Arthroscopic Treatment of Posttraumatic

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1 Arthroscopic Treatment of Posttraumatic Elbow Pain and Stiffness* Laura A. Timmerman, MD, and James R. Andrews, MD From the American Sports Medicine Institute, Birmingham, Alabama ABSTRACT Nineteen consecutive cases of posttraumatic arthrofibrosis of the elbow secondary to a fracture or fracturedislocation and treated with arthroscopic debridement and manipulation were retrospectively reviewed. All of the patients had pain and stiffness in their elbows, and all had failed a conservative therapy program. All 19 patients were followed postoperatively for an average of 29 months (range, 12 to 51). One hundred-point scoring systems were used to evaluate subjective (pain, swelling, locking, and activities) and objective (range of motion) results. The average preoperative subjective score of 39 improved to 91 postoperatively (P= ); the objective score improved from 46 preoperatively to 81 postoperatively (P ). Extension improved from = a mean of 29 to 11 ; flexion improved from an average of 123 to 134. Fourteen patients had limitations in their sports activity preoperatively; 11 were able to return to their preinjury levels of activity after surgery. This study demonstrated good-to-excellent overall results in 79% of the patients treated with arthroscopic debridement for posttraumatic elbow arthrofibrosis. Although complete return of preinjury motion was not obtained, each patient showed a significant improvement in motion and subjective symptoms. Loss of motion in the elbow after fractures and dislocations to treat. Recent literature of the joint is a difficult problem advocates early motion in treating elbow dislocations and operative stabilization for displaced intraarticular fractures.6, Despite these advances in treatment, posttraumatic arthrofibrosis remains a common complication of injuries to the elbow. In many cases, flexion contractures can be successfully treated with aggressive physical therapy and orthotic treatment.4 Options in treating severely ankylosed joints include interpositional and distraction arthroplasty, or a total elbow replacement when indicated. There remains a group of patients who fall between these two extremes. They are not candidates for more extensive surgery, but conservative treatment has failed, resulting in a painful elbow with loss of range of motion and preinjury function level. In 1944, Wilson 13 published a report on the use of anterior capsulectomy as a form of treatment for patients with fibrous thickening and contracture of the capsular ligament. In 1985, Urbaniak et a1.12 reported on a limited surgical procedure with an anterior capsulotomy but without release of the biceps tendon or brachialis muscle. The advantages of arthroscopy over open arthrotomies are well established and include improved visualization of intraarticular structures, less surgical morbidity, and the ability to start early range of motion. 1,3,5 Arthroscopy has been proposed as treatment for arthrofibrosis,1,3,5,10 but there has been no documentation in the literature that it is a successful form of treatment; a recent series had variable results in patients similar to the ones described here and stated that this treatment should be used with caution (C. Baker, et al., unpublished data, 1991). The purpose of this study was to describe the arthroscopic surgical technique of debridement of elbow arthrofibrosis and to report retrospectively on the results of this treatment in 19 patients with posttraumatic arthrofibrosis of the elbow. * Presented at the 18th annual meeting of the AOSSM, San Diego, California, July t Address correspondence to: Laura A. Timmerman, MD, Department of Orthopaedic Surgery, U.C. Davis Medical Center, 2230 Stockton Boulevard, Sacramento, CA t Address reprint requests to: James R. Andrews, MD, American Sports Medicine Institute, th Street South, Birmingham, AL No author or related institution has received any financial benefit from research in this study. MATERIALS AND METHODS Patient population, From 1987 to 1990, 19 consecutive patients underwent arthroscopic debridement by the senior author (JRA) for posttraumatic arthrofibrosis of the elbow. All of the patients were referred to the senior author with the complaint of 230

2 231 pain and stiffness in the elbow, and all had failed a conservative therapy program. All of the patients included in the study had a minimum of a 15 of flexion contracture of the elbow as compared with the contralateral side, a previous history of trauma to the elbow joint, and documented surgical finding of arthrofibrosis (defined as intraarticular capsular and soft tissue scarring) at arthroscopy. Patients with only loose bodies or osteophytes were not included. All of the patients were available for a minimum followup of 1 year. All 19 patients suffered a fracture, 6 with a dislocation of the elbow (Table 1). Twelve of the patients were male and 7 were female. The average age at the time of surgery was 36 years (range, 12 to 62). The dominant arm was involved in 11 of the 19 patients. The average interval between injury and surgery was 53 months (range, 3 months to 27 years). The mechanism of injury was a fall for 15 patients, motor-vehicle accident for 2, helicopter crash for 1, and arthrofibrosis after an arthrotomy for an osteochondral fragment in 1. None of the patients had any symptoms in their elbows before the injury. Three of the patients were workers compensation cases. Thirteen of the 19 patients had undergone surgery on their elbows after the injury, before the arthroscopic debridement. Ten of the patients had 1 previous operation, while 3 of the patients had multiple procedures. Twelve of these procedures were an initial open reduction and internal fixation of the fracture (3 procedures were performed in an attempt to regain motion), and 2 were ulnar nerve transpositions. All of the procedures were done by other surgeons before referral to the senior author. Before surgery, all of the patients complained of pain in their elbows. All of the patients had limitation in their activity levels. Fifteen of the patients had symptoms of locking or catching in the elbow, and 12 of the patients had difficulty with repeated effusions. The range of motion was recorded for flexion, extension, pronation, and supination. The average preoperative flexion was 123 (range, 105 to 140 ); extension was 29 (range, 10 to 70 ). Pronation was normal in 8 patients; the remaining 11 patients had an average of 49 of pronation (range, 20 to 80 ). Supination was normal in 7 patients; the remaining 12 patients had an average of 43 of supination (range, 10 to 75 ). Preoperative radiographs were available for review in all of the patients. There was no evidence of degenerative TABLE 1 Types of injuries a Arthrofibrosis status postarthrotomy for osteochondritis dissecans of the capitellum. changes in eight patients, six patients showed mild degenerative changes, four patients had moderate posttraumatic degenerative changes (50% decrease in joint space), and one patient had severe degenerative changes. Surgical technique General anesthesia and perioperative antibiotics were used in all cases. Arthroscopy of the elbow was performed as previously described., With the patient in a supine position, the hand and forearm were placed in a wrist splint and connected to an overhead pulley device. With the shoulder abducted 90 and the elbow flexed to 90, the entire arm was suspended free over the edge of the table. This allowed access to both the medial and lateral aspects of the elbow. A tourniquet was used for control of hemostasis. The bony landmarks were outlined before the procedure. A spinal needle via the direct lateral portal (soft spot) was used to distend the elbow joint. The anterolateral portal was used as the initial viewing portal in 17 of 19 cases; in the remaining 2 patients, the straight lateral portal was used initially because of extensive scarring anteriorly. In these 2 patients the anterior compartment was entered via this soft spot portal, and then the anterolateral portal was made under direct vision. The anterolateral portal is located approximately 3 cm distal and 1 cm anterior to the lateral epicondyle (depending on the size of the patient), just anterior to the radiocapitellar joint line. This joint was palpated to locate the portal site. The direct lateral portal is located in the soft spot. In 17 of the 19 patients an anteromedial portal was then made. Two of the patients had undergone a previous ulnar nerve transposition, so this portal was not used. In all of the patients there was extensive scarring in the anterior compartment; the joint was usually difficult to visualize. Through the combined anterolateral and anteromedial portals, the anterior scar tissue was debrided using a full radius resector. Once the joint could be visualized, attention was turned to the condition of the anterior osseous structures. If the coronoid was overgrown, prominent, and prevented full flexion, an osteotomy or debridment using a burr was done. With the bony impingement relieved, the anterior capsule was inspected. This was debrided with a full-radius resector. If the capsule remained tight, a small arthroscopic knife was inserted to cut the anterior scar tissue, resulting in an arthroscopic anterior capsulotomy. Caution was used regarding the anterior neurovascular structures. The anterior capsule was released off its humeral attachment and not excised to pre- to the anterior neurovascular structures. vent damage Through the straight lateral portal the lateral compartment was then inspected; this portal allowed better visualization of the capitellum and radial head. Lateral scar tissue was debrided using the straight lateral portal for visualization, with a second direct lateral portal used for instrumentation. The second direct lateral portal was made under direct visualization with a spinal needle used for localization approximately 1 cm from the first direct lateral portal. Using the direct lateral portal, the posterior compart-

3 232 ment of the elbow could sometimes be visualized; if so, the posterolateral portal could then be made under direct visualization using an 18-gauge needle. This was not always possible if there was extensive posterior scarring. After setting up the initial posterolateral portal for visualization, the posterior compartment was debrided using a second straight posterior portal (a fiber-splitting incision in the midline of the triceps tendon). A full-radius resector and arthroscopic knife were used as in the anterior compartment with great care taken along the ulnar gutter because of the close proximity to the ulnar nerve. Frequently, there was extensive scarring in the posterior fossa, along with posterior olecranon osteophytes. The arm was extended under arthroscopic visualization; if there was impingement in the posterior olecranon fossa or at the olecranon tip, the bony areas were removed using a burr and osteotome. Loose bodies were frequently found in the posterior and lateral compartments; they were removed as they were discovered. With adhesions and scar having been removed anteriorly and posteriorly, osteophytes causing blockage into flexion anteriorly and impingement into extension posteriorly debrided, and appropriate anterior capsulotomy performed, the arm was then manipulated in both flexion and extension under anesthesia. A small suction drain was placed through the portal site; the arm was placed in a bulky dressing. Surgical findings All of the patients had arthrofibrosis in the joint (Fig. 1). Fourteen patients had scarring in the anterior and posterior compartments, 4 had isolated anterior scarring, and 1 had isolated posterior scarring. Ten of the patients had loose bodies removed. Fifteen of the patients had debridement of lateral arthrofibrosis. Bony debridement was performed in the anterior compartment in 11 patients and in the posterior compartment in 12 patients. Postoperative care Postoperative care included perioperative antibiotics with the patient remaining in the hospital overnight. Twelve of the patients were fitted with a turn-buckle type of orthosis to force extension. Before discharge, the patients were started on physical therapy with the postoperative elbow protocol (Table 2). Figure 1. A, arthroscopic view of the anterior compartment of the right elbow with extensive anterior scar tissue from the anterolateral portal. B, view after debridement of anterior scar tissue and anterior capsulotomy (debrider is on humerus and coronoid is to the right). was used to obtain both subjective and objective scores; these two scores were then combined for overall final outcome score. To obtain a certain level, i.e., a good result, the patient had to have an overall point score at 80% for both objective or subjective scales. These criteria are more stringent than similar scores in previously reported studies (Refs. 1 and 3; C. Baker, et al., unpublished data, 1991). The pre- and postoperative scores were evaluated using a Student s paired t-test for statistical significance. Patient evaluation A detailed history was obtained from each patient with regard to pre- and postoperative subjective symptoms. All of the patients were examined and range of motion of the elbow recorded both pre- and postoperatively. A rating system (Table 3) was developed to reflect results as either excellent, good, fair, poor, or failure for both subjective and objective criteria. Subjective categories included pain, locking, swelling, and activity level. The objective scale included presence of a flexion contracture, amount of pronation and supination, and total arc of motion. A point system RESULTS All of the patients were evaluated at a mean followup of 29 months (range, 12 to 51). Overall rating The subjective and objective scores were combined to result in an overall rating. The average overall score preoperatively was 85; this improved postoperatively to 172 (P = ). Preoperatively, there were 16 patients in the poor

4 233 TABLE 2 Postoperative rehabilitative protocol for elbow arthroscopy TABLE 3 Scoring system category and 3 patients in the fair category. Postoperatively, there was 1 failure, leaving 18 patients with 3 fair, 9 good, and 6 excellent results. Subjective results The average preoperative subjective score was 39; this improved to a postoperative average of 91 (P ). Preoperatively, there were 16 patients in the poor category and = 3 patients in the fair category. There were no patients rated good or excellent. Postoperatively, there were no patients in the poor category, 1 patient in the fair category, 4 patients in the good category, 13 patients in the excellent category, and 1 failure. All of the patients improved after surgery with regard to subjective symptoms. One patient who underwent an open arthrotomy primarily for stiffness 5 months after the arthroscopic debridement had initial improvement in his subjective symptoms from fair to excellent, but he is considered a failure because of the reoperation. One patient required a second arthroscopic procedure for continued locking. Fourteen of the patients were active in sports before their injuries: a national elite-level gymnast returned to her previous level of competition, a professional baseball player was unable to return to his previous level but participates in recreational sports without restriction, and a school team player returned to the previous level. Of the remaining 11 recreational athletes, 1 did not return to sports, 2 returned with restrictions, and 8 regained their previous recreational levels of activity. Objective results The average preoperative objective score was 46; this improved to an average of 81 postoperatively (P = ). All of the patients had improvement in their range of motion. The preoperative flexion contracture of 29 improved to an average of 11 (P = ). The average flexion improved from 123 preoperatively to 134 (range, 94 to 145 ) postoperatively (P = ). The average arc of motion improved from 94 to 123. The 11 patients with abnormal pronation improved from 49 to 74 in their motion, and the 12 patients with abnormal supination improved from a

5 234 mean of 43 to 75. Preoperatively, there were 16 patients in the poor category, 2 patients in the fair category, and 1 patient in the excellent category. Postoperatively, all of the patients had an improvement in motion and were rated as 1 poor, 4 fair, 8 good, 9 excellent, and 1 failure secondary to subsequent open arthrotomy. Complications There were no perioperative complications. There was no incidence of failure to introduce the arthroscope into the elbow joint or to complete the procedure arthroscopically. One patient required a second arthroscopic procedure 9 months after his first arthroscopy to remove a large band of lateral scar tissue with redebridement of both his anterior and posterior compartments. After his second procedure he had minimal subjective complaints (score, 85; preoperative score, 55). His motion before the first procedure was 30 to 125 of flexion with 25 of supination; after the first procedure, this improved minimally to 30 to 135 of flexion with 40 of supination. After the second procedure, he had 15 to 135 of motion with near-normal pronation and supination. One patient underwent open arthrotomy 5 months after arthroscopy and was considered a failure of arthroscopic treatment. This patient had suffered a severe Type III open intracondylar distal humerus fracture 6 years earlier, which was treated initially with irrigation and debridement followed by 6 weeks of traction. He underwent one arthrotomy for debridement of osteophytes and a separate procedure for ulnar nerve transposition. Preoperatively, he complained primarily of restricted range of motion and pain with moderate activities. His preoperative subjective score was 65, and his objective score was 25 with his range of motion at 45 to 115 of flexion and near-normal pronation and supination. His preoperative radiographs showed severe degenerative changes in his elbow joint. Postoperatively, he initially improved in motion, with a flexion arc of 26 to weeks after surgery. He then returned to the military medical system and underwent an arthrotomy 5 months after arthroscopy for continued restricted motion. At latest followup (49 months), he had occasional pain, catching, and limitation in activity; objectively, his range of motion was from 32 to 115 of flexion with normal pronation and supination. DISCUSSION In our study, 16 of 19 patients (84%) had an overall good or excellent result after arthroscopic debridement of posttraumatic arthrofibrosis of the elbow. This is the first intermediate-term study of arthroscopic treatment for this difficult problem. In other reported treatments for this condition,8, 12,13 the patients tended to have more severe deformities. Thus, comparing results of arthroscopic treatment with open procedures such as distraction is not arthroplasty and fascial interposition arthroplasty possible. It is often cited that most activities of daily living can be performed with a functional range of motion of 30 to 130 of flexion and 100 of pronation-supination.9 Although most of our patients had elbow range of motion within the functional range preoperatively, they thought their activities were limited enough to warrant surgery. Several of our patients could not fully participate in sports activities. For a young, active, athletic population this &dquo;functional&dquo; range of motion is not adequate. All of our patients had pain preoperatively, and this was most often the primary indication for surgery. The im- : provement in subjective symptoms in the patients was significant, as was the increase in the range of motion. Except for two cases, the patients did not regain their preinjury range of motion, although 11 of the patients were able to participate in activities without restriction and 7 with only occasional restriction. Therefore, it seems that with removal of the scar tissue not only is motion improved, but pain in the elbow is also relieved. Urbaniak et au2 reported on a group of 15 patients treated with an anterior capsulotomy followed by immobilization for 2 weeks in full extension before beginning motion. The mean preoperative loss of extension of 48 improved to a mean postoperative deformity of 19 ; however, over 50% of the patients lost an average of 19 of flexion and there were three cases of transient nerve palsy. They noted better subjective results in patients without significant posttraumatic degenerative changes. In our series, the preoperative loss of extension was less severe, with an average of 29 ; postoperative loss averaged 11. Patients in our study had a mean improvement in flexion of 9. Fifteen of 19 patients showed improvement, and there were no cases where flexion decreased. The range of motion gained during surgery while the patient is under general anesthesia is usually more than the patient can achieve during the rehabilitation period, although the swelling seen about the elbow at the completion of the arthroscopic procedure makes evaluation of actual range of motion difficult. In 8 patients, the postmanipulation range of motion was recorded in the operative note; average extension was noted to be 9. The average final extension in these patients was 14. A previous study of long-term results of elbow arthroscopy in eight patients with degenerative changes and adhesions showed variable results with none of the patients showing a significant improvement in extension (C. Baker, et al., unpublished data, 1991). In our series, 42% of the patients had no radiographic changes; 31% had mild degenerative changes; and moderate-to-severe changes were seen in 26% of the patients. The one failure in our series was the only patient with severe arthritis. The three patients with overall fair results all had moderate changes preoperatively, and the one patient requiring reoperation had moderate degenerative changes before his first arthroscopy. In retrospect, our one patient that failed was not a good candidate for arthroscopic debridement because of the extensive changes in his elbow. The best results were obtained as expected in patients with absent or minimal radiographic changes. However, we did note that patients with moderate degenerative changes have significant improvement in subjective symptoms. This study did not include patients with osteoarthritis; all of the patients had suffered an intraarticular fracture, and 74% of the patients had no-to-mild degenerative changes on radiographic examination.

6 235 With trauma to the elbow joint, anterior capsule contracture restricts flexion. Extension is restricted both by posterior fossa scarring and osteophytes and via anterior scarring if the capsule is adherent to the distal humerus preventing the proximal movement of the coronoid process.l1 In our series, in addition to anterior and posterior scarring, lateral calcification and extensive lateral scarring was a common finding. Therefore, the overall improvement in motion is a combination of anterior, lateral, and posterior debridement of scar tissue. Once the scar is excised, prominent osteophytes, most commonly on the olecranon, coronoid process, and radial head, also need to be debrided to improve motion and prevent a bony block. Arthroscopy allows for more thorough debridement of all of the compartments of the elbow. For example, reaching the posterior aspect of the olecranon and trochlear groove is very difficult via an anterior arthrotomy incision. However, thorough arthroscopic debridement of the elbow, especially in an extensively scarred joint, is a technically demanding procedure that requires familiarity with routine elbow arthroscopy and a thorough understanding of the normal anatomy of the elbow. We were fortunate not to have had any perioperative complications in this most difficult group of patients. The senior author has had extensive experience with elbow arthroscopy, having performed over 500 elbow arthroscopic procedures in the last 10 years. Our results may indeed be difficult to reproduce by the average orthopaedic surgeon. However, in experienced hands we believe that arthroscopic debridement is useful in the treatment of arthrofibrosis of the elbow. SUMMARY This study demonstrated good-to-excellent overall results in 84% of patients treated with arthroscopic debridement for posttraumatic elbow arthrofibrosis. Minimal morbidity was associated with the procedure. The minimally invasive nature of elbow arthroscopy allowed a more aggressive and rapid early rehabilitation course to maintain the increase in joint motion gained at the time of surgery. The only failure was in a severely degenerated joint. We do not recommend arthroscopic treatment of posttraumatic arthrofibrosis in cases of severe fibrosis or bony ankylosis. This procedure is of limited value in patients with radiographic evidence of severe degenerative or posttraumatic arthritis. REFERENCES 1. Andrews JR, Carson WG: Arthroscopy of the elbow. Arthroscopy 1: , Andrews JR, St Pierre RK, Carson WG: Arthroscopy of the elbow. Clin Sports Med 5: , Andrews JR, Miller RH: Arthroscopic surgery of the elbow, in Chapman MW (ed): Operative Orthopaedics. Philadelphia, JP Lippincott, 1988, pp Green DP, McCoy H: Turnbuckle orthotic correction of elbow-flexion contractures after acute injunes. J Bone Joint Surg 61A: , Guhl JF: Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 8: , Josefsson PO, Gentz CF, Johnell O, et al: Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. J Bone Joint Surg 69A: , Mehlhoff TL, Noble PC, Bennett JB, et al: Simple dislocation of the elbow in the adult. J Bone Joint Surg 70A: , Morrey BF: Post-traumatic contracture of the elbow. J Bone Joint Surg 72A: , Morrey BF, Askew LJ, An KN, et al: A biomechanical study of normal functional elbow motion. J Bone Joint Surg 63A: , Parisien JS: Arthroscopic surgery of the elbow. Bull Hosp Jt Dis 48: , Tucker K: Some aspects of post-traumatic elbow stiffness. Injury 9: , Urbaniak JR, Hansen PE, Beissinger SF, et al: Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. J Bone Joint Surg 67A: , Wilson PD: Capsulectomy for the relief of flexion contractures of the elbow following fracture. J Bone Joint Surg 26: 71-86, 1944

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