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Chen, Andrew L. MD, MS; Joseph, Thomas N. MD; Zuckerman, Joseph D. MD

Author Information

Dr. Chen is Chief Resident, Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases, New York, NY. Dr. Joseph for 1 last update 2020/07/09 is Chief Resident, Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases. Dr. Zuckerman is Professor and Chairman, Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases.Dr. Chen is Chief Resident, Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases, New York, NY. Dr. Joseph is Chief Resident, Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases. Dr. Zuckerman is Professor and Chairman, Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases.

Reprint requests: Dr. Zuckerman, 301 East 17th Street, New York, NY 10003.

J Am Acad Orthop Surg 2003;

Journal of the American Academy of Orthopaedic Surgeons: January 2003 - Volume 11 - Issue 1 - p 12-24
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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.

Complications

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 2020/07/09 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.

Table 3:
Complications After Total Shoulder Arthroplasty and Shoulder Hemiarthroplasty

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.

Arthrodesis

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.

Sternoclavicular Involvement

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.

Summary

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.

References

1. Cuomo F, Greller MJ, Zuckerman JD: The rheumatoid shoulder. Rheum Dis Clin North Am 1998;24:67-82.
2. Petersson CJ: Painful shoulders in patients with rheumatoid arthritis: Prevalence, clinical and radiological features. Scand J Rheumatol 1986;15:275-279.
3. Lipsky PE: Rheumatoid arthritis, in Wilson JD, Braunwald E, Isselbacher KJ, et al (eds): Harrison''s Principles of Internal Medicine, ed 12. New York, NY: McGraw-Hill, 1991, pp 1475-1479.
13. Laine VAI, Vainio KJ, Pekanmäki K: Shoulder affections in rheumatoid arthritis. Ann Rheum Dis 1954;13:157-160.
14. Neer CS: The rheumatoid shoulder, in Crubbs RL, Mitchell NS (eds): The Surgical Management of Rheumatoid Arthritis. Philadelphia, PA: JB Lippincott, 1971, pp 117-127.
15. Rozental TD, Sculco TP: Intra-articular corticosteroids: An updated overview. Am J Orthop 2000;29:18-23.
16. Neer CS II: Reconstructive surgery and rehabilitation of the shoulder, in Kelley WN, Harris ED Jr, Ruddy S, Sledge CB (eds): Textbook of Rheumatology, ed 2. Philadelphia, PA: WB Saunders, 1985, vol 2, pp 1855-1870.
17. Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-337.
18. Friedman RJ, Ewald FC: Arthroplasty of the ipsilateral shoulder and elbow in patients who have rheumatoid arthritis. J Bone Joint Surg Am 1987;69:661-666.
19. Gill DR, Cofield RH, Morrey BF: Ipsilateral total shoulder and elbow arthroplasties in patients who have rheumatoid arthritis. J Bone Joint Surg Am 1999;81:1128-1137.
20. Hess EV: Rheumatoid arthritis: Treatment, in Schumacher HR Jr, Klippel JH, Robinson DR (eds): Primer on the Rheumatic Diseases, ed 9. Atlanta, GA: Arthritis Foundation, 1988, pp 93-96.
21. Petersson CJ: Shoulder surgery in rheumatoid arthritis. Acta Orthop Scand 1986;57:222-226.
22. Rozing PM, Brand R: Rotator cuff repair during shoulder arthroplasty in rheumatoid arthritis. J Arthroplasty 1998;13:311-319.
23. Cofield RH, Frankle MA, Zuckerman JD: Humeral head replacement for glenohumeral arthritis. Semin Arthroplasty 1995;6:214-221.
24. Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
25. McCoy SR, Warren RF, Bade HA III, Ranawat CS, Inglis AE: Total shoulder arthroplasty in rheumatoid arthritis. J Arthroplasty 1989;4:105-113.
26. Koorevaar RC, Merkies ND, de Waal Malefijt MC, Teeuwen M, van den Hoogen FH: Shoulder hemiarthroplasty in rheumatoid arthritis: 19 cases reexamined after 1-17 years. Acta Orthop Scand 1997;68:243-245.
27. Sojbjerg JO, Frich LH, Johannsen HV, Sneppen O: Late results of total shoulder replacement in patients with rheumatoid arthritis. Clin Orthop 1999;366:39-45.
28. Stewart MP, Kelly IG: Total shoulder replacement in rheumatoid disease: 7-to 13-year follow-up of 37 joints. J Bone Joint Surg Br 1997;79:68-72.
29. Friedman RJ, Thornhill TS, Thomas WH, Sledge CB: Non-constrained total shoulder replacement in patients who have rheumatoid arthritis and class-IV function. J Bone Joint Surg Am 1989;71:494-498.
30. Sneppen O, Fruensgaard S, Johannsen HV, Olsen BS, Sojbjerg JO, Andersen NH: Total shoulder replacement in rheumatoid arthritis: Proximal migration and loosening. J Shoulder Elbow Surg 1996;5:47-52.
31. Cofield RH, Chang W, Sperling JW: Complications of shoulder arthroplasty, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA: Lippincott Williams & Wilkins, 1999, pp 571-593.
32. Rybka V, Raunio P, Vainio K: Arthrodesis of the shoulder in rheumatoid arthritis: A review of forty-one cases. J Bone Joint Surg Br 1979;61:155-158.
33. Petersson CJ: The acromioclavicular joint in rheumatoid arthritis. Clin Orthop 1987;223:86-93.
34. Wirth MA, Rockwood CA Jr: Chronic conditions of the acromioclavicular and sternoclavicular joints, in Chapman MW, Madison M (eds): Operative Orthopaedics, ed 2. Philadelphia, PA: JB Lippincott, 1993, vol 2, pp 1673-1693.
© 2003 by American Academy of Orthopaedic Surgeons

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JAAOS - Journal of the American Academy of Orthopaedic Surgeons11(1):12-24, January-February 2003.
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