Extended report
Bone destruction, upward migration, and medialisation of
rheumatoid shoulder: a 15 year follow up study
J T Lehtinena, E A Beltb, M J Kauppib, K Kaarelab, P P Kuuselab, H J Kautiainenb, M U K Lehtoc
a Harvard Shoulder
Service, Massachusetts General Hospital, Boston, USA, b Rheumatism Foundation Hospital,
Heinola, Finland, c Tampere University Hospital, Tampere, Finland
Correspondence to: Dr E A Belt, Rheumatism Foundation Hospital, Department of Orthopaedics, FIN-18120 Heinola, Finland eero.beH{at}reuma.fimnet.fi
Accepted for publication 29 August
2000
OBJECTIVE
To evaluate
bone destruction, upward migration, and medialisation of the
glenohumeral (GH) joint in a cohort of 74 patients with seropositive
and erosive rheumatoid arthritis followed up prospectively.
METHODSAt the 15 year
follow up 148 shoulders were radiographed by a standard method. Bone
destruction in the GH joint was examined from the radiographs by four
methods, of which three measured the migration and one the remodelling
of the humeral head. The distances from the greater tuberosity of the
humeral head to the coracoid process (medialisation distance (MD)) and
to the articular surface of the humeral head (GA) have been previously
developed to evaluate the preoperative offsets of the arthritic GH
joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the
rheumatoid GH joint. Destruction of the GH joints was assessed by the
Larsen method on a scale of 0 to 5. The relation between the
measurements and the grade of destruction of the GH joints was
examined. UI was compared with our previous measurements of the
subacromial space.
RESULTSBoth the MI
and the UI had a negative correlation with the GH joint destruction
(Larsen grade), r=
0.49 (95% CI 0.36
to 0.60) and r=0.58 (95% CI 0.46
to 0.68). The UI correlated significantly with the subacromial
space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the
reported normal variation. The mean MD collapsed between Larsen grades
4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began
to flatten and erode from the grade 3 onwards and medial head
destruction was detected at grade 5.
CONCLUSIONSMedialisation
seems to be preceded by upward migration of the humeral head,
indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders
should be intensively followed up by clinical and radiological means.
If a total shoulder arthroplasty is considered, an orthopaedic
consultation is worthwhile at a sufficiently early stage (Larsen 3 and
4), when soft tissue structures responsible for function are still in
proper condition and timing of the operative procedure can be well planned.
© 2001 by Annals of the Rheumatic Diseases
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