Arthroscopic and Open Synovectomy of the Elbow in Rheumatoid Arthritis

Author(s): Tanaka, N, Sakahashi, H, Hirose, K, Ishima, K, Ishii, S

Source: Journal Bone and Joint Surg 88A:3, 521-525, 2006.

Summary:

This study compares the results of arthroscopic and open synovectomy of elbows in patients with rheumatoid arthritis with Larsen grade 2 or less radiographic changes.  Twenty-three elbows underwent arthroscopic and twenty-three underwent open synovectomy by two different surgeons.  The mean age of the patients at the time of surgery was 51 years (range, 31-64 years).  The average duration of rheumatoid disease and elbow pain were 7.6 years and 2.4 years, respectively.  The average follow up was 13 years (range, 10-18 years).  A standard arthroscopic synovectomy was performed using four portals with immediate postoperative range of motion without application of a splint.  The open synovectomy was performed via an extended Kocher approach with detachment of the lateral collateral ligament without resection of the radial head and long arm splinting for approximately one week prior to initiating range of motion exercises.  Forty-eight percent of the arthroscopic group and seventy percent of the open synovectomy group had minimal or no pain at the latest follow-up evaluation. However, there was no significant difference between the overall clinical results of these two groups.  In both, the average pain score, daily function score of the upper limb and mean Mayo Elbow Performance Score significantly improved.  However, the elbows with a preoperative arc of flexion less than 90 degrees had significantly better function on average following an arthroscopic synovectomy than the elbows following an open synovectomy at the mid-term evaluation.  Although the mean scores for pain were lower, the mean arcs of motion and the mean scores for function and the Mayo Elbow Performance Score were higher in the arthroscopy group than in those of the open synovectomy group at the midterm and latest evaluations.  In the 15 patients that had an open synovectomy with less than 90 degrees of elbow flexion preoperatively, three elbows ankylosed with progressive joint destruction and ultimately underwent a total elbow arthroplasty between eight and nine years after surgery.  There was one transient neurapraxia of the radial nerve in the arthroscopy group and there was one superficial infection in the open synovectomy group.  Although all patients started with a Larsen grade less than 2 preoperatively, at latest follow up, the average Larsen score was 3.1 with no significant difference between groups.

This study confirms the efficacy of arthroscopic elbow synovectomy in rheumatoid arthritis in patients without significant joint destruction with comparable pain relief to an open procedure.  There was a trend towards improved values in the open synovectomy group when preoperative flexion measured greater than 90 degrees.  In the group with significant limitation of  preoperative motion, there was significantly better function in the arthroscopic group at the midterm follow-up but not at final follow-up.  Few previous studies have compared the results of arthroscopic and open synovectomy in rheumatoid arthritis of the elbow. The retrospective nature of this comparison has limitations, but suggests that both approaches can be beneficial.   Of note, arthroscopic synovectomy in the rheumatoid elbow may be more difficult than in non-inflammatory conditions as the distinction between the capsule and synovium is not always clear.  This can put the neurovascular structures at greater risk, and the authors did have one radial nerve palsy, although transient. 

 

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Journal of Bone and Joint Surgery