arthroscopic synovectomy of rheumatoid shoulder and elbow

Orthopaedics and Traumatology

3 ( 1994)~ l 1-28 (No. 1/2), ~ Urban & Vogel. Munich 11

Arthroscopic Synovectomy of Rheumatoid Shoulder and Elbow

Klaus Schmidt, Rolf K. Miehlke

Northwest German Center for Rheumatology, St. Josef-Stift Sendenhorst, Department of Arthritis

Surgery, Sendenhorst, Germany

Surgical Principles

Radical arthroscopic synovectomy of rheumatoid shoulder and elbow.

Advantages

Reduced surgical trauma compared to open procedures [1, 3-5]. This results in significant less postoperative complaints compared to conventional open joint procedures.

No impairment of the complex muscle coordination of the shoulder.

Early postoperative physiotherapy enables rapid re- storation or improvement of range of motion.

The method is especially suited for early synov- ectomies: Because of the low postoperative mor- bidity, several joints can be treated at short intervals in cases of polyarticular involvement.

Indications

The principal indication is early synovectomy in rheumatoid arthritis.

Recurrent rheumatoid synovitis persisting for at least 6 months despite basic drug therapy.

Radiographic arthritis stage I to III according to Larsen et al. [2].

Contraindications

Gross bony destruction associated with synovitis. Excessive periarticular bursitis.

Disadvantages

The technique allows only limited additional procedures.

Bleeding or a tight capsule can greatly limit visualization of the joint.

Incomplete removal of periarticular synovial bursae connected to the joint.

Removal of the synovial membrane is not always complete and sometimes only limited parts of the synovium can be excised.

Revised Version from: Operat. Orthop. Traumatol. 4 (1992), 112-129 (German Edition).

Patient Information

An open procedure may be required if adequate ex- cision of the synovium is not possible.

Possible injury to periarticular neurovascular structures, including the cephalic vein and the axillary, ulnar, median and radial nerves.

Risk of postoperative haemarthrosis requiring aspiration.

Joint infection.

Reflex sympathetic dystrophy.

Recurrence of synovitis.

12

Klaus Schmidt, Rolf K. Miehlke: Arthroscopic S~.ncv,'ectomy of the Rheumatoid Shoulder and Elbow

Orthop. I raumatoL 3 (It)q4), 11-28 (No. 1~2)

Pre-Operative Work-Up

Epilation of surgical field on shoulder and axilla.

Application of alcohol-soaked dressings over the surgical field on the eve of the operat ion.

Surgical Instruments

- Conventional 5ram/30 ° angled arthroscope with camera unit.

- Motorized 4-ram and 6-ram synovial resectors (e.g. Rosenberg resectors).

- Curved and angled rongeurs of different dia- meters.

- An intraarticular electrocautery device. - I r r i g a t i o n bags with cooled Purisole solution

(approximately 2 ° C) with 0.33 mg/1 epinephrin in addition.

Positioning and Anaesthesia (Fig. 1 and 2)

- Both procedures are per formed under general anaesthesia.

- For elbow arthroscopy we exsanguinate the limb using a tourniquet (300 mm Hg).

J ' ~ . %

Fig. 1 Arthroscopic surgery of the shoulder is performed with the patient in a sitting ("beach-chair") position on the operating table. The back support on the side or surgery reaches to about the lower margin of the scapula. The arm is placed on a well- padded post that supports the upper arm at the junction of the proximal and middle thirds in about 30 ° of abduction. In- traoperatively, the shoulder can be distracted by applying lateral pressure to the elbow.

4 Fig. 2 For arthroscopic synovectomy of the elbow the patient is placed in a contralateral decubitus position. The arm rests on a well-padded post that supports the upper arm at the junction of the middle and distal thirds.

Klaus Schmidt. Roll K. Miehlke: Arthroscopic Synovectorny of the Rheumatoid Shoulder and Elbow

Orthop. Traumatoi. 3 (1994), 11-28 (No. I/2) 13

Surgical Technique Arthroscopic Synovectomy of the Shoulder

Fig. 3 to 7

30 ° anglec

1st

ItO-

Fig. 3 The posterior portal is established by puncturing the shoulder with a 5 cm long cannula approximately i cm caudal and medial to the posterior aspect of the acromion. The joint is filled with about 50ml Purisole solution. At the same site an arthroscope with sharp trocar is introduced through a stab incision and advanced through the posterior deltoid. The sharp trocar is changed to the blunt trocar and the infraspinatus is perforated in direction toward the coracoid process. The arthroscope is introduced and the joint is visualized before it is filled with cooled Purisole solution. Under direct arthroscopic control through the posterior portal, a spinal needle is introduced anteriorly about t cm lateral of the coracoid process. A stab incision is made and a small rongeur is inserted and withdrawn with the jaws opened to widen the portal. The anterior portal can be used to palpate intraarticular structures with a probe and to inspect joint structures from the front if the arthroscope is switched to the anterior portal. Shaver blades and abraders of different designs are used to trim surfaces or, in case of extensive loss of cartilage, for deepening of the glenoid cavity.

14

Klaus Schmidl. Roll K. Michlkc: Arthroscopic Syno' ,ccmmy of the Rheumatoid Shoulder and Elbow

Orlhop. Traumalol . 3 (19041. l 1-2g (No. liZ)

Inflow cannula \ \\ j J "

Shaver / / ¢ ~ ' ~ . ~ " ~ \ / - ' f "

.,h osoo0.

/

Fig. 4a

Fig. 4a to 4c For arthroscopic synovectomy an anterosuperior portal is established about I cm above the anteroinferior portal and a 4mm inflow cannula is inserted to achieve sufficient visualization despite intraarticular bleeding. A 4 or 6mm synoviat resector is used to excise the synovial membrane from the undersurface of the rotator cuff.

S h a v e r

i i

I I

M. subscapularis Caput humeri

Fig. 4b Fig. 4c

Klaus Schmidt, Rolf K. Miehlke: Arthroscopic Synovectomy of the Rheumatoid Shoulder and Elbow

Orthop. TraumaloL 3 (1904). 11-28 (No. 1/2) t5

J l /

[

Fig. 5a

Inflow cannula

Arthroscope \ \

\

:~IL7 - ' ~ -

"j / .,J ': \ Rongeur

Fig. 5a to 5c Curved rongeurs are used to excise the synovium in the anterior part of the inferior recess.

Gle

Rongeur

. . . . u m e r i

Synovial folds

Fig. 5b Fig. 5c

16

Klaus Schmidt, Roll K. Miehlke: Arthroscopic Synovectomy ~l the Rheumatoid Shoulder and Elho,,~

Orthop. Traumatol. 3 (1994). 11-28 (No./i2)

Shaver I

A rthroscope \\\ ~ ~ ~

. " : \ \

/? :, ~"X

t"TW t, / / k ) , i l /

Fig. 6a

Fig. 6a to 6c For synovectomy near the biceps tendon and in the superior compartment of the joint, the shaver is generally transferred to the anterosuperior portal and the inflow cannula to the anteroinferior portal.

Anterior rotator cuff \

Shaver

Caput humeri Fig. 6b Fig. 6c

Klaus Schmidt, Rolf K. Michlke: Arthroscopic Synovectomy of the Rheumatoid Shoulder and Elbow

Orlhop. Traumatol. 3 (1904), I 1 28 (No. 1/2) 17

Fig. 7a to 7c The arthroscope is switched to the anterior portal and the surgical instruments are inserted through the posterior portal for synovectomy of the posterior and posteroinferior joint compartments. A motorized resector and various curved rongeurs are used (c).

Fig. 7a

R o n g e u r

i I G leno id

! //

Fig. 7b Fig. 7c

The joint is copiously irrigated before insertion of a Redon drain through one of the stab incisions. The incisions are closed with vertical mattress sutures.

18

Klaus Schmidt, Rolf K. Miehlke: Arthroscopic Synovectorny of the Rheumatoid Shoulder and Elbow

Orthop, Fraumatol. 3 ( 1904)1 | 1-28 ( N o I/2)

Arthroscopic synovectomy of the elbow Fig. 8 to 12

Fig. 8a to 8c The elbow is punctured between the lateral epicondyle, the tip of the ecranon and the radial head and is dis- tended with 30 ml Ringer solution injected through a spinal needle. A stab incision is made at the puncture site. The arthroscopic sheath with sharp trocar is inserted into the olecranon fossa in a superomedial direction. After introduction of the arthroscope, the joint is filled with Perisole solution. Under direct arthroscopic control, a spinal needle is inserted into the joint 2 cm proximal and medial. There a synovial resector is introduced through a further stab incision. Generally, the synovial membrane must be excised under limited initial visualization before an adequate view is achieved.

Fig. 8a

Shaver

Synovial folds r

Fossa olecrani

Fig. 8b Fig. 8c

Kiaus Schmidt. Roll K. Michlkc: .,\rthroscopic S?novcctomy of the Rheumatoid Shoulder and Elbo~

Orthop [ ' raumato[ 3 (19t,~4), l 1 28 (No. 1/2) 19

Fig. 9a

Fig. 9a to 9c Further the synovial membrane in the posterior recess is excised by transferring the arthroscope to the proximal portal: synovectomy is then performed through the distal portal.

Olecranon

Fig. 9b

Ronge~.

Fig. 9c

Trochlea humeri

Fig. lOa


Orthop. Traumatol. 3 ( 1994L 11-28 (No. 1/2)

o 10c Since the rheumatoid joints are usually lax, this allows visualization and synovectomy in the region of head.

Fig. lOb

20

Shaver

i Caput radii i

Ulna

",ttU/ Fig. 10c


Orthop. Traumatol. 3 (1994), 11-28 (No. I/2) 2t

Fig. U a to l l c A further portal can be established with the elbow flexed in the space between the radial head and the radial epicondyle of the humerus. The anterior compartment is in- spected through this portal. A further anteroulnar portal is created; its location is determined by diaphanoscopy with the arthroscope advanced toward the ulna. Synovectomy of the anteroulnar compartment of the joint is performed through this portal.

!

Shaver Prec. coronoideus /

Fig. l i b

Cap[ qovial folds

Fig. l l c

22

Klaus SchmidI , Ro l f K. Mieh lke : ,A.rlhroscopic S y n o v e c t o m y of the R h e u m a t o i d S h o u l d e r and E l b o w

Or thop . T r a u m a t o l . 3 { 1994), } } - 28 ( No. 112 )

Fig. 12a to 12c The arthroscope is transferred to the ulnar portal. Synovectomy in the anterolateral joint compartment and the proximal radioulnar joint is carried out through the anteroradial portal. The joint is copiously irrigated before insertion of a Redon drain through one of the stab incisions. Closure of incisions with vertical mattress sutures.

S . . . . . . ;~'

C a p i t u l u m

h u m e r i

Fig. 12b b n a v e r

Fig. 12c

I rad i i

Klaus Schmidt. Roll K. Miehlke: Arthroscopic Synovectomy of the Rheumatoid Shoulder and Elbow

Orthop. Traumato[. 3 (1994). I 1-28 (Nil. 1/2) 23

Postoperative Management

The Redon drain is removed approximately 24 hours after surgery. In the case of severe postoperative pain, a local anaesthetic (10ml 0.5% Carbostesin ®, maximum 3 times daily) can be in- stilled through a bacterial filter attached to a catheter inserted into the joint during surgery.

The patient can begin active exercises in all planes of motion on the first postoperative day. The physio- therapist improves the range of motion with passive motion training. The capsule volume is expanded by translational gliding techniques and by muscle stretching after postisometric relaxation. Muscle strength is increased both by isometric and con- centric and excentric training. Neurophy- siological techniques especially proprioceptive neurovascular facilitation techniques (PNF) can be used to improve muscle coordination. If available, CPM devices (Artromot S and E Devices) or splints (Artroswing Splint) can be helpful.

The patient is discharged from the hospital after an average of 1 week. Elbow patients should continue assisted physiotherapy on an outpatient basis for another 2 weeks, shoulder patients for another 6 weeks.

Special Surgical Considerations

The positioning of the patient allows a change to a conventional open procedure at any time, if arthroscopic synovectomy proves inadequate.

Errors and Potential Hazards

If the joint is not filled with liquid before introduction of the arthroscope, or if an arthroscope with sharp trocar is inserted too forcefully into the joint, the articular surface can be damaged by scuffing of the cartilage.

Shoulder: The arthroscopic sleeve is not advanced toward the coracoid process: If the arthroscope is directed cranially, it will enter the subacromial space. If the trocar deviates caudally, the axillary nerve and, possibly, the brachial plexus can be injured.

The arthroscopic cannula is inserted anteriorly but not advanced lateral to the coracoid process aiming for the posterior portal: If the portal site or the cannula is placed too far medially, the musculo- cutaneous nerve may be injured. A cannula placed cranially may enter the subacromial space. A caudal placement may risk injury to the brachial plexus.

The cephalic vein can be injured when the anterior portal is installed.

Elbow: Forceful insertion of the arthroscope from posteroradial toward the ulna risks injury to the ulnar nerve.

If the arthroscope is inserted through the anterior portals and does not follow a course strictly parallel to the anterior aspect of the distal humerus, there is a significant risk of injury to the median and radial nerve as well as to the brachial artery and vein.

Use of an anteroulnar portal risks injury to the basilic vein.

Intra- and Post-Operative Complications

Injury to periarticular neurovascular structures, such as the cephalic vein and the ulnar, median and radial nerves: If the cephalic vein is injured, it can be ligated percutaneously. Other neurovascular injuries require open revision and appropriate surgical re- pair.

Development of a compartment syndrome due to penetration of the Purisole solution into sub- cutaneous tissue" If rapid resorption does not occur, open fasciotomy is indicated.

Development of haemarthrosis: If rapid sponta- neous resorption does not occur, aspiration or revision is necessary.

Results

Ten patients were treated with arthroscopic shoulder synovectomy and 16 with arthroscopic elbow synovectomy from October 1988 to July 1991.

This group included 22 women and 4 men (mean age: 52 years) with chronic rheumatoid arthritis for a mean period of 11 years and 2 months.

Immediately after surgery patients reported only slight to moderate discomfort, allowing passive, and active exercises with little pain on the first postoperative day.

Shoulder: The pre-operative pain at rest reported by all shoulder patients improved rapidly after surgery;

24 Klaus Schmidt. Rolf K. Miehike:

Arthroscopic Synovectomy of the Rheumatoid Shoulder and Elbow Orthop. Traumatol. 3 I1994), 11-2[4 (No. 1/2)

pain during motion took longer to subside. Only 4 of 10 patients still reported slight pain on motion at one year follow-up. Shoulder strength was improved in all patients. The pre-operative swelling disappeared rapidly postoperatively. There has been 1 temporary recurrence of synovitis in 1 patient until now (Table 1).

The range of motion showed immediate postoperative improvement, although a slight reduction was noted during the follow-up period (Table 2).

All patients were either satisfied or very satisfied with the results and would undergo the procedure again, if necessary (Table 3).

Elbow: Eight of 16 elbow patients complained of pain at rest pre-operatively. With one exception pain decreased within 6 weeks postoperatively and was entirely absent at 6-month follow-up in all patients. All patients reported pain on motion pre- operatively. Here too a rapid improvement was noted in the first postoperative weeks. One female patient complained of motion pain 1 year postoperatively, although less than before surgery. The patient described the pain as a snapping sensation on the lateral side of the elbow. Because pain persisted, radial head resection was performed 18 months after the synovectomy. This greatly reduced the motion pain. Four patients with pre-operative

Symptom Pre-op- Postoperative erative 2 weeks 3 months 6 months 1 year

Pain of rest 0 1 10 10 10 10

Pain of motion

Swelling

Subjective loss of strength

Object ive strength

+ 8

++ ~ 1

+ + +

0 5 6 5 6

+ 2 5 4 4 4

++ 7

+++ 1

0 7 9 10 10

+ 7 3 1

++ 3

+ + +

0 3 6 7 7 6

+ 6 3 3 3 4

++ 1 1

+++

5 4 5 7 8 8

4 4 4 3 2 2

3 2 1

2

0 = none; + = slight; ++ = moderate; +++ = severe.

Shoulder Abduct ion Anteversion External Internal

rotation rotation

Pre-operative 94 ° 113 ° 41 ° 59 °

Postoperat ive

2 w e e k s 140 ° 150 ° 52 ° 72 °

3mon ths 140 ° 154 ° 55 ° 57 °

6 months 140 ° 150 ° 59 ° 73 °

12 months 139 ° 142 ° 55 ° 75 °

Table 1. Symptoms in ar throscopic surgery of the shoulder.

Table 2. Average range of motion in patients undergoing ar throscopic shoulder

synovectomy.

Klaus Schmidt. Rolf K. Miehlke: Arthrosc~pic Synovectomy of the Rheumatoid Shoulder and Elbow

Orthop. Traumatol. 3 t t994). 11-28 INo, 1/2) 25

Painon Swelling Abduction/ Anteversion/ Internal/ Strength Subjective motion adduction retroversion external satisfaction

rotation Pre-op./ Pre-op./ Pre-op./ Pre-op./ Pre-op./ Pre-op,/ postop, postop, postop, postop, postop, postop.

Patient Larsen- Follow-up Pain at stage rest

Pre-op./ postop.

K.C. 2 4,7 years 0/0 +/0 +/0 30-0-30 40-0-20 10-0-10 5/4 Very 150-0-40 160-0-30 80-0-50 satisfied

B.E. 1 4.4 years +/0 ++/+ +/0 170-0-30 170-0-40 90-0-60 5/5 Satisfied 180-0-40 180-0-60 90-0-70

S. U, 4 4,4 years +/0 ++/(3 +/0 50-0-20 70-0-15 70-0-30 4/5 Satisfied 70-0-20 70-0-20 60-0-30

S.H. 2 ' 4.2 years +/0 ++/0 ++/0 90-0-30 160-0-40 80-0-60 4/5 Satisfied 170-0-40 170-0-40 80-0-60

S, A. 2 4.2 year +/0 ++/+ ++/(+)1 45-0-30 60-0-20 60-0-30 3/4 Satisfied 150-0-30 150-0-30 60-0-70

S.A. 3 4.1 years +/(3 ++/0 ++/0 40-0-20 60-0-20 10-0-10 3/5 Very 160-0-30 160-0-40 60-0-80 satisfied

W, A. 4 3.9 years +/0 ++/0 +/0 90-0-40 100-0-30 70-0-20 4/4 Satisfied 180-0-30 180-0-40 70-0-50

J.A. 1 2.8 years +/0 ++/0 +/0 180-0-30 180-0-30 70-0-30 5/5 Satisfied 160-0-30 160-0-40 80-0-40

M.M. 3 2.8 years +/0 +/0 +/0 60-0-30 110-0-30 70-0-40 4/4 Satisfied 90-0-40 100-0-30 70-0-30

W.A. 3 2.6 years +/0 ++/+ +/0 1 8 0 4 3 - 3 0 180-0-30 90-0-60 4/5 Very 120-0-40 180-0-30 90-0-60 satisfied

0 = none; (+) = occasionally slight; + = slight; ++ = moderate; +++ = severe.l Temporary recurrence of swelling 2.5 years postoperatively after discontinuing basis drug medication.

Table 3. Results of arthroscopic surgery of the shoulder.

motion pain reported occasional postoperative pain after prolonged activity. A marked increase in strength was noted in 7 of the 16 elbow patients.

The pre-operative swelling disappeared rapidly in all but 2 patients, who experienced diffuse soft tissue swelling 3 months and 1 year postoperatively. The latter patient revealed marked swelling of the elbow region both before and after surgery with induration of the entire soft tissue envelope but without hyper- thermia. Synoviorthesis with Varicocid ® did not improve the situation. We think the swelling represents persistent induration of the soft tissues following prolonged recurrent synovitis. Postoperative improvement, however, has occurred.

One female patient experienced a recurrence of swelling and pain of motion 1 year postoperatively. Temporary relief was achieved with 2 synoviortheses with Varicocid®; the patient was pain-free and satisfied except for moderate pain with prolonged use of the elbow joint. Swelling recurred 18 months postoperatively and another synovectomy was performed (Table 4).

The pre-operative limitation in range-of-motion was generally only moderate in elbow patients and showed slight improvement in extension after surgery (Table 5).

Fourteen of the 16 patients who underwent arthroscopic surgery of the elbow were satisfied or very

26

Klaus Schmidt, Roll K. Miehlke: Arthroscopic S~,novectomy of the Rheumatoid Shoulder and Elbow

Orthop Traurnatol. 3 (1994). 11-28 ( No. 112)

Symptom Pre-op- Postoperative erative 2 weeks 3 months 6 months 1 year

Pain at rest 0 8 13 15 16 16

Pain on motion

Swelling

Subjective loss of strength

Objective strength

+ 7 2 1

++ 1 1

+ + +

0 6 10 10 10

+ 10 9 5 6 4

++ 5 1 0

+++ 1 1

0 9 14 14 14

+ 9 6 2 2 2

++ 6 1 1

+++ 1

0 4 12 13 13 14

+ 11 4 3 3 2

++ 1 + + +

5 5 11 11 12 12

4 10 5 5 4 4

3 1

2

0 = none; + = slight; ++ = moderate; +++ = severe.

Elbow Flexion Extension Pronation Supination

Pre-operative 125 ° 24 ° 72 ° 68 °

Postoperative

2 weeks 128 ° 17 ° 73 ° 71 °

3 months 131 ° 14 ° 79 ° 74 °

6months 133 ° 14 ° 78 ° 78 °

12 months 134 ° 12 ° 80 ° 79 °

Table 4. Symptoms in arthroscopic surgery of the elbow.

Table 5. Average range of motion in patients undergoing arthroscopic elbow synovectomy.

satisfied with the results and would undergo the same operation if necessary. The 2 patients with sec- ondary operations were not satisfied with the results of the first procedure (Table 6).

Only slight changes in the radiographic findings were noted during the follow-up period. In general, radiological progression was evident in patients with Larsen stages III to IV of their disease.

KIaus Schmidt, Roll K. Miehlke: Arthroscopic Synovectomy of the Rheumatoid Shoulder and Elbow

Orthop. Traumato[. 3 (1994), l 1-28 (No. l /2) 27

Patient Larsen- Follow-up Pain at Painon Swelling Flexion/ Pronation/ Strength Subjective stage rest motion extension supination satisfaction

Pre-op./ Pre-op./ Pre-op./ Pre-op./ Pre-op./ Pre-op./ postop, postop, postop, postop, postop, postop.

G.M. 4 5,5 years ++/0 ++/+ ++/0 120-40-0 50-0-80 4/5 Satisfied 125-30-0 70-0-80

S.G. 1 4.7 years +/0 +/(+) ++/0 120-30-0 80-0-80 4/5 Very 130-10-0 90-0-90 satisfied

Z.M. 2 4.4 years 0/0 +/0 +/0 135-05-0 70-0-50 4/5 Very 135-05-0 70-0-70 satisfied

H.A. .2 4.3 years 0/0 +/0 ++ /+1 140-25-0 80-0-80 5/5 Not 140-20-0 80-0-80 satisfied

W.H. 3 4.3 years 0/0 +/(+) +/+2 130-20-0 90-0-70 5/5 Satisfied 120-10-0 90-0-70

S.H. 2 4.2 years +/0 ++/0 +/0 105-15-0 80-0-80 4/5 Very 120-0-10 90-0-90 satisfied

S.L. 2 3.9 years +/0 ++/0 +/0 110-30-0 70-0-20 4/5 Very 120-20-0 70-0-60 satisfied

E.U. 2 3.7 years 0/0 ++/(+) ++/0 120-25-0 50-0-50 4/5 Very 130-20-0 90-0-80 satisfied

J.I. 3 3.4 years +/0 ++/+3 +/0 150-10-0 90-0-80 4/4 Not 150-10-0 90-0-80 satisfied

S.H. 1 3.3 years 0/0 +/0 +/0 130-1043 80-0-80 5/5 Very 135-10-0 80-0-80 satisfied

K.S. 3 3.2 years 0/0 +/0 +/0 145-20-0 90-0-70 5/5 Satisfied 145-15-0 90-0-90

Z.A. 2 2.9 years +/0 +/+ +/0 135-15-0 70-0-80 5/5 Very 140-20-0 90-0-90 satisfied

H.M. 4 2.8 years 0/0 +/0 +/0 120-30-0 80-0-70 5/5 Satisfied 130-25-0 90-0-90

E.M. 3 2.8 years +/0 +/0 ++/0 110-30-0 10-0-45 5/5 Very 110-30-0 60-0-50 satisfied

0 = none; (+)= occasionally slight; + = slight; ++ = moderate; +++ = severe. 1 Patient with recurrence (cf. text). 2 Patient with persistent soft tissue induration (cf. text). 3 Patient with subluxation of radial head (cf. text).

Table 6. Results of arthroscopic surgery of the elbow.

28

Klaus Schmidt, Roif K. Miehlke: Arthroscopic Synovectomy of the Rheumatoid Shoulder and Elbow

Orthop. TraumatoL 3 (1994'~, 1 I -28 (No. | /2)

References

1. Ferlic, D. C., C. E. Patchett, M. L. Clayton, A. C. Freeman: Elbow synovectomy in rheumatoid arthritis. Longterm results. Clin. Orthop. 220 (1987), 119-125.

2. Larsen, A., K. Dale, M. Eek: Radiographic evaluation of rheumatoid arthritis and related conditions by stand- ard reference films. Acta radiol. Diagn. (Stockh.) 18 (1977), 481-492.

3. Pahle, J. A., L. Kvarnes: Shoulder synovectomy. Ann. Chir. Gynaec., Suppl. 198 (1985), 37-39.

4. Petersson, C. J.: Shoulder surgery in rheumatoid arthritis. Acta orthop, scand. 57 (1986), 222-226.

5. Porter, B. B., C. Richardson, K. Vainio: Rheumatoid arthritis of the elbow. The results of synovectomy. J. Bone Jt Surg. 56-B (1974), 427-437.

6. Schmidt, K., R. K. Miehlke: Die arthroskopische Syno- vektomie des Ellenbogengelenkes. Akt. Rheumatol. 19 (1994), 50-55.

7. Schmidt, K., R. K. Miehlke: Mittelfristige Ergebnisse nach arthroskopischer Synovektomie des Schulterge-

lenkes von Rheumatiken (cP). Akt. Rheumatol. 19 (1994).

8. Stegers, M., S. Tahira, R. K. Miehlke: Involvement of the shoulder in rheumatoid arthritis. In: Lettin, A. W. F., C. Petersson: Rheumatoid arthritis surgery of the shoulder. Karger, Mtinchen 1989, p. 24-30.

Key Words:

Arthroscopic surgery • Synovectomy shoulder, elbow • Rheumatoid arthritis

Address all correspondence to: Dr. Klaus Schmidt Nordwestdeutsches Rheumazentrum St. -Josef-Stift Sendenhorst Westtor 7 D-48324 Sendenhorst Germany

arthroscopic synovectomy of rheumatoid shoulder and elbow

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