Rheumatoid Arthritis

Rheumatoid Shoulder Xray

 

Xray

 

Typical changes of RA

- regional osteopenia

- marginal erosions and cysts

- humeral head erosions

- medial migration / protrusio

 

DDx

- septic arthritis

- gout / pseudogout

- Milwaukee shoulder (calcium hydroxyapatite crystals)

- rotator cuff arthropathy

- OA (beard osteophytes)

 

Issues

 

Rotator cuff

 

Incidence

 

75% of patients will have rotator cuff pathology

Incidence of full thickness tears varies 20 - 50%

 

Xray

 

Proximal migration on the humeral head on xray

 

Rotator cuff deficiency Rheumatoid arthritis

 

MRI / CTA / arthrogram

 

Indicated to evaluate cuff

 

Rheumatoid Shoulder Arthrogram

Arthrogram indicating full thickness rotator cuff tear in patient with RA

 

Surgery

 

Rotator cuff can become deficient after hemiarthroplasty or anatomic TSA

 

Glenoid

 

Levigne and Franceschi Classification

 

Three main patterns

 

Levigne and Franceschi Classification Rheumatoid Shoulder

1. Upward migration

- deficient rotator cuff, superior glenoid wear

- most common pattern

 

2. Concentric medial migration

- deficient bone stock with medialization of the humeral head

- loss of subchondral bone stock due to RA

 

Rheumatoid Shoulder 1RA shoulder CT

 

3. Destructive

 

Destruction rheumatoid shoulderDestructive rheumatoid shoulder 2

 

Management

 

Non operative Management

 

Injections

 

Cortisone / PRP / HA

Limited evidence for or against their use

 

Medications

 

Steroids

 

Methotrexate

 

Biologics

 

Anti-TNF - Adalimumab / Etanercept / Infliximab

IL - 1 receptor blocker - Anakinra

IL - 6 receptor blocker - Tocilizumab

 

Operative Management

 

Arthroscopic Synovectomy

Hemiarthroplasty

Anatomic TSA

Reverse TSA

 

Arthroscopic Synovectomy

 

RA arthroscopy shoulder 1RA shoulder arthroscopy 2RA shoulder arthroscopy 3RA shoulder arthroscopy 4

 

Kanbe et al. Eur J Orthop Surg Traumatol 2015

- arthroscopic synovectomy and capsular release for 54 RA shoulders

- mean follow up 5 years

- 67% receiving biologic treatments

- improvements in function and ROM

 

Hemiarthroplasty

 

Indications

 

Young patient

Insufficient glenoid bone stock for aTSA or revTSA

Rotator cuff not intact and too young for reverse - CTA head

 

Results

 

Barlow et al J Should Elbow Surg 2014

- 195 aTSA and 108 hemiarthroplasties with minimum 5 year follow up

- improved pain relief and abduction, and lower revision rate in aTSA compared with hemiarthroplasty

- 70% of glenoid components had lucencies

- 33% of glenoid components had shift in position

 

Anatomic TSA

 

Indications

- cuff intact

- sufficient glenoid bone stock

 

Results

 

Haleem et al. Shoulder Elbow 2022

- systematic review of aTSR for RA

- 10 studies with 279 shoulders

- mean follow up 10 years

- revision rate 8%

- radiolucency seen in 70%

 

Reverse TSA

 

Indications

- ruptured or deficient rotator cuff

 

Results

 

Cho et al. Clin Orthop Surg 2017

- systematic review of rTSR in RA

- 7 studies with 128 shoulders

- revision rate 7%

- 11% had intra-operative or postoperative fracture

- infection rate 3.3%