Inflammatory Arthropathies of the Shoulder

The Problem

Inflammatory arthropathies of the shoulder represent a spectrum of disease that can range from synovitis to advanced arthritis with bone loss. There are several types of inflammatory arthropathies with rheumatoid arthritis being the most common. Rheumatoid arthritis (RA) of the shoulder has a prevalence of 1% and typically affects females (3:1) more than males. Shoulder involvement is present in greater than 90% of patients who have been diagnosed with RA for more than 5 years. On occasion the shoulder can be the first joint affected, but more frequently involvement of other joints precedes the development of shoulder pain. Inflammatory arthritis typically presents in individuals between ages 30 to 50, with the prevalence increasing to 5% in people older than 70 years. Other conditions that can rarely present with inflammatory arthritis of the shoulder include psoriatic arthritis, Reiter’s syndrome, Lyme disease, polymalgia rheumatica, ankylosing spondylitis, and crystalline arthropathies (gout, pseudogout and Milwaukee shoulder).

Clinical Presentation

The presentation of inflammatory arthritis can be variable, with most patients presenting with a combination of joint pain, swelling, stiffness and limited function. Associated symptoms of fatigue, generalized musculoskeletal pain, fever and malaise are common in the initial presentation of rheumatoid arthritis. Inflammatory arthritis can be monoarticular but more frequently is polyarticular with the small joints of the hands and feet affected early and the shoulder, knee, ankle and elbow later in the disease course. Inflammatory arthropathy of the shoulder can affect the glenohumeral joint, acromioclavicular joint and sternoclavicular joint, as well as the subacromial or subdeltoid bursa. Involvement of the glenohumeral joint with asymptomatic acromioclavicular and sternoclavicular joints occurs in two thirds of cases. Rotator cuff pathology is present in 75% of cases, with one third developing full thickness tears. The most common presentation is the insidious onset of pain both at rest and with activity and the progressive loss of shoulder motion.

Diagnostic Workup

Classic physical exam findings

Inspection of the shoulder can reveal swelling, erythema or a joint effusion. In cases of associated rotator cuff pathology muscle atrophy of the supraspinatus or infraspinatus can be seen. However, the shoulder can often be normal on isolated inspection. Examination of the remainder of the extremities should be performed to look for systemic signs of inflammatory arthritis including rheumatoid nodules or involvement of the small joints of the hand and wrist. Shoulder range of motion will often be restricted, presenting at first with isolated loss of active motion due to pain, which will progress to loss of both active and passive motion and joint contractures as disease severity increases. Crepitation of the joint can be appreciated as the disease reaches advanced stages.

Imaging findings

The earliest sign of inflammatory arthritis on radiograph is regional osteopenia. This typically progresses to loss of joint space, periarticular erosions and cysts, and culminates with bone loss of both the humeral head and glenoid. (Figure 1 and Figure 2) Superior migration of the humeral head and superior glenoid bone wear will be encountered in those with tearing of the rotator cuff.

Figure 1.

Special diagnostic tests (injections, EMGs, etc)

MRI Scan: Can aid in the diagnosis of inflammatory arthropathy by demonstrating joint effusion, pannus formation, inflammation and periarticular erosions. MRI is more sensitive than plain radiographs or ultrasound in the diagnosis of the early disease and can demonstrate positive findings even if radiographs are normal. MRI is also indicated if suspicion for rotator cuff or other soft tissue pathology associated with inflammatory arthropathy.

CT Scan: Can be useful in cases of significant bone loss or deformity to determine if shoulder replacement surgery is possible and for pre-operative planning. CT arthrograms can be useful in assessing bone loss and the presence of rotator cuff pathology. (Figure 3 and Figure 4)

Ultrasound: Newer techniques have been developed to enhance the diagnosis of rheumatoid arthritis. Ultrasound of multiple joints can help with the early detection of inflammatory arthritis and has shown greater sensitivity than plain radiographs but is less sensitive than MRI. Ultrasound can also be effective in diagnosing associated rotator cuff or soft tissue pathology. The results of ultrasound are highly dependent on the skill and experience of the individual performing the study.

Joint aspiration: Joint fluid analysis and culture can be effective in both confirming inflammatory arthritis and ruling out other potential diagnoses such as septic arthritis or crystalline arthropathies. Fluid analysis from rheumatoid arthritis typically reveals clear, yellow-green fluid with decreased glucose and increased nucleated cell count (15,000 to 25,000) and 60% to 70% neutrophils. Septic arthritis typically has >100,000 nucleated cells with more than 75% neutrophils.

Non–Operative Management

The medical management of inflammatory arthropathies includes the use of non-steroidal anti-inflammatories, corticosteroids, analgesics and disease modifying anti-rheumatologic medications (DMARDs). The advent of DMARDs has greatly improved the treatment of inflammatory arthritis and decreased the need for surgical measures. Evaluation by a rheumatologist is appropriate for all patients with inflammatory arthropathies to evaluate if they meet criteria for disease modifying therapy. Several studies have shown better long term results with DMARDs when early diagnosis and treatment is initiated. Once radiographic studies demonstrate the loss of joint space or bone destruction the effectiveness of non-operative management decreases.

Intra-articular corticosteroid injections

Can result in dramatic symptom relief, however, results are inconsistent and long term use can result in damage to surrounding soft tissues. If injections do provide relief of symptoms for at least 8-12 weeks repeat injections can be considered. A limit of 3 to 5 injections is suggested to prevent compromise of the rotator cuff and articular cartilage.

Physical therapy

Therapy does not significantly alter the pathophysiology or the natural history of inflammatory arthropathy. However, maintenance of range of motion and function is important, especially during periods of acute inflammation. A program focused at stretching and gentle range of motion during inflammatory phases and progressing to strengthening as the inflammation subsides can help to maintain the best possible function of the patient’s shoulder.

Indications for Surgery

Surgical procedures are indicated when medical management, injections and therapy fail to control the patient’s pain and disability. Surgical treatment options include joint preserving and joint replacement procedures. The patient’s age, activity level and the severity of the disease are all factors that affect surgical decision-making. Joint preservation is indicated if there is still intact articular cartilage and no significant bone loss or deformity. In the absence of viable articular cartilage or the presence of bone loss joint replacement surgery is indicated. Joint replacement procedures include resurfacing arthroplasty, hemiarthroplasty, total shoulder arthroplasty, and reverse total shoulder arthroplasty. The decision of the type of replacement is influenced by multiple factors including the patient’s age, activity level, degree of bone loss and the status of the rotator cuff.

Contraindications to joint replacement surgery include septic arthritis, loss of deltoid or paralysis of the upper extremity. Relative contraindications include patient non-compliance, history of other prosthetic joint infections or the requirement for upper extremity weight bearing for ambulation.

Surgical Technique

Synovectomy/Debridement

Necessary Equipment/Instrumentation

Synovectomy and debridement can be performed open or arthroscopically, but arthroscopic techniques offer better access to the entire joint with less associated morbidity. The arthroscopic technique requires standard shoulder arthroscopic equipment including a 4 mm, 30 degree arthroscope, arthroscopic shaver and a radiofrequency wand. The use of a arthroscopic pump is helpful although gravity irrigation can be used.

Patient set-up

Arthroscopic synovectomy can be performed in either the lateral or beach chair position. The surgeon should choose the position that he/she is most comfortable with. Prepping and draping is performed according to surgeon preference. The author’s preference is to use the beach chair position and prepping is performed with a betadine scrub followed by prepping with Chloraprep (Figure 5).

Figure 5.

Step-by-step description of procedure:

• Diagnostic arthroscopy is initiated using a posterior portal to evaluate the articular cartilage, labrum, biceps tendon, rotator cuff, as well as the degree of joint synovitis and capsular contracture.

• Following completion of diagnostic arthroscopy an anterior working portal is created in the rotator interval. Any associated pathology is addressed including debridement of cartilage, labral lesions or rotator cuff tears, biceps tenotomy or tenodesis and contracture releases as needed. After the completion of all other procedures the synovectomy is performed. Removal of the entire synovial lining of the joint should be performed using the shaver. The ability to achieve compete removal the arthroscope will need to be moved between the anterior and posterior portals to allow for full visualization of the joint. Accessory portals may need to be created to allow access to the inferior joint capsule. Hemostasis can be performed using the radiofrequency wand with care to irrigate the joint to prevent thermal necrosis of the articular cartilage.

• After completion of the intra-articular arthroscopy the scope should be transitioned into the subacromial space. A compete subacromial bursectomy is performed using a lateral working portal. After bursectomy the rotator cuff should be evaluated for evidence of partial or full thickness tearing and treated appropriately. If there is evidence of subacromial impingement an acromioplasty should be performed.

• In patients with symptomatic acromioclavicular joint involvement a distal clavicle excision can be performed using an open or arthroscopic technique.

Joint replacement surgery

Necessary equipment/ Instrumentation

There are many options available for shoulder joint replacement, ranging from resurfacing to total shoulder arthroplasty. The surgeon will have to choose an implant type and manufacturer that they are comfortable with. The availability of shoulder specific retractors including a Brown deltoid retractor, Darrach retractors and glenoid retractors are important for exposure during joint replacement surgery. A surgical assistant to hold retractors is helpful but not essential with the use of self-retaining retractors. Pre-operative planning is essential for joint replacement surgery. Careful evaluation of the radiographs and CT scan is required to assess for glenoid version and bone loss. Using pre-operative templates can help to ensure the ability to correct deformity and place implants in the correct position and alignment. In cases of severe glenoid bone loss the use of advanced techniques such as bone grafting or augmentation may be required for glenoid insertion. In some cases bone loss may be so severe that a glenoid implant cannot be placed.

Patient set-up

Shoulder replacement surgery is typically performed in the beach chair position with the head of the bed elevated between 30 and 60 degrees. A bump should be placed along the medial border of the scapula of the operative side to prevent retraction of the scapula during the procedure. General anesthesia is required for shoulder replacement but the addition of a brachial plexus regional block can be effective in decreasing pain during and after the procedure. The authors protocol is to use a single injection interscalene block unless it is contraindicated in addition to general anesthesia. Surgical prep of the shoulder includes pre-operative chlorhexidine wipes used by the patient on the morning of surgery and in the pre-operative care unit, followed by betadine scrub and chloraprep in the operating room.

Step-by-step description of procedure:

A deltopectoral approach is used for all shoulder replacement surgery, although some surgeons prefer the superior approach for reverse total shoulder arthroplasty.

• Deltopectoral approach: The skin incision is made starting 1 cm superior to the coracoid process and extending distally toward the deltoid insertion for approximately 10-12 cm (Figure 6). Dissection through the subcutaneous fat is performed to expose the deltoid fascia. A medial skin flap is raised to expose the deltopectoral interval which is marked by a fat stripe and the presence of the cephalic vein. The vein is taken either medially or laterally depending on surgeon preference. Further exposure of the deltopectoral interval will expose the underlying conjoint tendon and clavipectoral fascia. The fascial layer is incised along the lateral edge of the conjoint tendon up to the coracoacromial ligament. The deltoid is then mobilized by releasing adhesions in the subdeltoid and subacromial bursa with care taken to avoid damage to the rotator cuff and the axillary neurovascular bundle located on the deep surface of the deltoid approximately 4 cm distal to the acromion. The conjoint tendon is then mobilized from the subscapularis tendon and the axillary nerve can be palpated anteriorly on the inferior border of the subscapularis tendon. In inflammatory arthropathy there is often a thickened or inflamed bursa that should be excised prior to proceeding with the remainder of the procedure. The rotator cuff should be evaluated for presence of tearing or dysfunction, and pathology should be addressed as needed with repair or reverse total shoulder arthroplasty.

• Biceps Tenodesis: Tenodesis of the biceps tendon helps to improve exposure and eliminates the possibility of biceps tendonitis as a source of pain for the post−arthroplasty patient. Multiple tenodesis techniques are described; the author’s preferred technique includes a soft tissue tenodesis to the pectoralis tendon with reinforcement at the time of the subscapularis repair using heavy sutures passed through the bone of the lesser tuberosity.

• Subscapularis tenotomy/lesser tuberosity osteotomy: Exposure of the joint will require release of the subscapularis tendon either using a tenotomy or a lesser tuberosity osteotomy. Despite much research and debate there is no clear benefit of one technique of another so each surgeon should choose the technique with which he/she is most comfortable. The author’s preference is to use a subscapularis tenotomy for patients with inflammatory arthritis due to the associated osteopenia and poor bone quality. The tenotomy is performed 1 cm medial to the insertion on the lesser tuberosity (Figure 7). The rotator interval is then split up to the level of the glenoid and the biceps tendon is released at the articular margin. The subscapularis is tagged with heavy suture to allow for mobilization and repair at the conclusion of the procedure.

• Inferior capsular release: The humeral attachment of the inferior glenohumeral ligament is released using electrocautery starting anterolaterally along the biceps tendon sheath and proceeding in a medial direction around the neck of the proximal humerus. The arm should be held in adduction and external rotation with care to stay directly on bone, and the use of a Darrach retractor to gently retract the axillary nerve will prevent nerve injury. There are often large osteophytes that may need to be removed to allow for full release of the inferior capsule (Figure 8). After release of the inferior capsule the humeral head can be dislocated anteriorly.

• Humeral Preparation: The humeral preparation varies depending on the implant system used. The author’s preferred technique involves the use of humeral cutting guides to create a humeral head osteotomy at 30 degrees of retroversion, and a fixed neck shaft angle of 130 degrees with the superior aspect of the osteotomy performed at the junction between the articular cartilage and the greater tuberosity with care not to violate the rotator cuff insertion. Alternative methods include free hand cuts at the anatomic neck or variable angle cutting guides. There is no clear benefit of one technique or another so the surgeon should follow the technique for the implant system that he/she chooses. The humeral preparation is completed with removal of osteophytes from the proximal humerus which helps to improve glenoid exposure.

• Glenoid Preparation: Glenoid exposure is the key to successful preparation. If adequate exposure is not achieved instrumentation can be difficult or impossible. Glenoid exposure can be limited by lack of deltoid mobilization, insufficient inferior capsule release, a humeral head osteotomy that is too high or presence of osteophytes. Paralysis is not typically required but in cases of difficult exposure can aid in retraction of the humerus. There are many options for glenoid retractors. The authors preference is to use three retractors: a posterior glenoid retractor placed at the posterior-inferior glenoid rim, a superior retractor placed just over the biceps tendon insertion and an anterior retractor placed between the subscapularis and the anterior joint capsule (Figure 9). The biceps tendon and labrum are excised to fully expose the glenoid bony anatomy and glenoid preparation is performed according to the technique for the desired implant. There are many commercially available implants including implants that incorporate bone ingrowth technology, however, all glenoid implants are currently only FDA approved with the use of bone cement. Synovectomy of the inflamed glenohumeral joint is performed prior to glenoid component insertion.

• Component Trialing: Trial implants are used to ensure appropriate size, orientation and stability of the implants. There are several factors that should be evaluated during trialing including component version, humeral head height, humeral off-set and component stability. The humeral and glenoid version should match such that when the arm is placed in neutral rotation the humeral head is pointed directly across from the glenoid. A mismatch in version can be corrected by changing the version of the humeral stem. The humeral height and off-set should be evaluated to reconstruct normal anatomic relationships. The superior aspect of the humeral head should be 5-9 mm above the greater tuberosity and the acromial off-set should be approximately 15 mm. The stability of the implant should be evaluated by taking the shoulder through a range of motion with full forward flexion, abduction, internal and external rotation without evidence of dislocation. With the arm held in a position of 30 degrees of abduction and 30 degrees of external rotation the humeral head should be able to be translated 40 – 50 percent posteriorly with immediate snap-back to the glenoid.

• Component insertion: After trialing, the selected implants are inserted according to the surgical technique for the implant. Humeral implants should be uncemented unless the bone quality is too poor to allow for press-fit insertion. Care in handling the implants with limitation of exposure time and prevention of contact with exposed skin surfaces are important for limiting post−operative infections.

• Subscapularis repair: The subscapularis tenotomy or lesser tuberosity osteotomy is repaired anatomically. The author’s preferred technique for repair of the subscapularis tenotomy involves heavy #2 sutures placed through the tendon insertion on the lesser tuberosity to repair the subscapularis back to bone and absorbable #2 sutures to repair the tendon to the tendon stump on the lesser tuberosity as well as the lateral portion of the rotator interval split (Figure 10). Subscapularis repair should be performed with the arm in at least 30 degrees of external rotation; if this is not possible further release of the subscapularis is needed to allow for mobilization. As mentioned previously the biceps tendon is incorporated into the subscapularis repair to augment the tenodesis performed during the exposure.

• Drain/Closure: The use of drains in shoulder arthroplasty is up to surgeon preference. There is no clear evidence that the use of a drain limits hematoma formation or the need for further operation. The author’s preference is to use a drain in all shoulder arthroplasty cases. Closure of the deltopectoral interval is performed with interrupted heavy absorbable sutures followed by skin closure with absorbable subcutaneous sutures.

Figure 6.

Figure 7.

Figure 8.

Figure 9.

Figure 10.

Pearls and Pitfalls of Technique

Pearls

• Pre-operative planning is essential for successful shoulder replacement procedures. It is the author’s protocol to obtain a CT scan on all patients and to template all cases to allow for appropriate component size and position.

• Glenoid exposure is the most challenging part of shoulder replacement surgery. Glenoid exposure starts with patient positioning, and attention to adequate capsular release and osteophyte removal are essential for exposure.

• Careful management of soft tissues and balancing are essential for a stable and functional shoulder arthroplasty.

• Discontinuation of disease modifying anti-rheumatologic medications prior to surgery is important to decrease the risk of infection. Coordination with the patient’s rheumatologist is essential, and some of the medications may need to be discontinued for 6 to 8 weeks prior to the procedure.

Pitfalls

• The most common reason for problems in shoulder arthroplasty are due to inadequate exposure. Recognizing the lack of exposure and revisiting the previous principles highlighted to achieve exposure is essential prior to attempting to place implants.

• Instability is often due to component malposition, inadequate soft tissue balancing or both. Pre-operative planning can help to eliminate problems with component malposition.

• Careful reaming and instrumentation of the glenoid and humerus is required in patients with inflammatory arthritis due to osteopenia. The incidence of fractures both intraoperatively and post−operatively is higher in patients with inflammatory arthropathy.

Potential Complications

Infection

Infection rates following total shoulder arthroplasty are 1-2% in most current series. Propionibacterium acnes is the most common pathogen infecting shoulder arthroplasty.

Bleeding/Hematoma

Rates of bleeding requiring transfusion or reoperation for evacuation of a hematoma are low following total shoulder arthroplasty.

Instability

Instability following total shoulder arthroplasty occurs in 1-2% can be the result of component malposition, lack of soft tissue balancing, failure of the subscapularis repair or a combination of all three. Revision surgery for instability has a high failure rate.

Nerve injury

Neuropraxias of the axillary, musculocutaneous or radial nerve have been reported in less than 1% of shoulder arthroplasties. The rates are increased with reverse shoulder arthroplasty compared to anatomic shoulder arthroplasty.

Fracture

Can occur intraoperatively or post-operatively. Treatment depends on the timing and location of the fracture, as well as, the stability and condition of the prosthesis.

Rotator cuff dysfunction

Tendonitis causing pain or full thickness tears resulting in limited function or pseudoparalysis is more common in inflammatory arthritis than osteoarthritis. An oversized or malpositioned humeral component can contribute to rotator cuff pathology post−operatively.

Post–operative Rehabilitation

Week 1-5: Patients are kept non-weight bearing in an immobilizer. Discharge from the hospital is performed on post−operative day one. Physical therapy is initiated focusing on pendulums and passive range of shoulder motion, as well as, active elbow, wrist and hand range motion.

Week 6-11:Immobilizer is discontinued and patients are allowed to use operative arm for light activities (up to 2-3 lbs). Physical therapy is focused on active and active assisted range of motion and isometric rotator cuff strengthening.

Week 12-18:Progressive return to full activity as tolerated. Physical therapy is continued with progression of rotator cuff strengthening and transition to home exercise program. Patients are encouraged to avoid strenuous activity and lifting >25lbs with operative arm for life. Yearly follow-up examination is performed with x-rays to assess component position and signs of loosening or wear.

Outcomes/Evidence in the Literature

Chen, AL, Joseph, TN, Zuckerman, JD. “Rheumatoid arthritis of the shoulder”. J Am Acad Orthop Surg. vol. 11. 2003. pp. 12-14. (Review article summarizing the diagnosis and treatment of rheumatoid arthritis of the shoulder. A treatment algorithm is presented for the treatment of RA of the shoulder with indications for non-operative management, synovectomy and joint replacement surgery.)

Collins, DN, Harryman II, DT, Wirth, MA. “Shoulder arthroplasty for the treatment of inflammatory arthritis”. JBJS. vol. 86. 2004. pp. 2489-2496. (Multicenter study of 12 centers evaluating the results of hemiarthroplasty (36) and total shoulder arthroplasty (25) for inflammatory arthropathies. There was significant improvement in all outcome measures (VAS pain score, simple shoulder test and an activities questionnaire) for both hemiarthroplasty and total shoulder arthroplasty. With the numbers available there was no difference between the hemiarthroplasty and total shoulder arthroplasty groups. Range of motion was improved in both groups, however, the improvement in the total shoulder arthroplasty group was significantly greater than that hemiarthroplasty group. There was no difference in outcome based on the severity of disease or the presence of a rotator cuff tear at the time of surgery.)

Finckh, A, Liang, MH, Van Herckenrode, CM, De Pablo, P. “Long-term impact of early treatment on radiographic progression in rheumatoid arthritis: a meta-analysis”. Arthritis & Rheumatism. vol. 55. 2006. pp. 864-872. (The authors identified 12 studies from 1966 to 2004 examining the association between delay treatment and the radiographic progression of rheumatoid arthritis that met their inclusion criteria. They found a 33 percent reduction in the long term progression rates if treatment was initiated early. The patients with more aggressive disease showed the most improvement with early disease modifying antirheumatic drug therapy.)

Hattrup, SJ, Sanchez-Sotelo, J, Sperling, JW, Cofield, RH. “Reverse shoulder replacement for patients with inflammatory arthritis”. J Hand Surg. vol. 37. 2012. pp. 1888-1894. (Retrospective review of 19 patients treated with reverse shoulder arthroplasty for inflammatory arthropathy that involved major damage to the rotator cuff. The average age of the patients was 70 years (58-81) with an average of 37 months of follow up. Outcome measures included VAS pain scores, ASES scores, Simple Shoulder Test and a modified Neer scale. There was significant improvement in all outcomes scores. The mean active elevation was 138 degrees and external rotation was 52 degrees. The Neer scale rating was excellent in 12, satisfactory in 5 and unsatisfactory in 2. There were five complications including two scapular spine fractures, an acromial stress fracture, an ulnar neuropathy and a dislocation. The authors concluded that reverse shoulder arthroplasty provides encouraging early results in inflammatory arthritis but there was concern regarding the occurrence of complications.)

Hermann, KA. “Rheumatoid arthritis of the shoulder joint: comparison of conventional radiography, ultrasound, and dynamic contrast-enhanced magnetic resonance imaging”. Arthritis & Rheumatism. vol. 48. 2003. pp. 3338-3349. (43 patients with known RA underwent clinical evaluation, radiography, MRI and ultrasound of the shoulder joint. MRI was the most sensitive for detecting erosions in the shoulder of patients with RA and ultrasound out-performed conventional radiography. The authors concluded that MRI and ultrasound are effective in the early diagnosis of RA of the shoulder when conventional radiographs are normal.)

Jamsen, E, Virta, LJ, Hakala, M, Kauppi, MU, Malmivaara, A, Lehto, MUK. “The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy”. Acta Orthopaedica. vol. 84. 2013. pp. 331-337. (The number of primary joint arthroplasties was obtained from the Finnish Arthroplasty Register and data regarding the purchases of disease-modifying anti-rheumatic drugs was collected. The incidence of all joint replacements for RA declined more than 40 percent from 1995 to 2010. Shoulder arthroplasty for RA declined more than 60 percent in the same time period. There was an associated increase in the number of users of disease modifying anti-rheumatic drugs. The authors attributed the decline in joint replacement for the treatment of RA to the improved medical management of the disease.)

Matthews, LS, LaBudde, JK. “Arthroscopic treatment of synovial diseases of the shoulder”. Ortho Clinics of North Am. vol. 24. 1993. pp. 101-109. (Review article of the arthroscopic management of inflammatory arthropathies of the shoulder. Description of the indications and surgical technique. The authors conclude that arthroscopic synovectomy can be successful in the diagnosis and treatment of inflammatory arthropathies, with the best results occurring when the procedure is performed prior to significant joint destruction.)

Young, AA, Smith, MM, Bacle, G, Moraga, C, Walch, G. “Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis”. JBJS. vol. 93. 2011. pp. 1915-1923. (Retrospective review of 18 patients treated with reverse shoulder arthroplasty for rheumatoid arthritis with associated rotator cuff compromise or severe glenoid erosion. The mean age of the patients was 70 years (46-83) with a mean follow up of 3.8 years (2-7). There was significant improvement in Constant scores and range of motion (138 degrees elevation) with the exception of external rotation at neutral abduction (20 degrees). There were 11 patients who were very satisfied, 6 satisfied and 1 disappointed at the time of most recent follow up. Complications included a transient axillary neuropathy and fractures of the coracoid, acromion, scapular spine, and two avulsion fractures of the greater tuberosity. The authors concluded that reverse shoulder arthroplasty resulted in significant improvement in pain and function in patients with rheumatoid arthritis, but advised caution due to lack of long term follow up and potential complications.)

Summary

Inflammatory arthropathy of the shoulder can be a painful and destructive disease. On occasion shoulder pain can be the initial presentation of rheumatoid or other systemic inflammatory arthropathies. The management of inflammatory arthropathies requires a multidisciplinary approach with collaboration between the rheumatologist and the orthopaedist. Early recognition and institution of disease modifying anti-rheumatologic drugs (DMARDs) can alter the natural history of the disease and help to eliminate the need for future joint replacement surgery. In young patients with intact cartilage, arthroscopic or open synovectomy can help to relieve pain and slow disease progression. In older patients or those with articular cartilage damage joint replacement surgery is indicated. Rotator cuff pathology is common in patients with inflammatory arthritis and treatment with repair or reverse total shoulder arthroplasty should be performed as appropriate. Results of shoulder arthroplasty for inflammatory arthritis are typically good and are comparable to those for osteoarthritic conditions.

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