Intraoperative findings reveal thick, villous synovium with or without rice bodies. The exudate covers the native articular cartilage from the margins, destroying the smooth edges of the cartilage and reducing the joint space.⁶ The often purulent joint effusion leads to friable articular cartilage in the centre of the joint, and as the elbow has a high level of constraint, this often leads to flaps of cartilage catching and/or locking the elbow as it extends. This, in addition to loose body formation, results in the common presentation of extension loss with anterior capsular tightness.

Classifications based on clinical presentation (Mayo Clinic Performance Index) and/or radiographic appearance (Mayo Clinic radiographic classification, Larsen Dale and Eek classification ⁵) (Table 42.1) have been published by Morrey and Adams⁷ (as well as the elbow functional assessment (EFA) scale⁸ and others), but no single classification covers the variety of clinical problems produced by rheumatoid disease in the elbow.

Table 42.1 Mayo Clinic classification of the rheumatoid elbow

Grade	Description
I	No radiographic abnormalities except periarticular osteopenia with accompanying soft tissue swelling. Mild to moderate synovitis is generally present
II	Mild to moderate joint space reduction with minimal or no architectural distortion. Recalcitrant synovitis that cannot be managed with non-steroidal antiinflammatory medications alone
III	Variable reduction in joint space with or without cyst formation. Architectural alteration, such as thinning of the olecranon, or resorption of the trochlea or capitellum. Synovitis is variable and may be quiescent
IV	Extensive articular damage with loss of subchondral bone and subluxation or ankylosis of the joint. Synovitis may be minimal

From Kauffman JI, Chen AL, Stuchin S, et al. Surgical management of the rheumatoid elbow. J Am Acad Orthop Surg 2003;11:100–108; data originally from Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg (Am) 1992;74:479–490.

Presentation

Painful synovitis

The rheumatoid elbow most commonly presents in the early stages with an effusion and boggy synovitis. The patient may be referred as a diagnostic problem or as a pauci-articular or mono-articular arthritis pending synovial biopsy. Proliferative synovitis is symptomatic due to inflammatory chemical mediators, and early synovectomy may be desirable in these cases.

Fixed flexion deformity

Later on, the patient may present with a fixed flexion deformity. Contractures of 30° or less are usually treated conservatively. However, as is commonly seen in rheumatoid arthritis, contracture can be more severe, requiring surgical intervention. Options for significant clinical deformity include soft tissue release (anterior capsulectomy) which may be either arthroscopic or open, or joint replacement surgery.

Articular pain, valgus deformity

The classic presentation of the severe chronic rheumatoid patient is with pain and stiffness. Pain occurs from the usual joint receptors, but also secondary to the invasive nature of the disease as there can be gross destruction of joint surfaces and of ligamentous attachments producing articular incongruity and deformity. Patients commonly present with valgus laxity due to disruption of the medial collateral ligament (MCL) as well as radial head destruction.⁹ Over time valgus deformity can also lead to a tardy ulnar nerve palsy.

Non-articular lesions

The proliferative synovitis may lead to synovial cyst formation. Occasionally this may also occur at the proximal radioulnar joint (PRUJ), which can result in an exertion of pressure on the posterior interosseous nerve (PIN).¹⁰ The ulnar nerve is at risk both from synovial proliferation due to its position within the cubital tunnel, and from a tardy ulnar nerve palsy from progressive valgus deformity.

Olecranon rheumatoid nodules can occur and ulcerate when pressure is applied. Olecranon bursitis can cause significant swelling over the olecranon tip and result in discomfort when resting the elbow down. Secondary cellulitis or infective bursitis can put the whole elbow joint at risk.

Investigation

General health

A patient with rheumatoid arthritis can also have various co-morbidities that require pre-anaesthetic evaluation. In particular, rheumatoid cervical spine disease can make operative positioning risky if not diagnosed or accommodated for.

It is also important to implement an appropriate order when planning surgery in these patients, as it is vital to consider quality of life and minimize the amount of time it is necessary to take off work. Routine practice is to operate first on the weight-bearing joints (hip, knee, ankle) if pain levels are similar, as the use of crutches in the postoperative period can have a detrimental effect on the elbow.

Serology

Exclusion of sepsis, and presence of rheumatoid factor (and other serological markers for inflammatory disease) can all be done with blood tests. Aspiration of the elbow allows screening and culture for infection, as well as the exclusion of crystal arthropathies (gout and pseudogout), foreign body synovitis and, rarely, malignancy.

Imaging

The most reliable radiological classification for rheumatoid arthritis of the elbow is the Larson classification (Fig. 42.1). Recent advances in computed tomography (CT) have led to excellent quality three-dimensional (3D) images of the elbow to localize sites of impingement, and also to examine congruity of the joint. Magnetic resonance imaging (MRI) is, however, the investigation of choice for assessing synovitis. The presence of fluid can be distinguished from boggy synovitis, and the sites of maximum involvement can help preoperative planning and decision making.¹¹ Ultrasound is of value when observing early synovitis and cysts, and is particularly useful when plotting the course of the radial nerve prior to surgery.¹²

Treatment options

Aims of these options

Surgical treatment of the elbow is used for several clinical purposes:

• Diagnosis: Arthroscopic synovial biopsy as part of arthroscopic treatment

• Debulking disease: Synovectomy can be performed both arthroscopically and open

• Regaining motion: Capsulectomy, removal of secondary spurs and resurfacing

• Pain relief: Radial head resection, synovectomy and joint resurfacing (Table 42.2).

Table 42.2 Procedural treatment options

Arthroscopic procedures	Arthroscopic synovial biopsy
	Arthroscopic synovectomy
	Arthroscopic capsular release
	Arthroscopic radial head resection
Open procedures
Lateral or Kocher approach	Synovectomy
	Synovectomy and capsulectomy
	Synovectomy/capsulectomy and radial head excision
	Posterior interosseous nerve release and excision of bursa
Posterior approach	Olecranon nodule
	Olecranon bursa ± spur
	‘OK’ procedure
Medial approach	Ulnar nerve release/transposition
Medial approach	Medial capsular release
Universal incision (posterior)
All of the above	Total elbow arthroplasty

Surgical techniques of typical conservative surgical procedures

Elbow arthroscopy

Technique

Elbow arthroscopy can be performed in either a supine, prone or lateral decubitus position. The preferred technique is in a lateral position between upright posts, allowing the non-dependent elbow to be flexed to 90° without undue stress being exerted on the shoulder. A small diameter ‘L’ bar is used to rest the arm over, and a tourniquet is positioned high on the arm. The use of TED stockings, adequate head and neck protection, and care for the contralateral arm (which is placed across the chest) is essential.

A series of protective techniques is highlighted to minimize the risk to local nerves, and in particular the posterior interosseous branch of the radial nerve.

Clinical Pearl 42.1 Five elbow arthroscopy nerve safety tips

1. Elbow must hang FREE of the elbow bar.

2. INSUFFLATE 20 mL of saline into joint.

3. Have an assistant PRONATE the arm when undertaking lateral.

4. SHARP dissection for anterolateral portal through SKIN ALONE.

5. Other anterior portals INSIDE OUT.

The preferred sequence is to begin with an anterolateral portal and examination of the anterior compartment. Next, a medial portal is established from inside out. With the latter the ulnar nerve is at risk, particularly if it has previously been transposed, or is prone to subluxation and, as such, care must be taken. A power shaver is then introduced through a cannula and a synovectomy of the anterior compartment undertaken. Again care must be taken as the median and, particularly, the radial nerve are in close proximity to the capsule.

If a capsulectomy is required then the safest technique is to release it off the humerus superiorly. Capsulectomy on the medial side of the joint is achieved by shaving to the layer of brachialis, which protects the median nerve. A retractor facilitates this by elevating the ‘at-risk’ structures during shaving.¹³ Laterally, the radial nerve can lie on the capsule and be in immediate danger when an anterior release is being undertaken; again use of a retractor may be helpful.

A curved narrow osteotome is then introduced medially which if required allows excision of the coronoid osteophyte. This may, however, produce a cartilage ledge on the articulating surface of the coronoid which must be resected manually (or with power) to prevent recurrence. Finally, the humeral articulating margin on the radial side often produces a ledge of bone which requires resection using a power burr to prevent radial head impingement.

The posterolateral portal is then established. This portal is used to visualize both the olecranon (posterior) fossa, and the posterolateral gutter posterior to the radial head. A switching stick is then used to approach each area respectively before sliding the arthroscopic cannula to this section of the joint.

Loose bodies often migrate to the posterolateral gutter. An accessory portal distal to the scope portal allows retrieval of these, and also access to shave any synovium within the gutter. An inflamed radiocapitellar plica is often present and can be removed at this point. Any loose cartilaginous attachments are also removed. On the lateral side it is not uncommon to see bone-on-bone contact between the radial head and capitellum. However, this may not necessarily be symptomatic and as such a decision to resect the radial head should not be made on the arthroscopic appearances alone, but on the clinical presentation of pain on the radial side of the elbow, particularly on pronosupination.

Clinical Pearl 42.2 The ‘LOST CORNER’ of the elbow; posterolateral gutter

• Access via the posterolateral corner portal but push blunt plunger DISTAL in towards the posterior radial head.

• Accessory (distal) posterolateral portal used to shave out capsule and plica, and find loose bodies.

• Excellent for capitellum examination if cartilage damage.

Attention is then turned to the olecranon fossa, where via a trans triceps portal a thorough synovectomy of the posterior synovium can be undertaken. The only risk here is from shaving outside the capsule over the medial gutter, with the close proximity of the ulnar nerve. If secondary osteoarthritic spurs are present, the impingement is usually not directly posteriorly, but along the condylar ridges from the sides of the olecranon. Therefore using a burr to debulk the condylar ridges is necessary. Several alternative portals are available posteriorly at varying levels above the joint to facilitate this process.

Whilst arthroscopic radial head resection has been described,¹⁴ there is a potential for damage to the posterior interosseous nerve which lies directly anterior to the resection site. Indeed it has been recommend that this procedure is only for the expert arthroscopist (Figs 42.2–42.4).

Figure 42.2 Elbow arthroscopic set-up.

Figure 42.3 (A,B) Elbow arthroscopy portals.

Figure 42.4 Bone on bone radial head to capitellum.

Rehabilitation

Elbow arthroscopy usually produces significant swelling around the elbow by the end of the procedure. Regaining full range of movement (or as near as possible) is the main aim of rehabilitation in the immediate postoperative period. This can be achieved by the use of passive motion machines, long-acting brachial plexus blocks, and/or intra-articular infusion of local anaesthesia. More recently, however, concerns have been raised about the chondrotoxicity of some local anaesthetics.¹⁵ There is no doubt, however, that early mobilization, particularly in the postoperative period will reduce the risk of subsequent scarring. Obviously any technique to minimize scar response or heterotopic ossification is worthwhile.¹⁶

Outcome and literature review

Arthroscopic synovectomy has been shown to produce good results in a select population, although these are tempered by longer-term studies showing a deterioration in this initial improvement. When comparing this method to open synovectomy (23 and 23 patients respectively), Tanaka et al ¹⁷ did not find a significant difference in clinical outcome after an average follow-up of 13 years. However, if the preoperative arc of flexion was less than 90°, then the patients who had undergone arthroscopic synovectomy had significantly better function. Finally, results also demonstrated an improvement in pain and function, with scores at mid- and long-term (13 years) follow-up, showing less deterioration over time with open synovectomy, although this was not statistically significant.

Jerosch et al ¹⁸ and Nemoto et al¹⁹ both reported significantly improved pain and function scores with arthroscopic synovectomy in 103 and 11 patients at an average of 6.2 and 3 years, respectively. Jerosch also found that patients with a shorter duration of preoperative symptoms tended to have a better outcome. Horiuchi et al²⁰ goes further to show that of 29 patients followed for 37 months, the Mayo Elbow Function Score (MEFS) and pain scores improved to a satisfactory level in patients with Larsen stage 1 or 2, compared with fair and poor results in Larsen stage 3 and 4. Lee and Morrey in 1997²¹ described 93% ‘excellent and good’ early results in 11 patients (14 elbows) treated by arthroscopic synovectomy, although this deteriorated to 57% at final 42 month follow-up with 4/14 conversions to total elbow arthroplasty. This finding is consistent with other studies showing a more rapid deterioration of symptoms following the arthroscopic technique as compared to open.

Irradiation therapy (radiosynoviorthesis) has had some reported success in the management of early rheumatoid at the elbow.²² Combining arthroscopic synovectomy with irradiation has also been successfully used to manage early rheumatoid arthritis of the knee, although this has yet to be reported in the elbow.²³ The results of arthroscopic resection of the radial head has been reported by Menth-Chiari et al¹⁴ in a cohort of 12 patients. They demonstrated an improved range of motion, diminished pain and improved function at a mean follow-up of 39 months. No patient was found to have instability.

Complications of treatment

All procedures are known to carry a risk of complications. Specifically for this procedure, the complications can be divided into those associated with elbow arthroscopy in general, and those for this particular procedure.

General elbow arthroscopy complications

Portal infection

This is often superficial, but can transfer into the joint and create a significant joint infection if left untreated.

Haemarthrosis

All involved joints will be affected by slight bleeding from portal sites, however, a significant intra-articular bleed will cause swelling and stiffness which may persist. Ultimately this will result in scarring, which may increase any existing stiffness.

Nerve injury

All the nerves around the elbow are at risk during routine arthroscopy.²¹ The ulnar nerve can be damaged by a poorly positioned medial portal, or an anterior portal if the ulnar nerve is subluxed. If an anterior capsulectomy is performed, both the median and, particularly, the radial nerve can be damaged.

Specific complications from arthroscopic rheumatoid synovectomy

There are several reported cases of heterotopic ossification following arthroscopic debridement of the elbow. Ultimately, these will require an open operation to restore motion. Generally, however, the long-term outcome is good.¹⁴ We have seen one case only of joint ankylosis following arthroscopic debridement (Fig. 42.5), which was in a young girl. There are no reports in the literature of this complication. Radial and ulnar nerve palsies usually resolve spontaneously, as discussed earlier.

Figure 42.5 Ankylosis post-arthroscopy.

Open radial head excision and synovectomy (RHES) (± capsulectomy)

Summary Box 42.2 Indications for RHE and synovectomy in rheumatoid arthritis

• Young or immunologically compromised patient with severe radiocapitellar disease.

• Manual worker with severe radiocapitellar disease (± radial head replacement).

• Patient on long-term crutches with severe radiocapitellar disease.

Technique

The procedure is usually undertaken under general anaesthesia, with the patient in a supine position. A high arm tourniquet is applied. Following preparation and draping the elbow is inspected for surface landmarks. An olecranon osteotomy may be necessary to achieve adequate exposure, although there is an added risk of non-union, loss of fixation and, ultimately, prominence of metalwork requiring removal. My preferred approach is via a Kocher incision if there is no requirement for capsular release. The alternative method is to perform a curved incision around the lateral epicondyle, following the humeral epicondylar ridge above the elbow and the common extensor origin below. This, like the lateral column procedure as published by Morrey et al,²⁴ allows access to the anterior compartment if necessary (Fig. 42.6). (Please see complete step by step images of this procedure on text website.)

Figure 42.6 Open approach.

The common extensor mass is split in the midline of the radial head. The lateral ulnar collateral ligament tissue (including extensor attachment) lies posterior to this division, meaning the elbow is not destabilized by this approach. The anterior tissue is stripped from the humerus, including the muscular attachment of the extensor carpi radialis longus. However, the brachioradialis muscle remains in situ.

The radial neck is captured between two Hohmann retractors, and a small oscillating saw is used to create a cut in the radial neck, 5 mm from the margin of the radial head. The radius is then rotated while sawing, in such a way that as the cut is completed the radial head stops rotating with the radial shaft. This indicates when the osteotomy is complete, and also helps prevent any damage from the saw blade.

The radial head is removed, and attempts are then made to ‘telescope’ the radial neck up to the capitellum. If any closure of this gap is noted, serious consideration should be given to replacing the radial head to prevent the ‘Essex-Lopresti’ effect occurring postoperatively.

Attention is then turned to the anterior capsule. The safest place to perform a capsulectomy is adjacent to the humeral reflection. Sharp dissection of the anterior margin of the humeral epicondylar ridge exposes the capsular attachment. Morrey describes a triangular resection with the apex at the medial margin. However, it is important to remember that the median and, indeed, the ulnar nerve if it has been previously transposed, are at risk. Care must also be taken to preserve the annular ligament and maintain stability. Anteriorly spurs may be present on the coronoid process, which require excision with an osteotome. It is also important to remember that impingement can occur along the ridges of the coronoid as well as at the centre of the articulation. Another common site for bony overgrowth is a ridge superior to the capitellum anteriorly which abuts the radial head in forced flexion. This should be burred back to achieve a healthy clearance on flexion.

After anterior capsulectomy, the anconeus compartment is opened and the area of ‘protected’ tissue that affords posterolateral stability is either preserved or reconstructed. The capsule posterior to this is then opened and the common lateral olecranon spur is trimmed. The elbow is then extended, to gain access to the olecranon fossa, where any clearance of loose bodies, spurs and capsule can be performed.

Determining stability is mandatory prior to closure. Specifically by examining for posterior elbow stability (after coronoid trimming), as well as posterolateral stability (after lateral approach) and finally telescope the radial neck towards the capitellum. Once satisfied that the elbow is stable, closure is performed in layers with strong dissolvable sutures. The skin is closed with either a subcuticular or continuous skin suture. Do not let the tourniquet down prior to closure. However, if there has been extensive soft tissue release, or there is any concern that larger vessels may be at risk, then achieving haemostasis prior to closure is recommended. Use of a drain is rarely required.

Rehabilitation

If there has been an extensive release, a continuous passive motion machine undoubtedly results in an improved early range of motion. However, it is important that this is monitored by experienced staff. Added to this, the patient shoulder receive adequate anaesthesia usually by way of continuous interscalene block.

An experienced elbow physiotherapist will undoubtedly improve the outcome of most elbow operations, and early assessment is helpful (even preoperatively for difficult cases). Aggressive physiotherapy is, however, felt by some to increase the risk of heterotopic ossification around the elbow, although the benefit of improved range of motion far outweighs this risk.

The use of postoperative indometacin for reducing the incidence of heterotopic ossification is recommended when treating hypertrophic osteoarthritis. In rheumatoid arthritis, however, this is a rare complication and, as such, this prophylaxis is not indicated.

Outcome

There are a number of publications relating to the outcome of this surgery, particularly as this procedure pre-dates elbow arthroplasty by several decades. Effective short-term results, medium-term results and, occasionally, long-term results are reported.

The most reliably improved outcome measure is for pain relief. Brumfield and Resnick ²⁵ reported on 42 elbows in 35 patients all with improved rest pain after open synovectomy and RHES at a minimum of 2 years follow-up, most of which had no further significant deterioration after an average of 7 years. Eichenblat et al²⁶ similarly showed improvement in rest pain in all but three of their 25 elbows in 21 patients at a follow-up of 2–11 years. Similarly Marmor²⁷ showed 17 of 19 patients had improvement at an average of 3.5 years. Lonner and Stuchin²⁸ retrospectively showed improvement in function and pain in all 11 patients (12 elbows) at an average of 6.1 years follow-up after open synovectomy, RHES and anterior capsule release. They also found no significant radiographic disease progression at final follow-up. Inglis et al²⁹ studied 28 elbows in 26 patients with improved pain despite three patients experiencing spontaneous ankylosis after a minimum of 1-year follow-up (average 3.5 years). Finally, Torgerson and Leach³⁰ reported five patients all of whom showed improvement at an average follow-up of 2 years. In all these studies the patients had advanced disease (stages III and IV) according the American Rheumatism Association criteria. In contrast, improvements regarding the arc of motion in flexion/extension are variable with at best 50% of patients showing improvement in the short term. The remaining patients reported no change, and up to 20% showed some loss of motion. Functional elbow outcome scores, however, have shown more durable improvements mainly as a result of pain relief, but as with motion, pain relief can deteriorate over time. Morrey in a review of the literature concludes that approximately 90% of patients experience relief from pain at 3 years, 75–80% at 5 years and 67% at 10 years.²⁴

Maenpaa et al ³¹ showed approximately 77% survivorship (no reoperation) at 5 years following 103 open synovectomies. Of the remaining 23%, eight re-synovectomies and 14 total elbow replacements were performed. Not surprisingly, none of the patients with a low Larsen stage (0–2) required conversion to total elbow replacement at final follow-up, and patients with a shorter duration of preoperative symptoms tended to have a better outcome. Comparisons of RHES conversion to total elbow replacement and primary total elbow replacement suggests that prior surgery makes arthroplasty surgery technically more difficult and increases the risk of complications (Schemitsch et al,³² Whaley et al³³ and Woods et al³⁴).

Complications

Whilst strictly not a complication, one of the problems of radial head resection and synovectomy (RHES) is that it does not alter the progression of disease. Specifically as the procedure does not address ulnohumeral cartilage damage, and if this progresses the patient will require further surgical intervention. Spontaneous ankylosis, decreased range of motion, nerve palsies (mainly radial and ulnar), instability and infection can all occur.²⁵^–²⁷ ^,29 ^,30 Ankylosis is more common in seronegative arthropathies such as dermatomyositis and ankylosing spondylitis²⁹ and usually occurs in the advanced stages of disease. Nerve palsies usually spontaneously resolve within 6 months. There can also be increased valgus instability after radial head resection, although this can be minimized by preserving the lateral collateral ligament complex and replacing the head if necessary. This occurs less often than one may expect due to the presence of concomitant disease at the distal radioulnar joint, which allows for compensatory motion. Finally, infection is a potential risk in many of these patients due to their often immunocompromised state. However, this can be avoided if close attention is given to haemostasis, wound closure and drain placement.

Summary Box 42.3 Comparison of relative indications of radial head excision/synovectomy and total elbow replacement

Radial head excision/synovectomy	Total elbow replacement
Younger	Older
Manual worker	Non-manual function
Reasonable bone stock	Poor bone stock
History of sepsis	No history of sepsis
Variable compliance	Good compliance