REVIEWSurgical treatment of the rheumatoid elbow
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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Solutions for the Unstable and Arthritic Elbow Joint
2020, Hand ClinicsCitation Excerpt :Finally, TEA remains a viable salvage option at a later time, if the benefits of the interposition arthroplasty deteriorate. Interposition arthroplasty with ligament reconstruction and internal joint stabilization is indicated for patients suffering from severe posttraumatic arthritis or stage II/IIA rheumatoid arthritis in young, high-demand patients20 (Fig. 2). This operation requires adequate bone stock.
Complex post-traumatic elbow stiffness: Nonunion, malunion, and post-traumatic arthritis
2016, Shoulder and Elbow Trauma and its ComplicationsTotal elbow arthroplasty: A prospective clinical outcome study of Discovery Elbow System with a 4-year mean follow-up
2015, Journal of Shoulder and Elbow SurgeryCitation Excerpt :The incidence of persistent ulnar neuropathy requiring surgical intervention was 3% in our series. Ulnar neuropathy is seen more commonly in patients with rheumatoid arthritis because the close proximity of the nerve to the elbow joint can lead to inflammation of the nerve due to synovitis in the nearby elbow joint and valgus instability can lead to stretching of the ulnar nerve.29 The incidence rate of ulnar neuropathy with the GSB III, Coonrad-Morrey, and Acclaim prostheses has been reported as 11% to 14%,8,23 12% to 26%,1,20 and 8%,6 respectively.
Elbow Interposition Arthroplasty
2011, Hand ClinicsCitation Excerpt :Prior series of interposition arthroplasty as reported by Fox and colleagues16 as well as Cheng and Morrey17 emphasized the importance of stability as a determinant of outcome. Interposition arthroplasty is a salvage procedure with limited indications for the painful and stiff arthritic elbow and is best indicated for severe posttraumatic elbow arthritis or stage II or IIA rheumatoid arthritis in young, high-demand patients with near normal bone anatomy (Figs. 1 and 2).18 As previously described, adequate bone stock and no gross instability are imperative for successful outcomes in posttraumatic and rheumatoid elbows.
Comparison of perioperative complications in patients with and without rheumatoid arthritis who receive total elbow replacement
2009, Journal of Shoulder and Elbow SurgeryPrimary total elbow arthroplasty
2002, Operative Techniques in Orthopaedics