Rheumatoid Arthritis

EpidemiologyRheumatoid Shoulder

 

Females

 

2/3 involved

- ACJ arthritis

- subacromial bursitis / rotator cuff pathology

- GHJ less commonly

 

Pathology

 

1.  ACJ 

- erosive arthritis

- joint expands with severe involvement

- ACJ capsular destruction / instability / impingement

 

2.  Subacromial Bursa

- becomes inflamed & thickened

- rupture of LH of biceps / cuff rupture

- rotator cuff arthropathy

 

3.  GHJ

- develop marked soft tissue inflammation

- 2° laxity capsule & folds of synovium

- followed by severe cartilage & bone erosion

 

Neer described 3 types RA shoulder

- Wet = Synovitic with soft tissue pathology

- Dry = Articular Surface Erosion

- Resorptive = Severe Bony Erosion

 

History

 

Shoulder pain & swelling with flares of RA

- gradually decreasing ROM

- functional impairment

 

Cuff Tendonosis 

- pain with overhead activity

 

Examination

 

Deformity 

- muscle wasting

- humeral medialisation 2° bone loss in glenoid cavity with humeral protrusion

- effusion with swelling

 

Cuff rupture 

- loss of abduction

 

Biceps rupture / popeye

 

Painful arc

 

Xray

 

Typical changes of RA

- regional osteopenia

- marginal erosions and cysts

- humeral head erosions

 

Rheumatoid Shoulder Erosions

 

Symmetric Arthritis

 

Protrusio

- medialisation of humeral head

- can erode anteriorly or posterior

- inferior glenoid preserved

 

Rheumatoid Shoulder 2

 

Superior migration due to cuff rupture

 

Arthritis mutilans

 

Arthritis Mutilans RA

 

US / MRI / Arthrogram

 

30% have cuff tear

 

Rheumatoid Shoulder Arthrogram Cuff Tear

 

CT

 

Assess glenoid stock

 

Rheumatoid Shoulder CT

 

Aspiration

 

RA

- 20 000 WBC / ml

- 60-70% neutrophils

 

Sepsis

- > 100 000 WBC / ml

- > 75% neutrophils

 

DDx

 

Septic arthritis

 

Gout

- sodium urate

 

Pseudogout

- calcium pyrophosphate

 

Milwaukee Shoulder

- calcium hydroxyapatite crystals

 

RC arthropathy

 

OA - beard osteophytes

 

Management

 

General

- Medical treatment

- HCLA injections

 

ACJ

 

Excision of outer 1/3 of clavicle

 

Subacromial Bursa

 

SAD

Bursectomy

 

GHJ

 

1.  Arthroscopic Synovectomy 

 

Indications

- mild arthritis / cuff intact

 

Technique

- synovectomy

- via anterior and posterior portals

- removal loose bodies

- biceps tenotomy

- bursectomy / ACJ resection if necessary

- minimal acromioplasty especially if cuff tear as must preserve CA ligament

 

Rheumatoid Shoulder Arthroscopy Rheumatoid Shoulder Post Debridement

 

Rheumatoid Shoulder Arthroscopy 2Rheumatoid Shoulder Arthroscopy 3

 

Cofield et al Arthroscopy 2006

- 16 shoulders followed up for 5 years

- 13/16 good pain relief

- some mild improvement in ROM

- arthritis tended to progress over time

 

2.  Hemiarthroplasty / TSR

 

Indications hemiarthroplasty

- young patient

- glenoid not involved / unusual

 

Indications TSR

- sufficient bone stock glenoid

- glenoid often deficient centrally and superior

- intact RC
 

Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR

 

4.  Reverse TSR

 

Indications

- ruptured cuff (30%)

 

Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects

 

5.  Arthrodesis

- indicated for severe bone loss

- problem is actual or potential involvement of other joints

 

6.  Excision arthroplasty

- salvage procedure