Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Introduction
Elbow stiffness secondary to trauma is multifactorial and may develop despite interventions to prevent its occurrence. While there is some evidence associating manipulation for elbow contraction with several risk factors and benefits, there is minimal evidence available on the benefit of manipulation under anesthesia for posttraumatic elbow stiffness.
Methods
The study includes 45 patients (average age of 45) who underwent a manipulation under anesthesia (MUA) procedure for stiff posttraumatic elbow due to moderate to severe elbow motion restrictions or lack of functional range of motion that showed no improvement. The procedure was performed under general anesthesia and consisted of the surgeon gently increasing the patient’s range of motion into flexion and extension. The study uses paired t-tests to compare ranges pre- and post-manipulation and considers a P value of 0.05 as significant.
Results
Range of motion at the elbow was recorded using a goniometer at follow-up visits. Most of the study participants followed through with formal physical therapy while some used a static or dynamic splint. The average length of follow up after the procedure was 565 days. Before manipulation, the average flexion arc was reported at 57.9 degrees. Intraoperatively, patients received an average of 17.8 degrees more in extension and 125.4 degrees flexion. On average at final follow up, patients showed a 25.8-degree improvement in the total flexion arc of motion; the study reported that finding as statistically significant. Following MUA and follow-up interventions, 3/17 patients in the late MUA (manipulation after 91 days) group achieved a functional arc of motion, while 6/10 patients in the early MUA (manipulation within 91 days) group achieved functional arc of motion; this difference was found to be statistically significant. Additionally, 14% of early manipulation and 18% of late manipulation achieved less than a 10-degree gain in motion. While 11% of early manipulation and 35% of late manipulation lost elbow motion.
Discussion
While both groups showed statistically significant intraoperative improvements in range of motion, only the early manipulation group retained significant improvement at follow-up. Researchers have concluded that MUA within 3 months of initial injury is most beneficial for improving range of motion. They reported that this conclusion agrees with other literature pertaining to different joints. They also suggest that physical therapy along with dynamic and static splinting may have resulted in more static and permanent improvements in total arc of motion, however many patients are limited by compliance and financial implications. Researchers included the following limitations: use of retrospective data, patient loss to follow up, lack of postmanipulation rehab protocols. Based on their study, they saw a low complication rate among their patients but still suggest caution when opting for MUA as surgeons.
Conclusion
In their opinion, MUA of the elbow is safe and effective for improving range of motion at the elbow if initiated within 3 months following initial injury resulting in posttraumatic stiffness.
Reference
Spitler, C.A., Doty, D.H., Johnson, M.D., Nowotarski, P.J., Kiner, D.W., Swafford, R.E., & Jemison, D.M. (2018). Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness. Journal of Orthopedic Trauma, 32(8), e304-e308. DOI: 10.1097/BOT.0000000000001222