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ELBOW ARTHROSCOPY IN THE MANAGMENET OF RHEUMATOID ARTHRITIS

ABSTRACT

Rheumatoid arthritis i s a disease of synovium which affects 1% of the population . The elbow is involved in over 50% of patients with polyarticular disease and is potentially disabling . Elbow arthroscopy permits the visualization of the joint space, cartilage and bone surfaces, as well as many of the extrinsic and intrinsic ligaments of the elbow joint. Elbow arthroscopy serves as a diagnostic tool, as well as a therapeutic option. This review provides clinicians and patients with information on new surgical therapeutic options in the management of patients with r heumatoid arthritis involving the elbow .

 

INTRODUCTION

Rheumatoid arthritis causes inflamed synovium which will destroy abutting tissue by enzymatic degradation. The destructive process will be accelerated if this inflamed synovium was placed under load. Both elbows are commonly involved, and the dominant elbow is typically more severely affected [1]. Patients initially present with pain and swelling due to synovitis and an effusion. Cartilage destruction, ligament attenuation, osseous erosions, and deformity progress as the disease becomes more severe. Secondary capsular contractures may develop, resulting in increasing stiffness. Elbow synovitis is associated with pain, stiffness, and loss of function. The major factors that cause restriction in the range of motion of the elbow are believed to be pain from synovitis, contracture of the anterior capsule , and loss of joint congruence, including spur formation, radial head deformity, and degenerative changes in the radiocapitellar joint.

 

Conventional Treatment

Rheumatoid elbow arthritis can be treated non-operatively, or surgically. In the past decade, improvement in and increased specification of medications for patients with r heumatoid arthritis has reduced surgical requirement. However, in cases where medical treatment is intolerable or conservative management cannot offer optimal symptom relief, surgery becomes an important option to be considered. Surgical procedures for rheumatoid arthritis include open radial head excision and synovectomy, arthroscopic synovectomy or total elbow arthroplasty. Elbows with less advanced articular destruction should be considered for synovectomy, whereas those with complete loss of articular cartilage and osseous deformities are best managed with total elbow arthroplasty.

Surgical synovectomy was first described over a hundred years ago and over the past few decades, had become a widely acceptable procedure to reduce symptoms in arthritic joints [2]. The goal of synovectomy is to prevent progression of chronic synovial inflammation . While o pen synovectomy is the operation for which the longest follow-up data are available and has been reported to provide long-term pain relief, but the risks of postoperative pain, wound breakdown, infection, and loss of ligamentous or muscular tissue supports may result in elbow stiffness. It can cause a delay in the initiation of rehabilitation and often aggravates the restriction of preoperative elbow movement, which reduces the ability of the patient to perform the activities of daily living [3,4,5,].

 

Surgical Therapeutic Option

Elbow arthroscopy has evolved over the past decade [2]. Initially used for simple removal of loose bodies or examination of a painful joint, it is now being employed for resection of symptomatic plicae, release of the capsule in elbow flexion contracture, synovectomy for inflammatory arthritis, management of osteochondritis dissecans, removal of osteophytes, debridement in lateral epicondylitis, and therapeutic option for selected elbow fractures [6-12]. Arthroscopic synovectomy has the advantages of being relatively atraumatic , offering better joint visualization and accessibility in multiarticulated complex elbow joint and quicker rehabilitation with l ess postoperative joint stiffness when compared with conventional open synovectomy.

As part of the pre-operative assessment, documentation of th e following aspects of the affected elbow is necessary [6]. The range of motion of the elbow and forearm should be measured ; limited motion may occur as a result of a tense effusion with synovitis, capsular contracture, or osseous deformity. Elbow stability should be evaluated with stress to the collateral ligaments with varus and valgus loading. Joint laxity should also be assessed as it is common sequel to loss of articular cartilage and to ligament attenuation from chronic inflammation. When a patient has lost forearm rotation, the distal radioulnar joint should also be examined clinically and radiologically to determine the contribution of the proximal and distal articulations to the forearm stiffness [6,13].

In general, arthroscopic elbow synovectomy is recommended for patients with some preserved articular cartilage and only mild bone deformity who have mild radiographic changes. Retention of the radial head should be considered for most patients unless there is severe deformity interfering with rotation. In the presence of a competent medial collateral ligament, for patients with articular deformity impeding rotation however, radial head excision should be considered, which can be performed arthroscopically at the time of synovectomy. Osteophyte removal and capsulectomy can also be performed arthroscopically along with the synovectomy to improve motion, if needed.

Pre-operative assessment of the range of elbow movement in terms of arc of flexion has been correlated with surgical outcomes. For flexion of > 90°, the clinical results of arthroscopic synovectomy have been comparable with those of open synovectomy. In elbows with a preoperative arc of flexion of <90°, arthroscopic synovectomy has been reported to provide significantly better function than open surgery at the time of the mid-term follow-up. One the other hand, it has been suggested that fibrous ankylosis of the elbow may be a contraindication to the safe performance of arthroscopic synovectomy [14].

Arthroscopic synovectomy has mid-term follow-up with cumulating long-term results becoming available [14-17]. The success depends on the severity of the arthritis; for instance, optimal results are achieved for elbows that do not have substantial osseous deformity and have some preserved articular cartilage [4,17]. Following arthroscopic synovectomy, immediate (on the day of surgery) rehabilitation can be employed and this might be an important factor in achieving the best long-term range of motion. Postoperative management of arthroscopic elbow procedure depends on the extent of the arthroscopic surgery. If only a synovectomy is being performed, a sling and with an early active range of motion can be administered. For patients who require a more extensive debridement with a capsulectomy, continuous passive motion or a splinting regimen will be required.

Like open synovectomy, recurrent synovitis may occur after arthroscopic synovectomy. Complications of elbow arthroscopy include compartment syndrome, infection including septic arthritis, nerve injury, prolonged drainage, and contracture [18]. The most common complication has been persistent portal drainage, and the most serious has been deep infection. The close proximity of major neurovascular structures means that the potential for injury to neurovascular structures remains a concern, and substantial injury involving the radial, median, and ulnar nerves has been reported during elbow arthroscopy [19-21]. Adequate exposure of the anatomical structures by retractors is probably the most important factor in preventing nerve injury [18].

 

Conclusion

Early surgical intervention with arthroscopic synovectomy may be warranted for patients with rheumatoid arthritis. It allows maximal benefit in terms of a positive, long-lasting effect with reduction in pain and increase in functional capacity of the joint. However, it cannot be over-emphasized that such procedure is technically demanding and requires advanced arthroscopic techniques of an experienced surgeon with vigilance to detail and an in-depth knowledge of joint anatomy especially in a stiff elbow. The best results and least complications of arthroscopic synovectomy in part depend on the arthroscopic experience of the surgeon.

With the availability of concomitant disease-modifying agents to control rheumatoid arthritis, the prevalence of uncontrolled synovitis of the elbow appears to be diminishing. Patients have a lower prevalence of recurrent synovitis and a better long-term outcome. The judicious use of arthroscopic synovectomy of the elbow is required for effective management of pain and optimization of function in patients with otherwise well-controlled disease.

 

THIS MATERIAL DOES NOT CONSTITUTE MEDICAL ADVICE. IT IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. PLEASE CONSULT A PHYSICIAN FOR SPECIFIC TREATMENT RECOMMENDATIONS.