Rheumatoid Elbow

Elbow Rheumatoid ArthritisElbow Rheumatoid Arthritis 2

 

Epidemiology

 

50% rheumatoid patients have elbow pathology

- 80% also have shoulder pathology

- 90% hand and wrist

 

Always consider entire upper limb

 

Pathology

 

Synovitis

- swelling and pain

- may develop FFD due to holding in flexed position

 

Annular ligament may rupture

- anterior displacement of radial head

- due to pull of biceps

 

Collateral ligaments may rupture

- ML instability

 

Ulna nerve neuropathy

- synovitis

- rheumatoid nodule

 

Cartilage and bone destruction

- severe cartilage damage

- instability

- bony destruction

 

Management

 

Non Operative

 

SMART / DMART / Immunological medications

 

HCLA

 

Splints

 

Turnbuckle braces

- night time

- for loss of extension

 

Operative

 

1.  Synovectomy +/- radial head excision

 

Indications

- minimal OA

- significant synovitis

- young patient

 

Radial head excision

- to improve rotation

 

Contra-indications

 

Elbow instability

- can worsen

- may develop progressive valgus

 

Options

 

1.  Open

 

A. Extended Kocher

- limited access to posterior olecranon

- limited access to medial side

 

B.  Universal Posterior approach

 

2.  Arthroscopic

 

Results

 

Maenpaa et al J Shoulder Elbow Surg 2003

- 103 synovectomies open synovectomies via Kocker approach

- 5 year survival (reoperation / TER) 77%

- best with early OA
- no improvement in ROM but good pain relief

 

2.  Arthrodesis / Resection arthroplasty

 

Salvage only

 

3.  Interposition arthroplasty

 

Results inferior to arthroplasty

 

4.  Arthroplasty

 

A.  Non constrained

 

Need ST stability and balancing

- there is an incidence of postoperative instability (7 - 19%)

- good ROM

- need stems to prevent loosening (high failure rate of resurfacing)

 

Ewald et al JBJS Am 1993

- 202 follow up for 6 years

- 1.5% revision 

 

B.  Constrained

 

Higher early rates of failure

- 22% 4 year revision rate

 

C.  Semi constrained

 

Morrey JBJS Am 1998

- Coonrad - Morrey prosthesis

- 97% minimally painful at 10 years

 

Coonrad-Morrey

- anterior flange on humeral prosthesis very important to survival

 

Latitude prosthesis

- unconstrained can be converted to constrained

 

Total Elbow Replacement RA LatitudeTotal Elbow Replacement RA Latitude