Elbow and Shoulder Surgery

The elbow and shoulder are common sites of joint involvement in RA. In many patients, the elbow is one of the earliest joints affected by the disease, with the earliest manifestation being a loss of complete extension.1,2 While symptoms affecting the shoulder may generally appear later than those affecting the elbow, the majority (65% to 90%) of people with RA experience shoulder symptoms (mostly pain) at some point in the course of the disease.3

In RA, the elbow typically becomes inflamed and swollen, with visible bulging between the radius and the upper end of the ulna. This swelling may cause nerve compression, resulting in numbness and tingling in the fingers. Inflammation of the bursa (bursitis) at the elbow also may occur. With chronic inflammation, over time the elbow joint structures may become damaged, with erosion of cartilage and bone. As joint damage progresses, dislocation and migration of bones may occur, resulting in the deformities of the elbow that are characteristic of RA.1,2

Inflammation affecting the shoulder causes pain on movement, making a range of common tasks difficult or impossible and leading to significant disability. Since the shoulder joint itself is hidden, swelling and inflammation may be difficult to detect on physical exam and evident only by decreased range of motion, loss of strength, and pain during movement, which may affect the ability of the individual to sleep soundly at night.3 Bursitis of the shoulder is not uncommon in RA.

 

Surgical interventions for the elbow and shoulder

If joint symptoms do not respond to medication or other management approaches (e.g. bracing, rehabilitation) and there is progressive loss of function in the elbow or shoulder, surgery may be used. The goal of elbow surgery is to improve or restore joint function and to provide pain relief.

 

Surgery for the elbow

If drug therapy, including injection of steroids directly into the joint space, fails to provide control of inflammation, then various surgical approaches are available depending on the nature and extent of joint damage. Sequencing of surgery in patients with RA is an important consideration. For instance, elbow replacement should generally be performed following shoulder replacement, as the effects of surgery on the shoulder will impact the use of the elbow. Similarly, surgery on the elbow should precede surgery on the hand and wrist, as surgical corrections to the elbow may influence the alignment of structures in the hand and wrist.

 

Synovectomy and radial head excision

Synovectomy may be used to remove inflamed synovial tissue in the elbow. This procedure may be performed by open incision or arthroscopically in patients with early disease or less severe joint damage. If there is significant damage to the radial head, radial head excision (cutting away and reshaping the head of the radius) may be performed at the same time as synovectomy.4

 

Total elbow arthroplasty

In patients with significant damage to the elbow, total elbow arthroplasty (joint replacement) may be performed. In many patients, this procedure provides pain relief and restoration of some joint function. However, it should be reserved as a last treatment option.4

 

A variety of prosthetic implants are available

Options differ in the degree of movement they provide and other design features, including whether they are cemented in place. Your surgeon will discuss with you the various options available.4

Arthroplasty for the elbow can provide relief of pain, correction of deformity, and increased joint stability. However, it is less reliable than hip or knee arthroplasty. The main reason for this is that the bones of the arm are much smaller than those of the leg and hip and, as a result, it is more difficult to achieve a durable and secure anchoring of the prosthesis to these bones.4

 

Rehabilitation and joint protection

A program of rehabilitation, tailored to increase strength and range of motion in the elbow, and measures for joint protection, including assistive devices, should be used following surgery as a means of restoring joint function.

 

Shoulder surgery

If symptoms affecting the shoulder do not respond to medication, including injection of steroids directly into the joint, and other management approaches and there is progressive loss of function in the shoulder, surgical interventions may be used. The goal of shoulder surgery is to improve or restore joint function and to provide pain relief. Sequencing of surgery in patients with RA is an important consideration. For instance, shoulder replacement should precede elbow replacement, as limitations on rotation of the shoulder will increase loads on the elbow. Similarly, replacement of hips or knees should precede shoulder replacement, as rehabilitation from hip and knee replacement will require use of crutches, which will increase stress on the shoulder.3

 

Synovectomy

Synovectomy may be performed on the shoulder in patients with synovitis to remove inflamed synovial tissue. Radiation synovectomy (also called isotopic synovectomy) may be useful in reducing inflammation, even if glucocorticoid injection has failed. Synovectomy may be performed by open incision or arthroscopically, depending on the nature and extent of joint involvement and damage. Athroscopic synovectomy has been shown to be effective in providing relief of shoulder pain, with effects lasting an average of 6 years. During synovectomy, resection (or removal) of a part of the clavicle may be necessary, depending on whether it has sustained damage.3

 

Arthroplasty

Shoulder replacement may be considered when imaging of the shoulder shows a loss of joint space and there is significant pain and loss of function. Shoulder arthroplasty is typically effective in relieving pain. A range of prosthetic options are available depending on the extent of damage to the joint and related structures.3,5

 

Rehabilitation and joint protection

Rehabilitation and joint protection following shoulder surgery are crucial to successful outcomes, including restoration of joint function. If you are having surgery on your shoulder, work with your doctor and physical therapist to arrange a rehab plan. This plan will include gentle static exercises, range of motion exercises, relaxation, breathing, massage, and correction of posture of the neck and shoulders. Use of assistive devices for daily activities is also recommended as joint function is restored.3

Written by: Jonathan Simmons | Last reviewed: September 2013.
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