Bennett W F, Gerber C
Curr Opin Rheumatol. 1994 Mar;6(2):177-82. doi: 10.1097/00002281-199403000-00010.
Rheumatoid arthritis can affect almost any joint. Shoulder involvement typically occurs late in the disease process and usually after other joints have manifested arthritic change. Any of the four shoulder articulations can be involved: scapulothoracic, acromioclavicular, sternoclavicular, and glenohumeral. In addition to bony involvement, many of the soft tissues of the shoulder joint can be affected. Early operative treatment includes synovectomy with or without bursectomy, which is indicated prior to radiographic evidence of arthritis. Early synovectomy provides for a slowing of the progression of the disease process. Patients who have incapacitating pain with loss of range of motion can benefit from total shoulder replacement. Most patients experience pain relief and some restoration of motion. The restoration of normal range of motion is dependent on anatomic reconstruction of the glenohumeral joint. Factors that can affect the range of motion include rotator cuff tears and the general health status and motivation of the patient. Although there is a 30% to 80% incidence of radiographic lucencies with nonconstrained prostheses, their presence does not indicate the need for revision surgery. Occasionally, there is medialization of the glenohumeral joint with central bony losses of the glenoid. The surgeon should try to bone graft the defect and lateralize the components. If there is massive medialization of the glenoid that is not reconstructable, then a hemiarthroplasty is the procedure of choice.
类风湿关节炎几乎可累及任何关节。肩部受累通常发生在疾病进程的后期，且往往在其他关节出现关节炎改变之后。肩部的四个关节中的任何一个都可能受累：肩胛胸壁关节、肩锁关节、胸锁关节和盂肱关节。除了骨质受累外，肩关节的许多软组织也可能受到影响。早期手术治疗包括滑膜切除术，可伴或不伴滑囊切除术，这在出现关节炎的影像学证据之前进行。早期滑膜切除术可减缓疾病进程。因活动范围丧失而出现致残性疼痛的患者可从全肩关节置换术中获益。大多数患者疼痛缓解，活动能力也有所恢复。正常活动范围的恢复取决于盂肱关节的解剖重建。影响活动范围的因素包括肩袖撕裂以及患者的总体健康状况和积极性。尽管非限制性假体出现影像学透亮区的发生率为30%至80%，但其出现并不意味着需要翻修手术。偶尔，盂肱关节会向内侧移位，同时肩胛盂出现中央骨质缺损。外科医生应尝试对缺损处进行骨移植，并将假体组件向外侧移位。如果肩胛盂出现无法重建的大量向内侧移位，那么半关节置换术是首选的手术方式。
