Rheumatoid Arthritis

 

Elbow RA 1Elbow RA 2

 

Epidemiology

 

50% rheumatoid patients have elbow pathology

 

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

- medial-lateral instability

 

Ulna nerve neuropathy

- synovitis

- rheumatoid nodule

 

Cartilage and bone destruction

- severe cartilage damage

- instability

- bony destruction

 

Xray

 

Articular destruction

Cysts

Osteopenia

Structural bone loss

 

Elbow RA 1Elbow RA 2

 

Management

 

Non Operative

 

Medications

 

SMARD - symptom modifying anti-rheumatic drugs

 

DMARD - disease modifying anti-rheumatic drugs

1. Conventional synthetic: methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide

2. Biological synthetic:

a. (TNF) inhibitors - etanercept, adalimumab, infliximab, certolizumab pegol, and golimumab

b. target other molecules: abatacept, rituximab, tocilizumab, sarilumab, and anakinra

 

Cortisone injections

 

Operative

 

Options

 

Synovectomy

Interposition arthroplasty

Total elbow arthroplasty

 

Synovectomy

 

Indications

- minimal OA

- significant synovitis

- young patient

- failure medications

 

Options

 

1.  Open

 

Extended Kocher

- limited access to posterior olecranon

- limited access to medial side

Universal Posterior approach

 

2.  Arthroscopic

 

Results

 

Gendi et al JBJS Br 1997

- 171 open synovectomies

- 81% survival at one year

- 54% survival at 6 years

 

Maenpaa et al J Shoulder Elbow Surg 2003

- 103 open synovectomies via Kocher approach

- 5 year survival (reoperation / TEA) 77%
- no improvement in ROM but good pain relief

- best with early OA

 

Kang et al Arthroscopy 2010

- 26 elbows underwent arthroscopic synovectomy

- at 30 months, 73% had good or excellent results

 

Interposition Arthroplasty

 

Ljung et al JSES 1996

- interposition arthroplasty in 35 RA elbows

- at 6 years 3 required TEA

 

Total Elbow Arthroplasty

 

Issues

 

Infection

Triceps - must preserve triceps insertion

Bone stock - deficient humeral columns

Intra-operative fracture - ulna at risk

Constraint

- unlinked require collateral and triceps integrity

- semiconstrained - linked pin and bushing with anterior humeral flange

 

TEA RA 1TEA RA 2

 

Results

 

Chou Bone Joint J 2020

- systematic review of 38 studies and 2118 patients with TEA for RA

- 7 year follow up

- implant failure 16%

- complication rate 25%

- young patients and unlinked design of TEA most at risk of aseptic loosening

 

Technique

 

Vumedi video TEA for RA

 

Boneschool Elbow Arthroplasty