV. Restoration of functions in the knee and elbow with Honge-distractor apparatus. J Bone Joint Surg 1975;57A:519-600. 14. HuangTT, Blackwell JJ, Lewis SR. Ten years of experience in managing patients with burn contractures of the axilla,

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elbow, wrist and knee joints. Plastic Reconstr Surg 1978; 61:70--6. 15. Satio T, Koschino T, Okamoto R, Horiuchi S. Radical synovectomy with muscle release for the rheumatoid elbow. Acta Orthop Scand 1986;57:71-3. 16. Richards RR, Beaton D, Bechard M. Restoration of elbow motion by anterior capsular release of post traumatic flexion contractures. J Bone Joint Surg 1991;73B(suppl 2):107.

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