Mid-term effectiveness of arthrolysis and hinged external fixation for treatment of stiff elbow caused by heterotrophic ossification_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHENG Xiaolong , YANG Mingyu ^# , MU Miduo , KANG Xia , YANG Aining ,  ZHOU Binghua ,  TANG Kanglai

Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University of Chinese PLA, Chongqing, 445000, P.R.China;

Corresponding?author：

ZHOU Binghua, Email: yijian510868@hotmail.com; TANG Kanglai, Email: tangkanglai@hotmail.com

Keywords：

Elbow; heterotrophic ossification; hinged external fixator; dysfunction; mid-term effectiveness

DOI：

10.7507/1002-1892.201902002

Video：

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Objective To evaluate the mid-term effectiveness of arthrolysis and hinged external fixation for the treatment of stiff elbow caused by heterotrophic ossification.Methods Between January 2014 and December 2017, 11 patients with stiff elbow caused by heterotrophic ossification were admitted. There were 9 males and 2 females with an average age of 32 years (range, 14-48 years), and left side in 6 cases and right side in 5 cases. The cause of stiff elbow included humerus fracture in 5 cases, ulna fracture in 2 cases, fracture of capitulum radii in 1 case, dislocation of capitulum radii in 1 case, terrible triad of the elbow in 1 case, and soft tissue injury in 1 case. The disease duration ranged from 7 to 18 months (mean, 11 months). Preoperative active range of motion of elbow was (19.6±17.5)° and Mayo score was 34.1±9.7. All patients received the treatment of arthrolysis and debridement of heterotrophic ossification lesion combining hinged external fixator, and active and passive rehabilitation with the help of hinged external fixator. The hinged external fixators were removed after 2 months.Results All patients were followed up 13-36 months (mean, 19.1 months). All incisions healed by first intention, and no complication of infection or nerve lesion occurred postoperatively. At last follow-up, the results of X-ray films showed that no heterotrophic ossification recurred. The active range of motion of elbow was (116.4±16.6)° and Mayo score was 93.2±7.8, showing significant differences when compared with preoperative ones (t=17.508, P=0.000; t=16.618, P=0.000).Conclusion The application of arthrolysis and debridement of heterotrophic ossification lesion combining hinged external fixator can improve the elbow’s range of motion significantly and obtain a good mid-term effectiveness.

Citation： ZHENG Xiaolong, YANG Mingyu, MU Miduo, KANG Xia, YANG Aining, ZHOU Binghua, TANG Kanglai. Mid-term effectiveness of arthrolysis and hinged external fixation for treatment of stiff elbow caused by heterotrophic ossification. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(10): 1299-1304. doi: 10.7507/1002-1892.201902002 Copy

1.	何樹坤, 黃富國. 創傷后肘關節異位骨化研究進展. 中國修復重建外科雜志, 2015, 29(6): 777-782.
2.	劉家志, 陳帥, 范存義. 開放松解術聯合橈骨遠端固定鉸鏈式外固定支架治療肘關節僵硬. 中國修復重建外科雜志, 2018, 32(2): 134-138.
3.	McKee MD, Bowden SH, King GJ, et al. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg (Br), 1998, 80(6): 1031-1036.
4.	Madey SM, Bottlang M, Steyers CM, et al. Hinged external fixation of the elbow: optimal axis alignment to minimize motion resistance. J Orthop Trauma, 2000, 14(1): 41-47.
5.	Bigazzi P, Biondi M, Corvi A, et al. A new autocentering hinged external fixator of the elbow: a device that stabilizes the elbow axis without use of the articular pin. J Shoulder Elbow Surg, 2015, 24(8): 1197-1205.
6.	Stavlas P, Gliatis J, Polyzois V, et al. Unilateral hinged external fixator of the elbow in complex elbow injuries. Injury, 2004, 35(11): 1158-1166.
7.	Chen NC, Julka A. Hinged external fixation of the elbow. Hand Clin, 2010, 26(3): 423-433.
8.	Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg (Am), 1981, 63(6): 872-877.
9.	Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg (Am), 1990, 72(4): 601-618.
10.	Temporin K, Shimada K, Oura K, et al. Arthroscopic release for the severely stiff elbow. Musculoskeletal Surgery, 2019. [Epub ahead of print].
11.	Sevimli R, Aslantürk O, Ergen E, et al. Mid-term outcomes of arthroscopic treatment in patients with a stiff elbow. Cureus, 2018, 10(5): e2630.
12.	He SK, Zhao SC, Guo JH, et al. Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24-month follow-up. ANZ J Surg, 2019, 89(3): 196-200.
13.	Sakai K, Shirahama M, Shiba N, et al. Primary hinged external fixation of terrible triad injuries and olecranon fracture-dislocations of the elbow. Kurume Medical J, 2017, 63(1.2): 7-14.
14.	Castelli A, D’amico S, Combi A, et al. Hinged external fixation for Regan-Morrey type I and II fractures and fracture-dislocations. J Orthop Traumatol, 2016, 17(2): 175-179.
15.	Wang W, Jiang SC, Liu S, et al. Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator. J Shoulder Elbow Surg, 2014, 23(10): 1537-1544.
16.	Stavlas P, Jensen SL, S?jbjerg JO. Kinematics of the ligamentous unstable elbow joint after application of a hinged external fixation device: a cadaveric study. J Shoulder Elbow Surg, 2007, 16(4): 491-496.
17.	McKee MD, Pugh DM, Wild LM, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg (Am), 2005, 87 Suppl 1(Pt 1): 22-32.
18.	Kulkarni GS, Kulkarni VS, Shyam AK, et al. Management of severe extra-articular contracture of the elbow by open arthrolysis and a monolateral hinged external fixator. J Bone Joint Surg (Br), 2010, 92(1): 92-97.
19.	Ring D, Bruinsma WE, Jupiter JB. Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clin Orthop Relat Res, 2014, 472(7): 2044-2048.
20.	Feranec M, Hart R, Kozák T, et al. Hinged elbow external fixation for severe elbow stiffness. Acta Chir Orthop Traumatol Cech, 2019, 86(2): 136-140.
21.	Liu S, Fan CY, Ruan HJ, et al. Combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow. J Trauma, 2011, 70(2): 373-376.
22.	Tan V, Daluiski A, Capo J, et al. Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg, 2005, 13(8): 503-514.
23.	Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg (Am), 2002, 84(9): 1630-1635.
24.	Koh KH, Lim TK, Lee HI, et al. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification. J Shoulder Elbow Surg, 2013, 22(8): 1128-1134.
25.	Cheung EV, O’Driscoll SW, Morrey BF. Complications of hinged external fixators of the elbow. J Shoulder Elbow Surg, 2008, 17(3): 447-453.
26.	蔡江瑜, 王偉, 范存義. 肘關節開放松解術后并發癥的研究進展. 中國修復重建外科雜志, 2015, 29(1): 113-117.
27.	Sun C, Zhou X, Yao C, et al. The timing of open surgical release of post-traumatic elbow stiffness: A systematic review. Medicine, 2017, 96(49): e9121.
28.	Chen S, Yu SY, Yan H, et al. The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. J Shoulder Elbow Surg, 2015, 24(8): 1165-1171.

1. 何樹坤, 黃富國. 創傷后肘關節異位骨化研究進展. 中國修復重建外科雜志, 2015, 29(6): 777-782.
2. 劉家志, 陳帥, 范存義. 開放松解術聯合橈骨遠端固定鉸鏈式外固定支架治療肘關節僵硬. 中國修復重建外科雜志, 2018, 32(2): 134-138.
3. McKee MD, Bowden SH, King GJ, et al. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg (Br), 1998, 80(6): 1031-1036.
4. Madey SM, Bottlang M, Steyers CM, et al. Hinged external fixation of the elbow: optimal axis alignment to minimize motion resistance. J Orthop Trauma, 2000, 14(1): 41-47.
5. Bigazzi P, Biondi M, Corvi A, et al. A new autocentering hinged external fixator of the elbow: a device that stabilizes the elbow axis without use of the articular pin. J Shoulder Elbow Surg, 2015, 24(8): 1197-1205.
6. Stavlas P, Gliatis J, Polyzois V, et al. Unilateral hinged external fixator of the elbow in complex elbow injuries. Injury, 2004, 35(11): 1158-1166.
7. Chen NC, Julka A. Hinged external fixation of the elbow. Hand Clin, 2010, 26(3): 423-433.
8. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg (Am), 1981, 63(6): 872-877.
9. Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg (Am), 1990, 72(4): 601-618.
10. Temporin K, Shimada K, Oura K, et al. Arthroscopic release for the severely stiff elbow. Musculoskeletal Surgery, 2019. [Epub ahead of print].
11. Sevimli R, Aslantürk O, Ergen E, et al. Mid-term outcomes of arthroscopic treatment in patients with a stiff elbow. Cureus, 2018, 10(5): e2630.
12. He SK, Zhao SC, Guo JH, et al. Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24-month follow-up. ANZ J Surg, 2019, 89(3): 196-200.
13. Sakai K, Shirahama M, Shiba N, et al. Primary hinged external fixation of terrible triad injuries and olecranon fracture-dislocations of the elbow. Kurume Medical J, 2017, 63(1.2): 7-14.
14. Castelli A, D’amico S, Combi A, et al. Hinged external fixation for Regan-Morrey type I and II fractures and fracture-dislocations. J Orthop Traumatol, 2016, 17(2): 175-179.
15. Wang W, Jiang SC, Liu S, et al. Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator. J Shoulder Elbow Surg, 2014, 23(10): 1537-1544.
16. Stavlas P, Jensen SL, S?jbjerg JO. Kinematics of the ligamentous unstable elbow joint after application of a hinged external fixation device: a cadaveric study. J Shoulder Elbow Surg, 2007, 16(4): 491-496.
17. McKee MD, Pugh DM, Wild LM, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg (Am), 2005, 87 Suppl 1(Pt 1): 22-32.
18. Kulkarni GS, Kulkarni VS, Shyam AK, et al. Management of severe extra-articular contracture of the elbow by open arthrolysis and a monolateral hinged external fixator. J Bone Joint Surg (Br), 2010, 92(1): 92-97.
19. Ring D, Bruinsma WE, Jupiter JB. Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clin Orthop Relat Res, 2014, 472(7): 2044-2048.
20. Feranec M, Hart R, Kozák T, et al. Hinged elbow external fixation for severe elbow stiffness. Acta Chir Orthop Traumatol Cech, 2019, 86(2): 136-140.
21. Liu S, Fan CY, Ruan HJ, et al. Combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow. J Trauma, 2011, 70(2): 373-376.
22. Tan V, Daluiski A, Capo J, et al. Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg, 2005, 13(8): 503-514.
23. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg (Am), 2002, 84(9): 1630-1635.
24. Koh KH, Lim TK, Lee HI, et al. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification. J Shoulder Elbow Surg, 2013, 22(8): 1128-1134.
25. Cheung EV, O’Driscoll SW, Morrey BF. Complications of hinged external fixators of the elbow. J Shoulder Elbow Surg, 2008, 17(3): 447-453.
26. 蔡江瑜, 王偉, 范存義. 肘關節開放松解術后并發癥的研究進展. 中國修復重建外科雜志, 2015, 29(1): 113-117.
27. Sun C, Zhou X, Yao C, et al. The timing of open surgical release of post-traumatic elbow stiffness: A systematic review. Medicine, 2017, 96(49): e9121.
28. Chen S, Yu SY, Yan H, et al. The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. J Shoulder Elbow Surg, 2015, 24(8): 1165-1171.

Chinese Journal of Reparative and Reconstructive Surgery

Mid-term effectiveness of arthrolysis and hinged external fixation for treatment of stiff elbow caused by heterotrophic ossification

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