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Surgical rehabilitation of shoulder and elbow in rheumatoid arthritis
Surgical Rehabilitation of Shoulder and Elbow in Rheumatoid Arthritis By PETER A. CASAGRANDE
s
URGICAL REHABILITATION OF THE SHOULDER is seldom indicated. The elbow requires surgical treatment more often, especially as a step in the rehabilitation of the hand. Infrequent surgery of these joints may be due to the fact that rheumatoid patients with multiple peripheral joint involvement have more pressing priority with the hands and weight-bearing joints. The overwhelming number of patients with shoulder pain are suffering from soft tissue involvement of the shoulder, such as the tendinous cuff, the several bursae and the bicipita1 tendon rather than intrinsic joint involvement. The most frequent bursal involvement is in the subacromial location and, unlike nonrheumatoid patients, is seldom associated with calcification within it or the underlying tendinous cuff. Patients do well with cold applications, analgesics, and local injections with a corticosteroid. Because they are particularly susceptible to loss of motion (frequently called “frozen shouder”) they are admonished to a complete range of motion exercises within their tolerance. In some cases where motion becomes restricted, gentle manipulation of the shoulder under anesthesia can restore function and control pain. However, care must be taken to select early cases of adhesive capsulitis, preferably shorter than 3 months in duration, and those that show a healthy mineralization of bony structures on X ray of the joint. Elevation exercises are most important in prophylaxis and in the restoration of shoulder motion. Rope and pulley exercises are preferred if the patient can manage them. Otherwise, the program must be designed to the patient’s ability. A few cases continue to suffer persistent pain in spite of this regime and may benefit from an acromionectomy. This procedure relieves periarticular pain but does not improve motion. Section of the long head of the biceps tendon or reinsertion into the bicipital groove is helpful when this syndrome is chronic and unresponsive to local corticosteroid injection. Many patients will eventually develop true glenohumeral arthritis. The pathologic process is typical of rheumatoid involvement in other joints. The synovium is the primary site of the inflammation. Excess synovial fluid is an early sign in some shoulders and occasionally causes an anterior enlargement due to involvement of the bursa (bursae) in front of the coracoid process which communicates with the glenohumeral joint. This excess fluid should be controlled by aspiration to prevent stretching of the capsule and ligaments causing instability of the humeral head. The treatment of rheumatoid involvement of the glenohumeral joint should be directed to relieving pain (and effusion, if present) and maintenance or From the Department PETER A.
Universify Children’s
of Medicine, State University of New York at Buffalo, Buffalo, N. Y. Assistant Clinical Professor of Orthopedic Surgery, State York at Buijalo; Attending Orthopedist, Buffalo General and Buffalo Consultant Orthopedist, Brooks Memorial Hospital, Baflalo, N. Y.
CASAGRANDE, M.D.:
of New Hospitals;
SEMINARS IN ARTHRITIS AND RHEUMATISM, VOL. I, No.
1 (MAY),
1971
3
4
PETER A. CASAGRANDE
restoration of motion. An exercise program is most important to prevent ankylosis of the joint. The exercises should be done several times each day after proper medication to lessen the pain. Local heat or cold is also helpful. When avascular necrosis occurs in the humeral head (this is extremely rare) the articular facing of the humeral head can be replaced with a prosthesis6 Avascular necrosis of the humeral head is usually associated with persistent and painful effusions, usually of considerable amounts. Synovectomy of the shoulder is rarely indicated. The synovia usually does not become hypertrophic and exuberant as in the elbow and knee. Persistent and large effusions may result in a large subcoracoid bursa. This may require resection. Pain and restricted motion due to involvement of the lateral and medial clavicular articulations is frequent when the joints are first involved. They usually present as tender enlargements, especially the stemoclavicular joint, and they may cause some concern in being differentiated from a “tumor.” Early, the joints show the typical characteristics of inflammation-pain, local swelling, heat, and redness. Radiographs at this stage show widening of the joint space, scalloping of the opposing articular margins and soft tissue tumefaction. The pain associated with this involvement is rarely severe. Most respond to local corticosteroid injections, analgesics, and occasionally systemic antiinflammatory drugs. They display a spontaneous healing cycle which requires a year or so. Later, in the evolutionary stage of healing, the pain subsides, the joint enlargement regresses somewhat and the radiographs show varying degrees of joint narrowing and osteophytosis to complete fusion in some cases. Resection of a portion of the clavicle of the involved joint may be necessary to relieve pain and/or restricted motion in a limited number of patients. Excision of the humeral head may serve a beneficial purpose in an extraordinary situation where some motion is desired to improve function of the hand. I cannot conceive of a situation in a rheumatoid patient requiring fusion of the shoulder. The elbow joint is very frequently involved in the rheumatoid process. Fortunately, it seldom requires surgery. However, there are some patients who develop a persistent synovial hyperplasia with associated effusion. If this is not controlled, the elbow will regress with destructive changes and instability or ankylosis, depending on whether the disease is of the “tight” or “loose” variety. Surgery in the form of synovectomy is indicated if the synovitis persists for over a year. The radial head is resected if subluxed or dislocated. It is wise to transpose the ulnar nerve or at least “free” it widely to avoid a tardy paralysis. Synovectomy is of no benefit when the joint has undergone advanced articular changes and the joint is unstable. Instability of the elbow presents a problem in treatment. One must consider the whole patient as well as the particular extremity before recommending a surgical course. This is particularly true when the individual requires a walking aid such as crutches or a walkerette. They may function better without surgery. When instability is a definite handicap to proper use of the arm then stabilization either by fusion or prosthetic replacement is indicated. Fusion is the
5
REHABILITATIONOF SHOULDER AND ELBOW
procedure of choice when and if the opposite elbow and the ipsilateral shoulder have adequate mobility. Otherwise a prosthesis (I prefer the Schier) cemented into position with methyl methacrylate is the procedure of choice. It provides a degree of stability and motion. The prosthesis is especially indicated in arthropathic elbows with marked instability (Charcot-like). It is rarely indicated in ankylosed elbows unless one joint must have mobility to provide hygienic and nutritional function. Before the introduction of methyl methacrylate it was unwise to replace the elbow with a prosthesis because of the inability to get good fixation of the metal to bone. At that time, arthroplasty of the elbow joint consisted of wide excision of the humeral condyles and the opposing radius and ulna. Fascia and skin were used by some surgeons as interposition material. This procedure is still in use today. Drawbacks, however, are unsatisfactory motion and varying instability. Eventually, prosthetic replacement of the elbow will relegate it to history. Ulnar nerve involvement is common in rheumatoid involvement of the elbow joint. It may involve only the sensory component of the nerve or it may result in sensory and motor deficits. Usually the symptoms are gradual in evolution, hence the term “tardy paralysis.” The nerve is compressed by the synovial proliferation and occasionally the rheumatoid tissue involves the nerve and destroys it. As soon as a diagnosis of ulnar nerve encroachment is made, treatment should be instituted promptly. Perineural injections of corticosteroids may cause regression of the proliferative synovium and relieve the situation. If not, neurolysis and anterior transposition of the nerve is indicated. Preliminary nerve conduction and electromyographic studies are helpful to confirm the clinical diagnosis. It is clear that some of the intrinsic atrophy noted in the hands of rheumatoid patients is due to ulnar nerve compression at the elbow or wrist. Resection of subcutaneous rheumatoid nodules along the proximal crest of the ulna and an involved olecranon bursa is indicated when the lesions are symptomatic or become ulcerated and secondarily injected. This latter situation is seen often in people using forearm crutches with resultant pressure. Rheumatoid nodules have a high incidence of recurrence after surgical excision. In most cases they are best left alone or controlled by intralesional injection with Triamcinilone.
REFERENCES
1. Torgerson, W. F., and Leach, R. E.: five cases synovectomy of the elbow in rheumatoid arthritis. J. Bone Joint Surg. [Amer.] 371, 1970. 2. Wilkinson, M. C., and Lowry, J. H.: Synovectomy for rheumatoid arthritis. J. Bone Joint Surg. [Brit.] 47:482, 1.965. 3. Straub, A.: Arthritis Surgery Conference. 1969. 4. Papavassilion, N., et al: Brit. J. Surg. 56:700, 1969.
5. Hollander, J. L.: Arthritis and Allied Conditions. Chapter 27. 6. Neer, C. S.: Articular replacement for the humeral head. J. Bone Joint Surg. [Amer.] 46:1607, 1964. 7. Sokolof, L., and Gleason, I. 0.: The Sterno-clavicular articulation in rheumatic diseases. Amer. J. Clin. Path. 24:406, 1954. 8. MacAusland, W. R.: Mobihzation of the stiff elbow by arthroplasty. 9. Smith-Pterson, M.N., Aufranc, 0. E.,
6 and Larson, C. B.: Arch. Surg. (Chicago) 46764, 1943. 10. Harty, M., Joyce, J. J.: Instructional course lecture surgical approaches to the elbow. J. Bone Joint Surg. [Amer.] 46598, 1964. 11. Casagrande, P.A.: Dixon, A. S. J.
PETER
A. CASAGRANDE
(Eds.): Progress in Clinical Rheumatology. London, Churchill, 1965. 12. Chapchal, G.: (Ed.) Synovectomy and Arthroplasty in Rheumatoid Arthritis, Second International Symposium, Jan. 27-29, 1967, Basel, Switzerland.
s
URGICAL REHABILITATION OF THE SHOULDER is seldom indicated. The elbow requires surgical treatment more often, especially as a step in the rehabilitation of the hand. Infrequent surgery of these joints may be due to the fact that rheumatoid patients with multiple peripheral joint involvement have more pressing priority with the hands and weight-bearing joints. The overwhelming number of patients with shoulder pain are suffering from soft tissue involvement of the shoulder, such as the tendinous cuff, the several bursae and the bicipita1 tendon rather than intrinsic joint involvement. The most frequent bursal involvement is in the subacromial location and, unlike nonrheumatoid patients, is seldom associated with calcification within it or the underlying tendinous cuff. Patients do well with cold applications, analgesics, and local injections with a corticosteroid. Because they are particularly susceptible to loss of motion (frequently called “frozen shouder”) they are admonished to a complete range of motion exercises within their tolerance. In some cases where motion becomes restricted, gentle manipulation of the shoulder under anesthesia can restore function and control pain. However, care must be taken to select early cases of adhesive capsulitis, preferably shorter than 3 months in duration, and those that show a healthy mineralization of bony structures on X ray of the joint. Elevation exercises are most important in prophylaxis and in the restoration of shoulder motion. Rope and pulley exercises are preferred if the patient can manage them. Otherwise, the program must be designed to the patient’s ability. A few cases continue to suffer persistent pain in spite of this regime and may benefit from an acromionectomy. This procedure relieves periarticular pain but does not improve motion. Section of the long head of the biceps tendon or reinsertion into the bicipital groove is helpful when this syndrome is chronic and unresponsive to local corticosteroid injection. Many patients will eventually develop true glenohumeral arthritis. The pathologic process is typical of rheumatoid involvement in other joints. The synovium is the primary site of the inflammation. Excess synovial fluid is an early sign in some shoulders and occasionally causes an anterior enlargement due to involvement of the bursa (bursae) in front of the coracoid process which communicates with the glenohumeral joint. This excess fluid should be controlled by aspiration to prevent stretching of the capsule and ligaments causing instability of the humeral head. The treatment of rheumatoid involvement of the glenohumeral joint should be directed to relieving pain (and effusion, if present) and maintenance or From the Department PETER A.
Universify Children’s
of Medicine, State University of New York at Buffalo, Buffalo, N. Y. Assistant Clinical Professor of Orthopedic Surgery, State York at Buijalo; Attending Orthopedist, Buffalo General and Buffalo Consultant Orthopedist, Brooks Memorial Hospital, Baflalo, N. Y.
CASAGRANDE, M.D.:
of New Hospitals;
SEMINARS IN ARTHRITIS AND RHEUMATISM, VOL. I, No.
1 (MAY),
1971
3
4
PETER A. CASAGRANDE
restoration of motion. An exercise program is most important to prevent ankylosis of the joint. The exercises should be done several times each day after proper medication to lessen the pain. Local heat or cold is also helpful. When avascular necrosis occurs in the humeral head (this is extremely rare) the articular facing of the humeral head can be replaced with a prosthesis6 Avascular necrosis of the humeral head is usually associated with persistent and painful effusions, usually of considerable amounts. Synovectomy of the shoulder is rarely indicated. The synovia usually does not become hypertrophic and exuberant as in the elbow and knee. Persistent and large effusions may result in a large subcoracoid bursa. This may require resection. Pain and restricted motion due to involvement of the lateral and medial clavicular articulations is frequent when the joints are first involved. They usually present as tender enlargements, especially the stemoclavicular joint, and they may cause some concern in being differentiated from a “tumor.” Early, the joints show the typical characteristics of inflammation-pain, local swelling, heat, and redness. Radiographs at this stage show widening of the joint space, scalloping of the opposing articular margins and soft tissue tumefaction. The pain associated with this involvement is rarely severe. Most respond to local corticosteroid injections, analgesics, and occasionally systemic antiinflammatory drugs. They display a spontaneous healing cycle which requires a year or so. Later, in the evolutionary stage of healing, the pain subsides, the joint enlargement regresses somewhat and the radiographs show varying degrees of joint narrowing and osteophytosis to complete fusion in some cases. Resection of a portion of the clavicle of the involved joint may be necessary to relieve pain and/or restricted motion in a limited number of patients. Excision of the humeral head may serve a beneficial purpose in an extraordinary situation where some motion is desired to improve function of the hand. I cannot conceive of a situation in a rheumatoid patient requiring fusion of the shoulder. The elbow joint is very frequently involved in the rheumatoid process. Fortunately, it seldom requires surgery. However, there are some patients who develop a persistent synovial hyperplasia with associated effusion. If this is not controlled, the elbow will regress with destructive changes and instability or ankylosis, depending on whether the disease is of the “tight” or “loose” variety. Surgery in the form of synovectomy is indicated if the synovitis persists for over a year. The radial head is resected if subluxed or dislocated. It is wise to transpose the ulnar nerve or at least “free” it widely to avoid a tardy paralysis. Synovectomy is of no benefit when the joint has undergone advanced articular changes and the joint is unstable. Instability of the elbow presents a problem in treatment. One must consider the whole patient as well as the particular extremity before recommending a surgical course. This is particularly true when the individual requires a walking aid such as crutches or a walkerette. They may function better without surgery. When instability is a definite handicap to proper use of the arm then stabilization either by fusion or prosthetic replacement is indicated. Fusion is the
5
REHABILITATIONOF SHOULDER AND ELBOW
procedure of choice when and if the opposite elbow and the ipsilateral shoulder have adequate mobility. Otherwise a prosthesis (I prefer the Schier) cemented into position with methyl methacrylate is the procedure of choice. It provides a degree of stability and motion. The prosthesis is especially indicated in arthropathic elbows with marked instability (Charcot-like). It is rarely indicated in ankylosed elbows unless one joint must have mobility to provide hygienic and nutritional function. Before the introduction of methyl methacrylate it was unwise to replace the elbow with a prosthesis because of the inability to get good fixation of the metal to bone. At that time, arthroplasty of the elbow joint consisted of wide excision of the humeral condyles and the opposing radius and ulna. Fascia and skin were used by some surgeons as interposition material. This procedure is still in use today. Drawbacks, however, are unsatisfactory motion and varying instability. Eventually, prosthetic replacement of the elbow will relegate it to history. Ulnar nerve involvement is common in rheumatoid involvement of the elbow joint. It may involve only the sensory component of the nerve or it may result in sensory and motor deficits. Usually the symptoms are gradual in evolution, hence the term “tardy paralysis.” The nerve is compressed by the synovial proliferation and occasionally the rheumatoid tissue involves the nerve and destroys it. As soon as a diagnosis of ulnar nerve encroachment is made, treatment should be instituted promptly. Perineural injections of corticosteroids may cause regression of the proliferative synovium and relieve the situation. If not, neurolysis and anterior transposition of the nerve is indicated. Preliminary nerve conduction and electromyographic studies are helpful to confirm the clinical diagnosis. It is clear that some of the intrinsic atrophy noted in the hands of rheumatoid patients is due to ulnar nerve compression at the elbow or wrist. Resection of subcutaneous rheumatoid nodules along the proximal crest of the ulna and an involved olecranon bursa is indicated when the lesions are symptomatic or become ulcerated and secondarily injected. This latter situation is seen often in people using forearm crutches with resultant pressure. Rheumatoid nodules have a high incidence of recurrence after surgical excision. In most cases they are best left alone or controlled by intralesional injection with Triamcinilone.
REFERENCES
1. Torgerson, W. F., and Leach, R. E.: five cases synovectomy of the elbow in rheumatoid arthritis. J. Bone Joint Surg. [Amer.] 371, 1970. 2. Wilkinson, M. C., and Lowry, J. H.: Synovectomy for rheumatoid arthritis. J. Bone Joint Surg. [Brit.] 47:482, 1.965. 3. Straub, A.: Arthritis Surgery Conference. 1969. 4. Papavassilion, N., et al: Brit. J. Surg. 56:700, 1969.
5. Hollander, J. L.: Arthritis and Allied Conditions. Chapter 27. 6. Neer, C. S.: Articular replacement for the humeral head. J. Bone Joint Surg. [Amer.] 46:1607, 1964. 7. Sokolof, L., and Gleason, I. 0.: The Sterno-clavicular articulation in rheumatic diseases. Amer. J. Clin. Path. 24:406, 1954. 8. MacAusland, W. R.: Mobihzation of the stiff elbow by arthroplasty. 9. Smith-Pterson, M.N., Aufranc, 0. E.,
6 and Larson, C. B.: Arch. Surg. (Chicago) 46764, 1943. 10. Harty, M., Joyce, J. J.: Instructional course lecture surgical approaches to the elbow. J. Bone Joint Surg. [Amer.] 46598, 1964. 11. Casagrande, P.A.: Dixon, A. S. J.
PETER
A. CASAGRANDE
(Eds.): Progress in Clinical Rheumatology. London, Churchill, 1965. 12. Chapchal, G.: (Ed.) Synovectomy and Arthroplasty in Rheumatoid Arthritis, Second International Symposium, Jan. 27-29, 1967, Basel, Switzerland.