Stiff elbows: Our experience

Abstract

Elbow stiffness is one of the difficult disorders because of its nature being vulnerable to contracture. The conservative treatment should be recommanded firstly, then the surgical intervention is indicated after the failure of conservative attempt. From 2010 to 2015, we have been treating 258 cases who suffered elbow stiffness in our center. The causes of stiff elbows included trauma, rheumatoid arthritis, burn, degenerative disease, and congenital malformations. We would like to share our cases and experiences with the peers worldwide, and we also will learn more from the communication. (1) Any surgical history is important, the details (including the incision, internal fixation, nerve intervention) would guide the plan of surgery. (2) An overall physical examination should be amphasized every time the patient comes to the office, including extension and flexion deficiency, rotation limited or not, stability, skin contracture, and nerve symptoms. All these could become a puzzle during operation. (3) Radiography assessment (X ray, CT scan, MRI) aims to address the heterotrophic ossification, malunion, joint space, and target pathologies such as synovium. The general joint condition and patient's expectation are the two key points to surgical indication. (1) A single lateral or medial approch is always sufficient for moderate elbow stiffness. We recommaned the combined medial and lateral approaches rather than posterior approach to treat severe stiff elbows, in which the lateral to reach anterior and medial to reach posterior. (2) General release and clearance should cover the hypertrophic capsule, humeroradial joint, triceps, olecranon fossa, fossa coronoidea, HO. (3) The anterior bundle of the medial collateral ligament (AMCL) and lateral ulnar collateral ligament should be left intact to prevent instability while we further release the ligament contracture. Intraoperative examination is necessory to detect the stability of the elbow, the ligament repair is very important for a functional joint. (4) We recommand ulnar nerve anterior transposition preventively. (5) We believe it reasonable and helpful to adopt a hinged external fixator in severe cases, it provides extra-stability and security for repaired ligaments, facilitate rehabilitation, and a less painful situation leads to more effective outcoming. Aiming to handle the target pathologies blocking mobility as well as the sufficient structures maintaining stability. (1) Preoperative education is very important, it is the doctor's responsibility to notify the importance of rehabilition. (2) We encourage early-stage exercises after surgery, starting from the first postoperative day, which follow a logical sequence of progression with some flexibility in application. The exercises consist of active, assisted, and passive elbow flexion and extension movements. The progressive exercise program is continued for as long as three months after the surgery. (3) During the interval of each exercise session, a compressive cryotherapy device is encouraged to be applied to relieve pain. We have performed a prospective, single-blinded, randomized controlled study to investigate the effect of cryotherapy after elbow arthrolysis. VAS scores were significantly lower in the cryotherapy group during the first 7 postoperative days, both at rest and in motion. (4) The applying of drains and indomethacin aims to reduce the pain as well as the incidence of edema and hetertopic ossification. The patient education and rehabilitation should be throughout the treatment, it will decide the final outcome.