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Surgical Management of the Rheumatoid Elbow Jeffrey I. Kauffman, MD, Andrew L. Chen, MD, MS, Steven Stuchin, MD, and Paul E. Di Cesare, MD Abstract Between 20% and 50% of patients with rheumatoid arthritis (RA) will demonstrate elbow involvement, usually within 5 years of disease onset. Destruction of the joint may seri- ously limit upper extremity function. Isolated presentation of RA of the elbow occurs in only about 5% of patients; approximately 90% of patients also have hand and wrist involvement, and 80% also have shoulder involvement. 1 Thus, a therapeutic program designed to provide relief for the elbow should consider the remainder of the extremity, , as well. Although nonsurgical treatment con- sisting of systemic therapy, physical therapy, judicious use of intra-articular corticosteroids, and bracing may be effective inmanycases,surgeryissome- times necessary. Both synovectomy and elbow arthroplasty may play a role. Pathology The patient with rheumatoid involvement of the elbow joint may initially have only marked synovitis and therefore present with pain and restriction of motion. In 10% of patients, the synovitis will spontane- ously resolve. 1 If synovitis persists, however, secondary changes may occur. A fixed flexion contracture may result in part from the patient’s holding the elbow in a flexed posi- tion to minimize pain caused by joint motion and capsular distension. Synovitis also may directly af- fect the ligamentous support of the elbow, with marked distension con- tributing to the impairment of elbow joint function. Destruction of the an- nular ligament surrounding the radial neck may cause radial head instability with anterior displacement resulting from the pull of the biceps brachii muscle. Damage to either or both the medial and lateral collateral ligamentous complexes, combined with bony and cartilaginous loss, may result in gross medial-lateral elbow instability. Proliferation of the synovium or distension of the joint capsule into the forearm may result in vascular, neural, or muscular dys- function, particularly compression of the ulnar or radial nerves. Prolonged synovitis ultimately is associated with erosion of the joint articular hyaline cartilage. Once the cartilage is lost, joint degeneration is accompanied by subchondral cyst and marginal osteophyte formation, further weakening the joint capsule and ligamentous supports. The end stage of disease in the elbow is marked by severe damage to the subchondral bone, loss of joint space, and progressive elbow instability, resulting in a joint that is painful, weak, and unstable. 1 Occasionally, synovitis may result in the formation of intraosseous synovial cysts within the distal humerus (trochlea, capitellum, or both) or the proximal ulna (coronoid and olecranon), facilitat- ing eventual collapse of the under- lying bone and causing the elbow to ″cave in on itself.″ 1 Dr. Kauffman is Attending Physician, Sacra- mento Knee & Sports Medicine, Sacramento, CA. Dr. Chen is Chief Resident, Orthopaedic Surgery, NYU–Hospital for Joint Diseases Or- thopaedic Institute, New York, NY. Dr. Stuchin is Associate Professor, Orthopaedic Surgery, NYU–Hospital for Joint Diseases Orthopaedic Institute. Dr. Di Cesare is Associate Professor, Orthopaedic Surgery and Cell Biology, NYU−Hospital for Joint Diseases Orthopaedic Institute. Reprint requests: Dr. Di Cesare, 301 East 21st Street, New York, NY 10003. Copyright 2003 by the American Academy of Orthopaedic Surgeons. Many patients with rheumatoid arthritis demonstrate elbow involvement that may limit upper extremity function, usually within 5 years of disease onset. Initial management consists of nonsurgical measures that address synovitis and capsular inflammation in an effort to diminish pain and maintain elbow range of motion. Disease progression may result in articular damage and ligamentous compromise, causing increased symptoms, elbow instability, and functional debilitation. For patients unresponsive to nonsurgical management, open or arthroscopic synovectomy may provide relief of symptoms. For those with more advanced disease, elbow arthroplasty is a reasonable alternative. Advancements in prosthetic technology and surgical techniques allow elbow arthroplasty to be reliably performed in patients with severe rheumatoid arthritis of the elbow. J Am Acad Orthop Surg 2003;11:100-108 100 Journal of the American Academy of Orthopaedic Surgeons Evaluation Because RA is a systemic disorder that can involve other joints and or- gan systems, a complete history and physical examination are integral to the evaluation. In particular, the functional performance and goals of the patient should be clearly elic- ited. The evaluation should include careful assessment of the ipsilateral hand, wrist, and shoulder as well as the entire contralateral upper extremity. It is crucial to understand that shoulder motion cannot fully compensate for limited elbow flexion and extension because elbow extension is necessary for extended reach of the upper extremity, especially on the dominant side. Anteroposterior and lateral radiographs of the involved elbow are needed for classification. Most classification schemes of RA of the elbow, such as the Hospital for Special Surgery (HSS) 1 or Mayo 2 schemes (Table 1), include the radiographic degree of joint involvement (Fig. 1) as well as clinical symptoms. Clini- cal evaluation also may be graded using the Mayo Clinic Performance Index, which takes into account the pain, motion, stability, and functional capacity of the involved elbow. 2 Nonsurgical Management Nonsurgical management of RA of the elbow focuses on maximizing treatment. Medical management is appropriate for patients with early (Mayo grade I or II) disease, as well as those with more advanced disease whose symptoms do not justify surgery. However, the response to medical treatment in patients with advanced RA is less predictable. The judicious use of intra-articular injec- tions of corticosteroids may be effective in those with late grade I or II disease who are not yet candidates for surgery. Physical therapy should emphasize pain control measures (eg, avoidance of activities that place stress on the elbow, regular periods of rest, and application of heat or cold) to encourage maintenance of mobility and muscle strength. Hinged elbow braces may be used during the day to provide comfort during flexion and extension while limiting painful varus and valgus stresses. Turnbuckle braces are occasionally used at night to reduce loss of motion. Patients who fail to respond to nonsurgical treatment may be candidates for surgical interven- tion. Optimization of functional capacity with preoperative physical therapy is desirable because the preoperative range of motion is often predictive of the postoperative arc of motion. Surgical Management Patients who fail to respond to nonsurgical measures often have severe A B Figure 1 Anteroposterior (A) and lateral (B) radiographs of moderate (Mayo grade II-III) RA of the elbow. Joint space narrowing and early subchondral cyst formation are evident. Table 1 Mayo Clinic Classification of the Rheumatoid Elbow 2 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 nonsteroidal anti-inflammatory medications alone. III Variable reduction in joint space with or without cyst formation. Architectural alteration, such as thinning of the olecranon, or re- sorption 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. Jeffrey I. Kauffman, MD, et al Vol 11, No 2, March/April 2003 101 disabling arthritis of more than one joint, many of which may require surgical management. The polyarticular nature of RA frequently necessitates surgery to address lower extremity involvement, as well. In general, the most disabling articulation should be addressed first, although staging also depends on the nature of the surgical procedure (ie, arthroscopic versus open). 1 When, with equivalent symptoma- tology, elbow surgery is performed first, lower extremity procedures should be delayed at least 3 months to avoid weight bearing on the re- covering elbow. This period may be extended to >6 months to allow for maximal functional recovery. When the lower extremity is addressed first, elbow surgery should be delayed until assistive ambulatory de- vices are no longer necessary. When there are multiple major disabilities of the upper extremity, treatment must be prioritized. Although the most appropriate sequence remains controversial, generally a joint sig- nificantly more involved than others should be treated first. Neer et al 3 preferred to operate on the shoulder before the elbow, arguing that a pain-free, mobile shoulder de- creases rotatory stress on the elbow and also may eliminate referred pain from the shoulder. Based on a retrospective review of 35 patients, Friedman and Ewald 4 recommended that if both the shoulder and elbow appear to be equally involved, the elbow should be operated on first. They found both subjectively and objectively that operating on the elbow first yields greater functional improvement of the upper limb and allows a longer interval between arthroplasties. Rarely, if ever, is there any indi- cation for arthrodesis in the treatment of rheumatoid disease of the elbow. A fused, rigid elbow places an increased functional demand on adjacent joints and is poorly toler- ated by patients because of its functional limitations, especially when combined with polyarticular rheumatoid disease. Synovectomy Elbow synovectomy with or without radial head excision is a well-recognized and accepted form of treatment for the rheumatoid elbow, especially for patients with grade II involvement. 5-13 Capsulot- omy and synovectomy with or without radial head excision, when done early, may be an effective treatment, lasting >10 years in up to 80% of patients. 6-12 Pain relief is common, but the rate of recurrence has been reported to increase markedly after 5 years. 13 There is controversy re- garding the success of synovectomy in later grades of rheumatoid disease, after articular destruction has occurred. However, extensive joint involvement is not an absolute con- traindication to synovectomy because even in patients with advanced disease (grades III and IV), synovectomy and capsular release with or without radial head excision may result in acceptable pain relief and increased elbow range of motion 11,14,15 (Fig. 2). Radial head excision may improve forearm rotation and reduce impingement between the radial head and the capitellum. However, radial head contouring also has been reported to give good return of forearm rotation. Elbow motion after radial head excision improved in 40% of patients, was unchanged in 45% of patients, and decreased slightly in 15%. 16 Although exposure during open synovectomy may be en- hanced by radial head excision, the loss of the radial head as an elbow stabilizer in the presence of ligamentous attenuation and loss of ulnotrochlear congruity may result in postoperative elbow instability and ulnar nerve irritation. Radial head excision is contrain- dicated in elbows with preexisting instability. Even in elbows without instability, removal of the radial head may result in recurrence of pain and loss of elbow rotation. The mechanical effects of radial head excision may contribute to long-term failure from factors such as overload of the medial collateral ligament, in- creasing valgus deformity, lateral subluxation, and progressive articular destruction secondary to increased ulnohumeral loading. 3,12 To reduce these risks, some have suggested radial head replacement. 13 However, radial head replacement with silicone has been associated with fragmentation and silicone synovitis and thus is not recommended. Results of radial head replacement for RA of the elbow with a metallic spacer have not yet been reported. Despite the favorable results reported for synovectomy, many of the patients who undergo the procedure are young and eventually will require further surgical procedures, such as total elbow arthroplasty. Ac- cordingly, it is important to understand the effect that synovectomy and particularly radial head excision can have on future arthroplasty. Only one report has examined this issue. 13 The authors evaluated patients who had undergone prior radial head excision and synovectomy and were converted to an uncon- strained capitellocondylar total elbow arthroplasty. Compared with patients who had undergone primary capitellocondylar total elbow arthroplasty, surgery was more difficult and led to inferior clinical results at a minimum 2-year follow- up. Each surgical approach to the elbow for synovectomy has limitations and advantages. The lateral approach is most commonly used for a limited subtotal synovectomy with removal of the radial head. This approach allows for removal of the bulk of the synovium within the elbow joint, but access to the synovium of the olecranon fossa poste- Surgical Management of the Rheumatoid Elbow 102 Journal of the American Academy of Orthopaedic Surgeons riorly is difficult and restricted, and exposure is insufficient for access to the medial joint recesses. This procedure usually can be done quickly and therefore is useful when a con- current wrist or hand operation is planned. 11 Although the extensile Kocher approach provides excellent visualization of the anterior capsule while preserving the medial collateral ligament, the ulnar nerve is not exposed and can be at risk. The Bryan-Morrey approach is advantageous for patients who may later require a total elbow replacement. In this posterior, triceps- reflecting approach, the fascia, triceps tendon, and periosteum from the proximal ulna are reflected lat- erally for exposure and later reat- tached to the ulna via drill holes. This approach does not allow the same visualization of the anterior capsule as does the extensile Kocher approach, but it does permit direct visualization of the ulnar nerve. Ole- cranon osteotomy (and nonunion as a complication) are avoided, and the same incision can be used for future total elbow replacement. However, many consider the approach unnec- essarily extensive for synovectomy because visualization of articular surfaces is limited if the collateral ligaments are retained. Thus, the Bryan-Morrey approach is rarely used unless prosthetic replacement is planned. Also, in a rheumatoid patient with soft-tissue deficiency over the olecranon, the partial release of the triceps insertion some- times fails to heal. Use of chemical synovectomy (eg, with osmic acid) has been limited because of the potential for cartilage damage and failure to address the radial head. Arthroscopic synovectomy has been done as a less inva- sive alternative to open procedures because of theoretically faster postoperative rehabilitation and posterior access to the synovium. The procedure is technically demanding and poses the risk of neurovascular in- jury. In one study of 14 arthroscopic synovectomies, an early success rate of 93% was reported; however, two cases of transient neurapraxia occurred. 17 The authors recommended arthroscopic synovectomy of the elbow in patients younger than 50 years with >90° of flexion arc and radiologic changes of grade III or less who fail to improve after 6 months of nonsurgical measures. Because of encouraging early results, arthroscopic synovectomy likely will become more routine in the management of the rheumatoid elbow, with faster postoperative rehabilitation and earlier return of motion. However, long-term follow-up studies are necessary to elucidate the lasting efficacy of arthroscopic syn- A B C D Figure 2 Anteroposterior (A) and lateral (B) radiographs of a patient with advanced (Mayo grade III-IV) RA of the elbow who complained of pain resistant to nonsurgical therapy, as well as a progressively diminished and painful arc of forearm rotation. The decreased and painful forearm rotation was attributed to synovitis and impingement of the degenerative radial head on the capitellum. Synovectomy, radial head resection, and débridement were done. Anteroposterior (C) and lateral (D) radiographs 6 years after surgery. The patient remained relatively pain free, with excellent range of forearm and elbow motion. Postero- lateral translation has occurred over time secondary to the loss of osseous (ulnotrochlear congruency, radial head) and soft-tissue (ligamentous attenuation) constraints. Jeffrey I. Kauffman, MD, et al Vol 11, No 2, March/April 2003 103 ovectomy. Horiuchi et al 18 examined the results of arthroscopic synovectomy of the elbow in 21 elbows (20 patients) followed for a minimum of 42 months. At a mean follow-up of 97 months, the Mayo elbow performance score improved from a mean of 48.3 points preoperatively to 77.5 points postoperatively, although only patients with mild radiographic changes had favorable long- term results with regard to total function. The authors concluded that arthroscopic synovectomy for the RA elbow can reliably alleviate pain, with the most durable results obtained for mild radiographic ar- thritic changes. 18 In a retrospective review of 473 consecutive elbow ar- throscopies, Kelly et al 19 reported serious complications (joint infec- tions) in 0.8% of procedures and mi- nor complications (superficial infection, persistent wound drainage, joint contracture ≤20°, and transient nerve palsy) in 11%. The authors concluded that although the complication rate after elbow arthroscopy was higher than previously reported, serious or permanent complications were uncommon. Arthroplasty In a report on soft-tissue interposition arthroplasty for RA of the elbow, Ljung et al 20 followed 35 elbows for a mean of 6 years. They concluded that pain relief is not as predictable, and functional result not as complete, as with joint replacement arthroplasty. These find- ings corroborate earlier reports on the results of interposition arthroplasty for the rheumatoid elbow. Re- section arthroplasty with and without interposition is now used as a salvage procedure, usually after infection, or to treat a failed, irretriev- able prosthetic joint. Prosthetic replacement is the procedure of choice for patients with advanced, debilitating (grades III and IV) RA of the elbow for which nonsurgical treatment and less aggres- sive surgical options (eg, synovectomy) have failed to provide adequate relief (Fig. 3). Elbow implants were first developed for posttraumatic arthritis and RA in 1947, in response to the inconsistent results of resection and interposition arthroplasty. Hemireplacement of the distal humerus was performed initially for destruction of the joint articular surfaces. The failure of these implants to adequately relieve pain led to the development of the total elbow prosthesis for replacement of both the humeral and ulnar articulating surfaces with a constrained design. 21 A B C D Figure 3 Radiographs of a nonconstrained total elbow prosthesis. Preoperative anteroposterior (A) and lateral (B) views. Postoperative anteroposterior (C) and lateral (D) views. Surgical Management of the Rheumatoid Elbow 104 Journal of the American Academy of Orthopaedic Surgeons Total replacement of the elbow with a constrained design (Fig. 4) for rheumatoid patients with pain, loss of motion, and/or instability was first reported in 1972. 21 Implants such as the Stanmore and the GSB-I (Gschwend, Scheier, Bähler) used a metal-to-metal hinge with polymeth- ylmethacrylate fixation. Loosening at bone-cement interfaces was a common complication thought to result from their rigid, constrained design. Morrey et al 22 reported a 24% failure rate at a mean of 4 years in a review of 80 total elbow replacements using the Coonrad or Mayo constrained prostheses and suggested using other prosthetic designs for patients requiring total elbow replacement. Semi- constrained implants with low-friction metal articulating with high-density polyethylene, as well as nonconstrained anatomic resurfacing mod- els, were developed in 1975 in an attempt to reduce loosening associated with constrained implants. Nonconstrained surface replacements use a cemented implant, rely- ing on the ligaments and surrounding musculature for joint stability. Examples of nonconstrained and semiconstrained prostheses are the Ewald capitellocondylar, Souter, Kudo, Pritchard-Walker, Mayo, GSB-III, and London prostheses. 2, 23-25 Constrained prostheses use a bearing system that has sufficient laxity (8° to 10° of varus- valgus and axial rotation) to prevent high torsional loading on the bone- cement interface yet provide stability independent of ligamentous in- tegrity. An example of the constrained system is the Coonrad-Morrey total elbow, which is permanently constrained and therefore cannot dislo- cate without hardware failure. 26 A meta-analysis demonstrated an overall complication rate of 43% and a revision rate of 18% for 828 total elbow replacements done primarily for RA over a 6-year period. 26 The most common complication cited was instability of nonconstrained prostheses. Permanent ulnar nerve sensory damage was reported in 1% to 3% of patients. The authors suggested that both complications may be avoided with more extensive surgical experience and use of constrained implants. Infection rates of 2% to 5% have been reported for all types of total elbow replacements. 26 With the newer constrained and nonconstrained designs, aseptic loosening is a less common complication in the rheumatoid elbow. Re- sults are summarized in Table 2. Nonconstrained Prostheses Nonconstrained implants generally have an anatomic design (Fig. 3). Current thought is that reasonable bone stock and ligament integ- rity, especially of the medial ligament complex, must be present if a successful result is to be obtained. However, further investigation is necessary to determine the contribu- tion of component malalignment and lateral ligament compromise to postimplant elbow stability. The in- A B C D Figure 4 Radiographs of a constrained total elbow prosthesis. Preoperative anteroposterior (A) and lateral (B) views. Postoperative anteroposterior (C) and lateral (D) views. Jeffrey I. Kauffman, MD, et al Vol 11, No 2, March/April 2003 105 sertion of nonconstrained implants can be challenging, requiring exact positioning as well as careful atten- tion to the soft tissues. In their meta- analysis, Gschwend et al 26 noted instability (dislocation, subluxation, or maltracking) in 7% to 19% of nonconstrained total elbow arthroplasties, with higher rates when bone or soft-tissue destruction or loss was notable. Barring complications, clinical results with nonconstrained surface replacements generally have been good. 27-33 In a large series of 202 capitellocondylar total elbow arthroplasties, Ewald et al 27 reported that at a mean follow-up of almost 6 years, elbow range of motion aver- aged −30° of extension to 135° of flexion, supination to 64°, and pron- ation to 72°. Radiographic evidence of loosening was noted in 4% of the humeral and 10% of the ulnar components; however, only 1.5% of patients required revision. Pöll and Rozing 23 reviewed the results of 34 consecutive Souter- Strathclyde implants (notable for hav- ing an extremely short humeral stem, extending only into the metaphy- seal region). Approximately 85% of the elbows were rated as satisfactory. Revision was performed in three patients because of instability and in one patient for aseptic loosening. One prosthesis was removed because of infection. Sjöden et al 30 reported on the results of 19 elbows in 18 patients with RAtreated with the Souter- Strathclyde prosthesis. At a mean 5-year follow-up, 6 prostheses demonstrated radiographic loosening, with migration of the humeral component. Two of the patients demonstrated clinical symptoms of loosening. The authors concluded that the use of long-stem humeral components is ad- visable in all patients. Simple replacement of the articular surfaces of the distal humerus and proximalulna has beenattempted, but because of the lack of intramedullary stems,thecomponents tended to loosen and displace. 34 A series of 32 unce- mented total elbow arthroplasties was reported to have a high rate of aseptic loosening; 16% needed revision for loosening at a mean of 3 years. 32 Kudo and Iwano 33 reported on a nonconstrained surface-replacement prosthesis in patients with RAand found that at an average of 9.5 years, 5 of 37 humeral implants had sustained gross posterior displacement. Most components now available have intramedullary stems, which help prevent the rocking or tilting motion that predisposes to aseptic loosening. Table 2 Results of Total Elbow Arthroplasty Study Type No. Patients No. Elbows/ RAElbows Mean Follow-up (yr) Pain Relief (%) Radiographic Loosening (%) Aseptic Revision (%) Compli- cations (%) Nonconstrained Prostheses Weiland et al 29 Capitellocondylar 35 40/32 7.2 94 25 0 43 Ewald et al 27 Capitellocondylar 172 202/202 5.75 87 10 1.5 34 Ruth and Wilde 35 Capitellocondylar 41 51/49 6.5 85 25 6 80 Rosenberg and Turner 28 Capitellocondylar 23 28/28 2.9 86 4 7 22 Davis et al 31 Capitellocondylar 27 30/28 3.3 NA 0 0 30 Kudo and Iwano 33 Kudo 1 and 2 36 37/37 9.5 83 70 11 NA Pöll and Rozing 23 Souter-Strathclyde 33 34/34 4 76 15 11 24 Sjöden et al 30 Souter-Strathclyde 18 19/19 5 79 32 0 26 Constrained and Semiconstrained Prostheses Inglis and Pellicci 34 Pritchard-Walker;triaxial 31 36/27 3.7 81 8 5.6 53 Morrey et al 22 Mayo, Coonrad 72 80/59 4 76 NA 15 55 Gill and Morrey 25 Coonrad-Morrey 69 78/78 10 * 97 6 7.6 14 Morrey and Adams 2 Modified Coonrad 54 58/58 3.8 91 0 3 22 Dee 21 Dee 12 12/12 1.2 91.6 0 8.4 8.4 NA = not applicable. * Forty-six elbows were followed for at least 10 years postoperatively. The remaining patients (32 elbows) died, had a revision <10 years postoperatively, or had been followed for <10 years. Surgical Management of the Rheumatoid Elbow 106 Journal of the American Academy of Orthopaedic Surgeons Constrained and Semiconstrained Prostheses Constrained ″sloppy hinge″ elbow prostheses allow for a degree of laxity that permits the soft tissues to absorb some of the stresses that would normally be transmitted to the prosthesis-bone interface (Fig. 4). In patients with RA, results with this type of prosthesis appear to be as good as those obtained with a nonconstrained total elbow design. When patient selection and surgical tech- nique are satisfactory, more than 85% of patients with RA have had good or excellent results with constrained prostheses. 24,25 In addition, motion is more predictably achieved than with a resurfacing prosthesis because a more nearly complete soft-tissue release can be done. In a study of 113 consecutive triaxial semiconstrained total elbow replacements, 90% of patients with RA had a satisfactory result at a minimum follow- up of 5 years. 24 A recent review of 78 Coonrad-Morrey constrained total elbow replacements, 46 of which were followed for at least 10 years, demonstrated that 97% of elbows were asymptomatic or minimally painful at final follow-up. 25 The authors reported 86% excellent or good results overall according to the Mayo elbow performance score and an overall survivorship of 92.4%. These results, although impressive, should be compared with the 4% revision rate of 202 capitellocondylar nonconstrained replacements reported by Ewald et al 27 and with similar results with the capitellocondylar elbow reported by others. 29,35 In a smaller series of constrained prostheses, Inglis and Pellicci 34 reported a 53% complication rate and a 22% revision surgery rate at a mean follow- up of 3.7 years. Four of the patients with complications went on to have unsatisfactory results; in total, seven patients had unsatisfactory results. The authors concluded that patient selection is a very important predic- tor of clinical outcome and that patients with severe inflammatory disease are the best candidates for total elbow replacement. 34 Because of the bone loss and soft- tissue involvement in severely involved elbows of rheumatoid patients, a constrained design is the prosthesis of choice for these patients. Nonconstrained prostheses may be an alternative for younger, more active patients because of the theoretic reduction of the risk of implant loosening and wear. Summary RA of the elbow is a progressive disease for which surgical management is indicated to relieve pain and improve function when nonsurgical measures have failed. Early arthritis may be managed with synovectomy for pain relief and improvement of elbow mobility. Progressive destruction resulting in joint instability or stiffness may be managed with total elbow arthroplasty. Advances in prosthetic design and surgical tech- nique have improved the reliability of elbow arthroplasty in these patients with low functional demand. Based on revision rates, elbow arthroplasty is nearly as reliable as hip and knee arthroplasties in patients with RA. References 1. Inglis AE, Figgie MP: Septic and non- traumatic conditions of the elbow: Rheumatoid arthritis, in Morrey BF (ed): The Elbow and its Disorders,ed2. Philadelphia, PA: WB Saunders, 1993, pp 751-766. 2. Morrey BF, Adams RA: Semicon- strained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74:479-490. 3. Neer CS II, Watson KC, Stanton FJ: Re- cent experience in total shoulder replacement. J Bone Joint Surg Am 1982; 64:319-337. 4. Friedman RJ, Ewald FC: Arthroplasty of the ipsilateral shoulder and elbow in patients who have rheumatoid arthritis. J Bone Joint Surg Am 1987;69:661-666. 5. Tulp NJ, Winia WP: Synovectomy of the elbow in rheumatoid arthritis: Long-term results. J Bone Joint Surg Br 1989;71:664-666. 6. Porter BB, Richardson C, Vainio K: Rheumatoid arthritis of the elbow: The results of synovectomy. J Bone Joint Surg Br 1974;56:427-437. 7. Saito T, Koshino T, Okamoto R, Hori- uchi S: Radical synovectomy with muscle release for the rheumatoid elbow. Acta Orthop Scand 1986;57;71-73. 8. Ferlic DC, Patchett CE, Clayton ML, Freeman AC: Elbow synovectomy in rheumatoid arthritis: Long-term results. Clin Orthop 1987;220:119-125. 9. Linclau LA,WiniaWP, Korst JK: Synovec- tomy of the elbow in rheumatoid arthritis. Acta Orthop Scand 1983;54;935-937. 10. Herold N, Schroder HA: Synovectomy and radial head excision in rheumatoid arthritis: 11patients followed for 14years. Acta Orthop Scand 1995;66:252-254. 11. Copeland SA, Taylor JG: Synovectomy of the elbow in rheumatoid arthritis: The place of excision of the head of the radius. J Bone Joint Surg Br 1979;61: 69-73. 12. Rymaszewski LA, Mackay I, Amis AA, Miller JH: Long-term effects of excision of the radial head in rheumatoid arthritis. J Bone Joint Surg Br 1984;66:109-113. 13. Lonner JH, Stuchin SA: Synovectomy, radial head excision, and anterior capsular release in stage III inflammatory arthritis of the elbow. J Hand Surg [Am] 1997;22:279-285. 14. Alexiades MM, Scott TS, Figgie MP, Inglis AE: Minimum ten year follow-up for elbow synovectomy for rheumatoid arthritis. Orthop Trans 1990;14:255. 15. Schemitsch EH, Ewald FC, Thornhill TS: Results of total elbow arthroplasty after excision of the radial head and synovectomy in patients who had rheumatoid arthritis. J Bone Joint Surg Am 1996;78:1541-1547. 16. Gendi NS, Axon JM, Carr AJ, Pile KD, Burge PD, Mowat AG: Synovectomy of the elbow and radial head excision in rheumatoid arthritis: Predictive factors Jeffrey I. Kauffman, MD, et al Vol 11, No 2, March/April 2003 107 and long-term outcome. J Bone Joint Surg Br 1997;79:918-923. 17. Lee BP, Morrey BF: Arthroscopic synovectomy of the elbow for rheumatoid arthritis: A prospective study. J Bone Joint Surg Br 1997;79:770-772. 18. Horiuchi K, Momohara S, Tomatsu T, Inoue K, Toyama Y: Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84: 342-347. 19. Kelly EW, Morrey BF, O’Driscoll SW: Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34. 20. Ljung P, Jonsson K, Larsson K, Rydholm U: Interposition arthroplasty of the elbow with rheumatoid arthritis. J Shoul- der Elbow Surg Am 1996;5(2 pt 1):81-85. 21. Dee R: Total replacement arthroplasty of the elbow for rheumatoid arthritis. J Bone Joint Surg Br 1972;54:88-95. 22. Morrey BF, Bryan RS, Dobyns JH, Lin- scheid RL: Total elbow replacement: A five-year experience at the Mayo Clinic. J Bone Joint Surg Am 1981;63:1050-1063. 23. Pöll RG, Rozing PM: Use of the Souter- Strathclyde total elbow prosthesis in patients who have rheumatoid arthritis. J Bone Joint Surg Am 1991;73:1227- 1233. 24. Kraay MJ, Figgie MP, Inglis AE, Wolfe SW, Ranawat CS: Primary semiconstrained total elbow arthroplasty: Sur- vival analysis of 113 consecutive cases. J Bone Joint Surg Br 1994;76:636-640. 25. Gill DR, Morrey BF: The Coonrad- Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: A ten to fifteen-year follow-up study. J Bone Joint Surg Am 1998;80:1327-1335. 26. Gschwend N, Simmen BR, Matejovsky Z: Late complications in elbow arthroplasty. J Shoulder Elbow Surg 1996;5(2 pt 1):86-96. 27. Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507. 28. Rosenberg GM, Turner RH: Noncon- strained total elbow arthroplasty. Clin Orthop 1984;187:154-162. 29. WeilandAJ, Weiss APC, WillsRP, Moore JR: Capitellocondylartotal elbow replacement:Along-term follow-upstudy. J Bone Joint Surg Am 1989;71:217-222. 30. Sjöden GO, Lundberg A, Blomgren GA: Late results of the Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis: 6/19 implants loose after 5 years. Acta Orthop Scand 1995;66:391-394. 31. Davis RF, Weiland AJ, Hungerford DS, Moore JR, Volenec-Dowling S: Noncon- strained total elbow arthroplasty. Clin Orthop 1982;171:156-160. 32. Kudo H, Iwano K, Nishino J: Cement- less or hybrid total elbow arthroplasty with titanium-alloy implants: A study of interim clinical results and spe- cific complications. J Arthroplasty 1994; 9:269-278. 33. Kudo H, Iwano K: Total elbow arthroplasty with a non-constrained surface- replacement prosthesis in patients who have rheumatoid arthritis: A long-term follow-up study. J Bone Joint Surg Am 1990;72:355-362. 34. Inglis AE, Pellicci PM: Total elbow replacement. J Bone Joint Surg Am 1980; 62:1252-1258. 35. Ruth JT, Wilde AH: Capitellocondylar total elbow replacement: A long-term follow-up study. J Bone Joint Surg Am 1992;74:95-100. Surgical Management of the Rheumatoid Elbow 108 Journal of the American Academy of Orthopaedic Surgeons . rheumatoid arthritis: 11patients followed for 14years. Acta Orthop Scand 1995;66:252-254. 11. Copeland SA, Taylor JG: Synovectomy of the elbow in rheumatoid arthritis: The place of excision of the head of the

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