Shoulder injuries can involve the acromioclavicular (AC), the glenoid labrum (a rim of cartilage around the shoulder ‘socket’ that helps stabilize the ‘ball’), the biceps tendon (which enters the shoulder joint before it attaches to the top of the ‘socket’), the rotator cuff (a group of four muscles that help to elevate the arm and stabilize the ball on the socket), or the ball and socket themselves. When shoulder problems get worse, arthritis can set in and become the major pain generator in the shoulder. Generally, arthritis occurs in two varieties: one is the regular ‘wear and tear’ arthritis that occurs with aging and overuse, also known as osteoarthritis; the second form of arthritis occurs in patients with advanced rotator cuff dysfunction, causing instability of the ball and socket configuration of the shoulder, which is called rotator cuff tear arthropathy. Initially, both forms of arthritis can be treated non-operatively, usually using anti-inflammatory medications and corticosteroid (cortisone) injections, but when symptoms persist and worsen despite medical treatment, shoulder replacement can be used to drastically reduce pain and improve the function in these degenerative shoulders. The goal of this article is to educate patients on the use of shoulder arthroplasty (replacement) for the treatment of advanced arthritis of the shoulder. First, we will discuss who is a candidate for shoulder replacement surgery, then describe the difference in shoulder replacements for wear and tear arthritis and for rotator cuff tear arthropathy, and finally, touch on the results and outcomes for each procedure.
Patients who are candidates for shoulder replacement surgery are those who have unremitting pain or poor motion from shoulder arthritis. Shoulder arthritis is generally initially treated medically, as is arthritis of the hip and knee and other joints. Your doctor will generally prescribe a regimen of anti-inflammatory medications and possibly a course of physical therapy to help increase mobility. Usually this is enough to ease the pain from shoulder arthritis and make the symptoms more tolerable. When anti-inflammatory medications do not do the trick, the next step involves some type of intra-articular cortisone injection, similar to those administered for hip and knee arthritis. Generally, the local anti-inflammatory actions of these cortisone injections help relieve pain in patients to a greater degree than the oral anti-inflammatory medications. It is not unusual, however, to have one injection that works well and have a smaller benefit from subsequent injections. When these medical treatments no longer achieve acceptable pain relief, or when shoulder range of motion has become so limited that activities of daily living are impossible to perform, a shoulder replacement should be considered. It is important to mention that patients are the ones who tell their doctors when they are ready for this procedure. Sometimes x-rays taken by your doctor may show advanced arthritis, but pain and function are not severely impaired, and sometimes the inverse is true. Generally a patient who may be ‘ready’ for a shoulder replacement is someone who has pain that is not adequately relieved by medication, that increases with an increase in activity, that persists at night, and/or severe limitations in range of motion of the shoulder.
Both forms of arthritis mentioned above – osteoarthritis and rotator cuff tear arthropathy – can cause the disabling symptoms of pain and limited motion of the shoulder, but the type of shoulder replacement needed will differ depending on the type of arthritis present. In osteoarthritis (wear and tear arthritis) the soft tissues surrounding the shoulder, including the rotator cuff, are generally in good shape and provide a stable soft tissue envelope for the shoulder. A normally functioning rotator cuff adds stability to the shoulder joint, keeping the ball centered on the socket. In these cases, a conventional total shoulder replacement, one that replaces both the ball and the socket of the shoulder, but has the same shape as the native shoulder (a ball at the top of the arm bone, and a shallow socket at the end of the shoulder blade – similar in appearance to a golf ball sitting on a golf tee), can be used. However, in the case of rotator cuff tear arthropathy, the soft tissue envelope around the shoulder is inadequate, leading to instability of the ball on the socket. In this cases, the deficient rotator cuff is unable to keep the ball centered on the socket, and the ball moves up and forward (anterosuperior) on the socket. If a conventional shoulder replacement is used in this setting, it will generally fail early. Therefore, a reverse shoulder arthroplasty can be used instead to add stability to the unstable shoulder joint. As its name implies, a reverse shoulder arthroplasty switches the location of the ball and socket relative to the native shoulder (it places the ball on the end of the shoulder blade and the socket at the top of the arm bone), and by doing so greatly increases the stability of the unstable shoulder joint. The procedure was developed in France about 25 years ago and has been performed in the United States since 2001, gaining FDA approval in 2005. The procedure offers a reliable treatment option for patients who have often been told that nothing can be done for their dysfunctional shoulders.
Each of these shoulder replacement options can dramatically reduce the pain of shoulder arthritis and improve a patient’s range of motion. Patients with osteoarthritis treated with a conventional total shoulder replacement generally see a return in their range of motion that approaches what they had prior to having shoulder problems in the first place. These shoulder replacements have a longevity and patient satisfaction similar to total hip and knee replacement surgeries. Those patients with shoulder dysfunction from rotator cuff tear arthropathy treated with a reverse shoulder replacement note similar pain relief to patients treated with a standard total shoulder arthroplasty. The ultimate range of motion achieved after a reverse replacement generally is slightly less than that obtained after a conventional total shoulder arthroplasty, but these patients generally start with a much more limited range of motion as well. In fact, cuff tear arthropathy is often associated with a clinical entity called the ‘pseudoparalytic’ shoulder – a condition characterized by such limited shoulder range of motion that patients are unable to elevate their arm at all! The life expectancy of reverse shoulder replacements is still being resolved, but studies show that almost 95% of patients treated with this procedure still have their implants in place at nine years out from the surgery.
When considering shoulder replacement surgery, it is important to visit a surgeon who has extensive experience with the procedure. Dr. Matthew Walker is one such surgeon, having completed a fellowship in shoulder surgery and specializing in all aspects of shoulder care. During his career, he has performed more than 300 shoulder replacements, over half of which were reverse shoulder replacements. Furthermore, he has extensive experience in revision shoulder surgery, and may be able to offer patients with prior surgery and continued pain and dysfunction options to improve their symptoms. Dr. Walker practices with Ortho Virginia and has office hours in both the Parham Road Office and the Hanover location.