Review Question - QID 216861

This patient has rheumatoid arthritis of the elbow, which is caused by pathologic pannus formation, leading to hyperplastic synovial proliferation and subsequent collagen and proteoglycan degradation.

Rheumatoid arthritis of the elbow is a common variation of elbow arthritis. The synovium becomes hyperplastic secondary to rheumatoid alterations and pannus formation. Synovial proliferation then leads to degeneration of collagen and proteoglycans, which affects the structure of the surrounding bones and soft tissues. Subsequently, the inflammatory cascade leads to chronic synovitis, ligament attenuation, periarticular osteopenia and contracture of the elbow. Osteophytic changes are not typically prominent as in primary/post-traumatic elbow osteoarthritis. Treatment is initially nonoperative with NSAIDs and steroid injections but total elbow arthroplasty (TEA) may provide significant benefit in patients with advanced disease, particularly those >65 years old. Semiconstrained components should be used, as there is often concomitant ligamentous instability.

Gill et al. reviewed the use of the Coonrad-Morrey TEA prosthesis in patients with rheumatoid arthritis. At 10-15 year follow-up 78 elbows were reviewed with 97% noted to be mildly painful or not painful. They noted that 14% of cases had complications and 13% required re-operation for various reasons. Ultimately, they concluded that in this population implant survival and success were both high.

Larsen et al. reviewed radiographic findings of rheumatoid arthritis for various joints. Typical radiographic findings of rheumatoid arthritis include periarticular erosion and cystic changes. Rheumatoid elbow arthritis can be graded on radiographs by the Larsen system.

Chen et al. reviewed rheumatoid arthritis of the shoulder, although they cover general principles of rheumatoid arthritis in all joints. They note that the pathologic process includes an inflammatory response which leads to synovitis, pannus formation and articular destruction. They conclude that surgical intervention in these cases can provide significant improvements in pain and functional status but attention must be paid to ensure the soft tissues are closely assessed.

Figure A demonstrates a lateral elbow radiograph with significant degeneration secondary to inflammatory rheumatoid arthritis.

Incorrect Answers:
Answer 2: Osteophytes are seen more commonly in primary osteoarthritis of the elbow, although this is less common than arthritis caused by rheumatoid disease.
Answer 3: TEA has typically been thought to have equal or better results when performed for rheumatoid compared to primary OA.
Answer 4: TEA should be managed with semiconstrained components due to concomitant ligamentous instability.
Answer 5: Pannus formation, not a rheumatoid factor mutation, is responsible for abnormal synovial proliferation leading to elbow destruction.