LAUSR

To the Editor: With the greatest interest we have read the article “Manipulation under anesthesia as a treatment of posttraumatic elbow stiffness” by Spitler et al.1 In this retrospective study, the authors evaluated the safety and efficacy of manipulation under anesthesia (MUA) in 45 patients suffering posttraumatic elbow stiffness. A significant—and clinically relevant—improvement in elbow flexion arc of 38 degrees was achieved (P , 0.001) in 28 patients, who underwent MUA within 3 months of their original trauma or most recent surgical procedure (group 1; early manipulation). In the 17 patients who underwent MUA after 3 months (group 2; late manipulation), an improvement of 3 degrees was observed. As such, the authors concluded MUA to be a safe and effective adjunct to improve range of motion (ROM) when used within 3 months from the original injury or time of surgery fixation. The results of the aforementioned study should be interpreted with caution as MUA is not without risks.2,3 Moreover, the following 2 critical points deserve attention before performing MUA at all, and within the 3 months’ time frame as suggested: 1. Selection bias 1: due to timing in group 1 (,3 months), as conservative treatment options are still (the most) effective in that given time frame. 2. Selection bias 2: due to the role of pain in group 2 (.3 months) that is correlated to measures of anxiety, depression, and lack of coping skills that is holding this group back in their rehabilitation (likely both after the index procedure and after subsequent MUA), resulting in posttraumatic elbow stiffness. First, the significant improvement of 38 degrees in the early manipulation group as reported by Spitler et al1 is comparable with several studies reporting on conservative treatment options in the early stadium of posttraumatic elbow stiffness.4–7 In other words, their patients in group 1 (,3 months) would have been very likely to have improved their ROM, without MUA. Prospective data from Lindenhovius et al,4 comparing 2 splints, showed an average increase in ROM of 29 degrees at 3 months, followed by 40 and 48 degrees at 6 and 12 months, respectively. A systematic review and meta-analysis of 13 studies by Muller et al reported on the effectiveness of progressive splinting (both static and dynamic) in the treatment of posttraumatic elbow stiffness and showed an increase in ROM of 38 degrees. Therefore, these authors strongly support the use of exercises combined with (static–progressive) stretching as a first line of treatment in patients with posttraumatic and postsurgical elbow stiffness.6 Second, the role of pain in posttraumatic elbow stiffness is unfortunately not taken into account in the study of Spitler et al1 and would be very interesting for the Journal of Orthopaedic Trauma readership. Previous studies by Doornberg et al8 and Lindenhovius et al9 showed that pain is the most important determinant of outcome in the early stage of posttraumatic elbow stiffness, holding patients back in their rehabilitation. Moreover, there is an abundance of subsequent evidence revealing the correlation of the subgroup of patients who experience more pain and the role of anxiety, depression, and (the lack of) coping skills and self-efficacy.10,11 It would be very interesting to have these measures for both groups 1 and 2 in the study by Spitler et al,1 as one could hypothesize that patients in group 2 are more likely to have poor coping skills and self-efficacy leading to (1) a stiff elbow after index trauma in the first place and (2) this is holding these patients back in rehabilitation after subsequent MUA as well. Based on current available evidence, one could strongly argue that conservative treatment is favorable in the first 6 months, and even up to 1 year from index injury or surgery.4 Surgeons can consult their patients that most of them will improve with an exercise protocol, with or without noninvasive adjuncts like static or dynamic splints up to 1 year. The dogma “no pain, no gain” has been scientifically shown to play a major role in the subgroup of patients who do not improve their elbow ROM (both after trauma and after MUA).8,10–12 These patients will benefit from cognitive therapy, improving their coping skills and selfefficacy, allowing them to be more efficacious during their rehabilitation regimen, and avoiding return to theatre for MUA or open posttraumatic contracture release.