Management of Glenohumeral Arthritis.

Last updated Wednesday, January 09, 2008

Figure 1

Surgical treatment

Surgical options

Synovectomy

Rheumatoid arthritis and other inflammatory arthropathies produce synovial tissue hyperplasia and its attendant symptoms. A benchmark article on care for rheumatoid joint problems was published in 1943 (Smith-Peterson, Aufranc and Larson, 1943) offering great insight into the surgical care of rheumatoid patients during the preprosthetic era. The authors observed that surgery was not always necessary or desirable, and surgery of the joint in and of itself would be unlikely to change the long-term course of the disease for the patient. When shoulder symptoms were severe and persistent, shoulder synovectomy, bursectomy, and acromioplasty seemed to alleviate pain and allow the patient improved use of the involved limb.

Patients may be considered for synovectomy if they have chronic refractory synovitis. Clinically this is evident as an enlarged, boggy-feeling shoulder, indicating either primary bursal hypertrophy or rotator cuff tearing with extension of synovial tissue and fluid into the subdeltoid bursa. A shoulder arthrogram may help define the severity and extent of the synovitis as well as information about the presence or absence of rotator cuff tearing.

Pahle and Kvarnes (Pahle and Kvarnes, 1985b) reported on the application and relative effectiveness of shoulder synovectomy. Their method included a subdeltoid and subacromial bursectomy, arthrotomy through the subscapularis, and synovectomy of all joint areas. In addition, any osteophytes or other joint irregularities are removed or smoothed. If there is tenosynovial hypertrophy surrounding the long head of the biceps brachii, this tissue is also removed. Postoperatively, a light abduction pillow is placed, and exercises are commenced two to three days following surgery. Pain relief in their patients was often quite good, with significant residual pain in only 10 of 54 shoulders (approximately one-half had significant joint surface irregularity). Motion in these patients was slightly improved but not dramatically so. A lessening of the pain did improve limb function.

Currently, synovectomy is reserved for patients with intact articular cartilage or cartilage that is at least one-half of its normal thickness. Synovectomy may be accomplished arthroscopically although great care is necessary to avoid nerve damage. Open synovectomy is approached through the deltopectoral interval. The subdeltoid bursal tissue is excised carefully, protecting the axillary nerve on the undersurface of the deltoid muscle. Rotator cuff defects are identified. Usually, the arthrotomy will include division of the subscapularis near its insertion and division of the anterior shoulder capsule at its humeral attachments. The capsular incision will extend up to the intra-articular portion of the long head of the biceps tendon and along this tendon to its glenoid origin. The incision will also extend inferiorly to the six o'clock position on the humeral head. Synovium is removed from the anterior portion of the shoulder and the subscapularis recess. Synovium is then removed from the inferior aspect of the joint. By preserving the fibrous layer beneath the synovial tissue, the axillary nerve will be protected. By working around the humeral head, the posterior synovial hypertrophy is removed. Exposure may be facilitated by partially dislocating the joint. Reparable cuff defects may be addressed by direct suturing or subscapularis transposition upward(Cofield, 1989). Drains are kept in place as long as fluid is being retrieved. Sutures are left in place for ten days. Postoperative care includes early passive range of motion. Active exercises are delayed untilhealing of tendon repairs is complete.

Resection arthroplasty

Before prostheses were available, resection of the humeral head was used to manage severe fractures and uncontrollable infection. (Craviotto, Seltzer, Wirth, et al., 1994; Mason, 1908; Steindler, 1940) Several authors have reported on excision of the glenoid in conjunction with synovectomy. (Gariepy, 1977; Wainwright, 1976) Milbrink and Wigren (Milbrink and Wigren, 1990) reported reasonable short term results from 13 resection arthroplasty for advanced rheumatoid arthritis. Pain relief was said to be good. Motion was best in those shoulders with a well-preserved and round humeral head.

Resection arthroplasty of the shoulder is useful as an adjunct to the care for septic arthritis of the shoulder with extensive humeral head and glenoid osteomyelitis. A joint resection also results after removal of infected or mechanically compromised implants. (Cofield, 1983a; Craviotto, Seltzer, Wirth, et al., 1994; Lettin, Copeland and Scales, 1982) The initial problem following resection is joint instability. Later, stiffness usually develops, and a few shoulders actually go on to bony arthrodesis. (Neer, 1955) Pain relief is variable. (Lettin, Copeland and Scales, 1982) Maximum active abduction is typically 60 to 80 degrees. (Cofield, 1983a; Craviotto, Seltzer, Wirth, et al., 1994; Lettin, Copeland and Scales, 1982; Mills, 1974; Svend-Hansen, 1974) However, moderate weakness persists. Suturing the rotator cuff to the remaining portion of the upper humerus may increase strength, but the results have been variable. (Jones, 1933; Jones, 1942; Knight and Mayne, 1957; Neer, Brown and McLaughlin, 1953)

Glenohumeral arthrodesis

Glenohumeral arthrodesis is usually reserved for attempts at salvaging septic arthritis or complex deficiencies of the joint surface associated with permanent loss of the cuff and deltoid. Early in this decade, there were many indications for arthrodesis of the shoulder, but now there are only a few. (Cofield, 1985; Cofield and Briggs, 1979) Most shoulder fusions today are done for one of four reasons: paralysis of the deltoid and rotator cuff, infection with loss of glenohumeral cartilage, refractory instability, or failed reconstructive procedures. (Rockwood, Jarman and Williams, 1991) Seldom, if ever, is shoulder fusion undertaken for treatment of the more usual causes of shoulder arthritis, even in younger individuals who wish to be active. An exception to this is expressed in the article by Rybka and co-workers from Finland. (Rybka, Raunio and Vainio, 1979) These authors defined the results of arthrodesis in a group of patients with rheumatoid arthritis. Thirty-seven of forty-one shoulders fused. Complications were few. A brace was used for postoperative support in the hope of avoiding the potential of elbow stiffness. This investigation suggested that arthrodesis was easily achieved, inexpensive, and a reliable method for the treatment of severely involved rheumatoid shoulders.

Some consensus has been reached about the desirable position of shoulder fusion. Rowe was the first to firmly state the advantages of less abduction and flexion for the surgically arthrodesed shoulder: 20 degrees of abduction, 30 degrees of flexion, and internal rotation of 40 degrees. (Rowe, 1974) Hawkins and Neer(Hawkins and Neer, 1987) recommended 25 to 40 degrees of abduction for the arm, 20 to 30 degrees of flexion, and 25 to 30 degrees of internal rotation. In determining arm position, the trunk is commonly used as the source of reference, with the scapula being held in the anatomical position. Jonsson et al(Jonsson, Lidgren and Rydholm, 1989) described a method for documenting the position of fusion using Moire photography.

The best candidates for this procedure are those patients with:

1. Permanent and severe weakness due to loss of cuff and deltoid function;
2. Good scapular motors (trapezius, pectoralis, serratus, rhomboids);
3. Good understanding of the limitations and potential complications of a shoulder fusion;
4. Good motivation; and
5. Minimal complaints of pain.

To establish the limitations of shoulder fusions, Harryman, et al (Harryman, Walker, Harris, et al., 1993; Matsen, Lippitt, Sidles, et al., 1994) studied twelve shoulders who had glenohumeral arthrodeses at least two years prior to the time of study. Elevation in the plus 90 degrees (anterior sagittal) plane averaged 47 degrees. Elevation in the minus 90 degrees (posterior sagittal) plane averaged 22 degrees. External rotation averaged 9 degrees and internal rotation 46 degrees. These ranges of motion were similar to the scapulothoracic motion measured in normal subjects. (Harryman, Walker, Harris, et al., 1993) Only one of the patients could reach his hair without bending his neck forward, only five could reach their perineum, six could reach the back pocket, seven the opposite axilla, and ten the side pocket.

These same authors studied normal in vivo shoulder kinematics to predict the functions which would be allowed by various positions of glenohumeral arthrodesis, assuming that the scapulothoracic motion would remain unchanged. (Matsen, Lippitt, Sidles, et al., 1994) Using the normal scapulothoracic motions they were able to model the functional effects of different fusion positions. They found that activities of daily living could be best performed if the joint was fused in 15 degrees of flexion, 15 degrees of abduction and 45 degrees of internal rotation (see figure 1). This low angle of elevation and relatively high degree of internal rotation facilitated sitting comfortably in a chair, lying flat in bed, as well as reaching the face, opposite axilla, and perineum. However, all positions represented major compromises of normal function. This is the primary reason for avoiding fusion in individuals with such conditions as osteoarthritis, rheumatoid arthritis, or traumatic arthritis when adequate bone stock and muscle function are present. Function following total shoulder arthroplasty is much better.

There are many techniques for shoulder arthrodesis. These are best classified as extra-articular, intra-articular, or a combination of the two. Extra-articular arthrodesis techniques, such as that of Putti, (Putti, 1933) Watson-Jones, (Watson-Jones, 1933) or Brittain (Brittain, 1942) had greatest usefulness as adjunctive care for infection, especially tuberculosis. With an extraarticular arthrodesis, the surgeon hoped to avoid the infectious focus and accomplish a fusion about the affected joint. Now, effective antimicrobial medications essentially obviate the need for this approach.

Intra-articular fusion offers the simplest and most direct method. The joint is debrided and remaining cartilage, scar, and dense subchondral bone are removed. Cancellous bone of the humeral head and glenoid are placed against each other, and with the arm in the desired position, fixation is placed. Different forms of fixation have been used, including screws, (Becker, 1975; Hauge, 1961; Matsunaga, 1972) wires, (Carroll, 1957) bone grafts, (Hucherson, 1959; Rountree and Rockwood, 1959) and pins. (De Velasco Polo and Cardoso Monterrubio, 1973) Currently, the use of screws seems to be favored. A cast is usually used following this technique and is continued for three to six months. This technique still seems reasonable for the individual with an excellent rotator cuff and capsule who might later be a candidate for prosthetic replacement.

Intra-articular fusion can be combined with extra-articular fusion. Extra-articular bone contact is achieved by bringing the humeral head against the acromion or by adding bone grafts between the humeral head and acromion or between the humeral neck and medial scapula adjacent to the glenoid. Fixation is obtained by screws, (Bayley and Kessel, 1982; Cofield and Briggs, 1979; Kalamchi, 1978; May, 1962; Rybka, Raunio and Vainio, 1979; Uematsu, 1979) staples, bone grafts, (Beltran, Trilla and Barjau, 1975; Brett, 1933) external fixation, (Charnley, 1951; Charnley and Houston, 1964; Johnson, Healy, Brooker, et al., 1986) or bone plates. (Debrunner and Cech, 1975; Laumann and Schilgen, 1977; Richards, Sherman, Hudson, et al., 1988; Richards, Waddel and Hudson, 1985; Riggins, 1976; Russe, 1978; Weigert and Gronert, 1974) Tension band wiring has been suggested if the bone is osteoporotic. (Blauth and Hepp, 1975) External fixation may be preferred if the shoulder is infected or in the presence of wound problems. External rotation carries the risk of radial nerve injury. (Charnley, 1951)

Internal fixation with one or more plates has the potential to obviate the need for long-term external cast or brace support during the postoperative period. (Wilde, Brems and Boumphrey, 1987) The arm position can be fixed securely in the position the surgeon wishes without worry that the arm position will change during healing. Narrow dynamic compression plates are often used. Recently, it has been suggested that pelvic reconstruction plates are easier to apply and may be equally effective. (Richards, Sherman, Hudson, et al., 1988)

The rate of bony fusion following many of these methods of shoulder arthrodesis is 80% to 90%. Shoulder fusion carries the risks of infection, reflex dystrophy, acromioclavicular arthritis, and symptomatic internal fixation needing later removal. Fracture of the operated extremity below the fusion has been reported. (Cofield, 1985)

Patient satisfaction can never be perfect after a procedure such as this, but it does approach 80 percent. (Cofield, 1985) Some patients have shoulder girdle pain in spite of a successful bone fusion. (Bayley and Kessel, 1982; Cofield, 1985) Richards et al(Richards, Beaton and Hudson, 1993) reviewed 57 patients who had fusion with a single plate to achieve glenohumeral and acromiohumeral arthrodesis. They used a 30,30,30 position (abduction, internal rotation and flexion). Only two of these fusions were for arthritis and two for failed shoulder arthroplasty (the rest were for brachial plexus palsy, refractory instability or sepsis). There were 14% complications and three required regrafting. Most patients except those in the instability group were satisfied. Persisting pain after a fusion is often difficult to explain. It used to be thought that resection of the distal clavicle would improve motion following shoulder fusion, however, our experience indicates that gains are minimal.

Preferred technique for shoulder arthrodesis

Periarticular osteotomy

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