- Email: [email protected]
Arthroscopic treatment of arthrofibrosis of the elbow joint
Arthroscopic Treatment of Arthrofibrosis of the Elbow Joint Barry B. Phillips, M.D., and Scott Strasburger, M.D.
Summary: Twenty-five patients with arthrofibrosis of the elbow were treated with arthroscopic debridement; 15 had post-traumatic arthrofibrosis and 10 had contractures caused by degenerative arthritis. At an average follow-up of 18 months, all patients had increased motion and decreased pain. One patient required reoperation because of continued stiffness and pain; she had moderate pain before surgery, mild pain after initial debridement, and occasional mild pain after the second operation. Patients with post-traumatic arthritis had more severe flexion contractures preoperatively than did those with degenerative arthritis, but they also had more improvement postoperatively. There were no perioperative or postoperative complications. Arthroscopic release and debridement of arthrofibrotic elbow joints appear to obtain improvement equal to that obtained by open techniques, with less morbidity and earlier rehabilitation. Key Words: Elbow—Arthrofibrosis— Arthroscopic debridement.
A
rthroscopy of the elbow is being used more frequently for diagnosis and treatment of a wide spectrum of symptomatic pathological elbow conditions. Arthrofibrosis has been included as an indication for arthroscopy of the elbow,1-8 but little has been published regarding arthroscopic treatment of this condition.9-13 To determine the efficacy of arthroscopic debridement in the treatment of arthrofibrosis of the elbow, we reviewed our results with this technique. MATERIALS AND METHODS From 1992 to 1994, 25 patients with arthrofibrosis of the elbow were referred to our clinic and were treated with arthroscopic debridement by the senior author (B.B.P.). Fifteen patients had post-traumatic arthrofibrosis and 10 had contractures caused by degenerative arthritis. All patients were followed by the senior author. From the Department of Orthopaedic Surgery, The University of Tennessee–Campbell Clinic, Memphis, Tennessee, U.S.A. Address correspondence and reprint requests to Barry B. Phillips, M.D., Department of Orthopaedic Surgery, The University of Tennessee–Campbell Clinic, 869 Madison Ave, Memphis, TN 38103, U.S.A. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1401-1393$3.00/0
38
The 15 patients with post-traumatic stiffness included 9 males and six females, with an average age at the time of arthroscopic surgery of 31.6 years (range, 12 to 66 years). Thirteen patients had fractures about the elbow, 3 of which were associated with elbow dislocation, and 2 patients had isolated elbow dislocations. Four patients had undergone open reduction and internal fixation of their fractures. The average interval between injury and arthroscopic surgery was 8 months (range, 2 to 24 months). All 15 patients presented with complaints of loss of motion; none had elbow symptoms before injury. All 10 patients with degenerative arthritis also presented with complaints of decreased motion and pain. Eight patients were male and 2 were female, and 8 had occupations or avocations that involved repetitive use of the arm, including 3 professional baseball pitchers and 1 competitive high school pitcher. The dominant arm was involved in 7 patients. The average age of this group of patients was 37.8 years (range, 13 to 56 years). Two pitchers had secondary diagnoses of valgus extension overload syndrome and one had severe osteochondritis dissecans of the capitellum. The fourth pitcher was retired and had ulnar collateral ligament insufficiency as the primary diagnosis. Five patients had loose bodies in the elbow joint. All 25 patients had constant or intermittent pain of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 1 (January-February), 1998: pp 38–44
ARTHROFIBROSIS OF THE ELBOW varying degrees. Pain was rated as severe, occurring at rest and during restricted activity; moderate, occurring with activities of daily living; or mild, restricting some activities. Twenty patients had moderate pain and 5 had mild pain. Indications for arthroscopic surgery were flexion contracture of more than 30°, decreased arc of motion, or inability to perform a sport. SURGICAL TECHNIQUE With the patient supine, a tourniquet is applied around the upper arm of the involved extremity. The limb is maintained in 90° of shoulder abduction and 90° of elbow flexion with balanced traction using a Dyonics suspension apparatus (Smith & Nephew Dyonics, Andover, MA). Sterile waterproof drapes from either a shoulder or knee pack may be used. A sterile stockingette is used in conjunction with the suspension apparatus, which is suspended with 5 to 6 lbs of traction. The surgeon and an assistant are comfortably seated with sterile waterproof table covers around their waists to insure sterility (Fig 1). Bony landmarks are carefully identified and outlined, including the lateral epicondyle, the radial head and radiocapitellar joint, the medial epicondyle, and the olecranon. The course of the ulnar nerve medially is also carefully outlined. Usually four arthroscopic portals are used. An anterolateral portal is made 1 cm anterior and just proximal to the palpable radiocapitel-
FIGURE 1. Surgical set-up for left elbow arthroscopy, with surgeons seated. The patient is supine, and the left elbow is held in 90/90 balanced suspension.
39
lar joint laterally (Fig 2). An anteromedial portal is made approximately 2 cm distal and 2 cm anterior to the medial epicondyle; this portal approximates the flexion crease of the elbow (Fig 3). A direct posterior portal is outlined 2.5 cm proximal to the tip of the olecranon with the elbow in 30° of flexion, and a posterolateral portal is marked just lateral to the palpable triceps tendon, about 2.5 to 3 cm proximal to the tip of the olecranon (Fig 4). The joint is distended with sterile lactated Ringer’s solution through the soft-spot (direct lateral) portal at the center of the triangle formed by the radial head, the lateral epicondyle, and the tip of the olecranon. The anterolateral portal is then confirmed by inserting a spinal needle directed medially and posteriorly toward the center of the elbow joint. A No. 11 blade is used to make a skin incision and small hemostats are used to dissect the soft tissues down to the area of the joint capsule, making sure not to injure the antebrachial cutaneous nerve. The joint is entered with a blunt trocar. Using the trocar to capture the capsule just anterior to the capitellum, the cannula is directed toward the joint center. The joint itself is palpated with the trocar to confirm entry into the joint. In an arthrofibrotic joint, the area of visualization may be very limited initially, and the position of the portal and intra-articular placement of the trocar must be carefully evaluated. The medial portal is then made under direct vision using a spinal needle. To increase visibil-
40
B. B. PHILLIPS AND S. STRASBURGER bony and soft-tissue impingement and that all loose bodies are removed. The posterior compartment is debrided and loose bodies are removed through a direct posterior portal and a posterolateral portal made under direct vision. After resecting the scar tissue from the olecranon fossa to improve visibility, the arthroscope is changed to the posterolateral portal and the resector or burr is placed through the direct posterior portal to complete the procedure. A combination of careful contracture release with a full-radius resector and blunt mobilization is used to release the posterolateral and posteromedial gutters, making sure to avoid injury to the ulnar nerve, which is in close proximity medially. Any impingement of the olecranon tip in the fossa or osteophyte formation is resected using an osteotome and completed with an arthroscopic burr. Bony hypertrophy creating impingement of the olecranon fossa may be relieved by using the burr to enlarge the fossa. When the procedure is completed, a drain is placed in the direct posterior portal and the portals are closed with nylon sutures. The elbow is gently manipulated to gain maximal motion, and then is splinted in maximal extension.
FIGURE 2. Lateral view of the elbow with radial head and lateral epicondyle outlined in relation to preferred arthroscopic portal 1-cm anterior and just proximal to the radiocapitellar joint. A recently described, more proximal portal also is shown, as is the soft-spot portal just posterior to the radiocapitellar joint.
ity, a 4.5-mm full-radius resector is placed through the anteromedial portal and the fibrotic tissue is carefully resected from the anterior part of the joint (Fig 5). Loose bodies are removed and full debridement of the anterior fibrous tissue is performed, using a combination of a full radius resector and electrocautery through the anteromedial and anterolateral portals (Fig 6). The resector is used to strip the capsule proximally off the distal humerus for approximately 2.5 cm proximal to the coronoid fossa or until the posterior fibers of the brachialis muscles are identified proximally. Complete release of the capsule is necessary to regain good functional motion. The coronoid fossa is recreated by using the resector and, if necessary, a burr to resect bony hypertrophy from the area. Any impingement of the coronoid that limits range of motion is relieved by partial resection of the tip of the coronoid (Fig 7). Care is taken to make sure the radioulnar joint is free of
Postoperative Care The splint is left in place for 24 hours. Then gentle active and passive range of motion of the elbow is
FIGURE 3. Medial side of the elbow with the ulnar nerve carefully outlined. The medial epicondyle and flexion crease of the elbow also are indicated. The anteromedial portal is marked approximately 2-cm anterior and 1- to 2-cm distal to the medial epicondyle. The proximal anteromedial portal is approximately 2-cm proximal to the medial epicondyle just anterior to the intermuscular septum.
ARTHROFIBROSIS OF THE ELBOW
FIGURE 5. tissue.
41
Appearance of the joint after resection of fibrotic scar
RESULTS
FIGURE 4. Posterior view of the elbow flexed about 30° with the tip of the olecranon outlined and the portal marked. The direct posterior portal is approximately 2.5-cm proximal to the tip of the olecranon and the posterolateral portal is 2.5-cm primal and just lateral to the edge of the triceps tendon.
begun. A removeable extension splint is worn between exercise periods. In patients with extensive posttraumatic arthrofibrosis and severe loss of flexion and extension, use of elbow continuous passive motion may be helpful to maintain range of motion during the first 3 weeks after surgery. At 1 week after surgery, a Joint Active Systems brace (Joint Active Systems, Effingham, IL) is used for 30 minutes three times a day, active and passive range of motion exercises are performed for 20 minutes four to five times a day at home, and supervised physical therapy is continued three times a week. An antiinflammatory medication (indomethacin) is prescribed for the first 3 weeks to decrease inflammation and the risk of myositis.
At an average follow-up of 18 months (range, 6 to 34 months), all patients had increased motion (Table 1). The average improvement in total arc of motion was 41°. Fifteen patients with moderate pain and 5 with mild pain preoperatively reported no pain postoperatively. Five patients with moderate preoperative pain reported mild postoperative pain. One patient required reoperation for continued stiffness and pain despite physical therapy. Her motion before arthroscopic surgery was from 81° flexion contracture to 97° maximum flexion. After the initial debridement, motion improved to 30° of extension and 118° of flexion. She had no further improvement with a 3-month postoperative therapy program and was reoperated, with improvement to 4° of maximum extension and
FIGURE 6. After more extensive release of fibrous tissue and anterior capsular release.
42
B. B. PHILLIPS AND S. STRASBURGER
FIGURE 7. Coronoid fossa after resection of bony hypertrophy and anterior osteophytes.
138° of maximum flexion. She had moderate pain before surgery, mild pain after the initial debridement, and occasional mild pain at 12-month follow-up after the second operation. Indications for reoperation include a gain of at least 15° of extension with the first release, failure to progress after 3 consecutive weeks of supervised therapy, and persistence of flexion contracture of 30° or more that causes patient dissatisfaction. The patient should be fully aware that no additional motion may be possible even with a second procedure. Both groups of patients (post-traumatic arthritis and degenerative arthritis) had statistically significant decreases in flexion contracture and increases in maximum flexion and arc of motion (Table 1). Patients with post-traumatic arthritis had more severe flexion contractures preoperatively (Figs 8 and 9) than did those with degenerative arthritis (37.7° and 22.2°, respectively), but also had more improvement postoperatively: an average decrease in flexion contracture of 31.8° for those with post-traumatic arthritis compared with 13.9° for those with degenerative arthritis. Both groups had similar preoperative maximum flexion (117.1° and 119.7°, respectively) and obtained similar postoperative motion (135.4° and 133.5°). Arc of motion improved more in patients with posttraumatic arthritis
FIGURE 8. Preoperative lateral radiograph of a medical student with a 45° post-traumatic flexion contracture, large loose bodies, and deformity of the radial head.
(an average of 50°) than in patients with degenerative arthritis (an average of 27.2°). Two of the three patients who were professional baseball pitchers resumed pitching at the same competitive level. The third patient had retired from baseball before the surgery was performed because of continued pain and locking of the elbow. Of the two active pitchers, one had surgery early in the season and was able to return to the pitching rotation after All-Star break. The last 2 years he has pitched in a regular
TABLE 1. Elbow Motion Before and After Arthroscopic Release of Arthrofibrosis Overall Averages (N ⫽ 25)
Flexion contracture Maximum flexion Arc of motion
Averages by Type of Arthrofibrosis Posttraumatic (n ⫽ 15) Degenerative (n ⫽ 10)
Preop
Postop
Preop
Postop
Preop
Postop
31.5° 118.2° 87.2°
6.8° 134.6° 128.2°
37.7° 117.1° 80.1°
5.9° (P ⫽ .001) 135.4° (P ⫽ .001) 130.2° (P ⫽ .001)
22.2° 119.7° 98.0°
8.3° (P ⫽ .001) 133.5° (P ⫽ .008) 125.2° (P ⫽ .001)
ARTHROFIBROSIS OF THE ELBOW
FIGURE 9. Postoperative radiographs after removal of loose bodies, capsular release, and resection of bony impingement. The patient now lacks 3° of full extension and 10° of full pronation and supination.
starting rotation at the major league level. The second pitcher had the procedure after completion of the season and was able to return to the starting rotation the following year. Three patients who were high school athletes also resumed competitive sports without complaints. In the two high-level professional athletes who participated in upper-extremity-dominant sports, a formal capsular release was not performed. Loose bodies were removed, scar tissue was released, and bony impingement was resected. The goals of surgery in athletes are to relieve pain and impingement, check for instability, and regain some motion without compromising capsular function. The average operative time for arthroscopic release was 79 minutes, with a range from 54 to 93 minutes. The average operative time decreased as more experience was gained. The one patient who required a second release might be considered a complication because of the failure to completely release the anterior capsule with the first procedure. To avoid this complication, we have begun to release the capsule completely enough to expose the muscular fibers of the brachialis but without violating the muscle, thus protecting the over-lying median nerve. DISCUSSION Despite recent emphasis on prevention, arthrofibrosis remains a relatively common complication of elbow fractures and dislocations. Repetitive overuse of
43
the elbow, especially in sports activities, may lead to osteoarthritis. Loss of motion or pain caused by either of these conditions can be difficult to treat. For patients with mild symptoms, aggressive physical therapy and orthoses14 may be sufficient. Those with more severe involvement usually require operative treatment. A number of surgical procedures have been described, with varying results. Wilson,15 in 1944, described excision of fibrotic portions of the capsular ligament for limitation of elbow motion, and Glynn and Niebauer16 reported good results with the technique in 5 of 6 patients. Urbaniak et al.17 reported 51% improvement in 15 patients with post-traumatic flexion contractures after anterior capsulotomy without release of the biceps tendon or brachialis muscle. Morrey18 reported that 24 (96%) of 25 patients were satisified with their results after operative release alone or after release and distraction arthroplasty. In the 6 patients with release alone, the average increase in arc of motion was 42°; in the 20 with distraction arthroplasty, the average increase was 74°. However, he noted that distraction arthroplasty is a difficult technique and complications were frequent. Ulnohumeral arthroplasty was reported to obtain good or excellent results in 12 (80%) of 15 patients with degenerative arthritis of the elbow.19 Since the mid and late 1980s, arthrofibrosis has been included in the indications for elbow arthroscopy, but clinical reports of its use did not appear until recently. Ogilvie-Harris and Schemitsche11 reported improvement in 89% of 34 patients after arthroscopic removal of loose bodies. Jones and Savoie9 reported improved motion and decreased pain in 12 patients with flexion contractures of the elbow treated with arthroscopic capsular release and debridement of the olecranon fossa. Timmerman and Andrews13 obtained good to excellent results in 16 (84%) of 19 patients with post-traumatic elbow pain and stiffness, and Byrd3 reported an average 44° increase in arc of motion in 5 patients with arthrofibrosis after radial head fractures. Our results are similar; all patients had increased motion (average 41° increase in arc of motion) and decreased pain at last follow-up, although one patient required a second operation. Urbaniak et al.17 noted better subjective results after open capsulotomy in patients without significant posttraumatic degenerative changes. In the series of Timmerman and Andrews13 the only failure was in a patient with severe post-traumatic arthritis. In our series, patients with post-traumatic arthritis had more severe flexion contractures than those with degenera-
44
B. B. PHILLIPS AND S. STRASBURGER
tive arthritis, but also had larger gains in total arc of motion. Redden and Stanley12 described an arthroscopic modification of the ‘‘OK’’ operation of Kashiwagi,20 in which fenestrations approximately 1 cm in diameter are made in the olecranon to allow complete debridement of the elbow joint and removal of intraarticular loose bodies. We have been able to adequately debride the posterior joint compartment, reshape the olecranon fossa, and remove loose bodies through posterior and posterolateral portals, and have not seen a need to make these fenestrations. According to O’Driscoll and Morrey,6 neural and vascular structures are at great risk of injury during elbow arthroscopy, especially the radial, posterior interosseous, ulnar, and median nerves, which are in close proximity to the anterolateral and anteromedial portals. Several cadaver studies4,5,10,21 have shown the close proximity of neurovascular structures to the elbow joint during arthroscopy, and reported neurovascular complications include compression neuropathy of the radial nerve,5,22-24 transient median and posterior interosseous nerve palsy,1,5,12,23 damage to the accessory branch of the radial nerve,4 and neuroma of a branch of the antebrachial cutaneous nerve.5 Jones and Savoie9 reported one permanent posterior interosseous nerve palsy among their 12 patients. We had no neurovascular complications in our patients. Placement of the portals just proximal to the joint articulations allows entry of the arthroscope and instruments farther from the vulnerable radial nerve. Ogilive-Harris and Schrmitsch11 emphasized the importance of inspection of the posterior compartment through a posterolateral portal because they found posterior loose bodies that were not visible on radiographs in 6 of their 34 patients. In only 12 of the 34 patients were anterolateral and anteromedial portals sufficient to find and remove all loose bodies. We agree that careful inspection of the posterior compartment is imperative, and release of the posterolateral and posteromedial gutters was necessary in all of our patients. Several also required resection of osteophytes and bony hypertrophy on the olecranon fossa. From our results and those reported in the literature, arthroscopic release and debridement of arthrofibrotic elbow joints appear to obtain improvement equal to that obtained by open techniques, with the advantages of less morbidity and earlier rehabilitation.
REFERENCES 1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 2. Andrews JR, St. Pierre RK, Carson WG. Arthroscopy of the elbow. Clin Sports Med 1986;5:654-662. 3. Byrd JWT. Elbow arthroscopy for arthrofibrosis after type I radial head fractures. Arthroscopy 1994;10:162-165. 4. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopaedics 1985;8:290-296. 5. Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:191-197. 6. O’Driscoll S, Morrey B. Arthroscopy of the elbow: Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg Am 1992;74:84-94. 7. Poehling G, Whipple T, Sisco L, Goldman B. Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224. 8. Woods CW. Elbow arthroscopy. Clin Sports Med 1987;6:557-564. 9. Jones GS, Savoie FH III. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 1993;9:277-283. 10. Nowicki KD, Shall LM. Arthroscopic release of a posttraumatic flexion contracture in the elbow: a case report and review of the literature. Arthroscopy 1992;8:544-547. 11. Ogilvie-Harris DJ, Schemitsch E. Arthroscopy of the elbow for removal of loose bodies. Arthroscopy 1993;9:5-8. 12. Redden JF, Stanley D. Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16. 13. Timmerman LA, Andrews JR. Arthroscopic treatment of post-traumatic elbow pain and stiffness. Am J Sports Med 1994;22:230-235. 14. Green DP, McCoy H. Turnbuckle orthotic correction of elbow flexion contractures after acute injuries. J Bone Joint Surg Am 1979;61:1092-1095. 15. Wilson PD. Capsulectomy for the relief of flexion contractures of the elbow following fracture. J Bone Joint Surg 1944;26:71-86. 16. Glynn JJ, Niebauer JJ. Flexion and extension contracture of the elbow: Surgical management. Clin Orthop Rel Res 1976;117: 289-291. 17. Urbaniak JR, Hansen PE, Beissinger ST, Aitken MS. Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. J Bone Joint Surg Am 1985;67:11601164. 18. Morrey BF. Post-traumatic contracture of the elbow: operative treatment, including distraction arthroplasty. J Bone Joint Surg Am 1990;72:413-417. 19. Morrey BF. Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74:409-413. 20. Kashiwagi D. Osteoarthritis of the elbow joint: Intraarticular changes and the special operative procedure: OuterbridgeKashiwagi method (OK method). In: Kashiwgi D, ed. Elbow joint. Amsterdam: Elsevier, 1985;177-188. 21. Lindenfeld TN. Medial approach in elbow arthroscopy. Am J Sports Med 1990;18:413-417. 22. Morrey BF. Arthroscopy of the elbow. In: Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Saunders, 1985;102-107. 23. Papilion JD, Neff RS, Shall LM. Compression neuropathy of the radial nerve as a complication of elbow arthroscopy: A case report and review of the literature. Arthroscopy 1988;4:284-286. 24. Thomas MA, Fast A, Shapiro A. Radial nerve damage as a complication of elbow arthroscopy. Clin Orthop Rel Res 1987;215:130-131.
Summary: Twenty-five patients with arthrofibrosis of the elbow were treated with arthroscopic debridement; 15 had post-traumatic arthrofibrosis and 10 had contractures caused by degenerative arthritis. At an average follow-up of 18 months, all patients had increased motion and decreased pain. One patient required reoperation because of continued stiffness and pain; she had moderate pain before surgery, mild pain after initial debridement, and occasional mild pain after the second operation. Patients with post-traumatic arthritis had more severe flexion contractures preoperatively than did those with degenerative arthritis, but they also had more improvement postoperatively. There were no perioperative or postoperative complications. Arthroscopic release and debridement of arthrofibrotic elbow joints appear to obtain improvement equal to that obtained by open techniques, with less morbidity and earlier rehabilitation. Key Words: Elbow—Arthrofibrosis— Arthroscopic debridement.
A
rthroscopy of the elbow is being used more frequently for diagnosis and treatment of a wide spectrum of symptomatic pathological elbow conditions. Arthrofibrosis has been included as an indication for arthroscopy of the elbow,1-8 but little has been published regarding arthroscopic treatment of this condition.9-13 To determine the efficacy of arthroscopic debridement in the treatment of arthrofibrosis of the elbow, we reviewed our results with this technique. MATERIALS AND METHODS From 1992 to 1994, 25 patients with arthrofibrosis of the elbow were referred to our clinic and were treated with arthroscopic debridement by the senior author (B.B.P.). Fifteen patients had post-traumatic arthrofibrosis and 10 had contractures caused by degenerative arthritis. All patients were followed by the senior author. From the Department of Orthopaedic Surgery, The University of Tennessee–Campbell Clinic, Memphis, Tennessee, U.S.A. Address correspondence and reprint requests to Barry B. Phillips, M.D., Department of Orthopaedic Surgery, The University of Tennessee–Campbell Clinic, 869 Madison Ave, Memphis, TN 38103, U.S.A. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1401-1393$3.00/0
38
The 15 patients with post-traumatic stiffness included 9 males and six females, with an average age at the time of arthroscopic surgery of 31.6 years (range, 12 to 66 years). Thirteen patients had fractures about the elbow, 3 of which were associated with elbow dislocation, and 2 patients had isolated elbow dislocations. Four patients had undergone open reduction and internal fixation of their fractures. The average interval between injury and arthroscopic surgery was 8 months (range, 2 to 24 months). All 15 patients presented with complaints of loss of motion; none had elbow symptoms before injury. All 10 patients with degenerative arthritis also presented with complaints of decreased motion and pain. Eight patients were male and 2 were female, and 8 had occupations or avocations that involved repetitive use of the arm, including 3 professional baseball pitchers and 1 competitive high school pitcher. The dominant arm was involved in 7 patients. The average age of this group of patients was 37.8 years (range, 13 to 56 years). Two pitchers had secondary diagnoses of valgus extension overload syndrome and one had severe osteochondritis dissecans of the capitellum. The fourth pitcher was retired and had ulnar collateral ligament insufficiency as the primary diagnosis. Five patients had loose bodies in the elbow joint. All 25 patients had constant or intermittent pain of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 1 (January-February), 1998: pp 38–44
ARTHROFIBROSIS OF THE ELBOW varying degrees. Pain was rated as severe, occurring at rest and during restricted activity; moderate, occurring with activities of daily living; or mild, restricting some activities. Twenty patients had moderate pain and 5 had mild pain. Indications for arthroscopic surgery were flexion contracture of more than 30°, decreased arc of motion, or inability to perform a sport. SURGICAL TECHNIQUE With the patient supine, a tourniquet is applied around the upper arm of the involved extremity. The limb is maintained in 90° of shoulder abduction and 90° of elbow flexion with balanced traction using a Dyonics suspension apparatus (Smith & Nephew Dyonics, Andover, MA). Sterile waterproof drapes from either a shoulder or knee pack may be used. A sterile stockingette is used in conjunction with the suspension apparatus, which is suspended with 5 to 6 lbs of traction. The surgeon and an assistant are comfortably seated with sterile waterproof table covers around their waists to insure sterility (Fig 1). Bony landmarks are carefully identified and outlined, including the lateral epicondyle, the radial head and radiocapitellar joint, the medial epicondyle, and the olecranon. The course of the ulnar nerve medially is also carefully outlined. Usually four arthroscopic portals are used. An anterolateral portal is made 1 cm anterior and just proximal to the palpable radiocapitel-
FIGURE 1. Surgical set-up for left elbow arthroscopy, with surgeons seated. The patient is supine, and the left elbow is held in 90/90 balanced suspension.
39
lar joint laterally (Fig 2). An anteromedial portal is made approximately 2 cm distal and 2 cm anterior to the medial epicondyle; this portal approximates the flexion crease of the elbow (Fig 3). A direct posterior portal is outlined 2.5 cm proximal to the tip of the olecranon with the elbow in 30° of flexion, and a posterolateral portal is marked just lateral to the palpable triceps tendon, about 2.5 to 3 cm proximal to the tip of the olecranon (Fig 4). The joint is distended with sterile lactated Ringer’s solution through the soft-spot (direct lateral) portal at the center of the triangle formed by the radial head, the lateral epicondyle, and the tip of the olecranon. The anterolateral portal is then confirmed by inserting a spinal needle directed medially and posteriorly toward the center of the elbow joint. A No. 11 blade is used to make a skin incision and small hemostats are used to dissect the soft tissues down to the area of the joint capsule, making sure not to injure the antebrachial cutaneous nerve. The joint is entered with a blunt trocar. Using the trocar to capture the capsule just anterior to the capitellum, the cannula is directed toward the joint center. The joint itself is palpated with the trocar to confirm entry into the joint. In an arthrofibrotic joint, the area of visualization may be very limited initially, and the position of the portal and intra-articular placement of the trocar must be carefully evaluated. The medial portal is then made under direct vision using a spinal needle. To increase visibil-
40
B. B. PHILLIPS AND S. STRASBURGER bony and soft-tissue impingement and that all loose bodies are removed. The posterior compartment is debrided and loose bodies are removed through a direct posterior portal and a posterolateral portal made under direct vision. After resecting the scar tissue from the olecranon fossa to improve visibility, the arthroscope is changed to the posterolateral portal and the resector or burr is placed through the direct posterior portal to complete the procedure. A combination of careful contracture release with a full-radius resector and blunt mobilization is used to release the posterolateral and posteromedial gutters, making sure to avoid injury to the ulnar nerve, which is in close proximity medially. Any impingement of the olecranon tip in the fossa or osteophyte formation is resected using an osteotome and completed with an arthroscopic burr. Bony hypertrophy creating impingement of the olecranon fossa may be relieved by using the burr to enlarge the fossa. When the procedure is completed, a drain is placed in the direct posterior portal and the portals are closed with nylon sutures. The elbow is gently manipulated to gain maximal motion, and then is splinted in maximal extension.
FIGURE 2. Lateral view of the elbow with radial head and lateral epicondyle outlined in relation to preferred arthroscopic portal 1-cm anterior and just proximal to the radiocapitellar joint. A recently described, more proximal portal also is shown, as is the soft-spot portal just posterior to the radiocapitellar joint.
ity, a 4.5-mm full-radius resector is placed through the anteromedial portal and the fibrotic tissue is carefully resected from the anterior part of the joint (Fig 5). Loose bodies are removed and full debridement of the anterior fibrous tissue is performed, using a combination of a full radius resector and electrocautery through the anteromedial and anterolateral portals (Fig 6). The resector is used to strip the capsule proximally off the distal humerus for approximately 2.5 cm proximal to the coronoid fossa or until the posterior fibers of the brachialis muscles are identified proximally. Complete release of the capsule is necessary to regain good functional motion. The coronoid fossa is recreated by using the resector and, if necessary, a burr to resect bony hypertrophy from the area. Any impingement of the coronoid that limits range of motion is relieved by partial resection of the tip of the coronoid (Fig 7). Care is taken to make sure the radioulnar joint is free of
Postoperative Care The splint is left in place for 24 hours. Then gentle active and passive range of motion of the elbow is
FIGURE 3. Medial side of the elbow with the ulnar nerve carefully outlined. The medial epicondyle and flexion crease of the elbow also are indicated. The anteromedial portal is marked approximately 2-cm anterior and 1- to 2-cm distal to the medial epicondyle. The proximal anteromedial portal is approximately 2-cm proximal to the medial epicondyle just anterior to the intermuscular septum.
ARTHROFIBROSIS OF THE ELBOW
FIGURE 5. tissue.
41
Appearance of the joint after resection of fibrotic scar
RESULTS
FIGURE 4. Posterior view of the elbow flexed about 30° with the tip of the olecranon outlined and the portal marked. The direct posterior portal is approximately 2.5-cm proximal to the tip of the olecranon and the posterolateral portal is 2.5-cm primal and just lateral to the edge of the triceps tendon.
begun. A removeable extension splint is worn between exercise periods. In patients with extensive posttraumatic arthrofibrosis and severe loss of flexion and extension, use of elbow continuous passive motion may be helpful to maintain range of motion during the first 3 weeks after surgery. At 1 week after surgery, a Joint Active Systems brace (Joint Active Systems, Effingham, IL) is used for 30 minutes three times a day, active and passive range of motion exercises are performed for 20 minutes four to five times a day at home, and supervised physical therapy is continued three times a week. An antiinflammatory medication (indomethacin) is prescribed for the first 3 weeks to decrease inflammation and the risk of myositis.
At an average follow-up of 18 months (range, 6 to 34 months), all patients had increased motion (Table 1). The average improvement in total arc of motion was 41°. Fifteen patients with moderate pain and 5 with mild pain preoperatively reported no pain postoperatively. Five patients with moderate preoperative pain reported mild postoperative pain. One patient required reoperation for continued stiffness and pain despite physical therapy. Her motion before arthroscopic surgery was from 81° flexion contracture to 97° maximum flexion. After the initial debridement, motion improved to 30° of extension and 118° of flexion. She had no further improvement with a 3-month postoperative therapy program and was reoperated, with improvement to 4° of maximum extension and
FIGURE 6. After more extensive release of fibrous tissue and anterior capsular release.
42
B. B. PHILLIPS AND S. STRASBURGER
FIGURE 7. Coronoid fossa after resection of bony hypertrophy and anterior osteophytes.
138° of maximum flexion. She had moderate pain before surgery, mild pain after the initial debridement, and occasional mild pain at 12-month follow-up after the second operation. Indications for reoperation include a gain of at least 15° of extension with the first release, failure to progress after 3 consecutive weeks of supervised therapy, and persistence of flexion contracture of 30° or more that causes patient dissatisfaction. The patient should be fully aware that no additional motion may be possible even with a second procedure. Both groups of patients (post-traumatic arthritis and degenerative arthritis) had statistically significant decreases in flexion contracture and increases in maximum flexion and arc of motion (Table 1). Patients with post-traumatic arthritis had more severe flexion contractures preoperatively (Figs 8 and 9) than did those with degenerative arthritis (37.7° and 22.2°, respectively), but also had more improvement postoperatively: an average decrease in flexion contracture of 31.8° for those with post-traumatic arthritis compared with 13.9° for those with degenerative arthritis. Both groups had similar preoperative maximum flexion (117.1° and 119.7°, respectively) and obtained similar postoperative motion (135.4° and 133.5°). Arc of motion improved more in patients with posttraumatic arthritis
FIGURE 8. Preoperative lateral radiograph of a medical student with a 45° post-traumatic flexion contracture, large loose bodies, and deformity of the radial head.
(an average of 50°) than in patients with degenerative arthritis (an average of 27.2°). Two of the three patients who were professional baseball pitchers resumed pitching at the same competitive level. The third patient had retired from baseball before the surgery was performed because of continued pain and locking of the elbow. Of the two active pitchers, one had surgery early in the season and was able to return to the pitching rotation after All-Star break. The last 2 years he has pitched in a regular
TABLE 1. Elbow Motion Before and After Arthroscopic Release of Arthrofibrosis Overall Averages (N ⫽ 25)
Flexion contracture Maximum flexion Arc of motion
Averages by Type of Arthrofibrosis Posttraumatic (n ⫽ 15) Degenerative (n ⫽ 10)
Preop
Postop
Preop
Postop
Preop
Postop
31.5° 118.2° 87.2°
6.8° 134.6° 128.2°
37.7° 117.1° 80.1°
5.9° (P ⫽ .001) 135.4° (P ⫽ .001) 130.2° (P ⫽ .001)
22.2° 119.7° 98.0°
8.3° (P ⫽ .001) 133.5° (P ⫽ .008) 125.2° (P ⫽ .001)
ARTHROFIBROSIS OF THE ELBOW
FIGURE 9. Postoperative radiographs after removal of loose bodies, capsular release, and resection of bony impingement. The patient now lacks 3° of full extension and 10° of full pronation and supination.
starting rotation at the major league level. The second pitcher had the procedure after completion of the season and was able to return to the starting rotation the following year. Three patients who were high school athletes also resumed competitive sports without complaints. In the two high-level professional athletes who participated in upper-extremity-dominant sports, a formal capsular release was not performed. Loose bodies were removed, scar tissue was released, and bony impingement was resected. The goals of surgery in athletes are to relieve pain and impingement, check for instability, and regain some motion without compromising capsular function. The average operative time for arthroscopic release was 79 minutes, with a range from 54 to 93 minutes. The average operative time decreased as more experience was gained. The one patient who required a second release might be considered a complication because of the failure to completely release the anterior capsule with the first procedure. To avoid this complication, we have begun to release the capsule completely enough to expose the muscular fibers of the brachialis but without violating the muscle, thus protecting the over-lying median nerve. DISCUSSION Despite recent emphasis on prevention, arthrofibrosis remains a relatively common complication of elbow fractures and dislocations. Repetitive overuse of
43
the elbow, especially in sports activities, may lead to osteoarthritis. Loss of motion or pain caused by either of these conditions can be difficult to treat. For patients with mild symptoms, aggressive physical therapy and orthoses14 may be sufficient. Those with more severe involvement usually require operative treatment. A number of surgical procedures have been described, with varying results. Wilson,15 in 1944, described excision of fibrotic portions of the capsular ligament for limitation of elbow motion, and Glynn and Niebauer16 reported good results with the technique in 5 of 6 patients. Urbaniak et al.17 reported 51% improvement in 15 patients with post-traumatic flexion contractures after anterior capsulotomy without release of the biceps tendon or brachialis muscle. Morrey18 reported that 24 (96%) of 25 patients were satisified with their results after operative release alone or after release and distraction arthroplasty. In the 6 patients with release alone, the average increase in arc of motion was 42°; in the 20 with distraction arthroplasty, the average increase was 74°. However, he noted that distraction arthroplasty is a difficult technique and complications were frequent. Ulnohumeral arthroplasty was reported to obtain good or excellent results in 12 (80%) of 15 patients with degenerative arthritis of the elbow.19 Since the mid and late 1980s, arthrofibrosis has been included in the indications for elbow arthroscopy, but clinical reports of its use did not appear until recently. Ogilvie-Harris and Schemitsche11 reported improvement in 89% of 34 patients after arthroscopic removal of loose bodies. Jones and Savoie9 reported improved motion and decreased pain in 12 patients with flexion contractures of the elbow treated with arthroscopic capsular release and debridement of the olecranon fossa. Timmerman and Andrews13 obtained good to excellent results in 16 (84%) of 19 patients with post-traumatic elbow pain and stiffness, and Byrd3 reported an average 44° increase in arc of motion in 5 patients with arthrofibrosis after radial head fractures. Our results are similar; all patients had increased motion (average 41° increase in arc of motion) and decreased pain at last follow-up, although one patient required a second operation. Urbaniak et al.17 noted better subjective results after open capsulotomy in patients without significant posttraumatic degenerative changes. In the series of Timmerman and Andrews13 the only failure was in a patient with severe post-traumatic arthritis. In our series, patients with post-traumatic arthritis had more severe flexion contractures than those with degenera-
44
B. B. PHILLIPS AND S. STRASBURGER
tive arthritis, but also had larger gains in total arc of motion. Redden and Stanley12 described an arthroscopic modification of the ‘‘OK’’ operation of Kashiwagi,20 in which fenestrations approximately 1 cm in diameter are made in the olecranon to allow complete debridement of the elbow joint and removal of intraarticular loose bodies. We have been able to adequately debride the posterior joint compartment, reshape the olecranon fossa, and remove loose bodies through posterior and posterolateral portals, and have not seen a need to make these fenestrations. According to O’Driscoll and Morrey,6 neural and vascular structures are at great risk of injury during elbow arthroscopy, especially the radial, posterior interosseous, ulnar, and median nerves, which are in close proximity to the anterolateral and anteromedial portals. Several cadaver studies4,5,10,21 have shown the close proximity of neurovascular structures to the elbow joint during arthroscopy, and reported neurovascular complications include compression neuropathy of the radial nerve,5,22-24 transient median and posterior interosseous nerve palsy,1,5,12,23 damage to the accessory branch of the radial nerve,4 and neuroma of a branch of the antebrachial cutaneous nerve.5 Jones and Savoie9 reported one permanent posterior interosseous nerve palsy among their 12 patients. We had no neurovascular complications in our patients. Placement of the portals just proximal to the joint articulations allows entry of the arthroscope and instruments farther from the vulnerable radial nerve. Ogilive-Harris and Schrmitsch11 emphasized the importance of inspection of the posterior compartment through a posterolateral portal because they found posterior loose bodies that were not visible on radiographs in 6 of their 34 patients. In only 12 of the 34 patients were anterolateral and anteromedial portals sufficient to find and remove all loose bodies. We agree that careful inspection of the posterior compartment is imperative, and release of the posterolateral and posteromedial gutters was necessary in all of our patients. Several also required resection of osteophytes and bony hypertrophy on the olecranon fossa. From our results and those reported in the literature, arthroscopic release and debridement of arthrofibrotic elbow joints appear to obtain improvement equal to that obtained by open techniques, with the advantages of less morbidity and earlier rehabilitation.
REFERENCES 1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 2. Andrews JR, St. Pierre RK, Carson WG. Arthroscopy of the elbow. Clin Sports Med 1986;5:654-662. 3. Byrd JWT. Elbow arthroscopy for arthrofibrosis after type I radial head fractures. Arthroscopy 1994;10:162-165. 4. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopaedics 1985;8:290-296. 5. Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:191-197. 6. O’Driscoll S, Morrey B. Arthroscopy of the elbow: Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg Am 1992;74:84-94. 7. Poehling G, Whipple T, Sisco L, Goldman B. Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224. 8. Woods CW. Elbow arthroscopy. Clin Sports Med 1987;6:557-564. 9. Jones GS, Savoie FH III. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 1993;9:277-283. 10. Nowicki KD, Shall LM. Arthroscopic release of a posttraumatic flexion contracture in the elbow: a case report and review of the literature. Arthroscopy 1992;8:544-547. 11. Ogilvie-Harris DJ, Schemitsch E. Arthroscopy of the elbow for removal of loose bodies. Arthroscopy 1993;9:5-8. 12. Redden JF, Stanley D. Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16. 13. Timmerman LA, Andrews JR. Arthroscopic treatment of post-traumatic elbow pain and stiffness. Am J Sports Med 1994;22:230-235. 14. Green DP, McCoy H. Turnbuckle orthotic correction of elbow flexion contractures after acute injuries. J Bone Joint Surg Am 1979;61:1092-1095. 15. Wilson PD. Capsulectomy for the relief of flexion contractures of the elbow following fracture. J Bone Joint Surg 1944;26:71-86. 16. Glynn JJ, Niebauer JJ. Flexion and extension contracture of the elbow: Surgical management. Clin Orthop Rel Res 1976;117: 289-291. 17. Urbaniak JR, Hansen PE, Beissinger ST, Aitken MS. Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. J Bone Joint Surg Am 1985;67:11601164. 18. Morrey BF. Post-traumatic contracture of the elbow: operative treatment, including distraction arthroplasty. J Bone Joint Surg Am 1990;72:413-417. 19. Morrey BF. Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74:409-413. 20. Kashiwagi D. Osteoarthritis of the elbow joint: Intraarticular changes and the special operative procedure: OuterbridgeKashiwagi method (OK method). In: Kashiwgi D, ed. Elbow joint. Amsterdam: Elsevier, 1985;177-188. 21. Lindenfeld TN. Medial approach in elbow arthroscopy. Am J Sports Med 1990;18:413-417. 22. Morrey BF. Arthroscopy of the elbow. In: Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Saunders, 1985;102-107. 23. Papilion JD, Neff RS, Shall LM. Compression neuropathy of the radial nerve as a complication of elbow arthroscopy: A case report and review of the literature. Arthroscopy 1988;4:284-286. 24. Thomas MA, Fast A, Shapiro A. Radial nerve damage as a complication of elbow arthroscopy. Clin Orthop Rel Res 1987;215:130-131.