3. Conclusion

Publication

Rittmeister

8 60.25 (range 34–86) 54.3 months

> et al. [116]

Holcomb

21 70.3 (range 53–86)

 36 months

ASES: 28

ASES: 82

74

14

99.6%

 3 (2 infection, 1

periprosthetic

fracture)

(range 24–

SST: 1

SST: 7

VAS

VAS

function

function

score:: 3

score: 6

73)

et al. [121] Young et al.

16 70.1 (range 46.3–

45.6 months

Constant:

Constant:

61.6

29.2

94%

 None

> (range 25–

22.5

64.9

84)

[123]

Tiusanen

76 70.7 (range 49–90)

 36 months

 N/A

 N/A

 48.5

5.5

90%

 25 scapular notching (Grade

I:19,

Grade II: 3, Grade III: 3)

et al. [120] Abbreviations:

Table 6.

Summary of previous

publications

 about reverse shoulder

Arthroplasty

 in RA patients.

 ER, external rotation; FF, forward flexion; ASES, American Shoulder and Elbow Surgeons Score; SST, Simple Shoulder Test; VAS, Visual Analogue Scale.

83.6)

(range 48–

17

63

73)

 N Age (Mean)

 Follow-up

 Pre-op

Post-op

Improvement

Improvement

Satisfaction

Complications

 Conclusion

Score

Constant:

Constant:

N/A

N/A

100%

 3

Reverse shoulder

(reosteosynthesis

arthroplasty

stable and functional

joint even though the

deltoid is the functioning

sole muscle when the

rotator cuff is beyond

restoration

Reverse shoulder

arthroplasty

treatment option for

rotator cuff deficient

rheumatoid

contrary to previous

reports, but long-term

results are needed.

Reverse shoulder

arthroplasty

rheumatoid

promising but care must

be taken against intra

and fractures in this

population

Even though external

and internal rotations are

limited, with no major

complication,

improved FF, extension;

high patient satisfaction

can be achieved.

 and

postoperative

 shoulder are

 results in

 shoulders in

 is a reliable

 provides a

192 Advances in Shoulder Surgery

of acromion

required)

Score

in FF

in ER

> We tried to simplify the indications, advantages and disadvantages above-mentioned treatment options in Table 7 and Figure 5. Main critical factors for decision making for optimal surgical treatment are patients' age, functional demand, rotator cuff status and remaining glenoid bone stock. Treatment for young-aged patients will require a long-term survival rated surgical treatments or a short-term treatment with preservation of bone stock to revise to prosthesis. If the patients' radiological evaluation is below Larsen class II, synovectomy or bursectomy may be preferred, but if it is moderately or severely deformed, rotator cuff status becomes the main identifier. If rotator cuff is intact, surgeon can prefer hemiarthroplasty or resurfacing arthroplasty which preserves glenoidal bone stock and with good survival rate. With torn rotator cuff, the situation becomes more dire, even though good functional outcomes can be achieved with anatomic TSA and rotator cuff repair, in long-term follow-up rotator cuff degeneration is inevitable which results in pain because of superior migration of prosthesis and loss of glenoidal bone stock, also tragically glenoidal component loosening due to rocking


Table7.Briefcomparisonoftreatmentmodalitiesinrheumatoidarthriticshoulder.

horse phenomenon. RSA can be an option but literature lacks young-aged patients

Figure 5. A treatment strategy for the surgical treatment of rheumatoid shoulder [50].

(>50 years) patients

tion for the surgeon dealing with RA.

Recently, researches about RSA are focused on the daily functioning of patients and the results are promising. It can be foreseen that RSA age limit will be lowered in the future. In old-aged

indicators are still rotator cuff and glenoidal bone stock for decision making. If the rotator cuff is intact and adequate glenoidal bone stock is present, TSA will be the optimal choice with long-term survival and good functional outcome. But if the glenoid bone stock is inadequate, hemiarthroplasty may be the optimal choice, also TSA with autograft use from humeral head would promise a better functional demand in these groups of patients. With the degeneration of the rotator cuff, surgical options narrow down to hemiarthroplasty and RSA. If glenoidal bone stock is adequate RSA would be optimal, but with inadequate glenoid bone stock, hemiarthroplasty still provides good functional demand but not better than autograft supported RSA. Even though these treatment indications are disputed, they will provide useful informa-

The decision making of a RA patient with shoulder pain is still a challenging concept. Not because of the mentioned criteria but also for the disease nature, lower extremity concerns which might have led the patient to use upper extremity for mobilization by an apparatus.

' radiological evaluation is mostly advanced to Larson class III. Main

' outcomes.

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 195

Figure 5. A treatment strategy for the surgical treatment of rheumatoid shoulder [50].

Procedure

Synovectomy

bursectomy

Resection

Controversial

 • Slows the progression

destruction

•

• Delays requirement

arthroplasty

Protects bone stock

 of

• •

Humeral head resorption

Limited range of motion

Convertible

choice for the young aged

arthroplasty

Yes

No

interposition

arthroplasty

Resurfacing

Yes

•

• High satisfaction

• Lower glenoid erosion

rate than HA

Hemiarthroplasty

 Yes

• Stable

•

• Good functional outcome

• Low loosening rates

> Total shoulder

Yes

• Stable

• Better functional outcome

than HA

• of destruction

> Reverse shoulder

Yes

• Good functional outcomes

even after RC tear occurs

• High satisfaction

 rates

arthroplasty

Abbreviations:

Table 7. Brief comparison

 of treatment modalities

 in rheumatoid

 arthritic shoulder.

 HA,

hemiarthroplasty;

 TSA, anatomical

 total shoulder

arthroplasty;

 RC, rotator cuff.

Prevents the progression

glenohumeral

 joint

•

Decreased functional

To achieve better

Yes

Yes

outcome after

of RC

•

Concern of glenoidal

loosening

• surgery

• No alternative

arthroplasty

Complicated

 revision

To achieve good functional

No

Yes

outcomes even after RC

tear occurs

deterioration

glenohumeral

alignment and functional

outcome

 joint

arthroplasty

Convertible

 to TSA

glenohumeral

 joint

• Painful glenoid erosion

•

rates after 10 years

Decreased satisfaction

 rates

Protects bone stock

•

• High radiological

loosening

Superior migration

Protects bone stock with

Yes (with intact RC,

No

lower rate of complication)

good functional results and

enables future revision

options

Pain relief without losing

No (with intact RC,

No

better functional

outcomes)

glenoid bone stock

arthroplasty

 and

Yes

• Easy to Perform

• Unable to prevent disease

Symptomatic

 relief

 No

progression

• Only early stage patients

can be candidates

 in the joint

 Pain relief

Advantages

Disadvantages

Purpose

Rotator cuff

Glenoidal bone

stock

requirement

No

194 Advances in Shoulder Surgery

dependency

horse phenomenon. RSA can be an option but literature lacks young-aged patients' outcomes. Recently, researches about RSA are focused on the daily functioning of patients and the results are promising. It can be foreseen that RSA age limit will be lowered in the future. In old-aged (>50 years) patients' radiological evaluation is mostly advanced to Larson class III. Main indicators are still rotator cuff and glenoidal bone stock for decision making. If the rotator cuff is intact and adequate glenoidal bone stock is present, TSA will be the optimal choice with long-term survival and good functional outcome. But if the glenoid bone stock is inadequate, hemiarthroplasty may be the optimal choice, also TSA with autograft use from humeral head would promise a better functional demand in these groups of patients. With the degeneration of the rotator cuff, surgical options narrow down to hemiarthroplasty and RSA. If glenoidal bone stock is adequate RSA would be optimal, but with inadequate glenoid bone stock, hemiarthroplasty still provides good functional demand but not better than autograft supported RSA. Even though these treatment indications are disputed, they will provide useful information for the surgeon dealing with RA.

The decision making of a RA patient with shoulder pain is still a challenging concept. Not because of the mentioned criteria but also for the disease nature, lower extremity concerns which might have led the patient to use upper extremity for mobilization by an apparatus. Thus the shoulder surgery might cause an immobilization and further decrease the quality of life for the patient. Consultation and working together with a rheumatologist for following-up is essential for the patient's health status because of cessation of RA drugs preoperatively and following-up postoperatively. Decision making process must be made according to other concerns and needs of the patient and discussed thoroughly with the patient and also his/her rheumatologist.

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