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
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.
How RA affects the elbow
Between 20% and 65% of people with RA will experience elbow involvement. RA can cause the elbow to gradually become painful, 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. When the elbow is affected by RA, the range of motion is decreased, and it can be difficult for people to use their arm for daily activities, like eating.1,2
Surgery for the elbow
If medications fail to provide control of inflammation and pain relief, various surgical approaches may be considered depending on the nature and extent of joint damage. Sequencing of surgery in patients with RA is an important consideration. For instance, hip or knee surgery should be performed prior to elbow surgery, as use of assistive devices like crutches or canes can put additional weight on the elbow and may cause complications.1,2
Synovectomy and radial head excision
Synovectomy is a procedure used to remove inflamed synovial tissue in the elbow. (The synovium is the soft tissue in the joint that acts as a cushion.) This procedure may be performed by open incision or arthroscopically (a minimally invasive procedure where lighted devices are placed through small incisions into the joint) 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 bone) may be performed at the same time as synovectomy. A synovectomy can help improve the pain and function of the elbow joint, but it does not stop RA from progressing at the elbow. Many people will need additional surgery down the road.1,3
Total elbow arthroplasty
In people with RA who have significant damage to the elbow, total elbow arthroplasty (joint replacement) may be performed. In this procedure, the joint and the surfaces of the bones are replaced with an implant. For many people, this procedure provides pain relief and restoration of some joint function. While a total elbow arthroplasty can make it difficult to fully straighten the arm, the function of being able to bend and use the arm is more important to most patients.2
Different options for elbow arthroplasty are available, including constrained, semi-constrained, and non-constrained. The choice largely depends on the amount of RA damage to the ligaments in the elbow. If RA has compromised the ligaments or if the individual has had previous surgeries to the area, the surgeon may recommend using an implant with less movement to keep the joint stable and reduce the risk of dislocation.2
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.2
Elbow 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.
How RA affects the shoulder
The shoulder has two joints: One joint is between the clavicle (collarbone) and the tip of the scapula (shoulder blade), called the acromioclavicular or AC joint, and the other is between the humerus (upper arm bone) and the scapula, called the glenohumeral joint. One or both of these joints may become inflamed from RA. Inflammation affecting the shoulder causes pain on movement, making a range of common tasks difficult or impossible and may lead 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.4
If RA symptoms affecting the shoulder do not respond to medication, including injection of steroids directly into the joint, 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.4 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.
Synovectomy may be performed on the shoulder to remove inflamed synovial tissue. 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 for several years. During synovectomy, resection (or removal) of a part of the clavicle may be necessary, depending on whether it has sustained damage.3
Acromioclavicular joint resection or resection arthroplasty
The acromioclavicular joint (between the collarbone and the tip of the shoulder blade) may be operated on in an acromioclavicular joint resection. In this procedure, the tip of the collarbone is shaved off to give the joint more mobility and less pain. The ligaments are left intact. This procedure is often performed through arthroscopy, using small incisions and lighted instruments placed into the joint.4,5
Shoulder replacement (arthroplasty) 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 and can improve range of motion. There are different types of shoulder arthroplasty, including:
- Hemiarthroplasty, in which just the head of the humerus is replaced with an implant
- Total shoulder arthroplasty, in which both the humerus and the glenoid (the socket portion of the scapula) are replaced with implants
- Reverse total shoulder arthroplasty, in which the ball and socket are reversed, with the ball implant being placed on the scapula and the socket implant placed on the humerus4
Shoulder 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 may also be recommended as joint function is restored.
Risks of surgery
All surgeries come with risks, such as infection, failure to heal, or loosening of the devices placed into joints. Some people may need repeat surgeries on a particular area.
- Sanchez-Sotelo J. Elbow rheumatoid elbow: surgical treatment options. Current Reviews in Musculoskeletal Medicine. 2016;9(2):224-231. doi:10.1007/s12178-016-9328-9.
- Elbow surgery. National Rheumatoid Arthritis Society. Available at https://www.nras.org.uk/elbow-surgery. Accessed 6/4/18.
- Elbow surgery options. Arthritis Foundation. Available at https://www.arthritis.org/living-with-arthritis/treatments/joint-surgery/types/other/elbow-surgery.php. Accessed 6/4/18.
- Arthritis of the shoulder. American Academy of Orthopedic Surgeons. Available at https://orthoinfo.aaos.org/en/diseases--conditions/arthritis-of-the-shoulder. Accessed 6/4/18.
- Simmen BR, Bogoch ER, Goldhahn J. Surgery insight: orthopedic treatment options in rheumatoid arthritis. Nat Clin Pract Rheumatol. 2008 May;4(5):266-73. doi: 10.1038/ncprheum0767. Epub 2008 Mar 11.