Shoulder and Elbow cases rheumatoid arthritis affecting the elbow

 

A 78-year-old female with a history of rheumatoid arthritis for the past 20 years presents to the office for an evaluation of her bilateral elbows. She initially

presented with symptoms in her hands and wrists and has been poorly compliant with her antirheumatic medication.

She has received multiple corticosteroid injections into her elbows over the past 3 years, but she no longer gets relief. Her images are shown (Figs. 2–99 to 2–102).

 

 

 

Figure 2–99

 

 

 

 

 

Figure 2–100

 

 

Figure 2–101

 

 

 

 

Figure 2–102

Approximately what percentage of patients with rheumatoid arthritis develop elbow involvement within 5 years?

1. 10%

2. 5%

3. 75%

4. 60%

5. 40%

 

Discussion

The correct answer is (E). Between 20% and 50% of patients with rheumatoid arthritis will develop elbow arthritis. Isolated presentation of the elbow is rare and only occurs about 5% of the time. Care should be given to provide the best treatment for the entire upper extremity when evaluating and treating a patient with rheumatoid arthritis.

Which of the following is the procedure of choice when treating an advanced, debilitating rheumatoid elbow?

1. Elbow arthrodesis

2. Open synovectomy

3. Radial head excision

4. Arthroscopic synovectomy

5. Semi-constrained total elbow

 

Discussion

The correct answer is (E). Semi-constrained total elbow is the definitive procedure of choice when treating an elbow with extensive articular damage and subluxation or ankylosis of the joint (see Fig. 2–103). Rheumatoid patients place a lower demand on the prosthesis than patients with primary osteoarthritis (OA), and thus have a lower incidence of mechanical loosening. Due to the ligamentous laxity, prosthetic instability is the complication that most commonly inhibits success.

 

 

 

Figure 2–103

 

Which of the following antirheumatic drugs should be continued prior to surgery?

1. Methotrexate

2. Sulfasalazine

3. Infliximab

4. Adalimumab

5. Etanercept

 

Discussion

The correct answer is (A). Methotrexate is the only agent that should be continued throughout the operative period. In general, biologic agents such as TNF antagonists (Infliximab, adalumimab, etanercept) should be withheld for 1 week preop and restarted 10 to 14 days postoperatively. The goal is to reduce the risk of infection and optimize wound healing. Routine consultation with the patient’s rheumatologist is recommended before undergoing any surgical procedure.

 

Objectives: Did you learn...?

 

 

Identify etiology and natural history of rheumatoid arthritis affecting the elbows? Become familiar with the variety of medical treatment options commonly used?

 

Recognize the potential surgical options including their outcomes and complications?