Reoperation rate after elbow synovectomy in rheumatoid arthritis

Reoperation rate after elbow synovectomy in rheumatoid arthritis Heikki M. Ma¨enpa¨a¨, MD, PhD,a Pekko P. Kuusela, MD,a Kalevi Kaarela, MD, PhD,b Hannu J. Kautiainen, BA,a Janne T. Lehtinen, MD, PhD,a and Eero A. Belt, MD, PhD,a Heinola, Finland

The purpose of this study was to evaluate the reoperation rate of elbow synovectomy in patients with rheumatoid arthritis. A total of 103 synovectomies were performed in 88 patients (61 women) with rheumatoid factor–positive rheumatoid arthritis with a mean follow-up of 5.2 years (range, 1-8 years). The survival rate after elbow synovectomy (free from reoperation) was 77% (95% confidence interval, 66%-85%) at 5 years. Eight resynovectomies and fourteen total elbow replacements were performed during the follow-up. No significant improvement in range of motion was detected after synovectomy, but pain relief and patient satisfaction were favorable. Elbows were classified preoperatively (before primary synovectomy) with the Larsen system. All resynovectomies were performed for elbows of grade 0-2 destruction. A significant difference was found between early (Larsen grade 0-2) and late (Larsen grade 3) synovectomies in relation to elbow replacement (P ⫽ .002) during the follow-up. Late synovectomy yielded more temporary pain relief with a high rate of elbow arthroplasties. (J Shoulder Elbow Surg 2003;12:480-3.)

T

he incidence of elbow involvement in rheumatoid arthritis (RA) has recently been shown in a prospective long-term follow-up study from our hospital.9 The first elbow synovectomy was performed by Schuller15 in 1893, and it still has a well-established position in surgery of the rheumatoid elbow.4-6,11,12 Pain relief has usually been favorable initially,2,6,11,12 but the positive effect could have deteriorated during the long-term follow-up.13,16 Improvement in the range of motion in flexion-extension has been limited, although radial head excision and anterior capsular release have been combined with the procedure.2,11,16 On From the Departments of Orthopaedicsa and Rheumatologyb, Rheumatism Foundation Hospital. Reprint requests: Eero A. Belt, MD, PhD, Rheumatism Foundation Hospital, FIN-18120, Heinola, Finland. (E-mail: eero.belt@ reuma.fi). Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 doi:10.1016/S1058-2746(03)00167-8

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the other hand, a low preoperative range of supination-pronation could be a strong predictor for success.5 Radial head excision is an essential part of the procedure in most reports,2,5,11,16 but some authors have emphasized the importance of conservation of the radial head.3,13 Early synovectomy is recommended in some reports,4,12,13 but it has also been suggested that advanced destruction of the elbow is not necessarily a contraindication to the procedure.2,11,16 The purpose of this study was to evaluate the outcome of 103 elbow synovectomies in patients with RA and to assess the need for further surgery, especially resynovectomies and total elbow replacements. MATERIALS AND METHODS A total of 103 elbow synovectomies were performed in 88 patients (61 women and 27 men) with rheumatoid factor–positive RA at the Rheumatism Foundation Hospital, Heinola, Finland, between 1991 and 1999. A bilateral procedure was performed in 15 patients (10 women and 5 men). The mean age at the time of surgery was 53 years (range, 27-75 years), and the mean disease duration before elbow synovectomy was 19 years (range, 2-39 years). The mean follow-up was 5.2 years (range, 1-8 years). The medication comprised prednisolone and nonsteroidal antiinflammatory drugs in 23 cases (22%), disease-modifying antirheumatic drugs in 52 cases (50%), and a combination of oral corticosteroids and disease-modifying antirheumatic drugs in 27 cases (26%). One patient received no specific medication. Shoulder replacements and wrist fusions performed before elbow synovectomy were recorded. Indications for synovectomy (and resynovectomy) were persistent synovitis despite antirheumatic medical treatment and glucocorticoid injections and the need for pain relief in elbows without significant instability or bony defects. Preoperative functional status was also recorded. The preoperative grade of destruction was assigned afterward (for study purposes) based on the classification of Larsen et al,8 in which the radiographs to be interpreted were compared with a standard series consisting of a scale from 0 to 5. The procedure was performed through a posteroradial exposure in a bloodless field with the pneumatic tourniquet pressure at 100 mm Hg above the preoperative systolic arm blood pressure. The radial head was excised in 46 cases showing significant destruction or subluxation, and anterior capsular release was performed in 14 cases to improve extension.

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Table I Functional ability of 88 patients (103 elbows) with RFpositive RA before and after elbow synovectomy with a mean follow-up period of 5.2 years (range, 1-8 years) Preoperative Postoperative Flexion (°) [mean (range)] Extension deficit, (°) [mean (range)] Supination, (°) [mean (range)] Pronation, (°) [mean (range)] Pain* No pain Mild pain Moderate pain Severe pain Subjective satisfaction in 86 elbows Excellent Good Moderate Poor

Figure 1 Survival rate (free from reoperation) after 103 elbow synovectomies in 88 patients with rheumatoid factor–positive rheumatoid arthritis is presented as survival curves. Early (Larsen grade 0-2) and late synovectomies (Larsen grade 3) are shown separately.

Functional ability and pain status were evaluated from patient documents at the latest follow-up visit. Longevity of the procedure was assessed, and the number of resynovectomies and elbow arthroplasties performed was carefully determined from patient documents. Resynovectomy, elbow replacement, or death of the patient served as the endpoint of the study. Moreover, during the year 2000, a complementary interview was arranged, in which the current ability, pain status, and longevity of synovectomy were ascertained. The results are presented as survival curves (free from resynovectomy or total elbow replacement) and separately for cases with early and late synovectomy. The term early synovectomy was used for elbows with a preoperative Larsen grade 0-2 and late synovectomy for those with a preoperative Larsen grade 3-5.8 The difference in survival rate was analyzed by the log-rank test.

RESULTS Four shoulder arthroplasties and twenty-three total wrist fusions were performed before elbow synovectomy. Synovectomy was performed in 55 cases on the right elbow and in 48 on the left; the procedure was bilateral in 15 patients. The radial head was excised in 46 elbows (45%), and the anterior capsule was released in 14 elbows (14%). Six patients had preoperative symptoms of ulnar nerve neuropathy, but only one ulnar nerve transposition was performed. Mild destruction of the elbow was documented in 64 cases (62%), moderate in 32 (31%), and severe in 7 (7%) during the procedure. Postoperative wound problems were present in one elbow and ulnar neuropathy in another. One incident of temporary radial nerve paresis, one of instability, and one of unex-

133 23 78 78

(90–150) (0–60) (40–90) (10–90) 0 51 45 6

134 19 81 78

(90–150) (0–70) (20–90) (7–90) 29 42 12 1 13 38 29 6

Subjective content was analyzed at the latest follow-up visit or with a complementary interview. *Information on pain status concerns 84 elbows.

pected stiffness occurred. Moreover, in one case prolonged antibiotic (trimethoprin-sulphamethoxazole) treatment was considered to be necessary with no further surgery. In the analysis of preoperative radiographs, the mean Larsen grade of all elbows was 1.8 (range, 0-3). The distribution of destruction was as follows: 2 elbows with grade 0 destruction, 37 with grade 1, 45 with grade 2, 19 with grade 3, and none with the most severe destruction of grade 4-5. A total of 8 resynovectomies (8%) (3 women and 5 men) and 14 elbow replacements (14%) (11 women and 3 men) were performed; 8 patients (5 women and 3 men) died during follow-up. The survival rate after elbow synovectomy (free from reoperation) was 77% (95% confidence interval [CI], 66%-85%) at 5 years. The survival rates while free from resynovectomy and from arthroplasty at 5 years were 91% (95% CI, 83%96%) and 84% (95% CI, 73%-91%), respectively. Functional ability and subjective satisfaction before the procedure and during follow-up are shown in Table I. Longevity of the procedure is presented as survival curves for additional procedures performed (resynovectomy or total elbow replacement) and separately as free from resynovectomy and from elbow replacement (Figures 1-3). The difference between early and late synovectomy was statistically significant (P ⫽ .002) only if the rate of elbow replacement (free from arthroplasty) was considered (Figure 3). DISCUSSION In this series patients were followed up for over 5 years after elbow synovectomy, and resynovectomy or arthroplasty served as an endpoint. The range of

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Figure 2 Survival rate while free from resynovectomy is presented. Early and late elbow synovectomies are shown separately.

Figure 3 Survival rate while free from arthroplasty is presented. Early and late elbow synovectomies are shown separately.

motion was not improved during the follow-up, which is in agreement with previous studies.2,5,16 The radial head was excised in only 45% of the elbows, and the anterior capsule was released in 14%. In some series improvement of the flexion arc was achieved by release combined with excision of the radial head.11,14 The influence of limited preoperative supination-pronation and radial head excision on the success of the procedure was not specifically evaluated in this series.5 The radial head was conserved if no significant destruction or subluxation was present to preserve elbow stability and to avoid problems with the inferior radioulnar joint.3,13 The procedure was defined as early synovectomy in cases in which no radiographic destruction was

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detected or the amount of destruction was low (Larsen grades 0-2). Late synovectomy was related to elbows with a higher grade of destruction. In this study the majority of elbow synovectomies (81%) showed a grade of destruction lower than Larsen grade 3.8 No significant difference in survival between early and late synovectomy was found if both resynovectomy and elbow replacement (free from operation; Figure 1) were counted. No resynovectomies were performed for the elbows of Larsen grade 3 destruction; thus, all 8 resynovectomies performed were for elbows with primary early synovectomy (Figure 2), but the difference was not significant. However, the difference between early and late synovectomy was highly significant if only the rate of elbow replacement (Figure 3) was considered in the survival curve. This is in agreement with the recommendation for the success of early synovectomy.4,12,13 To our knowledge, this is the first report in which a more favorable success rate for the early procedure could be shown. Half of the cases with Larsen grade 3 destruction went on to have elbow arthroplasty during the follow-up. We have previously demonstrated that a Larsen score (0-100) of the peripheral joints was related to the grade of elbow destruction; thus, patients with advanced elbow destruction have more severe disease.9 In such patients the disease is progressive, reflecting a higher need for arthroplasties.7 Unfortunately, the number of postoperative radiographs was not sufficient to evaluate the development of elbow destruction accurately during the follow-up period. The main indication for elbow synovectomy is pain relief in both early and late synovectomy. With early synovectomy, it is possible to prevent further deterioration of the elbow and maintain stability and functional ability of the joint, whereas late synovectomy is more or less a palliative procedure. Although antirheumatic medication has developed rapidly during recent years,1,10 synovectomy still holds a position in the treatment of RA. However, elbows with advanced destruction showed worse prognosis after synovectomy, and only temporary relief could be achieved for those years before elbow replacement became necessary in many cases. REFERENCES

1. Bathon JM, Martin RW, Fleischmann RM, et al. A comparison of etanercept and methotrexate in patients with early rheumatoid arthritis. N Engl J Med 2000;343:1586-92. 2. Brumfield RH, Resnick CT. Synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 1985;67:16-20. 3. 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. 4. Ferlic DC, Patchett CE, Clayton ML, Freeman AC. Elbow synovectomy in rheumatoid arthritis. Long-term results. Clin Orthop 1987;220:119-25. 5. Gendi NS, Axon JM, Carr AJ, et al. Synovectomy of the elbow

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6. 7. 8. 9. 10.

and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome. J Bone Joint Surg Br 1997;6:918-23. Inglis AE, Ranawat CS, Straub LR. Synovectomy and debridement of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 1971; 53:652-62. Kaarela K, Kautiainen H. Continuous progression of radiological destruction in seropositive rheumatoid arthritis. J Rheumatol 1997; 24:1285-7. Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn 1977;18:481-91. Lehtinen JT, Kaarela K, Kautiainen HJ, Kauppi MJ, Belt EA. Incidence of elbow involvement in seropositive rheumatoid arthritis. A 15-year endpoint study. J Rheumatol 2001;28:70-4. Lipsky PE, van der Heijde DMFM, St Clair EW. Infliximab and methotrexate in the treatment of rheumatoid arthritis. N Engl J Med 2000;343:1594-601.

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11. 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;22:279-85. 12. Porter BB, Richardson C, Vainio K. Rheumatoid arthritis of the elbow: the results of synovectomy. J Bone Joint Surg Br 1974; 56:427-37. 13. 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;66:109-13. 14. Saito T, Koshino T, Okamoto R, Horiuchi S. Radical synovectomy with muscle release for the rheumatoid elbow. Acta Orthop Scand 1986;57:71-3. 15. Schuller M. Chirurgiche Mitteilungen u¨ber die chronisch rheumatischen Gelenkentzundungen. Arch Klin Chir 1893;45:153. 16. Summers GD, Taylor AR, Webley M. Elbow synovectomy and excision of the radial head in rheumatoid arthritis: a short term palliative procedure. J Rheumatol 1988;15:566-9.