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Arthroscopic Synovectomy and Massive Rotator Cuff Repair in Patient with Rheumatoid Arthritis Shoulder
Department of Orthopaedics, Srinakarinwirot University, Thailand
Submission: January 24, 2018; Published: February 26, 2018
*Corresponding author: Pinkawas Kongmalai, Department of Orthopaedics, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakarinwirot University, 62 Moo 7 Nakhon Nayok 26120, Thailand, Tel: +66815703867; Email: firstname.lastname@example.org
How to cite this article: Pinkawas Kongmalai. Arthroscopic Synovectomy and Massive Rotator Cuff Repair in Patient with Rheumatoid Arthritis Shoulder.
Ortho & Rheum Open Access 2018; 10(5): 555796. DOI: 10.19080/OROAJ.2018.10.555796.
There is no definite guideline concerning patient selection for operative intervention on rotator cuff tears in rheumatoid arthritis patients. This article presents a case of elderly patient with massive rotator cuff tear from rheumatoid arthritis. Physical examination and imaging showed that the supraspinatus and subscapularis tear were reparable. The arthroscopic synovectomy with supraspinatus and subscapularis repair were performed with excellent clinical outcome.
Rheumatoid arthritis is a chronic inflammatory disease which characterized by an erosive, symmetrical polyarthritis that may lead to progressive disability . Rheumatoid involvement of the shoulder is not only the destruction of the joint, but also associated with soft-tissue pathology which often involving the insertion of the rotator cuff. Rheumatoid arthritis patients are prone to tendon tears due to longstanding medical treatment of tissue toxic drugs such as cortisone and cell growth inhibitors. The quality of muscle and tendon is poor, the tissues are fragile, and many patients have pre-existing shoulder pathology [2,3]. In this case report, we describe an arthroscopic synovectomy with rotator cuff repair for massive rotator cuff tear including supraspinatus and subscapularis tendon.
A 69-year-old right hand dominant female presented with left shoulder pain 6 months prior to admission. She had great difficulty raising her arm overhead as well as intense pain at night caused by sleeping. She sustained a minor fall from bicycle 10 months ago without significant disability. Her past medical history includes dyslipidemia and rheumatoid arthritis. Current medications are simvastatin, sulfasalazine, cyclophosphamide, methotrexate, chloroquine and folic acid. She denied alcohol drinking and tobacco use. The physical examination showed no obvious deformity or contusion. Mild tender at bicipital groove. Not tender at acromioclavicular joint. Active forward flexion was limited to 90 degrees and passive forward flexion is 160 degrees. Active arm abduction external rotation was 40 degrees, internal
rotation is 30 degrees. Full passive arm abduction external rotation and internal rotation. There was positive Drop arm test, Jobe test, Lift off test, and Belly off test. The external rotation lag sign was negative. The strength test revealed 5/5 for external rotation and 2/5 for internal rotation. The x-ray of left shoulder showed mild osteoarthritis of glenohumeral joint. No superior migration of humeral head was seen (Figure 1). The MRI showed complete tear of supraspinatus with medial retraction to the level of glenohumeral joint. Suspect tear of subscapularis tendon (Figure 2).
An arthroscopic synovectomy and rotator cuff repair was performed. Severe synovitis was found in both glenohumeral joint and subacromial space. The long head of biceps was torn. A large crescent shape tear involving the anteroposterior dimension of the supraspinatus tendon was found. The upper 2/3 of articular side of subscapularis tendon was torn. After synovectomy was done, we repaired the supraspinatus tendon in double row suture-bridge technique with two suture anchors (Y-Knot® RC; Conmed) at the articular margin, and two suture anchors (PopLok® Knotless Suture Anchor; Conmed) laterally. Repair of subscapularis tendon was done with a suture anchor (Y-Knot® RC; Conmed) in Mac-stitch technique. Adequate fixation was noted for both supraspinatus and subscapularis tendon.
The patient’s upper extremity was immobilized in an abduction sling. At 6-week follow-up, the sling was discontinued and the physical therapy was started for passive range of motion exercise. The shoulder pain was completely resolved at this period. At 12-week-follow-up, the patient had full passive
range of motion in all direction without pain. At 24 months after
surgery, the patient demonstrated 170° of active forward flexion
and abduction, external and internal rotation comparable to the
contralateral side. The belly off test was negative. The author
has obtained the patient’s written informed consent for print
and electronic publication of the case report and accompanying
The current information for rotator cuff tear in patients with
rheumatoid arthritis is very little. When rotator cuff tear occurs
in rheumatoid arthritis patients, they frequently have some
degrees of degenerative changes of the shoulder joint. Some
authors advocate against the surgical option of rotator cuff repair
alone [4-6]. The non-surgical treatment can begin with activity
modifications, medications, physical therapy or intra-articular
steroid injection. If conservative treatment fails, surgery may be
an option. It is crucial to understand the expectations of patients
before choosing the surgical options. In addition, the patient
should have goodwill to be compliant with the post-operative
protocol. The mainstay of surgical management for rheumatoid
arthritis shoulder has been synovectomy for early-stage and
arthroplasty for late-stage disease [2,7,8] Smith and colleagues
 report the series of rotator cuff repair in 23 shoulders with
rheumatoid arthritis. In this population, they found that durable
pain relief and patient satisfaction can be achieved. Interestingly,
the functional gains could not be expected in patients with
full-thickness rotator cuff tears. One should notice that only 5
patients of this series had a large to massive rotator cuff tear.
However, we thought that the general strategy for evaluation
of reparability of the rotator cuff should not be difference from
normal population. For massive rotator cuff tear, the decisive
factors whether to repair the rotator cuff are the tendon
retraction, the fatty infiltration and the upward migration
of humeral head. For this patient, although the stump of the
supraspinatus tendon was retracted nearly to the glenohumeral
joint level, the degree of fatty infiltration is Goutalier grade 2 and
there was no proximal migration. Therefore, we considered as
the reparable rotator cuff tear.
According to Smith , arthroscopic synovectomy offers
a reliable decrease in pain in rheumatoid arthritis shoulder.
Recently, Lim SJ et al.  showed the contradict result. This
study is the largest series of rotator cuff surgery in patients with
rheumatoid arthritis with total number of 29 patients. There
were ten large tears and seven massive tears. They found that the
rotator cuff repair improved the shoulder functional outcome
comparable to that in matched patients without rheumatoid
arthritis. Our patient is in agreement with them. However, both of
the above studies [9,10] did not mention the result of subgroup
analysis outcome in a massive rotator cuff tear patients.
We did not perform the acromioplasty, because of the fear
of sacrificing the coracoacromial ligament, thus compromising
the coracoacromial arch, which will lead to more superior
migration of humeral head. The acromioclavicular joint was
also left untouched because the physical examination for
acromioclavicular joint was negative. The Laine classification of
rheumatoid arthritis of glenohumeral joint has 3 stages based
on clinical and radiographic findings . From clinical and x-ray
findings, our patient was classified in stage 2. The reverse total
shoulder arthroplasty would be better option if the patient has
more severe arthritic change of the glenohumeral joint which
refers to Laine classification stage 3.
In conclusion, when considering surgical options for massive
rotator cuff tear in rheumatoid arthritis patient, the repair may
be performed with good functional outcome if there is no sign
of irreparable rotator cuff tear or severe arthritic change of the