The efficacy and cost-effectiveness of arthroscopic release for post-traumatic elbow stiffness: a single centre prospective randomized trial

TL;DR

This study compares arthroscopic and open surgery for elbow stiffness, finding both effective with similar costs and outcomes.

Contribution

A prospective randomized trial comparing arthroscopic and open release for post-traumatic elbow stiffness with cost-effectiveness analysis.

Findings

Both arthroscopic and open release improved elbow motion and function significantly.

Arthroscopic release had similar total costs and lower postoperative complication rates.

The small statistical advantage of arthroscopic release did not reach clinical significance.

Abstract

Post-traumatic elbow stiffness (PTES) severely limits elbow function, often necessitating surgical intervention after conservative measures fail. Although open arthrolysis (OA) is traditionally preferred, arthroscopic release (AR), being less invasive, could offer comparable or superior clinical outcomes with potentially lower complication rates. However, evidence from rigorous randomized trials directly comparing AR and OA for PTES remains scarce. This prospective randomized controlled trial aimed to evaluate and compare clinical outcomes, safety, and cost-effectiveness of arthroscopic release (AR) versus open arthrolysis (OA) in patients with PTES.

From November 2016 to December 2022, 192 patients diagnosed with PTES, unresponsive to non-operative treatment, were randomized equally into AR and OA groups. Surgical interventions followed standardized techniques, including routine ulnar nerve management. Postoperative rehabilitation protocols were identical for both groups. Primary outcomes assessed were elbow flexion-extension and forearm rotation range of motion (ROM) at one year post-surgery. Secondary outcomes included flexion strength, endurance, patient-reported outcome measures (PROMs), cost analysis, and adverse event incidence. Statistical analyses used linear mixed-effects models and incremental cost-effectiveness ratios (ICER).

At 1-year follow-up, both AR and OA produced substantial improvements in elbow motion and patient function and exceeded thresholds for clinically important gains. The between-group difference favoured AR (p < 0.05) but was very small in magnitude and below the minimal clinically important difference (25°). AR incurred higher intraoperative costs, but these were offset by significantly lower postoperative rehabilitation and follow-up care costs, resulting in similar total costs between groups and indicating that AR was cost-effective overall. Adverse event rates were similar (AR 32.3%; OA 38.5%, p > 0.05), though OA uniquely reported two cases of superficial infection and two cases of deep infection requiring reoperation (none in AR).

In this trial of post-traumatic stiff elbow, both arthroscopic and open release led to large, clinically meaningful improvements in motion and function. The small statistical advantage for AR in ROM did not reach clinical significance, and both approaches substantially benefited patients. AR appears to be a favourable option (with cost-effectiveness comparable to OA) for appropriately selected patients. These findings support offering arthroscopic release as an effective alternative for PTES when technically feasible, while acknowledging that either method can achieve excellent outcomes.

ChiCTR2500101723 (Chinese Clinical Trial Registry, https://www.chictr.org.cn/).

The online version contains supplementary material available at 10.1007/s00264-025-06668-0.

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