抄録
We have classified our original ‘Flexion Reach Scales’ of the upper extremities for patients with rheumatoid arthritis into 6 grades; Grade 0 means normal flexion activities, Grade 4 means that the fingers can reach just their mouth, Grade 5 means they can not reach their mouth. We believe patients in Grade 5, and those who have severe pain in daily activity, regardless of the grade, due to elbow or shoulder arthritis, are recommended to undergo total elbow arthroplasty or shoulder arthroplasty in either case, surely in Larsen grade 3 or worse on radiographic view.
We investigated 36 elbows that had undergone Kudo total elbow arthroplasty (TEA), 4 shoulders with total shoulder arthroplasty, and 5 shoulders with shoulder hemiarthroplasty (both types are regarded as TSA here) . All of them were in rheumatoid arthritis patients. We consider that TEA provides good intermediate to long-term outcomes. All 36 elbows have no pain, or have mild discomfort. There were adequate improvements with these patients in the mean range of active flexion (115°to 135°), supination and pronation, so their grades on the ‘Flexion Reach Scales’ were improved - from Grade 5 preopera-tively to Grade 4 and better postoperatively. Adequate activities of daily living (ADL) were also maintained throughout the follow-up period. Patients were divided into two groups depending on their radiographic assessments. Group A (3 patients) were those who had severe arthritic changes with loss of acromion-head, and Group B (5 patients) were those who had few or minimal changes. Severe glenohumeral changes were seen in both groups. In Group A, 3 shoulders had severe contracture preop-eratively and achieved only a little functional improvement postoperatively. All the shoulders in Group B had little contracture but severe pain preoperatively, then their pain was reduced postoperatively.
In most patients, motion and function of the upper extremities that are severely restricted by severe rheumatoid arthritis can only be improved with TEA, because motion and function of their upper extremities depend on the elbow more than on the shoulder. We therefore prefer TEA prior to TSA to improve the function of patients' upper extremities. If TEA does not help patients enough because of a disabled shoulder, then shoulder arthroplasty should be considered. Current TSA components seem to be designed mainly for glenohumeral arthritis, not for subacrominal arthritis. There is a possibility that this may reduce the indication for TSA components, to Group B only. Perhaps we should consider another (different) kind of TSA or hemiarthroplasty suitable not only for glenohumeral arthritis but also for acromio-humeral arthritis (which may produce severe contracture and pain) . We may also need more meticulous surgical technique to treat severe soft tissue contracture in Group A.
