Page 22 - ISAKOS 2018 Newsletter Volume 2

CURRENT CONCEPTS
The Stiff Elbow: Classification and Treatment Algorithm
With the incorporation of the capsule as a separate category and the addition of neurological factors, a new all-inclusive classification can be proposed. The advantage of this classification is that is all-inclusive, including all causes of elbow stiffness, not only post-traumatic ones. Moreover, with the correct identification of the pathological process present in each area, this classification allows the surgeon to address each component, and tailor the appropriate treatment.
Intra-articular pathologies can be managed with joint arthroscopy (eg chondral flaps, loose bodies, impinging osteophytes or synovitis). In advanced cases, simple debridement is unlikely to be successful; in which case a joint arthroplasty is required.
TABLE I. All-Inclusive Pathoanatomical Classification of Elbow Stiffness
Based on the ISAKOS shoulder stiffness classification1, this all-inclusive pathoanatomical classification of elbow stiffness makes it possible to identify the 4 causes of elbow stiffness: intra-articular, capsular, extra-articular, and neurological (Table I). As Morrey noted, some cases have a mixed etiology.
The advantage of this classification system is that is all- inclusive and includes all causes of elbow stiffness, not just post-traumatic causes. Moreover, with the correct identification of the pathological process in each area, this classification system allows the surgeon to address each component and tailor the treatment appropriately.
• Intra-articular pathologies (e.g., chondral flaps, loose bodies, impinging osteophytes, or synovitis) can be treated with joint arthroscopy. In advanced cases, simple debridement is unlikely to be successful and a joint arthroplasty is required.
• Extra-articular pathologies (e.g., heterotopic ossification, ulnar nerve neuropathy, and muscle/tendon contractures) are usually treated with an open procedure with resection or release of the offending structures. Endoscopic treatment for these conditions is possible but is still evolving.
• Capsular contractures can be treated with open or arthroscopic release or resection, usually with a good outcome.
• Cases with mixed causes require each area be specifically addressed.
S.T.I.F. Classification
TABLE II. S.T.I.F. Classification System*
*The S.T.I.F. system details the 5 common causes of stiffness and the 6 influencing factors. (Copyright Dr. A. Marinelli.)
In 1998, Kay4 proposed a practical classification for post- traumatic stiffness of the elbow that was based on the presence, severity, and combination of the 3 most common factors causing stiffness (capsular contracture, articular fractures, and heterotopic ossification), identifying 5 clinical situations.
INTRA- ARTICULAR (Bearings)
CAPSULAR (Constraints)
EXTRA- ARTICULAR (Motor, Cable, Levers)
NEURO- LOGICAL (Control, Electrics, Sensors)
Articular surface involvement (osteochon- dral defect, degeneration)
Ligament involvement (contracture, calcifications)
Muscle involvement (myopathy, fatty infiltration)
Central nervous system involvement (behavioral dystonia, spasticity)
Subchondral dysplasia, fractures, avascular necrosis, degeneration
Capsular involvement (contracture, calcifications)
Tendon
and bursa involvement (tears, calcifications, degeneration, bursitis)
Peripheral nervous system involvement (ulnar, radial, medial nerve symptoms; cutaneous nerve neuritis or neuropathy)
Synovial inflammation, crystal arthroplasty
Congruity- related findings (subluxation, dislocation)
Other findings external
to elbow (fracture, malignancy, heterotopic ossification, skin contracture)
Sensory and autonomic findings (Charcot joint, chronic regional pain syndrome)
20 ISAKOS NEWSLETTER 2018: VOLUME II