Surgical interventions for the rheumatoid shoulder

  • Review
  • Intervention

Authors


Abstract

Background

Involvment of the shoulder joint in patients with rheumatoid arthritis (RA) leads to severe destruction of the glenohumeral joint. When conservative treatment does not result in sufficient improvement, surgical procedures may be considered as the only beneficial treatment option.

Objectives

To assess beneficial and harmful effects of all forms of surgical treatment in the management of the shoulder in people with rheumatoid arthritis.

Search methods

Articles were identified by searches in The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCISEARCH and reference lists of relevant articles (January 1995 to May 2008).

Selection criteria

Randomised Controlled Trials, and Controlled Clinical Trials reporting on effects of shoulder surgery. In addition case-series were included for the assessment of complications.

Data collection and analysis

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data.

Main results

One RCT, one CCT and 21 case-series were included. The RCT compared cemented versus uncemented humeral stem fixation in arthroplasty and found no significant differences between the two groups after two years (low quality evidence). The CCT compared rotator cuff repair with augmented subscapularis transposition versus subscapularis transposition alone and reported significant differences in favour of the augmented subscapularis transposition after 2 years in function, mean difference (MD) 4.00 on a 0 to 30 scale (95% CI 1.11 to 6.89) and pain, MD 4.00 on a 0 to 20 scale (95% CI 0.84 to 7.16) (low quality evidence). Based on 11 case series (mean follow up 4.5 to 12 years) complications were reported in 11% (95% CI: 9.9% to 12.1%) of the total shoulder arthroplasties, while 10 case-series (mean follow-up 2.7 to 11.3 years) reported complications in 9.9% (95% CI: 8.4% to 11.4%) of the hemiarthroplasties (very low quality evidence).

Authors' conclusions

The effects of surgical treatment in the management of the shoulder in people with rheumatoid arthritis are largely unknown due to the paucity of randomised controlled trials.

摘要

類風濕肩關節炎的外科療法

研究背景

類風濕關節炎(rheumatoid arthritis; RA)的患者肩關節受到侵犯會導致盂肱關節的嚴重損害。當保守性療法不能改善時,外科手術可能是達到治療目的的唯一選擇。

研究目的

評估所有用來治療類風濕關節炎患者肩關節問題之手術治療效益與造成的傷害。

检索策略

搜尋The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCISEARCH等資料庫及參考資料上所列的相關文章(1995年1月至2008年5月)

标准/纳入排除标准

只收納報告肩關節手術效果之隨機對照試驗(Randomised Controlled Trials; RCTs)和對照臨床試驗(Controlled Clinical Trials; CCTs)的文章。另外亦涵蓋了案例系列(caseseries)報告的文章以評估併發症。

数据收集与分析

兩個作者分別各自篩選選入的試驗、評讀試驗的品質並從中取得數據。

主要结果

此分析共涵蓋了1篇RCT、1篇CCT以及21篇案例系列的文章。其中,RCT比較了關節置換術中,肱骨幹有無使用骨水泥固定的差別,發現兩群患者在兩年的追蹤後無顯著差異(低品質證據, low quality evidence)。CCT則是比較肩胛下肌轉位並以修補縫合旋轉環膜(rotator cuff)增強, 與單純肩胛下肌轉位兩種手術。在兩年的追蹤後發現,前者不論在功能上(平均差(mean difference; MD)在0到30的量表中為4.00 (95% CI 1.11 to 6.89))或疼痛的改善上(MD 在0到20的量表中為4.00, 95% CI 0.84 to 7.16, 低品質證據)都較後者好,且有顯著的差異。依據11篇案例系列(平均追蹤4.5到12年)的報告,11%的全肩關節制換術患者有產生併發症(95% CI: 9.9% to 12.1%);而另外10篇例系列(平均追蹤2.7到11.3年)的報告顯示,9.9%的半關節制換術患者有併發症產生(95% CI: 8.4 to 11.4%)(非常低品質證據, very low quality evidence)。

作者结论

因缺乏隨機對照試驗,外科手術在治療類風濕肩關節炎患者的效果大部分仍舊無法得知。

Plain language summary

Surgery for rheumatoid arthritis in the shoulder

This summary of a Cochrane review presents what we know from research about the effect of one type of surgery for rheumatoid arthritis (RA) in the shoulder.  Currently, there is a very limited amount of research on the effect of surgical treatments for the shoulder in people with RA.

 In this review the researchers were able to find just one study comparing one form of surgery called “augmented subscapularis transposition” to another involving just “subscapularis transposition”.

The review shows that in people with rheumatoid arthritis in the shoulder; a surgery involving Augmented subscapularis transposition:

·         may improve your physical function slightly compared to subscapularis transposition alone.

·         makes no difference in improving your pain compared to subscapularis transposition alone.

Infections were not reported.

We often do not have precise information about side effects and complications. This is particularly true for rare but serious side effects.

 

What is rheumatoid arthritis and what kind of surgery have been tried?

Rheumatoid arthritis is a disease in which the body's immune system attacks the lining of the joints, and the joints become swollen, stiff and painful. Usually, the joints of the hands and feet are affected first, but many people with rheumatoid arthritis are severely affected in their shoulders. There is no cure for RA at present, so treatments aim to relieve pain and stiffness, and improve the ability to move.

One common shoulder surgical treatment for people with RA is arthroplasty, i.e. the joint surface (and bone) is replaced with prosthesis (an artifical joint).

 

Best estimate of what happens to people with rheumatoid arthritis who have the type of shoulder surgery called “augmented subscapularis transposition”:

 

Function
People with Augmented subscapularis transposition rated their physical function to be 4 points better on a scale of 0-20 after 2 years compared to people who had augmented subscapularis alone.  (8% absolute improvement)

People with subscapularis transposition alone rated their physical function to be 11 points out of 20.

People with Augmented subscapularis transposition rated their physical function to be 15 points out of 20.

概要

治療類風濕肩關節炎之手術:從本篇Cochrane的文獻回顧中我們得知用於治療類風濕關節炎肩膀的手術效果。目前,關於這方面的研究數量相當有限。在此篇回顧文章中,研究者發現只有1篇文章比較了稱為增強肩胛下肌轉位對肩胛下肌轉位的手術結果。文中顯示了前者可以稍微改善患者的生理功能,但對疼痛的改善則無差異。沒有關於感染的結果。且大多沒有關於併發症的正確資訊,特別是罕見但嚴重的併發症。何謂類風濕關節炎?又曾使用過哪些手術?類風濕關節炎是一種自體的免疫系統攻擊關節表面的疾病,因此關節變的腫脹、僵硬且相當疼痛。一般而言,手和足部的關節最先受到侵犯,但多數患者的肩膀會受到嚴重的侵犯。現今仍無法治癒類風濕關節炎,因此治療目標為緩解關節疼痛和僵硬,並增加關節的運動能力。此類患者常用來治療肩關節的一種手術方式為關節置換術,也就是說關節表面(和骨頭)以假體(人工關節)來取代。評估接受增強肩胛下肌轉位手術的類風濕關節炎患者最好的方法是:功能。在術後兩年以0–20的量表評估自己的生理功能,發現接受增強肩胛下肌轉位手術的患者,較僅接受增強肩胛下肌手術的患者高出4分(8%有顯著的進步; absolute improvement)。僅接受肩胛下肌轉位手術的患者則評其生理功能為11分;而接受增強肩胛下肌手術的患者則評為15分。

翻译注解

Ancillary