The surgical treatment of the rheumatoid shoulder

Rheumatoid disease of the shoulder may affect not only the gleno-humeral joint but also the other joints of the shoulder girdle complex. Excision arthroplasty of the acromioclavicular and much less commonly of the sternoclavicular joints may be necessary to relieve persistent symptoms. Bursectomyin conjunction with anterior acromioplasty should provide a definitive solution to rheumatoid involvement of the subacromial bursa when this fails to respond to simple aspiration and hydrocortisone injection. Synovectomy has been little employed and perhaps deserves re-appraisal with regard to its role in the management of early cases of glenohumeral disease. Where pain is the predominant presenting symptom and until such time as joint replacement becomes more fully established and reliable double osteotomy may be worth considering as a very simple and in no way irrevocable surgical procedure. Glenoidectomy on the other hand should probably be regarded as obsolete except in cases where total joint replacement will be permanently contra-indicated. Even then arthrodesis may provide a stronger more stable and lasting solution, but before this operation is exhibited, pre-operative investigation must establish that the patient will be able post-operatively to remain independent with regard to routine activities of daily living and in particular perineal toilet. Arthroplasty of the shoulder must still be regarded as being in the developmental if not frankly experimental stage. The results from several sizeable series however are now beginning to show promising results. Moreover the pendulum is tending to swing towards the concept of a minimally constrained joint such as the Neer prosthesis which will mimic anatomical function and minimise the risks of scapular loosening. Careful attention to the soft tissues and very intensive and prolonged post-operative physio-therapy are vital to a successful outcome. It remains to be seen however whether more constrained joints would provide better functional results in the rheumatoid patient with severe bone erosion and rotator cuff destruction. In spite of the problems still to be solved, the author would regard total joint replacement as being the treatment of choice in the markedly eroded gleno-humeral joint presenting with severe pain and limitation of function. Moreover in the event of mechanical failure or infection, it would still seem to be possible to salvage adequate painfree function either by removal of the prosthesis and the creation of a pseudarthrosis or by arthrodesis.