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Reverse shoulder arthroplasty improves damage from inflammatory arthritis
Hattrup SJ. J Hand Surg Am. 2012. doi:10.1016/j.jhsa.2012.05.015.
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Early reverse shoulder arthroplasty can provide improvement for patients with inflammatory arthritis of the shoulder and a deficient rotator cuff, according to this study.
Researchers performed a retrospective review of 19 shoulders with rheumatoid arthritis or other inflammatory arthritis treated with reverse shoulder arthroplasty (RSA). Mean follow-up was 37 months. Researchers found a mean postoperative Visual Analog Pain scale score (VAPS) of 6.5 and average flexion of 68°, abduction of 66° and external rotation of 23°. VAPS decreased to 1 point postoperatively, and there was an increase in flexion (138°), abduction (134°) and external rotation (52°). Mean American Shoulder and Elbow Society scores increased from 27 points preoperatively to 76 points postoperatively, and Simple Shoulder Test scores increased from 1 point to 8 points.
There were 12 excellent, five satisfactory and two unsatisfactory results. Complications included two scapular spine fractures, one acromial fracture, one dislocation and one ulnar neuropathy. The investigators found 42% of shoulders had scapular notching. Six shoulders had grade 1 notching, and two shoulders had grade 2 notching, but they found no evidence of glenoid loosening.
“The RSA provides encouraging early results for the rheumatoid patient. The presence of any complications is also a source of concern. However, we believe these complications are balanced by the typical substantial improvement of pain and function from RSA in these patients. We continue cautiously to recommend this procedure to our patients,” the researchers wrote in the study.
Perspective
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Peter J. Millett, MD
Inflammatory arthritis presents a challenging problem for the orthopaedic surgeon who is charged with restoring function and decreasing pain in this patient population. Joint replacement surgery in patients with advanced disease appears to provide the most reliable and satisfactory results. However, although anatomic total shoulder replacement often provides adequate pain relief, functional limitations continue due to the presence in rheumatoid patients with synchronous or metachronous irreparable rotator cuff (RC) tears. Therefore, reverse total shoulder arthroplasty is an intriguing alternative for patients with advanced rheumatoid arthritis (RA) who have corresponding RC insufficiency.
The study by Hattrup and colleagues includes all patients undergoing reverse total shoulder arthroplasty for inflammatory arthritis, but fails to eliminate patients with intact RCs. Because RC insufficiency is a primary reason for considering reverse total shoulder arthroplasty in patients with RA, including patients without a full thickness RC potentially biases the outcomes of this study as patients without RC tears may have done well with standard total shoulder arthroplasty.
The indications for reverse total shoulder arthroplasty in this study were also unclear, being vaguely described as pain and/or dysfunction without taking into account RC status. In some cases, reverse total shoulder arthroplasty was presumably done in a prophylactic manner due to thin or at risk RC tissue. This seems to be a reasonable clinical decision that may prove to be beneficial to patients. However, while we can assume that many but not all patients with RA will develop RC disease, we cannot assume that all RA patients will perform well with reverse total shoulder arthroplasty. Therefore, further studies such as this should be undertaken so that specific surgical indications can be developed to help surgeons and patients make better shared clinical decisions, leading to improved and more reproducible outcomes. Other weaknesses in the study include the lack of a comparison group and the variability in surgical technique and implant choice.
Despite these limitations, this study does support the hypothesis that reverse total shoulder arthroplasty is an effective alternative in patients with advanced inflammatory arthritis and corresponding cuff deficiency.
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