The efficacy of synovectomy for joints at radiographically early stages and TEA for joints at radiographically advanced stages has been confirmed repeatedly (Brumfield and Resnick 1985
, Stein et al. 1975
, Saito 1986
, Ferlic et al. 1987
, Figgie et al 1989
, Tulp and Winia 1989
, Koshino 1991
, Gendi et al. 1997
, Connor and Morrey 1998
, Fuerst et al. 2006
, Nakagawa et al. 2007
). Our cases underwent open elbow synovectomy, but several reports suggest the efficacy of arthroscopic synovectomy for rheumatoid elbow at radiographically early stages (Lee and Morrey 1997
, Horiuchi et al. 2002
, Tanaka et al. 2006
). However, there have been few reports on long-term outcome of arthroscopic synovectomy (Tanaka et al. 2006
), and several authors have reported a relatively high incidence of complications such as local nerve impairment (Lee and Morrey 1997
). Thus, we performed open synovectomy to resect the synovium sufficiently and safely.
Medium-term results of elbow synovectomy with an average follow-up period of up to 10 years have been published by several authors. Ferlic et al. (1987)
reported excellent results with an average follow-up of 7 years and a maximum follow-up of 20 years. In their report, 44/57 elbows had excellent results, and they had better clinical results in patients who underwent surgery at earlier stages of the disease. Brumfield and Resnick (1985) stated that synovectomy was not contraindicated even for joints at radiographically advanced stages, such as Larsen grade 3 or 4, because an improvement in the range of motion can be expected. We also performed elbow synovectomy at advanced stages and this was not followed by substantial joint instability. In the present study, 12/16 elbows required conversion to TEA after a minimum of 10 years and an average of 15 years of follow-up. We consider this result to be more favorable than those in previous reports that included synovectomies for elbows at radiographically advanced stages (Ferlic et al. 1987
, Fuerst et al. 2006
). Recurrence of severe pain from progressive joint destruction was the most common cause of the conversion to TEA: 4 of 7 elbows of Larsen grade 5 underwent conversion.
During an elbow synovectomy, the radial head is often resected. Resection of the radial head enhances the operative visual field and the performance of an adequate resection of the joint synovium. Additionally, resection of the radial head improves flexion, especially in cases with anterior subluxation of the radial head. However, resection of the radial head during an elbow synovectomy is controversial. Ferlic et al. (1987)
reported that there was no difference in clinical results between cases that had resection of the radial head and those with resection and radial head replacement. Lehtinen et al. (2001)
reported that the elbow seemed to turn into valgus during rheumatoid destruction and resection of the radial head. Rymaszewski et al. (1984)
suggested that resection of the radial head caused joint instability in the long term, and recommended radial head replacement rather than radial head resection. In addition, Taylor et al. (1976)
and Copeland and Taylor (1979)
reported that resection of the radial head caused progression of valgus deformities of the elbow in more than half of their cases. They also found that excessive axial pressure to the ulna by resection of the radial head caused pain on the ulnar side of the wrist. We resected the radial head in all our cases with only a slight increase in the valgus angle at the final follow-up examination (mean 2 degrees). At the final examination, only 2 elbows showed marked valgus deformities with severe instability of the elbow joint. Thus, we believe that resection of the radial head is appropriate.
One of the limitations of our study was the evaluation of joint instability, which was assessed clinically, not radiographically. Radiographic examination is a more precise method.
In conclusion, synovectomy for the treatment of rheumatoid elbow gives a good long-term outcome, even for radiologically advanced joints of Larsen grades 3 or 4, but not for those of grade 5.