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Etiopathogenesis and management of stiff elbow

Etiopathogenesis and management of stiff elbow

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Stiff elbow Stiff elbow Presentation Transcript

  • Dr. Sushil Paudel
  • AnatomyComprises ofHumero-ulnar joint:Hinge jointDeterminant of osseous stabilityHumero-radial jointPivot jointRadial head acts as secondary stabilizer tovalgus stressMore stable in extreme flexion and extensionrather than mid-range
  • AnatomyStabilizersStatic:Bony articulationCapsuleMedial Collateral ligamentLateral Collateral ligamentDynamic:Muscles
  • Anatomy
  • Anatomy
  • Anatomy
  • Anatomy
  • AnatomyRange of MotionExtension: 0oFlexion: 145oPronation: 80oSupination: 75o
  • Functional Range of MotionRange of motion necessary for a individualto perform 90% of normal daily activity.Arc of elbow flexion of 100o, ranging from 30oto 130o.Arc of forearm rotation of 100o, ranging from50opronation to 50osupination.Morrey et al . A biomechanical study of normal function elbow motion.J Bone joint Surg 63 A: 872 – 877, 1981.
  • AetiologyPost traumatic:Joint incongruityDislocation/SubluxationHeterotopic OssificationBurnsCoronoid/Olecranon/Radial OsteophytesLoose BodiesTriceps/Biceps adhesionsChronic InfectionInflammatory ArthritisPatient NoncompliancePost Surgery
  • ClassificationExtrinsic Contractures:(Sparing of joint surface)Soft Tissue Ectopic OssificationCapsulo-ligamentousMuscular
  • ClassificationIntrinsic Contractures :usually associated with intraarticularfracturesIntraarticular adhesions from healed congruousjoint fractureLoss of articular cartilage due to avascularnecrosisGross distortion resulting from inadequate or failedreduction
  • PathogenesisPredisposing factors for posttraumaticelbow stiffnessHigh degree of articular congruity & conformityof joint predispose to limited motion afterarticular injuryBrachialis muscle covers anterior capsulepredisposing it to posttraumatic ectopicossificationDelayed mobilization after elbow injury usuallybecause of inability to achieve rigid fixation
  • ManagementConservative:SplintsStaticDynamicRange of motion exercisesActive ExercisesContinuous Passive Motion
  • ConservativeManagementStatic Splints
  • ConservativeManagementDynamic Splints
  • ConservativeManagementContinuous Passive Motion
  • ManagementOperative :Considerations before Planning SurgeryPatients expectations and limitationsPatients functional needsLikelihood that procedure will satisfy theseneeds.
  • ManagementOperative:Risk associated with surgeryPostoperative painInstability: as release of collateral ligamentrequired forAdequate soft tissue releaseRemoval of Ectopic BoneAdequate exposure if Intraarticular pathologyWeakness
  • Anterior Contracture ReleaseIndications:Loss of extension > 45oMinimal changes in articular surfaceContraindications:Significant alteration of the articularcontourloss of joint cartilage > 50%pathology requiring release of one orboth collateral ligamentsMotor deficiency or spasticity
  • Anterior Contracture ReleaseTechnique: (Column procedure)Posterolateral incisionDissection between Extensor Carpiulnaris and AnconeusSeparate extensor tendon from jointcapsule and LCLAnterior capsule exposed and incision madeover anterior capsule anterior and parallel toLCLAs wide a capsular excision is done aspossible
  • Anterior Contracture Release
  • Posterior Contracture ReleaseIf flexion limited:Interval between Triceps and ECRLexposedTriceps elevated from posterior aspect ofhumerusPosterior capsule excised
  • Posterior Contracture Release
  • Anterior Contracture ReleaseExcision of osteophytes at tip ofOlecranon & Coronoid process
  • Anterior Contracture ReleasePostoperative ManagementAdequate analgesiaContinuous passive motion:started immediatelyfor 3 weeksReassessed at 3 weeks and static splintsgivenSplintage primarily in extension for 3monthsGradual weaning from splints
  • Contracture ReleaseComplications:Ulnar nerve injuryMedian nerve injury ifcontracture > 90oMorrey B F . Master techniques in orthopaedic surgery – The Elbow
  • Arthrolysis (BhattacharyaProcedure)Removal of capsular contractureMobilizing Brachialis & Triceps from lower humerus ,Restoration of trochlear pulleyMinimal removal of Bone block without excisingarticular surfacePostoperative Management:After closure of wound 25 mg inj. Hydrocortisoneacetate injected in joint with 2 – 5 cc of Hyalase.Compression bandage with splint in full extensionSecond dose of Hydrocortisone is given with 2 – 4cc lignocaine (2%) on 7thor 10thday.
  • Distraction ArthroplastySimultaneous joint motion while ensuring stability byprotecting collateral lig.Indications:ReconstructiveAdjuvant to capsule release if ligamentsdamagedSignificant dissection making intraoperativemotion difficult> 50% joint surface void of cartilageModified joint contour
  • Distraction Arthroplasty
  • Distraction Arthroplasty
  • Distraction ArthroplastyGoalsSeparate joint surfacesReorient joint surfaceProtect ligament healingAllow motionContraindicationsInexperienceLocal sepsis# distal humerus or proximal ulna
  • Distraction ArthroplastyIf as adjuvant to capsular releaseCautionIdentification of Ulnar Nerve important atthree stepsReflecting TricepsCapsular DissectionPin Placement
  • Distraction ArthroplastyTechnique: Pin PlacementTubercle of capitellum (Lat) to just anteriorand inferior to medial epicondyleTwo Ulnar pins anterior and posterior tocenter of articulationPins should be placed parallel3 – 5 mm distraction
  • Distraction ArthroplastyPostoperative managementAdequate analgesiaContinuous passive motion for 3 weeksDistraction device removed at 3 weeksFlexion – Extension splints till 6 – 12 weeksMorrey B F . Master techniques in orthopaedic surgery – The Elbow
  • Fascial Interposition ArthroplastyIndications:Young adults with posttraumatic ankylosisof elbow with intact broad contour of distalhumerusYoung adult Stage I & II Rheumatoidarthritis,with intact boneContraindications:Active infectionGrossly unstable elbowCongenital ankylosis (lacks soft ts support)
  • Fascial Interposition ArthroplastyPreoperative planning:Selection of donor siteAvoid hairy donor site (risk of inclusion cysts)Cutis – preferred materialCutis – thick dermal layer of skin remainingafter superficial epidermis has been peeledoff.
  • Fascial Interposition ArthroplastyTechnique:Extended Kocher’s lateral approachExtensor mass,periosteum and LCL dissected offthe lateral condyleMedial collateral lig sectioned from withinElbow dislocated and distal end of humerus isprepared – removal of osteophytes,articularcartilage, bone fragmentsSmooth rounded surface obtained ~ 4 cm wide &~ 2 cm anterior to posteriorRadial head removed only if necessary to restorepronation & supination
  • Fascial Interposition ArthroplastyTechnique: (contd…..)Split thickness graft taken from donor siteDeep dermal layer is excised fromsubcutaneous fat (Cutis)Cutis graft draped over distal humerus withsuperficial cut surface of dermis applied to boneDermal graft sutured with drill holes in medialand lateral ridges
  • Fascial Interposition Arthroplasty
  • Fascial Interposition Arthroplasty
  • Fascial Interposition ArthroplastyPostoperative Management:Posterior plaster splint in 90oflexion for 2 weeksHinged cast brace for 4 weeksResistive flexion exercises started at 1 monthExtension strengthening exercises started at6 weeksComplications:Medial-lateral laxity
  • Elbow ArthroscopyApplications in Stiff elbow:Removal of loose bodiesDebridement of joint surface oradhesionsRelease of Capsular contracturesExcision of osteophytes causingimpingement (as in early osteoarthritisof ulnohumeral joint)
  • Elbow ArthroscopyContraindications:Altered Neuro-vascular anatomyExtraarticular deformity like ectopic bone ordisplaced radial neckSeverely contracted or fibrotic joint
  • Elbow ArthroscopyTechnique:Patient lying in lateral or supine positionElbow flexed at 90oPorts
  • Elbow ArthroscopyAdvantages:Complete examination & treatment optionsDebridement of intraarticular adhesionsimprove ROM as well as relieve painRelatively less soft ts trauma & post opscarring reduce risk of recurrentcontractures.
  • Elbow ArthroscopyComplications:Permanent nerve injuriesVicinity of Radial & median nerves toanterior portalsRestricted Capsular Distension (Capsulardistension achieved with 15 – 25 ml saline,intracapsular capacity ~ 6 ml in contractures)
  • Elbow Arthroscopy
  • Ectopic OssificationTypes:Heterotopic Ossification : formation ofmature lamellar bone in non-osseous tissueMyositis OssificansPeriarticular calcification : collection ofcalcium pyrophosphate crystals in softtissue (lacks trabecular pattern)
  • Ectopic OssificationPredisposing factors:Elbow traumaNeural axis traumaBurnsDiffuse skeletal HyperostosisHypertrophic osteoarthrosisAnkylosing spondylitisPaget’s DiseaseHistory of Ectopic ossification
  • Ectopic OssificationPresentation:Usually at 2 weeks after insultLocalized swelling, bone pain, Hyperemia,local tendernessElbow stiffness after 1 – 4 monthsNerve entrapment syndromes – ulnarnerve most common
  • Ectopic OssificationRadiological features:EarlyAbsence of trabeculaeIndistinct marginsMatureWell defined trabeculaedistinct margins
  • Ectopic OssificationZONE phenomenonMyositis Ossificans matures from inside toOutside , i.e. Core is composed of immatureosseous tissue , while the most superficialregion is composed of most mature osseoustissue.
  • Ectopic OssificationClassification:Based on Location:
  • Ectopic OssificationClassification:Randal W V et alType I : ossification of Proximal radio-ulnarjointType II : ossification of proximal RUJ with distalextension involving the bicipital tuberosityType III : ossification of radius & ulna distal to proximalRUJSubtype A – Anterior involvementSubtype B – Posterior involvementSubtype C – intraarticular involvement of PRUJ
  • Ectopic OssificationClassification:Functional classificationClass I : Radiologically evident elbow ectopic ossificationwithout clinical limitationClass II : Subtotal, functional, limitation of motionA: in flexion & extension planeB: in pronation & supination planeC: in both planesClass III : Ankylosis that eliminates motionA:, B:, C:.Hastings H, Graham TJ : The classification and treatment of heterotopicossification about elbow and forearm. Hand Clin 10:417-437, 1994.
  • Ectopic OssificationProphylaxis:Chemotherapeutic agents:Diphosphonates:? interfere with ossification of osteoid? Rebound calcificationNSAIDS: Indomethacinprevent precursor cells from differentiationRadiation Therapy:low dose external beam radiation
  • Ectopic OssificationNon-operative treatment:Aggressive motion programmeActive ExercisesSlow & aggressive passive Force? Enhance ectopic ossification &exacerbate elbow stiffness *Dynamic splinting*Stover SL, Hataway CJ: Heterotopic ossification in spinal cord-injuredpatients. Arch Phys Med Rehabil 56:199-204, 1975.
  • Ectopic OssificationOperative Treatment:Indications / CriteriaFunctionally limiting elbow stiffnessRadiographic union of fractureRadiographic evidence of intact ulno-humeralarticular surfaceStage of maturationStabilization of traumatic brain injury & motivationto complete therapySoft tissue stability
  • Ectopic OssificationOperative Treatment:Timing of surgeryAdvantages of Delayed interventionMetabolic quiescent ectopic boneMaximal neurological recoveryProblems with delayed InterventionProgressive soft tissue contracturePotential articular cartilage destructionProlonged infirmity
  • Ectopic OssificationEssentialsSelect incision allowing resection of all ectopicossificationDecompression of compressed nerveResection of anterior and posterior capsuleClearing of coronoid fossaDebridement of coronoid processClearing of Olecranon fossaExcision of terminal 1 – 1.5 cm of olecranonCorrection of elbow instabilityTransposition of ulnar nervePreserve anterior band of MCL & LCL & Orbicularcartilage even in presence of periarticularcalcification
  • Ectopic OssificationOperative Treatment:Complications:Recurrent stiff elbowTriceps ruptureAseptic resorption of CapitellumSkin necrosisHematoma formationRandall WV, Hastings H II: Treatment of Ectopic Ossification aboutElbow . CORR 370: 65 – 86, 2000.
  • Indications:Age > 60Advanced arthritis or posttraumatic destructionof jointsTotal Elbow ArthroplastyTypesSemi constrained or linked prosthesisUnconstrained or unlinked prosthesis
  • Total Elbow ArthroplastyUnconstrained / Unlinked prosthesisPrerequisiteGood Bone StockLittle DeformityStable Capsulo-ligamentous supportUncommon in a Posttraumatic elbowIndicationsElderly patients with primary RheumatoidjointPainless ankylosed elbow at 90oin youngpatient with Juvenile Rheumatoid ArthritisKudo ElbowIBP Elbow
  • Total Elbow Arthroplasty
  • Total Elbow ArthroplastyUnconstrained / Unlinked prosthesisExtended Kocher’s ApproachPost operative ManagementElbow placed in 60oflexion & full pronationROM exercises started usually by 2nddayActive Assisted elbow flexion & passivegravity extensionForearm placed in pronation to protect LCL for 6 wksResting splint in 90oflexionExtension beyond 30oavoided for first 3 - 4 weeks
  • Total Elbow ArthroplastySemi constrained / linked prosthesisPredominant role in reconstruction of posttraumaticelbowIndicationElderly patient with post traumatic / arthriticjoint destruction withDeficit Bone StockUnstable Capsulo-ligamentous supportDeformity
  • Total Elbow Arthroplasty
  • Total Elbow ArthroplastySemi constrained / linked prosthesisPosterior / Bryan-Morrey ApproachPost operative ManagementPostoperative splintage in full extensionAssisted flexion & forearm rotation started 2nddaywith gravity assisted extensionDaytime resting splint in 90oflexion for 6 weeksNight time extension splint for 12 weeksGSB III
  • Total Elbow ArthroplastyBaksi’s Sloppy Hinge prosthesis79 ( 69 Ankylosed ) elbows replaced withsloppy hinge prosthesis ,followed over 10 years.Painless stable motion in 59 ( 86.8 % )ankylosed elbows with average arc 88.8o.Aseptic loosening in 4 patientsBakshi : Sloppy Hinge prosthetic elbow replacement for posttraumaticankylosis or instability. J Bone Joint Surg 80 (B):614-619,1998.
  • Total Elbow ArthroplastyLife Time RestrictionsLifting weight not more than 5 kgAvoid upper limb impact sportsMorrey BF:Master Techniques in Orthopaedics – The ElbowMoro JK, King GJ: Total Elbow Arthroplasty in the Treatment ofPosttraumatic Conditions of the Elbow. CORR 370:102-114,2000.
  • Total Elbow ArthroplastyExpected to improve valgus androtational stability# ? Increased incidence of loosening ofhumeral component*Proper position & orientation ofprosthesis ????#O’Driscoll, King GJW: Treatment of instability after total elbowarthroplasty. Orthop Clin North Am 2001,32:679-695* Ewald FC et al.: Capitellocondylar total elbow arthroplasty. J Bone JointSurg 62(A) :1259,1980.??#!!/??Role of Radial Head Replacement
  • Adjuvant ProceduresLengthening of Triceps AponeurosisDebridement & SynovectomyManipulation under AnesthesiaRadial Head Excision
  • Posttraumatic Stiff ElbowAge < 60, motion < 45-115o,stability intactPain less, strength - normalAcute Sub acute ChronicRigid ORIF ?CPMSplints<6 mthsSplintsAnti-inflammatoryClose follow-up6-12 mthsX-Ray + TomoNo Ectopic Ossification Ectopic OssificationExtrinsic Intrinsic Bone bridge Soft tissuePosterior capsuleAnterior capsuleAdhesionsArticular deformityResect Muscle (Myositis Ossificans)CapsuleLigamentsMay need distraction
  • ImpingementCoronoidOlecranonArticularAcceptable SurfaceReleaseDistract if UnstablePoor ArticularSurface< 50% articular cartilage>50% cartilage avulsedMalunion of surfaceResurface fractureDistractionIntrinsic
  • ReferencesReconstructive Surgery of joints. Bernard F. Morrey.Master Techniques in Orthopaedic Surgery- TheElbow. Bernard F. Morrey.The Athletes Elbow. David W. AltchekGreen’s Operative hand SurgeryTextbook of orthopaedics & Trauma . Kulkarni.Clin Orthop 370,2000.J Bone Joint Surg 83-B,1998Current Opinion in Orthopaedics:Vol.1(4),2002.
  • KEEPCONFERENCEHALLCLEANPLEASE DISPOSEEMPTY BOXESOUTSIDE THE HALL