Posttraumatische Ellenbogengelenksteife - offene Arthrolyse über dorsale Inzision („global approach“)

Zusammenfassung

27 Patienten nach offener Ellenbogengelenkarthrolyse wurden im Mittel 21 Monate postoperativ (Minimum 12 Monate, Maximum 33 Monate) klinisch nachuntersucht. In allen Fällen erfolgte die Operation über eine dorsale Längsinzision mit Darstellung und primärer Schonung der Seitenbänder. Anteriore und posteriore Kapselektomien wurden bei 26 Patienten durchgeführt. Ein dynamischer gelenküberbrückender Bewegungsfixateur wurde bei 4 Patienten bei Instabilität verwendet. Das mittlere präoperative Flexionsausmaß von 109° wurde auf durchschnittlich 136° verbessert. Der Gesamtbewegungsumfang Flexion/Extension lag präoperativ bei 59° und wurde auf 112° verbessert, die Unterarmrotation lag präoperativ bei 118° und postoperativ bei 159°. Die Verbesserungen der Bewegungsausmaße waren statistisch signifikant (t < 0,005). Der präoperative Mayo Elbow Performance Score (MEPS) wurde von 60 auf 85 zum Zeitpunkt der Nachuntersuchung verbessert (p < 0,05). Alle Patienten hatten eine verbesserte Ellenbogengelenkbeweglichkeit und verminderte Schmerzen entsprechend des MEPS. An postoperativen Komplikationen traten heterotope Ossifikationen, milde symptomatische postero-laterale rotatorische Instabilität bei einem Patienten und ein Pin-Infekt auf. Keinerlei Komplikationen traten im Zusammenhang mit der dorsalen Hautinzision auf. Die dorsale Hautinzision erlaubt eine globale Darstellung der betroffenen Strukturen bei posttraumatischer Ellenbogengelenksteife. Die Arthrolyse über diesen Zugang ist erfolgversprechend und sicher. Die Armfunktion und Ellenbogengelenkbeweglichkeit können gut verbessert werden und eine Schmerzreduktion tritt ein. Die Patientenzufriedenheit dieses Eingriffes ist sehr hoch.

Abstract

Twenty-seven patients who underwent an elbow contracture release were independently reviewed a mean of 21 (range 12 - 33) months following surgery. In all cases, a single posterior longitudinal incision was utilized to expose and preserve collateral ligament insertions. Anterior and posterior capsulectomies were performed in 26 patients. An articulated external fixator was applied to four patients when instability was recognized intraoperatively. Mean preoperative flexion of 109° was improved to 136°. The mean preoperative flexion-extension arc of 59° was improved to 112° and forearm rotation arc of 118° was improved to 159° following surgery. All improvements in range of motion were statistically significant (p < 0.005). Preoperative Mayo elbow performance score (MEPS) was 60 and at follow-up was 85 (p < 0.05). All patients had improved elbow motion and function and diminished pain as reflected in the MEPS. Postoperative complications included recurrent formation of heterotopic bone in one patient, mild asymptomatic posterolateral rotatory instability in one patient, and a pin tract infection in one patient. There were no complications associated with the skin incision. The posterior skin incision safely allows global exposure of the elbow for contracture release. Elbow contracture release is worthwhile and safe when performed using a posterior incision. Arm function and elbow motion was improved and pain was diminished. Patient satisfaction with the procedure was high.

Literatur

• 1 Morrey B F. Post-traumatic contracture of the elbow.  J Bone Joint Surg. 1990;  72 601-618
• 2 Urbaniak J R, Hansen P E, Beissinger S F, Aitken M S. Correction of post-traumatic flexion contracture of the elbow by anterior capsulectomy.  J Bone Joint Surg. 1995;  67 1160-1164
• 3 Morrey B F, Askew R PT, An K N, Chao E Y. A biomechanical study of normal functional elbow motion.  J Bone Joint Surg. 1981;  72 601-618
• 4 Bonutti P M, Windau J E, Ables B A, Miller B G. Static progressive stretch to reestablish elbow range of motion.  Clin Orthop. 1994;  303 128-134
• 5 Duke J B, Tessler R H, Dell P C. Manipulation of the stiff elbow with patient under anesthesia.  J Hand Surg. 1991;  16 19-23
• 6 Glynn J J, Niebauer J J. Flexion and extension contracture of the elbow: surgical management.  Clin Orthop. 1976;  117 289-291
• 7 Green D P, McCoy H. Turnbuckle orthotic correction of elbow-flexion contractures after acute injuries.  J Bone Joint Surg. 1979;  61 1092-1095
• 8 Gelinas J J, Faber K J, Patterson S D, King G JW. Effectiveness of Turnbuckle splinting for elbow contractures.  J Bone Joint Surg. 2000;  82 74-78
• 9 Zander C L, Healy N L. Elbow flexion contractures treated with serial casts and conservative therapy.  J Hand Surg. 1992;  17 694-697
• 10 Boerboom A L, de Mayeier H E, Verburg A D, Verhaar J AN. Arthrolysis for post-traumatic stiffness of the elbow.  International Orthopaedics. 1993;  17 346-349
• 11 Gates III H S, Sullivan F L, Urbaniak J R. Anterior capsulectomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow: a prospective study.  J Bone Joint Surg. 1992;  74 1229-1234
• 12 Cohen M S, Hastings 2nd H. Post-traumatic contracture of the elbow. Operative release using a lateral collateral ligament sparing approach.  J Bone Joint Surg. 1998;  80 805-812
• 13 Hastings H, Graham T J. The classification and treatment of heterotopic ossification about the elbow and forearm.  Hand Clinics. 1994;  10 417-437
• 14 Hertzel R, Pisan M D, Ballmer F. Operative management of the stiff elbow: Sequential arthrolysis based on a transhumeral approach.  J Shoulder Elbow Surg. 1997;  6 81-88
• 15 Husband J B, Hastings H. The lateral approach for operative release of post-traumatic contracture of the elbow.  J Bone Joint Surg. 1990;  72 1353-1358
• 16 Jones G S, Savoie F H. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow.  Arthroscopy. 1993;  9 277-283
• 17 Karachalios T, Maxwell-Armstrong C, Atkins R M. Treatment of post-traumatic fixed flexion deformity of the elbow using an intermittent compression garment.  Injury. 1994;  25 313-315
• 18 Lamine A, Fikry T, Essadky B, Zryouil B. L'artholyse du coude - a propos de 70 cas.  Acta Orthop Belgica. 1993;  59 352-356
• 19 Wada T, Ishii S, Usui M, Miyano S. The medial approach for operative release of post-traumatic contracture of the elbow.  J Bone Joint Surg. 2000;  82 68-73
• 20 Kraushaar B S, Nirschl R P, Cox W. A modified lateral approach for release of posttraumatic elbow flexion contracture.  J Shoulder Elbow Surg. 1999;  8 476-484
• 21 Mansat P, Morrey B F. The column procedure: a limited lateral approach for extrinsic contracture of the elbow.  J Bone Joint Surg. 1998;  80 1603-1615
• 22 Viola R W, Hanel D P. Early “simple” release of posttraumatic elbow contracture associated with heterotopic ossification.  J Hand Surg. 1999;  24 370-380
• 23 Phillips B B, Strasburger S. Arthroscopic treatment of arthrofibrosis of the elbow joint.  Arthroscopy. 1998;  14 38-44
• 24 Nowicki K D, Shall L M. Arthroscopic release of a posttraumatic flexion contracture of the elbow: a case report and review of the literature.  Arthroscopy. 1992;  8 544-547
• 25 Roberts J B, Pankratz D G. The surgical treatment of heterotopic ossification following long term coma.  J Bone Joint Surg. 1979;  61 760-763
• 26 Seth M K, Khurana J K. Bony ankylosis of the elbow after burns.  J Bone Joint Surg. 1985;  67 747-749
• 27 Shahriaree H, Sajadi K, Silver C M, Sheikholeslamzadeh S. Excisional arthroplasty of the elbow.  J Bone Joint Surg. 1979;  61 922-927
• 28 Thompson H C, Garcia A. Myositis ossificans: Aftermath of elbow injuries.  Clin Orthop. 1967;  50 129-134
• 29 Timmerman L A, Andrews J A. Arthroscopic treatment of posttraumatic elbow pain and stiffness.  Am J Sports Med. 1994;  22 230-235
• 30 Weizenbluth M, Eichenblat M, Lipskeir E, Kessler I. Arthrolysis of the elbow: 13 cases of posttraumatic stiffness.  Acta Orthop Scand. 1989;  60 642-645
• 31 Wilson P D. Capsulectomy for the relief of flexion contractures of the elbow following fracture.  J Bone Joint Surg. 1944;  26 71-86
• 32 Dowdy P A, Bain G I, Patterson S DP, King G JW. The midline posterior elbow incision: an anatomic appraisal.  J Bone Joint Surg. 1995;  77 696-699
• 33 Kocher T. Textbook of Operative Surgery. 3rd Ed. (Stiles HJ, Paul CB [transls]). London; A & C Black 1911
• 34 Kaplan E B. Surgical approaches to the proximal end of the radius and its use in fractures of the head and the neck of the radius.  J Bone Joint Surg. 1941;  23 86
• 35 Hotchkiss R N. Compass Universal Hinge: Surgical Technique. Smith and Nephew 1998: 8-12
• 36 Morrey B F. The Elbow and its Disorders. 2nd Ed. Philadelphia; W. B. Saunders 1993
• 37 Morrey B F, An K N. Functional anatomy of the ligaments of the elbow.  Clin Orthop. 1985;  210 84-90