Rheumatoid arthritis of the elbow

1. High-Yield Summary

Rheumatoid arthritis (RA) involves the elbow in 20% to 50% of patients with established systemic disease, characteristically manifesting as chronic, bilateral, symmetric proliferative synovitis. Progressive disease leads to irreversible chondral degradation, subchondral bone resorption, capsular attenuation, and profound ligamentous instability or fibrous ankylosis.

• Core Pathology: Proliferative synovial pannus invades articular margins and subchondral bone, causing joint space narrowing, secondary capsular contracture, and attenuation of the medial and lateral collateral ligament complexes.
• Medical Management: Multidisciplinary intervention with rheumatology is paramount; conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs) form first-line therapy to arrest inflammatory synovitis and preserve structural bone stock.
• Early-Stage Surgical Intervention: Open or arthroscopic synovectomy with or without radial head excision is indicated for medically refractory synovitis (Larsen grade I–II, Mayo type I–II) with preserved osteoarticular architecture and collateral ligament stability.
• End-Stage Reconstruction: Total elbow arthroplasty (TEA) is the gold standard for severe destruction (Larsen grade III–V, Mayo type III–IV); semiconstrained linked designs (e.g., Coonrad-Morrey) are mandatory to overcome collateral ligament incompetence and bone loss.
• Lifelong Protection: Arthroplasty restores a functional arc of motion (30° to 130° flexion) and provides reliable pain relief, but mandates strict lifelong lifting restrictions (2.3 kg / 5 lbs repetitive, 4.5 kg / 10 lbs single) to avoid premature mechanical failure.

2. Anatomy

The elbow is a complex trochoginglymoid joint comprising three distinct articulations contained within a single joint capsule: the ulnohumeral joint (primary hinge stabilizer), the radiocapitellar joint, and the proximal radioulnar joint (PRUJ, responsible for forearm rotation). Normal activities of daily living require a functional arc of motion spanning 30° to 130° of flexion-extension and 50° of pronation to 50° of supination.

Surgical intervention in rheumatoid elbow disease requires precise familiarity with surrounding neurovascular danger zones and intermuscular planes:

• Neurovascular Danger Zones:
  • Ulnar Nerve: Traverses the retrocondylar fibro-osseous groove immediately posterior to the medial epicondyle beneath Osborne’s ligament. Vulnerable to direct compression from hypertrophic medial synovitis, rheumatoid nodules, and dynamic stretch during valgus collapse or surgical deformity correction. Routine mobilization and subcutaneous or submuscular transposition are standard during total elbow arthroplasty.
  • Radial and Posterior Interosseous Nerve (PIN): The radial nerve courses anterior to the radiocapitellar joint before the deep motor branch (PIN) traverses the arcade of Frohse between the superficial and deep heads of the supinator. The PIN lies directly adjacent to the anterior and lateral capsule; it is at critical risk during anterior capsulotomy, lateral synovectomy, and radial head resection. Radial head excision must remain strictly proximal to the annular ligament and biceps tuberosity (≤10 mm to 12 mm of resection).
  • Median Nerve and Brachial Artery: Positioned anterior to the brachialis muscle belly across the anterior joint capsule. Vulnerable to iatrogenic laceration or stretch during blind anterior capsulectomy or forceful retractor placement.
• Internervous and Surgical Planes:
  • Lateral (Kocher) Approach: Develops the internervous plane between the anconeus (radial nerve) and the extensor carpi ulnaris (ECU, posterior interosseous nerve). Provides direct, safe lateral exposure for radial head excision, lateral synovectomy, and anterior/posterior capsular release.
  • Posterior Exposures: Include the triceps-splitting (Campbell), triceps-reflecting (Bryan-Morrey), and triceps-sparing (paratricipital bilateral windows) approaches. The Bryan-Morrey approach reflects the triceps mechanism from medial to lateral in continuity with the forearm fascia and periosteum, affording wide articular exposure for linked arthroplasty while preserving extensor mechanism reattachment vectors.
• Critical Bony Landmarks:
  • Transepicondylar Axis: An imaginary line passing through the centers of the medial and lateral epicondyles represents the anatomical flexion-extension axis of the elbow, oriented in approximately 5° of internal rotation relative to the posterior humeral shaft cortex, with a 4° to 8° valgus carrying angle.
  • Trochlear Center of Rotation: Projects 30° anteriorly relative to the long axis of the humeral shaft; restoration of this center during arthroplasty is imperative to prevent edge loading, mechanical loosening, and triceps impingement.
  • Olecranon and Coronoid Bone Stock: The coronoid process provides essential anterior osseous buttressing and resists posterior subluxation. In rheumatoid arthritis, severe coronoid osteopenia and resorption necessitate linked prosthesis mechanics.

3. Pathogenesis

Rheumatoid arthritis is a systemic autoimmune disease characterized by immune-mediated chronic synovial inflammation. The biological sequence begins with endothelial activation, neoangiogenesis, and massive infiltration of the synovial sublining by CD4+ T helper cells, plasma cells, and macrophages. The synovial membrane transforms from a delicate two-cell layer into a hyperplastic, aggressive tissue mass termed pannus.

Pro-inflammatory cytokines, specifically tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6), drive the sustained destruction of the osteoarticular complex:

• Enzymatic Chondrolysis: Hypertrophic synoviocytes and infiltrating inflammatory cells produce elevated concentrations of matrix metalloproteinases (MMP-1, MMP-3, MMP-13) and aggrecanases (ADAMTS-4, ADAMTS-5). These enzymes degrade the extracellular proteoglycan ground substance and cleave type II collagen fibrils, leading to progressive, diffuse, full-thickness articular cartilage loss across the ulnohumeral and radiocapitellar joints.
• Subchondral Bone Resorption and Erosions: In inflammatory pannus, activated T lymphocytes express receptor activator of nuclear factor kappa-B ligand (RANKL), which binds RANK on monocyte-macrophage precursor cells. This stimulates vigorous osteoclastogenesis and bone resorption at the capsular reflection zones (“bare areas”) where bone lacks protective overlying cartilage. Marginal osteolytic erosions develop, subsequently expanding into subchondral cysts and extensive architectural column bone loss.
• Capsular and Ligamentous Attenuation: Continuous enzymatic breakdown, chronic effusion-induced mechanical stretching, and direct synovial invasion compromise the structural integrity of the medial collateral ligament (anterior bundle) and the lateral collateral ligament complex. Loss of static soft-tissue restraints results in progressive coronal plane deformity (severe valgus or varus collapse), rotatory instability, and eventually a totally unstable, “flail” elbow joint.

4. Natural History

Rheumatoid arthritis affects approximately 0.5% to 1.0% of the worldwide adult population, exhibiting a pronounced female predilection (3:1) and a peak incidence between the fourth and sixth decades of life. Symptomatic elbow involvement occurs in 20% to 50% of patients during the course of their disease and is typically bilateral and symmetric.

If untreated or inadequately controlled with disease-modifying pharmacotherapy, the natural history follows a predictable, debilitating trajectory:

• Early Inflammatory Stage: Recurrent joint effusions and proliferative synovitis cause joint distension, pain, and reflex muscle inhibition. Patients develop an early loss of terminal extension, adopting a resting posture of 30° to 45° of flexion where intra-articular pressure is lowest.
• Intermediate Destructive Stage: Persistent enzymatic chondrolysis and pannus invasion result in global articular cartilage loss. Capsular thickening and soft-tissue contracture produce fixed flexion deformities exceeding 30° to 50° and restrict forearm pronation and supination. Subchondral bone erosions weaken articular support columns.
• End-Stage Disintegration or Ankylosis: The disease diverges into two major phenotypes:
  • Resorptive / Flail Phenotype: Progressive osteolysis and collateral ligament destruction cause gross joint resorption, subluxation, and flail instability. The patient loses upper extremity cantilever support, rendering the arm unable to bear weight, push up from a chair, or support the hand in space.
  • Ankylosing Phenotype: Joint space obliteration culminates in dense fibrous or complete bony ankylosis, freezing the elbow in a non-functional position and severely compromising personal hygiene, eating, and upper limb ergonomics.

5. Clinical Presentation

History

Patients report a chronic, insidious onset of deep, aching joint pain that is exacerbated by movement and weight-bearing, but frequently persists at rest and awakens them at night. Morning stiffness localized to the elbows lasting greater than 60 minutes is characteristic of active inflammatory synovitis.

Key clinical history inquiries must elicit:

• Functional Limitations: Loss of reach, inability to perform personal hygiene (perineal care requires at least 110° flexion; grooming and eating require 130° flexion and 50° supination/pronation), and difficulty pushing out of seated positions due to axial pain and mechanical weakness.
• Mechanical Symptoms: Painful clicking, locking, or grinding during forearm rotation, indicative of radiocapitellar joint incongruity, loose bodies, or radial head impingement.
• Neuropathic Symptoms: Paresthesias, numbness, or burning sensations along the ring and small fingers, intrinsic hand weakness, or loss of grip strength, signaling secondary ulnar neuropathy at the cubital tunnel.
• Systemic and Pharmacological History: Duration and dosage of systemic corticosteroids, conventional synthetic DMARDs, and biologic therapies, which directly impact infection risk and soft-tissue integrity.

Physical Exam

Physical examination begins with visual inspection for subcutaneous rheumatoid nodules (frequently located over the subcutaneous border of the proximal ulna and olecranon), localized erythema, muscular atrophy (triceps and forearm musculature), and resting angular deformities. Palpation and provocative clinical maneuvers provide high diagnostic accuracy:

• Bulge / Effusion Sign: Palpation of a fluctuant, spongy mass within the “soft spot” (lateral triangle bounded by the lateral epicondyle, radial head, and tip of the olecranon) with the elbow held in 90° flexion → Positive finding: Distinct fluid wave or soft synovial fullness [Sensitivity 88%, Specificity 91%].
• Retrocondylar Palpation and Tinel’s Sign: Light percussion over the ulnar nerve in the retrocondylar groove posterior to the medial epicondyle → Positive finding: Paresthesias radiating into the fourth and fifth digits [Sensitivity 70%, Specificity 88%].
• Elbow Flexion Compression Test: Sustained elbow flexion beyond 90° with simultaneous gentle manual compression over the cubital tunnel maintained for 60 seconds → Positive finding: Reproduction or exacerbation of ulnar nerve paresthesias [Sensitivity 89%, Specificity 95%].
• Varus and Valgus Stress Instability Test: Evaluated with the elbow flexed to 30° to disengage the olecranon from the olecranon fossa → Positive finding: Palpable medial or lateral joint line opening, asymmetric gaping, or gross coronal laxity indicating collateral ligament disruption [Sensitivity 82%, Specificity 90%].
• Active and Passive Range of Motion Assessment: Precise goniometric measurement of flexion, extension, pronation, and supination. Pain elicited specifically during passive forearm rotation localizes pathology to the radiocapitellar and proximal radioulnar joints.

6. Imaging and Diagnostic Studies

Accurate assessment requires a structured imaging hierarchy from standard plain radiographs to cross-sectional computed tomography, alongside confirmatory serological testing:

• Standard Radiographs:
  • Views: True anteroposterior (AP), lateral (flexed to 90°), and bilateral oblique views.
  • Radiographic Hallmark Signs: Soft-tissue swelling with displacement of the anterior and posterior fat pads (sail sign); symmetric, concentric joint space narrowing across both ulnohumeral and radiocapitellar joints; localized periarticular osteopenia; subchondral marginal erosions; cystic radiolucencies; collapse of the trochlear groove; gross anterior, posterior, or valgus subluxation; and in advanced stages, complete osseous architectural dissolution or bony ankylosis.
• Cross-Sectional and Advanced Imaging:
  • High-Resolution Ultrasound: Highly sensitive for detecting early synovial thickening, joint effusion, cortical bone surface irregularities, and active microvascular hyperemia using Power Doppler imaging.
  • Magnetic Resonance Imaging (MRI): Optimal modality for detecting pre-radiographic synovitis, intraosseous bone marrow edema (an early predictor of rapid erosive progression), collateral ligament integrity, and occult ulnar nerve entrapment.
  • Computed Tomography (CT) with 3D Reconstructions: Indicated preoperatively when planning total elbow arthroplasty or complex debulking. Crucial for assessing residual medial and lateral humeral column bone stock, olecranon and coronoid architectural deficits, and medullary canal dimensions.
• Laboratory and Synovial Fluid Analysis:
  • Serological Markers: Rheumatoid factor (RF, sensitivity 70% to 80%, specificity 85%) and anti-cyclic citrullinated peptide (anti-CCP, sensitivity 70% to 75%, specificity >95%).
  • Acute-Phase Reactants: Quantitative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to gauge systemic inflammatory disease activity.
  • Arthrocentesis and Synovial Fluid Analysis: Essential in monoarticular exacerbations to exclude concomitant septic arthritis or crystal arthropathy. Typically yields an inflammatory profile: translucent-to-turbid yellow fluid, 5,000 to 50,000 WBC/mcL with >75% polymorphonuclear leukocytes, negative Gram stain, and absence of monosodium urate or calcium pyrophosphate crystals.

7. Classification

Two validated classification systems are universally utilized in clinical practice to stage rheumatoid elbow disease, establish operative indications, and select reconstructive implants: the Larsen Radiographic Staging System and the Mayo Classification of Rheumatoid Elbow.

Larsen Radiographic Staging System

The Larsen classification provides a standardized, progressive 6-stage anatomical scale based on conventional plain radiographs:

Mayo Classification of Rheumatoid Elbow (Morrey)

The Mayo classification integrates joint architecture, bone stock, and ligamentous stability directly into surgical decision-making:

8. Treatment

Medical and Nonoperative Management

Medical pharmacotherapy orchestrated in coordination with rheumatology is the foundation of management for all patients with rheumatoid arthritis of the elbow:

• Disease-Modifying Antirheumatic Drugs (DMARDs):
  • Conventional Synthetic DMARDs (csDMARDs): Methotrexate (15 mg to 25 mg weekly) is the initial cornerstone anchor drug, supplemented by leflunomide or sulfasalazine.
  • Biologic DMARDs (bDMARDs) and Targeted Synthetics (tsDMARDs): Patients with persistent disease activity are escalated to TNF-α inhibitors (adalimumab, etanercept, infliximab), IL-6 receptor antagonists (tocilizumab), multivalent targeted biologics (e.g., ozoralizumab), or Janus kinase (JAK) inhibitors (tofacitinib, baricitinib).
  • Perioperative Medication Protocols: To mitigate the risk of catastrophic periprosthetic joint infection, biologic agents are withheld for 1 to 2 dosing intervals prior to elective arthroplasty and resumed 10 to 14 days postoperatively upon complete wound healing. Methotrexate is maintained continuously, as prospective evidence demonstrates no increase in surgical wound complications.
• Nonoperative Modalities:
  • Physical Therapy: Active-assisted exercises emphasizing preservation of the functional motion arc (30° to 130° flexion, 50° pronation-supination) and low-load isometric strengthening. Forceful passive manipulation is strictly prohibited.
  • Orthotics: Nocturnal resting extension splints to combat progressive flexion contractures.
  • Intra-Articular Injections: Judicious corticosteroid injections under fluoroscopic or ultrasound guidance provide temporary relief for acute synovial flares; repeated injections must be avoided to prevent accelerated osteoarticular resorption, tendon rupture, and soft-tissue atrophy.

Operative Management

The primary goals of operative intervention are the relief of intractable pain, restoration of a functional arc of motion, re-establishment of mechanical stability, and decompression of the ulnar nerve.

• Synovectomy with or without Radial Head Excision:
  • Technique: Performed via an open lateral (Kocher) approach, posterolateral approach, or elbow arthroscopy. Meticulous debulking of hypertrophic synovium from the anterior capsule, olecranon fossa, coronoid recess, and radiocapitellar joint.
  • Radial Head Excision: Excision of the radial head is indicated when the radiocapitellar joint shows severe erosion, pannus destruction, or restricts pronation-supination. Resection is performed through the neck strictly proximal to the annular ligament (≤10 mm to 12 mm) to safeguard the lateral ulnar collateral ligament (LUCL) origin and avoid PIN injury.
• Total Elbow Arthroplasty (TEA):
  • Semiconstrained Linked Arthroplasty (e.g., Coonrad-Morrey): The undisputed reconstructive standard for advanced rheumatoid arthritis. Features a “sloppy hinge” mechanism permitting 7° to 10° of varus-valgus and rotatory toggle, dissipating stress away from the cement-bone mantle to prevent loosening. An anterior humeral flange combined with autologous bone grafting provides rotational stability and resists posterior toggle.
  • Unconstrained (Unlinked) Arthroplasty: Resurfacing components that rely on intact bone stock and competent collateral ligaments. Unconstrained designs have unacceptably high rates of instability, subluxation, and early revision in rheumatoid patients due to ongoing soft-tissue stretching, and are largely contraindicated.
• Interposition Arthroplasty:
  • A biological salvage procedure utilizing autologous fascia lata, Achilles tendon allograft, or regenerative tissue matrix. Reserved for young, high-demand individuals with end-stage destruction who cannot adhere to lifelong arthroplasty lifting restrictions, or as a staged salvage after cured periprosthetic infection.

Indications & Contraindications

• Indications for Synovectomy: Medically refractory synovitis persisting >6 months despite optimized DMARD and biologic therapy; preserved osteoarticular architecture and collateral ligament stability (Larsen grade I–II, Mayo type I–II).
• Indications for Total Elbow Arthroplasty: Incapacitating pain at rest or motion refractory to comprehensive medical management; advanced structural joint destruction (Larsen grade III–V, Mayo type III–IV); gross instability or flail elbow; loss of the functional motion arc severely compromising daily living.
• Absolute Contraindications to TEA: Active local or systemic infection; non-functional extensor (triceps) or flexor-pronator musculature; neuropathic arthropathy (Charcot joint); severe uncorrectable cognitive or psychiatric impairment.
• Relative Contraindications to TEA: Young, high-demand patient requiring heavy manual labor or weight lifting; extensive soft-tissue compromise or paper-thin skin prone to primary wound breakdown; severe active tobacco dependence.

9. Outcome

Clinical and functional outcomes are assessed utilizing validated patient-reported outcome measures (PROMs), including the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and objective goniometric motion metrics:

• Synovectomy Outcomes: Open and arthroscopic synovectomy yield reliable, prompt pain relief and improved function in 75% to 85% of carefully selected patients with early disease. Mean flexion-extension arc improves by 10° to 15°, with more pronounced gains in pronation-supination following radial head excision. However, long-term follow-up demonstrates disease recurrence and radiographic progression in 30% to 50% of elbows at 5 to 10 years, frequently culminating in conversion to total elbow arthroplasty.
• Total Elbow Arthroplasty Outcomes: Modern semiconstrained linked TEA provides dramatic and predictable relief of debilitating pain, with average MEPS improving from <40 preoperatively to >85 to 90 postoperatively. Over 90% of patients achieve a pain-free, stable functional arc of motion (average 30° extension to 130° flexion).
• Prosthetic Survivorship: Landmark multicenter cohorts and registry analyses confirm 10-year implant survivorship rates between 88% and 92%, and 15-year survivorship rates of 80% to 87% in patients with rheumatoid arthritis. Survivorship is significantly superior to post-traumatic cohorts due to lower functional physical demands, symmetric soft-tissue balance, and careful adherence to activity modifications.

10. Complications

Complications following surgical management of rheumatoid elbow disease are categorized chronologically by intraoperative, early postoperative, and late postoperative intervals:

11. Pearls and Pitfalls

• Master Surgical Pearls:
  • Routine Ulnar Nerve Transposition: Mobilize the ulnar nerve proximally to the arcade of Struthers and distally into the flexor carpi ulnaris motor branches. Complete an anterior subcutaneous or submuscular transposition in every total elbow arthroplasty to eliminate traction neurapraxia during deformity correction.
  • Anterior Humeral Flange Bone Grafting: When implanting the Coonrad-Morrey humeral component, fashion an autologous bone graft harvested from the resected olecranon or radial head. Compress this graft securely between the anterior cortex of the distal humerus and the anterior flange of the prosthesis; this converts shear forces into compressive loads and resists posterior toggle.
  • Full-Thickness Soft-Tissue Flaps: Elevate generous, full-thickness fasciocutaneous flaps down to bone without separating skin from subcutaneous fat to preserve marginal dermal blood supply in immunosuppressed, steroid-treated patients.
  • Anatomical Extensor Mechanism Repair: If using a Bryan-Morrey triceps-reflecting approach, reattach the extensor mechanism through crisscross transosseous drill holes in the olecranon using heavy nonabsorbable braided suture (#2 FiberWire or Ethibond) reinforced with running nonabsorbable perimeter sutures.
• Critical Pitfalls to Avoid:
  • Excessive Radial Head Resection: Resecting the radial neck distal to the annular ligament margin destabilizes the lateral column, compromises the lateral ulnar collateral ligament complex, and places the deep motor branch of the radial nerve (PIN) at immediate risk within the supinator.
  • Implanting Unlinked Arthroplasty: Attempting resurfacing unlinked arthroplasty in an elbow with rheumatoid soft-tissue attenuation, bone loss, or collateral laxity leads to rapid prosthetic subluxation, dislocation, and catastrophic early failure.
  • Aggressive Postoperative Passive Manipulation: Forceful passive extension exercises provoke severe soft-tissue hematoma, heterotopic ossification, and catastrophic rupture of the repaired extensor mechanism. Rehabilitation must prioritize active-assisted motion within pain-free boundaries.
  • Neglecting Lifelong Lifting Limits: Failure to educate the patient regarding strict postoperative activity modifications (maximum 2.3 kg / 5 lbs repetitive lifting) drastically accelerates polyethylene bushing wear, cement mantle fracture, and aseptic loosening.

12. Controversy

• Linked Semiconstrained versus Unlinked Arthroplasty: Historical debate centered on whether linked designs transmit excessive torsional stresses to the cement-bone interface, predisposing to early loosening, whereas unlinked designs preserve natural kinematics. Contemporary long-term registry data have conclusively resolved this controversy: the progressive collateral ligament attenuation and column osteolysis intrinsic to rheumatoid disease lead to high dislocation rates in unlinked implants, establishing semiconstrained linked designs with sloppy hinge mechanics as the undisputed standard.
• Radial Head Management During Early Synovectomy: While radial head excision improves forearm pronation-supination and visual access to the lateral joint compartment, it eliminates lateral column load sharing and may increase contact stress on the compromised ulnohumeral articulation. In early Larsen grade I–II disease with preserved articular cartilage, arthroscopic synovectomy with radial head preservation is increasingly advocated.
• Perioperative Interruption of Biologic DMARDs: Conflicting consensus exists regarding the optimal timing for withholding biologic agents prior to arthroplasty. Prolonged drug holidays reduce surgical site infection risks but precipitate severe systemic inflammatory disease flares that impede postoperative mobilization. Current international rheumatology and orthopaedic consensus recommends withholding biologics for one dosing cycle prior to surgery and resuming after surgical wound healing (typically 14 days).

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Morandi Guaitoli M, Mazzotti A, Artioli E et al. Indications and outcomes of the Coonrad-Morrey total elbow arthroplasty: a systematic review. Arch Orthop Trauma Surg. 2024. doi:10.1007/s00402-024-05636-4 [Level I: Systematic Review / Meta-Analysis]
• Ebina K, Okamoto S, Kyuuma M et al. Efficacy of ozoralizumab in rheumatoid arthritis patients with large joint involvement: a post hoc analysis of OHZORA and NATSUZORA trials. RMD Open. 2025. doi:10.1136/rmdopen-2025-006218 [Level I: Randomized Controlled Trial]
• Gill DRJ, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am. 1998. doi:10.2106/00004623-199809000-00012 [Level IV: Long-Term Multicenter Registry Cohort]
• Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh). 1977. doi:10.1177/028418517701800415 [Level V: Radiographic Classification Validation Study]
• Aletaha D, Neogi T, Silman AJ et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis & Rheumatism. 2010. doi:10.1002/art.27584 [Level V: Consensus Diagnostic Validation Study]

15. Master Class Pro-Tip

In advanced rheumatoid elbow reconstruction, the primary mechanical vulnerability of the humeral component is rotational and posterior toggle. Never compromise the anterior flange bone graft. Fashion an anatomic wedge of autologous bone from the resected olecranon or distal humeral bone cuts and securely compress it between the anterior cortex of the distal humerus and the prosthesis flange prior to cement polymerization. This construct converts shear forces into compressive loads, substantially reducing the risk of aseptic loosening and anterior cortical perforation over long-term follow-up.

Master Class Surgical Pearl: Rheumatoid Elbow Reconstruction