Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder of unclear etiology characterized by an erosive, symmetrical polyarthritis that may lead to progressive disability. The estimated prevalence is 1% worldwide, with a female-to-male ratio of 3:1 that diminishes with age. The prevalence increases starting in the third decade of life; RA affects more than 5% of the population older than 70 years. Approximately 91% of patients with long-standing RA (>5 years''s intraoperative assessment of the quality of the soft tissues, component stability, and any associated repairs. Patients should be counseled that maximum benefit after prosthetic shoulder replacement may not be realized until 6 months to 1 year after surgery.
Rehabilitation begins on the first postoperative day, with active range of motion for the ipsilateral hand, wrist, and elbow, and passive and active-assisted range of motion for the shoulder. Initially, this includes supine passive forward elevation and external rotation exercises with the arm at the side. The degree of external rotation allowed during the initial 6 postoperative weeks is determined by the intraoperative repair of the subscapularis tendon; in general, 30° to 40° of external rotation may be tolerated without placing undue tension on the repair. At approximately 4 to 6 weeks, a more active shoulder range of motion is initiated along with internal rotation behind the back. Isometric strengthening exercises are started 4 weeks after surgery, and resistive strengthening exercises usually are initiated 10 to 12 weeks postoperatively when active range of motion has progressed.
Adverse events have been reported in up to 11.0% of total shoulder arthroplasties and up to 15.7% of shoulder hemiarthroplasties31 (Table 3). Cofield et al31 categorized complications of shoulder arthroplasty into four groups: (1) coexisting injuries to the shoulder at the time of surgery, such as rotator cuff tear or chronic dislocation; (2) problems with the healing process after surgery, such as failure of subscapularis tendon healing the 1 last update 2020/06/03 resulting in anterior shoulder instability or weakness in internal rotation, or overexuberant postoperative fibrosis causing joint stiffness; (3) complications related to the general health of the patient, such as infection secondary to chronic immunosuppression; and (4) complications associated with joint arthroplasty, such as periprosthetic fracture or component loosening.Adverse events have been reported in up to 11.0% of total shoulder arthroplasties and up to 15.7% of shoulder hemiarthroplasties31 (Table 3). Cofield et al31 categorized complications of shoulder arthroplasty into four groups: (1) coexisting injuries to the shoulder at the time of surgery, such as rotator cuff tear or chronic dislocation; (2) problems with the healing process after surgery, such as failure of subscapularis tendon healing resulting in anterior shoulder instability or weakness in internal rotation, or overexuberant postoperative fibrosis causing joint stiffness; (3) complications related to the general health of the patient, such as infection secondary to chronic immunosuppression; and (4) complications associated with joint arthroplasty, such as periprosthetic fracture or component loosening.
Significant instability after shoulder arthroplasty usually is recognizable by physical examination and radiography and can be related to improper soft-tissue balancing, rotator cuff disruption, component malposition, improper component sizing, or component loosening. Other factors associated with instability after prosthetic replacement of the shoulder include older age, chronic preoperative shoulder dislocation, and aberrant glenoid anatomy resulting from glenoid bone deficiency or asymmetric wear. Soft-tissue balancing intraoperatively should allow for up to 50% translation both anteriorly and posteriorly. Superior subluxation of the glenohumeral component is not necessarily indicative of rotator cuff disruption; inferior subluxation in the immediate postoperative period usually represents deltoid atony but can indicate inadequate soft-tissue tensioning, which may require secondary surgical corrections.
Axillary nerve neurapraxia is the most common injury. The musculocutaneous nerve may also be injured during exposure or overzealous retraction of the conjoined tendon. Radial nerve palsy also has been described secondary to cement extrusion from the canal distally, especially with revision arthroplasty or inadvertent humeral cortical penetration. If this finding is noted on postoperative radiographs, exploration is indicated. Continuity of the nerve should be confirmed and all cement removed. In most other cases of nerve injury, an initial period of observation is indicated because most nerve injuries represent neurapraxia. If neurologic improvement does not occur within 4 weeks, electromyography should be done to document the degree of neurologic injury and assess the potential for recovery. Exploration may be indicated for nerve palsies that do not improve by 12 weeks.
Periprosthetic fractures may occur intraoperatively or postoperatively. Intraoperative fractures can occur during humeral shaft preparation or insertion of the humeral component; postoperative fractures usually are a result of trauma. Fractures entirely distal to the humeral component may be treated nonsurgically with a fracture brace. Fractures proximal to the tip of the stem can be treated by cerclage wiring, plate fixation combined with cerclage wires, or, for intraoperative fractures, insertion of a long-stem component combined with cerclage wiring.
The risk of infection after prosthetic replacement is increased in the presence of diabetes mellitus, RA, lupus erythematosus, remote sites of infection, prior shoulder surgery, or use of immunosuppressive medications. Little has been published that specifically addresses the treatment of infected shoulder arthroplasty. For acute or subacute infection (<3 months after prosthetic replacement), open irrigation and débridement, followed by 6 to 8 weeks of intravenous antibiotics, is usually adequate. For delayed infection, component removal and insertion of antibiotic-impregnated cement is necessary. Staged reimplantation may be undertaken after the successful eradication of infection, as documented by normalization of the white blood cell count, sedimentation rate, C-reactive protein level, and intraoperative frozen section.
Prosthetic loosening almost always involves the glenoid component and is best minimized by careful glenoid preparation with preservation of bone stock, meticulous cement technique, and close attention to soft-tissue balancing. Massive, unreconstructable rotator cuff tears are a relative contraindication to glenoid replacement. These tears underscore the importance of the rotator cuff in maintaining joint position and preventing excessive, eccentric glenoid loading that can increase the risk of early loosening. Clinically significant glenoid loosening is uncommon compared with radiographic findings suggestive of loosening. Accordingly, it is important to exclude other causes of shoulder pain, such as occult infection or rotator cuff tear. If glenoid revision is done, removal of the loose component may reveal a large central glenoid defect that may not be structurally amenable to component reinsertion, even after bone grafting. In such cases, impaction grafting may be done with contouring of the remaining glenoid bone to a slight concavity for pseudocongruence with the humeral head component.
Although arthrodesis of the glenohumeral joint has been described for end-stage RA,32 advances in prosthetic replacement and surgical technique have largely supplanted arthrodesis as the predominant primary treatment of the end-stage rheumatoid shoulder. Arthrodesis of the rheumatoid shoulder should be undertaken only for selected indications. These indications include failed total shoulder arthroplasty or end-stage involvement with a recent history of joint sepsis. In these situations, patients may benefit from glenohumeral fusion in 30° of abduction, 30° of forward flexion, and 30° of internal rotation to allow for handto-mouth and hygiene activities. Arthrodesis can be done using a variety of techniques, including screw fixation or plate-and-screw fixation. Although plate-and-screw fixation offers the potential avoidance of postoperative spica immobilization, the bone quality in rheumatoid patients may limit the security of the fixation, and additional external (spica) immobilization still will be needed postoperatively. The utility of shoulder arthrodesis must be evaluated in the context of ipsilateral and contralateral upper extremity involvement.
Arthritis Curehow to Arthritis Cure for Acromioclavicular Involvement
Rheumatoid involvement of the acromioclavicular joint is common, affecting up to 63% of rheumatoid patients with painful shoulders.33 It is often adequately addressed nonsurgically with medications and corticosteroid injection. However, persistent or progressively debilitating pain secondary to extensive, symptomatic erosions may necessitate distal clavicular resection with synovectomy, typically with successful results.7 Petersson33 reported acromioclavicular joint resection and subacromial bursectomy to be an effective procedure at follow-up of 18 to 62 months. Either open or arthroscopic resection of the distal clavicle may be done. In the setting of RA, however, resection rarely is performed as an isolated procedure; more often, it is done at the time of prosthetic replacement.
The reported incidence of rheumatoid involvement of the sternoclavicular joint ranges from 1% to 41%.34 Symptomatology typically is overshadowed by glenohumeral involvement and usually responds to nonsurgical intervention and intra-articular injections. Recalcitrant symptoms lasting more than 6 to 12 months may be addressed with sternoclavicular joint débridement and medial clavicle resection.34 Care must be taken to preserve the stabilizing ligaments to avoid complications associated with sternoclavicular instability.
Care of the patient with RA of the shoulder requires a multidisciplinary approach involving the primary care provider, rheumatologist, orthopaedic surgeon, and physical/ occupational therapists. Early rheumatoid involvement of the shoulder with minimal articular destruction and functional limitations may be managed nonsurgically with medications and physical therapy. Advanced rheumatoid disease of the shoulder with significant pain and articular destruction may necessitate surgical intervention, ranging from synovectomy to total shoulder arthroplasty. Although the results of prosthetic shoulder replacement for end-stage RA are not comparable to those achieved for osteoarthritis, symptomatic improvement often is dramatic, with satisfactory relief of pain, improved range of motion, and increased functional ability.
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