Open Arthrolysis Research Articles

Open versus arthroscopic treatment of the rheumatoid elbow arthritis: a comparison of complications at two years utilizing a nationally representative database.

Symptomatic rheumatoid arthritis (RA) can be addressed surgically with open procedures or elbow arthroscopy. Previous studies comparing outcomes of open to arthroscopic arthrolysis for the management of RA did not utilize a large database study. The aim was to compare demographics and two-year complications, in RA patients undergoing open or arthroscopic elbow arthrolysis. A retrospective, cohort study was performed utilizing a private, nationwide, all-payer database. We queried the database to identify patients undergoing open (n = 578) or arthroscopic (n = 379) arthrolysis for elbow RA. The primary goal of the study was to compare complications at two-years. Categorical variables were assessed utilizing the chi-squared test; while, continuous variables were analyzed using the Student's t-test. Multivariable logistic regression was performed to assess risk factors for infection following open or arthroscopic arthrolysis. RA patients undergoing open elbow arthrolysis were older (55 vs. 49years, p < 0.001), predominately female (61.6% vs 60.9%, p = 0.895), and likely to have chronic kidney disease (20.4 vs. 12.9%), and DM (45.2 vs. 32.2%) (both p < 0.005). Open elbow arthrolysis was also associated with higher rates of infection (31.7 vs. 4.7%) and wound complications (26.8 vs. 3.4%) (both p = 0.001). Nerve injury rates were found to be similar (8.3 vs. 9.0%, p = 0.81). On multivariable logistic regression, open elbow procedures were associated with the highest risk for infection (OR: 8.43). Patients undergoing open arthrolysis for RA were at a higher risk of infection and wound complications compared to arthroscopic arthrolysis utilizing a nationally representative database. While there appears to be a difference in outcomes following these two procedures, higher level evidence is needed to draw more definitive conclusions. Retrospective, Level III.

Open versus arthroscopic elbow arthrolysis for primary osteoarthritis: A comparison of demographics and complications at two years

IntroductionOpen techniques have traditionally been utilized in the surgical management of elbow osteoarthritis (OA). However, advances in elbow arthroscopy, in conjunction with the movement towards minimally invasive surgery, have led to an increase in the utilization of an arthroscopic approach. The primary aim of this investigation was to compare demographics and complication rates between patients undergoing open or arthroscopic arthrolysis for elbow OA with a secondary objective of identifying risk factors for infection with each treatment. MethodsA retrospective review of a private, all-payer database was performed to identify patients undergoing either open (n = 1482) or arthroscopic (n = 2341) arthrolysis for elbow osteoarthritis. The primary outcome was 2-year complications, which included infection, wound complications, and nerve injuries. Categorical variables were compared utilizing chi-square analyses, while continuous variables were compared using independent sample t-tests. Odd ratios (OR) were ascertained to quantify the risk attributed to open arthrolysis compared to arthroscopic. Multivariable logistic regression was performed to assess risk factors for infection following open or arthroscopic arthrolysis of an elbow with OA. ResultsAge was significantly higher in the open cohort (55 ± 13.4 years) compared to the arthroscopic cohort (52 ± 13.1 years) (p < 0.001). The open cohort was more likely to be female (32.0 vs. 22.9%, p < 0.001) and have a Charlson Comorbidity Index (CCI) greater than three (9.2 vs. 7.1%, p < 0.001). Open procedures were associated with an increased risk of nerve injury (OR: 1.50) and wound complications (OR: 7.70) compared to arthroscopic arthrolysis. Multivariable logistic regression identified open procedures as a risk factor for infection (OR: 11.15). Moreover, diabetes (OR: 1.48), chronic kidney disease (OR: 1.89) and tobacco use (OR: 2.29) were found as risk factors for infection among the open cohort. ConclusionsThis study found patients undergoing open arthrolysis of OA to be older and have a greater number of medical comorbidities compared to those undergoing arthroscopic arthrolysis. Open arthrolysis was associated with an increased rate of infection, nerve injury and wound complications compared to arthroscopic arthrolysis. After controlling for age and comorbidities with multivariable logistic regression, open arthrolysis remained a risk factor for infection. Arthroscopic elbow arthrolysis is associated with a lower risk of complications, including infection and may be favored for the management of OA of the elbow. Level of EvidenceIII (retrospective cohort study).

Elbow Kinematics and Function Following Treatment with Open Arthrolysis and Hinged External Fixator.

Open arthrolysis (OA) combined with hinged external fixator (HEF) is a promising surgical option for patients with elbow stiffness. This study aimed to investigate elbow kinematics and function following a combined treatment with OA and HEF in elbow stiffness cases. Patients treated with OA with or without HEF due to elbow stiffness were recruited between August 2017 and July 2019. Elbow flexion-extension motion and function (Mayo elbow performance scores, MEPS) were recorded and compared between patients with and without HEF during a 1-year follow-up period. Additionally, those with HEF were assessed by dual fluoroscopy at week 6 postoperatively. Flexion-extension and varus-valgus motions, as well as ligament insertion distances of the anterior medial collateral ligament (AMCL) and lateral ulnar collateral ligament (LUCL), were compared between the surgical and intact sides. This study included 42 patients, of which 12 with HEF demonstrated a similar flexion-extension angle and range of motion (ROM) and MEPS as the other patients. In patients with HEF, the surgical elbows showed limitations in flexion-extension (maximal flexion, 120.5° ± 5.3° vs 140.4° ± 6.8°; maximal extension, 13.1° ± 6.0° vs 6.4° ± 3.0°; ROM, 107.4° ± 9.9° vs 134.0° ± 6.8°; all Ps < 0.01) compared with the contralateral sides. During elbow flexion, a gradual valgus-to-varus transition of the ulna, increase in the AMCL insertion distance, and steady change in the LUCL insertion distance were observed, with no significant differences between the bilateral sides. Patients treated with OA and HEF demonstrated similar elbow flexion-extension motion and function to those treated with OA alone. Although the use of HEF could not restore an intact flexion-extension ROM and might result in some minor but not significant changes in kinematics, it contributed to clinical outcomes comparable to that of the treatment with OA alone.

Long-term results of open arthrolysis for elbow stiffness

Purpose&#x0D; Stiff elbow is a common upper extremity problem which can limit patients’ daily life activities. The purpose of this study was to evaluate the long-term outcomes of open arthrolysis for stiff elbow. Our hypothesis was that open arthrolysis would yield good functional results and patient satisfaction.&#x0D; Methods&#x0D; This retrospective study assessed 110 patients who underwent surgery for stiff elbow in a single institute between 2003-2012. Twenty-four of the patients who underwent open arthrolysis without heterotopic ossification excision and minimum followed up for 24 months were included in this study. All patient’s surgical procedure, ulnar nerve and radial head management, preoperative and postoperative ranges of elbow motion and complications were noted. Functional outcomes were evaluated with Quick-DASH and Mayo Elbow Performance score (MEPS).&#x0D; Results&#x0D; The mean age of the patients was 36.1 years at the time of open arthrolysis and mean follow-up period was 50.6 months. The mean preoperative flexion–extension arc increased form 52.4 to 96.5 and preoperative supination–pronation arc increased form 103.3 to 137.8 (p

Open Arthrolysis for Chronic Elbow Dislocation with Extremely Severe Stiffness in Children.

Studies on extremely severe elbow stiffness after chronic dislocation in children are scarce. This study aims to investigate the choice of surgical treatment modalities and to analyze their treatment efficacy in children with chronic elbow dislocation with extremely severe periarticular stiffness. Data of 21 children with chronic elbow dislocation with extremely severe periarticular stiffness diagnosed and treated in our department between February 2015 and February 2021 were retrospectively analyzed. Twenty boys and one girl were included in the study, their mean age was 11 ± 2.5 years, and they had concomitant distal humerus fractures. For the treatment protocol, all children with extremely severe elbow stiffness were treated with open arthrolysis, and elbow joint stability was intraoperatively assessed. All children performed passive functional exercises the day after surgery. The elbow flexion and extension angles, range of motion (ROM), and Mayo score were evaluated preoperatively and at the final follow-up. Of the 21 children, only one had recurrent severe stiffness of the elbow joint after surgery; nevertheless, the function was still improved compared with that before surgery. Preoperatively, the mean elbow extension and flexion angles were 72.2° ± 12.7° and 93.6° ± 11.1°, respectively, and the range of motion (ROM) of the elbow joint was 17.8° ± 8.3°. At the final follow-up, the mean elbow extension and flexion angles were 22.7° ± 18.6° and 118.8° ± 15.4°, respectively, and the elbow joint ROM was 96.1° ± 17.4°. The differences in the preoperative and postoperative ROMs, flexion angles, and extension angles of the elbow joint were significant (p < 0.01). The MEPS at the final follow-up was 78.57 ± 14.24, which was significantly higher than preoperative (29.76 ± 10.89), and the excellent rate was 81%. Open arthrolysis and open reduction and internal fixation of the elbow joint are effective in treating chronic elbow dislocation with extremely severe stiffness in children.

Open arthrolysis versus arthroplasty in the treatment of posttraumatic elbow stiffness

Elbow stiffness is a common problem following trauma to the elbow. Sixty-seven patients with posttraumatic elbow stiffness were surgically treated between 1985 - 2000. Sixty-one were clinically reviewed after a mean follow-up of 15 years (range: 7 to 19 years). The initial trauma had resulted in 8 intrinsic, in 31 extrinsic and in 28 mixed lesions. The mean preoperative flexion – extension arc of motion, was 46°. After an unsuccessful conservative treatment, open surgical arthrolysis was performed in 59 patients with exclusively extrinsic or mixed lesions, through a lateral approach combined with a medial approach when deemed necessary. In patients with complex intrinsic lesions was performed 3 resection arthroplasty and 5 total elbow arthroplasty. At final follow-up, the mean arc of motion of the elbow was significantly improved to 100° in 56 patients who had undergone open arthrolysis; 3 were lost to follow-up. Among the 3 patients who had undergone arthroplasty resection, only one had a markedly improved elbow function with a 90° arc of motion; elbow stiffness had recurred in the other two patients. Of the 5 patients who underwent total elbow arthroplasty, 3 were lost to follow-up; the other 2 patients had a stable elbow, with a fair arc of motion of 60° and 70° respectively, both with a flexion contracture of 20°. Complications included 2 superficial infections, which healed following conservative treatment, and one fracture following remodeling of a malunited distal fracture of the humerus. In the treatment of the posttraumatic stiffness of the elbow, the arthrolysis and the arthroplasty are indicated in dependence on the existent (extrinsic or intrinsic) lesions and on their severity.

Open release of stiff wrist: a medium to long term case series and literature review.

The authors reported a personal case series of open release of stiff wrists performed after previous internal osteosynthesis of distal radius fractures. From a series of 16 patients operated by a single surgeon, 12 were evaluated at a mean 7.1 years follow-up (range 2.25 to 19 years), while 4 were lost at follow-up. The ROM in flexion-extension achieved at the final control was measured with a goniometer and compared to that recorded before surgery. The PRWHE questionnaire was administred at the last follow-up. The mean flexion improved from 25.5° to 42.3° and the extension from 15.75° to 43°. The mean PRWHE value was 32.9. Although arthroscopic release is increasingly used in clinical practice for its minimal invasinevess and warranty of fast recovery, open arthrolysis in post-traumatic stiff wrists appears to be an effective procedure, adaptable to all types of stiffness, that lets get good long lasting functional results.

Arthrofibrosis of the hip joint : Diagnostic and therapeutic challenge

Arthrofibrosis is afrequent complication after total knee arthroplasty (TKA). Recently, arthrofibrosis could be successfully verified histologically after primary total hip arthroplasty (THA) and the clinical presentation on the hip could be described for the first time. Possible diagnostic and therapeutic approaches have not yet been published. The diagnostic work-up differs only slightly from that for the knee joint. Other causes, such as aseptic loosening, malalignment or periprosthetic joint infection should be excluded. The gold standard is still invasive diagnostics with histological evidence of arthrofibrosis according to the synovia-like interface membrane (SLIM) criteria. Conservative treatment approaches include mobilization under anesthesia and medication according to Traut, analogous to the knee joint. Surgical treatment should be carried out under strict interpretation of the indications and after detailed clarification for the patient. In contrast to the knee joint, open arthrolysis should be preferred to arthroscopic arthrolysis of the hip joint. It must be taken into consideration that the evidence for conservative as well as surgical treatment, including possible revision arthroplasty, cannot be assessed due to the absence of clinical data. Studies under controlled conditions on the possible treatment approaches in the presence of arthrofibrosis are desirable and necessary in order to be able to assess the significance of the symptoms. In addition to treatment, great importance should also be attached to the diagnostics. Histological confirmation of the diagnosis of arthrofibrosis should only be considered to alimited extent in the case of an assumed, only moderately successful surgical intervention.

Effectiveness and safety of a less-invasive MCL reconstruction technique for contracted or ossified ligaments in patients with elbow stiffness: An open-label, non-randomised, prospective, multicentre trial in China.

SummaryBackgroundThe elbow joint is sensitive to trauma from accidents, sports injuries, and surgical trauma. Some patients develop ossification or contracture of the medial collateral ligament (MCL) after elbow trauma. A less invasive reconstruction of the MCL can be performed after resection of diseased MCL. The biomechanical characteristics of this technique have been demonstrated and validated. However, its clinical effectiveness and safety require further confirmation in clinical practice.MethodsThis open-label, non-randomised, prospective, multicentre trial included consecutive patients with elbow stiffness from five orthopaedic centres in China. Patients willing to participate in the study, with elbow stiffness caused by traumatic injury, who had reached skeletal maturity, and who had a range of motion of <100° were eligible for inclusion. Patients with immunological or metabolic causes of elbow stiffness, burns, or central nervous system injuries were excluded. In addition, patients who did not require MCL release and reconstruction after intraoperative release of other structures were also excluded. All patients underwent resection of the diseased MCL part in an open arthrolysis. Medial stability of the elbow was reconstructed using a less invasive MCL reconstruction technique that uses fascia and tendon patches. In this study, the primary outcomes, including stability, Mayo Elbow Performance Score (MEPS), Amadio score, were used to comprehensively evaluate this technique. Outcomes were assessed at 6 weeks, 6 months, and 1 year postoperatively and annually thereafter. This study reports the results of one arm of the trial that has been registered with the Chinese Clinical Trial Registry (chictr.org.cn), ChiCTR-INC-16010019.FindingsBetween January 1, 2017 and March 1, 2020, 104 eligible patients were enrolled. The mean follow-up time was 43·47 (95% CI, 41·45 - 45·49) months. Among all 104 patients, 100 (96%) patients who underwent MCL reconstruction retained medial stability at the last follow-up. All outcomes from the last follow-up were used for comparison with the preoperative outcomes. No differences in preoperative and postoperative stability scores were observed (P = 0·7820). Extension, flexion, pronation, and supination of the injured elbow improved significantly (P < 0·0001, P < 0·0001, P < 0·0001, P < 0·0001). The mean range of motion (ROM) and forearm rotational range of motion (FRR) increased by 71·25° (152%) (P < 0·0001) and 30·83° (25%) (P < 0·0001), respectively. Additionally, the Mayo Elbow Performance Score (MEPS) and muscle strength had increased after evaluation at follow-ups (P < 0·0001, P < 0·0001). Drastic pain relief and nerve symptom reduction were observed, as evaluated using VAS scores and Amadio scores, respectively (P < 0·0001, P < 0·0001). Seventeen (16%) patients experienced a recurrence of elbow stiffness of varying severity, but only two patients had poor or fair results. Several common and non-severe complications, including infection in one (1%) patient, new nerve symptoms in seven (7%) patients, new pain in one (1%) patient, fracture in one (1%) patient, and valgus instability in four (4%) patients, were observed and properly treated in this study.InterpretationThe less invasive MCL reconstruction technique using fascia and tendon patches is an effective method for restoring medial stability in patients with elbow stiffness after complete arthrolysis with certain safety. The technique shows prospects for elbow MCL reconstruction in clinical practice.FundingThe study was supported by the National Key Research and Development Program of China (No. 2021YFC2400805), National Natural Science Foundation of China (No. 81830076), Young Elite Scientist Sponsorship Program by Cast (No. YESS20200153), Shanghai Sailing Program (No. 20YF1436000), Shanghai Municipal Science and Technology Commission Foundation (No.19ZR1439200), Municipal Hospital Newly-developing Cutting-edge Technologies Joint Research Program of Shanghai Shenkang Hospital Development Centre (No. SHDC12018130).

Surgical arthrolysis of the stiff elbow: a systematic review

IntroductionStiffness after elbow injuries can severely limit daily life. If adequate conservative treatment does not result in satisfactory improvement of elbow function, surgical intervention should be considered. Whether an open or arthroscopic procedure is preferable is still a topic of debate and a systematic review of functional outcomes is lacking.Materials and methodsWe systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE, for studies published between 2013 and 2021. Primary objective was to compare open and arthroscopic arthrolysis’ functional outcomes, respectively, especially ROM and MEPS, as well as the accompanied complications. The PRISMA guidelines were applied.Results27 studies comprising 1666 patients were included. 1059 patients (63.6%) were treated with open arthrolysis, and 607 patients (36.4%) were treated with arthroscopic arthrolysis. The results presented indicate satisfactory outcomes in open and arthroscopic arthrolysis with regard to functional outcome parameters. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score, among the patients treated with an open procedure was 88.8%; 6.3% required revision whereas 18.1% had complications without the need for revision surgery. Within the cohort of arthroscopically treated patients, treatment success was 91.8%. Revisions and complications without further surgical intervention were significantly less frequent than in the open cohort, at 1.6% and 9.1%, respectively.ConclusionsBoth open and arthroscopic arthrolysis provide good to excellent functional outcomes. Since the number of complications and revision increases with the invasiveness of the treatment, an arthroscopic procedure might be favored if feasible by indication. The role of forearm rotation and the use of a hinged external fixator remains of interest.Study designLevel IV; Systematic review.

Development and validation of a prognostic nomogram for open elbow arthrolysis : the Shanghai Prediction model for Elbow Stiffness Surgical Outcome.

AimsThe aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.MethodsWe developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation.ResultsBMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome.ConclusionThe newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment.Cite this article: Bone Joint J 2022;104-B(4):486–494.

Long-term outcomes of open arthrolysis combined with radial head arthroplasty for post-traumatic elbow stiffness: results are durable over 8 years.

Post-trauma elbow stiffness (PTES) is a common complication after elbow trauma that causes severe upper limb disability. Open elbow arthrolysis (OEA) with radial head arthroplasty (RHA) is an effective method to treat PTES with rotation limitation, or persistent pain/instability after radial head resection. However, no long-term results have been reported for this technique. This study aimed to show the clinical and radiographic outcomes of OEA with RHA over 8 years and compare its efficacy at 3 years (short-term). Patients with PTES treated by OEA with RHA between September 2010 and December 2012 were retrospectively reviewed. Seventeen patients were followed up over 8 years (range, 100-106 months). A bipolar prosthesis of RHA was performed during OEA. Preoperative, 3-year, and 8-year elbow and forearm motion, upper limb function, radiographic outcomes, and complications were recorded. Clinically important improvements in elbow motion and forearm rotation were obtained, from 34° and 58° preoperatively, to 109° and 135° at 3 years, which were maintained over 8 years, to 113° (P = .262) and 134° (P = .489). The Mayo Elbow Performance Index had clinically important increases from the preoperative level of 58 to 94 points at 3 years, and was maintained over 8 years (95 points, P = .422), with 100% reporting excellent to good outcomes. Pain and nerve symptoms were also improved. Complications consisted of new-onset ulnar nerve symptoms in 1 patient, nonclinically significant heterotopic ossification recurrence in 3, humeroulnar arthritis exacerbation in 4, and periprosthetic lucency in8. OEA with RHA yielded satisfactory short-term outcomes for PTES at 3 years, with substantial improvements in elbow mobility and function, and the results were durable over the long term (8 years).

Clinical results of a 10-year follow-up of surgical treatment for elbow stiffness in rheumatoid arthritis: A case series

BackgroundRheumatoid arthritis commonly causes transient limitation of joint motion, but the treatment of persistent stiffness in the rheumatoid elbow has rarely been reported. The purpose of this study was to evaluate the long-term clinical results of surgical treatment of rheumatoid elbow stiffness. MethodsSurgical treatment, including open arthrolysis with hinged external fixation, total synovectomy, and ulnar nerve release and anteriorization, was performed in 48 elbows in 43 patients with rheumatoid arthritis and early joint destruction. Mobility (flexion-extension and pronation-supination), Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score, muscle strength, nerve symptoms, postoperative complications, and recurrent synovitis were evaluated 9–11 years (average, 9.88 years) postoperatively. ResultsThe mobility of the elbow was significantly improved over the preoperative period either in extension, flexion, protonation, supination (P < .001, P < .001, P < .001, P = .002). The mean MEPS was significantly improved from 56.25 points (range, 30–90) to 87.40 points (range, 40–100) (P < .001). The pain was relieved, and the mean VAS score was reduced from 3.56 (range, 0–8) to 1.08 (range, 0–5) points (P < .001). Preoperative ulnar nerve symptoms were observed in 17 patients and relieved in 10 (59%) patients, and the mean Amadio score was raised from 6.9 (range, 3–9) to 7.96 (range, 4–9) points (P < .001). Through surgical treatment and postoperative rehabilitation, the mean grip strength of the patients was significantly improved from an average of 9.01 (range, 3.4–18.5) to 17.56 kg (range, 3.9–40.2) (P < .001). Five elbows developed recurrent synovitis, and one underwent total elbow arthroplasty. Postoperative complications were uncommon and not severe. ConclusionSurgical treatment is a reliable procedure for rheumatoid elbow stiffness and can be effective in improving elbow mobility, function, muscle strength, pain relief, and relief of nerve symptoms.

Functional outcomes before and after implant removal in patients with posttraumatic shoulder stiffness and healed proximal humerus fractures: does implant material (PEEK vs. titanium) have an impact? \u2013 a pilot study

BackgroundPosttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR).Methods16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR.ResultsIn group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%.ConclusionThere was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material.Level of evidenceII

Outcomes associated with secondary implant removal and arthrolysis in patients with a painful stiff shoulder after proximal humeral fracture fixation.

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome. Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively. A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS. ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J2022;104-B(1):157-167.

Reconstructive surgeries and endoprosthetics of the elbow joint: indications, possibilities and prospects

BACKGROUND: Severe injuries of the elbow joint and their consequences are a serious problem in modern traumatology and orthopedics due to the large number of unsatisfactory treatment results, in particular, due to the lack of a differentiated approach to the choice of tactics and the method of surgery.&#x0D; AIM: To evaluate the results of a differentiated approach to the choice of tactics and the method of surgical intervention in the treatment of patients with injuries and consequences of injuries of the elbow joint.&#x0D; MATERIALS AND METHODS: The results of treatment of 245 patients with injuries and consequences of damage to the elbow joint were assessed within 11 years from the date of surgery. Six groups of patients were identified: group 1 osteosynthesis of fractures of the elbow joint; 2nd open arthrolysis without the imposition of Oganesyans hinged distraction apparatus (HDA); 3rd open arthrolysis with the imposition of HDA; 4th arthroscopic arthrolysis without HDA imposition; 5th arthroscopic arthrolysis with the imposition of HDA; 6th elbow arthroplasty.&#x0D; RESULTS: In 93% of patients after osteosynthesis (1st group of patients), a good result was obtained (the deficit in the range of motion was not more than 10, the average score on the DASH scale was 8). In patients after arthrolysis, there is a twofold increase in the range of motion (on average from 4250 to 114120), and regardless of the method of arthrolysis (arthroscopic or open) and whether HDA was used or not. On the DASH scale, 89% of patients showed a decrease in points on average from 77 to 36. In the 6th group, an increase in the range of motion was noted on average from 4548 to 126135, on the DASH scale a decrease in points from 7982 to 3944 on average. Revision intervention was required in 28.4%.&#x0D; CONCLUSION: The choice of the method of surgical treatment of injuries and the consequences of severe injuries of the elbow joint directly depends on the degree and nature of destruction of the bone-articular and soft tissue structures, the deficit in the range of motion in the joint.

Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness

BackgroundTo evaluate and compare the functional outcomes of combined medial-lateral approach open arthrolysis with and without hinged external fixation.MethodsWe retrospectively collected and analyzed the clinical data of patients with severe elbow stiffness who were treated in our institution from January 2018 to January 2019. All of them were treated with combined medial-lateral approach arthrolysis. There were 20 patients who had the hinged external fixation placed and 29 patients without the placement of the external fixation. Their baseline characteristics and functional outcomes were evaluated and compared.ResultsThe average follow-up time was 28.4 ± 3.7 months. There were no significant differences in the ROM of the elbow, MEPS, VAS, DASH, or complications between the two groups. The operation time and treatment cost of the patients without external fixation were significantly lower than patients with external fixation.ConclusionCombined medial-lateral approach open elbow arthrolysis without external fixation is a safe and effective way to treat elbow stiffness.Level of evidenceTherapeutic Level III; Retrospective Cohort Comparison; Treatment Study.

English

Stiff elbow is a common problem associated with terrible triad injuries which if not managed properly can lead to significant functional limitations. Here we are describing a case of post-traumatic stiff elbow following terrible triad who presented to us after taking native treatment primarily. He was treated with open arthrolysis and prophylactic ulnar nerve decompression along with rigorous physiotherapy including dynamic splinting with hinge elbow bracing. The results were satisfactory in achieving a functional range of movement according to the patient's vocational need. This study aims to present the prompt management of post-traumatic stiff elbow case along with functional improvement postoperatively in a decisive way. Terrible triad injuries are a group of the rare and severely unstable fracturedislocations following which the chance of recurrent instability, elbow stiffness, and functional limitations increases coherently.1 To perform normal daily activities, painless motion at the elbow joint is very much necessary and critical. Following a traumatic insult, a cascade of events can lead to a decrease in the normal arc of motion and also cause stiffness of the elbow joint.2 Over the last two decades, there has been a lot of speculation revolving around the management of terrible triad injuries.3 Van Riet et al had documented that the majority of the terrible triad injuries need to be managed surgically whereas the non-operative treatment is reserved for a few selected cases. 4 The ones which were not managed adequately had higher chances of turning up into stiff elbow. Post-traumatic elbow stiffness is one of the dreaded complications following terrible triad injuries.3 The aim of managing the case of post-traumatic stiff elbow is to have a painless, near-normal range of motion which can help the patient to do daily activities by himself. We are presenting a case of post-traumatic type- 4 stiff elbow following native bandage treatment and how prompt management has led to satisfactory results.

Open posterior capsular release in stiff total knee arthroplasty: Surgical technique

Introduction: Total knee arthroplasty is the most efficient treatment for knee osteoarthritis. 4% to 16% of patients develop stiffness in the knee that impairs them to perform daily activities. There are multiple strategies to treat this condition, from non-operative as rehabilitation to complete replacement of the prosthesis. Open arthrolysis facilitates the posterior capsular release, and no surgical protocol has been described. We present a surgical tip to access this particular region.Surgical technique and postoperative management: In both medial and lateral side, we perform an incision to access the joint capsule, and when the capsule is presented, we incise it in the posterior edge. Once we open the joint and with the knee at 60º of flexion, we use a Cobb elevator to carefully release the posterior adhesion from the bone. When the Cobb elevator can pass from medial to lateral side (or vice versa), the knee is extended and complete extension is accomplished.We recommend an extension orthosis to keep the knee from accidental flexion. Total weight bearing can be made after two to three weeks of partial weight bearing.Conclusion: Stiffness is a rare complication in TKA, but when it happens is a very unpleasant complication for the patient. Open arthrolysis is widely used, but there is not much literature on how to perform it. We present this surgical tip that can be helpful mostly in patients with a flexion contracture, with minimal side effects.

Wrist Arthrolysis: A Systematic Review of Open and Arthroscopic Techniques.

Background Wrist arthrolysis is a viable option in wrist stiffness and can be performed via open or arthroscopic techniques. Purpose The aim of the study is to describe and evaluate the available techniques of open and arthroscopic arthrolysis of the radiocarpal joint and the distal radio ulnar joint (DRUJ) in posttraumatic wrist stiffness. Methods A systematic literature search was performed in PubMed to identify studies reporting on open and arthroscopic wrist arthrolysis. Key words included "open wrist arthrolysis," "arthroscopic wrist arthrolysis," "post-traumatic wrist stiffness," and "DRUJ arthrolysis." Data were extracted independently by a pair of reviewers. Results Overall, 637 studies were identified; 13 additional articles were found through previous publications (total 650 articles). A total of 612 records resulted after duplicates was removed. Fourteen studies were selected and only eight respected the inclusions criteria. One study focused on volar open arthrolysis and four studies on arthroscopic arthrolysis of the radiocarpal joint; two studies reported on open arthrolysis and two studies on arthroscopic DRUJ arthrolysis. Range of motion following open and arthroscopic wrist arthrolysis improved in all studies. Conclusion Both arthroscopic and open arthrolysis can lead to similar and satisfactory results in radiocarpal joint and DRUJ stiffness.. Level of Evidence This is a level 3a study.