Influence of previous open synovectomy on the outcome of Souter-Strathclyde total elbow prosthesis

J. C. T. van der Lugt, R. B. Geskus and P. M. Rozing

Leiden University Medical Center, Orthopaedics, Leiden, The Netherlands.

Correspondence to: J. C. T. van der Lugt. E-mail: j.c.t.van_der_lugt{at}lumc.nl


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objectives. Open synovectomy of the elbow joint is often performed in early stages of rheumatoid arthritis. Because of poor long-term results after synovectomy, insertion of a total elbow prosthesis is commonly used as a secondary procedure. The aim of this study is to evaluate the influence of previous synovectomy on the outcome after placement of a total elbow prosthesis.

Methods. We inserted 204 primary Souter-Strathclyde total elbow prostheses for rheumatoid arthritis. Two groups could be distinguished: group A with previous synovectomy 3.9 yr (mean) before the elbow replacement (n = 33) and group B without previous synovectomy (n = 171). The mean follow-up was 5.8 yr for group A and 6.3 yr for group B. All patients were assessed clinically and radiologically before the operation, 1 and 2 years later and then at regular intervals. The effect of previous synovectomy was analysed via a Cox model and a generalized linear mixed model for binomial data with multivariate normal random effects.

Results. No statistically significant effect of previous synovectomy on pain, function or complaints of the ulnar nerve could be found post-operatively. The post-operative flexion was significantly higher in group B than in group A. The complication-rates were similar for both groups. The overall survival rate for respectively group A and B with revision as endpoint was 66.9% (S.E. 13.4) versus 79.6 (S.E. 4.3) after 10 yr.

Conclusions. Previous synovectomy does not diminish the outcome after total elbow prosthesis in this series and could therefore be considered in early, painful stages of rheumatoid destruction of the elbow joint.

KEY WORDS: Elbow joint, Elbow prosthesis, Open synovectomy, Rheumatoid arthritis, Souter-Strathclyde


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Open synovectomy of the elbow joint, with or without excision of the radial head, is often performed in the early stages of rheumatoid arthritis. The treatment is simple, has low complication rates and more than 70% of the patients experience pain relief and improvement in function after this treatment [1–7]. Nevertheless, the long-term results of this procedure are poor. Half of the patients that have undergone synovectomy suffer from similar complaints 5 yr after surgery as they did pre-operatively [2, 5]. Excision of the radial head is still controversial. Some authors have found no differences in results when comparing synovectomy combined with excision of the radial head and synovectomy alone [6, 8]; other authors showed better outcome after excision [1, 2, 5]. At this moment, excision of the radial head is mainly considered in cases with pre-operative pain clearly located on the lateral side of the elbow [9].

Because of the poor long-term results of synovectomy, insertion of total elbow prosthesis is commonly performed as a secondary procedure, mainly for the elderly. After placement of an elbow prosthesis as a primary procedure, pain relief and functional improvement is seen in almost all cases; however, the complication rates are still high, ranging between 15 and 50% [7]. De Boer et al. [10] showed that patients’ satisfaction [measured on a visual analogue scale (VAS)] after total elbow prosthesis, without previous synovectomy, is significantly higher when compared with the satisfaction of patients who have undergone primary synovectomy. In fact, however, little is known about the results of total elbow prostheses inserted after synovectomy, with or without excision of the radial head. Schmetisch et al. [11] found more complications in 23 capitello-condylar elbow prostheses (unlinked) in patients with previous synovectomy than in patients who had not had prior synovectomy. These complications were related mainly to instability of the prosthesis due to insufficient quality of the soft tissues at the time of replacement surgery. Fink et al. [12] described more complications after total elbow prosthesis secondary to preceding rheumatoid surgery than in patients without such previous surgery, but these complications were mainly found after previous resection arthroplasty.

At our centre the unlinked Souter-Strathclyde total elbow prosthesis (Stryker Howmedica Osteonics®, Limerick, Ireland) has been used since June 1982 for primary total elbow replacements, mainly for rheumatoid arthritis [13]. We now present the results of 33 Souter-Strathclyde elbow prostheses inserted after open synovectomy and we compare them with 171 Souter-Strathclyde elbow prostheses without prior surgery. All elbows were affected with rheumatoid arthritis. None of the 204 elbows were lost to follow-up. The aim of this study is to evaluate the influence of previous synovectomy on the results after placement of total elbow prostheses. In addition, the role of synovectomy as treatment for the rheumatoid elbow joint will be discussed.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
We have inserted 204 primary Souter-Strathclyde total elbow prostheses for rheumatoid arthritis between June 1982 and December 2000. Of these, 33 had undergone open synovectomy 3.9 yr (mean, S.E. 0.6 yr) before the elbow replacement (Fig. 1). In 14 patients (14 elbows) the radial head was also excised because of severe pre-operative complaints of the radio-humeral joint. Two groups could be distinguished: group A with previous synovectomy (with or without radial head excision) (n = 33) and group B without previous synovectomy (n = 171). At the time of replacement surgery no significant differences between the groups were seen in sex, Larsen gradation, duration of rheumatoid arthritis or clinical scores (see Table 1). We had 118 women and 48 men with mean ages of 55.7 (S.E. 2.5) and 62.3 (S.E. 0.8) yr at operation for groups A and B respectively. The mean follow-up was 5.8 yr for group A and 6.3 yr for group B. All patients were examined by the senior author (PMR) and assessed clinically and radiologically before the operation, as well as 1 and 2 yr later and after that at regular intervals using a shortened version of the assessment developed by Souter [14]. The data for all patients were collected in MRDM (Medical Research Data Management, www.clinicalresearch.nl). All data were analysed using S-PLUS data software (Insightful, Seattle, USA).



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FIG. 1. Insertion of Souter-Strathclyde total elbow prosthesis 4 yr after open synovectomy (without excision of the radial head).

 

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TABLE 1. Characteristics, pre- and latest post-operative clinical characteristics of Souter-Strathclyde total elbow prosthesis with and without previous open synovectomy

 
Because all clinical scoring measurements had been obtained as part of normal (out-patient) follow-up after an elbow replacement, no additional ethical approval was needed from the Dutch Ethical Committee. All information about patients given in this work is anonymous.

Operation
Two surgeons, using the same technique, carried out the replacement operation (group A 30:3 and group B 143:28 operations for the two surgeons respectively) [15]. Prophylactic intravenous antibiotics were routinely employed. The patient lies on her/his contralateral side. The arm is supported by a padded rest so that the elbow can be flexed to beyond a right angle and a pneumatic tourniquet is applied. The skin is opened through a posterolateral incision. The lateral incision of the previous surgery was used in group A. After that the posterior aponeurosis is mobilized as a tongue. This tongue remains attached distally to the olecranon and the triceps muscle is divided longitudinally between the medial and lateral head. The annular ligament is split and the radial head is removed if this had not been done previously.

The supracondylar ridges, capitellum and the medial epicondyle are excavated with a ball-shaped burr. The ulna is excavated by using the same method. After insertion of a trial prosthesis both components are cemented with Palacos cement. For stabilization of the prosthesis careful reattachment of the annular ligament and both heads of the triceps is necessary.

The mean duration of the operation was 165 min (85–275) and there was no difference between the surgeons or groups. An ipsilateral shoulder arthroplasty was done in eight operations and an arthrodesis of the ipsilateral wrist in three operations at the same time.

Post-operative treatment
The patient is treated with compression dressing for 5 days post-operatively followed by collar and cuff immobilization. Passive and active flexion and extension exercises are started on the fifth day under a physiotherapist's supervision. Until 6 weeks after the operation all patients were treated with a posterior splint for protection at night.

Statistics
Except for the ages at the time of the elbow replacement no differences in patients’ characteristics were noted between both groups at the time of elbow replacement surgery ({chi}2 test, P<0.05). Besides that, the selection of whether or not to place an elbow prosthesis did not depend on previous synovectomy. Consequently, the matching of patients is not necessary in this study. The Cox model was used to investigate the effect of previous synovectomy on the chance of revision (significance at P<0.05) and the Kaplan–Meier survival method with revision as endpoint was used to analyse the overall survival of the prosthesis in both groups. The effect of previous synovectomy on the development of pain, severity of pain, function and ulnar nerve dysfunction after the operation was analysed via a generalized linear mixed model with multivariate normal random effects, using penalized quasi-likelihood (significance at P<0.05) [16, 17]. The development of the ordinal variable housekeeping ability was analysed in a standard linear mixed effects model, using restricted maximum likelihood (significance at P<0.05). Finally, the Student's t-test was used to compare the gain in range of motion after surgery between both groups (significance at P<0.05).


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
The pre-operative and latest clinical results are summarized in Table 1. No influence of age on the outcome was seen when using the Cox model (Wald test, P = 0.20). The post-operative flexion was significantly higher in group B when compared with group A. No further differences were noted between the groups. Table 2 shows the way in which clinical characteristics changed over time during follow-up, given by odds ratios. In all cases, pain increased during the post-operative follow-up, but the number of complaints of the ulnar nerve decreased and the elbow function improved (not significant). Previous synovectomy did not affect the intercepts or slopes significantly.


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TABLE 2. The way in which post-operative characteristics changed over time, given by odds ratios per year of follow-up, after insertion of a Souter-Strathclyde total elbow prosthesis. No statistically significant influence of previous synovectomy was found for all items

 
Post-operative complications
We have summarized the complications in Table 3. Group A had three post-operative infections. Of these, two were late infections (10 and 12 yr post-operatively). The infection-rate differs between both groups (9% in group A and 4% in group B), but the numbers are too small to draw conclusions. For all other post-operative complications, the percentages are similar between the two groups.


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TABLE 3. Reasons for removal, with or without revision, of the Souter-Strathclyde total elbow prosthesis in both groups

 
Survival of the prosthesis
The overall survival rate for group A and B respectively, according to the method of Kaplan–Meier with revision as endpoint, was 86.8% (S.E. 6.3) versus 90.8% (S.E. 2.4) after 5 yr and 66.9% (S.E. 13.4) versus 79.6% (SE 4.3) after 10 yr. The log-rank test did not find evidence of a difference in survival between the groups ({chi}2 test = 1.16, degrees of freedom = 1, P = 0.28). Overall, 90% (group A) and 96% (group B) of the patients were very satisfied with the prosthesis at the latest follow-up and would undergo this operation again.


    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Long-term follow-up results of total elbow prostheses have become available during the last years [18–22]. These results are promising, but the number of complications is still higher than for most other joint replacements. At the moment 90 to 95% of elbow prostheses are placed in rheumatoid arthritis [19, 21]. The indication for this surgery is pain combined with radiological destruction of the elbow joint.

The Souter-Strathclyde prosthesis has similar clinical results and complication rates as other elbow prostheses and is therefore, as are all elbow prostheses, only recommended in severe stages of elbow destruction [23]. For patients with early stages of rheumatoid destruction of the elbow combined with severe pain, synovectomy can be considered. But, in view of the poor long-term results after synovectomy, patients should always be aware of the possibility of replacement treatment in the future. Both the clinical results and the complication rates after insertion of a Souter-Strathclyde prosthesis are comparable for both groups. Even though the number of patients with previous synovectomy in this study is low, it still supports the restricted contribution of previous synovectomy on the outcome after insertion of an elbow prosthesis. However, if previous synovectomy were to affect the outcome after elbow joint replacement in larger series, the clinical relevance in the individual patient could be discussed.

In the literature the survival rate of the Souter-Strathclyde prosthesis is 69 to 87% after 10 yr when revision is taken as endpoint [23–25]. In this series the survival rate is equal to these rates and no statistically significant difference was found between the groups.

We have to point out that complaints of the ulnar nerve often exist before insertion of the elbow prosthesis. A surgeon has to discriminate between already existing complaints and new complaints after the operation. Previous synovectomy seems not to have any influence on the development of ulnar complaints in this study.

Although the range of motion is similar for both groups at the time of replacement surgery, the post-operative increase in flexion is lower in group A compared with group B. We think that the amount of scar tissues in group A might be higher due to the previous operation. On the other hand, the post-operative range of motion after total elbow prosthesis is sufficient for all daily activities in both groups [26].

The link between the amount of elbow destruction and the level of pain is still unclear. Two studies found no relationship between stages of disease and relief of pain after synovectomy [2, 5]. We therefore recommend synovectomy of the elbow as a reliable procedure that can alleviate pain in rheumatoid arthritis, but also state that no prediction about the influence on change or progression of elbow joint destruction can be made [27]. Arthroscopic synovectomy can probably decrease the morbidity with, like open synovectomy, preservation of good post-operative pain relief [28]. This treatment may be preceding elbow replacement more frequently in future, especially for early, painful stages of rheumatoid arthritis in younger patients. Furthermore, the role of anti-rheumatic drugs in prevention of destruction of the rheumatic elbow and introduction of more sophisticated painkillers will probably become more important in the early treatment of this disease in future. Nevertheless, for the secondary procedure after synovectomy total elbow prosthesis is nowadays evidently the first choice mainly for the elderly.


    Acknowledgments
 
We kindly thank Ms Margriet G. Kramer for reviewing this manuscript.

The authors have declared no conflicts of interest.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Submitted 10 September 2003; revised version accepted 28 May 2004.



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