A 46-year-old, nonsmoking, nulliparous woman with a 23-year history of rheumatoid arthritis presented with severely destructed right shoulder, right elbow, and right wrist joints, which resulted in a complete loss of working ability.Investigations
Physical examination, X-ray, MRI, ultrasound, functional staging using the Shoulder Pain and Disability Index, the Patient Rated Elbow Evaluation, the Disabilities of the Arm, Shoulder and Hand, and the health-related quality-of-life Short Form 36 questionnaire, determination of the c-reactive protein level, erythrocyte sedimentation rate, Disease Activity Score 28 and the metalloproteinase profile, and histology of removed synovial tissue.Diagnosis
Severe destruction of the right shoulder and elbow (Larsen grade IV) resulting from late-stage seropositive rheumatoid arthritis.Management
Reconstruction of the elbow and ipsilateral shoulder in a two-step procedure: replacement of the elbow joint with a semiconstrained Gschwend-Scheier-Bahler III (GSB III™) elbow prosthesis (Zimmer, Inc., Warsaw, IN) followed by replacement of the shoulder with the Promos® Modular Shoulder System (Plus Orthopedics AG, Rotkreuz, Switzerland) 1 month later. The patient received 4 weeks of inpatient rehabilitation.