The Role of Preoperative Factors, Surgical Approach, Mobilization Protocol for Improved Surgical Outcomes after Open Elbow Arthrolysis in Post-traumatic Elbow Stiffness - An Ambispective Cohort Study.

Abstract

Background: Post-traumatic elbow stiffness decreases the range of movements (ROM) and limits functional activities of the upper limb. Post-injury therapy and splints have been used to improve the ROM. Despite this, surgical release is required in several instances. Surgical approaches to open arthrolysis vary. However, the medial approach has been less discussed. Multiple factors impact prognosis, final ROM, and functional outcomes after arthrolysis. The objectives of this study were to analyze functional outcomes following open elbow arthrolysis, outline post-injury and postoperative mobilization protocol implemented, the role of the medial approach, and identify preoperative factors contributing towards favorable functional outcomes in post-traumatic elbow stiffness treated by open elbow arthrolysis.

Methods: In this single-center ambispective cohort study, we retrospectively recruited a cohort of post-traumatic elbow stiffness patients. They were placed in a structured preoperative therapy and splinting program. Those persisting with moderate to severe stiffness 3 to 6 months following the therapy underwent open elbow arthrolysis. A prospective study was done to evaluate the functional outcomes, pain, stability, and range of movements after elbow arthrolysis. The effect of the medial approach was evaluated for surgical outcomes. Clinical significance by minimal clinically important difference (MCID) and statistical significance of various preoperative factors for improved ROM and functional outcomes were evaluated.

Results: 94 patients with post-traumatic stiffness underwent the structured preoperative rehabilitation protocol. The severity of stiffness was downgraded with therapy in 39 patients, and the remaining 55 patients underwent open elbow arthrolysis. At a mean follow-up of 76.6±40.4 months, the mean gain in arc of motion from preop was 54°±32°, and the mean ROM at final follow-up was 88°±30° (p=0.026). An isolated medial approach was performed in 65.5%. The mean improvement in arc of motion with the isolated medial approach was 51°±28° and 45°±34° with the combined medial-lateral approach. The severity of preoperative stiffness showed statistical significance in improvement in arc of motion and postoperative Mayo Elbow Performance Score (p=0.033), while the interval from trauma to surgery was shown to be clinically significant by MCID.

Conclusions: Structured preoperative rehabilitation protocol downgrades the severity of elbow stiffness. The open elbow arthrolysis significantly improves arc of motion and MEPS. The medial approach demonstrates an improved arc of motion compared to combined and posterior approaches. The severity of preoperative stiffness and interval from trauma to surgery have a significant correlation to improvement in arc of motion and MEPS.