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Effect of disease duration on functional outcomes and complications after arthrolysis in patients with elbow stiffness
ARTICLE IN PRESS J Shoulder Elbow Surg (2017) ■■, ■■–■■
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ORIGINAL ARTICLE
Effect of disease duration on functional outcomes and complications after arthrolysis in patients with elbow stiffness Wei Zheng, MD1, Jialin Song, MD1, Ziyang Sun, MD1, Jiazhi Liu, MD, Shuai Chen, MD, Cunyi Fan, MD, PhD* Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China Hypothesis: The purpose of this study was to determine the effect of a long duration of elbow stiffness on functional outcomes and complications after arthrolysis. Methods: Participants included consecutive patients with a long duration of elbow stiffness (≥5 years, n = 23) and control patients matched for age, sex, and initial injury type (n = 46). All patients underwent elbow arthrolysis combined with hinged external fixation between March 2014 and March 2016. At baseline and follow-up, we evaluated elbow motion (flexion, extension, supination, pronation, and range of motion) and patient-reported outcomes, including the Mayo Elbow Performance Score (MEPS) and visual analog scale for pain. Postoperative complications including infection, nerve dysfunction, and instability were recorded. Results: There were no significant differences in preoperative elbow pain, range of motion, or MEPS between groups. Postoperatively, pronation and the MEPS in patients with a long disease duration were inferior to those in control patients (P = .041 and P = .016, respectively). Patients with a long disease duration also had a significantly higher incidence of complications than control patients (P = .002). At final follow-up, 7 patients (30%) in the long disease duration group and 3 patients (7%) in the control group presented with nerve symptoms (P = .022). Conclusions: A long duration of elbow stiffness may negatively influence functional outcomes and increase the risk of complications after arthrolysis. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Disease duration; elbow stiffness; arthrolysis; elbow motion; functional performance; complications
This is a retrospective study without intervention of therapy. We contacted the ethics committee of our hospital, and it was concluded that no approval of the committee was necessary because of the retrospective design of the study. All patients signed informed consent forms to collect, file, and use the data. 1 These authors contributed equally to this study as co-first authors. *Reprint requests: Cunyi Fan, MD, Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China. E-mail address: [email protected] (C. Fan).
Elbow stiffness with decreased active and passive range of motion (ROM) is one of the most common complications after elbow trauma and surgery.12 The incidence of elbow stiffness varies from 5%-40% according to the type of elbow injury.11,17,18 As ROM limitation progresses, activities of daily living may be greatly affected. Currently, open arthrolysis is used widely and it has proved effective to restore ROM in patients with severe elbow stiffness and even ankylosis, with a low rate of complications.3,13,19,20
1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2017.11.012
ARTICLE IN PRESS 2 Recently, to help patients achieve more satisfactory outcomes, numerous studies have focused on identifying factors associated with better outcomes after orthopedic surgery, including demographic data and specific disease parameters; as an important parameter, disease duration has been studied extensively. Chen et al9 retrospectively reviewed 164 patients with post-traumatic elbow stiffness and found that postoperative ROM, Mayo Elbow Performance Score (MEPS), and heterotopic ossification (HO) recurrence were similar between early and late surgical excision patients. A long-term duration of elbow stiffness may result in fatty atrophy of the upper limb muscles, nerve dysfunction, and joint degeneration.3,14 However, there has been no study focusing on the effect of disease duration on the outcomes of arthrolysis for post-traumatic elbow stiffness. Therefore, the purposes of this study were (1) to compare the severity of elbow stiffness between different disease duration groups, (2) to determine the surgical outcomes of open arthrolysis in patients with a long-term duration of elbow stiffness, and (3) to explore whether a longer disease duration correlates with less satisfactory functional outcomes and an increased rate of complications.
Methods Participants This was a retrospective study of patients with post-traumatic elbow stiffness receiving open arthrolysis at our hospital between March 2014 and March 2016. Patient medical records were reviewed via an electronic database. Open arthrolysis was performed in cases with (1) ROM less than 100°, (2) substantial HO formation, and (3) conservative treatment such as rehabilitation that failed to restore elbow motion. The inclusion criteria were as follows: (1) skeletal maturity, (2) a minimum disease duration of 5 years, (3) treatment with open arthrolysis followed by rehabilitation exercises, and (4) a minimum follow-up period of 1 year. The exclusion criteria were as follows: (1) other elbow arthrolysis since initial injury; (2) severe osteoarthritis (grade 3 according to the Broberg and Morrey classification), inflammatory arthritis, malunion, or nonunion of the elbow; and (3) unwillingness to participate in the study. According to the Broberg and Morrey classification, elbow osteoarthritis was classified as follows: grade 0, normal joint; grade 1, slight joint space narrowing with minimal osteophyte formation; grade 2, moderate joint space narrowing with moderate osteophyte formation; or grade 3, severe degenerative change with gross destruction of the joint.2 We identified 29 patients with elbow stiffness for 5 years or more from March 2014 to March 2016. After reviewing the patients’ medical records, we excluded 3 with incomplete records, 1 who was lost to follow-up, 1 with previous elbow arthrolysis, and 1 with ulnar deformity requiring revision surgery (Fig. 1). Finally, a total of 23 patients with a minimum disease duration of 5 years were included in this study. Control participants were chosen randomly by matching cases according to age, sex, and initial injury in a 2:1 ratio among patients with a disease duration of less than 5 years (control group). The final case-control study comprised 69 patients, 23 of whom had a long disease duration and 46 of whom were controls. All study participants provided informed consent.
W. Zheng et al.
Figure 1
Flowchart showing patient inclusion and exclusion.
Data collection For all participants, demographic characteristics, history of injury and treatment, elbow functional evaluation, and imaging data were recorded at baseline. Demographic data included sex, age, marital status, body mass index, tobacco use, and comorbidities. Detailed initial injury data included disease duration, disease side, fracture location, and treatment history. Fracture location was classified as singular (distal humerus, radial head, olecranon, or coronoid) or combined (concomitant fractures of the distal humerus, radial head, or proximal ulna involving >1 location). Original treatment history was classified as open reduction–internal fixation or nonoperative treatment. Elbow physical examinations included flexion, extension, supination, pronation, and ROM (flexion-extension). Questionnaires regarding health status, including the MEPS and visual analog scale (VAS) for pain, also were obtained at baseline. The MEPS is a widely used elbow-specific questionnaire including 4 subscales—pain, ROM, stability, and activities of daily living— that generate a total score ranging from 0 to 100, with higher scores indicating better elbow function.10 The VAS for pain is a widely used tool for patients to measure pain intensity along a 10-cm line, ranging from no pain (left end) to worst pain (right end). Neuropathy symptoms, including radial, median, and ulnar nerve dysfunction, also were recorded. At the final postoperative follow-up, elbow motion, MEPS, and VAS data were evaluated. In addition, intraoperative and postoperative complications, including infection, fracture, instability, and nerve symptoms, were recorded. All data were collected by 2 independent observers. If there was any discrepancy regarding the medical data, the senior physician reviewed the data and made the final decision.
Surgical technique and postoperative rehabilitation All patients underwent open elbow arthrolysis combined with hinged external fixation.8 The approach used was based on the previous approach and location of disease. In general, patients underwent arthrolysis via a combination of the lateral column approach and medial approach posterior to the medial epicondyle. If the patient had undergone surgery via a posterior approach, we performed the approach along the previous scar. Through a lateral approach, we
ARTICLE IN PRESS Effect of disease duration on outcomes
3
excised the hypertrophic capsule and cleared the coronoid fossa. If the patient presented with forearm rotation limitation, the annular ligament and radiohumeral joint were released. Through a medial approach, the posterior band of the medial collateral ligament and posterior capsule were released, and HO or scar tissue was excised. During the operation, the anterior part of the medial collateral ligament and ulnar bundle of the lateral collateral ligament were preserved for elbow stability. If the patient required surgical release on the medial side of the elbow, presented with a substantial flexion deficit, or had ulnar nerve symptoms preoperatively, the ulnar nerve was released and subcutaneously transposed. Atraumatic suture anchors were applied to reattach the ligaments. Suction drainage was applied before skin closure. Finally, considering that the conditions of the ligaments and soft tissue after release in case of severe elbow stiffness were not satisfactory, hinged external fixation was applied to facilitate rehabilitation. Postoperative rehabilitation was divided into 3 stages. Stage 1 lasted from the first day to 6 weeks postoperatively. Starting on the first day after surgery, patients were prescribed celecoxib, 200 mg orally, twice a day. Patients were instructed to lift the upper limb and perform active muscle contraction. They performed 30 active flexion and extension exercises, increasing the number by 30 times a day until reaching 150 times a day. At the same time, passive movements were performed by rehabilitation physicians. Suction drainage was removed when drainage was less than 50 mL. Starting 1 week after surgery, patients were instructed to perform active rotation exercises for 30 minutes twice a day under protection. After the stitches were removed at 2 weeks postoperatively, patients were discharged and instructed to gradually increase flexion and extension exercises to 300 times a day. Hinged external fixation was removed at 6 weeks postoperatively in the outpatient operating room; regional anesthesia was applied if the patient demanded it. Stage 2 lasted from 6 weeks to 3 months postoperatively. After external fixation was removed, besides flexion and extension exercises, patients were instructed to increase the intensity of active forearm rotation exercises. Stage 3 lasted from 3 months to 1 year postoperatively. Patients were instructed to continue exercises for at least 30 minutes, 3 times a day. They also were encouraged to perform weightbearing exercises starting with 2 kg under supervision. Patients’ rehabilitation exercises were followed up at 6 weeks, 3 months, and 1 year postoperatively in the outpatient room or by telephone. If
Table I
patients still had serious difficulty recovering ROM at 3 months after surgery, they were asked to visit the outpatient clinic to receive further rehabilitation therapy, such as static splinting or static progressive splinting, in the rehabilitation department of our hospital.
Statistical analysis All continuous variables were described as mean ± standard deviation, while qualitative variables were described as proportions. Twotailed t tests were used to compare continuous data, while the Pearson χ2 test or Fisher exact test was used to compare qualitative data. P ≤ .05 was considered statistically significant. Statistical analysis was performed using SPSS software (version 19.0; IBM, Armonk, NY, USA).
Results In the long disease duration group, the average age was 35 ± 11 years and the average duration of elbow stiffness was 162 ± 77 months (range, 60-348 months) (Table I). Regarding injury type, 21 patients had a singular fracture (distal humerus in 11, radial head in 2, olecranon in 7, and coronoid 1) and 2 had combined fractures (combination of distal humerus and olecranon in 1 and combination of distal humerus and radial head in 1). In the long disease duration group, 15 patients (65%) underwent operative treatment after initial injury. The long disease duration and control groups were comparable in terms of age, sex, disease side, and initial injury. However, the disease duration was significantly shorter in the control group (16 months, P < .001). Of the 69 patients in total, 9 had a radial head fracture, but none of them underwent radial head replacement. The severity of elbow stiffness, as measured by elbow flexion, extension, supination, pronation, and ROM, showed no difference between the long disease duration and control groups (Table II). No pain about the elbow was reported by 8 patients (34%) in the long disease duration group and 20 (43%) in the control group. The average VAS scores for pain
Demographic and clinical characteristics of patients
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
No. of patients Age, mean ± SD, y Male, n Tobacco use, n Disease duration, mean ± SD, mo Diseased side, n Right Left Initial injury, n Singular fracture Combined fractures Previous elbow ORIF, n Follow-up period, mean ± SD, mo
23 35 ± 11 15 (65%) 1 (4%) 162 ± 77
46 37 ± 12 29 (63%) 6 (13%) 16 ± 10
12 (52%) 11 (48%)
21 (46%) 25 (54%)
21 (91%) 2 (9%) 15 (65%) 19 ± 4
41 (89%) 5 (11%) 39 (85%) 19 ± 5
ORIF, open reduction–internal fixation.
P value .431 .859 .259 <.001 .609
.778
.063 .814
ARTICLE IN PRESS 4
W. Zheng et al. Table II
Preoperative elbow performance evaluation
Table IV
Distribution of postoperative complications
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
P value
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
P value
Extension, ° Flexion, ° Pronation, ° Supination, ° Range of motion, ° VAS MEPS Nerve symptoms Ulnar nerve Median nerve Radial nerve
41 ± 22 84 ± 34 53 ± 36 77 ± 21 43 ± 28 0.9 ± 1.1 60 ± 11
34 ± 17 77 ± 23 53 ± 25 66 ± 34 43 ± 26 0.8 ± 0.9 62 ± 10
.119 .336 .918 .097 .997 .596 .500 .453
9 2
4 0
.002
8 1 0
11 0 1
Total number, n Infection, n New-onset or exacerbation of nerve symptoms, n Ulnar nerve Median nerve Radial nerve Instability, n
4 0 0 3
2 1 0 1
VAS, visual analog scale; MEPS, Mayo Elbow Performance Score. Data are presented as mean ± standard deviation or number of cases.
Table III
Postoperative elbow performance evaluation
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
P value
Extension, ° Flexion, ° Pronation, ° Supination, ° Range of motion, ° VAS MEPS
11 ± 11 125 ± 15 54 ± 38 80 ± 14 114 ± 22 0.7 ± 1.0 89 ± 9
11 ± 10 122 ± 11 72 ± 11 77 ± 14 112 ± 19 0.3 ± 0.7 95 ± 6
.839 .528 .041 .457 .769 .110 .016
VAS, visual analog scale; MEPS, Mayo Elbow Performance Score. Data are presented as mean ± standard deviation.
were low in both groups (0.9 vs 0.8, P = .596), indicating that pain was not the main problem for patients with elbow stiffness. In the long disease duration group, 8 patients reported 9 cases of nerve dysfunction (8 ulnar nerve and 1 median nerve), which was similar to the findings in the control group (P = .453). No intraoperative complications occurred in either group. The average follow-up period was 19 ± 4 months and 19 ± 5 months in the long disease duration and control groups, respectively. At the final postoperative follow-up, all patients showed significant improvement in elbow function. In the long disease duration group, average ROM was 114° ± 22°, with average flexion of 125° ± 15° and average extension of 11° ± 11° (Table III). The average MEPS was 89 ± 9 in the long disease duration group, which was slightly inferior to that in the control group (95 ± 6, P = .016). According to the MEPS, 12 patients (52%) in the long disease duration group had excellent elbow function, which was fewer than the 37 patients (80%) with excellent function in the control group (P = .015). The average VAS scores were 0.7 ± 1.0 and
0.3 ± 0.7 in the long disease duration and control groups, respectively (P = .110, Table III). The long disease duration group had a significantly higher incidence of postoperative complications (9 cases, 39%) than the control group (4 cases, 9%) (P = .002, Table IV). In the long disease duration group, 2 patients with elbow infection underwent débridement, and in 4 patients, new-onset ulnar dysfunction developed and conservative treatment was performed. In addition, moderate instability developed in 1 patient, and gross instability developed in 2 patients; 1 patient with gross instability underwent revision surgery, while the other 2 patients underwent conservative treatment. In the control group, new-onset nerve dysfunction developed in 3 patients, and moderate instability developed in 1 patient; all underwent conservative treatment. After elbow arthrolysis, 3 of 8 patients (38%) in the long disease duration group and 10 of 12 patients (83%) in the control group recovered from preoperative nerve dysfunction. At the final postoperative follow-up, 7 patients (30%) in the long disease duration group and 3 patients (7%) in the control group reported nerve symptoms (P = .022).
Discussion Restoring motion and function and resolving nerve symptoms are the main goals of elbow arthrolysis. Recent studies have reported satisfactory outcomes of arthrolysis for elbow stiffness caused by HO and/or soft-tissue contracture.3,13,20 However, postoperative outcomes vary among patients. Exploring the effect of various factors on outcomes will help to improve postoperative recovery and avoid complications. However, there has been no previous study evaluating the association between disease duration and outcomes of elbow arthrolysis. In this study, we found that a long duration of elbow stiffness is a potential predictor of such outcomes. In our study, no differences in preoperative parameters were observed between the long disease duration and control groups. Therefore, we suggest that a prolonged disease duration did not affect the severity of stiffness or nerve dysfunction. Similarly, MOON Shoulder Group et al16 conducted a prospective
ARTICLE IN PRESS Effect of disease duration on outcomes cohort study of 450 patients with full-thickness rotator cuff tears and found no significant correlations between a longer duration of symptoms and decreased ROM, tear severity, or validated patient-reported outcome measures. At the final postoperative follow-up, most patients gained satisfactory improvement in elbow motion and function, indicating that arthrolysis combined with early rehabilitation can effectively restore elbow function after a long duration of stiffness. In our study, postoperative pronation and the MEPS in the long disease duration group were inferior to those in the control group, suggesting increased difficulty in restoration of rotation function in patients with a long symptom duration. Koh et al13 reviewed 77 patients with elbow stiffness caused by HO and found that those with a disease duration of more than 19 months showed significantly inferior outcomes. Ando et al1 reported no significant association between treatment outcomes and duration of symptoms. When patients underwent nonoperative treatment of shoulder stiffness, the recovery time was comparable between patients with a prolonged duration and those with a short duration of symptoms.1 In addition, our study showed no significant differences in postoperative pain, extension, flexion, supination, or ROM of the elbow between the long disease duration and control groups. Our study found a significantly higher incidence of postoperative complications in patients with a long disease duration. We noticed a relatively high incidence (13%) of postoperative instability in the long disease duration group, which was much higher than that in the control group and in previous reports.13,15,20,21 Cai et al5 systematically reviewed 810 patients who underwent elbow arthrolysis, and they reported a 1.0% ± 0.7% incidence of postoperative instability. Many researchers have recommended early mobilization after elbow surgery, such as arthrolysis and open reduction–internal fixation. The collateral ligaments play a pivotal role in maintaining elbow stability. When we performed elbow arthrolysis, the collateral ligaments were partly released and then reconstructed. The purpose of applying external fixation was to protect the collateral ligaments and muscles during early rehabilitation. However, a long duration of stiffness would lead to decreased quality and impaired ability to repair the ligaments and muscles. Therefore, we consider that in patients with a long duration of elbow stiffness, the period of external fixation could be extended. In our previous study involving 260 patients with post-traumatic elbow stiffness, the incidence of new-onset nerve dysfunction was 9.2% after arthrolysis, which was similar to the incidence in the control group (8.6%).6 At final follow-up, we found that 10 patients (83%) with preoperative nerve symptoms in the control group recovered whereas only 3 patients (38%) in the long disease duration group recovered. Several previous studies also have reported a negative effect of a longer disease duration on neurologic status after orthopedic surgery. Charles et al 7 retrospectively reviewed 49 patients who underwent anterior transposition of the ulnar nerve and found worse outcomes in those with a symptom duration of more than 6 months. Yamamoto et al22 also demonstrated a significant association
5 between a long duration (>3 years) of ulnar neuropathy at the elbow and poor surgical outcomes. Similarly, Burns et al4 reported a prolonged recovery time in patients with a duration of ulnar neuropathy at the elbow of more than 3 months. There were several limitations in our study that should be mentioned. First, on the basis of the retrospective design, there was some unavoidable recall bias that might have influenced the results. Second, we did not use additional general or specific patient-related outcome measures, such as the Short Form 36 survey; Disabilities of the Arm, Shoulder and Hand questionnaire; or American Shoulder and Elbow Surgeons– Elbow evaluation. Therefore, we are planning to conduct a prospective study to obtain more convincing evidence. Third, the sample size was relatively small, and as such, complications were not common after elbow arthrolysis. To better evaluate the effect of a long disease duration on postoperative functional outcomes and complications, a larger sample size might provide more reliable results. Finally, the followup was relatively short, and thus, the long-term results still need to be evaluated.
Conclusion Arthrolysis is effective in restoring motion and function in patients with a long duration of elbow stiffness. However, we also found that patients with a long disease duration had difficulty with improvement in forearm rotation. Moreover, a longer disease duration may increase the incidence of various postoperative complications, including infection, instability, and nerve dysfunction. Careful followup and long-term rehabilitation are needed to reduce complications after elbow arthrolysis.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Ando A, Sugaya H, Hagiwara Y, Takahashi N, Watanabe T. Identification of prognostic factors for the nonoperative treatment of stiff shoulder. Int Orthop 2013;37:859-64. http://dx.doi.org/10.1007/s00264-013-1859-8 2. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 1987;216:109-19. 3. Brouwer KM, Lindenhovius ALC, de Witte PB, Jupiter JB, Ring D. Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction. J Hand Surg Am 2010;35:1115-9. http://dx.doi.org/10.1016/j.jhsa.2010.03.040 4. Burns PB, Kim HM, Gaston RG, Haase SC, Hammert WC, Lawton JN, et al. Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study
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W. Zheng et al. group. Arch Phys Med Rehabil 2014;95:680-5. http://dx.doi.org/ 10.1016/j.apmr.2013.10.028 Cai J, Wang W, Yan H, Sun Y, Chen W, Chen S, et al. Complications of open elbow arthrolysis in post-traumatic elbow stiffness: a systematic review. PLoS One 2015;10:e0138547. http://dx.doi.org/10.1371/ journal.pone.0138547 Cai J, Zhou Y, Chen S, Sun Y, Yuanming O, Ruan H, et al. Ulnar neuritis after open elbow arthrolysis combined with ulnar nerve subcutaneous transposition for post-traumatic elbow stiffness: outcome and risk factors. J Shoulder Elbow Surg 2016;25:1027-33. http://dx.doi.org/10.1016/ j.jse.2016.01.013 Charles YP, Coulet B, Rouzaud JC, Daures JP, Chammas M. Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Am 2009;34:866-74. http://dx.doi.org/10.1016/j.jhsa.2009.01.008 Chen S, Liu J, Cai J, Zheng W, Li Z, Chen W, et al. Results and outcome predictors after open release of complete ankylosis of the elbow caused by heterotopic ossification. Int Orthop 2017;41:1627-32. http:// dx.doi.org/10.1007/s00264-016-3395-9 Chen S, Yu S, Yan H, Cai J, Ouyang Y, Ruan H, et al. The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. J Shoulder Elbow Surg 2015;24:1165-71. http://dx.doi.org/10.1016/ j.jse.2015.05.044 Cusick MC, Bonnaig NS, Azar FM, Mauck BM, Smith RA, Throckmorton TW. Accuracy and reliability of the Mayo Elbow Performance Score. J Hand Surg Am 2014;39:1146-50. http://dx.doi.org/ 10.1016/j.jhsa.2014.01.041 Evans PJ, Nandi S, Maschke S, Hoyen HA, Lawton JN. Prevention and treatment of elbow stiffness. J Hand Surg Am 2009;34:769-78. http:// dx.doi.org/10.1016/j.jhsa.2009.02.020 Everding NG, Maschke SD, Hoyen HA, Evans PJ. Prevention and treatment of elbow stiffness: a 5-year update. J Hand Surg Am 2013;38:2496-507. http://dx.doi.org/10.1016/j.jhsa.2013.06.007
13. Koh KH, Lim TK, Lee HI, Park MJ. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification. J Shoulder Elbow Surg 2013;22:1128-34. http://dx.doi.org/10.1016/j.jse.2013.04.019 14. Lindenhovius AL, Buijze GA, Kloen P, Ring DC. Correspondence between perceived disability and objective physical impairment after elbow trauma. J Bone Joint Surg Am 2008;90:2090-7. http://dx.doi.org/ 10.2106/JBJS.G.00793 15. Liu S, Fan CY, Ruan HJ, Li FF, Tian J. Combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow. J Trauma 2011;70:373-6. http://dx.doi.org/ 10.1097/TA.0b013e3181e4f5e3 16. MOON Shoulder Group, Unruh KP, Kuhn JE, Sanders R, An Q, Baumgarten KM, et al. The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg 2014;23:1052-8. http://dx.doi.org/ 10.1016/j.jse.2013.10.001 17. Myden C, Hildebrand K. Elbow joint contracture after traumatic injury. J Shoulder Elbow Surg 2011;20:39-44. http://dx.doi.org/10.1016/ j.jse.2010.07.013 18. Nandi S, Maschke S, Evans PJ, Lawton JN. The stiff elbow. Hand 2009;4:368-79. http://dx.doi.org/10.1007/s11552-009-9181-z 19. Oishi SN, Agranovich O, Pajardi GE, Novelli C, Baindurashvili AG, Trofimova SI, et al. Treatment of the upper extremity contracture/ deformities. J Pediatr Orthop 2017;37:S9-15. http://dx.doi.org/10.1097/ BPO.0000000000001002 20. Park MJ, Chang MJ, Lee YB, Kang HJ. Surgical release for posttraumatic loss of elbow flexion. J Bone Joint Surg Am 2010;92:2692-9. http:// dx.doi.org/10.2106/JBJS.I.01367 21. Ring D, Adey L, Zurakowski D, Jupiter JB. Elbow capsulectomy for posttraumatic elbow stiffness. J Hand Surg Am 2006;31:1264-71. http://dx.doi.org/10.1016/j.jhsa.2006.06.009 22. Yamamoto K, Shishido T, Masaoka T, Katori Y, Tanaka S. Postoperative clinical results in cubital tunnel syndrome. Orthopedics 2006;29:347-53.
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ORIGINAL ARTICLE
Effect of disease duration on functional outcomes and complications after arthrolysis in patients with elbow stiffness Wei Zheng, MD1, Jialin Song, MD1, Ziyang Sun, MD1, Jiazhi Liu, MD, Shuai Chen, MD, Cunyi Fan, MD, PhD* Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China Hypothesis: The purpose of this study was to determine the effect of a long duration of elbow stiffness on functional outcomes and complications after arthrolysis. Methods: Participants included consecutive patients with a long duration of elbow stiffness (≥5 years, n = 23) and control patients matched for age, sex, and initial injury type (n = 46). All patients underwent elbow arthrolysis combined with hinged external fixation between March 2014 and March 2016. At baseline and follow-up, we evaluated elbow motion (flexion, extension, supination, pronation, and range of motion) and patient-reported outcomes, including the Mayo Elbow Performance Score (MEPS) and visual analog scale for pain. Postoperative complications including infection, nerve dysfunction, and instability were recorded. Results: There were no significant differences in preoperative elbow pain, range of motion, or MEPS between groups. Postoperatively, pronation and the MEPS in patients with a long disease duration were inferior to those in control patients (P = .041 and P = .016, respectively). Patients with a long disease duration also had a significantly higher incidence of complications than control patients (P = .002). At final follow-up, 7 patients (30%) in the long disease duration group and 3 patients (7%) in the control group presented with nerve symptoms (P = .022). Conclusions: A long duration of elbow stiffness may negatively influence functional outcomes and increase the risk of complications after arthrolysis. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Disease duration; elbow stiffness; arthrolysis; elbow motion; functional performance; complications
This is a retrospective study without intervention of therapy. We contacted the ethics committee of our hospital, and it was concluded that no approval of the committee was necessary because of the retrospective design of the study. All patients signed informed consent forms to collect, file, and use the data. 1 These authors contributed equally to this study as co-first authors. *Reprint requests: Cunyi Fan, MD, Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China. E-mail address: [email protected] (C. Fan).
Elbow stiffness with decreased active and passive range of motion (ROM) is one of the most common complications after elbow trauma and surgery.12 The incidence of elbow stiffness varies from 5%-40% according to the type of elbow injury.11,17,18 As ROM limitation progresses, activities of daily living may be greatly affected. Currently, open arthrolysis is used widely and it has proved effective to restore ROM in patients with severe elbow stiffness and even ankylosis, with a low rate of complications.3,13,19,20
1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2017.11.012
ARTICLE IN PRESS 2 Recently, to help patients achieve more satisfactory outcomes, numerous studies have focused on identifying factors associated with better outcomes after orthopedic surgery, including demographic data and specific disease parameters; as an important parameter, disease duration has been studied extensively. Chen et al9 retrospectively reviewed 164 patients with post-traumatic elbow stiffness and found that postoperative ROM, Mayo Elbow Performance Score (MEPS), and heterotopic ossification (HO) recurrence were similar between early and late surgical excision patients. A long-term duration of elbow stiffness may result in fatty atrophy of the upper limb muscles, nerve dysfunction, and joint degeneration.3,14 However, there has been no study focusing on the effect of disease duration on the outcomes of arthrolysis for post-traumatic elbow stiffness. Therefore, the purposes of this study were (1) to compare the severity of elbow stiffness between different disease duration groups, (2) to determine the surgical outcomes of open arthrolysis in patients with a long-term duration of elbow stiffness, and (3) to explore whether a longer disease duration correlates with less satisfactory functional outcomes and an increased rate of complications.
Methods Participants This was a retrospective study of patients with post-traumatic elbow stiffness receiving open arthrolysis at our hospital between March 2014 and March 2016. Patient medical records were reviewed via an electronic database. Open arthrolysis was performed in cases with (1) ROM less than 100°, (2) substantial HO formation, and (3) conservative treatment such as rehabilitation that failed to restore elbow motion. The inclusion criteria were as follows: (1) skeletal maturity, (2) a minimum disease duration of 5 years, (3) treatment with open arthrolysis followed by rehabilitation exercises, and (4) a minimum follow-up period of 1 year. The exclusion criteria were as follows: (1) other elbow arthrolysis since initial injury; (2) severe osteoarthritis (grade 3 according to the Broberg and Morrey classification), inflammatory arthritis, malunion, or nonunion of the elbow; and (3) unwillingness to participate in the study. According to the Broberg and Morrey classification, elbow osteoarthritis was classified as follows: grade 0, normal joint; grade 1, slight joint space narrowing with minimal osteophyte formation; grade 2, moderate joint space narrowing with moderate osteophyte formation; or grade 3, severe degenerative change with gross destruction of the joint.2 We identified 29 patients with elbow stiffness for 5 years or more from March 2014 to March 2016. After reviewing the patients’ medical records, we excluded 3 with incomplete records, 1 who was lost to follow-up, 1 with previous elbow arthrolysis, and 1 with ulnar deformity requiring revision surgery (Fig. 1). Finally, a total of 23 patients with a minimum disease duration of 5 years were included in this study. Control participants were chosen randomly by matching cases according to age, sex, and initial injury in a 2:1 ratio among patients with a disease duration of less than 5 years (control group). The final case-control study comprised 69 patients, 23 of whom had a long disease duration and 46 of whom were controls. All study participants provided informed consent.
W. Zheng et al.
Figure 1
Flowchart showing patient inclusion and exclusion.
Data collection For all participants, demographic characteristics, history of injury and treatment, elbow functional evaluation, and imaging data were recorded at baseline. Demographic data included sex, age, marital status, body mass index, tobacco use, and comorbidities. Detailed initial injury data included disease duration, disease side, fracture location, and treatment history. Fracture location was classified as singular (distal humerus, radial head, olecranon, or coronoid) or combined (concomitant fractures of the distal humerus, radial head, or proximal ulna involving >1 location). Original treatment history was classified as open reduction–internal fixation or nonoperative treatment. Elbow physical examinations included flexion, extension, supination, pronation, and ROM (flexion-extension). Questionnaires regarding health status, including the MEPS and visual analog scale (VAS) for pain, also were obtained at baseline. The MEPS is a widely used elbow-specific questionnaire including 4 subscales—pain, ROM, stability, and activities of daily living— that generate a total score ranging from 0 to 100, with higher scores indicating better elbow function.10 The VAS for pain is a widely used tool for patients to measure pain intensity along a 10-cm line, ranging from no pain (left end) to worst pain (right end). Neuropathy symptoms, including radial, median, and ulnar nerve dysfunction, also were recorded. At the final postoperative follow-up, elbow motion, MEPS, and VAS data were evaluated. In addition, intraoperative and postoperative complications, including infection, fracture, instability, and nerve symptoms, were recorded. All data were collected by 2 independent observers. If there was any discrepancy regarding the medical data, the senior physician reviewed the data and made the final decision.
Surgical technique and postoperative rehabilitation All patients underwent open elbow arthrolysis combined with hinged external fixation.8 The approach used was based on the previous approach and location of disease. In general, patients underwent arthrolysis via a combination of the lateral column approach and medial approach posterior to the medial epicondyle. If the patient had undergone surgery via a posterior approach, we performed the approach along the previous scar. Through a lateral approach, we
ARTICLE IN PRESS Effect of disease duration on outcomes
3
excised the hypertrophic capsule and cleared the coronoid fossa. If the patient presented with forearm rotation limitation, the annular ligament and radiohumeral joint were released. Through a medial approach, the posterior band of the medial collateral ligament and posterior capsule were released, and HO or scar tissue was excised. During the operation, the anterior part of the medial collateral ligament and ulnar bundle of the lateral collateral ligament were preserved for elbow stability. If the patient required surgical release on the medial side of the elbow, presented with a substantial flexion deficit, or had ulnar nerve symptoms preoperatively, the ulnar nerve was released and subcutaneously transposed. Atraumatic suture anchors were applied to reattach the ligaments. Suction drainage was applied before skin closure. Finally, considering that the conditions of the ligaments and soft tissue after release in case of severe elbow stiffness were not satisfactory, hinged external fixation was applied to facilitate rehabilitation. Postoperative rehabilitation was divided into 3 stages. Stage 1 lasted from the first day to 6 weeks postoperatively. Starting on the first day after surgery, patients were prescribed celecoxib, 200 mg orally, twice a day. Patients were instructed to lift the upper limb and perform active muscle contraction. They performed 30 active flexion and extension exercises, increasing the number by 30 times a day until reaching 150 times a day. At the same time, passive movements were performed by rehabilitation physicians. Suction drainage was removed when drainage was less than 50 mL. Starting 1 week after surgery, patients were instructed to perform active rotation exercises for 30 minutes twice a day under protection. After the stitches were removed at 2 weeks postoperatively, patients were discharged and instructed to gradually increase flexion and extension exercises to 300 times a day. Hinged external fixation was removed at 6 weeks postoperatively in the outpatient operating room; regional anesthesia was applied if the patient demanded it. Stage 2 lasted from 6 weeks to 3 months postoperatively. After external fixation was removed, besides flexion and extension exercises, patients were instructed to increase the intensity of active forearm rotation exercises. Stage 3 lasted from 3 months to 1 year postoperatively. Patients were instructed to continue exercises for at least 30 minutes, 3 times a day. They also were encouraged to perform weightbearing exercises starting with 2 kg under supervision. Patients’ rehabilitation exercises were followed up at 6 weeks, 3 months, and 1 year postoperatively in the outpatient room or by telephone. If
Table I
patients still had serious difficulty recovering ROM at 3 months after surgery, they were asked to visit the outpatient clinic to receive further rehabilitation therapy, such as static splinting or static progressive splinting, in the rehabilitation department of our hospital.
Statistical analysis All continuous variables were described as mean ± standard deviation, while qualitative variables were described as proportions. Twotailed t tests were used to compare continuous data, while the Pearson χ2 test or Fisher exact test was used to compare qualitative data. P ≤ .05 was considered statistically significant. Statistical analysis was performed using SPSS software (version 19.0; IBM, Armonk, NY, USA).
Results In the long disease duration group, the average age was 35 ± 11 years and the average duration of elbow stiffness was 162 ± 77 months (range, 60-348 months) (Table I). Regarding injury type, 21 patients had a singular fracture (distal humerus in 11, radial head in 2, olecranon in 7, and coronoid 1) and 2 had combined fractures (combination of distal humerus and olecranon in 1 and combination of distal humerus and radial head in 1). In the long disease duration group, 15 patients (65%) underwent operative treatment after initial injury. The long disease duration and control groups were comparable in terms of age, sex, disease side, and initial injury. However, the disease duration was significantly shorter in the control group (16 months, P < .001). Of the 69 patients in total, 9 had a radial head fracture, but none of them underwent radial head replacement. The severity of elbow stiffness, as measured by elbow flexion, extension, supination, pronation, and ROM, showed no difference between the long disease duration and control groups (Table II). No pain about the elbow was reported by 8 patients (34%) in the long disease duration group and 20 (43%) in the control group. The average VAS scores for pain
Demographic and clinical characteristics of patients
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
No. of patients Age, mean ± SD, y Male, n Tobacco use, n Disease duration, mean ± SD, mo Diseased side, n Right Left Initial injury, n Singular fracture Combined fractures Previous elbow ORIF, n Follow-up period, mean ± SD, mo
23 35 ± 11 15 (65%) 1 (4%) 162 ± 77
46 37 ± 12 29 (63%) 6 (13%) 16 ± 10
12 (52%) 11 (48%)
21 (46%) 25 (54%)
21 (91%) 2 (9%) 15 (65%) 19 ± 4
41 (89%) 5 (11%) 39 (85%) 19 ± 5
ORIF, open reduction–internal fixation.
P value .431 .859 .259 <.001 .609
.778
.063 .814
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W. Zheng et al. Table II
Preoperative elbow performance evaluation
Table IV
Distribution of postoperative complications
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
P value
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
P value
Extension, ° Flexion, ° Pronation, ° Supination, ° Range of motion, ° VAS MEPS Nerve symptoms Ulnar nerve Median nerve Radial nerve
41 ± 22 84 ± 34 53 ± 36 77 ± 21 43 ± 28 0.9 ± 1.1 60 ± 11
34 ± 17 77 ± 23 53 ± 25 66 ± 34 43 ± 26 0.8 ± 0.9 62 ± 10
.119 .336 .918 .097 .997 .596 .500 .453
9 2
4 0
.002
8 1 0
11 0 1
Total number, n Infection, n New-onset or exacerbation of nerve symptoms, n Ulnar nerve Median nerve Radial nerve Instability, n
4 0 0 3
2 1 0 1
VAS, visual analog scale; MEPS, Mayo Elbow Performance Score. Data are presented as mean ± standard deviation or number of cases.
Table III
Postoperative elbow performance evaluation
Characteristic
Long disease duration (≥5 y)
Control (<5 y)
P value
Extension, ° Flexion, ° Pronation, ° Supination, ° Range of motion, ° VAS MEPS
11 ± 11 125 ± 15 54 ± 38 80 ± 14 114 ± 22 0.7 ± 1.0 89 ± 9
11 ± 10 122 ± 11 72 ± 11 77 ± 14 112 ± 19 0.3 ± 0.7 95 ± 6
.839 .528 .041 .457 .769 .110 .016
VAS, visual analog scale; MEPS, Mayo Elbow Performance Score. Data are presented as mean ± standard deviation.
were low in both groups (0.9 vs 0.8, P = .596), indicating that pain was not the main problem for patients with elbow stiffness. In the long disease duration group, 8 patients reported 9 cases of nerve dysfunction (8 ulnar nerve and 1 median nerve), which was similar to the findings in the control group (P = .453). No intraoperative complications occurred in either group. The average follow-up period was 19 ± 4 months and 19 ± 5 months in the long disease duration and control groups, respectively. At the final postoperative follow-up, all patients showed significant improvement in elbow function. In the long disease duration group, average ROM was 114° ± 22°, with average flexion of 125° ± 15° and average extension of 11° ± 11° (Table III). The average MEPS was 89 ± 9 in the long disease duration group, which was slightly inferior to that in the control group (95 ± 6, P = .016). According to the MEPS, 12 patients (52%) in the long disease duration group had excellent elbow function, which was fewer than the 37 patients (80%) with excellent function in the control group (P = .015). The average VAS scores were 0.7 ± 1.0 and
0.3 ± 0.7 in the long disease duration and control groups, respectively (P = .110, Table III). The long disease duration group had a significantly higher incidence of postoperative complications (9 cases, 39%) than the control group (4 cases, 9%) (P = .002, Table IV). In the long disease duration group, 2 patients with elbow infection underwent débridement, and in 4 patients, new-onset ulnar dysfunction developed and conservative treatment was performed. In addition, moderate instability developed in 1 patient, and gross instability developed in 2 patients; 1 patient with gross instability underwent revision surgery, while the other 2 patients underwent conservative treatment. In the control group, new-onset nerve dysfunction developed in 3 patients, and moderate instability developed in 1 patient; all underwent conservative treatment. After elbow arthrolysis, 3 of 8 patients (38%) in the long disease duration group and 10 of 12 patients (83%) in the control group recovered from preoperative nerve dysfunction. At the final postoperative follow-up, 7 patients (30%) in the long disease duration group and 3 patients (7%) in the control group reported nerve symptoms (P = .022).
Discussion Restoring motion and function and resolving nerve symptoms are the main goals of elbow arthrolysis. Recent studies have reported satisfactory outcomes of arthrolysis for elbow stiffness caused by HO and/or soft-tissue contracture.3,13,20 However, postoperative outcomes vary among patients. Exploring the effect of various factors on outcomes will help to improve postoperative recovery and avoid complications. However, there has been no previous study evaluating the association between disease duration and outcomes of elbow arthrolysis. In this study, we found that a long duration of elbow stiffness is a potential predictor of such outcomes. In our study, no differences in preoperative parameters were observed between the long disease duration and control groups. Therefore, we suggest that a prolonged disease duration did not affect the severity of stiffness or nerve dysfunction. Similarly, MOON Shoulder Group et al16 conducted a prospective
ARTICLE IN PRESS Effect of disease duration on outcomes cohort study of 450 patients with full-thickness rotator cuff tears and found no significant correlations between a longer duration of symptoms and decreased ROM, tear severity, or validated patient-reported outcome measures. At the final postoperative follow-up, most patients gained satisfactory improvement in elbow motion and function, indicating that arthrolysis combined with early rehabilitation can effectively restore elbow function after a long duration of stiffness. In our study, postoperative pronation and the MEPS in the long disease duration group were inferior to those in the control group, suggesting increased difficulty in restoration of rotation function in patients with a long symptom duration. Koh et al13 reviewed 77 patients with elbow stiffness caused by HO and found that those with a disease duration of more than 19 months showed significantly inferior outcomes. Ando et al1 reported no significant association between treatment outcomes and duration of symptoms. When patients underwent nonoperative treatment of shoulder stiffness, the recovery time was comparable between patients with a prolonged duration and those with a short duration of symptoms.1 In addition, our study showed no significant differences in postoperative pain, extension, flexion, supination, or ROM of the elbow between the long disease duration and control groups. Our study found a significantly higher incidence of postoperative complications in patients with a long disease duration. We noticed a relatively high incidence (13%) of postoperative instability in the long disease duration group, which was much higher than that in the control group and in previous reports.13,15,20,21 Cai et al5 systematically reviewed 810 patients who underwent elbow arthrolysis, and they reported a 1.0% ± 0.7% incidence of postoperative instability. Many researchers have recommended early mobilization after elbow surgery, such as arthrolysis and open reduction–internal fixation. The collateral ligaments play a pivotal role in maintaining elbow stability. When we performed elbow arthrolysis, the collateral ligaments were partly released and then reconstructed. The purpose of applying external fixation was to protect the collateral ligaments and muscles during early rehabilitation. However, a long duration of stiffness would lead to decreased quality and impaired ability to repair the ligaments and muscles. Therefore, we consider that in patients with a long duration of elbow stiffness, the period of external fixation could be extended. In our previous study involving 260 patients with post-traumatic elbow stiffness, the incidence of new-onset nerve dysfunction was 9.2% after arthrolysis, which was similar to the incidence in the control group (8.6%).6 At final follow-up, we found that 10 patients (83%) with preoperative nerve symptoms in the control group recovered whereas only 3 patients (38%) in the long disease duration group recovered. Several previous studies also have reported a negative effect of a longer disease duration on neurologic status after orthopedic surgery. Charles et al 7 retrospectively reviewed 49 patients who underwent anterior transposition of the ulnar nerve and found worse outcomes in those with a symptom duration of more than 6 months. Yamamoto et al22 also demonstrated a significant association
5 between a long duration (>3 years) of ulnar neuropathy at the elbow and poor surgical outcomes. Similarly, Burns et al4 reported a prolonged recovery time in patients with a duration of ulnar neuropathy at the elbow of more than 3 months. There were several limitations in our study that should be mentioned. First, on the basis of the retrospective design, there was some unavoidable recall bias that might have influenced the results. Second, we did not use additional general or specific patient-related outcome measures, such as the Short Form 36 survey; Disabilities of the Arm, Shoulder and Hand questionnaire; or American Shoulder and Elbow Surgeons– Elbow evaluation. Therefore, we are planning to conduct a prospective study to obtain more convincing evidence. Third, the sample size was relatively small, and as such, complications were not common after elbow arthrolysis. To better evaluate the effect of a long disease duration on postoperative functional outcomes and complications, a larger sample size might provide more reliable results. Finally, the followup was relatively short, and thus, the long-term results still need to be evaluated.
Conclusion Arthrolysis is effective in restoring motion and function in patients with a long duration of elbow stiffness. However, we also found that patients with a long disease duration had difficulty with improvement in forearm rotation. Moreover, a longer disease duration may increase the incidence of various postoperative complications, including infection, instability, and nerve dysfunction. Careful followup and long-term rehabilitation are needed to reduce complications after elbow arthrolysis.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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