Introduction

Involvement of the elbow is rarely the initial presenting sign of rheumatoid arthritis, nor does it usually present in isolation. The clinical signs in elbow pathology generally occur with more extensive disease, affecting up to 60% of the rheumatoid population.¹ Patients often present late, and the options for treatment can be dramatically reduced due to age, disease progression and post-management rehabilitation requirements.

This chapter will focus on the indications and techniques of surgical management in adult disease excluding joint replacement. Discussion will include open versus arthroscopic techniques for synovectomy and capsulectomy with or without radial head resection and olecranon bursectomy. It will not include total elbow arthroplasty.

Background/aetiology

Recent advances in medical management (especially the anti-tumour necrosis factor (TNF) α drugs including etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira)) have significantly slowed the rate of disease progression and therefore dramatically reduced the number of patients presenting with severe rheumatoid joint deformity and destruction.² Consequently early detection of the disease and medical intervention where appropriate have become a priority.

The presentation of rheumatoid arthritis is extremely variable, with systemic symptoms sometimes complicating the picture. When joint symptoms predominate it is often a symmetrical polyarthritis. Certainly, the hands and wrists are the most frequently affected joints, with the elbow being involved in 20–60% of cases.¹ Despite this variable presentation, joint involvement in rheumatoid arthritis is always characterized by inflammation and synovial hypertrophy.³ Treatment should be tailored to the pathology as it progresses through the relatively predictable radiographic Larsen stages of disease⁴ (Fig. 42.1). Put simply, the inflammation and synovial thickening lead to effusion, cartilage breakdown, erosions, nodules and capsulo-ligamentous thinning.

Figure 42.1 Larsen grade 3 rheumatoid arthritis elbow. (A) Anteroposterior view. (B) Oblique view.

Initially alternative causes of pain, effusion and swelling in the elbow must be excluded, such as septic arthritis, posttrauma, gout and even osteoarthritis. In the earlier stages of disease the diagnosis can be difficult, especially in rheumatoid monoarthritis or pauci-articular rheumatoid arthritis, and a synovial biopsy may be desirable. Arthroscopy facilitates diagnostic biopsy, with less morbidity in experienced hands than an open procedure.⁵

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.

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).