Shoulder and Elbow

Rheumatoid Elbow

The Problem

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown etiology marked by a symmetric, peripheral polyarthritis. It is the most common form of chronic inflammatory arthritis (0.5 – 1% of the adult population worldwide) and often results in joint damage and physical disability, in addition to a variety of extraarticular manifestations. Involvement of the elbow joint is reported in 20% to 65% of patients with RA. The outcomes of patients with RA have experienced a remarkable improvement in the last two decades thanks to the development of new medications and the adoption of early treatment interventions. As a result, the classic crippled patient with RA has been replaced by patients with a much higher activity level, which changes patient expectations and also may impact on the longevity of reconstructive surgical procedures. When non-operative treatment fails to provide improvement, surgical options for the rheumatoid elbow typically include synovectomy, replacement arthroplasty, or interposition arthroplasty.

Clinical Presentation

The elbow joint is the only joint affected in only 5% of rheumatoid patients; most patients will present with polyarticular disease. At the elbow joint, classic symptoms may include pain, swelling, motion loss, subjective instability, crepitus, and sometimes evidence of ulnar nerve entrapment. Most patients are under the care of a rheumatologist when they present to the orthopedic surgeon for evaluation of the elbow. From an orthopedic perspective, it is very important to determine involvement of other joints in the upper extremity (shoulder, wrist, hand), as well as the cervical spine (it may impact anesthesia techniques), and the lower extremities (the use of assistive devices may increase the loads across the elbow joint).

Diagnostic Workup

Physical examination of the elbow

On inspection, some patients with RA may present with rheumatoid nodules, olecranon bursitis, and various amounts of swelling secondary to synovitis. The condition of the skin may also be affected by chronic use of steroids, malnutrition secondary to systemic problems, or previous surgical procedures.

Elbow range of motion is assessed and recorded in flexion, extension, pronation and supination. Elbow stability is assessed by stressing the elbow into varus and valgus to detect attenuation of the medial and lateral stabilizing structures. Special attention should be paid to examination of the ulnar nerve for both motor and sensory changes; not uncommonly, the ulnar nerve is involved by synovitis, bony changes and angular deformity. Pain related specifically to the radial head may be assessed trying to reproduce pain with pronation and supination or by flexing and extending the elbow with a valgus torque. In patients with previous surgical exposures that may have violated the extensor mechanism, careful examination of the triceps is required to determine its integrity.

Imaging and special diagnostic tests

The clinical diagnosis of RA is largely based on signs, symptoms and radiographic findings of a chronic inflammatory arthritis. Additional laboratory and imaging studies are useful to understand the severity of the disease in a given location and classify patients. The 2010 revised ACR/EULAR classification criteria are used to predict at the onset of the disease which patients are likely to develop chronic joint damage; a score of 6 is considered consistent with definite RA subsidiary of early medical treatment. Calculation of this score requires laboratory studies in peripheral blood, including c-reactive protein, sedimentation rate, rheumatoid factor, and anti-CCP (cyclic citrulinated peptides) antibodies. See Table I.

Plain radiographs are the main imaging modality used for the evaluation of most rheumatoid elbows. Typical findings may include various degrees of joint line space narrowing, osteopenia, cysts, and structural bone loss in the distal humerus, proximal ulna and/or proximal radius. Radiographic changes may be graded using the Larsen evaluation system (See Table II), which can be used for any joint involved.

More commonly, we use the Mayo classification system, specifically designed to classify the rheumatoid elbow in various degrees of severity (See Table III).

Advanced imaging studies are selectively used. CT scans are useful to plan joint debridement procedures. MRI offers the greatest sensitivity for detecting synovitis and early bone and cartilage changes.

Non–Operative Management

Pharmacologic treatment

Pharmacologic options to treat RA have changed tremendously over the last few years. Currently, NSAIDs and steroids are used mostly as adjunctive drugs, and most patients benefit from so-called disease-modifying antirheumatic drugs (DMARDs). DMARDs are classified as conventional (i.e., methotrexate) or biologic (anti-TNF, IL-1 and IL-6 receptor antagonists, T-cell blockers, B-lymphocyte modulators).

Most patients are started on methotrexate; a biologic DMARD is added to methotrexate for non-responders. Patients may be switched amongst various biologic DMARDs depending on their response, maintaining methotrexate in the background. Corticosteroids are used when DMARDs are first introduced, in order to control symptoms while the DMARDs are becoming effective (typically 4 – 6 weeks), as well as for episodes of flare up; they are rarely used chronically for patients not responding to anything else. Intraarticular injections with steroids may also be considered when inflammatory symptoms at the elbow flare up. NSAIDs are selectively used for pain control.

Physical therapy and braces

A comprehensive program of physical therapy seems to improve overall muscle strength and perceived health status. However, physical therapy per se has little value for the rheumatoid elbow prior to surgery. Selective use of elbow braces splinting the elbow in extension overnight may help those patients developing a flexion contracture.

Indications for Surgery

The main indications for surgery in patients with rheumatoid arthritis of the elbow are (1) inability to provide adequate pain relief with non-operative treatment, (2) stiffness that interferes with the ability to perform activities of daily living, (3) gross instability leading to marked dysfunction, and/or (4) progression of disease with almost catastrophic bone loss compromising future surgical options or leading to impending fracture.

Various procedures may be considered for surgical treatment of the rheumatoid elbow, including synovectomy and debridement, total elbow arthroplasty, and interposition arthroplasty. The indication for each of the procedures is mostly based on disease severity, patient’s age, activity level and expectations.

Surgical Technique

Synovectomy and debridement

Since synovitis is a major element involved in both symptoms and joint damage, surgical removal of inflamed synovium has been performed for decades for patients with uncontrolled rheumatoid arthritis. The classic procedure was an open synovectomy with radial head removal; it is possible that the need to remove the radial head was to gain further exposure with open techniques. Currently, synovectomy is most commonly performed arthroscopically, and the rate of combined radial head resection/synovectomy has decreased; the radial head is removed when it is clearly identified as a source of symptoms in the pre-operative evaluation. In addition, the value of improving range of motion is now clearly recognized, and oftentimes patients undergo arthroscopic capsulectomy and recontouring of areas of bone impingement at the time of synovectomy. Finally, loose bodies and cartilage flaps can be removed as well for a complete arthroscopic debridement. Not uncommonly, the ulnar nerve is decompressed in situ in patients with pre-operative symptoms or a high-degree extension contracture.

Equipment

Arthroscopic synovectomy requires use of arthroscopic equipment. The specific equipment to be used is largely based on surgeon’s preference. We perform this procedure with a standard large-joint arthroscopic camera, and use arthroscopic shaver and burr terminals as well as thermal ablation devices. Instruments for retraction of soft tissues during arthroscopy are extremely useful.

Patient set–up

Our preference is to perform this procedure in the lateral decubitus position. After placing a tourniquet, the elbow is positioned on an arm holder high enough so that the trunk of the patient will not interfere with motion of the surgeon’s hands in front of the elbow (Figure 1).

Figure 1.

Patient positioning.

Procedure

The ulnar nerve is decompressed in some but not all patients. Our preference is to decompress the nerve through a mini-open approach before starting the arthroscopic portion of the procedure. I typically address the anterior compartment of the elbow joint first, but some surgeons prefer to start the arthroscopic portion of the procedure posteriorly. For elbows with stiffness undergoing capsulectomy, the goal should be to achieve a complete arc of flexion and extension intraoperatively. Forced manipulations should be avoided in rheumatoid patients, since they are typically osteopenic and prone to fracture.

1. Ulnar nerve decompression

A posteromedial skin incision measuring 2-3 centimeters is placed over the ulnar tunnel. The skin can be retracted proximally and distally to provide an adequate subcutaneous decompression beyond the extent of the skin incision, dividing the fascial tissue over the ulnar nerve proximally on the medial side of the triceps and distally in the ulnar tunnel and fascia of the flexor carpi ulnaris.

2. Anterior compartment

Our preference is to start the procedure using a proximal anteromedial portal as a viewing portal and an anterolateral portal as a working portal (Figure 2). The proximal anteromedial portal is established 2-3 cm anterior to the medial intermuscular septum (palpable under the skin) and 2-3 cm proximal to the medial epicondyle. The anterolateral portal is established under direct vision anterior and proximal to the lateral epicondyle. A third accessory proximal anterolateral portal is used for retractor placement.

Figure 2.

Anterior portals.

Prior to use of any instruments, it is important to confirm an intraarticular view (Figure 3). A shaver may be used to start the synovectomy, which is most commonly completed with a thermal ablation device. Loose fragments of cartilage are removed. Areas of bony impingement are recontoured with an arthroscopic burr when present. The capsulectomy is not performed until all bony work is completed. The capsulectomy is started as a horizontal capsulotomy with an arthroscopic biter, and completed with a shaver. Portals are switched as needed.

Figure 3.

Intraarticular view.

Iatrogenic injury to the radial nerve is one of the most feared complications of arthroscopic elbow surgery. Beware of the location of the radial nerve just anterior to the 12 o'clock position of the radial head, and avoid use of suction connected to the shaver as well as the use of thermal devices in this particular location. Some surgeons recommend leaving the capsule in front of the radial head completely intact to avoid radial nerve injury.

Arthroscopic resection of the radial head is considered in patients with symptomatic radiocapitellar involvement. It may be started anteriorly and completed inserting the burr from a posterior “soft-spot” portal.

3. Posterior compartment

Our preference is to start using a posterolateral portal as a viewing portal and a posterocentral portal as a working portal (Figure 4). Removal of all soft-tissues from the olecranon fossa is safe and can be performed quite effectively. A retractor may be placed in the proximal posteromedial portal when needed. Work on the posterolateral gutter is facilitated by establishing a portal in the “soft-spot’. Special precautions should be taken when working in the posteromedial gutter, due to the proximity of the ulnar nerve; consideration may be given to completing the soft-tissue debridement posteromedially through the mini-open approach used to decompress the ulnar nerve.

Figure 4.

Posterior portals.

Total elbow arthroplasty

Equipment

Modern elbow arthroplasty systems provide accurate instrumentation for bone preparation (Figure 5 and Figure 6). Most elbow arthroplasties are fixed with bone cement. Insertion of polymethylmetacrylate in the canals of the humerus, and especially the ulna, is difficult to achieve with conventional cement nozzles; a thin flexible nozzle facilitates introduction of bone cement. Our preference is to add antibiotic powder to bone cement (typically 1 gram of vancomycin per batch of cement). We also add methylene blue (1 mL per batch) to facilitate visualization of bone cement in case of future revision surgery. Flexible reamers are useful in patients with very narrow canals or marked deformity; intraoperative fluoroscopy may be occasionally required.

Figure 5.

Total elbow arthroplasty: AP view.

Figure 6.

Total elbow arthroplasty: lateral view.

Patient set–up

The patient is positioned supine and the procedure performed with the upper extremity across the chest. We prefer to use an iodophor impregnated adhesive film on the skin and a sterile tourniquet. However, care must be taking when removing the adhesive film at the end of the case, as some patients with RA will have marked skin fragility that may lead to skin damage when the adhesive film is peeled at the end.

Procedure

1. Skin

Elbow arthroplasty is performed though a posterior midline skin incision avoiding the very tip of the olecranon by curving the incision medially at its center. An effort should be made to minimize raising subcutaneous flaps beyond what is required for deep dissection.

2. Ulnar nerve

Although somewhat controversial, our preference is to perform a subcutaneous transposition of the ulnar nerve routinely. Care must be taken to preserve the vasa nervorum as best as possible, and to perform an ample transposition, in order to minimize post-operative symptoms. In some rheumatoid patients, synovitis may encroach the nerve, making the dissection more cumbersome.

3. Deep exposure

Joint exposure for replacement may be achieved in several different ways. Classically, the triceps is detached or divided to gain deep exposure. Recent recognition of the underreported rate of triceps dysfunction after elbow arthroplasty has prompted interest in triceps-preserving or “triceps-on” approaches.

Elbows with severe distal humerus bone loss can easily be exposed by working on both sides of the triceps (bilaterotricipital approach): the absent distal humerus provides sufficient working space for canal preparation and component implantation. In elbows with well-preserved bone stock, elbow replacement leaving the triceps on is technically more challenging, but may be performed using the paraolecranon approach or by subperiosteal pealing of the whole distal humerus. Alternatively, the triceps may be divided in the midline (triceps split), divided at the myotendinous junction (triceps tongue) or pealed subperiosteally off the ulna (triceps reflection). Secure repair of the extensor mechanism cannot be overemphasized.

Occasionally, rheumatoid elbows may sustain a spontaneous fracture of an already thinned out olecranon at the time of arthroplasty. In those circumstances, we approach the elbow through the olecranon nonunion, which is secured at the end of the case with wires, suture or a plate.

4. Humeral preparation

Most systems provide instrumentation to prepare the distal humerus and humeral canal. Some require sizing of the articulation prior to selection of the appropriate humeral component size. The depth of insertion can be referenced off the transepicondylar axis or the roof of the olecranon fossa; in the presence of severe flexion contracture, the humeral component may need to be implanted deeper (more proximal) in order to gain extension. The rotational alignment can be referenced off the posterior cortex of the humerus (the component should be internally rotated approximately 15 degrees from this landmark) or the transepicondylar axis (the component should be internally rotated approximately 3 degrees from this landmark).

5. Ulnar preparation

As with the humeral side, most systems provide instrumentation to prepare the proximal ulna and the ulnar canal. Care must be taking not to perforate the ulnar cortex when identifying the ulnar canal, especially in patients with severe osteopenia or ultra-narrow canals. The depth of insertion may be referenced off the tip of the olecranon and coronoid (the center of rotation of the component should be equidistant); very rarely, deeper insertion of the ulnar component is required to obtain adequate elbow extension, in which case the radius may need to be shortened as well. The rotational alignment of the ulnar component may be referenced off the equator of the radial head or the dorsal aspect of the olecranon (should be parallel to both).

6. The radial head

Some systems provide the alternative of using a radial head component. Classically, the radial head component has represented a source of complications and implant failure. The radial head may be simply resected, trimmed down or replaced if it is a source of symptoms. Oftentimes, the radial head may be ignored with little impact on the final outcome of the procedure.

7. Component implantation and linkage

Implant fixation is most commonly achieved with bone cement. As mentioned previously, we add vancomycin and methylene blue to polymethylmetacrylate at the time of component implantation. Cement restrictors are difficult to use but extremely valuable. On the ulnar side the canal is oftentimes too narrow to accept a commercially available cement restrictor, and a piece of bone can be used instead. On the humeral side, the entrance to the canal is oftentimes narrower than the midportion of the canal, and a restrictor that will pass through the entrance will not really become engaged in the canal and will fail to restrict cement propagation. The goal is to have minimal cement past the tip of the stems to facilitate revision surgery if it became necessary. A thin flexible cement nozzle facilitates cement delivery inside the canals.

Biomechanical and clinical studies seem to demonstrate the value of an anterior flange on the humeral component. In some systems the flange engages the anterior humeral cortex directly, whereas in others a bone graft needs to be placed in between the prosthetic flange and the anterior cortex. The graft may be captured at the time of humeral component insertion or after the cement is completely hard.

Components used for elbow arthroplasty may be linked, unlinked or linkable. Our preference is to link the components in most patients. Use of an unlinked implant requires good ligament integrity and triceps function.

8. Closure

When the triceps is divided or detached, meticulous repair is paramount. Non-absorbable sutures through bone tunnels are commonly used for repair. Careful closure of the subcutaneous tissues is important in order to leave the ulnar nerve in an anterior subcutaneous position and avoid wound complications.

Interposition arthroplasty

The goals of interposition arthroplasty are to (1) perform a thorough debridement, synovectomy and capsulectomy, (2) interpose soft-tissue at the elbow joint, and (3) keep the joint distracted for 3-6 weeks while allowing range of motion (Figure 7).

Figure 7.

Interposition arthroplasty.

Equipment

Interposition arthroplasty requires use of soft-tissue material to interpose as well as a dynamic external fixator for motion under distraction. Various soft-tissue materials have been used for elbow interposition over time; we currently favor use of an Achilles tendon allograft. The allograft may be fixed to the underlying bone with non-absorbable sutures using either suture anchors or bone tunnels.

Patient set–up

The patient set-up is identical to the one described for total elbow arthroplasty: supine position, arm over the chest, iodophor impregnated adhesive film, and sterile tourniquet.

Procedure

1. Exposure

The elbow is exposed through a posterior midline skin incision curved slightly medial to the tip of the olecranon. The ulnar nerve is identified and either decompressed or transposed. Deep exposure is typically gained through an extensile Kocher’s approach, with detachment of the origin of the lateral collateral ligament from its humeral origin and partial versus complete detachment of the triceps insertion from lateral to medial.

2. Interposition

The exposed joint is debrided and a synovectomy and capsulectomy are performed. Most commonly, the Achilles tendon allograft is draped over the humerus. Any remaining cartilage is removed and the distal humerus is recontoured and freshened with a burr. A portion of the Achilles allograft wide and thick enough to cover the distal humerus is draped over and fixed with bone tunnels or suture anchors. An effort is made to keep the allograft draped tightly and fixed securely. In patients with collateral ligament complex insufficiency, tails of the Achilles tendon allograft may be used to reconstruct the ligament complexes.

3. Application of external fixator

We favor use of a dynamic external fixator able to provide joint distraction. The axis of flexion and extension is identified by connecting the geometric centers of the outlines of the capitellum and medial trochlea. These landmarks typically correspond to the center of the lateral epicondyle laterally and the junction of the medial epicondyle and the trochlea medially. A targeting guide is used to align the fixation with the correct axis and fix it to the humerus with two pins. Care must be taking to avoid injury to the radial nerve during insertion of the humeral pins. The ulna and radius and then reduced over the humerus and the frame is fixed to the ulna with two pins. Distraction is applied (typically 2-3 mm), and the elbow is ranged through motion to confirm the adequacy of the reconstruction.

Pearls and Pitfalls of Technique

Pearls

Carefully review the pharmacologic treatment for every patient. Make sure the potential help from pharmacologic treatment has been maximized. Beware of the potential side effects of DMARDs, especially wound healing problems and immune suppression; they both increase the risk of surgical site infection and some should be stopped around the time of surgery.

Assess the patient as a whole, understanding extraarticular manifestations of the disease as well as involvement of other joints in the lower extremities, spine and upper extremities. Sequence treatment of various joints involved accordingly.

Synovectomy, elbow replacement, and interposition arthroplasty are each best for different patients depending on the severity of elbow involvement as well as age and activity level. Failed synovectomy and failed interposition can be successfully revised to an elbow arthroplasty provided prior surgery is not complicated by deep infection.

Pitfalls

Rheumatoid arthritis compromises bone and soft-tissue quality, increasing the risk of intraoperative fracture, triceps insufficiency and wound complications. Careful soft-tissue dissection and gentle bone manipulation cannot be overemphasized.

Bone loss typically is progressive in rheumatoid arthritis. Progressive bone loss may compromise the outcome of surgery. When progressive bone loss is noted on radiographs, surgery should be recommended to the patient sooner rather than later.

Persistent ulnar neuropathy may ruin the results of the most successful procedure. Assess, address and protect the ulnar nerve at the time of synovectomy, arthroplasty and interposition.

Potential Complications

The most common complications of surgery for elbow rheumatoid arthritis include infection, nerve injury (iatrogenic or secondary to aggravation of pre-existing ulnar neuropathy), wound complications, recurrence of stiffness, triceps insufficiency after surgical violation of the extensor mechanism, and fracture.

Post–operative Rehabilitation

Synovectomy

Most patients who undergo synovectomy and capsulectomy benefit from a physical therapy program to maintain the improved motion obtained in surgery. Our preference is to use continuous passive motion for 2-3 weeks followed by bracing for 2-3 months. Alternatively, a program of active and active assisted range of motion exercises may be initiated right away, combined with braces.

Total elbow arthroplasty

In order to minimize swelling and decrease wound complications, the elbow is immobilized in extension and kept elevated for the first 1-3 days after surgery. Active and active assisted range of motion exercises are started then. When the triceps has been detached and repaired, patients are recommended to avoid active extension against resistance for 6 weeks. Patients with severe preoperative stiffness may benefit from braces.

Interposition arthroplasty

Patients start a program of active and active assisted range of motion exercises as soon as the swelling subsides, typically 2-3 days post-operatively. Pin site care is extremely important. The fixator is removed at week 6 unless the pins become infected or loose earlier. At the time of removal of the fixator, the elbow may be examined under anesthesia and fluoroscopy to determine residual stiffness and/or instability. If stiff, the elbow can be gently manipulated. Brace treatment can be continued for the following 1 - 2 months to protect and stretch the elbow joint.

Outcomes/Evidence in the Literature

Gendi, NS, Axon, JM, Carr, AJ, Pile, KD, Burge, PD, Mowat, AG. "Synovectomy of the elbow and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome". J Bone Joint Surg Br. vol. 79. 1997. pp. 918-23.

(A survival analysis was performed in a cohort of 171 rheumatoid elbows after open synovectomy. Most underwent radial head excision at the time of synovectomy, and only a few had the ulnar nerve decompressed or transposed. Synovectomy resulted in improved flexion-extension (average 11 degrees) and pronation-supination (average 50 degrees). Failure, defined as severe pain or reoperation, was 19% during the first year, declined at a rate of 2.6% per year, and reached 46% at 6.5 years. Radiographic degeneration according to the Larsen scale continued over time. At most recent follow-up instability was documented in 36% and ulnar neuropathy in 19%. Predictors for failure included long duration of symptoms and limited pre-operative forearm rotation and or flexion-extension.)

Horiuchi, K, Momohara, Tomatsu, T, Inoue, K, Toyama, Y. "Arthroscopic synovectomy of the elbow in rheumatoid arthritis". J Bone Joint Surg Am. vol. 84. 2002. pp. 342-7.

(Twenty-one rheumatoid elbows were evaluated at a mean follow-up time of 8 years after arthroscopic synovectomy. The mean Mayo Elbow Performance Score improved from 48 to 77 points at 2 years of follow-up, but decreased at final follow-up, with a good or excellent score maintained in only 43%. Clinically apparent synovitis recurred in five elbows. There were no major improvements in range of motion at most recent follow-up (flexion-extension improved by 8 degrees, forearm rotation decreased by 6 degrees). The best results were obtained in patients with Larsen grades 1 or 2.)

Kang, HJ, Park, MJ, Ahn, JH, Lee, SH. "Arthroscopic synovectomy for the rheumatoid elbow". Arthroscopy. vol. 29. 2010. pp. 1195-202.

(Twenty-six rheumatoid elbows Larsen grade 3 or less were followed for a mean of almost 3 years. VAS for pain improved from 6.5 to 31 and the flexion-extension arc improved from 98 - 113 degrees. According to the MEPS, there were good or excellent results in 73% of the elbows. There was clinically evident recurrent synovitis in four elbows and radiographic progression of disease in seven elbows.)

Larson, NA, Morrey, BF. "Interposition arthroplasty with an Achilles tendon allograft as a salvage procedure for the elbow". J Bone Joint Surg. vol. 90. 2008. pp. 2714-23.

(Eleven elbows with inflammatory arthritis were analyzed as part of a larger group of 69 interposition arthroplasties performed using an Achilles tendon allograft. Two patients had complete ankylosis. The mean age was 32 years (range, 20 to 54). Their MEPS score improved from 47 to 72 points. The most recent DASH score was 30 points (range, 10 to 57). No patient required a reoperation or was unsatisfied. These results were substantially better than those obtained in patients with post-traumatic osteoarthritis (for the whole group, only 40% had good or excellent MEPS).)

Ljung, P, Jonhsson, K, Larsson, K, Rydholm, U. "Interposition arthroplasty of the elbow with rheumatoid arthritis". J Shoulder Elbow Surg. vol. 5. 1996. pp. 81-5.

(Thirty-five rheumatoid elbows were evaluated a median of 6 years after interposition arthroplasty. Surgery improved pain but did not change motion. Radiographic progression was documented in 50% of the elbows. Three elbows subsequently required arthroplasty. The authors found worse outcome with interposition than with replacement arthroplasty.)

Ishii, K, Mochida, Y, Harigane, K, Mitsugi, N, Taki, N, Mitsuhashi, S, Akamatsu, Y, Saito, T. "Clinical and radiological results of GSB III total elbow arthroplasty in patients with rheumatoid arthritis". Mod Rheumatol. vol. 22. 2011. pp. 223-7.

(Thirty-five GSB III elbow arthroplasties performed for rheumatoid arthritis were followed for a mean of 6 years (range, 2 – 10 years). Elbow arthroplasty resulted in improved MEPS (48 to 83). Complications included intraoperative fracture (4), postoperative fracture (1), ulnar nerve palsy (2), humeral loosening (14.3%) and ulnar loosening (5.7%).)

Qureshi, F, Draviaraj, KP, Stanley, D. "The Kudo 5 total elbow replacement in the treatment of the rheumatoid elbow: results at a minimum of ten years". J Bone Joint Surg Br. vol. 92. 2010. pp. 1416-21.

(Twenty-two Kudo 5 arthroplasties performed for elbow rheumatoid arthritis were reviewed at a mean of 12 years (range 10 – 14). Reoperation was performed for loosening in 4 elbows and infection in 2 elbows, for a 12-year survival rate of 74%. Of the 16 survival implants, there was no or mild pain in 14, and the mean arc of motion was 106 degrees (65 – 130).)

Prasad, N, Dent, C. "Outcome of total elbow replacement for rheumatoid arthritis: single surgeon's series with Souter-Strathclyde and Coonrad-Morrey prosthesis". J Shoulder Elbow Surg. vol. 19. 2010. pp. 376-83.

(Ninety-nine elbow arthroplasties performed for rheumatoid arthritis by a single surgeon were reviewed, including 44 using the Souter design and 55 using the Coonrad-Morrey design. The follow-up time was longer for Souter implants (9 and 5 years respectively). Both designs provided similar rates of clinical improvement. However, Coonrad-Morey implants had better 5-year survival (100% versus 93%). At 10 years, the survival of Souter implants was 76%, with reoperations due to loosening (18%) and instability (9%).)

Gill, DR, Morrey, BF. "The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study". J Bone Joint Surg Am. vol. 80. 1998. pp. 1327-35.

(Seventy-eight total elbow arthroplasties were performed for rheumatoid arthritis using the Coonrad-Morrey design at a single institution; forty-six elbows had at least 10 years of follow-up. Arthroplasty led to substantial improvements in pain and motion. Complications requiring reoperation included deep infection (2), ulnar fracture (2), triceps insufficiency (3), aseptic loosening (2), and ulnar component fracture (1). Radiographic loosening was appreciated in 2 additional elbows and bushing wear in 15%. The 10-year survival was 92%.)

Baghdadi, YM, Jacobson, JA, Duquin, TR, Larson, DR, Morrey, BF, Sanchez-Sotelo, J. "The outcome of total elbow arthroplasty in juvenile idiopathic arthritis (juvenile rheumatoid arthritis) patients". J Shoulder Elbow Surg. 2014.

(Twenty-nine total elbow arthroplasties were performed in patients with juvenile rheumatoid arthritis at a mean age of 37 years (range, 24 – 68). Modified or customized implants were used in 9 and 5 elbows respectively. Pain and range of motion were both improved. The 10-year survival was 80%.)

Summary

The elbow is commonly affected in patients with rheumatoid arthritis. Surgery is commonly considered for patients with persistent symptoms despite pharmacologic treatment, as well as those with severe stiffness, gross instability or rapid progression of bone loss. In the earlier stages of elbow involvement, arthroscopic synovectomy with capsulectomy provides satisfactory outcomes. Total elbow arthroplasty is reliable and durable for patients with more advanced disease. Interposition arthroplasty is considered for a selected group of younger, more active patients with severe involvement but a high risk of mechanical failure after arthroplasty. Careful management of perioperative pharmacologic therapy, meticulous soft-tissue handling, gentle bone preparation, and adequate surgical management of the ulnar nerve are extremely important to obtain a good outcome and avoid complications.

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