Elsevier

Joint Bone Spine

Volume 68, Issue 3, May 2001, Pages 198-210
Joint Bone Spine

REVIEW
Surgical treatment of the rheumatoid elbow

https://doi.org/10.1016/S1297-319X(01)00273-1Get rights and content

Abstract

In rheumatoid arthritis, the elbow is involved in 20 to 50% of the cases. Surgical treatment for rheumatoid arthritis is proposed to patients in whom an appropriate and adequate attempt at medical management has failed. Improvements in surgical technique and prosthetic design have led to more predictable results in the surgical treatment of the rheumatoid elbow. Surgical treatment of the patient with rheumatoid arthritis continues to evolve. Synovectomy continues to be an effective palliative procedure, preferred in the early stages of disease (I, II, IIIA) with or without radial head resection. Further investigation into the use of arthroscopic techniques may result in decreased morbidity and a quicker recovery. In more advanced stages (IIIA, IIIB, IV), total elbow replacements by experienced surgeons employing contemporary designs, unconstrained or semiconstrained, and surgical techniques are associated with a high degree of success with long-term follow-up, approaching that for total hip and knee replacement. Finally, interposition arthroplasty can be proposed for young adults with stage II or IIIA rheumatoid arthritis in whom the elbow is mainly stiff and painful.

Section snippets

Pathoanatomy

RA in the elbow begins usually with a proliferative synovitis. As the disease progresses, there is a destruction of articular cartilage, with symmetric joint-space narrowing and progressive distension of the collateral ligaments about the elbow. At a latter stage, there is destruction and loss of subchondral bone leading to loss of normal joint contour. The combination of bone and soft-tissue loss can in some cases induce an unstable elbow. In the latter stages of the disease, the joint space

Clinical presentation and evaluation

The clinical presentation of the patient with RA of the elbow depends on the stage of disease. Complaints of pain and loss of functional motion, however, are common to all stages of the disease. Early in the disease, synovitis is a prominent feature. Patients present with a warm, swollen elbow and painful limitation of the flexion arc and rotation arc. Often there is a mild flexion contracture. Synovitis is easily demonstrable by palpating over a lateral triangle defined by the radial head,

Surgical treatment options

Satisfactory management of the pain and debilitation caused by RA involvement of the elbow is not always possible with conservative measures. When these treatments are insufficient, the patient and surgeon have five surgical options. The mainstays of surgical treatment include synovectomy and total elbow arthroplasty (TEA). There are other treatment options with limited application. These include arthrodesis, resection arthroplasty, and distraction arthroplasty with fascial interposition.

Synovectomy

Elbow synovectomy continues to be an effective treatment option for patients with RA; however, the role of synovectomy must be defined in the context of improved success with TEA. The primary indication for elbow synovectomy in a patient with RA is persistent, painful synovitis unresponsive to 6 months of appropriate medical management.

Total elbow replacement

TEA has become a viable and predictable treatment option for many patients with elbow arthritis. The goals of elbow replacement are to provide a durable, pain-free, and stable elbow joint with a functional range of motion, allowing for the independent performance of activities of daily living. Improvements in prosthetic design and surgical technique have made realization of these goals more predictable.

Nonconstrained implants

The largest experience of nonconstrained implants is with the capitello-condylar prosthesis (CPTC) (figure 3). From 1974 to 1987, Ewald 〚40〛 reported 202 capitellocondylar implants performed in 172 patients with rheumatoid arthritis. With a 69-month average follow-up (range, 24 to 178), relief of pain was reported in 87% and the average arc of motion was 30 to 138°. Lucent lines were present around the humeral component in eight cases, and around the ulnar component in 19. Three of the 202

Conclusion

Surgical treatment of the patient with rheumatoid arthritis continues to evolve. Synovectomy continues to be an effective palliative procedure, preferred in the early stages of disease (I, II, IIIA) with or without radial head resection. Further investigation into the use of arthroscopic techniques may result in decreased morbidity and a quicker recovery. In more advanced stages (IIIA, IIIB, IV) total elbow replacement by experienced surgeons employing contemporary designs and surgical

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