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Treatment of the stiff elbow joint

Bo Sanderhoff Olsen

Abstract
Elbow joint stiffness is a signicant problem after elbow trauma, in degenerative and arthritic elbow joint disease, and following surgery to the elbow joint. Treatment of the disease can be difcult and it requires a team that can access a range of conservative and surgical treatment options. This paper describes the clinical presentation of the disease, its causes, diagnosis and management. The results obtained after treatment will be discussed, based both on the current literature and the senior authors extensive personal experience in treating patients with elbow joint stiffness.

motion decits can severely affect the volume of this sphere by shortening the radius.2,3 The joint consists of articulations between the humerus, the ulna and the radius. The humeroulnar joint is a functional hinge joint with a high degree of congruency between the deep trochlea of the humerus and the greater sigmoid notch of the ulna. The articulation is stabilized through its bony anatomy and through strong lateral collateral ligaments (LCL) and medial collateral ligaments (MCL). Furthermore, the anterior capsule has some stabilizing effect in the extended joint position. The articulation allows exion and extension movements of the forearm relative to the humerus . The humeroradial joint and the proximal radioulnar joint cooperate to allow rotational or pivoting movements of the forearm around the forearm axis. The proximal surface of the radial head, with its concavity, and the spherical capitellum articulate with concavity compression, with constraint from the annular ligament that surrounds the radial head.3e7

Keywords arthroscopy; elbow; elbow stiffness; elbow surgery; elbow

trauma

Pathogenesis of stiffness
Lack of elbow joint extension: is often the most troublesome problem for the patient. It is usually caused either by anterior capsular stiffness, with or without calcication and/or osteophytes on the olecranon, free bodies located in the olecranon fossa or stiff synovial tissue in the same location. These causes can often be successfully treated surgically (Figure 1). Lack of elbow joint exion: is usually caused by stiffness of the posterior and posterolateral joint capsule and/or osteophytes on the coronoid process, free bodies located in the coronoid fossa or heterotopic/periarticular calcications in the anterior compartment

Introduction
Stiffness of the elbow joint is a relatively common problem. It can be caused by congenital defects, trauma or degenerative joint disease. In an increasing number of adult patients this condition can be successfully treated with surgery, whereas congenital elbow joint stiffness or stiffness that developed in childhood rarely requires surgery. In 1981 Morrey et al. described the range of elbow joint motion needed to lead a relatively normal life.1 The authors showed that most everyday tasks can be performed with forearm rotation between 50 supination and 50 pronation, and a range of exion from 30 to 130 . This has become the reference range of motion (ROM) that surgeons aim to obtain by surgical treatment. It is important to understand that even minor elbow motion decits can cause major problems for patients in specic situations, however, and the tolerance of elbow motion decits is individual.2 The objective of this paper is to describe current indications and treatment options in the management of elbow joint stiffness in adults.

Anatomy
The elbow joint is a complex trocho-ginglymoid joint, which allows positioning of the hand inside a sphere around the body created by shoulder movement and with the length of the arm and forearm forming the radius. Therefore, even minor elbow
Figure 1 Preoperative lateral radiograph of a 34 years old female 1 years after an operatively treated acute elbow joint dislocation treated by external xation initially. There is calcication extending from the olecranon into the triceps tendon and a bone anchor that was used for reinsertion of the LCL. This patient was treated with operative removal of the posterior calcication.

Bo Sanderhoff Olsen MD PhD Senior Consultant, Ass. Professor, Section for Surgery on the Shoulder and the Elbow, Orthopaedic Department T, Herlev Hospital, Copenhagen University, Denmark. Conicts of interests: none.

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Figure 2 Preoperative lateral radiograph of an arthritic elbow joint in a 54 years old male carpenter with no history of trauma. Note anterior and posterior degenerative changes limiting elbow range of movement. This patient was treated with open release and radial head resection. Figure 4 Preoperative AP radiograph of a 23 years old female with juvenile rheumatoid arthritis. Note rheumatoid induced changes in the humeroulnar and radiohumeral articulations. This patient was treated with synovectomy, release and radial head resection.

of the joint, blocking exion. These causes can often be successfully treated surgically (Figure 2). Joint changes that might impair exion The radial head might, through degeneration, inammatory change or fracture, be responsible for diminished elbow joint motion. Simple resection may be indicated accompanied by surgical joint release (arthrolysis) (Figure 3).

Occasionally the cause can be articular incongruency of the elbow following trauma, degenerative or inammatory joint disease, leading secondarily to the above described soft tissue changes (Figure 4). These causes can be dealt with surgically without a prosthesis. However, on occasions a total- or a hemielbow implant is indicated. Mal-united or non-united supra or intercondylar fractures are rare causes (Figure 5). In these cases the treatment involves internal xation with osteotomy and/or grafting as indicated.8 Lack of forearm rotation Lack of rotation can impose signicant disability. The condition can be caused by a range of pathologies. In the elbow joint the condition is usually caused by radial head fractures with resulting incongruence or adhesions between the annular ligament and the radial head following trauma and immobilization (Figure 3). Furthermore, degenerative or inammatory joint disease in the radiohumeral joint can cause pain and stiffness (Figure 4). Infrequently calcications or synostosis involving the interosseous membrane of the forearm can be caused by fracture dislocations or, for example, surgery for distal biceps tendon rupture (Figure 6). Finally, forearm fractures and wrist problems can cause a lack of forearm rotation. Treatment can involve radial head resection or surgical lysis of adhesions between the radial head and the capsule. In the case of synostosis following distal biceps tendon repair, resection of the mature bone may improve rotation. In other situations surgical release of forearm rotation is difcult.

Figure 3 Preoperative lateral radiograph of a 62 years old female teacher following a radial head fracture.

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Figure 5 Preoperative lateral radiograph of a 23 years old male with malunion 2 years after a supracondylar humeral fracture. This patient was treated with osteotomy and arthrolysis.

Classication
There are different classication systems. The clinically relevant systems relate to both pathophysiology and treatment. We use the system dened by Morrey.9 This classication system deals with extrinsic, intrinsic and mixed causes for the elbow joint stiffness. The extrinsic causes are located outside the joint space, the intrinsic causes inside the joint space and the mixed causes affect both locations. Extrinsic causes Capsular contractures may result from prolonged immobilization or lack of use due to pain. Often, the anterior capsule is involved and is found to be stiff and thick. Sometimes there are ossications around the joint, situated in either the ligaments, capsule or muscles. Furthermore, elbow contractures can be caused by the skin, as in severe burns, or by extra-articular painful bony malor non-unions. Intrinsic causes Intrinsic causes include articular mal- and non-unions or joint side destruction due to elbow arthritis. Furthermore, intra-articular loose bodies can block movement and osteophytes can cause impingement, leading to contracture formation. Finally, adhesions between the joint surfaces can cause lack of motion. Mixed contractures Contractures with involvement of intra- as well as extra-articular structures are the most frequent of elbow contractures, since capsular stiffness is almost always part of the condition.8
Figure 6 Preoperative lateral radiograph of a 52 years old male with synostosis 1 year after treatment for a traumatic distal biceps tendon rupture. The synostosis was operatively resected with the application of a fascia lata graft.

Jupiter et al. classify the contractures as either simple or complex. Simple contractures have mild to moderate contracture, no prior surgery, no ulnar nerve transposition, no heterotopic ossication and preserved anatomy.10

Clinical presentation
Patients present with stiffness in the exion axis and/or in the forearm rotation axis. In posttraumatic cases pain, when present, is reported in the extremes of motion, whereas in cases of degeneration or inammatory joint disease the condition is characterized by periodic painful joint effusions and generalized elbow joint pain. In the later stages, signicant joint destruction can be observed.

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The history elicited from the patient is important, focussing on the onset of symptoms, trauma, occupation, age, hand dominance, night-pain etc. We always perform a visual analogue scale (VAS) related to pain at activity and at rest. Furthermore we always observe the spontaneous use of the elbow during undressing and in the consultation in general, followed by measurements of the exact elbow ROM in exion and rotation, specied for active and passive motion. Palpation for pain and crepitus is important and ulnar nerve symptoms, including mobility of the nerve during ROM, should be evaluated in a similar fashion to the evaluation of other upper extremity nerves. Finally, we always examine the stability of the elbow joint although instability is rarely present in cases of elbow stiffness. Certain elbow scores exists, which facilitate clinical evaluation as well as measuring outcome after treatment. We use an elbow modied Constant score: the so called Functional Elbow Score, but better validated scores exists as the DASH and the Oxford Elbow Score and it has been recommended to use those.11,12 Finally, when considering posttraumatic contractures, it is important to wait until a nal ROM has been reached. In cases of heterotopic bone formation, maturation of the bone formation is important prior to surgery. We often wait at least 6 months, with stable ROM at more consultations before decision on release surgery is drawn. Improvements in elbow ROM during training or splinting can appear late following trauma or surgery.

Figure 7 Preoperative CT-scan of anterior joint side changes in an arthritic elbow joint in a middle-aged male.

Diagnostic approach
In all cases of elbow joint stiffness we perform anteroposterior and lateral plain radiographs (Figures 3 and 4). This allows examination of the joint architecture and identies bony causes for contracture of the joint. In selected cases we perform computed tomography (Figure 7) in order to dene the bony pathology that needs resection or correction during surgery: this is particularly the case in distal humeral mal- or non-union.8 If traumatic articular cartilage defects are suspected a magnetic resonance imaging (MRI) scan can be helpful. With ulnar neuropathy and ulnar nerve pain we occasionally request neurophysiological testing (EMG) in order to evaluate the status of the nerve. In cases with inammatory disease or suspected infection blood counts and microbiological examination of articular uid are performed.

Physiotherapy Guided exercises following elbow trauma are generally recommended but poorly documented.12 The majority of reports on the surgical release of stiff elbows recommend the early onset of guided training in order to avoid recurrence of stiffness. Currently the use of active or passive stretching of the elbow is debated.12,16 Several authors discuss the use of CPM (Continuous Passive Motion) devices in the postoperative phase with the aim of preventing recurrent elbow joint stiffness.17,18 The majority of reports on the surgical treatment of stiff elbows using open techniques advocate its use in the immediate postoperative period.16,17 Splinting techniques Splints and bandaging can be used as both treatment and prevention in elbow joint stiffness.8,19e21 A recent study documents the use of splinting for elbow joint stiffness.19 This paper, by Lindenhovius et al., documents the use of both dynamic and static splinting with results that, in select cases, are comparable to results seen following surgical release of the elbow joint.19 Other recent publications recommend the use of splints combined with closed manipulation.20,21 Closed elbow manipulation under anaesthesia This was previously used as a treatment in its own right and e referred to as Brissemnt of the elbow. Araghi et al. described manipulation as an adjunct to surgical release and as a possible remedy in the early postoperative period after a surgical elbow joint release when persistent or recurrent stiffness is problematic.20 In 2012 a publication has advocated early manipulation in posttraumatic cases, combined with splinting.21 Caution in cases with ulnar nerve paresthesiae has been recommended, however.20

Treatment and clinical outcome

Prevention Measures should be taken to avoid the development of posttraumatic elbow joint stiffness after injury.13,14 Reports increasingly advocate early mobilization following dislocation or fracture. Mehlhoff et al. reported worse results in patients following conservative treatment of acute elbow dislocation who had immobilization for more than 3 weeks.14 Other authors have advocated mobilization even earlier than 3 weeks. Following elbow joint fracture, stable internal xation is the aim, to allow early mobilization. Several reports document success with immobilization as short as 8e10 days.15

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Arthroscopic release Arthroscopic release is increasingly being used for the treatment of elbow joint stiffness. The procedure is technically demanding and initially severe complications were reported.22,23 In the more recent literature the incidence of reported complications is lower.22,24 The outcome following arthroscopic management is comparable to the outcome obtained with open surgery, even in complex patients.22,24,25 Current reports show signicant increases in the exion range of up to 34 .22,24 In the extension range signicant improvements were also reported, with ultimate decits in extension of 6 and 7 .22,25 Open release This is the traditional surgical approach to the posttraumatic or degenerative stiff elbow.8e10,12,26 Mansat reported the limited lateral approach, named the column procedure, and reported increases in exion of a mean 45 with only few complications.26 Other authors reported their results with the extensive open approach using a range of different surgical techniques and observed increases in elbow exion between 23 and up to 86 .12,17,20 In a few small series distraction arthroplasty with external xation was also noted to be successful.12 The largest improvements following open elbow release were seen in the stiffest elbow joints. Complication rates of 15% are reported, the majority being minor. Ulnar neuritis and residual stiffness are the most common complications described.12 Total elbow arthroplasty (TEA) TEA has been reported as a salvage procedure in selected cases of ankylosed or fused elbow joints, especially in cases with no other possible surgical treatment options in the old and less active patient.8,12,27 Signicant complications have been reported, with reoperations in more than 50% of the patients. However, a good range of elbow exion of a mean 80 has been achieved.27

Figure 8 Patient positioning for elbow arthroscopy. Note the padded rest under the mid-portion of the humerus.

The authors approach to surgical treatment for stiffness of the elbow joint
In posttraumatic or degenerative cases a stable degree of elbow stiffness with signicant disability has to be present. In our practice the exact measured restriction is less important than the resulting handicap reported by the patient. After acute elbow trauma we introduce guided elbow mobilization and physiotherapy as soon as possible in order to avoid or minimize the elbow stiffness induced by immobilization. Generally we avoid immobilization of the elbow joint as much as possible and rarely would any elbow be totally immobilized for more than 3 weeks.13,14 In the case of minor motion decits with no signicant bone lesions to be removed, a ROM >80 , extension decit <40 and where a radial head resection is not indicated, we carry out an arthroscopic joint release and synovectomy. We place the patients in the lateral position, apply a tourniquet, and support the mid portion of the humerus on a padded rest (Figure 8). This allows easy access to the front as well as the posterior part of the joint, and multiple portals can be employed. With this set-up the surgery can be performed with only a nurse assistant and the joint can be moved during the surgery. Finally this set-up allows easy conversion to an open procedure.

We draw landmarks, marking the ulnar nerve and the portals, and insufate the joint with 20 ml marcaine with adrenalin. We use a standard 45 4 mm arthroscope and a radiofrequency ablation device or shaver. In cases where osseous resection is needed we also use a burr (Figure 9). Normally, we enter the joint from the anterolateral portal and we create an anteromedial portal using an inside-out technique, completing the anterior compartment release before approaching the posterior part of the joint. We normally then use two portals centred on the olecranon fossa to facilitate posterior compartment release and debridement. If severe swelling occurs or if there is loss of the view of the posterior compartment we occasionally proceed to a mini-open posterior release through a direct posterior approach by extending one of the posterior portals, usually the most lateral.

Figure 9 Arthroscopic surgery in the posterior compartment of the elbow joint. Note the landmarks.

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Occasionally a posterior or lateral portal directly overlying the radiocapitellar joint line is used for evaluating and handling radiohumeral pathology. In the case of major motion decits and in situations where bony release, radial head resection or ulnar nerve release or transposition is needed, we tend to do an open procedure. We position the patient is as described above, except that placement of the padded rest is beneath the distal part of the humerus. We always use a tourniquet. A midline posterior incision is made with subcutaneous dissection (Figure 10). Normally we carry out a staged procedure and the rst stage is a posterolateral release. This is, in our hands, a debridement of the olecranon fossa with resection of impinging olecranon and removal of loose bodies. We then resect the posterolateral capsule, identify the lateral collateral ligament (LCL) and normally release this ligament from its humeral insertion in order to give easy and secure access to the anterior compartment through posterolateral joint subluxation. The anterior capsule is then released from inside out and the coronoid fossa is debrided of calcications and loose bodies. When needed we resect the tip of the coronoid process. Only rarely do we preserve the lateral collateral ligament as described by Mansat in the column procedure26 and rarely do we resect the capsular tissue. If this alone is not sufcient to give free elbow motion on the table we continue to the second stage. In this, the ulnar nerve is released and protected before resection of the posteromedial capsule (Figure 10). We then identify the medial collateral ligament (MCL) and resect its posterior band and then try to release the anterior capsule near the preserved anterior band of the collateral ligament. We try to spare the anterior band of the MCL in order to preserve elbow joint stability. Only in very rare cases is it necessary to release the anterior band at its humeral insertion in order to obtain a full ROM. In this situation the surgeon

has to consider if the anterior band MCL release is necessary or if a minor extension decit can be accepted by the patient. The ulnar nerve is release then protected throughout, but we do not normally transpose it at the end. If the anterior band in the MCL is released, we reinsert the ligament using a bone anchor applied in the origin of the MCL at the medial humeral epicondyle. Then, the LCL is reinserted using another bone anchor inserted in the origin of the LCL, at the undersurface of the lateral humeral epicondyle (Figure 11). Radial head resection is reserved for special indications where joint stiffness in exion or rotation is mediated by the radial head. Occasionally we perform a capsular release and trim or resect bony osteophytes at or around the radial head but preserve it.12 After posterolateral release alone elbow joint instability is rarely a problem, since the LCL is reinserted at the end of the procedure as described above (Figure 11).12 In major releases where the radial head is resected and/or the anterior band in the MCL released and reinserted, elbow joint instability might be a problem. In those cases we consider applying a temporary external xator.

Figure 10 The direct posterior approach for open elbow joint release. This is the situation where both stages of the procedure are needed. Therefore the ulnar nerve is released and protected and the joint is prepared for a full triceps split.

Figure 11 A postoperative AP radiograph of the patient seen in gure 2 following an open elbow joint release, showing radial head resection and reinsertion of the LCL using a bone anchor at the undersurface of the lateral epicondyle.

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Postoperative treatment
Multiple postoperative rehabilitation programmes to follow elbow joint release have been published.12 Generally the publications agree that early mobilization is important. In order to facilitate this, early mobilization and pain management are probably the most important components of the postoperative regime. Usually pain is prominent in the rst few postoperative days.12,28 In minor arthroscopic releases physiotherapy is initiated immediately after surgery. Surgery is performed under an ultrasound guided infraclavicular one-shot block. Physiotherapy is initiated with the block effect still present. Most of our arthroscopic releases are done as day-case surgery and the patient attends rehabilitation sessions from day one. In major open releases we use an infraclavicular low brachial plexus block applied through an ultrasound guided indwelling catheter. This allows continuous infusion of ropivacain at up to 20 mg/h. This block is used for 24e48 h postoperatively to allow early application of a CPM device. CPM use beyond 48 h is debated.12,17,18 We tend to avoid at home CPM treatment. Following the block we normally prescribe oral tramadol 50e100 mg and paracetamol 1 g four times per day. We also use non-steroidal anti-inammatory medications to prevent heterotopic bone formation when needed. At discharge from our department at day 2, the patients are closely followed up in our physiotherapy department to ensure maintenance of the range of movement. We use a combination of active assisted exercises and passive elbow stretching. The physiotherapist carries out regular visual analogue pain scores and if intolerable pain that prevents adequate rehabilitation the pain management regime is changed. Rehabilitation sessions continue until elbow joint motion has stabilized.

Arthroscopic procedures These were performed in seven cases for degenerative joint disease or arthritis. Only two cases had posttraumatic elbow joint stiffness. There were ve females. The mean age at surgery was 37 years (Range 14e57 years). The mean preoperative extension loss was 19 (Range 0 e40 ) and maximal exion was 119 (Range 100 e135 ). The ROM arc was a mean of 100 (Range 65 e120 ) before surgery. After a minimum of 3 months follow-up the mean postoperative extension decit was 7 (Range 0 e30 ) and the mean maximal exion was 130 (Range 120 e135 ). The ROM arc was 123 (Range 100 e135 ) after surgery. There was a mean gain in the exion arc of 23 (Range 15e40  ). No patient had any decrease in forearm rotation before or after surgery. All patients had preoperative pain and four patients experienced locking. At follow-up none had locking and all experienced pain relief; only two patients reported any residual pain at follow-up. One patient had two arthroscopic procedures before the end result was achieved.

Conclusion
Treatment of the stiff elbow is a discipline with many possible approaches. We have tried to review the current status, presenting the different surgical and non-surgical approaches. As an illustration of the application of the principles described, I have described our philosophy at Herlev Hospital and the early results that we expect, which are comparable to other studies reported in the literature. It is important to give the patient a realistic expectation of what he or she can achieve after surgery. We inform the patient that the surgery restore up to 50% of the preoperative ROM decit and in the majority of cases pain is decreased locking is cured. In our department the current trend, with increasing experience with arthroscopic elbow joint release and debridement, is that more procedures are performed arthroscopically, and our indications for which kind of procedure we chose are slowly changing. It is helpful in this process to always retain the possibility of conversion from arthroscopic to an open procedure in order to minimize the risk of serious complications and to secure the best postoperative result for the patient. Recommended further reading The reader is directed to references 2,8,10,12,24,26 for much further useful information on this topic. A

Our results
In 2011 we performed 26 surgical procedures for chronic elbow joint stiffness. We did 17 open elbow joint release procedures and nine arthroscopic procedures. Open procedures These were performed in 13 cases due to sequelae of trauma (Figure 3), and in the rest the indications were degenerative joint disease (Figures 2 and 4). There were 12 males. The mean age at surgery was 48 years (Range 27e73 years). The mean preoperative loss of extension was 37 (Range  15 e60 ) and exion was possible up to 105 (Range 80 e125 ). The ROM arc before surgery was a mean 68 (Range 30 e110 ). After a minimum of 3 months follow up, the mean postoperative extension loss was 15 (Range 0 e40 ) and the mean maximum exion was 128 (Range 110 e135 ). The ROM arc was 113 (Range 70 e135 ) after surgery. There was a mean gain in exion of 45 (Range 25 e65 ). Six patients had preoperative decits of forearm rotation. One was unchanged at follow-up. Three were normalized and two had improved forearm rotation at follow-up. We observed a general decrease in pain scores and one case of ulnar nerve paraesthesiae at follow-up. One patient needed another open operation before the end result was reached.

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