Elbow - Arthroscopic Treatment of Elbow Stiffness - OrthoDoc@aaos ...

oscopic Treatment of
Stiffness
tJdadra. Matthew T Provenchel; Mark S. Cohen,
A. Romeo

PITFALLS
• Look for evidence of heterotopic
ossification as the source of
elbow joint loss of motion.
• Significant heterotopic
ossification will preclude
arthroscopic intervention for
adequate return of function.
• Procedure should not be
considered unless the surgeon is
highly skilled in elbow
arthroscopy.
Controversies
• When to decompress the ulnar
nerve
• Indications for whether open or
arthroscopic elbow release
would be most appropriate
Indications
• Loss of elbow functional range of motion (ROM)
prevents the patient from performing activities of
daily living and occupational or vocational activities,
and failure of nonoperative treatment modalities
Examination/Imaging
PHYSICAL EXAMINATION
• It is critical to determine the degree of functional
impairment for each patient and base management
decisions on subjective impairment, not necessarily
the amount of motion loss (Jupiter et aI., 2003).
• Obtain a history of associated conditions; ne ""Innil'.
peripheral nerve, or brain injury may influence
management decisions.
• Determine function of the entire ipsilateral and
contralateral upper extremity.
• Determine hand dominance, occupation, and extrmtl
of prior therapy, including bracing (both static and
dynamic).
• Evaluate the shoulder joint to ensure good strength
and ROM .
• Carefully assess nerve function .
• Two-point discrimination
• Assess all hand digits on radial and ulnar
• Describe amount of discrimination (normal is

• Document function of the FPL, median-anterior
interosseous nerve, extensor pollicis longus, and
radial-posterior interosseous nerves. Score with
standard muscle resistance grade of 0 to 5.
• It is important to document function
preoperatively as elbow arthroscopic instruments
work near these structures .
• Elbow active and passive ROM
• Place humerus at 90° and assess both active and
passive flexion and extension with a goniometer.
• Evaluate for soft ("spongy") versus hard endpoints
of flexion and extension. A soft endpoint can
indicate soft tissue constraint; a hard endpoint may
represent bony impingement.
• Score ROM to provide baseline measurement:
• Normal: 0-140°
• Minimal impairment: >90°
• Moderate impairment: 61-90°
• Severe impairment: 31-61 °
• Very severe impairment: total arc of

Treatment Options
• Consider nonoperative
management up to 4-6 months
after contracture onset.
• Static progressive splints, which
allow for stress relaxation of the
soft tissues, are more effective
and better tolerated than
dynamic splints.
• Results of arthroscopic elbow
release and debridement have
not differed significantly from
those of traditional open
treatment.
PLAIN RADIOGRAPHS
• Anteroposterior (AP), lateral, and oblique views are
usually adequate.
• The AP provides joint line and subchondral bone
visualization. It allows visualization of the collateral
ligament regions. If an elbow is contracted more
than 4SO, the AP view of the joint line is usually
distorted, but advanced imaging is rarely necessary
unless a fracture or malunion is present (Morrey,
2005).
• The lateral view may demonstrate osteophytes on
the olecranon or coronoid (Fig. 1; note the
absence of heterotopic ossification).
• If there is articular incongruity or other joint
abnormalities, consider a computed tomography
scan with AP and lateral reformatted images in the
coronal and sagittal planes. Three-dimensional
surface renderings can be very helpful in
preoperative planning, especially if there is
evidence of bony impingment. Many times this is
the only way to appreciated bony overgrowth, for
example, in the fossae (Fig. 2).
FIGURE 1

Osteophytes
FIGURE 2
• Radiographs can be utilized to follow the maturation
process of heterotopic ossification. Arthroscopic
treatment is usually not recommended in the
presence of heterotopic ossification, which usually
signifies multiple extrinsic ca uses of elbow
contracture not amenable to arthroscopic treatment
(Fig. 3).
FIGURE 3

Surgical Anatomy
• The elbow has a predilection for stiffness based on
anatomy: the close relationship of the capsule to the
surrounding ligaments and muscles, and the
presence of three joints within a synovium-lined
cavity (Fig. 4A): a hinge (ginglymus) ulnohumeral
articulation and rotatory joint (trochoid) of both the
radiohumeral and radioulnar joints (Jupiter et aI.,
2003).
• The anterior elbow capsule proximally attaches
above the coronoid fossa and distally extends to the
coronoid (medial) and the annular ligament (lateral).
• The posterior capsule starts proximally just above
olecranon fossa and inserts at the articular margin of
the sigmoid notch and annular ligament (Fig. 4B).
• The anterior capsule is taut in extension and lax in
flexion, with strength of the capsule provided from
the cruciate orientation of anterior cruciate fibers
(Morrey, 2000).
• The greatest capsular capacity is at 80° of flexion,
with the normal capacity of 25ml reduced
significantly in a contracture state to around 6ml
(Gallay et aI., 1993; O'Driscoll and Morrey, 1990).
• The elbow joint capsule is innervated by branches
from all the major nerves that cross the joint
law), and the musculocutaneous nerve (Morrey,
2000) (Fig. 5).
• Laterally, the radial nerve (posterior interosseous) ·
at greatest risk, located just outside the capsule
and anterior to approximately the midline of the
radiocapitellar joint (0' Driscoll, 2006).
• The brachialis muscle protects the median nprve-.
avoid penetration of this muscle.
• The ulnar nerve is at risk during posterior joint
arthroscopy. It is located just outside the capsule
the medial gutter.

P EA RL S
• If there is the possibility of
performing an open elbow
procedure after arthroscopy, the
prone position is helpful to free
the shoulder and allow improved
access medially and laterally.
• Tn the prone position, we place a
tigl1t roll of blankets under the
arm to keep the arm parallel to
the floo r during arthroscopy (see
Fig. 6B).
A
FIGURE 6
Positioning
• Elbow arthroscopy is typically performed in either
lateral decubitus or prone position .
• Lateral decubitus (Fig. 6A): well-padded pillow at
edge of beanbag underneath elbow antecubital
fossa. An arm suppport is very useful .
• Prone (Fig. 6B): adequate chest and arm
shoulder abducted to 90°, elbow flexed to 90' .
The prone pOSition allows improved access to the
posterior aspect of the joint.
• A well-padded sterile tourniquet is used for both
positions.
• Clearly mark the course of the ulnar nerve and
landmarks w ith a surgical marker (Fig . 7). Also
the portal sites: posterolateral (PL), lateral (L),
midlateral (ML), and trans-triceps (TI) (see Fig. 7).
B
Lateral
epicondyle
Lateral
FIGURE 7
Medial
epicondyle
Medial
portal
Ulnar
nerve
Medial

PITF A LLS
tile arm mllst be as
possible (pre(era bly
IInder the allteClibital
allows (or greater
the arthroscopic
rrumen'ts and provides an
the elbow during
r procedll re,
by surgeon preferen ce
concomitant procedures,
Portals/Exposures
• Visualization can be provided by way of fluid
distention or by the use of intra-articular retractors.
• The elbow joint is distended with saline through
the soft spot (up to 20ml, less depending on
contractu re).
• As loss of intracapsular volume makes visualization
difficult, retractors are extremely useful during the
procedure (O'Driscoll and Morrey, 1990) .
• The key to avoiding nerve injury is knowing where
the nerves are located at all times .
• If decompression of the ulnar nerve is indicated or
planned, releasing this structure prior to
arthroscopy allows easier identification of tissue
planes.
• In Figure 8, the ulnar nerve (marked with a
Penrose drain) is being released prior to
arthroscopy. The arthroscope is placed through the
medial joint space.
FIGURE 8

Controversies
• Outcome efficacy of complete
capsulectomy versus more
simple capsular release
(capsulotomy) remains to be
demonstrated in comparative or
randomized studies.
FIGURE 11
• The brachialis muscle should be visualized and the
plane between the capsule and brachialis
developed from the lateral working portal. A view
from the lateral portal in Figure 11 shows a
partially completed release. The concavity in the
coronoid and trochlear fossa areas is formed, but
the anterior capsulectomy is not yet completed .
• Once the anterior bony recontouring is completed,
perform a capsulotomy anteriorly from the proximal
humerus with a wide-mouthed duckling punch in a
medial-lateral direction.
• Continue incising the capsule from lateral to
medial. The capsulotomy should be continued to
the level of the collateral ligaments on each side,
leaving the ligaments intact (0' Driscoll, 2006).
• It may be safest to remove the capsule well
proximal to the joint line on the lateral side to
avoid risk of radial nerve injury .
• Switch portals medially and laterally to obtain a
view from both sides of the joint to ensure
adequate release.
STEP 2: POSTERIOR CAPSULAR RELEASE
• Establish a posterior-central portal (Fig . 12A) for
arthroscope (4cm proximal to olecranon tip
triceps) (Ball et aI., 2002) and posterolateral
portal (approximately 2cm proximal to the

PEARLS
use of a retractor placed
the proximal lateral
be effective ill
better visualization
rm,·,.u','v near the
steTG,me,1ial capsule to avoid
nerve injury.
a cannula in the anterior
to allow for outflow and
fluid extravasation il1to soft
PITFALLS
and radiofrequency
utilized along the medial
can cause inadvertent
to the ulnar nerve.
A
B
process
Olecranon J
l ateral
epicondyle
J
Olecranon
process
Lateral
epicondyle
FIGURE 12
between the tip of the olecranon laterally and the
lateral epicondyle) (Fig. 12B). Open these widely
with a knife down into the olecranon fossa with the
elbow extended (protecting the articular surface).
• The shaver is utilized to debride and open the
space, and to remove loose bodies and
osteophytes.
• Elevate the capsule from the distal humerus
proximally with a shaver or elevator.
• Once a view and working space are created,
perform all bone recontouring, removing any
osteophytes from the olecranon and appropriately
deepening the olecranon fossa if indicated.
•

Instrumentation/
Implantation
• A radiofrequency ablation
device can be used to remove
dense scar tissue in the
olecranon fossa and around the
tip of the olecranon process
posteriorly.
Controversies
• When to perform a limited open
exposure to identify and protect
the ulnar nerve
• The posterior capsule is released with a basket
cutter or arthroscopic elevator on the medial and
lateral sides.
• The release is stopped prior to the medial asp
of the olecranon fossa (to avoid injury to the
ulnar nerve) (Ball et aI., 2002).
• Figure 13 is an arthroscopic view of the elbow
joint after capsulectomy and deepening of the
coronoid and radial fossa. The dissection is
carried down to the fibers of the brachialis
muscle .
• The posteromedial capsule should be resected in
the setting of significant flexion loss (posterior
band of the medial collateral ligament) (O'Dris(
2006). However, this is extremely dangerous and
places the ulnar nerve at greatest risk.
• Alternatively, this capsule can be released after
the ulnar nerve has been dissected out through
limited open approach.
• The posteromedial capsule forms the floor of
cubital tunnel.
• Perform a final inspection from both portals to
ensure adequate release.
STEP 3: WOUND CLOSURE AND
I NTRAOPERATIVE SPLINTING
• If desired, a drain can be placed through the
proximal anterolateral portal as accumulation of fl .
may compromise ROM .
• A soft compressive postoperative dressing is typic
used. The anterior aspect of the dressing is remo
in the region of the antecubital fossa to allow for
elbow flexion postoperatively.
• We recommend immediate postoperative continu
passive motion (CPM) under a long-acting regio
anesthetic block. Alternatively, an anterior plaster
slab over the elbow can be utilized initially with
joint in full extension (Morrey, 2006).
• A postoperative dressing with a drain was applied
the patient in Figure 14 in the operating room a
capsular release. Flexion was obtained after rem
some of the material of the splint from the
antecubital fossa. Immediate CPM was instituted.

PEARLS
mllst be from full flexion
extension to prevent more
aCClImlllation around the
Jlweillinii catheters or a long.
reJii,ona, block may be
facilitate CPM (from fil II
extension), which
while in the
FIGURE 13
FIGURE 14
Postoperative Care and
Expected Outcomes
• Prior to starting CPM, if a splint was used, change
the dressing to a soft, noncompressive gauze to
prevent skin complications (O' Driscoll, 2006).
• Initial emphasis is placed on maintaining maximum
active and gentle passive motion with edema control
modalities (elastic sleeve, nonsteroidal anti·
inflammatory medication). Formal therapy and a
home program are utilized.
• CPM should continue at home up to 4 weeks and
should be utilized in full ROM (0-145°) with a
bolster behind the elbow (Savoie and Field, 2001).

Controversies
• The efficacy of postoperative
administration of indomethacin
in preventing recurrent
heterotopic ossification is
unknown.
• Consider heterotopic ossification prophylaxis
(indomethacin) and concomitant gastrointestinal
prophylaxis (famotidine). This may also help limit
postoperative inflammation.
• Patients usually regain approximately 50% of lost
motion (Jupiter et aI., 2003; O'Driscoll, 2006).
• Approximately 80% obtain a functional arc of
motion greater than 100° (Jupiter et aI., 2003).
• Ball et al. (2002) reported on 14 patients with
mean flexion improvement from 11 r to 133',
extension from 35° to 9°, and mean arc of
improved from 69' to 119° (in 10 patients who
had motion arc of less than 100°).
• It is difficult to compare arthroscopic versus open
capsular release series.
• Cohen and Hastings (1998) reported on 22
patients w ith open capsular release w ho had
amean improvement in ROM from 74° to 129',
representing a significant improvement in pain
function.
• Arthroscopic release series compare favorably to
open release series in properly selected patients.
Savoie and Field (2001) reported on 200 patllenll
w ith arthroscopic capsular release who had a
improvement in extension of - 46° to _3' and in
flexion of 96-138°, with a decrease in pain scale
from 6.5 to 1.5.
Evidence
Ball eM, Meunier M, Galatz LM , Calfee R, Yamaguchi K. Arthroscopic treatment
post-traumatic elbow contracture. J Shoulder Elbow Surg. 2002;1' :624·9.
In this study, the authors noted a compa rable improvement in elbow ROM and
outcome in patients who IInderwent an arthroscopic release verSllS an open
posttraumatic elbow contracture. (Level IV evidence)
Cohen MS. Heterotopic ossification of the elbow. In Jupiter JB (ed). The Stiff
Rosemont, Il: American Academy of Orthopaedic Surgeons, 2006:31 -40.
This chapter provides a detailed review of tile patlw/ogy, diagnosis, and
treatment options in patients with heterotopic ossification of the elbow.
Cohen MS, Hastings H. Post-traumatic contracture of the elbow: operative
using a lateral collateral sparing approach. J Bone Joint Surg [Br].
This techniques article demonstrated tlle authors' modified lateral elbow
whicl! allowed release of posttraumatic contractllre without dim/ption
collateral ligament or extensor origin.
Gallay S, Richa rds R, O'Driscoll SW. Intraarticular capacity and compliance of
normal elbows. Arthroscopy. 1993;9:9-13.
This study showed that adequate capsular distention of the stiff elbow
possible, increasing the potential for neurovascular injury with lise of the
portals in elbow artlJroscopy. (Level IV evidence)

Jupiter JS, O'Driscoll SW, Cohen MS. Th e assessment and management of the stiff
elbow. Instr Course lect. 2003;52:93- 111 .
Tliis is a lalldwark review paper Oil tile preselltatioll, diagnosis, mlft variolls trealmellt
optiolls of patients with elbow cOlltmclures.
King GI, Faber KJ. Posttraumatic elbow stiffness. Orthop (lin North Am. 2000;31:
129-43.
Tllis review paper provided a comprehensive approach to open versus arthroscopic
treatmellt of elbow stiffiless amilliglllighted tile fact that, although surgical release of
elbow colltracture may result ill a Iligh incidence of success, there ;$ still a reasonable
risk of complicatiolls.
Morrey SF. Anatomy of the elbow jOint. In Morrey SF (ed). The Elbow and Its
Disorders. Philadelphia: WS Saunders, 2000:13-42.
This cllapter provides a detailed look at the relevant al/atomy of the elbow joi"t for
ope" versus arthroscopic release o( lhe elbow joint.
Morrey SF. The posttraumatic stiff elbow. (lin Orth op Relat Res. 2005;(431 ):26-35.
n,is review paper provides a comprdle1lsi\'e descriptio/! of the relevallt pathology,
etiology, presentatio", ami treatmellt optio"s ill patients with posttmllmatic stiff
elbows.
Morrey SF. The stiff elbow with articular involvement. In Jupiter JS (ed). The Stiff
Elbow. Rosemont, Il: American Academy of Orthopaedic Surgeons, 2006:21-30.
This chapter provides a detailed mmlysis of treatmetiL options in patients with jl/traartiClllar
elbow patltology.
O'Driscoll SW. Clinical assessment an d open and arthrosco pic treatment of the stiff
elbow. In Jupiter IS (ed). The Stiff Elbow. Rosemont, Il: American Academy of
Orthopaedic Surgeons, 2006:9-19.
n,is chapler describes the optiollS currently available to treat patients with elbow
stiffness.
O'Driscoll SW, Morrey 8F, An K. Intra-articular pressure and capacity of the elbow.
Arthroscopy. 1990;6:100-3.
This basic science shldy detailed the fluid capacity of the 1I0rmal elbow joillt mId
fOlllld lIlat this joint capsule tends to mptllre or penn;t extravasation of fluid iI/to the
periarticular soft tissues when fluids are iI/fused during arthroscopy.
Savoie FH 3rd, Field lD. Arthrofibrosis and complications in arthroscopy of the elbow.
C1in Sports Mod. 2001;20:123-9.
The (lI IO lOrS offered concise procedural advice for artllfoscopic treat,lle,.,t of {1exio"
cOlltractllres of tile elbow, bracketed by illdicatiollS for treotmmt mid recomU/elldatiollS
regardillg postoperative compficatiolls. (Level IV evidellce)