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Rheumatologists, Orthopaedic Surgeon Collaborate in Advanced Shoulder Arthritis Presentations

Surgical expertise helpful in treating complex shoulder joint inflammation

A collaboration between specialists in the Divisions of Rheumatology and Immunology and Orthopaedics at Duke is improving care for patients with complex shoulder arthritis and osteoarthritis presentations.

Orthopaedic surgeon Christopher S. Klifto, MD, initiated a collaboration with Duke Rheumatology physicians, including Jennifer L. Rogers, director of the Duke Lupus Clinic, to improve communication and care decisions for patients with advanced shoulder arthritis and tendon conditions.

By working together to identify optimal medical and surgical approaches to arthritis, patients may experience better long-term outcomes for patients, say Rogers and Klifto. The collaboration is particularly effective for patients with painful joint conditions who may eventually require surgery. Rogers and Klifto acknowledge the complexity of these conditions but agree that direct collaboration regarding diagnosis and treatment contribute to optimal outcomes.

Klifto emphasizes early diagnosis of shoulder arthritis with plain radiographs or rotator cuff tears with MRI, although he emphasizes that the differential diagnosis should include the potential for cervical spine disease (C5-7). His work with the rheumatology division is generally focused on RA presentations of shoulder arthritis and rotator cuff disorders.

Klifto focuses on shoulder osteoarthritis (primary or secondary) and inflammatory arthritis as well other presentations of the disease, including crystal deposition, acromegaly, dysplasia, charcot, avascular necrosis (AVN) or septic arthritis. Klifto reviews decisions with rheumatologists when surgical options are considered.

Shared advice on challenging pathologies

“The rheumatologists advise me on drug recommendations, and we collaborate on the challenging pathology that is often encountered in the inflammatory arthritis population,” Klifto says. “We always begin with a conservative approach but discuss surgical options when they are relevant.  Since we have initiated this collaboration with the rheumatology division, I believe patients have received better care and outcomes.”

Klifto also develops recommendations for patients with avascular necrosis (AVN), a condition present in patients with inflammatory arthritis. “AVN is certainly a relevant condition in patients who have received long-term steroid therapy,” he adds.

Rogers says she consults with Klifto most often regarding patients with advanced osteoarthritis, rotator cuff arthropathy, AVN, and patients with severe inflammatory arthritis who have failed medical therapy and who may benefit from joint replacement surgery. She involves a surgeon if she identifies a concern about an atypical infection or a diagnostic dilemma in which a synovial biopsy would be helpful.

“If the anatomy is very complicated or if we are working with advanced RA or OA that may need a surgical intervention, it is useful to engage the surgeons early in the process to help guide imaging and to discuss perioperative immunosuppressive therapy,” Rogers says.

Klifto is also consulted for procedures involving tendons such as rotator cuff tears or other conditions of the upper extremity.