Geyer Stephanie, Seilern Und Aspang Jesse, Geyer Michael, Schoch Christian
Department for Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
Department for Orthopedics, St. Vinzenz Klinik, Kirchenweg 15, 87459, Pfronten, Germany.
Eur J Orthop Surg Traumatol. 2021 Aug;31(6):1135-1141. doi: 10.1007/s00590-020-02846-5. Epub 2021 Jan 8.
Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet.
The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow.
From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed.
Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%).
Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations.
IV.
隐匿性不稳定可能是创伤后肘关节松解术后反复出现僵硬的原因之一。创伤后僵硬肘关节合并的不稳定在临床上很难检测到。在同一手术环境中针对不稳定和僵硬进行手术治疗具有挑战性，且目前尚未得到评估。
主要假设为（1）存在创伤后“僵硬且不稳定的肘关节”，以及（2）通过关节镜不稳定测试可检测到并存的不稳定。次要目标是报告创伤后僵硬且不稳定肘关节松解及韧带稳定修复术后的中期结果。
2005年至2015年，我院55例因创伤后肘关节僵硬接受肘关节镜松解术的患者。关节镜下不稳定程度用转换棒分为三级：I级（=稳定）、II级（轻度不稳定）和III级（严重不稳定）。对于持续存在不稳定（II - III级）的病例，进行韧带稳定修复手术，所有患者至少随访12个月。除了活动度和临床关节稳定性外，采用患者肘关节评估评分（PREE）和牛津肘关节评分（OES）评估患者报告结局（PROs）。此外，还评估了梅奥肘关节功能评分（MEPS）。
55例接受肘关节松解术的患者中，22例（40%）在关节镜不稳定测试中检测到并存的肘关节不稳定。所有22例患者均接受了额外的韧带稳定修复手术。术后平均随访62.7±35.7个月时，有20例患者（12例男性，8例女性）可供评估，平均年龄42±16.8岁。PREE、OES和MEPS评分分别为19.8±25.3、37.5±9.8和80±14.5。术后活动度从95°±29°显著提高到110°±24°（p = 0.045）。5例患者在随访期间需要再次进行肘关节松解术（20%）。1例患者仍存在不稳定（5%）。
关节镜下肘关节松解术中的不稳定诊断有助于发现持续存在的创伤后不稳定，并可为同时进行的韧带稳定修复手术提供有力指征。本研究首次报告了创伤后僵硬且不稳定肘关节松解并稳定修复术后的结果。然而，结果存在异质性，25%的患者需要再次进行肘关节松解术。因此，僵硬但不稳定的肘关节仍然是一种复杂的临床表现，需要进一步研究。
IV级
