Rheumatoid arthritis can be such a difficult disease to live with! I have always admired people affected with rheumatoid arthritis, coping with so much pain and so many limitations…, and almost always with a smile on their face. Since the shoulder and the elbow are very commonly affected, I have had the opportunity to treat many patients with rheumatoid arthritis. Did you know that one or both elbows are eventually involved in between 20 and 65% of rheumatoid patients?
What are the symptoms?
Elbow, pain, swelling and stiffness are all common. The elbow may look and feel swollen, especially on the outside. Pain may be present most of the time, but becomes worse with movement and use of the arm. Over time, many individuals note that their elbow cannot be fully straightened or bent, and turning the palm up or down may become painful and difficult as well. Lumps can occasionally grow on the skin at the back of the elbow (they are called rheumatoid nodules). Tingling at the ring and baby fingers may develop when one of the nerves in the arm (the ulnar nerve) is inflamed or pinched at the elbow. Radiographs may be normal at the very beginning, but they eventually show joint line thinning, cysts, and bone destruction to some extent.
Get better and protect your joint, all at once!
The most helpful step for individuals with rheumatoid arthritis is to work closely with a Rheumatologist. A major revolution happened in the management of rheumatoid arthritis with the development of a number of medications called DMARDs (Disease Modifying Anti-Rheumatic Drugs). These drugs not only improve pain and quality of life, but they also protect against progressive joint destruction to some extent. Some patients need to take two of more medications together to keep their inflammation under control. This can be supplemented with non-steroidal anti-inflammatory drugs (NSAIDs) if needed.
Unfortunately, despite use of the best combination of drugs, the rheumatoid elbow will sometimes not respond. In these circumstances, injecting the elbow with steroids is commonly tried. Braces can also help protect the joint and maintain motion. Physical therapy will also help some patients. If all this fails, it is time to see an elbow surgeon, and an expert is really needed: not many orthopedic surgeons have lots of experience with the rheumatoid elbow.
What will the elbow surgeon do?
Examination of the elbow and evaluation of radiographs allow elbow surgeons to understand the severity of joint damage. In earlier stages, when destruction of the articular cartilage and bone are limited, the inflamed tissue that erodes the joint away can be removed surgically; this procedure is called synovectomy. In later stages, the only reliable surgical solution is elbow replacement.
Normal joints are enclosed by capsule. The inside of capsules is lined with synovium, a thin slippery layer of tissue largely responsible for joint lubrication and nutrition. In rheumatoid arthritis, the synovium becomes inflamed: it gets thicker and red. Inside the synovium, inflammatory cells and chemicals known as enzymes dissolve, erode and damage the articular cartilage and underlying bone. This abnormal inflamed synovium extends over the joint covering the surfaces like a red cloth: the pannus (derived from the Latin word for cloth). As a reaction, the overlying capsule becomes thicker and looses elasticity, contributing to motion loss.
The main goal of synovectomy is to surgically removed the pannus. Technological advances allow elbow surgeons to perform this procedure arthroscopically: a camera is introduced into the elbow joint through a puncture hole in the skin, and additional punctures holes around the joint are used to shave or remove pannus. If the capsule is too thick, it can be released as well, leading to better motion. Flaps of damaged cartilage and bone irregularities may be smoothed out as well. Synovectomy is very reliable in improving pain, motion and function in the earlier stages of rheumatoid arthritis. However, pannus may regrow, and some studies show that within 5 years a number of individuals may need to consider additional treatment.
When joint damage is advanced, the best surgical solution is elbow replacement. Artificial parts known as implants or prostheses are attached to the bones in the arm and forearm to replace the joint surfaces. Elbow replacement is less commonly performed than replacement of other joints, such as the knee, hip or shoulder. It is very successful in terms of pain relief and restoration of motion, stability and function. However, it does require a longer recovery time (typically three months), and in a small number of patients it can lead to substantial complications. Elbow replacement is probably one of the best operations an individual can consider when rheumatoid arthritis has affected the elbow joint really bad, so if that is your case, do not hesitate finding an orthopedic surgeon with experience in elbow replacement.
If you want to learn more… Rheumatoid elbow surgical treatment options Curr Rev Musculoskelet Med 2016 Jun 9 224-31