Glenohumeral Joint and Rheumatoid Arthritis

Q: What is the Best Arthroplasty Option in a Shoulder With Rheumatoid Arthritis?

Issue: June 2016

ByT. Bradley Edwards, MD

ByMatthew D. Williams, MD

A: Rheumatoid arthritis is an inflammatory disease of the synovium that causes synovial hyperplasia and disabling erosive arthritis. Progression of the disease involves the entire glenohumeral joint and surrounding structures, including the bone, acromioclavicular joint, subacromial bursa and rotator cuff tendons. The treatment algorithm for rheumatoid arthritis of the glenohumeral joint involves both nonoperative and minimally invasive arthroscopic procedures.

Failure of these modalities or advanced disease at presentation may necessitate glenohumeral joint replacement to alleviate pain and improve function in these patients. Joint replacement procedures in the shoulder include hemiarthroplasty, total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty. The decision about which implant is best for the treatment of rheumatoid arthritis (RA) in the shoulder is based on the progression of disease in each individual patient (ie, what anatomic structures are involved that will affect postoperative shoulder function).

Early complaints in rheumatoid patients are pain, swelling and decreasing shoulder motion. Pain and restriction of mobility worsen with advancement of the disease. Medial migration of the humeral head causes erosion of the glenoid and obliteration of the joint space, which are visible on radiographs. Patients with RA have osteopenic bone with periarticular cyst formation. These periarticular erosions affect the superior humeral head and may also be found in the glenoid. Cysts in the superior humeral head coupled with rheumatoid rotator cuff tendon degeneration lead to rotator cuff compromise. Cysts in the glenoid hasten the loss of bone stock.

Patients with RA are evaluated thoroughly because in our experience they have numerous confounding concomitant problems. Importantly, radiculopathy or myelopathy secondary to cervical spine involvement causing pain or weakness must be examined. Imaging is fundamental to appropriate treatment of this group of patients. Periarticular cysts in the humeral head may affect component fixation, and rotator cuff deficiency or glenoid bone loss may preclude placement of a glenoid component altogether. Preoperative planning for shoulder arthroplasty in patients with RA includes a CT arthrogram in our practice to adequately evaluate the rotator cuff and both the humeral and glenoid bone stock.

Figure 1. Anteroposterior shoulder radiographs of patients with rheumatoid arthritis (RA) demonstrate the stratification of patients. The first radiograph portrays RA with an intact rotator cuff (A). The second radiograph demonstrates a cuff-deficient rheumatoid shoulder (B). The third radiograph shows RA with both humeral head and glenoid destruction (C).

Figure 2. Anteroposterior postoperative radiographs demonstrate three treatment options. Total shoulder arthroplasty for rheumatoid shoulders with an intact rotator cuff is shown (A). Reverse shoulder arthroplasty for a cuff-deficient shoulder is shown (B). Hemiarthroplasty is reserved for rheumatoid shoulders with glenoid bone loss that does not allow for glenoid component implantation (C).

Shoulder arthroplasty in patients with advanced rheumatoid disease with an intact rotator cuff and mild glenoid bone loss is acceptable using either hemiarthroplasty or TSA with glenoid resurfacing. There has been a shift in opinion during the past few years as to whether hemiarthroplasty or TSA is best. Previously, experience with glenoid resurfacing was limited and many surgeons were not comfortable with implanting a glenoid component; therefore, total shoulder replacement cohorts were small, resulting in equal or lesser results than hemiarthroplasty. However, with increasing experience and patient follow-up, the literature demonstrates that TSA produces superior results. Collins and colleagues reported on 61 patients treated with hemiarthroplasty or TSA for RA. Both treatment groups showed improvements in pain, motion, and function scores, but those undergoing TSA had greater improvement. In a large comparison study of more than 300 patients followed for a mean of 11 years, Sperling and colleagues found TSA was the preferred procedure for RA of the shoulder with an intact rotator cuff.

Contraindications to TSA include glenoid bone loss and an incompetent rotator cuff. Large periarticular cysts involving the glenoid coupled with medial humeral head migration lead to severe loss of glenoid bone stock. Glenoid bone insufficient to accept and anchor a polyethylene component is a contraindication to TSA, and a hemiarthroplasty should be chosen. Rotator cuff–deficient shoulders suffer from superior humeral migration and are not candidates for glenoid resurfacing secondary to glenoid failure. These patients also function poorly after hemiarthroplasty due to anterior-superior instability. Rheumatoid patients with an incompetent rotator cuff are treated with reverse shoulder arthroplasty.

In our practice, patients with RA awaiting shoulder replacement are placed into one of three treatment groups: those with an intact rotator cuff and adequate glenoid bone stock; those with an intact rotator cuff and poor glenoid bone stock; and those with cuff deficient shoulders (Figure 1). Patients with an intact rotator cuff and adequate glenoid bone stock on preoperative CT scanning to accommodate a polyethylene glenoid component are treated with TSA. We routinely employ press-fit humeral components; however, we are always prepared to use a cemented humeral stem when proximal humeral bone stock is lacking due to cyst formation. Resurfacing of the glenoid is performed with a cemented all-polyethylene component; we do not have a preference toward a keeled or pegged design. We perform a hemiarthroplasty if preoperative CT scanning demonstrates inadequate glenoid bone stock for placement of a glenoid component. Patients with rotator cuff–deficient shoulders are treated with a reverse shoulder arthroplasty (Figure 2).

Excerpted from:

References:
Collins DN, et al. J Bone Joint Surg Am. 2004;86:2489-2496.
Franklin JL, et al. J Arthroplasty. 1988;3:39-46.
Rittmeister M, et al. J Shoulder Elbow Surg. 2001;43:2152-2159.
Sperling J, et al. Total shoulder arthroplasty vs. hemiarthroplasty for rheumatoid arthritis: Results of 303 consecutive cases. Presented at: American Shoulder and Elbow Surgeons Specialty Day; San Diego; Feb. 17, 2007.
Trail IA, et al. J Bone Joint Surg Br. 2002;84:1121-1125.

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