Shoulder replacement for rheumatoid arthritis. Total shoulder or hemi-arthroplasty?

The following case is a female in her mid 30s who presented in the office one year ago with shoulder pain and erosive bone on bone arthritis without deformity to the glenoid. The patient was treated for a year with oral corticosteroids and infusions of anti TNF medications. She experienced minimal relief of her symptoms from rheumatological treatment and one year later she came back complaining of severe shoulder pain with intact rotator cuff muscle strength and active forward elevation of the shoulder to 45 deg due to shoulder pain.

Xrays one year apart prior to surgery are shown below and demonstrate erosion of the glenoid within the timeframe of 12 months.

12 months before surgery AP view

12 months before surgery Grashey view

Prior to surgery (5 days preop). AP view shows progression of the RA disease with further erosive changes to the central part of the glenoid

Axillary prior to surgery

We elected to proceed with a total shoulder replacement instead of a hemi-arthroplasty with the following advantages/disadvantages:

Advantages:
(1) avoidance of medial erosion of the glenoid as seen in RA patients treated with hemi-arthroplasty
(2) better pain relief compared to hemi-arthroplasty
(3) better motion compared to to hemi-arthroplasty

Disadvantages:
(1) 0.8% annualized rate of glenoid component revision. Survivorship of 80-90% at 10 years
(2) 1.2% annualized rate of symptomatic glenoid component loosening.
(3) 7.3% annualized rate of asymptomatic radiolucent lines.

For patients with DJD of the shoulder some studies report up to 50% chance of radiolucent lines at 5 years postoperatively but the need for revision is not common for polyethelyne glenoid components.

In addition, we elected pegged over keeled all polyethylene glenoid component due to better survivorship

For further information:
Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. Papadonikolakis A, Neradilek MB, Matsen FA 3rd. J Bone Joint Surg Am. 2013 Dec 18;95(24):2205-12.

Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH, Sperling JW. J Shoulder Elbow Surg. 2014 Jun;23(6):791-9.

An all poly -ethylene glenoid (cemented) component over metal backed glenoid (uncemented) was selected due to significantly higher rate of metal backed glenoid component failure and need for glenoid revision compared to the all poly-ethylene design (see Metal-Backed Glenoid Components Have a Higher Rate of Failure and Fail by Different Modes in Comparison with All-Polyethylene Components: A Systematic Review. Papadonikolakis A, Matsen FA 3rd. J Bone Joint Surg Am. 2014 Jun 18;96(12):1041-1047.)

Postoperative pictures are shown below:

Immediate postoperative Grashey view with minimal cementation of the humeral component

Axillary postoperative XR shows no dislocation or subluxation and the appropriate position and size of the humeral head

Cementation of the humeral component was necessary due to the poor bone quality because of osteopenia from long term use of oral corticosteroids.

Xrays at 6 weeks shown below