Surgery for rheumatoid arthritis in the shoulder

This summary of a Cochrane review presents what we know from research about the effect of one type of surgery for rheumatoid arthritis (RA) in the shoulder.  Currently, there is a very limited amount of research on the effect of surgical treatments for the shoulder in people with RA.

 In this review the researchers were able to find just one study comparing one form of surgery called “augmented subscapularis transposition” to another involving just “subscapularis transposition”.

The review shows that in people with rheumatoid arthritis in the shoulder; a surgery involving Augmented subscapularis transposition:

·         may improve your physical function slightly compared to subscapularis transposition alone.

·         makes no difference in improving your pain compared to subscapularis transposition alone.

Infections were not reported.

We often do not have precise information about side effects and complications. This is particularly true for rare but serious side effects.

 

What is rheumatoid arthritis and what kind of surgery have been tried?

Rheumatoid arthritis is a disease in which the body's immune system attacks the lining of the joints, and the joints become swollen, stiff and painful. Usually, the joints of the hands and feet are affected first, but many people with rheumatoid arthritis are severely affected in their shoulders. There is no cure for RA at present, so treatments aim to relieve pain and stiffness, and improve the ability to move.

One common shoulder surgical treatment for people with RA is arthroplasty, i.e. the joint surface (and bone) is replaced with prosthesis (an artifical joint).

 

Best estimate of what happens to people with rheumatoid arthritis who have the type of shoulder surgery called “augmented subscapularis transposition”:

 

Function
People with Augmented subscapularis transposition rated their physical function to be 4 points better on a scale of 0-20 after 2 years compared to people who had augmented subscapularis alone.  (8% absolute improvement)

People with subscapularis transposition alone rated their physical function to be 11 points out of 20.

People with Augmented subscapularis transposition rated their physical function to be 15 points out of 20.

Authors' conclusions: 

The effects of surgical treatment in the management of the shoulder in people with rheumatoid arthritis are largely unknown due to the paucity of randomised controlled trials.

Read the full abstract...
Background: 

Involvment of the shoulder joint in patients with rheumatoid arthritis (RA) leads to severe destruction of the glenohumeral joint. When conservative treatment does not result in sufficient improvement, surgical procedures may be considered as the only beneficial treatment option.

Objectives: 

To assess beneficial and harmful effects of all forms of surgical treatment in the management of the shoulder in people with rheumatoid arthritis.

Search strategy: 

Articles were identified by searches in The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCISEARCH and reference lists of relevant articles (January 1995 to May 2008).

Selection criteria: 

Randomised Controlled Trials, and Controlled Clinical Trials reporting on effects of shoulder surgery. In addition case-series were included for the assessment of complications.

Data collection and analysis: 

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data.

Main results: 

One RCT, one CCT and 21 case-series were included. The RCT compared cemented versus uncemented humeral stem fixation in arthroplasty and found no significant differences between the two groups after two years (low quality evidence). The CCT compared rotator cuff repair with augmented subscapularis transposition versus subscapularis transposition alone and reported significant differences in favour of the augmented subscapularis transposition after 2 years in function, mean difference (MD) 4.00 on a 0 to 30 scale (95% CI 1.11 to 6.89) and pain, MD 4.00 on a 0 to 20 scale (95% CI 0.84 to 7.16) (low quality evidence). Based on 11 case series (mean follow up 4.5 to 12 years) complications were reported in 11% (95% CI: 9.9% to 12.1%) of the total shoulder arthroplasties, while 10 case-series (mean follow-up 2.7 to 11.3 years) reported complications in 9.9% (95% CI: 8.4% to 11.4%) of the hemiarthroplasties (very low quality evidence).

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