- Email: [email protected]
Total shoulder arthroplasty in rheumatoid arthritis
Total Shoulder Arthroplast¥ in R h e u m a t o i d Arthritis
S t e p h e n R. M c C o y , MD,* Russell F. W a r r e n , MD,-[- H a r r y A. B a d e HI, MD,:[: C h i t r a n j a n S. R a n a w a t , MD,-[- a n d A l l a n E. Inglis, MD-[-
Abstract: Twenty-nine Neer-type total shoulder anhroplasties were performed in 26 patients with rheumatoid arthritis. The average age was 55.5 years and the average follow-up period was 37 months. On a 100-point scoring system, the average preoperative score of 25 improved to 71 after surgery. ]-he most significant improvement was noted in pain relief. Radiographs demonstrated nonprogressive radiolucent lines in 86% of the glenoid components and 31% of the humeral components. Surgical problems included bone loss of the glenoid, acromioclavicular joint arthritis, and rotator cuff tears, in 7 of 29 shoulders. Follow-up study demonstrated poorer results for patients with rotator cuff tears. However, significant pain relief was achieved in 93% of our patients, despite limited functional improvements. K e y words: total shoulder arthroplasty, rheumatoid anhritis, rotator cuff.
were unavailable, and one patient had had arthroplasty with an O'Leary-Walker prosthesis, an early design model no longer used clinically. This left 29 Neer-type shoulders (23 Neer II and 6 Neer I) in 26 patients available for study. The follow-up study consisted of a clinical evaluation utilizing a 100point scoring system that assesses pain relief, function, strength, and range of active motion (Table 1). In addition, the preoperative bone stock and followup radiographs were evaluated.
Total shoulder arthroplasties have been performed for more than a decade with satisfying results. Patients undergoing arthroplasty for rheumatoid arthritis offer unique challenges, due to the destructive nature of the disease, which affects both the quality of the bone and the surrounding soft tissues.
Methods Between 1975 and 1983, 93 patients with 104 shoulders had total should arthroplasty. Of these, 33 patients (38 shoulders) were diagnosed as having rheumatoid arthritis. At the time of follow-up study, four patients (5 shoulders) had died, three patients
Surgical Considerations At surgery, in addition to replacement of the glenohumeral part, further procedures were performed in 12 patients. These included two acromioplasties, one coracoacromial ligament excision, and three biceps tenodeses. There were several technical problems encountered in performing total shoulder arthroplasty in the
* From Charlotte Hungerford Medical Center, Torrington, Connecticut. "~From the Hospital for Special Surgery, New York, New York. From Monmouth Medical Center, Long Branch, New Jersey.
Reprint requests: RussellF. Warren, MD, 535 East70th Street, New York, NY 10021.
105
106
The Journal of Arthroplasty Vol. 4 No. 2 June 1989
T a b l e 1. T h e H o s p i t a l for S p e c i a l S u r g e r y S y s t e m for Assessing Shoulder Function Function Pain on motion (max., 15 points) None--ignores Mild--occasional, no compromise in activity Moderate--tolerable, makes concession, uses ASA Severe--serious limitations, disabling, uses codeine, etc. Pain at rest (max., 15 points) None--ignores Mild--occasional, no meds, no effect on activity or sleep Moderate--uses ASA, limited activity Severe--marked meds, stronger than ASA Function (max., 20 points) Comb hair Lie on shoulder Hook brassiere Iback) Toilet Function (max., 10 points) Lift weight Muscle strength (max., 15 points) Forward flexion Normal Good Poor Abduction Normal Good Poor Adduction Normal Good Poor Intemal rotation Normal Good Poor Extemal rotation Normal Good Poor Range of motion (max., 25 points) Fonvard flexion (max., 7 points) Abduction (max., 8 points) Adducfion (max., 2 points) Internal rotation (max., 5 points) External rotation (max., 3 points)
Score 15 10 5 0 15 10 5 0 5 5 5 5
The status of the rotator cuff and the ability to perform a repair if a tear is present are critical to the success of a nonconstrained total shoulder arthroplasty. Overall, significant cuff disease was present in 11 of our patients, with a complete tear in 7. Four patients had an intact, but thin and attenuated, cuff. In three patients, a massive irreparable tear with loss of tissue was present. In two of these patients no repair was attempted, and in the remaining patient a repair described as poor was affected. In the four patients with a large tear (3-5 cm wide), a repair using standard techniques was affected. In those patients with a large tear, the surgical approach to the cuff included extensive relaxation of the contractures of the cuff both within and outside the joint (Fig. 1). In massive tears (>5 cm), a shift of the upper twothirds of the subscapularis may allow closure of the defect (Fig. 2). If this was impossible, then a total shoulder arthroplasty of a nonconstrained type with a limited goal approach was used.
1 point per pound
Complications
3 2 0
There were several complications noted as a result of the operation. In addition to the two glenoid perforations, there was one transient ulnar nerve dysesthesia, one w o u n d hematoma delaying physical therapy, two cases of pneumonia, and one postoperative perforated gastric ulcer. There were no deaths.
3 2 0 3 2 0 3 2 0
Results
3 2 0 1 point 1 point 1 point l point 1 point
per per per per per
motion 20 ° motion 20 ° motion 20 ° motion 20 ° motion 20 °
rheumatoid patient. Due to the often severe bony erosion and osteoporosis seen in this disease, two glenoids were perforated in the process of making the fixation hole. One glenoid was perforated anteroinferiorly and the other was perforated anteriorly and posteriorly. Both patients had bone grafting without complication. In addition, six patients required trimming of the glenoid prosthetic tip due to protrusion of the glenoid. Two additional patients required trimming of the humeral stems to seat them correctly in the humerus.
The follow-up period averaged 37 months (range, 12-88 months) and the average age of the patient was 55.5 years (range, 29-83 years). Twenty-four of the arthroplasties were performed in w o m e n and the dominant arm was involved in 18 patients. Five of the patients (7 shoulders) were diagnosed as having juvenile rheumatoid arthritis.
Total Scores Using the Hospital for Special Surgery lO0-point scoring system, the average patient improved from a preoperative score of 25 points to a postoperative score of 71 points (Fig. 3). The five patients with juvenile rheumatoid arthritis improved from a preoperative score of 38 points to a postoperative score of 81 points.
TSA in RA
A
•
McCoy et al.
107
B
Fig. 1. Method for releasing the capsular attaclnnent within the joint to facilitate advancement of the rotator cuff during the repair procedure. The capsule is detached from the labium extensively anteriorly and posteriorly.
j-"
,
/i ~
I
subscapu aris
" ~
Fig. 2. Method for managing a. massive rotator cuff tear with fixed retraction. Advancement and migration of the superior two-thirds of the subscapularis is often necessary.
108
The Journal of Arthroplasty Vol. 4 No. 2 June 1989
Table 2. Rotator Cuff Disease and Follow-up Scores
Pre-op Post~p
No. of Patients
Preop Score
Postop Score
4 3 4
25 19 20
59 67 63
Cuff tom and repaired Cuff irreparable Cuff attentuated P
30
O
25.5
i ¢
19.9
20
Rotlon
Total
Function
rJtn
$¢rensth
Fig. 3. Preoperative and follow-up scores for 29 total shoulder arthroplasties. Eleven shoulders were found to have significant rotator cuff disease. These included four large tears, w h i c h were repaired, three massive tears, w h i c h w e r e n o t reparable, and four cuffs that were found to be attentuated at surgery. The average preoperative score of patients with rotator cuff disease w a s 22, compared with 28 for the remainder of the group. After surgery, the 11 patients with rotator cuff disease improved to a score of 63 points, compared with 76 points for the intact cuff group (P < .05). This represents a 21% difference in total scores b e t w e e n the t w o groups (Fig. 4). W h e n the 11 patients with cuff disease were c o m pared at follow-up evaluation, the score improvem e n t and the follow-up score for those with a t o m
and repaired rotator cuff, irreparable cuff, and attentuated cuff were similar (Table 2). The clinical results were graded excellent ( 8 5 - 1 0 0 points), good ( 7 0 - 8 4 ) , fair ( 5 0 - 6 9 ) , or failures ( < 5 0 ) . There were 6 excellent, 10 good, and 8 fair results and 5 failures. W h e n the status of the rotator cuff was noted, 8 of 11 shoulders (72.7%) with rotator cuff disease were rated as fair or failures, c o m pared with 5 of 18 shoulders (27.7%) with intact rotator cuffs.
Pain Relief
The patients were evaluated as to degree of pain both at rest and during motion, with a total possible score of 30 points awarded for complete absence of pain. Their average preoperative score of 6 points improved to 26 points after surgery. This improvem e n t represented 42% of the entire increase in the total score (Fig. 3). The average preoperative score of the 11 patients with rotator cuff disease w a s 3 points, versus 9 points for the group with the cuff intact. After surgery, the t w o groups experienced similar improvements, reaching 25 and 26 points, respectively (Fig. 5).
90
Total
76.4
Cuff 911ease
Intact
Cuff
N-li
70.9
~°15
"'~'-":"
Z;;-:'-".~
/
D
Total
30
Cuff Disease N'll
/
Intact Cuff N-18 63.2
/
/
25.5
: .: :. .:.'/.: ': : ;
:(:..-.:.:-: .:.= ....
28.0 25.6
/ / f ~-
• ...... • ~..*o_o-
/
.......
/
/
/
/
f
..... =.....-
/
•"-'C'::i
/
....
;..
f
iC?'-!
/
.-..:;:: •: . - - . - - .
j"
j
-
/ ~
15
~
:.-.,~..-;:
26.1
24.6
~/
9.4
:~-.-.-.~.
/
/ - / -
"""'~'"
: :::;;:""
6.2 2.7
Fre-operative
.......
.
• .. . . . . . .
~*-~
~i:!.Y'.:"i
/
Post-operative
Fig. 4. Effects of cuff disease on the total score.
~
/
Pre-operatlve
Post-operatlve
Fig. 5. Pain relief following total shoulder arthroplasty was not significantly affected by the presence of rotator cuff disease.
TSAinRA Function
* McCoyetal.
109
Total 30
The function score reflected the ability to use the shoulder to perform certain tasks involved with activities of daily living. This included activities such as combing hair, lying on the shoulder, dressing, and performing toilet function, with a total of 30 points possible (Table 1). The average preoperative score of only 5 points improved to 20 points aftery surgery. This represented 33% of the total improvement in scores following surgery (Fig. 3). Only one patient could perform more than two of the tasks before surgery, whereas after surgery 23 of the 29 shoulders could perform more than two of the tasks (Fig. 6). In evaluating the effect of cuff disease, w e found that the patients with intact cuffs improved from 6 to 22 points (P < .05). This represented a 37% difference between the two groups (Fig. 7).
Strength Strength was evaluated clinically in a standard method testing five positions (Table 1). The average preoperative score of 6 points improved to 11 points following surgery (Fig. 3). Patients with intact rotator cuffs demonstrated a 36% improvement, compared to those with cuff disease, with scores of 13 and 9 points, respectively (Fig. 8).
C u f f Disease Iatlet
Cuff
N-11 N*I8
22.4 10.9 ':-"-""
/
16.3
/
/
/
15
5.8 4.9
:7.':?,::i .. .. .-. :. o. . . :. :.:.--::.
/ / / / / /
. .o;........
/-
. . .....
3.6
Pce-oDer~ r l y e
.I
/ /
Post-operative
Fig. 7. Shoulder function following total shoulder anhroplasty. shoulders had an improvement in forward flexion, averaging 37 ° (range, 15°-75°). Eight shoulders had no change in forward flexion, and three shoulders lost motion, averaging 40 °. The patient with the greatest postoperative loss 0fflexion (50 °) had severe ipsilateral elbow disease. The other two patients both were discharged from the hospital with less than 4 days of rehabilitation of the shoulder, which likely contributed to their diminished range of motion. The average forward flexion for those with and without intact cuffs was 82 ° and 67 °, respectively (P < .05) (Fig. 9).
Range of Motion The range of motion was scored on a basis of 25 points, with a preoperative average of 9. After surgery, this average improved to 14 points (Fig. 3). The average motion with respect to active forward flexion improved from 61 ° to 76 °. Eighteen of the 29
preoperative [ ]
Radiographic Findings Evaluation of the humeral prosthesis revealed radiolucent lines at the bone-cement interface in nine shoulders. This represented a 31% incidence. Only 15
Total C u f f Disease
postoperative D"
Intact
Cuff
20-
N=11
12.8 B-18 n.3
18-
10,
; --';'...-.o..
f
9,4
j
j-
j
16-
.=__
t4-
o 13..
12-
"6
Z
/
, . . . . , . _....... .
/
/
•: - ' _ _ ' . -_"
/-
J"
• ;-;.... %;.°;.
.f
/
/
108-
E=
•" : : : : : : :
6.9
3.6
,~.:. i'V;::
6-
-::% 4L~C:
,;:-:;:
2O-
Pre-operatlve
0 1 2 3 Fig. 6. Number of functions performed.
4
Post-operat
lye
Fig. 8. Clinical strength assessment following total shoulder arthroplasty.
110
The Journal of Arthroplasty Vol. 4 No. 2 June 1989
~0
~
Total
82.3 ,f/" . f je,
Cuff Disease .~"ll Intact Cuff .~-18 66.5 6z.o
/ /
D
e
";: :"::':
//
g
""--" • ":'" .,-.-.:.. -.'--" ---
/
r
7::::::
i 4i
66.7
...... ".':"v
// //
-..--.;
.........
~
"" ~ J
//
~ J / /
~ :.'.'.:-':
3o
/
76.1
/ /
i?'i".'":
f/ /
'~ i 7.'::.::
/. f j/" //
.::.:..-:
!!~-~:'.:!
/ /
!i::!'-i':
iI//
........-.
i.";:-i!: :::-::: ::.'t::::. .:-: ~,:: .
Pre-cperat lye
// ,f
i
//
/
/
/
Post-operat Ive
Fig. 9. Active forward flexion demonstrated the adverse effects of rotator cuff disease. one was greater than 1 nun and progressive. This case demonstrated a progression of lucency but clinically remains asymptomatic. A review of the glenoid components, using both a true anteroposterior view of the glenoid and an axillary view, revealed that 25 of the 29 shoulders had radiolucencies, an incidence of 86%. This is slightly higher than most previously reported series involving different etiologies in addition to rheumatoid arthritis (3). Of the 25 shoulders with radiolucencies, 22 remained less than 1 m m and 3 increased from 0 m m immediately after surgery to less than 1 m m at follow-up evaluation. The remaining shoulder increased from 0 m m to 2 m m over the follow-up period, with slight pain on motion. This patient remained active as a handball player.
shoulder arthroplasty in other disease states, we found that the rheumatoid patient's improvement is slightly greater (71 points) than in patients with severe trauma (60 points) but is less successful than in patients with osteoarthfitis (77 points) or avascular necrosis (94 points) (1) (Fig. 10). The overall results compare favorably with those of prior studies (2, 4, 6, 10). In each study, pain relief in the rheumatoid patient has been good while the increased elevation of the arm has been less than in other disease states. We found an average increase in elevation of only 15 °, from 61 ° before surgery to 76 ° at follow-up evaluation. This is similar to the results of a study by Kelly et al., in which 37 rheumatoid patients had an average flexion increase from 55 ° to 75 ° (8). These values are less than those reported by Cofield, whose 29 rheumatoid patients had 56 ° of abduction increasing to 103 ° at follow-up (4). This difference is not accounted for by the presence of fullthickness rotator cuff tears, as Cofleld reported 7 of 29 patients, identical to our findings. The overall poorer functional quality of the end result in rheumatoid patients appears to be related to the extensive soft tissue disease that is concurrent with the articular injury, as well as the multiple joint involvement that m a y prejudice the end result evaluation. In selecting rheumatoid patients for total shoulder arthroplasty, we would agree with Friedman and Ewald in suggesting that in those with equally severe disease affecting both the shoulder and elbow, the more distal joint should be selected for the initial procedure (6). They noted that there was greater functional improvement after the elhow arthroplasty and that there was a longer interval between proPre-cp
80
Discussion Total shoulder arthroplasty in severe rheumatoid arthritis has been beneficial to our patients in contrast to more limited procedures such as synovectomy or hemiarthroplasty (11). Our results show that significant pain relief was achieved in most patients (93%), whereas functional improvements have been more limited, depending o n the quality of the soft tissues. W h e n comparing our postoperative results in rheumatoid arthritis with our previous study for total
Post-op
i00
60
40
93.8 77.3
71
F
0.3
20
R.A.
TRALTLA*
O.A.*
A.V.N.
Fig. 10. A comparison of follow-up total scores by diagnostic indication demonstrates the poorer results noted on rheumatoid arthritis as compared to osteoarthritis (OA) and avascular necrosis (AVN).
TSA in RA
cedures w h e n the elbow was the initial procedure (45 vs. 13.5 months). In terms of regaining motion and pain relief, performing an arthroplasty of the elbow did not compromise the result of shoulder surgery (6). It should be pointed out that prior to inserting the humeral component, it is best to place a cement restrictor distally, as the ability to insert a subsequent stem on an elbow prosthesis m a y be compromised. Patients in w h o m lower extremity disease is severe should have this aspect treated initially, to remove the need for crutches and the subsequent high loads on the shoulder. However, to date patients with total shoulder arthroplasties have been able to use crutches without adverse affects. W h e n performing shoulder arthroplasty in rheumatoid patients, the preoperative assessment of the bony and soft tissue anatomy is critical, as rheumatoid patients have an increased frequency of glenoid protrusio, osteopenia, and rotator cuff disease. In our series, 6 of 29 shoulders had deficiency of the glenoid requiring trimming of the glenoid stem. Neer and Morrison, in a recent report on the need for glenoid bone graft, noted that 7 of 108 patients with deficiency required grafting and 2 required trimming of the stem of the glenoid prosthesis (9). To evaluate the glenoid, a true anteroposterior view of the shoulder as well as an axillary view or CT scan are helpful. On the true anteroposterior shoulder radiograph, the glenoid depth, as measured from the midpoint of the base of the coracoid to the joint sur-
A
•
McCoy et al.
111
face, should measure approximately 2 cm. In our series this distance averaged 1.4 cm, with eight patients having a depth of less than 1 cm. If the bone stock is insufficient, then the surgeon m a y have to consider a bone graft or, if bone graft is impossible, a hemiarthroplasty. In performing a bone graft in rheumatoid patients the deficiency is often anterior or central, in contrast to osterarthritis, w h e n the bone loss is generally posterior. In repairing the defect, a bone graft may be fashioned from the humeral head and pinned or screwed to the remaining glenoid (Fig. 11). It is important that the graft be fixed to the glenoid with pins or screws, which are placed to avoid the central hole created for the prosthetic peg. In addition, the graft placement must be such that the cement application does not prevent bone healing to the graft. In evaluating the humerus, the depth and width of the shaft must be noted, as two patients in our series required trimming of the stem. This is particularly true in patients with juvenile rheumatoid arthritis, in w h o m poor bone development is more common. It appears that the stem of the Neer humeral component is too long for m a n y of these patients and that a shorter stem is sufficient. A major concern in rheumatoid patients is the presence of rotator cuff disease. Overall, we found that 38% of our patients had involvement of the rotator cuff, with a full-thickness tear in seven patients (24%). This incidence is similar to that noted by Cofield (4). At follow-up study those with rotator cuff
B
C
Fig. 11. (A, B) Preparation of the glenoid and insertion of the prosthesis avoiding stem penetration. (C) If there is bone loss, a graft may be necessary. Fixation with pins or screws is necessary to avoid interference with the central stem of the glenoid.
112
The J o u r n a l of A r t h r o p l a s t y Vol. 4 No. 2 J u n e 1989
disease (11 patients) faired poorer than those without, as only one patient was regarded as excellent, two as good, five as fair, and three as failures (Table 3). The ability to complete a repair may be severely impaired by the lack of tendons; in two patients no repair was attempted. In a comparison of patients with and without rotator cuff disease, those with deficient cuffs scored 37% lower o n function scores and 36% less in strength (Figs. 7, 8). The range of motion as represented by forward flexion was reduced by 15 °, averaging 67 ° versus 82 °. Matsen, in reporting o n 50 total shoulder anhroplasties for several etiologies, including rheumatoid arthritis in 11, also noted the affect of rotator cuff tears and found that the patient's degree of elevation after surgery, despite cuff repair, averaged only 62 °, versus 100 ° for the entire population (2). In our study, pain relief in those with a cuff tear was still obtained, as there was only a 6% difference in the pain rating in those with or without cuff disease. Of c o n c e m in patients with a rotator cuff tear is the possibility of loosening of the glenoid compartment. Matsen reported this as a significant problem resulting in glenoid loosening in four patients, each of w h o m had a massive cuff tear. Loosening was noted, both clinically and radiographically, 30 months after surgery. In each patient there was superior migration and superior tipping of the glenoid component. It appears that the unopposed deltoid will increase superior shear on the glenoid, resulting in higher stresses o n the glenoid c o m p o n e n t and subsequent loosening in some patients with rotator cuff tears. However, in our patients with cuff tears none were noted to have developed a loose glenoid. Matsen's patients included nine rotator cuff tears with rheumatoid arthritis as the etiology in only three (2). Of the four patients with a massive rotator cuff tear and glenoid loosening none had rheumatoid arthritis. This m a y be a result of the limited demands placed on the shoulders of more severely involved rheumatoid patients, in contrast to those with osteoarthritis or traumatic arthritis. Despite the presence of significant rotator cuff tears, pain relief was achieved (in our patients) to a degree similar to that in patients with an intact cuff. Table 3. Comparison of End ResuIts of Patients With and Without Rotator Cuff D i s e a s e With Disease Without Disease (n = 11) (n = 18)
Excellent (85-100 points)
Good (70-84) Fair (50-69) Failures (<50)
1 2 5 3
5 8 3 2
Failures
The presence of rotator cuff disease was a significant factor in patients regarded as treatment failures. Five patients were categorized as failures, with follow-up scores of less than 50 points. Four of t h e s e five patients had rotator cuff tears. This included one patient with a recurrent tear following repair at surgery, one patient with a major tear not repaired at surgery, and two patients with follow-up radiographs suggestive of tears based o n a prosthetic head-to-acromion distance of less than 3 mm. In one of these, this distance decreased from 9 m m to 2 m m over the follow-up period and in the other there was erosion of the acromion. In addition, three of these patients classified as failures had difficulties with the ipsilateral elbow, which impaired their use of the upper extremity. The best means of surgical replacement in patients with significant rotator cuff disease remains in debate. The two primary functions of the rotator cuff are to act as a stabilizer of the glenohumeral joint and to provide power for motion (3). By working as a force couple with the deltoid, a fulcrum is established about which the humeral head m a y rotate. Shoulders w h o s e cuffs are severely involved at the time of arthroplasty are currently destined for less than optimal results. As the disease may affect the m u s c l e a s well as the tendon, function itself m a y be diminished, despite an adequate repair of the rotator cuff. Currently there are several methods of treatment available for patients with destroyed rotator cuffs of a magnitude precluding a reasonable attempt at repair. These include using a nonconstrained prosthesis with a limited goals rehabilitation program (5, 6), an oversized glenoid c o m p o n e n t with superior coverage (5, 6), and a fixed-fulcrum prosthesis (7, 10). The advantage offered by a more constrained prosthesis is greater stabilization of the glenohumeral joint, to allow the remaining functional musculature to perform adequately. However, this is balanced by the higher rate of loosening or dislocation generally seen with a constrained prosthesis (7). In rheumatoid patients, this is further complicated by the poor quality of the bone and erosion of the glenoid that are common, making fixation of the larger, more constrained prosthesis increasingly difficult. These factors make the secure long-term implantation of a constrained prosthesis even less predictable. Our current preference is to use a standard glenoid with a limited goals approach, avoiding a fixed-fulcrum prosthesis.
TSA in RA
At the time of surgery, it is necessary to examine other causes of shoulder pain in addition to the glen o h u m e r a l joint arthritis. These include disease involving the acromioclavicular joint and impingem e n t problems. The acromioclavicular joint was resected in only 4 of our 29 cases, despite radiographic changes. It is r e c o m m e n d e d that this joint be preserved, if possible, for muscle attachment. If there is a prominence inferiofly, then burring of this area is indicated with resection only if the joint is acutely painful. Finally, it appears that patients with juvenile rheumatoid arthritis m a y fit into a category distinct from the rest of the rheumatoid population. As a group (5 patients, 7 shoulders), their total score was higher (81 vs. 68), there w e r e no failures, and only one of the rotator cuffs was attenuated. Two shoulders s h o w e d glenoid protrusio and only one patient required trimming of the glenoid stem. This is likely due to the fact that these patients are generally y o u n g e r (average age, 43.5 years), with less time for the m o r e destructive bone and tendon changes to Occur.
Summary Twenty-nine Neer-type total shoulder arthroplasties in patients with rheumatoid arthritis w e r e reviewed, with an average follow-up period of 37 months. An i m p r o v e m e n t in pain has been seen in virtually all patients, as have significant improvem e n t s in motion, function, and strength. Patients with large rotator cufftears had m o r e limited results, with minimal i m p r o v e m e n t s in function and motion,
*
McCoy et al.
113
but pain relief was still achieved. I m p r o v e d methods of handling rotator cuff disease are required.
References 1. Bade HA, Warren RF, Ranawat CS, Inglis AE: Longterm results of Neer total shoulder replacement, p. 294. In Bateman JE (ed): Surgery of the shoulder. Decker, Philadelphia, 1984 2. Barrett WP, Franklin JL, Jackins SEet al: Total shoulder arthroplasty. J Bone Joint Surg 69A:865, 1987 3. Clarke JC, Sew Hoy AL, Gruen TA, Amstutz HC: Clinical and radiographic assessment of a non-constrained total shoulder. Int Onhop 5:1, 1981 4. Cofield RH: Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg 66A:899, 1984 5. Cofield RH: Unconstrained total shoulder prosthesis. Clin Orthop 173:97, 1983 6. Friedman ILl, Ewald FC: Arthroplasty of the ipsilateral shoulder and elbow in patients who have rheumatoid arthritis. J Bone Joint Surg 69A:661, 1987 7. Gristina AG, Webb L: The Trispherical total shoulder prosthesis, p. 49. In: Inglis AE (ed): Symposium on total joint replacement of the upper extremity. CV Mosby, St. Louis, 1982 8. Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg 69B:723, 1987 9. Neer CS, Morrison DS: Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint Surg 70A:1154, 1988 10. Neer CS, Watson KC, Stanton FJ: Recent experiences in total shoulder replacements. J Bone Joint Surg 64A:319, 1982 I 1. Post M, Jablon M: Constrained total'shoulder arthroplasty. Clin Orthop 173:109, 1983 12. Ranawat CS, Warren RF, Inglis AE: Total shoulder replacement arthroplasty. Orthop Clin North Am 11:367, 1980
S t e p h e n R. M c C o y , MD,* Russell F. W a r r e n , MD,-[- H a r r y A. B a d e HI, MD,:[: C h i t r a n j a n S. R a n a w a t , MD,-[- a n d A l l a n E. Inglis, MD-[-
Abstract: Twenty-nine Neer-type total shoulder anhroplasties were performed in 26 patients with rheumatoid arthritis. The average age was 55.5 years and the average follow-up period was 37 months. On a 100-point scoring system, the average preoperative score of 25 improved to 71 after surgery. ]-he most significant improvement was noted in pain relief. Radiographs demonstrated nonprogressive radiolucent lines in 86% of the glenoid components and 31% of the humeral components. Surgical problems included bone loss of the glenoid, acromioclavicular joint arthritis, and rotator cuff tears, in 7 of 29 shoulders. Follow-up study demonstrated poorer results for patients with rotator cuff tears. However, significant pain relief was achieved in 93% of our patients, despite limited functional improvements. K e y words: total shoulder arthroplasty, rheumatoid anhritis, rotator cuff.
were unavailable, and one patient had had arthroplasty with an O'Leary-Walker prosthesis, an early design model no longer used clinically. This left 29 Neer-type shoulders (23 Neer II and 6 Neer I) in 26 patients available for study. The follow-up study consisted of a clinical evaluation utilizing a 100point scoring system that assesses pain relief, function, strength, and range of active motion (Table 1). In addition, the preoperative bone stock and followup radiographs were evaluated.
Total shoulder arthroplasties have been performed for more than a decade with satisfying results. Patients undergoing arthroplasty for rheumatoid arthritis offer unique challenges, due to the destructive nature of the disease, which affects both the quality of the bone and the surrounding soft tissues.
Methods Between 1975 and 1983, 93 patients with 104 shoulders had total should arthroplasty. Of these, 33 patients (38 shoulders) were diagnosed as having rheumatoid arthritis. At the time of follow-up study, four patients (5 shoulders) had died, three patients
Surgical Considerations At surgery, in addition to replacement of the glenohumeral part, further procedures were performed in 12 patients. These included two acromioplasties, one coracoacromial ligament excision, and three biceps tenodeses. There were several technical problems encountered in performing total shoulder arthroplasty in the
* From Charlotte Hungerford Medical Center, Torrington, Connecticut. "~From the Hospital for Special Surgery, New York, New York. From Monmouth Medical Center, Long Branch, New Jersey.
Reprint requests: RussellF. Warren, MD, 535 East70th Street, New York, NY 10021.
105
106
The Journal of Arthroplasty Vol. 4 No. 2 June 1989
T a b l e 1. T h e H o s p i t a l for S p e c i a l S u r g e r y S y s t e m for Assessing Shoulder Function Function Pain on motion (max., 15 points) None--ignores Mild--occasional, no compromise in activity Moderate--tolerable, makes concession, uses ASA Severe--serious limitations, disabling, uses codeine, etc. Pain at rest (max., 15 points) None--ignores Mild--occasional, no meds, no effect on activity or sleep Moderate--uses ASA, limited activity Severe--marked meds, stronger than ASA Function (max., 20 points) Comb hair Lie on shoulder Hook brassiere Iback) Toilet Function (max., 10 points) Lift weight Muscle strength (max., 15 points) Forward flexion Normal Good Poor Abduction Normal Good Poor Adduction Normal Good Poor Intemal rotation Normal Good Poor Extemal rotation Normal Good Poor Range of motion (max., 25 points) Fonvard flexion (max., 7 points) Abduction (max., 8 points) Adducfion (max., 2 points) Internal rotation (max., 5 points) External rotation (max., 3 points)
Score 15 10 5 0 15 10 5 0 5 5 5 5
The status of the rotator cuff and the ability to perform a repair if a tear is present are critical to the success of a nonconstrained total shoulder arthroplasty. Overall, significant cuff disease was present in 11 of our patients, with a complete tear in 7. Four patients had an intact, but thin and attenuated, cuff. In three patients, a massive irreparable tear with loss of tissue was present. In two of these patients no repair was attempted, and in the remaining patient a repair described as poor was affected. In the four patients with a large tear (3-5 cm wide), a repair using standard techniques was affected. In those patients with a large tear, the surgical approach to the cuff included extensive relaxation of the contractures of the cuff both within and outside the joint (Fig. 1). In massive tears (>5 cm), a shift of the upper twothirds of the subscapularis may allow closure of the defect (Fig. 2). If this was impossible, then a total shoulder arthroplasty of a nonconstrained type with a limited goal approach was used.
1 point per pound
Complications
3 2 0
There were several complications noted as a result of the operation. In addition to the two glenoid perforations, there was one transient ulnar nerve dysesthesia, one w o u n d hematoma delaying physical therapy, two cases of pneumonia, and one postoperative perforated gastric ulcer. There were no deaths.
3 2 0 3 2 0 3 2 0
Results
3 2 0 1 point 1 point 1 point l point 1 point
per per per per per
motion 20 ° motion 20 ° motion 20 ° motion 20 ° motion 20 °
rheumatoid patient. Due to the often severe bony erosion and osteoporosis seen in this disease, two glenoids were perforated in the process of making the fixation hole. One glenoid was perforated anteroinferiorly and the other was perforated anteriorly and posteriorly. Both patients had bone grafting without complication. In addition, six patients required trimming of the glenoid prosthetic tip due to protrusion of the glenoid. Two additional patients required trimming of the humeral stems to seat them correctly in the humerus.
The follow-up period averaged 37 months (range, 12-88 months) and the average age of the patient was 55.5 years (range, 29-83 years). Twenty-four of the arthroplasties were performed in w o m e n and the dominant arm was involved in 18 patients. Five of the patients (7 shoulders) were diagnosed as having juvenile rheumatoid arthritis.
Total Scores Using the Hospital for Special Surgery lO0-point scoring system, the average patient improved from a preoperative score of 25 points to a postoperative score of 71 points (Fig. 3). The five patients with juvenile rheumatoid arthritis improved from a preoperative score of 38 points to a postoperative score of 81 points.
TSA in RA
A
•
McCoy et al.
107
B
Fig. 1. Method for releasing the capsular attaclnnent within the joint to facilitate advancement of the rotator cuff during the repair procedure. The capsule is detached from the labium extensively anteriorly and posteriorly.
j-"
,
/i ~
I
subscapu aris
" ~
Fig. 2. Method for managing a. massive rotator cuff tear with fixed retraction. Advancement and migration of the superior two-thirds of the subscapularis is often necessary.
108
The Journal of Arthroplasty Vol. 4 No. 2 June 1989
Table 2. Rotator Cuff Disease and Follow-up Scores
Pre-op Post~p
No. of Patients
Preop Score
Postop Score
4 3 4
25 19 20
59 67 63
Cuff tom and repaired Cuff irreparable Cuff attentuated P
30
O
25.5
i ¢
19.9
20
Rotlon
Total
Function
rJtn
$¢rensth
Fig. 3. Preoperative and follow-up scores for 29 total shoulder arthroplasties. Eleven shoulders were found to have significant rotator cuff disease. These included four large tears, w h i c h were repaired, three massive tears, w h i c h w e r e n o t reparable, and four cuffs that were found to be attentuated at surgery. The average preoperative score of patients with rotator cuff disease w a s 22, compared with 28 for the remainder of the group. After surgery, the 11 patients with rotator cuff disease improved to a score of 63 points, compared with 76 points for the intact cuff group (P < .05). This represents a 21% difference in total scores b e t w e e n the t w o groups (Fig. 4). W h e n the 11 patients with cuff disease were c o m pared at follow-up evaluation, the score improvem e n t and the follow-up score for those with a t o m
and repaired rotator cuff, irreparable cuff, and attentuated cuff were similar (Table 2). The clinical results were graded excellent ( 8 5 - 1 0 0 points), good ( 7 0 - 8 4 ) , fair ( 5 0 - 6 9 ) , or failures ( < 5 0 ) . There were 6 excellent, 10 good, and 8 fair results and 5 failures. W h e n the status of the rotator cuff was noted, 8 of 11 shoulders (72.7%) with rotator cuff disease were rated as fair or failures, c o m pared with 5 of 18 shoulders (27.7%) with intact rotator cuffs.
Pain Relief
The patients were evaluated as to degree of pain both at rest and during motion, with a total possible score of 30 points awarded for complete absence of pain. Their average preoperative score of 6 points improved to 26 points after surgery. This improvem e n t represented 42% of the entire increase in the total score (Fig. 3). The average preoperative score of the 11 patients with rotator cuff disease w a s 3 points, versus 9 points for the group with the cuff intact. After surgery, the t w o groups experienced similar improvements, reaching 25 and 26 points, respectively (Fig. 5).
90
Total
76.4
Cuff 911ease
Intact
Cuff
N-li
70.9
~°15
"'~'-":"
Z;;-:'-".~
/
D
Total
30
Cuff Disease N'll
/
Intact Cuff N-18 63.2
/
/
25.5
: .: :. .:.'/.: ': : ;
:(:..-.:.:-: .:.= ....
28.0 25.6
/ / f ~-
• ...... • ~..*o_o-
/
.......
/
/
/
/
f
..... =.....-
/
•"-'C'::i
/
....
;..
f
iC?'-!
/
.-..:;:: •: . - - . - - .
j"
j
-
/ ~
15
~
:.-.,~..-;:
26.1
24.6
~/
9.4
:~-.-.-.~.
/
/ - / -
"""'~'"
: :::;;:""
6.2 2.7
Fre-operative
.......
.
• .. . . . . . .
~*-~
~i:!.Y'.:"i
/
Post-operative
Fig. 4. Effects of cuff disease on the total score.
~
/
Pre-operatlve
Post-operatlve
Fig. 5. Pain relief following total shoulder arthroplasty was not significantly affected by the presence of rotator cuff disease.
TSAinRA Function
* McCoyetal.
109
Total 30
The function score reflected the ability to use the shoulder to perform certain tasks involved with activities of daily living. This included activities such as combing hair, lying on the shoulder, dressing, and performing toilet function, with a total of 30 points possible (Table 1). The average preoperative score of only 5 points improved to 20 points aftery surgery. This represented 33% of the total improvement in scores following surgery (Fig. 3). Only one patient could perform more than two of the tasks before surgery, whereas after surgery 23 of the 29 shoulders could perform more than two of the tasks (Fig. 6). In evaluating the effect of cuff disease, w e found that the patients with intact cuffs improved from 6 to 22 points (P < .05). This represented a 37% difference between the two groups (Fig. 7).
Strength Strength was evaluated clinically in a standard method testing five positions (Table 1). The average preoperative score of 6 points improved to 11 points following surgery (Fig. 3). Patients with intact rotator cuffs demonstrated a 36% improvement, compared to those with cuff disease, with scores of 13 and 9 points, respectively (Fig. 8).
C u f f Disease Iatlet
Cuff
N-11 N*I8
22.4 10.9 ':-"-""
/
16.3
/
/
/
15
5.8 4.9
:7.':?,::i .. .. .-. :. o. . . :. :.:.--::.
/ / / / / /
. .o;........
/-
. . .....
3.6
Pce-oDer~ r l y e
.I
/ /
Post-operative
Fig. 7. Shoulder function following total shoulder anhroplasty. shoulders had an improvement in forward flexion, averaging 37 ° (range, 15°-75°). Eight shoulders had no change in forward flexion, and three shoulders lost motion, averaging 40 °. The patient with the greatest postoperative loss 0fflexion (50 °) had severe ipsilateral elbow disease. The other two patients both were discharged from the hospital with less than 4 days of rehabilitation of the shoulder, which likely contributed to their diminished range of motion. The average forward flexion for those with and without intact cuffs was 82 ° and 67 °, respectively (P < .05) (Fig. 9).
Range of Motion The range of motion was scored on a basis of 25 points, with a preoperative average of 9. After surgery, this average improved to 14 points (Fig. 3). The average motion with respect to active forward flexion improved from 61 ° to 76 °. Eighteen of the 29
preoperative [ ]
Radiographic Findings Evaluation of the humeral prosthesis revealed radiolucent lines at the bone-cement interface in nine shoulders. This represented a 31% incidence. Only 15
Total C u f f Disease
postoperative D"
Intact
Cuff
20-
N=11
12.8 B-18 n.3
18-
10,
; --';'...-.o..
f
9,4
j
j-
j
16-
.=__
t4-
o 13..
12-
"6
Z
/
, . . . . , . _....... .
/
/
•: - ' _ _ ' . -_"
/-
J"
• ;-;.... %;.°;.
.f
/
/
108-
E=
•" : : : : : : :
6.9
3.6
,~.:. i'V;::
6-
-::% 4L~C:
,;:-:;:
2O-
Pre-operatlve
0 1 2 3 Fig. 6. Number of functions performed.
4
Post-operat
lye
Fig. 8. Clinical strength assessment following total shoulder arthroplasty.
110
The Journal of Arthroplasty Vol. 4 No. 2 June 1989
~0
~
Total
82.3 ,f/" . f je,
Cuff Disease .~"ll Intact Cuff .~-18 66.5 6z.o
/ /
D
e
";: :"::':
//
g
""--" • ":'" .,-.-.:.. -.'--" ---
/
r
7::::::
i 4i
66.7
...... ".':"v
// //
-..--.;
.........
~
"" ~ J
//
~ J / /
~ :.'.'.:-':
3o
/
76.1
/ /
i?'i".'":
f/ /
'~ i 7.'::.::
/. f j/" //
.::.:..-:
!!~-~:'.:!
/ /
!i::!'-i':
iI//
........-.
i.";:-i!: :::-::: ::.'t::::. .:-: ~,:: .
Pre-cperat lye
// ,f
i
//
/
/
/
Post-operat Ive
Fig. 9. Active forward flexion demonstrated the adverse effects of rotator cuff disease. one was greater than 1 nun and progressive. This case demonstrated a progression of lucency but clinically remains asymptomatic. A review of the glenoid components, using both a true anteroposterior view of the glenoid and an axillary view, revealed that 25 of the 29 shoulders had radiolucencies, an incidence of 86%. This is slightly higher than most previously reported series involving different etiologies in addition to rheumatoid arthritis (3). Of the 25 shoulders with radiolucencies, 22 remained less than 1 m m and 3 increased from 0 m m immediately after surgery to less than 1 m m at follow-up evaluation. The remaining shoulder increased from 0 m m to 2 m m over the follow-up period, with slight pain on motion. This patient remained active as a handball player.
shoulder arthroplasty in other disease states, we found that the rheumatoid patient's improvement is slightly greater (71 points) than in patients with severe trauma (60 points) but is less successful than in patients with osteoarthfitis (77 points) or avascular necrosis (94 points) (1) (Fig. 10). The overall results compare favorably with those of prior studies (2, 4, 6, 10). In each study, pain relief in the rheumatoid patient has been good while the increased elevation of the arm has been less than in other disease states. We found an average increase in elevation of only 15 °, from 61 ° before surgery to 76 ° at follow-up evaluation. This is similar to the results of a study by Kelly et al., in which 37 rheumatoid patients had an average flexion increase from 55 ° to 75 ° (8). These values are less than those reported by Cofield, whose 29 rheumatoid patients had 56 ° of abduction increasing to 103 ° at follow-up (4). This difference is not accounted for by the presence of fullthickness rotator cuff tears, as Cofleld reported 7 of 29 patients, identical to our findings. The overall poorer functional quality of the end result in rheumatoid patients appears to be related to the extensive soft tissue disease that is concurrent with the articular injury, as well as the multiple joint involvement that m a y prejudice the end result evaluation. In selecting rheumatoid patients for total shoulder arthroplasty, we would agree with Friedman and Ewald in suggesting that in those with equally severe disease affecting both the shoulder and elbow, the more distal joint should be selected for the initial procedure (6). They noted that there was greater functional improvement after the elhow arthroplasty and that there was a longer interval between proPre-cp
80
Discussion Total shoulder arthroplasty in severe rheumatoid arthritis has been beneficial to our patients in contrast to more limited procedures such as synovectomy or hemiarthroplasty (11). Our results show that significant pain relief was achieved in most patients (93%), whereas functional improvements have been more limited, depending o n the quality of the soft tissues. W h e n comparing our postoperative results in rheumatoid arthritis with our previous study for total
Post-op
i00
60
40
93.8 77.3
71
F
0.3
20
R.A.
TRALTLA*
O.A.*
A.V.N.
Fig. 10. A comparison of follow-up total scores by diagnostic indication demonstrates the poorer results noted on rheumatoid arthritis as compared to osteoarthritis (OA) and avascular necrosis (AVN).
TSA in RA
cedures w h e n the elbow was the initial procedure (45 vs. 13.5 months). In terms of regaining motion and pain relief, performing an arthroplasty of the elbow did not compromise the result of shoulder surgery (6). It should be pointed out that prior to inserting the humeral component, it is best to place a cement restrictor distally, as the ability to insert a subsequent stem on an elbow prosthesis m a y be compromised. Patients in w h o m lower extremity disease is severe should have this aspect treated initially, to remove the need for crutches and the subsequent high loads on the shoulder. However, to date patients with total shoulder arthroplasties have been able to use crutches without adverse affects. W h e n performing shoulder arthroplasty in rheumatoid patients, the preoperative assessment of the bony and soft tissue anatomy is critical, as rheumatoid patients have an increased frequency of glenoid protrusio, osteopenia, and rotator cuff disease. In our series, 6 of 29 shoulders had deficiency of the glenoid requiring trimming of the glenoid stem. Neer and Morrison, in a recent report on the need for glenoid bone graft, noted that 7 of 108 patients with deficiency required grafting and 2 required trimming of the stem of the glenoid prosthesis (9). To evaluate the glenoid, a true anteroposterior view of the shoulder as well as an axillary view or CT scan are helpful. On the true anteroposterior shoulder radiograph, the glenoid depth, as measured from the midpoint of the base of the coracoid to the joint sur-
A
•
McCoy et al.
111
face, should measure approximately 2 cm. In our series this distance averaged 1.4 cm, with eight patients having a depth of less than 1 cm. If the bone stock is insufficient, then the surgeon m a y have to consider a bone graft or, if bone graft is impossible, a hemiarthroplasty. In performing a bone graft in rheumatoid patients the deficiency is often anterior or central, in contrast to osterarthritis, w h e n the bone loss is generally posterior. In repairing the defect, a bone graft may be fashioned from the humeral head and pinned or screwed to the remaining glenoid (Fig. 11). It is important that the graft be fixed to the glenoid with pins or screws, which are placed to avoid the central hole created for the prosthetic peg. In addition, the graft placement must be such that the cement application does not prevent bone healing to the graft. In evaluating the humerus, the depth and width of the shaft must be noted, as two patients in our series required trimming of the stem. This is particularly true in patients with juvenile rheumatoid arthritis, in w h o m poor bone development is more common. It appears that the stem of the Neer humeral component is too long for m a n y of these patients and that a shorter stem is sufficient. A major concern in rheumatoid patients is the presence of rotator cuff disease. Overall, we found that 38% of our patients had involvement of the rotator cuff, with a full-thickness tear in seven patients (24%). This incidence is similar to that noted by Cofield (4). At follow-up study those with rotator cuff
B
C
Fig. 11. (A, B) Preparation of the glenoid and insertion of the prosthesis avoiding stem penetration. (C) If there is bone loss, a graft may be necessary. Fixation with pins or screws is necessary to avoid interference with the central stem of the glenoid.
112
The J o u r n a l of A r t h r o p l a s t y Vol. 4 No. 2 J u n e 1989
disease (11 patients) faired poorer than those without, as only one patient was regarded as excellent, two as good, five as fair, and three as failures (Table 3). The ability to complete a repair may be severely impaired by the lack of tendons; in two patients no repair was attempted. In a comparison of patients with and without rotator cuff disease, those with deficient cuffs scored 37% lower o n function scores and 36% less in strength (Figs. 7, 8). The range of motion as represented by forward flexion was reduced by 15 °, averaging 67 ° versus 82 °. Matsen, in reporting o n 50 total shoulder anhroplasties for several etiologies, including rheumatoid arthritis in 11, also noted the affect of rotator cuff tears and found that the patient's degree of elevation after surgery, despite cuff repair, averaged only 62 °, versus 100 ° for the entire population (2). In our study, pain relief in those with a cuff tear was still obtained, as there was only a 6% difference in the pain rating in those with or without cuff disease. Of c o n c e m in patients with a rotator cuff tear is the possibility of loosening of the glenoid compartment. Matsen reported this as a significant problem resulting in glenoid loosening in four patients, each of w h o m had a massive cuff tear. Loosening was noted, both clinically and radiographically, 30 months after surgery. In each patient there was superior migration and superior tipping of the glenoid component. It appears that the unopposed deltoid will increase superior shear on the glenoid, resulting in higher stresses o n the glenoid c o m p o n e n t and subsequent loosening in some patients with rotator cuff tears. However, in our patients with cuff tears none were noted to have developed a loose glenoid. Matsen's patients included nine rotator cuff tears with rheumatoid arthritis as the etiology in only three (2). Of the four patients with a massive rotator cuff tear and glenoid loosening none had rheumatoid arthritis. This m a y be a result of the limited demands placed on the shoulders of more severely involved rheumatoid patients, in contrast to those with osteoarthritis or traumatic arthritis. Despite the presence of significant rotator cuff tears, pain relief was achieved (in our patients) to a degree similar to that in patients with an intact cuff. Table 3. Comparison of End ResuIts of Patients With and Without Rotator Cuff D i s e a s e With Disease Without Disease (n = 11) (n = 18)
Excellent (85-100 points)
Good (70-84) Fair (50-69) Failures (<50)
1 2 5 3
5 8 3 2
Failures
The presence of rotator cuff disease was a significant factor in patients regarded as treatment failures. Five patients were categorized as failures, with follow-up scores of less than 50 points. Four of t h e s e five patients had rotator cuff tears. This included one patient with a recurrent tear following repair at surgery, one patient with a major tear not repaired at surgery, and two patients with follow-up radiographs suggestive of tears based o n a prosthetic head-to-acromion distance of less than 3 mm. In one of these, this distance decreased from 9 m m to 2 m m over the follow-up period and in the other there was erosion of the acromion. In addition, three of these patients classified as failures had difficulties with the ipsilateral elbow, which impaired their use of the upper extremity. The best means of surgical replacement in patients with significant rotator cuff disease remains in debate. The two primary functions of the rotator cuff are to act as a stabilizer of the glenohumeral joint and to provide power for motion (3). By working as a force couple with the deltoid, a fulcrum is established about which the humeral head m a y rotate. Shoulders w h o s e cuffs are severely involved at the time of arthroplasty are currently destined for less than optimal results. As the disease may affect the m u s c l e a s well as the tendon, function itself m a y be diminished, despite an adequate repair of the rotator cuff. Currently there are several methods of treatment available for patients with destroyed rotator cuffs of a magnitude precluding a reasonable attempt at repair. These include using a nonconstrained prosthesis with a limited goals rehabilitation program (5, 6), an oversized glenoid c o m p o n e n t with superior coverage (5, 6), and a fixed-fulcrum prosthesis (7, 10). The advantage offered by a more constrained prosthesis is greater stabilization of the glenohumeral joint, to allow the remaining functional musculature to perform adequately. However, this is balanced by the higher rate of loosening or dislocation generally seen with a constrained prosthesis (7). In rheumatoid patients, this is further complicated by the poor quality of the bone and erosion of the glenoid that are common, making fixation of the larger, more constrained prosthesis increasingly difficult. These factors make the secure long-term implantation of a constrained prosthesis even less predictable. Our current preference is to use a standard glenoid with a limited goals approach, avoiding a fixed-fulcrum prosthesis.
TSA in RA
At the time of surgery, it is necessary to examine other causes of shoulder pain in addition to the glen o h u m e r a l joint arthritis. These include disease involving the acromioclavicular joint and impingem e n t problems. The acromioclavicular joint was resected in only 4 of our 29 cases, despite radiographic changes. It is r e c o m m e n d e d that this joint be preserved, if possible, for muscle attachment. If there is a prominence inferiofly, then burring of this area is indicated with resection only if the joint is acutely painful. Finally, it appears that patients with juvenile rheumatoid arthritis m a y fit into a category distinct from the rest of the rheumatoid population. As a group (5 patients, 7 shoulders), their total score was higher (81 vs. 68), there w e r e no failures, and only one of the rotator cuffs was attenuated. Two shoulders s h o w e d glenoid protrusio and only one patient required trimming of the glenoid stem. This is likely due to the fact that these patients are generally y o u n g e r (average age, 43.5 years), with less time for the m o r e destructive bone and tendon changes to Occur.
Summary Twenty-nine Neer-type total shoulder arthroplasties in patients with rheumatoid arthritis w e r e reviewed, with an average follow-up period of 37 months. An i m p r o v e m e n t in pain has been seen in virtually all patients, as have significant improvem e n t s in motion, function, and strength. Patients with large rotator cufftears had m o r e limited results, with minimal i m p r o v e m e n t s in function and motion,
*
McCoy et al.
113
but pain relief was still achieved. I m p r o v e d methods of handling rotator cuff disease are required.
References 1. Bade HA, Warren RF, Ranawat CS, Inglis AE: Longterm results of Neer total shoulder replacement, p. 294. In Bateman JE (ed): Surgery of the shoulder. Decker, Philadelphia, 1984 2. Barrett WP, Franklin JL, Jackins SEet al: Total shoulder arthroplasty. J Bone Joint Surg 69A:865, 1987 3. Clarke JC, Sew Hoy AL, Gruen TA, Amstutz HC: Clinical and radiographic assessment of a non-constrained total shoulder. Int Onhop 5:1, 1981 4. Cofield RH: Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg 66A:899, 1984 5. Cofield RH: Unconstrained total shoulder prosthesis. Clin Orthop 173:97, 1983 6. Friedman ILl, Ewald FC: Arthroplasty of the ipsilateral shoulder and elbow in patients who have rheumatoid arthritis. J Bone Joint Surg 69A:661, 1987 7. Gristina AG, Webb L: The Trispherical total shoulder prosthesis, p. 49. In: Inglis AE (ed): Symposium on total joint replacement of the upper extremity. CV Mosby, St. Louis, 1982 8. Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg 69B:723, 1987 9. Neer CS, Morrison DS: Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint Surg 70A:1154, 1988 10. Neer CS, Watson KC, Stanton FJ: Recent experiences in total shoulder replacements. J Bone Joint Surg 64A:319, 1982 I 1. Post M, Jablon M: Constrained total'shoulder arthroplasty. Clin Orthop 173:109, 1983 12. Ranawat CS, Warren RF, Inglis AE: Total shoulder replacement arthroplasty. Orthop Clin North Am 11:367, 1980