Page 23 - ISAKOS 2018 Newsletter Volume 2
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 More recently, in collaboration with Shawn O’Driscoll from the Mayo Clinic, members of our department (Roberto Rotini, Alessandro Marinelli, Enrico Guerra) developed the S.T.I.F. (Stiffness Types and Influencing Factors) classification system (Table II)5. This system, which was presented for the first time at the Rizzoli Elbow Course 2017 in Bologna, highlights the 5 common disorders causing stiffness as well as the 6 influencing factors that often effect the treatment and clinical outcome. The S.T.I.F. classification system also highlights the importance of the ulnar nerve, which can be entrapped in the cubital tunnel by scar tissue or heterotopic ossification and is at risk during the surgical treatment of elbow stiffness.
Treatment Algorithm
TABLE III. The S.T.I.F. Treatment Algorithm for Elbow Stiffness*
*The type of stiffness, its severity, and the age of the patient are all factors that direct the preferred type of surgery. H.O. = heterotopic ossification, TEA = total elbow arthroplasty, and ORIF = open reduction and internal fixation. (Copyright Dr. A. Marinelli)
We propose a treatment algorithm, based the S.T.I.F. classification system, that includes the severity of the disorder as a guide to surgical treatment and the preferred operative approach (open or arthroscopic) (Table III).
Over the last 20 years, we have witnessed dramatic changes in the approach to elbow stiffness. Understanding the involved plane of movement as well as the severity and etiology of the stiffness is important. There have been advances in the methods of assessment of osseous disorders (including 2D and 3D CT scanning) and in the evolution of surgical techniques (open and arthroscopic). The elbow machine diagram is useful for identifying how the joint is mobilized and for understanding the causes of joint stiffness.
The new classification system highlights the etiology of the stiffness and provides a framework to better understand the natural history, direct the surgical management, and interpret the likely clinical outcome.
Other important factors that affect the decision-making process, dictate the preferred treatment, and likely affect the outcome include the ulnar nerve, existing implants, and prior surgery (Table IV).
TABLE IV. Elements to Consider When Assessing Elbow Stiffness*
   Age, comorbidities, needs, expectations, compliance
 Flexion/forearm rotation
   Duration of stiffness/improvements
   Neurological symptoms
 Prior surgery/internal fixation
   Skin condition
 Prior surgery
   Hand/shoulder/neck function
  *Copyright Dr. A. Marinelli.
1. Bain GI, Clitherow HDS. The Pathogenesis and Classification of Shoulder Stiffness. In E. Itoi et al. (eds.), Shoulder Stiffness: Current Concepts and Concerns, ISAKOS 2015. 2. Jupiter JB, O’Driscoll SW and Cohen MS. The assessment and management of the stiff elbow. Instr Course Lect 2003;52:93-111. 3. Watts AC, Bain GI. New Techniques in Elbow Arthroscopy. In: AANA Advanced Arthroscopy: The elbow and wrist. Editors Savoie FH & Field LD, Philadelphia: Saunders-Elsevier; 2010:124-131. 4. Kay NR. Arthrolysis of the post-traumatic stiff elbow. In Stanley D, Kay NR, editors. Surgery of the elbow. London: Arnold; 1998. P 228-34 5. Marinelli A, Rotini R, Guerra E, O’Driscoll S. The S.T.I.F classification: a new classification for elbow stiffness, considering Stiffness Types and Influencing Factors. Presented at the Rizzoli Elbow Course, Bologna (Italy) 2017.

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