Review Question - QID 214856

The patient is presenting with degenerative changes to the elbow in the setting of rheumatoid arthritis. In the early stages of the disease, this can be effectively managed with arthroscopic synovectomy.

Rheumatoid arthritis is an inflammatory process that results in extensive synovitis of the large and small articular joints leading to erosive changes and deformity in prolonged uncontrolled cases. Early stages affecting the elbow can be successfully treated with arthroscopic synovectomy, especially if the arc of motion is greater than 90°. Several studies have demonstrated significant improvement in patient satisfaction and reported pain following arthroscopic synovectomy.

Tanaka et al. performed a retrospective study of 53 patients undergoing arthroscopic or open synovectomy for elbow rheumatoid arthritis. The authors reported minimal to no pain reported in 48% of patients in the arthroscopic group and 70% in the open group with no significant difference in the clinical results between the two procedures. They concluded that arthroscopic synovectomy is a reliable procedure and is indicated in patients with early rheumatoid arthritis and elbow range of motion >90°.

Horiuchi et al. retrospectively studied the outcomes of arthroscopic synovectomy of rheumatoid elbows. They reported a mean improvement in May elbow performance score from 48.3 points preoperatively to 77.5 points 2-years postoperatively and patients with Larsen grade 1 and 2 radiographic changes to have clinically favorable outcomes at 2 years. They concluded that arthroscopic synovectomy is a reliable procedure for rheumatoid arthritis of the elbow in the presence of early-stage radiographic changes.

Mäenpää et al. performed a retrospective study of 88 patients with rheumatoid arthritis of the elbow treated with synovectomy. They reported a 5-year reoperation-free rate of 77% with improved patient satisfaction and pain scores. They concluded that late-stage radiographic changes (Larsen 3) were associated with higher reoperation rates and conversion to total elbow arthroplasty.

Figures A and B are the AP and lateral radiographs of the right elbow with moderate degenerative changes of the radiocapitellar and ulnohumeral joint.

Incorrect Answers:
Answers 1 and 2: Patients with late-stage disease demonstrated by extensive erosive changes of the ulnohumeral and radiocapitellar joint are more suitable for a total elbow arthroplasty.
Answer 3: A fascial arthroplasty is an option for patients without elbow instability and those with a high degree of joint space narrowing. This would not be a first-line treatment option for early-stage elbow arthritis.
Answer 4: Open synovectomy with radial head excision is a treatment option for patients with extensive radiocapitellar disease or those with dislocation of the radial head leading to posterior interosseous nerve palsy.