Sunday, December 8, 2013

Shoulder arthroplasty for rheumatoid arthritis

Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up

The authors report the minimum 5-year clinical follow-up on 303 consecutive shoulder arthroplasties (108 hemiarthroplasties, 195 total shoulder arthroplasties) for rheumatoid arthritis.  There were 255 arthroplasties in the clinical analysis and 188 in the radiographic analysis.

Survivorship free of revision at 5 years and 10 years was 96.1% and 92.9% for total shoulder arthroplasty (TSA) and 89.2% and 87.9% for hemiarthroplasty (HA). 

The leading causes of TSA revision were glenoid loosening (5%) and infection (2%).
The leading cause of HA revision was glenoid arthrosis (7%).

Approximately 30% of humeral components and 73% of glenoid components had periprosthetic lucencies. There was a shift in position of the glenoid in 33% of TSAs, and 36% were “at risk.” 

Eighty-one percent of HAs had moderate or severe glenoid erosion.

Our comment: rheumatoid arthritis presents a special challenge in shoulder arthroplasty. The bone is softer and more prone to fracture, the bone is often eroded, the cuff is thin and often compromised, the joints are tighter making it more difficult to safely access the glenoid,  the patient is often on medications that increase the risk of infection and compromise healing, the neck and mouth may be stiffer making anesthesia more risky, and other joints are involved making rehabilitation more difficult and falls more likely.

While it is accepted that TSA has some substantial advantages in the shoulder with rheumatoid arthritis, surgeons often decide against it for various reasons (as was the case in over a third of the cases in this series. These surgeons are obviously able to do either procedure, so the key to understanding these results lies in understanding why HA was elected instead of TSA. In that, as the authors suggest, inferior cuff status, bone stock, desired activity levels may have weighed into the decision, the two populations are unlikely to be comparable so that meaningful comparisons may not be possible. 

The authors provide detail on the complications, including 13 nerve injuries, 4 wound problems, 9 intraoperative fractures, and one deltoid tear. These all speak to the fragility of some of these patients. 


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