import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Branches from radial nerve 6cm proximal to radiocapitellar joint. Dives through supinator at arcade of Frohse. Lies on ANTERIOR aspect of radial neck, 4-6cm distal to radiocapitellar joint. Moves anteriorly with supination. **Protection**: (1) Full forearm SUPINATION during radial head excision moves PIN anteriorly and proximally. (2) Subperiosteal dissection on radial neck. (3) Limit distal dissection to 2-3cm from radial head. (4) No sharp dissection anterior to radius. **Location**: Lies in spiral groove on posterolateral humerus, 10-12cm proximal to lateral epicondyle. Pierces lateral intermuscular septum and travels anterior to lateral epicondyle between brachialis and brachioradialis. **Protection**: (1) Stay distal to lateral epicondyle during approach. (2) If extending proximally, remain anterior to intermuscular septum. (3) Identify nerve if extensive proximal exposure needed. (4) Gentle retraction only. **Location**: Lies 2-3cm posterior to medial epicondyle in cubital tunnel. Travels between medial epicondyle and olecranon. Passes under Osborne's ligament (arcuate ligament), then between two heads of FCU. **Protection**: (1) Lateral Kocher approach stays 3cm from medial structures. (2) If posterior compartment access needed, identify nerve before capsulotomy. (3) Avoid medial retraction. (4) In-situ decompression if symptoms present. **Location**: Lie medial to biceps tendon in antecubital fossa. Pass deep to lacertus fibrosus (bicipital aponeurosis). Median nerve crosses anterior to brachialis then passes between two heads of pronator teres. **Protection**: (1) Lateral approach avoids these anterior-medial structures. (2) If anterior capsular release needed, stay subperiosteal on bone. (3) No blind medial retraction. (4) Identify structures if extensive anterior release required. **Location**: LUCL (lateral ulnar collateral ligament) originates from lateral epicondyle, courses posteroinferiorly to supinator crest of ulna. RCL blends with annular ligament. Annular ligament encircles radial head. **Protection**: (1) Develop interval anterior to LCL complex. (2) Incise capsule ANTERIOR to ligaments. (3) Preserve LUCL insertion on ulna. (4) Divide annular ligament only for radial head excision. (5) Repair if inadvertently damaged. **Primary Indications**: - Persistent elbow synovitis despite 6 months optimal medical management (DMARDs, biologics) - Painful limited range of motion interfering with ADLs - Larsen Grade I-III disease (preserved joint space on radiographs) - Painful radial head involvement with crepitus, erosions, or cystic changes - Radiocapitellar impingement causing mechanical symptoms - Palpable synovial thickening with effusion **Contraindications**: - Larsen Grade IV-V disease (advanced joint destruction) - consider arthroplasty - Active infection or recent septic arthritis - Severe medical comorbidities precluding surgery - Poor bone quality with fracture risk - Combined MCL and radial head insufficiency (causes severe valgus instability) - Unrealistic patient expectations **Larsen Classification System**: - **Grade 0**: Normal radiographs, no abnormalities - **Grade I**: Soft tissue swelling, periarticular osteopenia, NO erosions present - **Grade II**: Erosions present, joint space preserved (normal width) - **Grade III**: Joint space narrowing with less than 50% loss - **Grade IV**: Joint space narrowing with more than 50% loss - **Grade V**: Complete joint destruction, ankylosis, or complete obliteration **Surgical Decision Algorithm**: - **Grades I-II**: Synovectomy alone, preserve radial head if possible - **Grade III**: Synovectomy + radial head excision if symptomatic - **Grades IV-V**: Total elbow arthroplasty or interposition arthroplasty **Expected Outcomes**: - Pain relief in 70-80% at 5 years - Improved ROM by 20-30 degrees average - Recurrent synovitis in 30-50% at 5-10 years - Buys 5-10 years before arthroplasty consideration - Patient satisfaction 75-85% **Clinical Examination**: - ROM measurement: Normal elbow flexion 0-150°, pronation/supination 80°/80° - Flexion contracture quantification (common in RA) - Valgus/varus stability testing (MCL/LCL integrity) - Ulnar nerve assessment (Tinel's, subluxation, motor/sensory function) - Radial head palpation with forearm rotation (crepitus, pain, synovitis) **Imaging**: - **AP/Lateral radiographs**: Larsen grading, joint space preservation, erosions - **Oblique views**: Better visualization of radial head, radiocapitellar joint - **MRI** (optional): Synovial hypertrophy quantification, cartilage assessment - **CT** (if arthroplasty considered): Bone stock assessment, deformity evaluation **Medical Optimization**: - Rheumatology coordination for medication management - DMARDs: Continue methotrexate (low infection risk), consider holding biologics 1-2 weeks perioperatively - Steroids: Continue physiologic doses, stress dose coverage if prolonged use - Anticoagulation: Manage per guidelines (aspirin continue, warfarin bridge if needed) - Nutritional status: RA patients often malnourished, optimize protein intake **Lateral Elbow Anatomy**: **Kocher Interval** (TRUE Internervous Plane): - **Posterior**: Anconeus muscle (supplied by radial nerve main trunk) - **Anterior**: Extensor carpi ulnaris (supplied by posterior interosseous nerve) - This is a TRUE internervous plane - different nerve supply to muscles - Deep to interval: Joint capsule, radiocapitellar joint, lateral collateral ligament complex **Lateral Collateral Ligament Complex**: 1. **Radial Collateral Ligament (RCL)**: Lateral epicondyle to annular ligament, provides varus stability 2. **Lateral Ulnar Collateral Ligament (LUCL)**: MOST IMPORTANT - lateral epicondyle to supinator crest of ulna, prevents PLRI 3. **Annular Ligament**: Encircles radial head, allows rotation, blends with RCL 4. **Accessory LCL**: Variable, blends with annular ligament **Posterior Interosseous Nerve (PIN) Course**: - Branches from radial nerve 6cm proximal to radiocapitellar joint - Radial nerve divides into superficial (sensory) and deep (motor = PIN) branches - PIN dives posteriorly through supinator muscle - Enters supinator at **Arcade of Frohse** (fibrous arch at proximal supinator edge) - Winds around radial neck from posterior to ANTERIOR - At radial neck level (4-6cm distal to joint), PIN lies ANTERIOR to bone - Supplies all finger/thumb extensors: EPL, EPB, EIP, EDC, EDM, ECU proximally **Radial Nerve Main Trunk**: - Travels in spiral groove posterolateral humerus - 10-12cm proximal to lateral epicondyle - Pierces lateral intermuscular septum - Travels anterior to lateral epicondyle between brachialis and brachioradialis - Divides into superficial and deep (PIN) branches at radiocapitellar joint level **Ulnar Nerve**: - Posterior to medial epicondyle, 2-3cm from palpable prominence - Travels in cubital tunnel (bony floor: medial epicondyle and olecranon) - Osborne's ligament (arcuate ligament) forms roof of tunnel - Passes between two heads of FCU distally - Commonly compressed or subluxing in RA patients **Median Nerve and Brachial Artery**: - Medial to biceps tendon in antecubital fossa - Deep to lacertus fibrosus (bicipital aponeurosis) - Median nerve crosses anterior to brachialis - Passes between two heads of pronator teres - Stay lateral and on bone to avoid these structures **Patient Positioning**: - **Supine with arm across chest**: Arm rests on bolster, exposes lateral elbow, comfortable for patient - **Lateral decubitus**: Alternative position, arm supported on arm board - **Prone**: Rarely used for elbow, limits anterior access - General or regional anesthesia (interscalene or axillary block) - Tourniquet high on arm (250-300 mmHg), exsanguinate with elevation **Landmarks**: - **Lateral epicondyle**: Most prominent lateral bony landmark - **Radial head**: Palpate 2cm distal to lateral epicondyle, rotates with forearm - **Olecranon**: Posterior prominence, tip easily palpable - **Ulnar nerve**: 2-3cm posterior to medial epicondyle (palpable, rolls under finger) **Skin Incision**: - 8-10cm longitudinal incision from lateral epicondyle distally - Centered over radial head - Extends proximally over lateral epicondyle, distally over proximal radius - Can curve posteriorly if posterior access needed **Superficial Dissection**: - Incise subcutaneous tissue in line with skin - Identify fascia between anconeus (posterior) and ECU (anterior) - Anconeus fibers run obliquely from lateral epicondyle to ulna - ECU fibers run longitudinally along posterior forearm - Develop interval by blunt dissection (finger or scissors) **Deep Dissection**: - Split fascia between muscles - Anconeus retracts posteriorly, ECU anteriorly - Visualize joint capsule deep to muscles - Identify lateral collateral ligament complex (preserve) - Make longitudinal capsulotomy ANTERIOR to LCL complex **Internervous Plane Advantage**: - No motor nerves crossed during dissection - Anconeus (radial nerve), ECU (PIN) have different innervation - Safe approach with minimal denervation risk - Direct access to radiocapitellar joint and lateral compartment ### Step 1: Assessment & Planning Assessment & Planning: Clinical assessment of ROM (normal flexion 0-150°, pronation/supination 80°/80°), stability testing, neurovascular examination. Review imaging: AP/lateral radiographs for Larsen classification, assess articular cartilage preservation. LARSEN grading: 0 equals normal, I equals soft tissue swelling only, II equals erosions present, III equals less than 50% joint space loss, IV equals more than 50% loss, V equals complete destruction. Surgery appropriate for Grades I-III with preserved joint space. **Larsen Classification**: Grade I-III suitable for synovectomy (joint space preserved). Grade IV-V needs arthroplasty. Synovectomy provides 5-10 years pain relief before progression. Key exam point: Know that cartilage preservation is essential for synovectomy success. - Operating on Larsen IV-V has poor outcomes, high failure rate - Unrealistic expectations if patient not counseled about recurrence risk ### Step 2: Positioning & Landmarks Positioning: Supine with arm across chest on bolster (best exposure of lateral elbow). Alternatively lateral decubitus with arm supported. Tourniquet high on arm (250-300 mmHg). Mark bony landmarks: LATERAL EPICONDYLE (most prominent), RADIAL HEAD (palpate with forearm rotation, 2cm distal to epicondyle), OLECRANON (posterior tip). Plan incision along lateral epicondyle-radial head axis. **Positioning Technique**: Supine with arm across chest provides excellent lateral access. Radial head palpated by rotating forearm - head rotates under finger. Mark before prepping to ensure accurate incision placement. - Inadequate exposure if arm not properly positioned across chest - Tourniquet too distal limits proximal exposure ### Step 3: Lateral (Kocher) Incision Incision: 8-10cm longitudinal incision from lateral epicondyle distally over radial head. Extend proximally 3-4cm above epicondyle, distally 5-6cm below. Divide subcutaneous tissue in line with skin. Identify fascial interval between ANCONEUS (posterior) and ECU (anterior). TRUE INTERNERVOUS PLANE: Anconeus supplied by radial nerve main trunk, ECU by posterior interosseous nerve (PIN). **Internervous Plane**: Kocher is TRUE internervous plane - anconeus (radial nerve) posterior, ECU (PIN) anterior. Safest approach for lateral elbow. No motor nerves crossed during dissection. Key exam distinction from Henry approach (not internervous). - PIN lies deep to ECU - at risk during deep dissection anterior to muscle - Radial nerve main trunk 10-12cm proximal - avoid excessive proximal dissection ### Step 4: Superficial Dissection Superficial dissection: Divide fascia between anconeus and ECU sharply with knife. Develop interval by blunt dissection (finger or Mayo scissors). Anconeus fibers run obliquely posteriorly, ECU fibers longitudinal. Retract anconeus posteriorly, ECU anteriorly. Visualize lateral collateral ligament complex deep - PRESERVE intact for stability. Identify joint capsule deep to LCL. **LCL Preservation**: LCL complex critical for stability. LUCL (lateral ulnar collateral ligament) is primary restraint to PLRI. Originates lateral epicondyle, inserts supinator crest of ulna. Injury causes posterolateral rotatory instability with apprehension, clicking, subluxation. - LCL injury causes posterolateral rotatory instability (PLRI) - Excessive capsular release anteriorly can cause instability - PIN lies anterior to radial neck deep to field ### Step 5: Capsulotomy & Synovectomy Capsulotomy: Longitudinal capsular incision ANTERIOR to LCL complex. Extend proximally and distally along joint line. Preserve LCL complex posteriorly. SYNOVECTOMY: Remove hypertrophic inflamed synovium using rongeurs, shavers, small curettes. Clear anterior compartment thoroughly. Remove pannus from articular surfaces of capitellum and radial head. Access posterior compartment by extending capsulotomy posteromedially (be aware of ulnar nerve location). **Complete Synovectomy**: Both anterior AND posterior compartments must be cleared. Anterior: capitellum, radial head, coronoid fossa. Posterior: olecranon fossa, posterior capsule. Incomplete synovectomy causes early recurrence. Use systematic approach to ensure complete clearance. - Ulnar nerve lies 2-3cm posterior to medial epicondyle - at risk with posterior access - Incomplete synovectomy leads to early recurrence (30-50% at 5 years) - Aggressive synovectomy can destabilize joint if ligaments damaged ### Step 6: Radial Head Assessment Assessment: Inspect radial head for erosions, cystic changes, cartilage loss. Palpate for crepitus with passive pronation/supination. Assess radiocapitellar articulation - capitellum erosions, joint space narrowing. If radial head painful, eroded, cystic, or causing impingement, proceed with excision. If intact cartilage and pain-free, preserve radial head (contributes to valgus stability, longitudinal forearm stability). **Radial Head Decision**: Excise if: (1) Painful with rotation, (2) Erosions or cystic changes, (3) Radiocapitellar impingement, (4) Mechanical symptoms. Preserve if intact - radial head provides valgus stability (secondary stabilizer) and axial load transmission (30-50% of forearm load). - Unnecessary excision removes valgus stabilizer - risk instability if MCL deficient - Preserving severely eroded head leaves pain source ### Step 7: Radial Head Excision Excision technique: CRITICAL STEP - Protect PIN by placing forearm in FULL SUPINATION (moves PIN anteriorly away from radial neck). Circumferentially expose radial neck with subperiosteal dissection using periosteal elevator. Stay on bone. Divide annular ligament circumferentially with knife. Use oscillating saw to perform osteotomy of radial neck 2-3mm distal to radiocapitellar joint (just below articular surface). Remove radial head specimen. Smooth bony edges with rongeur. PRESERVE 2-3cm of proximal radius distal to osteotomy - excessive excision causes proximal radial migration and DRUJ instability. **PIN Protection Technique**: FULL SUPINATION is key protective maneuver. Supination rotates radius, moving PIN anteriorly and proximally away from surgical field. PIN lies 4-6cm distal to joint on ANTERIOR radial neck. Subperiosteal dissection stays on bone, protects nerve. Limit distal dissection to 2-3cm below osteotomy. - PIN injury (1-2% risk) - causes finger/thumb extension weakness (EPL, EPB, EIP, EDC, EDM loss) - Excessive excision (greater than 3cm distal to joint) causes proximal radial migration, DRUJ pain and instability - Valgus instability if radial head excised in presence of MCL insufficiency (combined injury) - Lateral synovial fistula if inadequate soft tissue closure ### Step 8: Anterior Capsular Release (if flexion contracture) Release for contracture: If flexion contracture exceeds 30°: Perform anterior capsular release. Excise thickened anterior capsule sharply. Release adhesions in coronoid fossa using curette. Elevate brachialis muscle fibers off anterior distal humerus. Extend release proximally if needed. Goal: achieve less than 30° flexion contracture intraoperatively (some loss expected postoperatively). **Flexion Contracture Management**: Common in RA elbow (loss of extension). Release anterior capsule, brachialis, coronoid fossa to regain extension. Anterior coronoid osteophytes block extension, posterior olecranon osteophytes block flexion. Address both for full ROM. Realistic goal: less than 30° contracture postop. - Median nerve and brachial artery lie medially in antecubital fossa - stay lateral and on bone - Radial nerve laterally at spiral groove if extending proximal release - Over-aggressive release can cause instability ### Step 9: Posterior Compartment Access (if needed) Posterior access: For posterior synovitis or olecranon impingement: Extend interval posteromedially between anconeus and FCU. Develop plane carefully (ulnar nerve nearby). Access posterior elbow compartment. Remove posterior synovium from olecranon fossa. Excise olecranon osteophytes if causing impingement (blocking flexion). Remove loose bodies if present. **Posterior Pathology**: Posterior olecranon osteophytes cause loss of FLEXION (mechanical block in olecranon fossa). Anterior coronoid fossa osteophytes cause loss of EXTENSION. Must address both anterior and posterior to maximize ROM. Posterior synovitis common in RA, contributes to recurrence if not cleared. - Ulnar nerve lies 2-3cm posterior to medial epicondyle in cubital tunnel - easily injured - Palpate nerve, protect during posterior dissection - Excessive triceps detachment weakens extension ### Step 10: Ulnar Nerve Assessment & Decompression Ulnar nerve management: If preoperative ulnar nerve symptoms (numbness, tingling, weakness in ulnar distribution): Identify ulnar nerve posterior to medial epicondyle. Assess for subluxation (with elbow flexion), compression, synovial compression. Perform IN-SITU DECOMPRESSION: Release Osborne's ligament (arcuate ligament over cubital tunnel). Divide arcade of Struthers proximally (medial intermuscular septum). Divide FCU fascia distally. Neurolysis if perineural scarring present. Anterior transposition if severe symptoms, instability, or failed in-situ decompression. **Ulnar Neuropathy in RA**: Common (30-50% have symptoms) from synovitis compressing nerve in cubital tunnel, subluxation over medial epicondyle, or chronic elbow flexion. In-situ decompression adequate for most - release Osborne's ligament, FCU fascia. Anterior transposition if unstable or severe. RA patients have higher complication rate with transposition (thin soft tissue, poor healing). - Direct ulnar nerve injury during mobilization or neurolysis - Devascularization if excessive stripping of nerve (perineural vessels) - Kinking if anterior transposition performed incorrectly ### Step 11: Range of Motion Assessment ROM testing: Release tourniquet temporarily. Passively assess ROM: Flexion (goal 130-140°), Extension (goal less than 30° flexion contracture), Pronation/supination (goal 70°/70° each direction). Test stability: Valgus stress (MCL integrity), Varus stress (LCL integrity), Posterolateral rotatory instability (lateral pivot shift test). If unstable, consider ligament repair (rare in synovectomy, more common if ligament injured iatrogenically). **Intraoperative ROM Goals**: Flexion greater than 130°, extension deficit less than 30°, pronation/supination 70°/70°. Some loss expected postoperatively with scarring. Stability testing essential - if unstable, may need ligament reconstruction or modify plan. Gentle manipulation only - osteopenic bone fractures easily in RA. - Forced manipulation can fracture osteopenic bone (supracondylar, olecranon) - Instability suggests ligament injury - may need repair ### Step 12: Hemostasis & Drain Placement Hemostasis: Release tourniquet definitively. Achieve meticulous hemostasis with bipolar electrocautery. RA patients often on anticoagulation (aspirin, warfarin), DMARDs, steroids - all impair hemostasis. Irrigate thoroughly. Place small drain (10Fr round or 7mm flat drain) - exit posteriorly to avoid radial nerve. Avoid large bore drains (increase bleeding). Consider fibrin sealant or tranexamic acid if oozy field. **Hemostasis in RA**: Critical step. RA patients on multiple medications impairing hemostasis: Aspirin, NSAIDs, warfarin, steroids, DMARDs, biologics. Meticulous cautery essential. Small drain for 24-48hrs reduces hematoma risk. Hematoma increases infection risk and causes stiffness. - Hematoma formation common in anticoagulated patients - increases infection risk - Large drain can increase bleeding - Radial nerve injury from posterior drain placement ### Step 13: Closure Layered closure: Attempt capsular closure if tissue adequate (often thin and deficient in RA). Use 2-0 absorbable suture. Close ECU-anconeus interval with 2-0 Vicryl interrupted sutures. Subcutaneous layer with 3-0 Vicryl. Skin closure with 3-0 or 4-0 nylon interrupted vertical mattress sutures (allows drainage) OR subcuticular 4-0 Monocryl. Interrupted sutures preferred in RA (easier to remove if wound issues, allows drainage between sutures). **Closure Considerations**: Capsule often too thin/deficient to repair in RA. Stability relies on intact LCL complex. Skin: Interrupted sutures allow better drainage than subcuticular in RA patients (higher wound complication risk). Avoid tension - thin skin prone to dehiscence. - Wound dehiscence common in RA (thin skin, steroids, poor healing) - Infection risk 2-5% (higher than non-RA due to immunosuppression) ### Step 14: Dressing & Splinting Postoperative dressing: Apply bulky soft dressing with fluffed gauze. Posterior splint in 90° flexion, neutral forearm rotation (mid pronation-supination). Splint for comfort only, NOT rigid immobilization. Remove drain at 24-48hrs when output less than 30mL per 8hrs. Early ROM critical - begin at 48-72hrs. **Avoid Prolonged Immobilization**: Early ROM essential in RA elbow - stiffness develops rapidly if immobilized. Splint for comfort only initially. Begin gentle active ROM at 48-72hrs. Goal: minimize stiffness while protecting soft tissues during healing. RA patients stiffen faster than normal. - Prolonged immobilization (greater than 3-5 days) causes permanent stiffness in RA - Tight dressing can cause compartment syndrome or nerve compression ### Step 15: Postoperative Rehabilitation Rehabilitation protocol: Remove drain 24-48hrs. Begin gentle active ROM at 48-72hrs (avoid passive stretching initially - increases inflammation). Frequency: 5-10 minutes every 1-2 hours. Progress to active-assisted ROM at 1-2 weeks. Therapist-supervised therapy at 2 weeks. Full active ROM by 3-4 weeks. Strengthening at 6-8 weeks (light resistance, progressive). Monitor for recurrent synovitis (warmth, swelling, loss of motion). Coordinate with rheumatology for optimal medical management (DMARDs, biologics) to slow disease progression. **Early ROM Protocol**: Active ROM 48-72hrs, active-assisted 1-2 weeks, strengthening 6-8 weeks. Coordinate with rheumatology - optimize medical management to prevent recurrence. Biologics (anti-TNF, anti-IL6) reduce synovitis recurrence. Patient education: Synovectomy temporizing, not curative - disease continues. - Recurrent synovitis in 30-50% at 5-10 years (disease progression, incomplete synovectomy) - Progression to arthroplasty eventual in many patients (Larsen grade worsens over time) - Stiffness if inadequate rehabilitation compliance ## References 1. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am. 1985;67(3):418-421. doi:10.2106/00004623-198567030-00010 2. Mori T, Miyamoto H, Keira T, et al. Long-term outcomes of elbow synovectomy and radial head excision in patients with rheumatoid arthritis. Mod Rheumatol. 2014;24(4):601-605. doi:10.3109/14397595.2013.850765 3. Gschwend N, Simmen BR, Matejovsky Z. Late complications in elbow arthroplasty. J Shoulder Elbow Surg. 1996;5(2 Pt 1):86-96. doi:10.1016/s1058-2746(96)80002-7 4. Porter BB, Richardson RA, Varacallo M. Anatomy, Shoulder and Upper Limb, Radial Nerve. StatPearls Publishing; 2023. PMID: 30969667 5. Tsai P, Steinberg DR. Median and radial nerve compression about the elbow. Instr Course Lect. 2008;57:177-185. PMID: 18399577 6. O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440-446. PMID: 1997770 7. Kocher T. Textbook of Operative Surgery. 3rd ed. Adam & Charles Black; 1911. 8. Frohse F, Fränkel M. Die Muskeln des menschlichen Armes. In: von Bardeleben K, ed. Handbuch der Anatomie des Menschen. Vol 2. Gustav Fischer; 1908:223-356. 9. Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh). 1977;18(4):481-491. doi:10.1177/028418517701800415 10. Blaine TA, Adams R, Morrey BF. Total elbow arthroplasty after interposition arthroplasty for elbow arthritis. J Bone Joint Surg Am. 2005;87(2):286-292. doi:10.2106/JBJS.C.01330

Rheumatoid Elbow Synovectomy & Radial Head Excision

Rheumatoid Elbow Synovectomy & Radial Head Excision