Arthroplasty in Rheumatologic Conditions: Special Considerations



Shoulder arthroplasty has been to shown to provide reliable, long-term pain relief in rheumatoid arthritis (RA) patients with severe degenerative arthritis. Rotator cuff tearing is common in rheumatoid patients and should be accounted for when discussing surgical options. Patients with RA have significant problems with bone quality and are at higher risk of intraoperative humeral fracture and humeral and glenoid loosening over time.


  • 1

    A team approach for medical and surgical management is best in patients with inflammatory arthritis.

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    Medical management should be maximized prior to any attempts at surgery.

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    Biceps and acromioclavicular pathology can be a significant source of pain.

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    Cervical pathology may be a primary or associated diagnosis in RA patients with shoulder pain.

  • 5

    Bone quality is generally poor in RA patients, with higher rates of prosthetic loosening and intraoperative fractures.

  • 6

    High rates of rotator cuff thinning and tearing are seen in RA patients.


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    Preoperative flexion and extension radiographs of all RA patients are necessary to assess for underlying cervical pathology.

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    The anteromedial approach may be used in some patients with severe scarring and stiffness in order to maximize visualization and avoid unnecessary stress on the humerus.

  • 3

    In patients with an intact rotator cuff and adequate bone stock, glenoid replacement is appropriate, with lower rates of revision and more reliable pain relief.

  • 4

    Rotator cuff tears that are reparable should be addressed at the time of surgery and are not a contraindication to total shoulder replacement if secure repair is obtained.


  • 1

    Patients with massive irreparable cuff tears or those poor-quality cuff tissue may be best treated with hemiarthroplasty alone.

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    Preoperative flexion and extension radiographs of all RA patients are necessary to assess for underlying cervical pathology.

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    Cement fixation of the humeral component may be indicated in patients with poor bone quality.

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    Glenoid loosening in RA patients is not uncommon. However, revision rates have been demonstrated to be higher for painful glenoid arthritis than for glenoid component loosening.


Not applicable.

Patients with rheumatologic diseases present unique challenges to a shoulder surgeon. The spectrum of pathology in this patient population is broad, ranging from occasional mild synovitis that is well controlled by oral medications to severe shoulder dysfunction with bone deficiency. Patients with end-stage arthritic changes due to rheumatologic disease who have failed nonoperative treatments may be candidates for shoulder arthroplasty.

Each patient requires careful thought with regard to the potential benefits and pitfalls of surgical intervention. Compromised bone and soft tissue due to the disease process make the decision between hemiarthroplasty and total shoulder arthroplasty (TSA) a controversial choice. Moreover, reports have varied significantly in regard to incidence and influence of rotator cuff pathology on the outcome of patients with rheumatoid arthritis (RA).

This wide range of problems leads to difficulties assessing the effectiveness of surgical intervention. Although many rheumatologic diseases cause synovitis and arthritis of the shoulder, RA is the most commonly encountered and will be the focus of this chapter. This chapter will examine the critical issues related to shoulder arthroplasty in the rheumatoid patient.


History and Physical Examination

Evaluation of the patient with RA and severe arthritis of the shoulder starts with taking a thorough history. It is critically important to understand the severity of patients’ symptoms and their ability to comply with postoperative rehabilitation and restrictions. The severity of pain at rest and at night and alleviating and aggravating factors should be determined.

Care should be taken to examine the patient’s current medical treatment regimens to ensure that maximal medical management has been attempted. Although operative treatment may be necessary, patients are best managed with a team approach with a consulting rheumatologist. Every attempt should be made to maximize medical management oral medications and injection therapy in order to avoid operative intervention in this patient population, which may be predisposed to infection and often have associated medical comorbidities. This nonoperative approach includes oral and injectable medications and intra-articular injections.

Only rarely do patients with rheumatologic disease present with shoulder pain as the initial complaint. Often patients are seen in referral for shoulder pain that has been resistant to nonoperative interventions, including changes in oral medications and failed trials of therapy. Patients may complain about pain (at rest, at night, and with activities) and loss of strength and motion. Physical examination often demonstrates shoulder swelling with effusion in the subacromial or and subdeltoid space. There may be significant crepitance with gentle motion. Limitations in all planes of active and passive motion, including elevation, external, and internal rotation, are common due to underlying arthrofibrosis. Motion may be painful, which may lead to deficits in strength despite structurally intact rotator cuff tendons.

Other considerations include careful examination of the acromioclavicular joint and biceps tendon. Provocative maneuvers should be performed to assess for pathology in these commonly involved structures. Rheumatoid patients who are considered to be operative candidates should also be evaluated for neck pain and neurologic or radicular symptoms.

In this population, underlying cervical pathology is often associated with shoulder pain and may be an exacerbating pain generator. Furthermore, there is a high incidence of underlying cervical instability due to rheumatoid-induced ligamentous laxity. Radiographs of the neck, including flexion and extension views, should be obtained prior to consideration for operative intervention to assess for cervical subluxation.

Radiographic Studies

Radiographs of the affected shoulder typically include four views: 40 degree posterior oblique views with internal and external rotation, axillary view, and lateral scapula or Y view. Acromiohumeral distance also should be assessed to evaluate proximal humeral migration on the anteroposterior view of the proximal humerus from the midportion of the acromion to the highest portion of the humeral head. Although less than 6 mm of acromiohumeral distance is associated with rotator cuff tearing, diminished acromiohumeral distance in patients with rheumatoid arthritis does necessarily indicate complete rotator cuff tearing.

Advanced imaging with magnetic resonance imaging (MRI) can be helpful for assessment of underlying soft tissue changes such as rotator cuff and biceps tendon abnormalities. Patients with underlying synovitis often demonstrate thinning or full-thickness tearing of the rotator cuff tendons and inflammation, fraying, or tearing of the biceps tendon. MRI can also demonstrate the extent of the intra-articular synovitis and subacromial bursitis.

Computed tomography (CT) scans are an invaluable tool to assess the shoulder prior to shoulder arthroplasty. Specifically, in the setting of significant glenoid erosion, CT scans provide significant information concerning glenoid version and the amount of bone loss. Recently, in complex settings, we have started to use three-dimensional (3D) CT to evaluate the humerus and glenoid in order to obtain a more complete understanding of the glenohumeral morphology.


Several classifications for rheumatoid arthritis have been used. However, the system defined by Crossan and Vallance is specific to the shoulder and allows for assessment of the severity of arthritic changes. Shoulders with stage 1 disease have no abnormal features except for mild osteopenia. Stage 2 is characterized by a spherical humeral head with a normal glenohumeral joint, but with humeral head erosions. Stage 3 will demonstrate proximal humeral migration with a maintained glenohumeral joint space. Stage 4 has reduced overall joint space and a spherical humeral head, usually with proximal humeral migration and periarticular marginal erosions. Patients with stage 5 changes demonstrate glenohumeral distortion, glenoid erosions, and medial humeral displacement.

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Mar 22, 2019 | Posted by in ORTHOPEDIC | Comments Off on Arthroplasty in Rheumatologic Conditions: Special Considerations

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