Elbow in RA Patient

- Discussion:
    - RA manifests itself in many  ways in elbow joint, including nodules and bursae, synovitis, progressive joint destruction, antecubital cysts, & ulnar or, rarely posterior interosseous palsy;
    - note that involvement of the RA elbow is infrequently an isolated and therefore it is important to consider possible involvement in the wrist and shoulder;

- Synovitis:
    - antecubital cysts usually occur during acute episodes of extremely hyperplastic synovitis due to herniation of synovium thru relatively weak anterior capsule of joint;
              - nerve palsies also result from synovial herniation;
    - ulnar nerve: (see cubital tunnel)
              - in case of ulnar nerve, pressure may arise from protrussion of synovium under transverse section of MCL bridging gap between posterior and anterior bands of that structure;
              - synovial cyst confined to cubital tunnel formed by posterior surface of medial epicondyle anteriorly & arcuate ligament posteriorly can readily give rise to ulnar neuropathy;
    - posterior interosseous nerve syndrome:
         - any protrussion from synovium is likely to displace PIN against sharp tendinous margins of origin of ECRB & superficial humeral lamina of supinator (ligament of Frohse);
         - paralysis of posterior interosseous nerve will result in loss of finger extension and should be distinguished from extensor tendon rupture;

- Stages:
    1: soft tissue swelling and osteoporosis
    2: mild narrowing of the joint space and some marginal erosion;
          - consider steroids injections, synovectomy, & possibly w/ excision of the head of the radius;
    3: joint space is significantly narrowed;
          - main destruction affects humeral-ulnar joint;
          - there may occur an anterior subluxation of the radial head;
               - here it may act as a mechanical block to flexion & extension, once there is erosive changes in trochlea;
               - consider excision of radial head to restore optimal f(x);
               - consider total joint replacement for severe intractable pain loss of extension beyond 60 deg, & instability 2nd to severe bone destruction;
    4: integrity of subchondral plates is breached by deep erosions;
          - there is extensive destructive of humeroulnar joint causing trachlear notch of olecranon to migrate proximally into deficient trochlea of  humerus;
          - w/ humeroulnar destruction, the radial head may be acting as a major stabilising force against the front of the capitellum;
                 - hence, radial head excision may worsen instability;
          - at this stage of the disease consider joint replacement;
    5: total joint destruction w/ complete loss of normal articular surface
          - ironically, as pt passes from stage 4 to stage 5, pt may become pain free, in a way achieveing self arthoplasty;


- Synovectomy:
    - pain should be a major indication for this procedure;
    - as noted by Gendi NS, et al (1997), strongest predictor of good results was limited pronation/supination w/ retained flexion-extension;
          - cummlative survival was 81% at one year and decreased 2.6% per year;
          - limited flexion-extension was an independent risk factor for a poor result;
          - patients may expect better gains in pronation and supination than flexion/extension;        
          - gains in supination are especially appreciated by patients, because supination cannot be well compensated for by shoulder motion (unlike pronation which is compensated for by shoulder abduction);
          - references:
                    - Arthroscopic and open synovectomy of the elbow in rheumatoid arthritis.
                    - Synovectomy of the elbow in rheumatoid arthritis. Long-term results.
                    - Elbow synovectomy and excision of the radial head in rheumatoid arthritis: a short term palliative procedure.
                    - Elbow synovectomy in rheumatoid arthritis. Long-term results.
                    - Synovectomy of the elbow and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome.
                    - Arthroscopic synovectomy of the elbow in rheumatoid arthritis.
                    - Surgery for rheumatoid arthritis of the elbow: a comparison of radial-head excision and synovectomy with total elbow replacement.

- Total Elbow Replacement

Surgical treatment of the elbow in rheumatoid arthritis.    

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, September 4, 2012 12:39 pm