The elbow is prone to stiffness after trauma, with up to twelve percent of all posttraumatic elbows ending up with a flexion contracture requiring surgical intervention. The etiopathogenesis remains largely unknown. According to Morrey and colleagues most of the activities of daily living can be accomplished with 100 degrees of elbow flexion (30 to 130) and 100 degrees of forearm rotation (50 to 50). More recently Sardelli and colleagues concluded that functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks.
To regain functional elbow motion several conservative and surgical treatment options are available. Surgical contracture release can be performed open or arthroscopically depending on the type of deformity of the posttraumatic elbow and surgeons’ preference. The results of both techniques are largely comparable. Recurrence of elbow stiffness remains a point of concern and is unrelated to the techniques used to date. Another disadvantage of operative treatment is the risk of complications. According to a systematic review by our group and colleagues arthroscopic and open arthrolysis have similar results in terms of functional outcome; however, the amount of complications seems to rise with the extent of the surgical procedure.
Post-operative rehabilitation protocols after operative release for a patient with a posttraumatic stiff elbow includes: physical therapy (PT), continuous passive motion (CPM), intra articular injections with corticosteroids, or a static progressive or dynamic splinting program as prospectively studied by our group. In a retrospective study, we previously found that CPM may be redundant. The best Evidence-based rehabilitation protocol for patients after an operative release is unknown, and differs per surgeon, hospital and country. The most recent review on this topic does not show a clear clinical benefit of any of the respective post-op rehabilitation protocols. This justifies the current study that may alter post-operative treatment in a tremendous way: from 3 in-hospital days of costly CPM and PT to an outpatient one-day procedure with delayed PT.
Objective of current study is to compare continuous passive motion with physical therapy (CPM) versus early motion supervised physical therapy (PT) versus outpatient delayed physical therapy (DPT) as rehabilitation protocol after surgery for posttraumatic elbow contractures in a prospective randomized controlled trial, comparing elbow range of motion at 8 weeks, 5 months and 1 year after treatment.
Secondary objectives are QALYs and overall patient- (PROMs) and physician-based functional recovery measured with the Mayo Elbow Performance Index (MEPI), Quick-DASH, Oxford Elbow Score (OES) and VAS. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment.
Tertiary outcome concerns patient perceived disability (PROMs) and pain according to standardized measurements to evaluate the influence of depression and pain on clinical outcome CES-D (Center for Epidemiologic Studies Depression Scale) as well as the Pain Catastrophizing Scale (PCS) and SF-36. These measurements are collected at baseline and 1 year after treatment.