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Functional Outcomes of Arthroscopic Capsular Releaseof the Elbow

Duong Nguyen, M.D., F.R.C.S.C., Stewart I. W. Proper, M.D., F.R.A.C.S.,Joy C. MacDermid, Ph.D., B.Sc.P.T., Graham J. W. King, M.D., M.Sc., F.R.C.S.C.,

and Kenneth J. Faber, M.D., M.H.P.E., F.R.C.S.C.

Purpose: Elbow contracture is a common and difficult problem to manage. The purpose of this studywas to determine the functional outcomes of arthroscopic capsular release in the management ofelbow contractures. Methods: A total of 22 patients (14 males, 8 females; mean age, 42 years)undergoing arthroscopic contracture release were retrospectively reviewed at a minimum follow-upof 1 year (mean, 25 months). In all, 20 patients had a capsulectomy, and 2 underwent capsulotomy.Patient-rated questionnaires (Disability of the Arm, Shoulder, and Hand questionnaire [DASH],American Shoulder and Elbow Surgeons Elbow Form [ASES-e], and Short Form-36 [SF-36]) andclinical, radiographic, and objective evaluations were used to assess outcomes. Motion and strengthwere measured by independent evaluators through standard goniometry and the LIDO IsokineticSystem (Loredan Biomedical, West Sacramento, CA). Results: Mean flexion significantly improvedfrom 122° � 15° to 141° � 12° (P � .001). Mean extension significantly improved from 38° � 18° to19° � 13° (P � .001). Mean arc improvement was 38° � 23° (P � .001). None of the patients hadinstability, and no major neurovascular complications were reported. All patients had improved elbowfunction with a mean ASES-e score of 31 out of 36. Most patients were satisfied with their surgery,experienced minimal pain, and exhibited minimal impairment on the DASH. Conclusions: Arthroscopicdebridement and capsulectomy of the contracted elbow is effective. Results are comparable with those ofother reports in the literature in which both arthroscopic and open methods were used. Level of Evidence:Level IV. Key Words: Arthroscopy—Contracture—Capsulectomy.

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lbow contracture is a common and difficult prob-lem to manage.1 The goal of treatment is to

estore a functional range of flexion, which has beenefined as 30° to 130°.2 Traditional open releases haveood clinical outcomes.3-5 However, they leave large

From the Department of Surgery, Hand and Limb Centre, Uni-ersity of Western Ontario (D.N., G.J.W.K., K.J.F.), London, On-ario, Canada; Cabrini Medical Centre (S.I.W.P.), Malvern, Vic-oria, Australia; Department of Clinical Epidemiology, Clinicalesearch Laboratory, Hand and Upper Limb Centre, University ofestern Ontario (J.C.M.), London, Ontario, Canada.The authors report no conflict of interest.Address correspondence and reprint requests to Graham J. W.

ing, M.D., M.Sc., F.R.C.S.C., Hand and Limb Centre, Monsignoroney Building, 268 Grosvenor St, London, Ontario, N6A 4L6,anada. E-mail: gking@uwo.ca© 2006 by the Arthroscopy Association of North America

a0749-8063/06/2208-0539$32.00/0doi:10.1016/j.arthro.2006.04.100

42 Arthroscopy: The Journal of Arthroscopic and Related S

cars and cause increased soft tissue trauma, whichay lead to recurrence of the contracture and can

elay the progress of physiotherapy programs.6

Arthroscopy offers improved joint visualization, re-uced pain, smaller scars, accelerated rehabilitation,nd shorter hospital stay, potentially making arthro-copic release an outpatient procedure. Disadvantagesnclude the inability to deal with ulnar nerve disease oreterotopic ossification. Arthroscopic release is chal-enging because of the close proximity of neurovasculartructures to portals and the restricted working spacefforded by the congruity of the joint and a noncompliantapsule.7-10 Reported complications include major nervenjury, inadequate release, recurrent stiffness, heterotopicssification, and synovial fistula.11-13

Good results have been reported to date with arthro-copic debridement and fenestration14-16 and with

rthroscopic capsulotomy,17-21 which involves incis-

urgery, Vol 22, No 8 (August), 2006: pp 842-849

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ng the capsule and releasing it anteriorly off theumerus.The purpose of this study was to use validated

utcome measures to determine the functional out-omes of arthroscopic capsular release in the manage-ent of elbow contracture.22-24 We hypothesized that

he outcomes of arthroscopic release would be com-arable with those of traditional open techniques.

METHODS

Between September 1999 and September 2002, theperative lists of participating surgeons at St. Joseph’sealth Care (London, Ontario, Canada) were re-iewed retrospectively to identify patients undergoingrthroscopic release for elbow contractures. Inclusionriteria were failure of nonsurgical treatment for ateast 6 months and interference with activities of dailyiving, avocation, sports, or hobbies. Exclusion criteriancluded insufficient nonsurgical treatment, active in-ection, inadequate motion or skin coverage, likeli-ood of postoperative noncompliance, poor articular

TABLE 1.

Pt SexAge, y

M � 42 Dom. Et.PreopFlex.

PreopExt.

PA

1 M 35 Y OA/PS 115 352 F 51 N RHF 120 403 F 45 Y RHF 135 404 F 27 Y D 135 30 15 F 43 N NST 75 306 M 60 Y NST 120 357 F 37 Y FD 120 508 F 40 Y RHF 135 459 M 45 Y NST 120 15 10 M 12 Y OCD 105 1001 M 51 Y OA 120 402 M 29 N OA 135 20 13 M 45 Y OA/PS 100 304 M 67 Y OA/PS 135 20 15 F 13 Y OCD 140 556 M 55 Y OCD 130 30 1

7 M 42 N OA 110 408 M 65 N OA 135 459 M 43 Y OA 120 350 M 34 N OA 140 35 11 F 36 N RA 125 552 M 49 Y OA 125 20 1

Abbreviations: Pt, patient; M, mean age; Dom., dominant side;xtension; Postop Flex., postoperative flexion; Postop Ext., postopations; OA, osteoarthritis; RHF, radial head fracture; D, disloconspecific trauma; PS, previous surgery; RA, rheumatoid arthritis;

ortal tenderness; imping. Ext., impingement pain in extension; rc�uhurgery.

urfaces, and heterotopic ossification. All patientsere treated in a single academic teaching center, and

urgical procedures were performed by or under theirect supervision of 1 of the 2 senior authors (K.J.F.,.J.W.K.).In all, 25 consecutive patients met the inclusion

riteria. Three were lost to follow-up, and 22 patientseturned for comprehensive assessment by clinicalesearch personnel who were not involved with theirare. Patients were reviewed at a minimum follow-upf 1 year (mean, 25 months; range, 12 to 47 months)nd included 14 men and 8 women with a mean age of2 years (range, 13 to 67 years). Most patients hadombined extrinsic and intrinsic causes for contrac-ures (Table 1). Twenty patients had a capsulectomy,nd 2 patients early in the series underwent an isolatedapsulotomy.

Clinical, radiographic, and objective evaluationsere used to assess impairment-based outcomes. Mo-

ion was measured with standard goniometry accord-ng to an established protocol.22 Isometric strength ofhe elbow flexors, extensors, and forearm rotators was

ent Data

PostopFlex.

PostopExt.

PostopArc

PreopMEPI

PostopMEPI Cx

110 30 80 33 61 MACN150 10 140 67 90 rc tend.145 15 130 62 100 imping. Ext.140 5 135 38 57 rc�uh tend.140 10 130 52 96145 15 130 61 90 imping. Ext.145 30 115 55 88145 10 135 71 95150 0 150 72 100105 55 50 35 77140 10 130 68 94155 10 145 60 96150 10 140 67 97140 20 120 40 69135 35 100 55 83145 15 130 53 81 rc�uh tend.,

2nd Sx145 25 120 61 90135 35 100 50 81145 25 120 65 91140 10 130 60 100145 30 115 61 97140 10 130 60 99

ology; Preop Flex., preoperative flexion; Preop Ext., preoperativeextension; MEPI, Mayo Elbow Performance Index; Cx, compli-

FD, fracture-dislocation; OCD, osteochondritis dissecans; NST,, medial antebrachial cutaneous neuroma; rc tend., radiocapitellar

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easured by a research assistant, who used the LIDOsokinetic Workset (Loredan Biomedical, West Sac-amento, CA).25,26 Grip strength in position 2 of theigits Grip Device27 and key pinch28 were measuredith the NK Hand Assessment System (NK Biotech-ical Engineering, Minneapolis, MN); motion mea-urement was repeated with computerized goniom-try.

Radiographic evaluation consisted of anteroposte-ior and lateral views of the elbow. Patient self-reportuestionnaires measured upper extremity disabilityDisability of the Arm, Shoulder, and Hand question-aire [DASH]),23 the physical components of generalealth (Short Form-36 Physical Component Summarycore [SF-PCSS]29), and elbow pain and functionalbility (American Shoulder and Elbow Surgeonslbow Form [ASES-e]).24,30

urgical Technique

Principles of arthroscopic release include detailednowledge of anatomy, precise portal placement,areful fluid management, and nerve retraction. Stan-ard instruments included a 4.5-mm, 30° arthroscope;lunt probes; punches; osteotomes; shavers; and burrsnd resectors. Fluid was managed with use of an arthro-copic infusion pump on low pressure or through gravitynflow.

Patients were placed in the lateral decubitus posi-ion, and the arm was supported by a specially de-igned arm positioner that prevents pressure over thentecubital fossa (Western Elbow Positioner; Tenetedical, Calgary, AB). General anesthesia was given

o all patients. The limb was exsanguinated, and theourniquet was inflated to 250 mm Hg.

Bony landmarks and the course of the ulnar nervend portals were marked. An average of 6 portalsas used per case (Fig 1). The elbow was infiltratedith 20 mL of Ringer’s lactate through the soft spotortal so that adequate joint distention could bettained. Posterior and lateral arthroscopy was per-ormed first, followed by anterior arthroscopy andapsular release. A direct proximal posterior centralortal was placed through the triceps, and a supple-ental midposterolateral working portal was estab-

ished. Adequate debridement of the olecranonossa and medial and lateral gutters and resection oflecranon spurs were performed. Osteophytes wereemoved with a burr. The ulnar nerve was protecteduring debridement of the medial gutter. A directistal posterolateral portal was then established for

he arthroscope, and the abrader was used from the r

idposterolateral portal. The posterior aspect of theateral gutter and the region around the radial headnd proximal radioulnar joint were debrided as nec-ssary.The arthroscope was inserted anteriorly through a

roximal anterolateral portal. A proximal anterome-ial portal was then established through an outside-inechnique. The first step of arthroscopic release in-olved gaining a good view of the joint with debride-ent, synovectomy, and removal of adhesions with

esectors. Howarth elevators were used as retractorsnd were placed as needed through additional mi-anteromedial and midanterolateral portals. Osteo-hytes on the coronoid were removed when impinge-ent in flexion was observed. Loose bodies were

IGURE 1. (A) Lateral and (B) medial views of arthroscopicandmarks and portals.

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845FUNCTIONAL OUTCOMES OF ARTHROSCOPIC CAPSULAR RELEASE

Anterior capsulectomy was initiated laterally. Thenterior capsule was divided with a duckbill forcepsear its humeral attachment site, coming across to-ard the mid axis. The brachialis muscle and theosterior interosseous nerve were retracted with aowarth elevator that was held by an assistant before

nterior capsulectomy was performed (Fig 2). Withse of a full radius resector, a 1- to 1.5-cm segment ofhe anterior capsule was resected under direct vision.are was taken to protect the posterior interosseouserve by careful retraction when work was performednterior to the radial head. Distal excision of theapsule was avoided in this high-risk area.

The arthroscope was then switched from the medialo the lateral side, and capsulotomy was performedith the use of duckbill forceps. Capsulectomy was

arefully performed with a full radius resector and the

IGURE 2. Views from the (A) proximal anteromedial andB) proximal anterolateral portals showing the anterior compart-ent with the Howarth retractor elevating the brachialis prior to

txcision of the capsule.

se of gravity outflow alone rather than suction torevent inadvertent excision of noncapsular soft tis-ues.

After the instruments had been removed, intraoper-tive elbow range of motion was documented andortals were sutured. Postoperatively, a continuousassive motion machine (10 patients) and continuousxillary block (15 patients) were used for 48 hours.ifteen patients stayed in the hospital postoperativelyor initiation of range of motion exercises (mean, 2ays; range, 1 to 3 days). Patients were counseledegarding home exercises and extension splinting atight (all patients). Heterotopic ossification prophy-axis (indomethacin 25 mg 3 times daily) was used for

weeks (17 patients). A flexion daytime cuff wasnitiated 3 weeks postoperatively for elbow flexion (allatients).

tatistics

All data were entered into the Statistical Packageor the Social Sciences, version 11.0 (SPSS, Chicago,L), and descriptive summaries of the data were pre-ared. SF-36 was compared with normal control val-es29 with use of a Student t test. A 2-tailed paired test was used for range of motion comparisons.

tests were used to determine whether or not vari-nces were statistically different. The presence of kur-osis and skewing indicated a deviation from normallyistributed data; repeat statistical assessment with usef Wilcoxon’s (nonparametric) test produced similaresults and levels of significance (P � .001). Simpleinear regression analysis was used to determinehether age and duration of symptoms had any effectsn motion gains.

RESULTS

Surgical findings are listed in Table 2. All patientsad capsular fibrosis, and most had some elements ofynovitis.

ange of Motion

Mean flexion significantly improved from 122° �5° to 141° � 12° (P � .001). Mean extension sig-ificantly improved from 38° � 18° to 19° � 13°P � .001). Mean arc improvement was 38° � 23°P � .001) (Fig 3). Of the 22 patients, 15 had an arcf motion before surgery of less than 100°. A func-ional arc of motion of 100° or more between 30° and30° was attained in 20 of the 22 patients postopera-

ively. The gain in extension was similar (mean, 20° �

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0°; range, 0° to 45°) to the gain in flexion (mean,8° � 18°; range, �5° to 65°). All except 1 patientxperienced improvement in extension after surgerymean 20° � 11°; range, 0° to 40°). Two patients lost° flexion; in 1 patient, the arc did not change, and inhe other patient, the arc improved by 15°. Flexion didot improve in 3 patients, but they all exhibited im-rovement in the arc of motion (mean, 27° � 18°;ange, 10° to 45°). The mean prosupination arc was50° � 41° preoperatively and 148° � 18° postoper-tively (P � .05).

Patient 14 had only a 5° gain in the flexion–exten-ion arc but gained 100° in the prosupination arc. Head had a Silastic radial head implanted 30 yearsarlier and sustained a decrease in forearm rotationfter opening a jar. His contracture occurred as theesult of Silastic synovitis, post-traumatic arthritis,nd capsular fibrosis.

Patient 1 revealed no gain in arc of motion andeveloped a permanent medial antebrachial cutaneouseuroma. He was a 41-year-old unemployed mechanicith osteoarthritis. He returned to the clinic only once

nd was noncompliant with his physiotherapy. He hadpoor rating on satisfaction (4 of 10) and reportedoderate disability. This patient was atypical, and his

cores tended to skew the means reported (therefore,edian responses are included in data tables).Three patients were lost to follow-up at the time of

he study. Review of their charts revealed improvedange of motion and function with no reported com-lications. Mean flexion at the time of last follow-upmean, 26 months) was 135° � 5°. Mean extensionas 27° � 23°, and the mean arc was 115° � 18°.atient outcomes were similar to those of patientseviewed in this series.

Sex, arm dominance, age, and duration of symptomsad no significant effect on motion gains (P � .05).

trength

No significant differences in forearm strength were

TABLE 2. Surgical Findings (n � 22)

Surgical Findings

Capsular fibrosis 22Osteophytes (coronoid/olecranon) 12Synovitis 19Loose bodies 13Arthritis (Radiocapitellar) 15Arthritis (Ulnohumeral) 6Debris 9

oted between the operated and the nonoperated el-Fa

ow (P � .05). Mean grip, pinch, and flexion andxtension strengths in the affected limb were 36 � 14g, 9 � 3 kg, 51 � 27 Newton-meters, and 44 � 23ewton-meters, respectively. In the unaffected limb,ean grip, pinch, and flexion and extension strengthsere 38 � 11 kg, 10 � 2 kg, 53 � 24 Newton-meters,

nd 44 � 20 Newton-meters, respectively.

adiographic Outcomes

Six patients exhibited mild arthritis on radiographicnalysis at the time of follow-up; this was unchangedrom preoperative radiographs. One patient requiredepeat surgery to remove a residual loose body 4onths postoperatively. Two patients developed mild

eterotopic ossification of the medial collateral liga-ent and anterior capsule that did not affect their

unctional outcomes. Both patients were given pro-hylactic indomethacin for 3 weeks; however, theirevel of compliance with this medication is unclear.

unctional Outcomes

All patients had good elbow function, with a meanSES-e score of 31 out of 36 (Fig 4). Most patientsere satisfied with their surgery, had minimal pain,

howed themselves to be in good physical health onhe SF-36, and revealed minimal impairment on theASH (Table 3). Stiffness in only 2 patients was work

elated, and both had good functional outcomes. Theean postoperative Mayo Elbow Performance Index

MEPI) was 88 � 12 (14, excellent; 5, good; 2, fair; 1,oor; range, 57 to 100). The mean preoperative MEPIas 57 � 11 (12, fair; 10, poor; range, 33 to 72).In all, 3 patients had mild tenderness at the portals.

atient 4 was a 27-year-old homemaker who had

IGURE 3. Preoperative and postoperative flexion, extension, andrc (*P � .001).

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847FUNCTIONAL OUTCOMES OF ARTHROSCOPIC CAPSULAR RELEASE

xperienced a previous dislocation while inebriated.he regained a functional arc of motion but developedadiocapitellar and ulnohumeral portal tenderness,hus lowering her MEPI. Two patients had mild im-ingement pain in extension. None of the patients hadnstability, and no major neurovascular complicationsere reported.Patient 15 had a capitellar osteochondritis dissecans

OCD) lesion that was microfractured. Loose bodiesontributed to her stiffness. She was functioning wellt 2-year follow-up with no significant radiographichanges.

Patient 10 developed gradual post-traumatic stiff-

IGURE 4. (A) Preoperativenterior-posterior and (B) lat-ral radiographs of patient 19.e was a 41-year-old police-an with elbow contracture

aused by degenerative arthri-is. His preoperative range ofotion was 35° to 120°. (C)nterior–posterior and (D) lat-

ral radiographs of patient 19 atweeks postoperatively. Clin-

cal photos of ranges of (E)exion and (F) extension of pa-

ient 19 at 1-year follow-up.ollowing arthroscopic de-ridement and capsulectomy,is range was 25° to 145°. Head minimal pain and wasunctioning well.

TABLE 3. Patient-Rated Outcomes (n � 22)

Mean Maximum SD Range Median

unction ASES-e 31 36 4 22–36 31atisfaction ASES-e 9 10 2 4–10 9ain ASES-e 11 50 11 0–42 8F-36 (PCCS) 44 65 13 17–61 49ASH 12 100 13 0–57 7EPI (preop) 57 72 11 33–72 60EPI (postop) 88 100 12 57–100 91

Abbreviations: SD, standard deviation; ASES-e, Americanhoulder and Elbow Surgeons Elbow form; SF-36 (PCCS), Shortorm-36 Physical Component Summary Score; DASH, Disabilityf the Arm, Shoulder, and Hand questionnaire; MEPI, Mayo El-ow Performance Index.

ess after the age of 5. Magnetic resonance imagingMRI) revealed abnormal trochlear and capitellar de-elopment, a hypoplastic ulna, a subluxed radial head,nd numerous loose bodies. The surgical goal wasimited to restoring some functional motion. The pa-ient was asymptomatic at 4 years’ follow-up and wasble to write and play in a band.

We currently recommend concurrent ulnar nerveecompression in patients with preoperative flexion ofess than 100° when an improvement in flexion mightesult in stretching of a chronically shortened ulnarerve and, hence, the postoperative development of anlnar neuropathy. Patient 10 developed acute lockingrom loose bodies, which put him at less risk ofeveloping a neuropathy.Patient 5 (preoperative flexion, 75°) was operated

n early in our series and did not have a concurrentlnar nerve decompression. She developed an ulnarerve neuropathy, which had resolved completely at 3ears’ follow-up.

DISCUSSION

Arthroscopic debridement and anterior capsulec-omy is effective in the treatment of patients withlbow contracture. Mean flexion improved from 122°o 141°, and mean extension improved from 38° to9°. Results are comparable with those of open tech-

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iques described by Cohen and Hastings5 and Mansatnd Morrey.3

Recovery of flexion may have been greater if pos-erior capsulectomy had been carried out in 17 of the2 patients. Arthroscopic release of the posteromedialapsule is, however, technically difficult because ofhe close proximity of the ulnar nerve.

None of the patients in this series had instability,nd no major neurovascular complications were re-orted. Patients who experienced portal tendernessnd impingement pain in extension described onlyinor discomfort. Cutting only the skin and then

sing blunt dissection when establishing medial por-als may have prevented the medial antebrachial cu-aneous neuroma.

In 20 of 22 patients, the anterior capsule was re-ected by releasing it off the humeral attachment. Inhe remaining 2 patients, isolated capsulotomy waserformed. Outcomes were similar in both groups.owever, because of the small number of patientsho underwent an isolated capsulotomy, no conclu-

ion can be drawn regarding the superiority of arthro-copic capsulectomy over arthroscopic capsulotomy.t is currently believed that more complete excision ofhe capsule may reduce the amount of hypertrophiccarring and more effectively prevent recurrence of theontracture compared with an isolated capsulotomy.31

owever, capsulectomy might be associated with aigher risk of neurovascular injury than capsulotomy.32

Because of the proximity of the posterior interosse-us nerve when the capsule anterior to the radial heads excised, the surgeon may choose to leave some ofhe more distal capsule in this area (authors’ prefer-nce) if an adequate range of motion is achieved or,lternatively, may expose the radial nerve arthroscopi-ally to protect it.

Limitations of this study include its retrospectiveesign and heterogeneous patient population. Inclu-ion criteria for this study were broad to includeatients with early degenerative arthritis and post-raumatic contractures who had debilitating restrictionf flexion–extension and of pronation–supination. Al-hough this allows for a broader evaluation of theutcomes of arthroscopic capsulectomy, it decreaseshe strength of the conclusions one can make aboutny particular subgroup. Similar to Kim and Shin’study,11 we found no significant difference in preop-rative flexion, extension, or motion gain (P � .05)etween degenerative and post-traumatic contractures.Self-report data provide an indication of the func-

ional status achieved. Unfortunately, the lack of pre-

perative scores limits the ability to attribute specific

mprovements to surgery alone. Postoperative scoresndicated minimal residual deficits. The mean DASHcore of 12 (median � 7) compared favorably with theS mean population score (DASH � 12). It is supe-

ior to scores reported by patients who had recoveredrom a variety of upper extremity problems but wereeportedly able to work (DASH � 27) and to donything they wanted to do (DASH � 24).33,34 Simi-arly, elbow-specific pain and disability were within aild range. Overall, the mean physical health scoreas lower than that of the US population mean of 50

44), but it appeared favorable when reflected by theedian response (49), which minimizes the impact of

he single, failed procedure. The poor outcomes re-orted by this patient reflect the importance of com-liance with postoperative follow-up and rehabilita-ion toward achieving optimal outcomes.

A formal, organized postoperative rehabilitationrogram is an integral component of elbow contrac-ure management. Continuous brachial plexus block-de is often used to control pain and to facilitate earlyobilization of the elbow. Ice and anti-inflammatoryedications are useful in controlling pain and edema.1

ndomethacin was used as a prophylaxis against het-rotopic ossification, although its exact role in elbowrthroscopy remains unclear.35 Continuous passiveotion may be helpful for maintaining motion post-

peratively, but it requires special attention and closeupervision. Early active motion can also be achievedy alternating resting daytime flexion and nighttimextension splints.1 Future studies are required to de-ermine the importance of each of these modalities inugmenting the outcome of surgical release.

Results of this study are comparable with those ofther reports in the literature in which both arthro-copic10-21 and open methods were used.3-5 These re-orts focused on arthroscopic debridement or isolatedrthroscopic capsulotomy.17-21 In this series, we haveooked specifically at the gain in range of motion andunctional outcome of patients who primarily underwentapsulectomy for the management of elbow contrac-ures. We have attained encouraging short-term resultsith arthroscopic elbow capsular release, performedith validated outcome measures assessed by indepen-ent evaluators. Careful selection of motivated patientsith adequate joint surfaces is recommended.

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1

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3

3

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3

3

849FUNCTIONAL OUTCOMES OF ARTHROSCOPIC CAPSULAR RELEASE

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