Effectiveness of arthroscopic elbow synovectomy in rheumatoid arthritis patients: Long-term follow-up of clinical and functional outcomes

Abstract

Objective:
To determine the long-term clinical and functional results of arthroscopic elbow synovectomy in rheumatoid arthritis patients with refractory elbow synovitis in terms of improvement in pain, function, and active range of motion (AROM) or arc of motion.

Method:
Fifteen rheumatoid elbows in 13 patients, not responding to DMARD therapy and with radiological changes not more than Larsen grade 3 were taken, who underwent arthroscopic elbow synovectomy. The main outcome measured in forms of Mayo Elbow Performance Scale (MEPS) score, measurement of pain using a Visual Analogue Scale (VAS), radiological angles of elbow, disease activity score (DAS-28), arc of motions (AOM) and complications, which were assessed at follow-up periods of 6 months, 24 months, and 30 months. Statistical analysis was done both qualitatively and quantitatively. Mann-Whitney U test, chi-square test, and Student t test were used as the statistical test for determining significance.

Results:
In the study group, the improvement was sustained and significant as compared to baseline (VAS 1.28, MEPS 81.07 and mean flexion range 85°) (p value <0.001). No significant complications were encountered postoperatively after elbow synovectomy.

Conclusion:
The study assesses the long-term results of arthroscopic synovectomy in elbow synovitis secondary to rheumatoid arthritis with significant results favoring arthroscopic synovectomy.

Full text

Original
article
Effectiveness
of
arthroscopic
elbow
synovectomy
in
rheumatoid
arthritis
patients:
Long-term
follow-up
of
clinical
and
functional
outcomes
Vivek
Shankar
a
,
Pankaj
Sharma
b,
*,
Ravi
Mittal
b
,
Samarth
Mittal
b
,
Uma
Kumar
c
,
Shivanand
Gamanagatti
d
a
Department
of
Orthopaedics,
Sports
Injury
Centre,
New
Delhi,
India
b
Department
of
Orthopaedics,
All
India
Institute
of
Medical
Sciences,
Ansari
Nagar,
New
Delhi
110029,
India
c
Department
of
Rheumatology,
All
India
Institute
of
Medical
Sciences,
Ansari
Nagar,
New
Delhi
110029,
India
d
Department
of
Radiodiagnosis,
All
India
Institute
of
Medical
Sciences,
Ansari
Nagar,
New
Delhi
110029,
India
1.
Introduction
Rheumatoid
arthritis
(RA)
is
a
chronic
inflammatory
condition,
autoimmune
in
nature,
involving
multiple
joints
usually
present-
ing
with
pain,
swelling,
inflammation,
stiffness,
and
possible
loss
of
functions
at
joints.
1,2
The
pattern
of
joint
involvement
varies,
wrist
being
the
most
frequently
involved
joint
(87%),
whereas
shoulder,
knees,
ankle,
and
elbow
are
involved
in
47%,
56%,
53%,
21%
respectively
at
the
time
of
presentation.
3
Rheumatoid
arthritis
is
the
most
common
cause
of
elbow
arthritis.
Involvement
of
elbow
joint
in
rheumatoid
arthritis
occurs
in
20–25%
within
5
years,
and
about
66%
will
show
definitive
involvement
within
15
years
of
disease
onset.
4,5
Incidence
of
disease
is
variable
in
different
regions
but
generally
increases
between
25
and
55
years
of
age,
remain
stable
or
in
a
static
manner
up
to
the
age
of
75
years
and
then
decreases.
1,2
Drugs
commonly
used
for
treatment
are
NSAIDs,
DMARDs,
Steroids,
and
new
biological
modifier
drugs
including
anti-TNF
drugs.
Due
to
their
high
cost,
non-availability,
poor
motivation
for
drugs
schedule,
and
observation
of
outcome
in
Indian
population,
these
drugs
are
not
widely
used.
There
are
poor
immunity
status
and
unhygienic
conditions
in
Indian
localities,
which
may
lead
to
accentuation
of
active
and
latent
infective
complications
and
respiratory
problems.
There
are
several
diseases
in
India
like
high
prevalence
of
tuberculosis,
which
may
be
aggravated,
or
their
progression
and
pathogenesis
altered
with
Journal
of
Clinical
Orthopaedics
and
Trauma
7S
(2016)
230–235
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
2
April
2016
Received
in
revised
form
20
May
2016
Accepted
30
May
2016
Available
online
23
June
2016
Keywords:
Arthroscopic
synovectomy
Visual
Analogue
Scale
(VAS)
score
Mayo
Elbow
Performance
Scale
(MEPS)
Arc
of
motion
(AOM)
Disease
activity
score
(DAS-28)
Larsen
grading
A
B
S
T
R
A
C
T
Objective:
To
determine
the
long-term
clinical
and
functional
results
of
arthroscopic
elbow
synovectomy
in
rheumatoid
arthritis
patients
with
refractory
elbow
synovitis
in
terms
of
improvement
in
pain,
function,
and
active
range
of
motion
(AROM)
or
arc
of
motion.
Method:
Fifteen
rheumatoid
elbows
in
13
patients,
not
responding
to
DMARD
therapy
and
with
radiological
changes
not
more
than
Larsen
grade
3
were
taken,
who
underwent
arthroscopic
elbow
synovectomy.
The
main
outcome
measured
in
forms
of
Mayo
Elbow
Performance
Scale
(MEPS)
score,
measurement
of
pain
using
a
Visual
Analogue
Scale
(VAS),
radiological
angles
of
elbow,
disease
activity
score
(DAS-28),
arc
of
motions
(AOM)
and
complications,
which
were
assessed
at
follow-up
periods
of
6
months,
24
months,
and
30
months.
Statistical
analysis
was
done
both
qualitatively
and
quantitatively.
Mann–Whitney
U
test,
chi-square
test,
and
Student
t
test
were
used
as
the
statistical
test
for
determining
significance.
Results:
In
the
study
group,
the
improvement
was
sustained
and
significant
as
compared
to
baseline
(VAS
1.28,
MEPS
81.07
and
mean
flexion
range
858)
(p
value
<0.001).
No
significant
complications
were
encountered
postoperatively
after
elbow
synovectomy.
Conclusion:
The
study
assesses
the
long-term
results
of
arthroscopic
synovectomy
in
elbow
synovitis
secondary
to
rheumatoid
arthritis
with
significant
results
favoring
arthroscopic
synovectomy.
ß
2016
Delhi
Orthopedic
Association.
All
rights
reserved.
*Corresponding
author
at:
Room
no
206,
F.T.A.
Flats,
A.V.
Nagar,
New
Delhi
110049,
India.
Tel.:
+91
9013590572.
E-mail
addresses:
drshankarvivek@gmail.com
(V.
Shankar),
dr.pankajkristwal@gmail.com
(P.
Sharma),
ravimittal66@hotmail.com
(R.
Mittal),
samarthmittal@gmail.com
(S.
Mittal),
Umaakumar@yahoo.com
(U.
Kumar),
shiv223@gmail.com
(S.
Gamanagatti).
Contents
lists
available
at
ScienceDirect
Journal
of
Clinical
Orthopaedics
and
Trauma
jou
r
nal
h
o
mep
ag
e:
w
ww
.elsevier
.co
m
/loc
ate/jc
o
t
http://dx.doi.org/10.1016/j.jcot.2016.05.011
0976-5662/ß
2016
Delhi
Orthopedic
Association.
All
rights
reserved.

changing
immune
status
by
mentioned
drugs.
6
Open
or
arthro-
scopic
synovectomy
may
be
useful
in
some
patients
with
persistent
mono-arthritis
(mild
to
moderate),
particularly
when
refractory
to
conservative
management.
As
synovium
primarily
plays
an
important
role
in
the
pathogenesis
and
disease
progres-
sion,
synovectomy
or
removal
of
inflamed
synovial
membrane
is
the
corner
stone
in
the
management
of
joint
inflammation
refractory
to
optimal
DMARD
therapy.
Arthroscopies
are
being
done
with
increasing
frequency
to
diagnose
and
treat
elbow
disorders
and
arthroscopic
synovectomy
of
elbow
joint
can
be
used
successfully
to
provide
pain
relief.
6–9
Unfortunately,
there
are
very
few
studies
dealing
with
the
effectiveness
of
elbow
arthroscopic
synovectomy
in
rheumatoid
arthritis
and
there
are
none
from
the
Indian
sub-continent.
The
present
study
was
undertaken
to
evaluate
the
effectiveness
of
arthroscopic
synovectomy
in
rheumatoid
arthritis
involving
elbow
joint.
2.
Material
and
methods
Fifteen
diagnosed
cases
of
rheumatoid
elbow
based
on
‘‘The
American
College
of
Rheumatology
1987
Revised
Criteria’’
for
the
diagnosis
of
rheumatoid
arthritis
not
responsive
to
optimal
DMARD
therapy
and
radiological
changes
not
more
than
Larsen
grade
3
were
selected.
Exclusion
criteria
included
history
of
trauma
to
the
affected
joint,
patient
with
history
of
septic
arthritis
of
elbow
joint,
gross
deformity
of
the
elbow,
and
severe
radiological
destruction
of
the
joint
with
Larsen
grade
4
or
more.
All
the
patients
continued
to
have
DMARD
therapy.
3.
Operative
method
All
the
patients
were
given
general
anesthesia
and
placed
in
prone
position
with
high
tourniquet
in
the
upper
arm.
The
arm
was
abducted
to
908
and
elbow
flexed
to
908
with
keeping
forearm
hanging
free.
The
bony
anatomical
landmarks
viz.,
the
radial
head,
the
olecranon,
and
the
lateral
and
medial
humeral
epicondyles
were
outlined
with
a
marking
pen.
Ulnar
nerve
was
also
palpated
and
marked.
20
ml
of
sterile
normal
saline
was
injected
into
the
elbow
joint
through
the
soft
spot,
to
distend
it.
Anteromedial,
anterolateral,
midlateral,
posterocentral,
and
posterolateral
por-
tals
were
used
for
surgery
to
get
a
maximum
view
of
the
joint
and
to
remove
the
synovium
with
help
of
4
mm
shaver
tip.
Posteromedial
portal
was
omitted
for
arthroscopy
to
avoid
ulnar
nerve
injury
in
such
a
stiff
joint.
Anteromedial
portal
(proximal
medial
portal)
is
the
primary
viewing
portal
for
arthroscopy
of
the
elbow
in
the
prone
position,
located
approx.
one
finger
breadth
proximal
to
the
medial
epicondyle
and
1–2
cm
anterior
to
the
intermuscular
septum.
With
the
joint
distended,
median
nerve
lies
approximately
2
cm,
and
the
brachial
artery
2.2
cm
from
the
portal.
The
ulnar
nerve
is
protected
by
keeping
the
trocar
anterior
to
the
intermuscular
septum.
Anterolateral
portal
(proximal
lateral
portal)
is
located
2
cm
proximal
to
the
lateral
epicondyle
and
1
cm
anterior
to
the
inter-muscular
septum.
It
is
approximately
4.8
mm
away
from
the
radial
nerve
with
the
elbow
in
extension
and
approximately
9.9
mm
away
with
the
elbow
in
flexion.
Midlateral
portal
(soft
spot
portal)
is
located
in
the
center
of
the
triangle
formed
by
the
radial
head,
the
lateral
epicondyle
of
the
humerus,
and
the
tip
of
the
olecranon.
It
is
the
portal
most
often
used
for
the
distension
of
the
joint.
Posterocentral
(straight
posterior)
portal
is
located
in
the
midline,
approximately
3
cm
proximal
to
the
tip
of
the
olecranon.
It
enters
directly
through
the
triceps
tendon
and
is
therefore
safe.
The
midlateral
and
posterocentral
(straight
posterior)
portals
can
be
used
alternately
as
diagnostic
and
operative
portals.
Posterolateral
portal
lies
just
lateral
to
the
posterior
portal,
i.e.,
3
cm
proximal
to
olecranon
tip
just
lateral
to
the
midline.
All
the
synovium
from
medial,
lateral
and
posterior
compartments
was
removed.
No
attempt
was
made
to
view
the
posteromedial
compartment
in
order
to
avoid
any
risk
to
the
ulnar
nerve.
Radial
head
excision
was
not
done
in
any
patient
but
clearing
of
soft
tissue
and
loose
bodies
from
olecranon
fossa
took
place.
The
joint
was
washed
thoroughly
with
three
liters
of
normal
saline
and
portals
were
closed
with
2.0
nylon
sutures.
Antiseptic
dressing
was
applied
and
compression
bandages
were
given.
Cefotaxime
coverage
was
continued
for
two
days
and
stopped.
Oral
analgesics
were
given
for
seven
days
postoperatively.
Elbow
mobilization
and
physiotherapy
were
started
from
the
second
post-operative
day.
3.1.
Evaluation
and
biostatics
analysis
We
studied
and
followed
the
following
parameters
in
our
study.
5–11
-
Visual
analogue
score
for
pain
-
Mayo
elbow
performance
score
including
100
maximum
points
(pain,
max.
45),
(motions,
max.
20),
(daily
function,
max.
25)
and
(stability,
max.
10
points)
-
Arc
of
flexion
-
Coronoid
height
ratio
-
Modified
Larsen
grade
-
Disease
activity
score-28
(DAS-28)
These
parameters
were
recorded
before
the
intervention
and
at
6
months,
24
months,
and
30
months
after
intervention.
The
statistical
analysis
would
be
carried
out
by
using
SPSS
version
15
for
qualitative
data.
The
analytical
technique
used
would
be
chi
square
test
or
Fisher
test
wherever
necessary.
For
quantitative
data,
Student
t-test
or
Mann–Whitney
test
would
be
done.
The
changeover
period
of
time
in
VAS
score
and
CoHR
would
be
analyzed
by
applying
repeated
measure
analysis
followed
by
post-
hoc
test.
The
p
value
of
<0.05
would
be
considered
as
significant.
Clinical
and
radiological
follow-up
of
two
patients
are
illustrated
in
Figs.
1
and
2
(clinical
and
radiological
photographs
of
a
patient
at
pre-op
and
different
follow-up
periods).
4.
Observation
and
results
Patient
profile
and
parameters
at
the
commencement
of
study
are
listed
in
Table
1.
In
this
study,
the
patient’s
age
ranged
from
26
to
62
years,
the
mean
age
being
41.7

9.7
years.
Male:female
ratio
was
1:12.
All
the
parameters
included
and
observed
in
study
are
summarized
in
Table
2.
There
was
significant
improvement
in
VAS
after
arthroscopic
procedure
when
compared
to
pre-operative
status
at
the
end
of
6
months,
24
months,
and
30
months
observation.
One
patient
had
exacerbation
of
pain
and
one
of
them
experienced
similar
pain
as
pre-operative
status
Table
1
Parameters
and
characteristics
of
patients
at
the
start
of
study.
Parameters
Mean

S.D.
Age
(years)
41.7

9.7
Duration
of
disease
(months)
94

74.5
Duration
of
right
elbow
involvement
(months)
59.2

80
Duration
of
left
elbow
involvement
(months)
54

79
E.S.R.
(mm/1
h)
58.5

16.6
Duration
of
NSAID
intake
(months)
101.6

72.1
Duration
of
DMARD
intake
(months)
51.7

64.3
Pre-op
visual
analogue
score
6.4

1.7
Pre-op
Mayo
elbow
performance
score
53.3

17
Pre-op
arc
of
flexion
67.66

27.70
Pre-op
modified
Larsen
score
2.5

0.5
Pre-op
coronoid
height
ratio
50.4

10.8
Pre-op
disease
activity
score
6.6

1.1
V.
Shankar
et
al.
/
Journal
of
Clinical
Orthopaedics
and
Trauma
7S
(2016)
230–235
231

during
this
period.
There
was
significant
improvement
in
MEPS
score
after
the
surgical
procedure
at
the
end
of
6
months,
24
months,
and
at
30
months.
All
patients
in
our
study
presented
with
improvement
in
MEPS
except
for
one
patient
where
the
score
remained
the
same.
No
patient
had
any
loss
of
function
in
this
group.
We
did
not
observe
any
significant
difference
in
the
mean
CoHR
and
modified
Larsen
scores
between
pre-operative
and
post-operative
values
in
group.
In
our
study,
we
observed
significant
results
when
Fig.
2.
Clinical
and
radiological
photographs
of
a
patient
at
pre-op
and
different
follow-up
periods.
Fig.
1.
Clinical
and
radiological
photographs
of
a
patient
at
pre-op
and
different
follow-up
periods.
V.
Shankar
et
al.
/
Journal
of
Clinical
Orthopaedics
and
Trauma
7S
(2016)
230–235
232

compared
between
pre-op
arc
of
flexion
and
30-month
follow-up
and
p
value
was
found
to
be
0.026.
Our
study
being
followed
up
of
thirteen
months
was
not
of
enough
period
to
note
any
significant
radiological
changes.
Hence,
we
suggest
that
a
long-term
follow-up
may
give
better
information
on
the
above
to
parameters
with
respect
to
time.
Clinical
and
radiological
photographs
of
two
patients
are
illustrated
in
Figs.
1
and
2,
which
elaborate
changes
over
follow-up
periods.
According
to
the
EULAR
response
criteria,
there
were
no
response
over
the
time
points
in
study
group
for
6,
24,
and
30
months
follow-
up
post-operatively
as
shown
in
Table
3.
11
In
the
study,
patients
group
performed
better
at
6
months
follow-up,
but
it
was
difficult
to
conclude
whether
improvement
was
due
to
arthroscopy
or
continuation
of
DMARD.
It
is
also
difficult
to
make
any
decision
regarding
effectiveness
of
surmise
that,
how
synovectomy
of
a
single
joint
can
have
such
a
significant
generalized
improvement.
5.
Discussion
It
is
an
autoimmune
disease
where
the
body’s
immune
system
affects
joints,
soft
tissues,
and
periarticular
soft
tissues
leading
to
inflammation
and
producing
various
symptoms,
ranging
from
pain,
morning
stiffness
to
deformities
of
joints.
Management
of
patients
with
RA
involves
an
interdisciplinary
approach,
which
attempts
to
deal
with
the
various
problems
that
persist
in
systemic
manner.
Drug
treatment
includes
various
drugs,
either
single
or
in
combinations
form.
Combination
drug
therapy,
using
disease-
modifying
anti-rheumatic
drugs
and
biologic
therapies
are
very
effective,
and
complete
resolution
of
signs
and
symptoms
is
achievable
in
approximately
10%
of
patients.
Intra-articular
steroid
injection
may
relieve
joint
inflammation
and
reduce
symptoms
in
early
stages.
Surgery
plays
an
important
role
in
the
management
of
patients
with
severely
damaged
joints
by
considering
age,
functional
demands,
etiology,
and
severity
of
elbow
arthritis.
Synovectomy,
arthroplasty,
and
arthrodesis
of
elbow
have
been
practiced
since
long
with
variable
results.
Synovectomy
for
inflamed
joint
has
been
practiced
for
long
and
has
shown
good
results
for
pain
relief
in
the
past.
12
Various
studies
have
shown
to
improve
the
function
of
the
joint
following
synovectomy,
either
in
the
form
of
open
or
arthroscopic
synovectomy.
13–20
Open
synovectomy
is
quiet
easier
and
less
demanding
technically
than
arthroscopic
procedure
but
there
is
less
morbidity
and
early
rehabilitation
in
arthroscopic
approach.
20
By
avoiding
neurovascular
structures
injury
with
proper
pre-operative
planning
and
intraoperative
precautions,
arthroscopic
synovectomy
can
give
better
results
in
terms
of
less
morbidity
and
early
functional
outcome.
The
mean
duration
of
disease
in
study
group
was
94
months
and
the
mean
age
of
the
patients
in
it
was
41.7

9.7
years.
Male
to
female
ratio
was
1:12.
The
mean
visual
analogue
score
(VAS)
at
the
time
of
enrolment
in
the
study
was
6.21

1.57
(dreadful
pain).
Post-
operatively,
at
6-months
follow-up,
it
was
0.42

0.5
(nearly
no
pain).
As
the
time
passed
away,
pain
increased
progressively
over
2
year
in
these
patients.
Mean
VAS
at
the
24
months
and
30
months
follow-up
were
1.14

0.84
and
1.285

1.06
(mild
pain),
respectively.
Chung
et
al.
conducted
a
study
in
13
elbow
joints
for
mean
34-months
(range
18–78)
follow-up.
21
The
mean
VAS
pain
score
decreased
significantly
from
nine
(range
5–10)
preoperatively
to
four
(range
2–6)
at
one
week
and
to
one
(range
0–7)
at
the
final
follow-up
of
34
months.
The
results
were
significant
with
p
value
of
0.005
and
0.004,
respectively.
These
were
similar
to
our
results.
Kang
performed
arthroscopic
synovectomy
and
studied
mean
follow-up
of
33.9
months
on
26
rheumatoid
elbows
in
25
patients.
22
The
mean
VAS
for
pain
decreased
from
6.5
points
(range
5.1–9.2)
preoperatively
to
3.1
points
(range
1.5–8.2
points)
at
the
final
follow-up,
showing
significantly
less
pain
post-operatively
with
p
value
of
0.001.
Our
final
VAS
for
pain
score
was
1.285

1.06,
much
lower
than
this
study.
These
changes
over
the
time
are
illustrated
in
graph
(Fig.
3).
The
mean
modified
Larsen
grade
at
the
time
of
commencement
of
the
study
was
2.428

0.5
(range
2–3),
and
remained
same
at
6-
months
follow-up.
The
mean
values
for
score
were
2.50

0.65
(range
2–4)
at
24-months
and
30-months
follow-up.
Kang
et
al.
started
a
study
of
26
patients,
in
which
ten
included
in
grade
1,
thirteen
in
grade
2,
and
three
patients
in
grade
3.
22
At
final
follow-up,
10
elbows
were
classified
as
grade
1,
10
as
grade
2,
4
as
grade
3,
and
2
as
grade
4.
After
33.9-months
follow-up,
there
was
a
reduction
in
degenerative
change
by
one
grade
in
6
elbows,
progression
by
grade
in
7
elbows
and
no
change
in
thirteen
elbows.
Chung
et
al.
mentioned
Modified
Larsen
Grading
for
radiological
assessment
in
pre-operative
period,
but
did
not
evaluate
same
parameter
in
post-operative
follow-up.
21
Horiuchi
et
al.
followed
21
patients,
who
underwent
arthroscopic
synovectomy
with
observation
for
a
mean
period
of
97
months.
20
Larsen
grade
increased
in
17
out
of
21
elbows
even
after
surgery.
We
did
not
find
any
significant
changes
in
modified
Larsen
grading.
A
Table
3
Change
in
disease
activity
score
(DAS-28)
improvement
over
time
points
(6,
24,
30
months)
post-operatively.
DAS-28
(>5.1)
0–6
months
0–24
months
0–30
months
0.78
0.62
0.51
No
response
No
response
No
response
Table
2
Patients
parameters
at
pre-intervention
and
follow-up
periods
of
6,
24
and
30
months.
Parameters
(mean

S.D.)
0
month
6
months
follow-up
24
months
follow-up
30
months
follow-up
p
value
(0
and
6
months)
p
value
(0
and
24
months)
p
value
(0
and
30
months)
VAS
6.21

1.5
0.42

0.5
1.14

0.5
1.28

0.5
0.001
0.001
0.001
MEPS
54.28

17.19
91.07

10.4
82.5

15.28
81.07

15.08
0.001
0.001
0.001
Arc
of
flexion
68.9

28.29
94.2

23.44
85.0

21.03
85.0

21.03
0.003
0.026
0.026
Modified
Larsen
score
2.42

0.5
2.42

0.5
2.5

0.65
2.5

0.65
1.0
0.336
0.336
CoHR
49.5

10.63
49.85

10.21
50.92

10.9
51.14

10.78
0.81
0.24
0.17
DAS-28
6.48

1.01
5.7

1.04
5.86

1.09
5.97

1.09
0.001
0.005
0.005
Fig.
3.
VAS
score
for
pain
in
arthroscopy
group
patients.
V.
Shankar
et
al.
/
Journal
of
Clinical
Orthopaedics
and
Trauma
7S
(2016)
230–235
233

long-term
follow-up
of
97
months
may
be
a
cause
of
such
deterioration
in
above
study
in
comparison
to
our
study.
These
changes
over
the
time
are
illustrated
in
graph
(Fig.
4).
The
mean
coronoid
height
ratio
(CoHR)
at
the
time
of
commencement
of
our
study
was
49.5

10.63
(range
33–70)
and
49.85

10.2
(range
30–70)
at
6-months
follow-up.
It
changed
over
time
at
the
24-
and
30-months
follow-up,
50.928

10.91
and
51.142

10.75,
respectively.
Nemoto
et
al.
conducted
a
study
and
evaluated
the
results
of
arthroscopic
synovectomy
of
eleven
rheumatoid
elbows
in
10
patients
with
a
mean
follow-up
of
3
years
and
1
month.
19
The
mean
CoHR
in
group
A
preoperatively
was
54.2

7.3
and
postoperatively
was
56.3

6.8
and
was
found
not
significant.
But
in
Group
B
preoperatively
CoHR
was
62.4

6.2
and
postoperatively
was
67.4

3.1
and
it
was
found
significant
when
compared
with
p
<
0.05.
We
had
patients
only
in
Larsen
grade
2
or
3
in
our
arthroscopic
synovectomy
group.
We
did
not
observe
any
significant
difference
in
the
mean
CoHR
between
pre-operative
and
post-operative
group
similar
to
their
study
at
the
end
of
our
follow-
up.
As
there
were
no
patients
operated
with
a
pre-operative
Larsen
grade
4,
a
correlation
is
not
possible
with
group
B.
These
changes
over
the
time
are
illustrated
in
graph
(Fig.
5).
The
mean
disease
activity
score
(DAS-28)
at
the
time
of
commencement
of
our
study
was
6.48

1.01
(range
4.9–7.9)
and
5.70

1.04
(range
4.3–7.9)
at
6-months
follow-up,
which
changed
at
24
months
as
5.86

1.095
and
at
30
months,
to
5.97

1.094
(range
4.4–7.68)
in
patients.
There
are
no
studies
in
literature,
which
show
correlation
between
arthroscopy
and
DAS-28.
The
mean
arc
of
flexion
at
the
time
of
commencement
was
68.92

28.29
(range
20–1308)
and
94.28

23.44
(range
30–130)
at
6-months
follow-up,
which
further
decreased
in
mean
values
around
85

21.031
(range
30–120)
at
final
follow-up
of
30
months.
In
Kang
et
al.,
study,
the
mean
flexion-extension
arc
improved
from
98.18
preoperatively
to
113.38
post-operatively.
22
The
results
were
signifi-
cant
with
p
value
of
0.032.
The
mean
rotation
arc
increased
insignificantly
from
146.38
to
159.58
post-operatively,
with
p
value
of
0.75.
In
our
study,
we
observed
significant
results
when
compared
between
pre-op
arc
of
flexion
and
30-months
follow-up
and
p
value
was
found
to
be
0.026.
Results
were
similar
to
this
study
and
show
the
effectiveness
of
arthroscopic
synovectomy
in
rheumatoid
elbow.
Chung
et
al.
in
their
study
of
arthroscopic
synovectomy
of
26
elbows
observed
for
34
months.
21
The
median
elbow
flexion-extension
arc
improved
significantly
from
758
to
1058,
with
p
value
of
0.004.
Result
was
similar
to
that
of
our
study.
Lee
and
Morrey,
evaluated
fourteen
arthroscopic
synovectomies
with
mean
arc
of
flexion
preoperatively
91
(range
45–1308)
and
the
mean
in
post-operative
period
108
(range
75–1208),
showing
an
improvement
of
178.
23
We
reported
16.088
improvement
in
our
study.
These
changes
over
the
time
are
illustrated
in
graph
(Fig.
6).
Pre-operative
mean
value
of
MEPS
was
54.28

17.19
(signifying
poor
elbow
performance
score)
in
the
group.
At
6-months
follow-up,
it
was
91.07

10.77
with
excellent
elbow
performance
score,
while
at
the
24
and
30
months,
the
mean
values
were
82.5

15.28
and
81.07

15.086,
respectively.
We
observed
good
results
in
all
patients
except
one
where
the
score
deteriorated
over
the
time
of
24
months
and
30
months.
We
also
noticed
no
failure
during
our
6-months
follow-up.
Kang
et
al.,
in
their
study
of
26
patients,
observed
improvement
in
mean
Mayo
elbow
performance
score
from
58.5
points
preoperatively
to
77.4
points
at
the
final
follow-up
with
the
p
value
of
0.02.
22
Inglis
et
al.,
in
their
study
of
28
patients,
graded
result
as
good,
satisfactory,
and
poor
without
using
of
MEPS.
13
They
reported
50%
good
results
(14
out
of
28
patients).
6
patients
had
satisfactory
results,
while
4
as
failures,
with
3
ankylosed
joints
and
1
recurrent
synovitis.
Tanaka
et
al.,
conducted
a
study
of
58
arthro-
scopic
synovectomy
and
53
open
synovectomy
with
a
follow-up
of
13
years
and
3–5
years
mid-term
follow-up.
18
Mean
MEPS
in
both
the
groups
were
50
preoperatively.
There
was
a
similar
improvement
in
MEPS
in
both
the
group
at
3–5
year
follow-up
with
MEPS
78
but
noted
a
difference
at
13
year
follow
up
with
MEPS
in
arthroscopy
group
67
and
open
synovectomy
group
71
and
concluded
that
there
is
a
significant
improvement
in
MEPS
in
both
arthroscopy
and
open
synovectomy
at
short-term
and
long-term
follow-up
but
the
gain
in
improvement
tends
to
decrease
more
in
arthroscopy
group
than
in
open
synovectomy
group.
Our
study
has
a
better
gain
in
the
MEPS
(81.07

15.086)
at
the
30-months
follow-up
but
the
results
are
formalized
in
30-months
follow-up
as
compared
to
13-years
follow-
up
in
the
above
study.
Lee
and
Morrey,
performed
arthroscopic
synovectomy
on
14
elbows
and
reported
post-operative
MEPS
as
78
(signifying
good
elbow
performance
score).
23
He
concluded
that
arthroscopic
synovectomy
has
a
good
short-term
success
but
tends
to
deteriorate
with
time.
Similar
results
were
found
in
Horiuchi
et
al.
study,
where
they
performed
arthroscopic
synovectomy
in
Fig.
6.
Arc
of
flexion
in
arthroscopy
group
patients.
Fig.
4.
Modified
Larsen
score
in
arthroscopy
group
patients.
Fig.
5.
Coronoid
height
ratio
(CoHR)
in
arthroscopy
group
patients.
V.
Shankar
et
al.
/
Journal
of
Clinical
Orthopaedics
and
Trauma
7S
(2016)
230–235
234

21
patients.
20
Mean
MEPS
at
2-years
follow-up
was
77.5
while
at
11-
years
follow-up,
it
was
69.8.
We
noticed
in
all
previous
studies
that
MEPS
had
improved
significantly
but
there
is
a
trend
to
deteriorate
with
passage
of
time.
In
a
similar
way,
our
study
has
excellent
result
at
6
months
but
deteriorate
progressively
at
the
24-months
and
30-
months
follow-up.
These
changes
over
the
time
are
illustrated
in
graph
(Fig.
7).
6.
Limitations
The
sample
size
was
small
and
the
follow-up
was
only
for
two
and
an
half
years.
A
longer
follow-up
can
reveal
a
different
pattern
of
disease
status,
particularly
radio-graphically.
DMARDs
and
other
drugs
prescribed
by
rheumatologist
were
different
in
different
patient
according
to
their
clinical
picture.
This
confound-
ing
factor
was
not
included
in
the
study.
7.
Conclusions
We
concluded
in
our
study
that
Pain
and
decreased
range
of
movements
of
joints
were
the
most
important
indications
for
any
intervention
in
patients
of
rheumatoid
arthritis.
Short-term
(at
6
months)
pain
relief
after
arthroscopic
synovectomy
was
excellent.
Long-term
(at
30
months)
pain
relief
is
better
achieved
with
arthroscopic
synovectomy
along
with
DMARD.
Arthroscopic
synovectomy
produces
satisfactory
improvement
in
elbow
func-
tions
in
form
of
range
of
moments
and
MEPS
parameters,
both
in
short-term
and
long-term
follow-up.
Little
deterioration
over
the
time
was
observed
in
all
the
mentioned
parameters.
Significant
changes
in
radiological
grade
are
not
notable
in
short-term
(6
month)
and
long-term
(30
months)
follow-up.
There
is
no
response,
according
to
new
EULAR
classification
criteria
in
short-
term
as
well
as
in
long-term
follow-up
study
for
DAS-28
scoring.
Therefore,
arthroscopic
synovectomy
considered
as
an
effective
intervention,
as
a
surgical
management
of
rheumatoid
elbow,
refractory
to
conservative
treatment.
Ethical
statement
The
study
was
started
after
obtaining
ethical
approval
from
members
of
ethics
committee
of
institute
with
reference
number
IESC/T-207/06.05.2011.
Informed
consent
Informed
written
consent
was
obtained
from
patients
and
their
attendants.
Financial
support
No
author
had
any
financial
support
for
study
and
article.
Conflicts
of
interest
The
authors
have
none
to
declare.
Acknowledgement
We
are
thankful
to
all
patients
and
persons,
who
are
actively
involved
in
this
study.
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