Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3032-3
ELBOW
Outcomes of arthroscopic arthrolysis for the post-traumatic elbow
stiffness
Xinghuo Wu • Hong Wang • Chunqing Meng •
Shuhua Yang • Deyu Duan • Weihua Xu •
Xianzhe Liu • Ming Tang • Jianning Zhao
Received: 10 December 2013 / Accepted: 19 April 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Post-traumatic contracture is a common com-
plication after elbow trauma. If conservative therapy fails
to restore adequate elbow motion, surgical release is rec-
ommended. Increase in arthroscopy knowledge and skills,
as well as technological advances in the passed decade of
years, has made arthroscopic arthrolysis a safe and reliable
treatment for patients with a post-traumatic elbow con-
tracture. The aim of this study was to report on the clinical
outcome and improvement of ROM in post-traumatic stiff
elbow treated by arthroscopic arthrolysis.
Methods Between 2008 and 2012, 34 consecutive
patients with post-traumatic stiffness were treated with
arthroscopic arthrolysis. Active and passive elbow move-
ment is encouraged the day after operation with the
effective pain management. Mayo Elbow Performance
Index (MEPI) and visual analogue scale were measured.
Results At the final follow-up, the average arc of elbow
motion increased from 48.6 ± 19.3 pre-operatively to
114.5 ± 25.7, with a mean improvement of 65.9°. The
MEPI score improved from 68.2 ± 16.4 pre-operatively
to 92.4 ± 21.6, with a mean improvement of 24.2
(p \ 0.001). Results were good to excellent in 29 patients.
Conclusion Injuries are the most common cause of elbow
stiffness requiring surgical release. The procedure of
arthroscopic arthrolysis is a good option for the treatment
of post-traumatic elbow stiffness as it restores normal
X. Wu
H. Wang (&)
C. Meng
S. Yang
D. Duan

W. Xu
X. Liu
M. Tang
J. Zhao
Department of Orthopaedics, Union Hospital, Tongji Medical
College, Huazhong University of Science and Technology,
Wuhan 430022, Hubei, China
e-mail: wanghwh64@aliyun.com
elbow function. Early passive/active post-operative reha-
bilitation is very important.
Level of evidence Case series, treatment study, Level IV.
Keywords Arthroscopic
Arthrolysis
Post-traumatic

Stiffness
Exercise
Introduction
The range of motion (ROM) of the elbow joint in healthy
people varies considerably and decreases during life; exten-
sion varies from -21° to 12° and flexion varies from 122° to
164° [29]. Elbow stiffness is generally defined as a flexion/
extension arc of \100° and/or flexion contracture of [30°,
and a loss of 50° of motion will result in a functional loss of
80 % in activities of daily living [18]. Restriction of elbow
mobility and elbow stiffness are frequent complaints after
elbow trauma or surgery, with an incidence upward of 5 %
[20]. Post-traumatic elbow contractures can be the result of
intrinsic (intra-articular) or extrinsic (extra-articular) or both
intrinsic and extrinsic causes [2]. And most patients with
significant stiffness have suffered an intra-articular fracture.
Despite advances in the management of injuries around
the elbow, approximately 12 % of elbow injuries (frac-
tures, dislocations and biceps tendon ruptures) result in
contractures requiring surgical release [19]. Since the
introduction of open arthrolysis for post-traumatic elbow
contractures by Wilson [32], numerous different operative
techniques have been described and clinical outcomes in
the recent literature are broadly similar, reporting that
elbow motion improves in nearly all patients, with a mean
gain of 52°, and that the majority achieve the functional arc
of 30°–130° [1, 5, 8, 21, 22, 25, 32]. Increase in arthros-
copy knowledge and skills, as well as technological
123

advances in the passed decade of years, has made
arthroscopy widely used in the diagnosis and treatment of
elbow pathology, even though the elbow has always been
considered a difficult joint to be arthroscopically explored
[23, 30]. Arthroscopic arthrolysis with debridement has
become a safe and an effective treatment for stiff elbow
with an increase in flexion, extension and elbow functional
assessment scores.
For years, the gold standard for the treatment of stiff
elbows was open surgical release. This method could
obtain good clinical outcomes, but it also induced haema-
toma, large skin or muscular scar, more soft tissue trauma,
nerve injury and heterotopic ossification (HO), etc. [6, 16,
24]. Arthroscopic arthrolysis has improved dramatically,
along with the development of surgical technique and
medical equipment; however, it is challenging because the
neurovascular structures are close to the portals and the
restricted working space [7, 26]. The purpose of this study
was to evaluate clinical outcome and improvement of
ROM after arthroscopic arthrolysis of the post-traumatic
stiff elbow with functional exercise after treatment.
Materials and methods
Between 2008 and 2012, 34 consecutive patients with post-
traumatic stiffness were treated with arthroscopic arthroly-
sis. There were 24 men and 10 women in the study group
with a median age of 39.6 ± 11.8 years (19–51). A total 13
of them were left elbow stiffness and the other 21 were right
elbow stiffness. According to Morrey’s [15] elbow stiffness
classification, 7 of the patients were very serious (flexion/
extension ROM \ 30), 16 serious (30°–60°), 10 moderate
(60°–90°), 1 mild ([90°). Radiographs and/or computer
tomography (CT) scans were taken for all patients to assess
the origin of the contracture. Inclusion criteria were as
Fig. 1 Operative procedures: a lable the bony marks; b the hyperplasia osteophyte were cleared using abrasive drill
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Knee Surg Sports Traumatol Arthrosc
follows: (1) the elbow joint stiffness makes daily activities
more difficult; (2) the patients received non-surgical treat-
ment for 6 months or more without significant improvement
of elbow motion; (3) X-ray indicates that the elbow gap still
exists, with or without osteophyte formation; (4) HO is
obvious, but there’s no continuity callus across the joint.
Exclusion criteria were as follows: (1) significant bony
deformities of the elbow joint, which need correction sur-
gery; (2) the patients with primary degenerative or inflam-
matory arthritis of the elbow; (3) skin infections around the
elbow; (4) the joint gap has almost disappeared, such as
bony ankylosis of the joint.
Surgical technique
Arthroscopic arthrolysis is routinely done under general
anaesthesia with the patient placed in supine position.
Before insufflating the joint, bony landmarks and the ulnar
nerve were marked (Fig. 1a). After 20 ml of saline was
injected into the joint, the first portal–anterolateral portal
was made. Then, penetrate the arthroscopy from antero-
lateral of the elbow to the subcutaneous tissue of the
opposite side, and the second portal was made under
arthroscopy. After establishing the portal, all osteophytes,
loose bodies and fibrotic tissue were removed using a 3.5-
mm abrasive drill (Fig. 1b) or a 4-mm cylindric shaver or
an electrosurgical unit under the monitor and control of
arthroscopy. Then, release anterior contracture joint cap-
sule and excise the tip of the coronoid using an abrasive
drill. Sometimes, a posterolateral portal was used to deb-
ride the posterior compartment. After that, manipulative
release was adopted again to obtain satisfactory joint ROM.
Finally, a drainage tube was inserted into the articular
cavity, and the elbow joint was fixed in an orthosis in
extension position. Indometacin tablets were used to pre-
vent myositis ossificans.
Knee Surg Sports Traumatol Arthrosc

Rehabilitation programme Evaluation

Early motion post-operatively requires adequate pain con-
trol. The day after surgery, our rehabilitation protocol
begins with very slow continuous passive motion (CPM),
thrice a day for 30 min with the help of oral NSAIDs drugs.
On day 2, CPM is performed four times a day for 30 min,
plus self-active movements four times a day for 30 min.
When the patients do active function exercise, progressive
resistance exercise was encouraged to enhance muscle
strength (Fig. 2b, c).
Evaluation took place pre-operatively, after 3, 6 and
12 months, using the Mayo Elbow Performance Index
(MEPI) [17], which assesses pain, ROM, stability and func-
tion. All measurements of ROM were performed using a
hand-held goniometer by a single observer (C. Q. M). Pain at
rest was evaluated on a visual analogue scale (VAS) pre-
operatively and post-operatively. Radiographs and computed
tomography (CT) were performed regularly to evaluate the
osseous abnormalities in all patients pre-operatively (Fig. 2).

Fig. 2 Typical cases. Case 1: A

19-year-old female patient of
right elbow stiffness. Pre-
operative (a) and post-operative
(b) clinical photographs after
arthroscopic arthrolysis. Case 2:
A 28-year-old male patient of
right elbow stiffness. Pre-
operative (c) and post-operative
(d) clinical photographs after
arthroscopic arthrolysis for the
post-traumatic elbow stiffness

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 Knee Surg Sports Traumatol Arthrosc

IRB approval Table 2 Pre-operative and post-operative visual analogue scale

The study was approved by the Ethics Committee of Tongji
Medical College (No: 2008/05), and all participants have
signed informed consent.
Statistical analysis
Pre-operative and post-operative changes in MEPI and
VAS score were tested using the paired t test. All data were
presented as the mean ± SEM. All analyses were per-
formed with GraphPad Prism 5. Statistical differences were
considered significant for p values \0.05. With a statistical
power of 90 % at the 5 % significance level, the sample
size was 30 for the nonparametric Wilcoxon’s test.
Results
In the study, 31 of the 34 patients (91 %) were available at
the final follow-up. No patient converted to open surgery or
required further surgery. The time between surgical inter-
vention and trauma varied from 1 to 5 years.
The average arc of elbow motion increased from
48.6 ± 19.3 pre-operatively to 114.5 ± 25.7 at the final
follow-up, a mean improvement of 65.9° (p \ 0.001). For
the 15 patients with 3 years of follow-up data, no signifi-
cant increase in ROM was seen after 1 year: the mean
ROM was 114.5 ± 25.7 at 1 year and 113.5 ± 28.3 at
2 years (n.s.). The MEPI score improved from 68.2 ± 16.4
pre-operatively to 92.4 ± 21.6 at the final follow-up, a
mean improvement of 24.2 (p \ 0.001) (Table 1). Results
were good to excellent in 29 patients and fair in 2 patients,
and none of the patients showed poor results.
The VAS score at rest 12 months post-operatively was 0
in 19 patients and 1 in 12, respectively. Among them, one
patient had improved from 3 to 0, two patients from 2 to 0,
one patient from 2 to 0. These changes were significant
from pre-operative to post-operative (Table 2).
During the follow-up, one patient failed to gain a total
arc of [100°, and HO was regarded as the major reason of
failure. No deep infection developed in the cases. Super-
ficial infection occurred in two patients; the infection was
(VAS) score at rest
VAS score Pre-operative (n) Post-operative (n)
3 months 6 months 12 months
0 5 17 17 19
1 22 13 14 12
2 3 1 0 0
3 1 0 0 0
successfully controlled by intravenous antibiotics, and the
patients gained a total ROM of [100° at the final evalua-
tion. The ulnar nerve symptom occurred in three patients
after operation, but no case developed an ulnar nerve
neuropathy, and all the patients gained spontaneous
recovery within 6 months. Pre-operatively, the ROM of
these three patients was 37.6°, 40.2° and 35.4°,
respectively.
Discussion
The most important finding of the present study was
arthroscopic arthrolysis of stiff elbows is a good option for
the treatment of post-traumatic elbow stiffness as it restores
normal elbow function. And early passive/active post-
operative rehabilitation is very essential for the recovery.
As we know, the most frequently reported complication
following arthroscopic arthrolysis was persistent limitation
in ROM, thus requiring another surgical release. Good
ROM could usually be obtained intra-operatively, but, as
time passing, the improved ROM could not be maintained
without effective exercise. Therefore, the clinical outcome
was often disappointing at the final follow-up. In the study,
active and passive elbow movement is encouraged the day
after operation with the effective pain management, aimed
to gain a better ROM. At the final follow-up, the results
were good to excellent in 29 patients and fair in 2 patients,
and none of the patients showed poor results, with the fine/
excellent rate of 93.5 %.
Treatment options focus on elbow stiffness can be
divided into conservative and surgical. Non-operative

Table 1 Pre-operative and post-operative ROM and MEPI (n = 31)

Variable Pre-operative Post-operative p
3 months 6 months 12 months*

ROM 48.6 ± 19.3 102.4 ? 23.6 113.2 ? 26.4 114.5 ± 25.7 \.0.001
MEPI score 68.2 ± 16.4 82.4 ± 23.6 90.2 ± 23.8 92.4 ± 21.6 \.0.001
MEPI Mayo Elbow Performance Index, ROM range of motion
* p value: compare post-operative to pre-operative

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Knee Surg Sports Traumatol Arthrosc
treatment includes physiotherapy, dynamic splinting, static
progressive splinting and manipulation under anaesthesia,
which are advised to be continued for at least 6 months,
according to many authors [10, 13, 25]. Surgical arthrolysis
will be recommended to those patients failed versus the
adequate conservative treatment. Gundlach and Eygendaal
[9] demonstrated that the patients who have failed a min-
imum of 6–12 months of non-surgical management and
who are motivated to comply with a strict post-operative
rehabilitation programme are candidates for surgical
release. Arthrolysis of the stiff elbow can be done by an
open or arthroscopic surgery depending on the surgeon’s
expertise level with elbow arthroscopy, status of the ulnar
nerve, formation and location of HOs, extent of the con-
tracture, and articular surface damage [14].
At present, arthroscopic arthrolysis of stiff elbows has
been introduced as a safe surgical procedure with low
complication rate [12, 27]. Pederzini et al. [23] evaluated
the functional outcomes of arthroscopic surgery in 243
patients with post-traumatic or degenerative elbow stiff-
ness. The post-operative improvement of the MEPI was
significant and showed a full recovery of working life,
sports and relationships for the majority of patients. Cefo
and Eygendaal [4] lead a study to investigate the effects of
elbow arthroscopy on post-traumatic elbow stiffness, and
they indicated that arthroscopic arthrolysis was a safe and
reliable treatment for patients with a post-traumatic elbow
contracture, with the advantages of improved joint visual-
ization, reduced pain, smaller scars, accelerated rehabili-
tation and shorter hospital stay. For the good results,
continuous passive movement (CPM) is widely used as part
of rehabilitation following elbow surgery to maintain the
movement achieved during surgery.
Passive function exercise, like CPM, could reduce the
risk of adhesion formation that can significantly limit the
movement recovery. But, the use of CPM after arthrol-
ysis is controversial. In 1984, Salter et al. [28] empha-
sized the role of CPM, which seems to be painless,
stimulated the healing and regeneration of articular car-
tilage, prevent joint stiffness and permit the normal
healing of arthrotomy incision. In 1990, Husband and
Hastings II [11] reported good results after arthrolysis
carried out under continual brachial plexus block with
CPM post-operatively. In opposite side, Higgs et al. [10]
reported that in patients with a stiff elbow after injury,
good results may be obtained after elbow arthrolysis
without using passive stretching during rehabilitation,
such outpatient physiotherapy, manipulation under
anaesthesia, turnbuckle or dynamic splints. Similarly,
Swaroop et al. [30] introduced a retrospective and pro-
spective study on elbow stiffness without post-operative
CPM, nineteen(76 %) out of 25 patients had excellent
results with a mean pre-operative ROM of 38.4° and
post-operative ROM of 106.80°. Therefore, whether post-
operative CPM works or not remains to be further
objective evaluated.
According to our experience, passive function exercise
is not enough. The day after operation, continuous passive
motion (CPM) is recommended, then convert to active and
passive movement. When the patients do active function
exercise, progressive resistance exercise to the muscles was
encouraged to enhance muscle endurance and strength. The
strengthen muscles around your joints could reduce pain
and swelling and increase the ability to recovery joint to
full ROM. More importantly, the post-operative functional
rehabilitation programme should be instituted as early as
possible to maintain the ROM obtained intra-operatively
[1, 3, 10, 15, 31]. But early mobilization of the elbow after
arthrolysis is usually recommended for pain relief. There-
fore, they are mutually contradictory. To solve the prob-
lem, good quality post-operative pain control is
recommended; otherwise post-operative exercise is too
painful to perform [10].
However, there are several limitations of the study.
First, there are only a few series on the arthroscopic
treatment of the stiff elbow; second, there is no comparison
group of the type of treatment and rehabilitation; third,
follow-up period of the study is too short to measure the
clinical outcomes objectively. Therefore, a large-scale,
hospital-based case–control study with long-term follow-
up is required in future. Additionally, the pathological
changes in intra-/extra-capsular fractures play an important
role in inducing joint dysfunctions, which will influence the
operative method and the clinical outcomes. Thus, it is
necessary to classify the pathogenic factors of elbow
stiffness significantly and to investigate the relationship
between pathogenic factors of elbow stiffness and the
clinical outcomes under the same method.
Conclusion
In conclusion, this study demonstrates that satisfactory
outcomes in terms of ROM, function and pain relief can be
achieved at 1 year following arthroscopic arthrolysis of the
elbow with the use of active and passive exercise in the
post-operative period. Taking into consideration the satis-
factory clinical outcomes and low rate of complications,
we conclude that arthroscopic arthrolysis is a good option
for the treatment of post-traumatic elbow stiffness as it
restores normal elbow function.
Acknowledgments Grant sponsor: National Natural Science
Foundation of China. Grant Number: 81201393.
Conflict of interest None.
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