Shoulder and Elbow cases glenohumeral rheumatoid arthritis

A 55-year-old female with a history of rheumatoid arthritis diagnosed at age 40 presents to your clinic complaining of 3 years of right shoulder pain acutely worsening over the past week to the point that she is unable to reach for objects from high shelves and needs help getting dressed in the morning. She also notes recent intermittent fevers and severe pain in her left hand and decreased range of motion of the fingers. She participated in a 6-week course of physical therapy last year prescribed by her rheumatologist which provided no relief. She receives an injection of a TNF-alpha inhibitor every 8 weeks. Physical examination reveals

tenderness to palpation, swelling and warmth about the left shoulder with decreased range of motion throughout. Her left hand is neurovascularly intact with ulnar deviation of the fingers and severe limitation of range of motion. Imaging of the right shoulder is shown in Figure 2–52.

 

 

 

Figure 2–52

 

What is the most appropriate next step in diagnosis/treatment?

1. MRI of the right shoulder

2. In-office injection of the subacromial space with corticosteroids

3. Physical therapy prescription for rotator cuff strengthening and improvement of shoulder range of motion

4. CBC, CRP, ESR, and aspiration of the glenohumeral joint with fluid culture and cell count

Discussion

The correct answer is (D). In a patient with rheumatoid arthritis, the most likely diagnosis is inflammatory arthropathy involving the shoulder, however, the presence of fevers and acutely worsening pain with swelling and warmth on physical examination necessitates a workup for septic arthritis. MRI of the shoulder (Answer A) might be indicated in the future if there is question about rotator cuff integrity in the setting of a decision to perform a total shoulder arthroplasty, but not at the time of initial diagnosis. Subacromial steroid injection (Answer B) would not be indicated in a patient in whom septic arthritis is suspected. Physical therapy (Answer C) would be helpful for conservative management of inflammatory

arthritis but is not the best choice for initial diagnosis.

Aspiration of the right glenohumeral joint reveals approximately 20 cc of turbid fluid, which is sent for analysis. Gram stain reveals PMNs but no organisms, and cell count WBC 20,000, 65% polymorphonuclear leukocytes, positive for cholesterol crystals.

What is the most likely diagnosis?

1. Infection of the shoulder joint with P. acnes

2. Rheumatoid arthritis

3. Chondrocalcinosis

4. Osteoarthritis

 

Discussion

The correct answer is (B). While there are some similarities between the synovial fluid of septic arthritis (Choice A), including turbid quality and an increased volume of fluid in the joint, the cell count in septic arthritis is generally much higher (>50,000 WBCs) and may have organisms present on gram stain. Also, while infection with P. acnes may have synovial fluid with a lower number of WBCs on analysis than is generally found with infection by other organisms and may not show organisms on gram stain (see Case 20), it is more likely found in the presence of orthopaedic implants or after shoulder surgery. Answer C is incorrect because it would be characterized by calcium pyrophosphate crystals in the synovial fluid, not cholesterol crystals which can be present in rheumatoid arthritis. Answer D is incorrect because the synovial fluid of arthritis is generally not turbid and has a much lower cell count (<2,000 WBCs). See Table 2–6 for more details about diagnosis based on synovial fluid analysis.

 

Table 2–6

 

	WBC/Diff	Glucose	Protein
Septic arthritis	>100,000/mL, >75% neutrophils	<50% serum glucose	Increased
Osteoarthritis	<2,000/mL, <25% neutrophils	Same as serum glucose	Normal
Rheumatoid arthritis	15–20,000/mL, 60–70% neutrophils	<25% serum glucose	Normal/increased

Reprinted with permission from Chen A, Joseph T, Zuckerman J. Rheumatoid arthritis of the shoulder. JAAOS

2003;11:12–24.

The patient’s synovial fluid aspirate is held for 3 weeks with no growth. You diagnose her with rheumatoid arthritis of the shoulder.

What is the most appropriate next step in treatment?

1. Right total shoulder arthroplasty

2. Right shoulder hemiarthroplasty

3. Referral to a colleague for evaluation of her left hand deformity

4. Right shoulder arthrodesis

 

Discussion

The correct answer is (C). It is important in patients with rheumatoid arthritis to address other sources of pain that might impede the postoperative rehabilitation process. This patient will be unable to use her right, dominant hand as effectively after shoulder surgery, and will be far more reliant on her left hand in the postoperative period. Since she has severe pain and deformity of the left hand, she should be evaluated by a hand surgeon to determine whether this issue might be addressed prior to her undergoing an operation on her shoulder. Choice A is incorrect not only because the left hand should be evaluated first, but because imaging of her right shoulder reveals severe erosion as well as osteopenia of the glenoid, which is a contraindication to total shoulder arthroplasty due to placement of the glenoid component. Choice B is incorrect only because of the timing with this patient; it is actually the most appropriate operative choice given her poor glenoid bone stock and relatively younger age. Choice D is incorrect as arthrodesis is more appropriate for patients with failed total shoulder arthroplasty, and end-stage rheumatoid arthritis (arthritis mutilans) complicated by septic arthritis.

The patient returns to your clinic in 5 months complaining of continued right shoulder pain. She has since undergone multiple MCP joint reconstructions in the left hand and is recovering well with decreased pain and increased range of motion compared with prior to surgery. You decide to treat the patient with a cemented hemiarthroplasty of the right shoulder.

For which complication is she at a greater risk compared with the general population?

1. Chronic regional pain syndrome

2. Loosening of the humeral component

3. Radial nerve palsy

4. Postoperative infection

 

Discussion

The correct answer is (D). Patients with rheumatoid arthritis are more susceptible to postoperative infections than the general population undergoing surgery. This patient is especially at risk given her use of a TNF-alpha inhibitor, which is a potent immunosuppressant. In general, it is advisable to avoid the use of such medications within 2 weeks of surgery. Choices A, B, and C are incorrect because, while they are all possible complications after hemiarthroplasty of the shoulder, this patient is at no higher risk of developing them than the general population.

 

Objectives: Did you learn...?

 

Recognize the clinical and radiographic presentation of glenohumeral rheumatoid arthritis?

 

 

Surgically treat a patient with glenohumeral rheumatoid arthritis? Perioperatively manage a patient with glenohumeral rheumatoid arthritis?