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Rheumatology 2001; 40: 384-386
© 2001 British Society for Rheumatology
Arthroscopic subacromial surgery in inflammatory arthritis of the shoulder
Melbourne Shoulder and Elbow Centre and Monash Medical Centre, Melbourne, Australia
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Abstract |
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Objective. To evaluate the effectiveness of shoulder arthroscopy, with predominantly subacromial surgery, in patients with inflammatory arthritis.
Methods. Twelve patients with inflammatory arthropathy underwent arthroscopic shoulder surgery with subacromial decompression, debridement, and limited synovectomy. All clinically had symptoms predominantly arising from the subacromial region.
Results. In the final review, ten patients (83%) were satisfied with the result. Two year follow-up was achieved in 11 patients. Seven rated their recovery as good or excellent, one was fair, and three were poor. All three poor results had fairly advanced glenohumeral chondral damage.
Conclusion. In patients with inflammatory arthropathy and shoulder pain which clinically appears related predominantly to the subacromial region, provided there is no major chondral damage, then a reasonable result can be expected with arthroscopic debridement and modified subacromial decompression.
KEY WORDS: Shoulder, Inflammatory arthritis, Subacromial impingement, Arthroscopic surgery.
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Introduction |
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In patients with inflammatory arthropathy, shoulder symptoms often arise from the glenohumeral joint, related to either synovitis or chondral damage. However, in some cases, pain and loss of function may be due primarily to subacromial inflammation, secondary impingement and rotator cuff damage. Arthroscopic acromioplasty has been shown to give good pain relief for non-inflammatory subacromial rotator cuff degeneration and impingement [1–3]. It is proposed that arthroscopic surgery, principally in the subacromial area, would also be beneficial in patients with inflammatory shoulder disease. Arthroscopy allows assessment, synovectomy, subacromial bursectomy, rotator cuff debridement and modified acromioplasty with preservation of the coracoacromial ligament, yet it remains a minor procedure. This is especially important in those with rheumatoid arthritis whose ability to undergo more lengthy procedures may be compromised.
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Materials and methods |
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The study population consisted of 12 patients with inflammatory arthropathy who underwent arthroscopic shoulder surgery for clinically evident subacromial disease.
The patients were all under the care of a rheumatologist who referred them to the senior author (SB). All had shoulder symptoms, especially pain, which had failed to respond to standard conservative management. The shoulder pain was rated by all patients as one of the most significant problems of their inflammatory arthropathy. Average age was 58 yr (range 23–77 yr). Nine patients were female and three male. Nine were right-handed and three left-handed. Two subjects underwent arthroscopy on the non-dominant side. Eight patients had rheumatoid arthritis, three seronegative arthritis and one psoriatic arthritis. Three of the patients had had features of inflammatory arthropathy for less than 2 yr. Nine had been treated with methotrexate and five were taking prednisolone prior to surgery. All patients had received at least one preoperative cortisone injection to the shoulder.
The study group were selected on the basis of severe subacromial symptoms and signs [4] unresponsive to conservative measures. All had a good range of passive glenohumeral movement. Active forward elevation was restricted in nine shoulders, with average anti-gravity elevation of 127°. Five had less than 130° of elevation. In all patients there was pain on testing the power of the supraspinatus and the Neer impingement sign [4] was positive in 10 shoulders. On standard radiographs, none had greater than minor glenohumeral changes. All 12 patients, prior to surgery, had significant inflammatory problems in other joints, in addition to the shoulder.
Shoulder arthroscopy was performed under general anaesthetic with the patient in the lateral position with the arm in traction [1, 5], taking due care of the cervical spine. Routine posterior, anterior and lateral portals were used. In nine cases intra-articular debridement and partial synovectomy were carried out.
Glenohumeral chondral damage was noted at arthroscopy in five cases. In one of these patients there was severe articular surface damage involving three-quarters of the glenoid and the centre of the humeral head down to the subchondral bone. In one case moderate chondral damage was present over the centre of the humeral head, with a normal glenoid, and three other cases had mild chondral changes.
All 12 patients underwent subacromial bursectomy and rotator cuff debridement. Ten underwent acromioplasty, with preservation of the coracoacromial arch in nine of these. The acromioplasty involved resection of the anterior [6] and inferior acromion [1]. Arthroscopic evaluation indicated that two patients did not require acromioplasty. One of these had no arthroscopic features of impingement, and in the other there was severe erosion of a thin acromion. In eight patients a rotator cuff tear was present, which was debrided but not repaired. Portals were closed with 3/0 Prolene and Steristrips. Patients started an exercise programme the next day. Medications such as methotrexate were continued throughout the perioperative period. Postoperatively the medical management of most of the patients remained unchanged. Two patients had prednisolone added to their medical regime.
All patients were interviewed and examined, and completed an assessment questionnaire to establish the functional status of the shoulder according to the UCLA (University of California, Los Angeles) [1], Constant [7] and American Shoulder Society [8] score indices.
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Results |
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One patient, who had a good clinical result when assessed 3 months after operation, was lost to later follow-up when she left the country. Eleven patients were therefore left for longer-term analysis with a follow-up period of 8 months to 4 yr (average 2 yr).
There was one complication, which was related to the operative procedure. This patient (with severe glenohumeral chondral damage) developed postoperative haemarthrosis, which required a second arthroscopy.
At final follow-up, nine of the remaining eleven patients (82%) reported that their shoulder was still satisfactory when compared to its preoperative condition. These patients demonstrated less pain and improved function, including an overall improvement in active forward elevation. On UCLA score, seven patients rated good or excellent, one rated fair and three rated poor. The average Constant score was 61 (range 35–100). The American Shoulder Society index showed an average score of 70 (range 18.3–99.8). In all three scoring systems, the same patients were rated in the ‘poor’ and ‘fair’ categories, demonstrating consistency between scores. The one patient with a ‘fair’ score was pleased enough with the result to request the same procedure on the other side. Therefore, three patients were rated as having a poor result, defined as residual shoulder pain and active elevation of the arm of less than 130°. Two reported that they were dissatisfied with the result. Further analysis demonstrated that at arthroscopy these three patients had the most advanced glenohumeral chondral damage of the group. All three patients rated as having a poor result were female, had previously had surgery to other joints, had long-standing rheumatoid arthritis, and preoperatively were prescribed methotrexate. Two were also on prednisolone. After the arthroscopy, all three underwent yttrium injection in the glenohumeral joint for ongoing synovitis.
There were eight patients with a fair, good or excellent result on the rating scales. The eight shoulders demonstrated considerable improvement in function, with active elevation or more than 130° in all of them (average 142°). Seven patients had minimal pain, and two had mild night pain. Six rated their overall function as good. All eight patients at arthroscopy had fairly good preservation of the chondral surfaces, and at final clinical review none demonstrated any impingement on clinical testing.
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Discussion |
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This preliminary study has demonstrated good functional improvement and pain relief from symptoms in the shoulder related to inflammatory disease following arthroscopic subacromial surgery. Improvement was greatest in patients with little or no chondral damage of the glenohumeral joint. All the patients in this study group had unresolved inflammatory arthritis, affecting more than one joint, which required preoperative systemic medication. The shoulder symptoms were felt by all patients to be one of their most troublesome problems, despite ongoing medical management by a rheumatologist. The main limitation of this study is that it was open and uncontrolled. In this clinical situation, however, it was difficult to have a control group, as all patients had received all standard conservative measures, they still had severe symptoms necessitating further treatment, and surgery was the only treatment option remaining.
The interpretation of the longer-term results of subacromial arthroscopic shoulder surgery in patients with inflammatory arthritis needs to be modified when such patients are compared with patients with rotator cuff tendinitis related to non-inflammatory intrinsic cuff degeneration and secondary impingement. In the inflammatory group, any recurrence of the underlying disease process following operative treatment can produce inflammation in the subacromial bursa and glenohumeral joint. This can further destroy the rotator cuff and chondral surfaces, and consequently diminish the long-term result. Therefore, any improvement with a mechanical approach, such as in this series, might only be expected to help for a limited period, which naturally depends on the degree of control of the primary disease process. All the patients in this study required continued systemic medication postoperatively. In the light of this, a long-term satisfaction rate of 82% is pleasing. This is despite there being eight cases with a rotator cuff tear. It is possible that the subacromial decompression, by mechanically removing the impingement of the rotator cuff and increasing the subacromial space, may allow recurrence of some inflammation but, initially at least, without the redevelopment of symptoms.
The score indices available and used in this study were designed for assessing patients with non-inflammatory disease. In a patient with an inflammatory arthropathy there is no allowance by the assessment scales for generalized disease, and in particular hand, elbow and neck pathology, which may influence detrimentally both pain and functional assessment. In particular, the power assessment of the Constant score was difficult in this group. The scores, therefore, may not reflect the full benefit of the procedure.
The natural history of the disease process and the prevalence of rotator cuff damage influence the type of shoulder surgery considered for patients with inflammatory arthropathy. Open acromioplasty and rotator cuff repair carries the risk of wound breakdown, deltoid detachment [9], and recurrence of the disease process, which could ultimately destroy any rotator cuff repair. Therefore, in this series all procedures were arthroscopic, without repair of any rotator cuff tear. The presence in most cases of poor rotator cuff function suggests there is a benefit, when carrying out subacromial decompression, in preserving the coracoacromial ligament. This should control to some extent any tendency for superior subluxation of the humeral head related to increasing rotator cuff damage. This should also be beneficial in any later prosthetic arthroplasty. Therefore, in all except the first decompression in this series, the coracohumeral ligament was left intact. Technically, this does require specific modification of the normal arthroscopic acromioplasty technique. In particular, it is helpful at an early stage of the operation to have the burr in the posterior portal, which brings it almost parallel to the periosteum over the superior acromion, which needs to be preserved.
The patients with the most severe chondral damage in the glenohumeral joint had the worst clinical result. One of these patients had loss of articular cartilage to bare bone in the glenohumeral joint, which was not evident on plain X-rays. It is now our practice to obtain a computed tomography scan preoperatively, as it demonstrates the state of the glenohumeral joint more accurately. If significant glenohumeral damage is seen, we now consider that the chances of improvement with arthroscopic surgery are low.
This series has demonstrated encouraging results in a small group of patients for whom there are limited options. Further prospective studies are necessary to assess the specific indications for, and results of, arthroscopic surgery in the management of inflammatory arthritis in the shoulder.
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Conclusion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionConclusionReferences |
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From this study it appears that if a patient with inflammatory arthropathy has shoulder pain, limited function, clinical evidence of rotator cuff tendinitis with positive impingement signs and no major chondral damage, a reasonable result can be expected for several years with an arthroscopic debridement and modified subacromial decompression. This should be undertaken in conjunction with ongoing disease management and appropriate medication.
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Notes |
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Correspondence to: S. Bell, Melbourne Shoulder and Elbow Centre, 31 Normanby Street, Brighton, Victoria 3186, Australia
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References |
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- Ellman H. Arthroscopic subacromial decompression: Analysis of one to three year results. Arthroscopy1987;3:173–81.[Medline]
- Esch JC, Ozerkis LR, Helgager JA, Kane N, Lilliott N. Arthroscopic subacromial decompression: Results according to the degree of rotator cuff tear. Arthroscopy1988;4:241–9.[Medline]
- Ogilvie-Harris DJ, D'Angelo G. Arthroscopic surgery of the shoulder. Sports Med1990;9:120–8.[Web of Science][Medline]
- Neer CS II. Impingement lesions. Clin Orthop1983; 173:70–7.
- Cofield RH. Arthroscopy of the shoulder. Mayo Clin Proc1983;58:501–8.[Web of Science][Medline]
- Rockwood CA, Lyons FR. Shoulder impingement syndrome: diagnosis, radiographic evaluation and treatment with a modified Neer acromioplasty. J Bone Joint Surg1993;75A:409–24.
- Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop1987;214:160–4.[Medline]
- Richards RR, An KN, Bigliani LU et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg1994;3:347–52.
- Souter WA. The surgical treatment of the rheumatoid shoulder. Ann Acad Med1983;12:243–55.
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