Results of elbow synovectomy in rheumatoid arthritis

Summary Synovectomy of the elbow was performed on 54 patients (70 elbows) with rheumatoid arthritis. The mean follow-up time was 7.5 years (range 1.5–22 years). Clinical evaluation showed marked relief of pain in 58 elbows (40%). In 27 cases (38.5%) the pain was moderate but still less than preoperatively. Severe pain was recorded in 15 cases (21.5%) at the time of check up. As to postoperative range of movement, the mean flexion are was 114.5° and the mean rotation are 134.5°. Latitudinal instability was recorded up to 5° in 33 (47%) elbows, up to 10° in 20 (28.5%), up to 15° in 6 (8.5%), and more than 15° in 11 (16%). The mean carrying angle was 10° in valgus. Measurement of strength in flexion and extension showed a reduction of approximately 50% compared to age-matched healthy controls. Reoperations were performed in 10 elbows (14%); the interval between the primary synovectomy and second operation in these cases averaged 8 years.     

Results of the Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis: A preliminary report

The results of 19 consecutive Souter-Strathclyde total elbow arthroplasties (Zimmer, London) in 17 patients with a mean follow-up time of 41 months are reported. Pain relief was achieved in all cases, with 13 elbows becoming entirely painfree. The mean range of flexion increased 24° and extension improved 8°, with upper limb function greatly improved. The complication rate was 32%, including three nerve palsies, of which two resolved completely, and three early postoperative dislocations. There were two cases of prosthetic loosening, one following revision surgery for a traumatic humeral fracture in the early postoperative period. The authors consider the overall functional results with the Souter-Strathclyde prosthesis to be satisfactory in this group of patients.     

The Kudo total elbow arthroplasty in patients with rheumatoid arthritis

A Kudo total elbow arthroplasty (TEA) was performed in 36 elbows in 35 patients with rheumatoid arthritis. Of those 35, 4 died, 6 prostheses were revised, and 2 were lost to follow-up. Twenty-four elbows with a mean follow-up of 58 months were radiologically and clinically reviewed. Sixteen were scored as excellent by use of the Mayo score and Hospital for Special Surgery 2 score. The mean increase in active motion was 25 degrees. Two humeral and four ulnar radiologic loosenings were noted. Two early dislocations were successfully treated with closed reduction and cast immobilization, two patients used an elbow brace after the closed reduction, and one patient underwent a resection arthroplasty for instability and deep wound infection. Four aseptic loosenings, of which three had an intraoperative fracture at the index operation and one had instability, were revised. Despite initially excellent results, longer follow-up of TEA in rheumatoid patients demonstrated deterioration of the outcome and increased loosening.     

Mid-term outcome of GSB-III total elbow arthroplasty in patients with rheumatoid arthritis and patients with post-traumatic arthritis

Introduction  

We reviewed the mid-term outcome of GSB-III semi-constrained total elbow arthroplasty (TEA) and compared the results of patients with rheumatoid arthritis (RA) and those suffering from post-traumatic arthritis (PTA).     

Micromotion of the Souter-Strathclyde total elbow prosthesis in patients with rheumatoid arthritis

21 elbows in 18 patients with rheumatoid arthritis were treated with a Souter-Strathclyde total elbow prosthesis. 18 elbows were included in a radiostereometry (RSA) study. The aim of this clinical RSA study was to assess the three-dimensional micromotion pattern of the Souter-Strathclyde prosthesis, and thereby gain insight in the aseptic loosening process of this prosthesis. Implants were defined as at risk of aseptic loosening when the translation rate during the second postoperative year was more than 0.4 mm along one or more coordinate axes and/or the rate of rotation was more than 1° about one or more coordinate axes. Clinical examination revealed an increase in the range of motion and a marked reduction in pain. The RSA showed that 8 of 18 humeral components were at risk of aseptic loosening, although no signs of such loosening - defined as a complete radiolucent line of 2 mm or more - were found on the plain radiographs. In 7 humeral components, an anterior tilt about the transverse axis was seen that resulted in an anterior translation of the proximal tip and a posterior translation of the component's trochlea. Long-term studies of the Souter-Strathclyde prosthesis, have shown that this rotation is a specific pattern of failure in some implants. None of the ulnar components was at risk for aseptic loosening. Improvements in fixation of the Souter-Strathclyde total elbow arthroplasty should focus on the humeral component. At present, the lateral flange of the implant is enlarged to improve rotational stability about the transverse and longitudinal axes. The effect of this change in design on micromotion of the Souter-Strathclyde total elbow prosthesis will be studied in a randomized RSA study comparing the new design to the existing one.     

Total elbow arthroplasty in rheumatoid arthritis

Background and purpose Although total elbow arthroplasty (TEA) is a recognized procedure for the treatment of the painful arthritic elbow, the choice of implant is still obscure. We evaluated the survival of different TEA designs and factors associated with survival using data from a nationwide arthroplasty register.

Methods 1,457 primary TEAs for rheumatoid elbow destruction were performed during 1982 to 2006 in one hospital specialized in the treatment of rheumatoid arthritis (n = 776) and in 19 other hospitals (n = 681). The mean age of the patients was 59 years and 87% of the TEAs were performed in women. We selected different contemporary TEA designs, each used in more than 40 operations including the Souter-Strathclyde (n = 912), i.B.P./Kudo (n = 218), Coonrad-Morrey (n = 164), and NESimplavit/Norway (n = 63) to assess their individual survival rates. Kaplan-Meier analysis and the Cox regression model were used for survival analysis.

Results The most frequent reason for revision was aseptic loosening (47%). We found no differences in survival rates between different TEA designs. We did, however, find a 1.5-fold (95% CI: 1.1–2.1) elevated risk of revision in unspecialized hospitals as compared to the one hospital specialized in treatment of rheumatoid arthritis. In the Souter-Strathclyde subgroup, there was a reduced risk of revision (RR 0.6, p = 0.001) in TEAs implanted over 1994–2006 as compared to those implanted earlier (1982–1993). The 10-year survivorship for the whole TEA cohort was 83% (95% CI: 81–86), which agrees with earlier reports.

Interpretation The influence of implant choice on the survival of TEA is minor compared to hip and knee arthroplasties. Inferior survival rates of the TEAs performed in the unspecialized hospitals demonstrates the importance of proper indications, surgical technique, and postoperative follow-up, and endorses the need for centralization of these operations at specialized units.     

Long-term results of unconstrained Roper-Tuke total elbow arthroplasty in patients with rheumatoid arthritis

We evaluated the long-term results of 12 unconstrained Roper-Tuke total elbow replacements that were performed in 12 patients with rheumatoid arthritis from 1983 to 1989. The mean follow-up period was 9.5 years (range 8 to 13 years). We used the Ewald elbow-scoring system to chart results. This showed that the scores for the 12 elbows had improved from an average preoperative score of 39 points (range 17 to 72 points) to an average postoperative score of 80 points (range 45 to 97 points). The greatest improvements were in terms of pain relief, function, and range of motion. Eight elbows were free, of pain by the end of follow-up. Average elbow flexion increased from 115° before operation to 140° after operation, and pronation and supination increased from 52° to 61° and 42° to 71°, respectively. Radiographs of the 12 elbows showed constant wear of the ulnar polyethylene with loosening of 2 ulnar components. Revision of the prosthesis was necessary in 2 elbows because of aseptic loosening. Complications included 1 subluxation, 1 supracondylar fracture, and 2 ulnar neuropathies. Despite some excellent clinical results with a follow-up of over 10 years, the authors no longer recommend the use of this kind of elbow prosthesis in patients with rheumatoid arthritis because of the high complication rate and the impossibility of adapting this implant in the event of bone loss. The authors propose a new classification of humeral bone loss that will allow for better planning of primary and revision total elbow arthroplasties.     

Synovectomy of the elbow in rheumatoid arthritis

The combined procedure of synovectomy and resection of the radial head was performed in thirty-five patients (forty-two elbows) with Stage-III or IV rheumatoid arthritis. These patients were followed postoperatively for a minimum period of two years (average, seven years). The result was graded as excellent in four, good in fifteen, fair in fourteen, and poor in nine elbows. Pain was diminished from the preoperative level in all but six elbows, but motion was not much improved. Synovitis recurred postoperatively in thirteen elbows, but in only five did the destructive process progress to a degree requiring a second operation. We think that synovectomy for relief of pain in the elbow is not contraindicated in the presence of Stage-III or IV rheumatoid disease, but that little improvement of elbow motion can be expected.     

Arthroplasty of the elbow in rheumatoid arthritis

Summary The study consists of 208 elbow arthroplasties performed on rheumatoid arthritic patients. A straight resection of the joint was used in 53 cases and a modified Hass arthroplasty with skin interposition in 155 cases. The average postoperative range of motion in these groups was 100 degrees and 96 degrees respectively. Postoperatively the joint was painless in 81 and 67% of the elbows respectively. The Hass arthroplasty gave a better stability and extension power. The most common complications were paresthesias in the region of the ulnar nerve and bone resorption in the region of the olecranon fossa.

---

Zusammenfassung Diese Untersuchung umfaßt 208 Arthroplastikoperationen am Ellbogengelenk bei Patienten mit primär chronischer Polyarthritis (Arthritis rheumatoides). Die gerade Resektion in diesem Gelenk wurde in 53 Fällen und die modifizierte Arthroplastik nach Hass mit Interposition der Haut in 155 Fällen durchgeführt. Das durchschnittliche Motilitätsausmaß entsprach in diesen Gruppen 100 bzw. 90°. Postoperative Indolenz war entsprechend bei 81 und 67% der Fälle festzustellen. Die Arthroplastik nach Hass ergab eine bessere Stabilität und Extensionskraft. Die häufigsten Komplikationen waren Paraesthesien im Gebiet des Nervus ulnaris und Knochenresorption im Gebiet der Fossa olecrani.

     

Upper limb function improvement following total elbow arthroplasty in patients with rheumatoid arthritis

Thirty-one primary total elbow replacements were implanted in 25 patients with rheumatoid arthritis between 2000 and 2004 by a surgeon. Twenty-six implants were GSB III. Seven were Coonrad–Morrey prostheses. The mean age of the patients was 70 years (40–88); 18 women, 6 men. DASH scores were recorded pre-operatively and at their latest review. Patients were also assessed according to the Mayo elbow performance score post-operatively. Mean follow-up was 29 months (8–55). The mean improvement in DASH (disabilities of the arm, shoulder and hand) was 25 (+6 to −45). The mean Mayo score (Corectly is the Mayo Elbow Score, there is also a Mayo liver score and other scores prposed in this center) was 85 (15–100). One implant was removed following deep infection (3%). One implant has been revised secondary to ulnar component fracture. Our overall major complication rate was 7%.     

Imaging in rheumatoid arthritis of the elbow

Early specific radiologic changes of rheumatoid arthritis can usually be detected in the hands and feet. Later stages of the disease process show a typical centripetal spread of the affected joints, i.e., shoulder, elbow, and knee. For prognostic assessment of cubital rheumatoid arthritis, conventional radiography still remains the gold standard. X-rays allow objective scoring and thus classification into standardized stages. A concentric destruction of the rheumatic joint as compared to deformity in the degenerative joint is the typical radiologic symptom to look for. For soft tissue assessment, ultrasound (US) should be the diagnostic tool of choice. Due to the thin surrounding soft tissue layer, as well as the advanced high-resolution technology, bony structures can also be well demonstrated in any plane. In the early arthritic stages, particularly the small changes, e.g., minimal erosions of the cortical area, are very well detectable by US. The use of "color" allows good evaluation of the synovial inflammatory status. Modern imaging methods such as computer- assisted tomography (CAT) scan and magnetic resonance imaging (MRI) are restricted to a few set indications and should not be chosen for routine examination. More invasive methods such as arthrography are no longer indicated for assessment of cubital rheumatoid arthritis.     

Arthroplasty of the first metatarsophalangeal joint with a double-stem silicone implant. Results in patients who have degenerative joint disease failure of previous operations, or rheumatoid arthritis.

Sixty-six patients who had a total of eighty-six double-stem silicone implants in the first metatarsophalangeal joint were followed prospectively for an average of 5.8 years (range, two to fifteen years). There were two groups of patients: thirty-four patients (thirty-seven implants) who had degenerative joint disease (including those who had hallux rigidus or in whom a previous operation on a bunion had failed) and thirty-two patients (forty-nine implants) who had rheumatoid arthritis. The implants were used only if the patient was a candidate for an excisional arthroplasty or an arthrodesis; they were not used in patients who wished to maintain or adopt very active use of the foot (such as in running, jogging, and tennis) or to wear very high heels. Twenty-eight (82 per cent) of the thirty-four patients in the first group were completely satisfied and three (9 per cent) were somewhat satisfied. However, three patients (9 per cent), all of whom had had a failed bunionectomy, were dissatisfied; the ages of these three patients were less than the average age of all patients in the first group. Radiographs showed a fracture in three implants, but the patients had a good clinical result and an additional operation was not warranted. Twenty-seven (84 per cent) of the thirty-two patients in the second group were completely satisfied, four (13 per cent) were somewhat satisfied, and one (3 per cent) was dissatisfied. Radiographs showed a fracture in five implants. Four of the implants caused no symptoms, and the result was good; the fifth one was fragmented and was removed because of symptoms. Radiographs showed radiolucent areas around the implant and hypertrophic changes in many patients. There was no evidence of synovitis, such as that caused by silicone, either clinically or radiographically. We found that the double-stem silicone implant was effective in reconstructing the first metatarsophalangeal joint but emphasize our belief that it should be used only in carefully selected patients.     

Recurring synovitis as a possible reason for aseptic loosening of knee endoprostheses in patients with rheumatoid arthritis

We evaluated histologically samples of synovial tissue from the knees of 50 patients with rheumatoid arthritis (RA). The samples were taken during revision for aseptic loosening. The findings were compared with those in 64 knees with osteoarthritis (OA) and aseptic loosening and in 18 knees with RA without loosening. The last group had been revised because of failure of the inlay or the coupling system of a constrained prosthesis. All the patients had had a total ventral synovectomy before implantation of the primary prosthesis. In all three groups a foreign-body reaction and lymphocellular infiltration were seen in more than 80% of the tissue samples. Deposits of fibrin were observed in about one-third to one-half of the knees in all groups. Typical signs of the reactivation of RA such as rheumatoid necrosis and/or proliferation of synovial stromal cells were found in 26% of knees with RA and loosening, but not in those with OA and loosening and in those with RA without loosening. Our findings show that reactivation of rheumatoid synovitis occurs after total knee replacement and may be a cofactor in aseptic loosening in patients with RA.     

The Kudo elbow prosthesis in rheumatoid arthritis

The Kudo prosthesis is the most commonly used elbow implant in Sweden. However, there are few reports of the results, besides those reported by Kudo himself. I have implanted 30 Kudo type 4 or 5 elbow prostheses in 28 patients with rheumatoid arthritis. 3 arthroplastics were revised, 2 because of loosening and 1 because of a periprosthetic ulnar fracture. 6 major peroperative or early postoperative complications occurred, but only 1 of these was a failure. 2 patients developed postoperative ulnar neuropathy, one was transient and the other patient died 1 year after surgery. 26 elbows were available for follow-up at an average 5 (2-8) years after implantation. All 26 functioned well although radiographic loosening of the humeral component was found in 1 patient. The average range of flexion increased by 14 degrees while the extension lag was unchanged (35 degrees). Activities of daily living had improved markedly and all but 3 patients were satisfied with their elbow. Radiolucent lines were seen around the proximal part of the ulnar component in 18/26 elbows. Although progressive in 1 patient only, this is a matter of concern, indicating that this component may be the weak part of the Kudo prosthesis.