DEFINITION

Elbow synovectomy surgically removes the thickened, inflamed, and painful synovium of the elbow joint.

Synovectomy is commonly performed for rheumatoid arthritis, hemophiliac synovitis, synovial chondromatosis, and inflammatory arthropathies.

In the past, synovectomy has been performed through an open arthrotomy, but currently, arthroscopic synovectomy is the treatment of choice.

Compared with open synovectomy, arthroscopic synovectomy can be performed as an outpatient procedure, allows more rapid recovery, and offers visualization of the entire elbow joint and recognition of concomitant pathology.

 

 

ANATOMY

 

On the medial side of the elbow, knowledge of the location of the median and ulnar nerves is essential for the safe establishment of medial portals (FIG 1A).

 

On the lateral side, knowledge of the location of the radial nerve and posterior interosseous nerve (PIN) is essential for the safe establishment of lateral portals (FIG 1B).

 

 

Proximal portals are safer than distal portals, as they are further away from the neurovascular structures. Posterior portals should never stray medial to midline to avoid iatrogenic damage to the ulnar nerve.

 

Proliferation of the synovium and distension of the joint capsule may result in compression neuropathies of the radial or ulnar nerves.

 

 

 

FIG 1 • A,B. Cadaveric dissection demonstrating anteromedial and anterolateral portals. The proximal anteromedial portal (A) is further from the median nerve than more distal portals. The proximal anterolateral portal

(B) is further from the radial nerve than more distal portals. (Photographs obtained with permission from Larry D.

Field, MD, Mississippi Sports Medicine and Orthopaedic Center, Jackson, MS.)

 

PATHOGENESIS

 

Rheumatoid disease is a chronic, systemic autoimmune condition that causes a microvascular disease of the synovium and synovial cell proliferation with perivascular lymphocytosis.13

 

Synovial tissue hypertrophy is the hallmark of the disease.

 

Inflammation of the synovium causes a joint effusion, leading to pain, swelling, and limited range of motion.

 

Continued inflammation results in the formation of an erosive, hyperplastic synovium known as a pannus. The release of inflammatory cytokines results in continued cartilage damage, periarticular bone erosions, and soft tissue degradation.14

 

Capsular distension and synovial hypertrophy can lead to gradual ligamentous, cartilaginous, and bony destruction resulting in progressive instability and deformity.

 

Recurrent hemarthroses in factor 8 or 9 deficient hemophiliac patients often leads to hemophiliac arthropathy. Hemarthroses lead to blood absorption by the synovium with reactive synovitis which causes the synovium to produce proteolytic enzymes to destroy the blood, articular cartilage, and adjacent bone.

 

NATURAL HISTORY

 

The patient with elbow synovitis will initially present with an elbow effusion, with pain, and restriction of motion. In early stages of inflammatory arthritis, deformity of cartilage and bone are not present. In the case of hemophiliac synovitis, the swollen hypervascular synovium is friable and recurrently bleeds into the elbow joint.

 

 

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In 10% of rheumatoid patients, synovitis will spontaneously resolve.7

 

In the rheumatoid patient, early medical management may slow natural disease progression.2 This should be attempted prior to surgical intervention.

 

If synovitis persists, secondary changes may occur.

 

 

A fixed flexion contracture may result from the patient holding the elbow in a flexed position to minimize pain caused by joint motion and capsular distension.

 

The disease may result in atrophy of the brachialis muscle, bringing the median nerve and brachial artery much closer to the synovial lining.

 

Destruction of the annular ligament may cause radial head instability with anterior displacement resulting from the pull of the biceps brachii muscle.

 

Damage to either or both of the medial collateral ligament and lateral collateral ligament (LCL) complexes may result in gross mediolateral elbow instability.

 

Proliferation of the synovium or distension of the joint capsule into the forearm may result in vascular, neural, or muscular dysfunction, particularly compression neuropathies of the ulnar or radial nerves.

 

Prolonged synovitis ultimately results in erosion of the articular hyaline cartilage.

 

Progressive cartilage degeneration and advancing arthritis is associated with subchondral cyst and marginal osteophyte formation, further weakening the joint capsule and ligamentous supports. Hemophiliac arthropathy of the elbow may create pseudocysts in the adjacent bone.

 

The end stage of disease in the elbow is marked by severe loss of joint space, damage to subchondral bone

and collapse, and progressive elbow instability. This results in a joint that is painful, weak, and unstable.7

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients will present with a chief complaint of pain and stiffness in the elbow, especially in early stages of synovitis. Stiffness is typically the biggest problem, with loss of terminal flexion and extension. Pain may be present at rest and exacerbated by activities.

 

 

Patients may report swelling and fullness in the elbow with impingement-type symptoms. Hemophiliac patients often report recurrent painful bleeding into the joint.

 

Physical examination often reveals a boggy swelling posterolaterally, indicative of synovitis or effusion. Effusion and synovial hypertrophy can be palpated in the anconeus triangle and posterolateral gutter.

 

Elbow range of motion in flexion, extension, and forearm rotation should be measured with a goniometer. If there is loss of motion, a soft end point suggests a soft tissue cause, such as tense effusion with synovitis or capsular contracture, whereas a firm end point suggests osseous deformity. Limited rotation may be caused by radial head deformity or instability.

 

In rheumatoid patients with loss of rotation, examination and imaging of the wrist is important to evaluate for pathology of the distal radioulnar joint, which is commonly involved in these patients.

 

Hemophiliac patients most often have an elbow flexion contracture, even if it is painless.

 

Ligamentous examination includes varus and valgus stress testing to evaluate the collateral ligaments. The supine lateral pivot shift test and push-off test evaluate for posterolateral rotatory instability (PLRI). The radial head should be palpated during forearm rotation to evaluate for deformity or instability.

 

Elbow instability is usually associated with more advanced disease, when joint effusion and synovial hypertrophy have caused ligamentous incompetence. Crepitus may present as degeneration of articular cartilage develops.

 

 

A routine neurovascular examination is essential. The PIN and ulnar nerve may be compressed by synovitis.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Plain radiographs include anteroposterior (AP), lateral, and oblique views to evaluate the degree of joint destruction. This aids in predicting the efficacy of synovectomy for pain relief.

 

The Mayo classification of rheumatoid elbows12 grades the severity of disease based on radiographic appearance (FIG 2A-E).

 

 

Grade I is primarily synovitis with no radiographic changes other than periarticular osteopenia or soft tissue swelling (FIG 2A,B).

 

Grade II shows narrowing of the joint, but the architecture of the joint is intact (FIG 2C).

 

Grade III demonstrates alteration of the subchondral architecture of the joint, such as thinning of the olecranon or resorption of the trochlea or capitellum (FIG 2D-E).

 

 

Grade IV shows gross destruction of the joint. Grade V is ankylosis.

 

The Arnold and Hilgartner classification of hemophiliac arthropathy is divided into five stages from mild to severe.1

 

Computed tomography (CT) is helpful to better define osseous anatomy, such as osteophyte formation, radial

head deformity, or loose bodies.

 

Magnetic resonance imaging (MRI) can determine the extent of synovitis, intra-articular nonossified loose bodies, and the integrity of the collateral ligament complexes.

 

DIFFERENTIAL DIAGNOSIS

Rheumatoid arthritis

Inflammatory arthropathies (Lupus, psoriatic arthritis) Hemophilic arthropathy

Pigmented villonodular synovitis (PVNS)

 

 

NONOPERATIVE MANAGEMENT

 

 

Systemic antirheumatoid agents may help control inflammation in rheumatoid patients. Nonsteroidal anti-inflammatory drugs (NSAIDS)

 

 

Infusion of specific clotting factors for factor-deficient hemophilia patients, according to their specific deficiency Judicious use of intra-articular corticosteroid injections

 

 

Physical therapy to control swelling and regain range of motion Dynamic bracing to improve terminal flexion/extension

SURGICAL MANAGEMENT

 

Indications for surgery are persistent, painful synovitis with functional impairment despite a trial of appropriate nonoperative management.

 

 

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FIG 2 • Radiographs demonstrating differing stages of elbow disease. A,B. Reveal normal joint alignment with anterior soft tissue swelling from synovitis. C. Shows joint space narrowing with maintenance of the normal joint architecture. D,E. Demonstrate loss of normal architecture with thinning of the olecranon and resorption of the capitellum and coronoid.

 

 

Indicated for rheumatoid arthritis (most common), inflammatory arthropathies, hemophilia with recurrent painful elbow hemarthroses, psoriatic arthritis, and acute septic arthritis.

 

Contraindications: inadequate medical management for at least 6 months and gross instability of the elbow joint with bony destruction and ligamentous incompetence, as synovectomy alone will not adequately address all of the pathology. Radial head resection is contraindicated in elbows with preexisting instability.

 

Contraindications to arthroscopic synovectomy: inadequate expertise of the surgeon, as distorted anatomy with a thin capsule with close proximity of neurovascular structures make iatrogenic injury a concern

 

Preoperative Planning

 

Patients with rheumatoid disease often have multiple joints affected. Typically, the most symptomatic joint will be

 

operated on first. If the elbow and shoulder are equally

 

symptomatic, most surgeons will advocate operating on the elbow first.

 

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Every patient with rheumatoid disease must receive a thorough evaluation of the cervical spine for instability prior to any purposed surgery.

 

Surgery on hemophilia patients must be carefully coordinated with the hematology team to ensure the appropriate delivery of clotting factors in the immediate pre-, intra-, and postoperative periods.

 

Patient positioning must be considered if concomitant procedures are to be performed on the elbow, wrist, and shoulder.

 

Examination under anesthesia should be performed at the beginning of every case to determine preoperative range of motion, the presence of soft or firm end points to motion, ligamentous stability, and the presence of ulnar nerve subluxation. A subluxating ulnar nerve may necessitate a small incision to identify and protect the ulnar nerve.

 

Positioning

 

For arthroscopic synovectomy, three patient positions are acceptable. Use of a pneumatic tourniquet is standard.

 

 

Prone: The upper arm is supported by a bolster or arm holder. This stabilizes the arm and provides excellent access to the posterior compartment. The arm can be externally rotated through the shoulder if a lateral approach is necessary. With this position, airway management is more difficult for the anesthesia team.

 

Lateral decubitus: The patient is placed on a beanbag and the arm is supported by an arm holder. This also stabilizes the arm and provides excellent access to the posterior compartment, and airway management is more accessible for the anesthesia team.

 

Supine: The arm is suspended with an arm suspensory device. The arm is not stabilized as well as when using the arm holder. Airway management is not an issue.

 

 

 

FIG 3 • The prone position for elbow arthroscopy, with the arm supported by a bolster, provides excellent

access to the posterior compartment.

 

 

We prefer to perform elbow arthroscopy with the patient prone and the operative arm supported by a bolster or arm holder (FIG 3).

 

Open synovectomy is typically performed with the patient supine through a lateral approach. A pneumatic tourniquet is used with the arm supported on an arm board. If a posterior midline approach is chosen, the prone or lateral decubitus position may be appropriate.

 

Approach

 

Arthroscopic synovectomy is performed through standard arthroscopic portals.

 

Open synovectomy is typically performed through a lateral approach for subtotal synovectomy with or without radial head resection. The extensile Kocher approach provides excellent visualization of the anterior capsule

and (with radial head resection) to the synovium of the medial gutter.10 Access to the olecranon and posterior fossa can be accomplished through this same approach.

 

A posterior midline incision offers access to both medial and lateral sides of the elbow. The Bryan-Morrey triceps-reflecting approach is unnecessarily extensive for synovectomy.3

 

TECHNIQUES

• Arthroscopic Synovectomy

 

Establish an anteromedial viewing portal.

 

A standard 4.0-mm arthroscope is used. Gravity inflow or a pump with low inflow pressure (<30 mm Hg) is used to limit fluid extravasation and soft tissue swelling.

 

We prefer to begin the synovectomy in the anterior compartment. The joint is insufflated with 30 mL of saline. A proximal anteromedial portal is established as the viewing portal (TECH FIG 1A), by advancing a blunt trocar anterior to the medial intermuscular septum. The initial view is usually poor due to synovial hypertrophy (TECH FIG 1B) and capsular tightness resulting in a limited working space.

 

Establish an anterolateral working portal.

 

A proximal anterolateral working portal is established using a spinal needle and an outside-in technique to localize portal placement. In general, proximal portals are safer than distal portals in the anterior compartment, as they are further away from neurovascular structures.

 

In the presence of significant capsular tightness and a limited working space, a switching stick through the proximal anterolateral portal can be used to elevate the capsule off the anterior humerus proximally. This creates additional working space by increasing capsular volume without disrupting the integrity of the capsule across the front of the joint.

 

Perform anterior compartment synovectomy from lateral portal.

 

A 4.5-mm full-radius motorized shaver is introduced through the proximal anterolateral portal, and the synovectomy is initiated.

 

Do not begin shaving until the shaver is in full view (TECH FIG 2A,B). The joint synovium is removed while preserving the joint capsule, and visualization improves as the synovium is removed.

 

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TECH FIG 1 • We typically establish a proximal anteromedial portal as the initial viewing portal (A). The initial view may be poor (B) due to synovial hypertrophy.

 

 

Use limited suction with the shaver blade facing away from the capsule. Make sure the tip of the shaver is always in the view of the arthroscope. The capsule is often very thin in rheumatoid elbows, and it is best not to disrupt the capsular integrity.

 

Judicious use of retractors (either switching sticks or Freer elevators) through more proximal or distal portals can help retract the capsule to improve visualization as well as protect neurovascular structures (TECH FIG 2C,D).

 

Begin the synovectomy on the lateral side of the elbow to gain visualization of the radial head. Take great caution during synovectomy anterior to the radial head to avoid iatrogenic injury to the PIN.

 

Continue the synovectomy across the anterior elbow joint to the medial side of the elbow as far as can be safely visualized.

 

Perform diagnostic arthroscopy, evaluate for osteophytes and radial head deformity.

 

Once hypertrophic synovium has been removed and visualization has improved, diagnostic arthroscopy can be performed.

 

 

 

TECH FIG 2 • Initial visualization may be difficult due to capsular tightness and synovial hypertrophy (A). Do not begin shaving until the motorized shaver is in full view of the arthroscope (B). A switching stick placed through a proximal anterolateral portal (C) can be used as an intra-articular retractor (D) to elevate the anterior capsule and protect the radial nerve.

 

 

Evaluate the radial head and radiocapitellar joint for deformity and arthritis (TECH FIG 3). Evaluate the annular ligament and LCL complex for laxity. Evaluate the tip of the coronoid and coronoid fossa for osteophytes. Osteophytes and loose bodies may be identified and removed. If severe radiocapitellar arthritis is present, a radial head resection may be indicated and performed arthroscopically.

 

Perform arthroscopic radial head resection if indicated.

 

When preoperative imaging/examination and arthroscopic evaluation reveal severe radiocapitellar arthritis, radial head resection may be indicated. Radial head resection should be reserved for those patients with a stable elbow and radial head deformity impeding forearm rotation.

 

A motorized burr is introduced through the proximal anterolateral portal, and the anterior half of the radial head can be resected (TECH FIG 4A). By pronating and supinating the forearm, the entire anterior half of the

 

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radial head can be brought into view and resected with the burr.

 

 

 

TECH FIG 3 • View of the radiocapitellar joint from a proximal anteromedial viewing portal, demonstrating synovial hypertrophy and severe radiocapitellar arthritis.

 

 

Next, a lateral soft spot portal can be established using a spinal needle, and the burr can be introduced through the posterior aspect of the radiocapitellar joint (TECH FIG 4B). The radial head resection can be completed using a cutting block technique level with the anterior resection. The resection should be carried distally to the level of the annular ligament (TECH FIG 4C).

 

Perform anterior compartment synovectomy from medial portal.

 

Use a switching stick to maintain the portals and switch the arthroscope from the medial to the lateral portal. With the shaver in the medial portal, continue the synovectomy from the midaspect of the elbow joint across the front to the medial side of the elbow.

 

 

Osteophytes in the coronoid fossa or on the tip of the coronoid can be resected with the burr. Use limited suction on the shaver to avoid capsular penetration.

 

Access the posterior compartment.

 

Make a direct posterior transtendon portal 2 to 3 cm proximal to the tip of the olecranon. Make sure not to stray medial to midline to avoid injury to the ulnar nerve. Advance the blunt trocar through the triceps tendon and into the olecranon fossa.

 

 

 

TECH FIG 4 • The anterior half of the radial head can be resected from the anterolateral portal (A). A burr is then introduced through the soft spot portal (B) to complete the radial head resection (C).

 

 

Initial visualization is often poor due to synovial hypertrophy.

 

Establish a posterolateral working portal for the shaver. Place the shaver through the posterolateral portal into the olecranon fossa. Use tactile sensation to feel the tip of the shaver with the tip of the arthroscope, and the shaver should come into view. Begin shaving to clear the olecranon fossa of bursitis and synovitis and create a working space (TECH FIG 5). Identify the tip of the olecranon.

 

Remove osteophytes from the tip of the olecranon.

 

A burr can be introduced through the posterolateral portal, and osteophytes present on the tip of the olecranon can be resected.

 

Perform synovectomy in the posterior compartment.

 

Advance the arthroscope down the posteromedial gutter. Loose bodies can be identified and removed. Synovectomy can be performed in the posteromedial gutter.

 

Take great care when working in the posteromedial gutter to avoid injury to the ulnar nerve. Do not use suction and keep the shaver blade facing away from the capsule.

 

Next, advance the arthroscope down the posterolateral gutter (TECH FIG 6). Loose bodies are often identified in the posterolateral gutter and can be removed.

 

The arthroscope can be advanced down the lateral gutter to view the posterior radiocapitellar joint. An inflamed posterolateral plica will be visualized and can be resected with the shaver through a lateral soft spot portal.

 

Closure of portals with suture.

 

The arthroscope is removed from the elbow and arthroscopic fluid is expressed from the joint.

 

Portals are sutured with 3-0 nylon using a figure-of-eight portal stitch. Suture closure of portals limits postoperative drainage and decreases risk of postoperative infection and fistula formation.

 

Apply dressing.

 

A bulky soft dressing is applied to the elbow to limit swelling and facilitate immediate range of motion exercises.

 

 

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TECH FIG 5 • View of the posterior compartment, with the shaver defining the tip of the olecranon.

 

 

 

TECH FIG 6 • The posterior radiocapitellar joint can be visualized by advancing the arthroscope down the posterolateral gutter.

• Open Synovectomy

 

Lateral approach to the elbow

 

The arm is elevated and exsanguinated and a pneumatic tourniquet inflated.

 

A 12-cm curvilinear incision is made on the lateral aspect of the elbow centered over the radiocapitellar joint. Dissection is carried sharply with scalpel down to the fascia, and fullthickness skin flaps are raised both anterior and posterior.

 

The extended Kocher approach is typically used.10 A fatty stripe can be visualized that defines the interval between the anconeus and extensor carpi ulnaris (ECU). The fascia over the fatty stripe is incised, and blunt dissection with an elevator lifts the ECU anteriorly and anconeus posteriorly to expose the joint capsule. Keep the forearm pronated to protect the PIN.

 

Alternatively, the lateral approach to the elbow can be used by developing the interval between the extensor digitorum communis (EDC) and the extensor carpi radialis longus (ECRL) or by splitting the EDC tendon. Through the lateral approach, the PIN is at risk of injury.

 

The capsule and LCL complex should be in view.

 

Make capsulotomy to access the elbow joint.

 

Incise the capsule anterior to the equator of the radiocapitellar joint in line with the radius.

 

Capsular incision should be made anterior to the lateral ulnar collateral ligament (LUCL) to avoid PLRI. The capsulotomy will go through a portion of the radial collateral ligament (RCL), which can be repaired at the completion of the case.

 

Extend exposure with release of the LCL complex.

 

With the LCL clearly identified, sharp release of the LCL off of the lateral epicondyle of the humerus allows the elbow joint to “book open” while preserving the integrity of the ligament.

 

This provides excellent exposure to the anterior capsule and anterior compartment.

 

The LCL complex can be repaired at the completion of the case through drill holes in the lateral epicondyle or with use of a double-loaded suture anchor.

 

Incise annular ligament.

 

The annular ligament can be incised in line with the radius and tagged for later repair.

 

Take great caution in exposure distal to the annular ligament, as the PIN is at risk of injury. If dissection must be carried distal to the annular ligament, the PIN must first be identified and protected.

 

Resect or keep radial head.

 

At this stage, a radial head resection can be performed if indicated.

 

Place small Hohmann retractors around the radial neck to protect the PIN and resect the radial head with a microsagittal saw.

 

If the radial head is preserved, the anterior capsule can be exposed anterior to the radiocapitellar joint.

 

Perform anterior synovectomy.

 

Retractors can be placed into the elbow joint so the anterior musculature can be retracted anteriorly. The synovium can be excised with a rongeur, leaving the anterior capsule intact.

 

 

If using electrocautery, take great care not to damage the articular cartilage. The medial recess cannot be accessed through this exposure.

 

Extend exposure proximally to gain access to posterior compartment.

 

Proximally, the interval between the triceps and ECRL can be defined. The triceps is retracted posterior and ECRL retracted anterior to gain access to the posterior compartment.

 

A retractor can be placed deep to the triceps to access the posterior compartment.

A synovectomy of the posterior compartment and the olecranon fossa can be performed.

Expose the ulnar nerve if necessary.

If indicated, the ulnar nerve can be exposed through a medial approach. Once the ulnar nerve is identified and protected, the posteromedial gutter can be exposed to complete the posterior synovectomy.

Closure

The LCL complex is repaired back to the lateral epicondyle of the humerus through drill holes or using a doubleloaded suture anchor.

The capsulotomy is closed with interrupted suture, also repairing the split in the RCL. The interval between the anconeus and ECU is closed with suture.

The subcutaneous layer and skin are closed with suture.

Apply dressing.

A bulky soft dressing is applied to the elbow to limit swelling and facilitate immediate range-of-motion exercises.

 

 

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PEARLS AND PITFALLS
	Arthroscopic Synovectomy   Avoid ▪ Keep inflow pressure low (<30 mm Hg if using pump), avoid capsular resection, excessive soft wrap forearm with elastic dressing during surgery tissue swelling   Create a ▪ If initial view is limited due to capsular tightness, use a switching stick through the working lateral portal to elevate the capsule anteriorly off of the humerus. space   Preserve ▪ Use a nonaggressive full-radius shaver, keep shaver blades pointed away from capsular capsule, use limited suction integrity   Avoid ▪ Know your three-dimensional anatomy and where nerves are at risk, judicious iatrogenic use of retractors to elevate the capsule and protect neurovascular structures, injury to limited use of suction when working anterior to the radiocapitellar joint and in the neurovascular medial gutter structures   Open Synovectomy   Avoid damage ▪ Stay anterior to the equator of the radiocapitellar joint to avoid injury to the radial to the LCL ulnar humeral ligament (RUHL) and resulting posterolateral instability; taking the

 

 

complex

entire LCL complex sharply off the lateral epicondyle preserves the integrity of the ligament.

 

Avoid damage to the PIN

• Do not carry dissection distal to the annular ligament.

   

  Avoid iatrogenic injury to neurovascular structures

• Appropriate use of retractors; do not resect the capsule in the anterior compartment; do not attempt synovectomy in the medial gutter through the lateral approach unless the radial head has been removed. Most hemophiliac patients requiring elbow synovectomy will also require radial head resection for the radiocapitellar joint destruction. Bony curettage and osteoplasty may be required for hemophiliac pseudocysts in which the synovium has eroded subchondral bone into the medullary cavity especially between the trochlea and olecranon with telescoping.

   

  Increase exposure

  • Use an extensile approach; flex the elbow to remove tension from the anterior musculature and improve visualization in the anterior compartment; extend the elbow to improve visualization in the posterior compartment

 

POSTOPERATIVE CARE

 

Postoperative management depends on the extent of the surgery.

 

Synovectomy alone is an outpatient procedure with initiation of early range of motion.

 

Significant osseous resection or capsulectomy may be admitted for 23-hour observation with use of a postoperative drain, continuous passive motion (CPM), and cryocompression device.

 

Indomethacin can electively be prescribed for heterotopic ossification prophylaxis.

 

Patients are discharged with a continuous brachial plexus block for 72 hours for postoperative analgesia.

 

Patients with severe hemophilia requiring factor 8 or 9 infusion during surgery will require infusion postoperative for several days as the hematologists taper the factor replacement dose.

 

The bulky soft dressing is removed by the patient 48 to 72 hours postoperative, and range of motion is initiated. The portal sites are dressed with Band-Aids.

 

Sutures are removed 7 to 10 days following surgery, and physical therapy is initiated for range of motion, terminal stretching, and edema control. Strengthening is begun at 4 to 6 weeks postoperative.

 

OUTCOMES

Elbow synovectomy, with or without radial head resection, is an effective treatment for the rheumatoid elbow and the hemophiliac elbow.

The best results of elbow synovectomy, either open or arthroscopic, are in younger patients with greater than 90 degrees of flexion/extension, preserved articular cartilage, and mild bony deformities.12

Studies indicate that 70% to 90% of patients have satisfactory outcomes within the first 3 to 5 years, although the results deteriorate with time.12

Arthroscopic synovectomy offers the advantages of being less invasive with less soft tissue injury, which

 

speeds recovery and rehabilitation and limits postoperative pain. The surgeon can visualize all intra-articular pathology and has superior access to the posterior compartment of the elbow.

 

In 1997, Lee and Morrey11 reported on 14 patients who underwent arthroscopic synovectomy, with 93% good and excellent results. These results deteriorated to 57% at 42 months postoperative. Two cases of transient neurapraxia were reported and 4 patients were converted to total elbow arthroplasty.

 

Horiuchi et al6 reported the results of 21 elbows after arthroscopic synovectomy, with good and excellent results for 71% of patients at 2 years. The Mayo Elbow Performance Score improved from 48.3 points preoperatively to 77.5 points postoperatively. The results deteriorated to 43% by 8 years. If elbows with advanced cartilage loss and bony deformity were excluded, the results were 100% and 71% of patients with good and excellent results at 2 and 8 years, respectively. Three patients had transient ulnar nerve paresthesias and two were converted to total elbow arthroplasty.

 

In 2006, Tanaka and colleagues16 reported a prospective comparative study of arthroscopic versus open synovectomy with 23 elbows in each group. At a mean follow-up of

 

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10 years, 48% of those treated arthroscopically and 70% of those treated with open synovectomy had little or no pain. There was no significant difference with respect to pain, range of motion, or level of function.

The results of both groups deteriorated with time.

 

In 2011, Chalmers and coworkers4 performed a metaanalysis to compare the effects of arthroscopic versus open synovectomy on pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent total joint arthroplasty. Patients undergoing arthroscopic synovectomy had similar pain reduction, but more frequent recurrences of synovitis and radiographic progression when compared to open synovectomy. The risk of subsequent total elbow arthroplasty was similar between the two groups.

 

Kang et al9 reported on arthroscopic synovectomy in 26 rheumatoid elbows with radiographic changes that were mild to moderate. At a mean follow-up of 34 months, 73% of patients had good to excellent results.

Pain decreased from 6.5 to 3.1, the mean flexion arc increased from 98 to 113 degrees, and the Mayo Elbow Performance Score improved from 58.5 to 77.4. Seven patients had radiographic progression of disease and four patients developed recurrent synovitis.

 

Limited studies exist in the literature regarding the results of arthroscopic synovectomy for hemophilic arthropathy of the elbow.5,8,15,17 Studies are limited to very small numbers and often combine results of synovectomy of other joints. Either open or arthroscopic synovectomy dramatically decrease the rate of

recurrent hemarthroses.

 

COMPLICATIONS

Nerve injury (PIN, median nerve, ulnar nerve) Instability with ligamentous injury

Infection, the risk of postoperative infection is higher in rheumatoid patients taking disease-modifying agents, which should be stopped 7 days prior to surgery

Heterotopic ossification Recurrence of synovitis

 

 

REFERENCES

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2. Breedveld FC. Current and future management approaches for rheumatoid arthritis. Arthritis Res 2002;4(suppl 2):S16-S21.

    

    

3. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow joint. A triceps sparing approach. Clin Orthop Relat Res 1982;(166):188-192.

    

    

4. Chalmers PN, Sherman SL, Raphael BS, et al. Rheumatoid synovectomy: does the surgical approach matter? Clin Orthop Relat Res 2011;469(7):2062-2071.

    

    

5. Dunn AL, Busch MT, Wyly JB, et al. Arthroscopic synovectomy for hemophilic joint disease in a pediatric population. J Pediatr Orthop 2004;24:414-426.

    

    

6. Horiuchi K, Momohara S, Tomatsu T, et al. Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84:342-347.

    

    

7. Inglis AE, Figgie MP. Septic and non-traumatic conditions of the elbow: rheumatoid arthritis. In: Morrey BF, ed. The Elbow and Its Disorders, ed 2. Philadelphia: WB Saunders, 1993:751-766.

    

    

8. Journeycake JM, Miller KL, Anderson AM, et al. Arthroscopic synovectomy in children and adolescents with hemophilia. J Pediatr Hematol Oncol 2003;9:726-731.

    

    

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