2. Current surgical treatments

Joint status of the RA patients was needed to be evaluated after biological agent administration for remission of the disease. Joint destruction pattern under biologic agents were widely discussed. Fukae et al. [21] had shown under X-ray imaging of fingers, Yoshimi et al. [22] by ultrasound and Suzuki et al. [23] evaluated the synovitis of the hand by the help of MRI. Yonemoto et al. had chosen the 18F-fluorodeoxyglucose positron emission tomography for the evaluation of the destruction. They shared the results of the previous studies of the authors mentioned that even though clinical status of the patient may improve, the synovitis thus

In multiple-joint involvement type of the disease, shoulder joint is commonly involved. But it is rarely affected in monoarticular fashion. The clinical presentation may be different in every patient. It can be symmetrical, episodic and silent between periods of remission. The clinical presentation may start with musculoskeletal pain, fever, fatigue or malaise. At the same time, other joints may present with erythema, pain and stiffness after inactivity. In the early stages of this disease, inflammatory changes of the subacromial soft tissue like bursitis, tenosynovitis of the long head of the biceps tendon resulting in defects of the rotator cuff. Rotator cuff is affected both by the synovial proliferations of the glenohumeral joint and the synovitis of the subacromial bursa. The starting point of the destruction of the rotator cuff is often a partial defect of the supraspinatus tendon at the attachment side to the humeral head. The intraoperative rate of this pathology lies between 30 and 90% of the cases, intratendinous defects between 20 and 40%, partial defects and simply thinning-out is found 80% of the cases [25]. Glenohumeral joint, at the beginning, is not really painful because of the large intracapsular space. The first cartilage bone change starts from humeral head that leads to deformation of the head [26]. Pain originates from the capsule, that is sensitive to stretch and distension. The increase in the synovial fluid and hypertrophy of the synovium leads to increase in intra-articular pressure. To overcome this condition, the shoulder is positioned in slight flexion and internal rotation. By this way, the

The initial presentation around the shoulder is pain and loss of motion. With the progression of the disease, loss of elevation and external rotation are noted. The initial presentation of the disease can be subacromial bursitis with giant rice bodies in some patients, which may mimic impingement syndrome [27]. Villous synovial hypertrophic tissues (pannus) may result in crepitation and pain during motion. At the inflammatory phase, the patient experiences a constant aching even at rest and being worst at night. In rare cases, scapulothoracic bursa can become inflamed and painful [28]. It should be kept in mind that, in rheumatoid shoulder, the affected joint is not only the GH joint, also acromioclavicular joint (AC) is affected. It was found that in RA patients, AC joint is affected more frequently than the GH joint, but in half of the patients both joints are involved. This should be remembered when treating painful rheuma-

The shoulder joint is affected in approximately 60% of hospitalized patients with RA [30, 31]. The pain around the shoulder area was reported in 50% of newly diagnosed RA patients [32]. The degree of dysfunction of the shoulder is related to the severity of the rheumatoid disease [33]. It was reported that 48% of RA patients developed glenohumeral erosive changes and 13% developed pathologic joint space narrowing. Plain radiographs of the rheumatoid shoulder are the

destruction was only slowed [24].

172 Advances in Shoulder Surgery

capsular volume is increased [1].

toid shoulder [29].

## 2.1. Synovectomy and bursectomy

In RA, synovium produces chemokines and cytokines, which are responsible for pain and swelling of the joint and later for the articular destruction [41]. Synovectomy is a treatment method aimed for pain relief and treatment of joint swelling before bony erosions occur [42].

Indication of synovectomy may be considered when appropriate medical treatment fails after a period of 6–12 months [41]. Open synovectomy and bursectomy was first described by Pahle in 1973 [43]. Schmidt et al. accomplished arthroscopic approach for synovectomy in 1994 [44]. Although the clinical results are not significantly different between open and arthroscopic synovectomy, due to the immunosuppression resulted by medical treatments and disease itself, arthroscopic approach is mostly preferred. Also short hospital stay and lower risk of shoulder motion restriction are the additional advantages of arthroscopic approach [42]. The results of this treatment method for rheumatoid shoulder are widely discussed in the literature [42–46].

Ossyssek et al. reported two-staged synovectomy in rheumatoid knee. In the first stage, synovectomy was performed and the prominent area of synovitis was marked. In the second look, previously marked synovium area was collected and investigated by immunofluorescence. After the first stage, 94% of the patients' pain was relieved and was linked to the results of immunofluorescence which has shown reduced sensory innervations [47].

In Petersson's open synovectomy series, 21 patients who had gradually increased pain and restriction of motion despite medical management and hydrocortisone injections, were included. Three of 21 patients had advanced arthritic changes at the time of surgery and was not excluded. A mean follow-up of 4 years revealed that if joint cartilage is well preserved, the efficacy of synovectomy and bursectomy increases, thus the functional outcome [45]. Also Petersson stated that in spite of Pahle et al.'s report for synovectomy's favorable outcomes in advanced arthritis, synovectomized 2 out of 3 advanced arthritic patients were dissatisfied and required arthroplasty [45, 48].

On contrary, Kanbe et al. performed arthroscopic synovectomy and capsular release to 54 patients and reported that excellent outcomes can be achieved even if the radiological changes have been occurred. These patients' had shorter disease duration, younger age and lower prednisolone usage. Based on these prognostic factors, a patient even with bone and cartilage destruction might have a good clinical outcome after synovectomy. They also suggested that medical treatment alone will not suffice to stop the progression of inflammation and synovectomy should be performed to obtain improved quality of life before rotator cuff tear occurs [42].

As for late stage rheumatoid shoulders, Wakitani et al. accepted success of synovectomy for pain relief, but pointed out shoulder arthroplasty had better functional outcomes in addition to pain relief, which limited the indications of synovectomy for early stage rheumatoid shoulders [49].

In conclusion, arthroscopic synovectomy and bursectomy is the first line of surgical treatment not a decisive solution in early staged rheumatoid shoulder. But this treatment is mostly symptomatic because of the inability to stop the progression of erosions in the joint. This procedure can delay the need for arthroplasty for the patients approximately 4 years, but as the disease progresses, the need for arthroplasty will be evident. In Table 2, the literature is summarized according to functional status and complications. When considering the surgical outcomes, the limitations of this surgery should be widely discussed with the patients [50].

Publications

Kanbe et al.

7 A 13 (range 13)

 62 (range 49–68) N/E

 Decreased CRP levels,

N/A

 N/A

—

Combination

treatment and

synovectomy,

progression

 of arthritis

 slows the

 of medical

> increased efficacy of

RA medications

 15 increase in ER

ASES: N/A

ASES: 60

1

Good functional results and pain relief in rotator

cuff intact shoulders

(range 47–67)

SST: 8 (range 6–11)

SST: N/A

34 increase in FF

(statistically

significant)

[41]

Smith et al.

16 A 66 (range 12–120) 49 (range 28–71) 13/16

[46]

Kanbe et al.

54 A 60

 40.92

 53.3 (range N/A) N/E

 30 increase ER

JOA:

JOA:

—

Good functional results

can be obtained before the

tear of

rotator cuff

36.65

 7.66

84.61

 12.74

48 increase FF

[42]

Pahle [48] Petersson

13 O 48 (range N/A)

 60 (range 31–73) 5/12

 29 increase ER

N/A

 Pain Score:

2

Good functional results in

early stages

1.3 (range 1–3)

44 increase FF

[45]

Abbreviations:

Simple Shoulder Test; JOA, Japanese Orthopedic

\*Satisfied patients with pain-free or mild pain.

\*\*Total number of participated

Table 2.

Summary of previous

publications

 about

synovectomy

 and bursectomy

 in RA patients.

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 175

 patients.

 CRP, C-reactive

 protein; RA, rheumatoid

 arthritis; ER, external rotation; FF, forward flexion; ASES. American Shoulder and Elbow Surgeons Score; SST,

 Association

 Score; N/E, not evaluated.

 54 O 64 (range N/A)

 N/A

6/54

 %10 increased

N/A

 N/A

6

Good functional results in

early stages

shoulder functions

 n A/O Follow-up (mean) (months)

Age (mean)

Pain

Result

Pre-op

Post-op score Conversion

to

Conclusion

arthroplasty

score

relief\*/\*\*

(years)


Indication of synovectomy may be considered when appropriate medical treatment fails after a period of 6–12 months [41]. Open synovectomy and bursectomy was first described by Pahle in 1973 [43]. Schmidt et al. accomplished arthroscopic approach for synovectomy in 1994 [44]. Although the clinical results are not significantly different between open and arthroscopic synovectomy, due to the immunosuppression resulted by medical treatments and disease itself, arthroscopic approach is mostly preferred. Also short hospital stay and lower risk of shoulder motion restriction are the additional advantages of arthroscopic approach [42]. The results of this treatment method for rheumatoid shoulder are widely discussed in the

Ossyssek et al. reported two-staged synovectomy in rheumatoid knee. In the first stage, synovectomy was performed and the prominent area of synovitis was marked. In the second look, previously marked synovium area was collected and investigated by immunofluorescence. After the first stage, 94% of the patients' pain was relieved and was linked to the results

In Petersson's open synovectomy series, 21 patients who had gradually increased pain and restriction of motion despite medical management and hydrocortisone injections, were included. Three of 21 patients had advanced arthritic changes at the time of surgery and was not excluded. A mean follow-up of 4 years revealed that if joint cartilage is well preserved, the efficacy of synovectomy and bursectomy increases, thus the functional outcome [45]. Also Petersson stated that in spite of Pahle et al.'s report for synovectomy's favorable outcomes in advanced arthritis, synovectomized 2 out of 3 advanced arthritic patients were dissatisfied and

On contrary, Kanbe et al. performed arthroscopic synovectomy and capsular release to 54 patients and reported that excellent outcomes can be achieved even if the radiological changes have been occurred. These patients' had shorter disease duration, younger age and lower prednisolone usage. Based on these prognostic factors, a patient even with bone and cartilage destruction might have a good clinical outcome after synovectomy. They also suggested that medical treatment alone will not suffice to stop the progression of inflammation and synovectomy should be performed to obtain improved quality of life before rotator cuff tear

As for late stage rheumatoid shoulders, Wakitani et al. accepted success of synovectomy for pain relief, but pointed out shoulder arthroplasty had better functional outcomes in addition to pain relief, which limited the indications of synovectomy for early stage rheumatoid shoul-

In conclusion, arthroscopic synovectomy and bursectomy is the first line of surgical treatment not a decisive solution in early staged rheumatoid shoulder. But this treatment is mostly symptomatic because of the inability to stop the progression of erosions in the joint. This procedure can delay the need for arthroplasty for the patients approximately 4 years, but as the disease progresses, the need for arthroplasty will be evident. In Table 2, the literature is summarized according to functional status and complications. When considering the surgical outcomes, the limitations of this surgery should be widely discussed with the patients [50].

of immunofluorescence which has shown reduced sensory innervations [47].

literature [42–46].

174 Advances in Shoulder Surgery

required arthroplasty [45, 48].

occurs [42].

ders [49].


\*\*Total number of participated patients. Table 2. Summary of previous publications about synovectomy and bursectomy in RA patients.
