Shoulder Replacement Surgery
The shoulder joint is normally made up of the humeral head which sits in the glenoid (the cup of the shoulder). Each surface is normally lined with cartilage which produces near frictionless movement in our joints; however, with aging or trauma this can wear out. When this cartilage is lost and degeneration of the joint occurs a shoulder replacement may be indicated. While shoulder replacement surgery can replace the cartilage with something better than arthritis, it is still, unfortunately, no where near as efficient as our natural cartilage is at moving without friction.
When this cartilage breaks down our body does not know how to heal it so instead bone will often create bone spurs as a repair process, but this does nothing to alleviate pain or increase motion. Sometimes the opposite occurs in that decreased motion occurs, and more pain occurs due to the bone spurs which just worsens the arthritis. In fact common symptoms include:
- Atrophy (wasting) of muscles
- Crepitus (clicking, popping or crunching sound)
- Tenderness to touch
Non-operative treatment remains the same as with other orthopaedic conditions. NSAIDs (naproxen, ibuprofen), activity limitation, and cortisone injections may help to alleviate these symptoms. Once these fail, and activities of daily living/quality of life are being impacted surgery should be discussed. The real key here is activities of daily living and quality of life. If you are thinking about your shoulder more often than not, and your shoulder (due to pain and how it “feels” that particular day) and not YOU is driving your day to day decision making processes than you shoulder consider a replacement.
To determine what type of shoulder replacement surgery I recommend, a thorough review of your physical examination, x-rays (recent ones are very helpful), and any advanced imaging is helpful to review. Assuming an intact rotator cuff, I usually recommend a Total Shoulder Replacement (arthroplasty also means replacement in medical terms) in this circumstance. If the rotator cuff is torn and you have arthritis, you most likely require a reverse shoulder arthroplasty which can also be used to address some fractures as well as some revision shoulder arthroplasty work as well. Some patients with severe rotator cuff tears that are irreparable would benefit from a reverse shoulder arthroplasty as well. Some rare patients may just have problems with one half of the shoulder (the ball most commonly), and we can get away with a type of resurfacing of the humeral head called a hemiarthroplasty (literally half of a replacement because the cup or the glenoid of the shoulder is untouched). Hemiarthroplasty may be more common in younger patients and or patients that have severe humeral head disease with no problem of the cup of the shoulder (no glenoid arthritis). This would be commonly seen in patients with avascular necrosis of the shoulder for example. In general, total shoulder arthroplasty yields superior results to hemiarthroplasty however certain cases may do better with a hemiarthroplasty.
Regardless of the replacement chosen, in order to do the surgery (any type of replacement) I need to surgically approach the shoulder. I make an incision down the arm, and start meticulously approaching the shoulder (a) then I will then release the subscapularis tendon which must be repaired and protected at the conclusion of the surgery (b). In certain select patients it is possible to protect the subscapularis and perform the surgery subscapularis sparingly. If this is of interest, ask Dr. Schwartz if you’re a candidate. The presence of large osteophytes (bone spurs) at the inferior aspect of the humeral head (the bottom of the ball) can be a contraindication to this approach.
I will excise the humeral head, removing the arthritis from it (c) And remove arthritis from the glenoid, or cup. (d)
The implants are then placed into the shoulder (a new metal head articulating – moving – on a plastic cup). The subscapularis is then repaired if taken down, and must be protected. This is the reason why you are in a sling for 6 weeks after the surgery. This tendon MUST heal. After 6 weeks in a sling, rehabilitation will begin, and I will of course follow you closely to insure an excellent clinical course. As I remind all shoulder replacement patients in my practice, this establishes a life long relationship with me, for annual follow ups.
Complications can always occur as with any operation. Infection occurs in approximately 1% of these surgeries, and mechanical wear of the shoulder is all but expected as it is a man made device implanted into a human. The survival rate (probability that in 15 years the same shoulder is still in you, and has not been removed or “revised”) is higher than 90%, so odds are the shoulder should last 10-15 years assuming you take good care of our mutual work!