Inflammatory arthritis and the elbow surgeon

Abstract

The treatment of inflammatory arthritis with disease modifying drugs and biological agents had reduced the number of patients needing surgical treatment. Surgical treatment of patients with inflammatory arthritis is challenging not only due to the factors such as bone stock and status of soft tissue but also due to the comorbidities associated with inflammatory arthritis. Multidisciplinary approach to these patients is recommended to deal with the complex poly-articular involvement and systemic physiological impairment especially when planning surgery. This review will cover the key articular and peri-articular pathologies that can affect the elbow in inflammatory arthritis and discuss the treatment strategies available to the orthopaedic surgeon in their management. From surgical point of view, the rheumatoid elbow can be classified into 4 types: 1) classic soft tissue type with increased joint laxity, malalignment and instability; 2) osteoarthritic type with stiffness, hypertrophic joints (hypertrophic) and preserved alignment; 3) nodular type with subcutaneous nodules and enthesopathies but preserved jointly; 4) mutilans with bone and joint destruction. Surgical managements of the articular problem in each of the subtypes are discussed in this review. On the other hand, the seronegative arthritis such as psoarisis, gout and lupus seems to affect the peri-articular tissue of the elbow more than the joint itself and the disease specific management of the peri-articular soft tissue problems, such as enthesopathies and inflammatory nodules, are also outlined.

1. Introduction

During the latter part of the 20th century, the medical treatment of inflammatory arthritis involved predominantly analgesics with or without steroids. As well as the associated side effects and complications of systemic steroid use, progressive articular destruction would occur, often requiring open surgery in the form of open synovectomy, excision arthroplasty, arthrodesis and arthroplasty. The development of disease-modifying antirheumatic drugs (DMARDs) that helped prevent damaging synovitis in patients and then more recently newer biologic agents have reduced the need for surgical treatment. Though currently fewer in number, patients are still presenting for surgery due to failure of their medical management. However, it appears that the demand for joint replacement in rheumatic arthritis remains high¹ with the total elbow replacement being no exception.

This review will cover the key articular and peri-articular pathologies that can affect the elbow in inflammatory arthritis and discuss the treatment strategies. Whilst rheumatoid arthritis is the commonest inflammatory arthritis affecting the elbow, other specific inflammatory arthritis, such as ankylosing spondylitis, psoriatic arthropathy and gout, have the disease specific manifestation which are different from rheumatoid arthritis in the elbow.

1.1. Rheumatoid arthritis

The most common inflammatory arthropathy is rheumatoid arthritis (RA) with the elbow involved as a monoarthropathy in 5% and as part of a polyarthropathy in 20–65% of cases.^2,3 Though the elbow is less commonly involved in the spondylo-arthritides the clinical manifestations are similar to those encountered in RA. RA differs as it is more a disease of the synovium with characteristic joint damage whereas the sero-negative arthritides more often involve the enthesis.

1.2. Aetiology and pathology

The aetiology of RA, though the most common chronic inflammatory arthritis occurring in just under of 1% of the population worldwide,² is unknown. Rheumatoid arthritis is a disease of synovium which may involve the articular surfaces if remain untreated. Juxta-articular soft tissues also get affected contributing to pain and deformities of the rheumatoid elbow. Rheumatoid pannus can be considered a synovial tumour which tends to form in the recesses of joints, behaving as an erosive mass causing progressive destruction of adjacent ligaments and bone. It can also compress tendons and their sheaths although most tendon ruptures occur in areas of nodular degeneration or over sharp bone edges. This soft tissue and ligamentous damage can result in articular damage via instability, poor joint mechanics and malalignment. The articular surface damage occurs late and therefore early treatment of the synovitis either medically or surgically should delay or prevent secondary damage to the joint.

Less commonly, pannus can also reside in the joint itself damaging the articular surfaces directly or chemically.

1.3. ‘Surgical’ classification

In general, there are 4 major types of RA from the surgical point of view.

• 1.Classic soft tissue type: Increased joint laxity, Z deformities, subluxation, malalignment and instability (Fig. 1 showing classic synovium hypertrophy in rheumatoid elbow).
• 2.Osteoarthritic type: Stiffness, ‘knobbly’ joints (hypertrophic) and preserved alignment (Fig. 2 showing a osteoarthritic type rheumatoid elbow).
• 3.Nodular type: Subcutaneous nodules and also affecting tendons with joints relatively spared.
• 4.Mutilans: Bone loss, joint destruction (‘floppy’ joints) and shortening.

Fig. 1.

Showing classic synovium hypertrophy in rheumatoid elbow).

Fig. 2.

Showing a osteoarthritic type rheumatoid elbow).

1.4. Radiological classification

Though the degree of damage to the joint can be classified using systems such as Larsen's 6 grade system⁴ this may not be as useful for decision-making as individual radiological assessment using plain radiographs and/or 3D CT images. Ultrasound can be used for assessing structural damage in enthesitis, but MRI is superior in detecting inflammation at the bony attachment of tendons.⁵

1.5. Surgical treatment of rheumatoid elbow

1.5.1. General considerations

Indications for surgery in inflammatory arthritis include the management of pain or to address specific functional deficits. Targeted surgery for functional improvement in a joint such as the elbow can be more straight forward than treating pain. Involvement of other joints and their likely treatment should be taken into consideration when planning surgical management of a rheumatoid elbow. An experienced surgeon would provisionally plan the treatment of all affected joints; although would carry them in stages and be prepared to change the plan if the results of previous surgery vary from original expectations. No need to say, operations with conflicting postoperative regimes should not be combined.

Surgical planning for rheumatoid patients requires a balanced approach. Functional improvement including pain relief should be the goal of surgery rather than the improvement in the range of movement or appearance of the limb. A modest improvement in the range of flexion of elbow in a young woman allowing her to wash her face, feed herself and do her make-up, would be life changing for her.

Rheumatoid elbow can worsen rapidly so it is important that patients should be reviewed closer to the date of surgery to make sure that the proposed surgical plans are still adequate and relevant.

Patients with RA and other inflammatory arthropathies should always be treated as high-risk patients. In the American Society of Anaesthesiologists' ASA classification of severity, they are almost always grade 3, i.e. ‘a patient with severe systemic disease that is not life-threatening’, or above).

1.6. Multidisciplinary team approach to surgery

Current medical management of rheumatoid arthritis requires specialist input hens the involvement of the rheumatologist and pharmacist in surgical management of these patients is prudent and they should be the part of multidisciplinary team managing these patients.⁶ Anaesthetist should also be involved in the surgical planning as these patients often have comorbidities including involvement of cervical spine and may present an anaesthetic challenge.

The improved medical treatment of inflammatory arthritis has changed the profile of joints requiring surgery. They have less synovitis and more ‘dry’ joints but still with extensive wear.

The biologic agents including DMARD's due to their risk of increasing infection, should be withheld at least twice their half-lives before and after major surgery. This may not be necessary in minor procedures with lower associated risks of infection and impaired wound healing.³ Restarting therapy post-operatively depends on an individual's healing progress, however an early return to medication would help prevent post-operative disease flares which in turn can facilitate rehabilitation.⁷ Methotrexate can be continued perioperatively unless there is evidence of medical complications associated with it.

1.7. Patient positioning

Surgery for rheumatoid elbow should preferably be done in supine position as the stiffness and deformity in the shoulder and other joints may make it difficult to operate in other positions. Anaesthetist, if prewarned, should be able to look after a stiff or deformed cervical spine during induction and maintenance of anaesthesia. Attention should be paid to make sure that all the vulnerable joints have been adequately padded. Surgeon should be prepared to work with constraints if the lateral position is necessary such as in arthroscopic surgery of the elbow.

1.8. Synovectomy

The major surgical intervention before the use of disease modifying drugs was open synovectomy of joints, tendons and their sheaths. If the main cause of the secondary damage as well as pain is from the volume of synovium then surgical synovectomy is a viable alternative treatment to pharmacological methods. This can be of particular use to the patients unable to tolerate DMARDs.

Though open synovectomy of the main joints has now been superseded by arthroscopic synovectomy, it has a role often combined with arthroscopy, in certain cases particularly when nerve decompression is also required or where there are large or inaccessible osteophytes as in the more hypertrophic types of RA.

For RA in the elbow, the results of synovectomy appear good though initially there was great concern about the complications particularly of nerve injury due to the distorted anatomy and the thin weak joint capsule.^8,9 Improved surgical technique and instrumentation appears to have addressed this.

In the elbow, arthroscopic synovectomy has been shown to have good long-term results for both early stage (Larsen grades 1 and 2) as well as advanced stage (Larsen grades 3–4) disease although results are not as good in grade 5 disease.¹⁰ Of note in this study was the high survivorship rate of the operation with low conversion rates to total elbow replacement of 3% at 10 years, 25% at 15 years and 30% at 20 years.

1.9. Bursitis

Rheumatoid bursitis around the elbow including the olecranon bursitis is best treated with aspiration and steroid injection though compression and oral medication may be just as good. There are few large-scale trials in this area.^11,12 It is preferrable to use a high concentration, low-volume steroid for injection to maintain apposition of bursal surfaces and prevent hydro-distention. Steroid injections around the elbow have a significant rate of skin complication and one must also be wary about introducing infection¹³ or producing tendon ruptures.

Open excision of olecranon bursae has a high rate of wound problems and bursae often recur even after full excision.¹⁴ Surprisingly, systemic steroids can help to close sinuses associated with bursae. Endoscopic bursectomy could be contemplated instead of open procedures if nonsurgical treatment has failed.¹⁵

Though rare, inflammatory arthritis can also affect the bicipitoradial bursa and this has been reported in RA, psoriatic arthritis and even synovial chondromatosis.¹⁶

1.10. Rheumatoid nodules

Rheumatoid nodule is a common extra-articular manifestation of RA, occurring in approximately 25% of patients. Subcutaneous nodules overlying the ulna may require excision due to their size or tenderness. Nodules can sometimes ulcerate and become infected and may be a sign of underlying chest disease, vasculitis, and wound healing problems. The elbow itself rarely has tendon complications associated with rheumatoid nodules.

Excision, though the skin is often adherent, is straight forward and recommended¹⁷ though one must be careful about wound healing and try to avoid scarring over the pressure points. Nodules often recur or arise again de novo so there should be a compromise reached between scarring versus wide excision of the adherent skin.

1.10.1. Nerves

Prior to DMARDs and the subsequent reduction in synovitis and pannus in the elbow, compression of all three major nerves around the elbow was a relatively common entity. In current practice, the orthopaedic surgeon is most likely to see the ulnar nerve problems. In the rheumatoid elbow there may be preoperative fixed flexion contracture resulting in ulnar nerve symptoms as well intraoperative nerve injury and post-operative fibrosis. There may be distorted anatomy increasing the risk of iatrogenic injury to the nerve in both open and arthroscopic surgery.

It remains controversial whether the ulnar nerve should be left in situ or transposed during any open elbow surgery. When making the decision, surgeons should take into consideration the likelihood of recurrent compression post-operatively, the technical ease of the procedure, the site of any metalwork and the possibility of revision surgery which could be more challenging in the context of a transposed nerve.

1.10.2. Tendons

Though enthesitis is common in the elbow, true tendinitis is confined to the distal biceps. However, rupture of the biceps tendon due to rheumatoid is much more common proximally in the shoulder rather than distally. As mentioned, bicipito-radial bursitis can exist in rheumatoid and psoriatic arthritis.¹⁸

1.11. Arthritic joint

Elbow arthroplasties had been successful in improving the quality of life in patients of severe erosive rheumatoid elbows, which are not responding to medical treatment, by improving the elbow function. Elbow replacement had gain popularities in the 1980's and 90's but the initial success was followed by disappointing early failures due to implant wear and loosening.¹⁹ Arthrodesis, originally indicated in tuberculosis, is a treatment option for failed total elbow replacement or patient unsuitable for elbow replacement.²⁰ Interposition arthroplasty of the elbow, on the other hand, is also a viable option for young and active patients,²¹ especially in a subgroup of Juvenile Idiopathic Arthritis patients with early onset severe erosive monoarthritis of the elbow.²²

1.11.1. Arthrodesis

Though originally used for tuberculous infections elbow arthrodesis may rarely be required as a salvage procedure in chronic infection, failed arthroplasty or where there is severe bone loss.

There is no consensus on the optimal angle of fusion in the elbow. It is patient specific and a trial of arthrodesis by putting the arm in a cast in the intended angle of fusion, would be helpful. Of note, there is a high incidence of fracture with arthrodesis particularly distal to an arthrodesis plate.²³

For the RA patient with adjacent joint problems a flail elbow may be functionally better than an arthrodesed joint and careful consideration must be made in these patients. It is not uncommon for rheumatoid patients following removal of a failed or infected arthroplasty to prefer neither brace nor fusion, particularly after a trial in a cast.

1.12. Arthroplasty - total elbow replacement

Total elbow replacement (TER) remains the most successful end stage operation for rheumatoid elbow even though the percentage of patients requiring TER is decreasing due to better medical management of rheumatoid arthritis. Linked elbow replacement, of which several successful designs are available (Coonrad Morrey, Discovery, Latitute EV, Nexel - to name a few) is the preferred choice of most surgeons as it does not require the competent soft tissue envelop, can be done in presence of significant bone and soft tissue defect and provides a painless, functional elbow with long term survival comparative to hip and knee replacement, in majority of patients. In a review of 461 total elbow replacements performed for rheumatoid arthritis survival rates were 92%, 83% and 68% at 10, 15 and 20 years respectively.²⁴ There also appears to be better satisfaction following this operation for these relatively low demand patients who generally remain positive through most treatment as well as having a great capacity to cope with pain and adversity.

1.13. Precautions during surgery

TER for rheumatoid elbow is no different than TER for any other reason. Surgeon has to carefully select and assess the patient, get the appropriate imaging and have all the necessary implants and equipment available, including those to deal with possible intra-operative complications. Extra care is required to avoid the damage to fragile soft tissues and intra-operative fractures.

When raising skin flaps, subcutaneous fat should be incised at 90° to the skin to avoid undercutting of the wound edge and the flap should not be lifted until the muscle fascia is reached. Ulnar nerve should be mobilised carefully with least soft tissue disruption. If the approach requires releasing the triceps insertion, it should be done with a thin sliver of olecranon so as to ensure satisfactory healing and avoid the later subluxation of triceps tendon.

Reaming and making the cuts for the prosthetic elbow should be gentle without any forceful manoeuvres. Perforation of ulna should be avoided by careful reaming, if necessary, with fluoroscopic control.

1.13.1. Wound healing problems

Wound breakdown remains a common concern after TER in rheumatoid elbow. With the aim of reducing swelling and fluid collection, the senior author uses suction drain, nonabsorbable sutures and avoid any circumferential tight bandage. Post-operatively, arm is elevated on pillows, dressing reduced and drain removed after 24 h. Active mobilisation of elbow started as soon as possible, and patient is kept in the hospital, till able to actively flex the elbow to 90°.

1.13.2. Prosthetic joint infection

Unfortunately elbow replacement has the highest infection rate of all the major joint replacements.²⁵ This may be due to the high rate of RA in elbow arthroplasty in early cases²⁶ with an associated infection rate of about 6%. Although the infection rate in RA has now reduced, it remains the disastrous complication similar to TER in non-rheumatoid group. Principles of treatment are no different.

Principles of treatment of infected TER in patients with rheumatoid arthritis are the same as for non-rheumatoids infected TER with removal of the prosthesis and long periods of intravenous antibiotic therapy but it is associated with both functional decline and, more critically, has a mortality rate of 2.7%–18%.²⁷

Due to low number of TER performed by most surgeons, it is difficult to accumulate experience to treat prosthetic joint infection (PJI) in TER. One way forward can be to benefit from the experience of lower limb arthroplasty surgeons who treat comparatively larger number of PJI cases.

1.13.3. Periprosthetic fracture

Periprosthetic fractures are not uncommon following TER for rheumatoid arthritis mainly due to osteopenic and fragile bone and stress riser from the prosthetic stem of the shoulder replacement on the same side. The treatment of peri-prosthetic fractures in these patients can be very challenging. While fractures may be treated by revision with a longer stem prothesis or plating with or without strut grafting, patients often require specialised protheses which sometimes need to be custom-made.²⁸ Peri-prosthetic fracture treatment may therefore be best in selected centres equipped to deal with such complication.

Proximal radio-ulnar joint (PRUJ) in Rheumatoid Arthritis.

The proximal radio-ulnar joint with significant wear of the radial head is frequently involved in rheumatoid elbow. Before the advent of arthroplasty open synovectomy and excision of the radial head was a standard procedure. Radial head excision is still practiced as a stand-alone treatment of rheumatoid elbow mainly involving radiocapitellar joint. It can be done open or arthroscopic with the later gaining in popularity. It may postpone the need for TER. A systematic review has reported that isolated radial head excision in rheumatoid arthritis improved range of movement but not pain whereas in post-traumatic arthritis, it improved both.²⁹ Radial head excision may still be done along with TER if necessary. Some of the prosthetic design (e.g., Latitude EV) have the option of simultaneous replacement of radial head although there does not appear any advantage of it in every TER.

1.13.4. Interpositional arthroplasty

Interposition arthroplasty has a limited role in treatment of rheumatoid elbow in a relatively young and active patient who is not the ideal candidate for TER. The procedure involves open synovectomy, debridement of the joint, capsulectomy, recontouring the articular surface and interposing a soft tissue material such as dermis (autograft),³⁰ tendoachilles,³¹ anconeus (allograft) or a synthetic materials in the joint. An external fixator is normally applied for distraction of the joint for around 4 weeks.^30,32 Interpositional arthroplasty seems to be more successful in post-traumatic arthritis than in inflammatory arthritis.³³ Interpositional arthroplasty can be revised again in young patients²⁹ or converted to total elbow arthroplasty when indicated.³⁴ In rheumatoid arthritis, interpositional arthroplasty provides good pain relief but the bony destruction often continues to progress which makes revision to elbow arthroplasty exceedingly difficult.³⁵ TER is preferable in rheumatoid elbows in older and less active patients.

1.14. Other arthritides

1.14.1. Sero-negative disorders

• -Spondylo-arthritides (SpA)
• -Ankylosing spondylitis
• -Psoriatic arthritis
• -Enteropathic arthritis
• -Juvenile idiopathic arthritis
• -Reactive arthritis (Formally called Reiters disease)
• -Gout
• -Lupus

1.15. General

These are a group of heterogeneous inflammatory joint disorders which produce inflammation at the site of tendon and ligament attachments to bone (enthesitis) which are one of the hallmark traits of SpAs and is when they most commonly involve the elbow surgeon.

They are negative for rheumatoid factor (RF) but can show a high incidence of HLA-B27. As with many arthritides, laboratory testing is difficult and diagnosis is normally based on clinical symptoms and/or a family history of other generalised inflammatory conditions like anterior uveitis, inflammatory bowel disease, urethritis or the presence of specific conditions such as sacroiliitis or psoriatic skin changes.

Out of all, only those commonly affecting the elbow would be discussed in this review.

1.16. Psoriatic arthritis

A quarter of patients with psoriasis have psoriatic arthritis (PsA).³⁶ The significance of enthesopathies or enthesitis (found in 50% of PsA) in both the symptomology and the development of arthritis has gained a lot of impetus and understanding in the rheumatological literature.

PsA patients usually have symmetrical polyarthritis similar to RA and diagnosis is made when there is a sero-negative arthritis (to RF) and concomitant presence of skin plaques. Unfortunately, one of the most common sites of the psoriatic skin lesion is overlying the olecranon. Whilst elective surgery is best performed when skin disease is stable or in remission, complications of surgery through skin plaques is surprisingly low.

One possible complication of surgery in PsA is the Koebner phenomenon where damage to the epidermis and dermis can produce psoriatic plaques in otherwise normal or unaffected skin.

1.17. Gout

Gout can occur in the elbow as a mono-arthropathy though the classic site of involvement around the elbow is the olecranon bursa. It is thought that the crystallisation of uric acid in gout occurs in areas of the body that are pressure points and have a lower temperature. It explains, why the olecranon could be involved in gout. Diagnosis of gout is challenging as serum uric acid levels are often normal. However, if they are raised, it is diagnostic. The true definitive diagnosis test for gout is to find crystals in the aspirated fluid. A painful olecranon bursa due to gout should be treated by excision.

Gouty tophi, if painful around the elbow should be excised. Normally they are not painful but can cause ulceration, infection and poor wound healing.

Though it remains uncommon, gout can present with a rapidly and extremely painful mono-arthropathy of the elbow. For this reason, as well as the fact that patients may also present with a temperature, it can be difficult to distinguish it from septic arthritis. In this instance, early joint aspiration of the inflamed joint is required.

1.18. Lupus

Lupus is a chronic autoimmune disease that usually affects peripheral joints, particularly in the hands and feet, but can also affect the elbow where it can produce enthesopathies³⁷ and can also result in the formation of rashes surrounding the elbow.

Articular involvement is common in Lupus, usually affecting the hand and occasionally the elbow³⁸ but is normally transient and reversible. Occasionally it can produce a deforming but non-erosive arthropathy known as Jaccoud's arthropathy which is an erosive symmetrical polyarthritis similar to rheumatois and is sometimes also called Rhupus syndrome.³⁹

2. Conclusion

The most important message to take home when considering treating patients with inflammatory arthritis is that they are surprisingly fragile medically and of all patients require an extended team approach.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.