Development Of A New Classification And Functional Score For Elbow Stiffness And Exploration Of Long-term Clinical Outcomes Of Open Arthrolysis

Background: There are some deficiencies and shortcomings in the current classification and functional scores for elbow stiffness,and there have been no articles on the long-term clinical outcomes of open elbow arthrolysis(OEA)combined with hinged external fixator(ex-Fix).Therefore,the purposes of this study are to develop a new classification and functional score for elbow stiffness,and explore the long-term clinical outcomes of OEA combined with ex-Fix in our center,and the risk factors that may limit range of motion(ROM)recovery.Methods: The new classification is consisted of two parts,in which 4types in flexion-extension(tethers alone,tethers with blocks,articular malformation,and bony ankylosis),and 3 types in forearm rotation(contracture alone,radial head mal-or non-union,and proximal radioulnar bony ankylosis).The new functional score is consisted of three parts: elbow motion(8-item “daily activity form”,48%),symptoms(pain,nerve function,muscle strength,and stability,40%),and patient satisfaction(12%).In the treatment of OEA,a combined medial-lateral approach was performed to address the tethers and any blocks to elbow motion,and an ex-Fix was applied to maintain elbow stability and help early rehabilitation.Results: After arthrolysis according to the new classification,the mean ROM of all patients increased from 40° preoperatively to 118° at follow-up,and 88.4% regained ROM of 100° or greater;the forearm rotation arc(FRA)of patients with rotation dysfunction increased from a preoperative mean of76° to 128°,and 81.6% regained an FRA of 100° or greater;the mean Mayo Elbow Performance Index of all patients increased from 63 to 91 points,and94.9% reached good or excellent results.The new functional score has a positive reliability and adequate homogeneity;a good to excellent validity,with at least moderate correlations with classical functional scores in total scores,elbow motion and symptom parts,respectively;high responsiveness;no ceiling or floor effects;and significant correlations with patient satisfaction.At the long-term follow-up,the mean ROM of all patients increased from 27° preoperatively to 131°,and 98.0% regained functional motion range(30°?130°);improvements were also seen in elbow functional scores,life qualities,pain,and ulnar nerve symptoms;the total incidence of complications was 16.3%,including 4 new-onset ulnar nerve symptoms,one clinically recurrent heterotopic ossification,and 3 pin tract-related infections;After dividing the long-term ROM into two groups according with modern life demands(?120° and >120°)and controlling for potential confounding variables,tobacco use was found as the only independent risk factor examined(odds ratio,9;p=0.009)associated with recovery of ROM.Conclusions: The new classification specifies the operative approaches and steps of arthrolysis,and standardized the treatment.The new functional score is a comprehensive,scientific,and valid system to evaluate joint function in patients with elbow stiffness,and provides scientific basis for clinical applications.OEA combined with ex-Fix has a satisfied long-term result on severe post-traumatic elbow stiffness,and the importance of preoperative discontinuation of tobacco use should be emphasized in the mean while.