By Martin R. Coleman, MD
Just about everyone has a friend or relative who has had a hip or knee replacement. Much rarer are people who suffer from severe pain from arthritis of the shoulder. Most joint replacements are done for hips and knees, but shoulder replacement is becoming more and more popular as a remedy for arthritis and fractures of the shoulder.
Total shoulder replacement, also known as total shoulder arthroplasty (TSA), is a tremendously successful procedure for treating the severe pain and stiffness that often result at the end stage of various forms of arthritis or degenerative joint disease of the shoulder joint. The primary goal of shoulder replacement surgery is pain relief, but it also has the benefit of improving motion, strength, and function. Each year, thousands of TSAs are performed successfully in the United States. As an orthopaedist specializing in the care and treatment of the shoulder, I have extensive experience with total shoulder replacement surgery. However, a conventional shoulder replacement will not help patients with massive rotator cuff tears who have developed a complex type of shoulder arthritis called rotator cuff tear arthropathy.
Rotator cuff tear arthropathy is a devastating condition that seriously compromises the comfort and function of the shoulder. This condition is characterized by the irreparable loss of the rotator cuff tendons and destruction of the normal joint surface of the shoulder. The function of the cuff tendons cannot be restored so the shoulder is often weak, painful, and unstable. At OSC, we recommend that a patient suffering from this condition try to alleviate the pain and weakness with other options, such as rest, medications, cortisone injections, and physical therapy. Once these options have been exhausted, we may recommend surgery.
For patients with rotator cuff tear arthropathy, a conventional total shoulder replacement may result in persistent pain and limited function, therefore, a reverse total shoulder replacement may be an option. In a healthy shoulder, the upper arm bone (humerus) ends in a ball shape. The ball fits into a socket formed by the shoulder blade (scapula). Together this ball and socket form the shoulder. When arthritis has destroyed the cartilage covering the bony surfaces, the joint has to be replaced. In a conventional shoulder replacement the ball is replaced by a metal ball and the socket is replaced with a plastic socket. In a reverse total shoulder replacement, the anatomy of the healthy shoulder is reversed. The socket is replaced with a metal ball and the ball is replaced with a plastic socket.
Reverse total shoulder replacement works well for people with rotator cuff tear arthropathy because allows the deltoid muscle, instead of the rotator cuff, to power and position the arm. Extensive physical therapy is required in the months following surgery to retrain the deltoid muscle to perform a new function, but most people are able to regain much of the overhead motion and strength that had been lost. This procedure is of particular interest to me as a solution for a condition that could not be helped in the past. Doctors in Europe have been using this surgery for over 20 years. It received FDA approval in 2004, so it is a fairly new procedure in the United States.
With this form of joint replacement, stability and function are dependent upon the healing of soft tissues. When implanted by trained surgeons in the appropriate patients, the prosthesis provides restored motion, pain relief and increased stability.
A typical patient comes to the hospital on the day of the surgery, which lasts about two hours. They are then admitted overnight for observation. The next day they receive two sessions of Physical Therapy. If they are doing well, most go home that night. They have a sling, but we encourage them to use it only for comfort and to start moving the arm as much as possible.
They return to the office after a week for a post-op check with new X-rays. Formal therapy is then started and is scheduled in a physical therapy office three times a week. All patients tend to need two months of therapy to regain maximum function, but some need a third month.
Most of the patients we see have suffered for years with severe shoulder pain, and many have been told that there is nothing that can be done to help them. Many of my patients had such severe pain that they had to give up their favorite activities, such as golf, tennis, and gardening. I am proud to hear how so many of my patients are delighted that they have returned to these activities. In fact, a very common comment is that they only wish they had not waited so long to have the surgery, because it made their quality of life so much better.
The ideal candidate for the reverse total shoulder is a patient with serious shoulder pain, without severe heart or lung disease that would make surgery unsafe, and 60 years of age or older. As long as a patient is able to cooperate with the physical therapy required for recovery, we have no upper age limit. Patients with shoulder pain due to severe arthritis, even with no functioning rotator cuff can now expect an end to their suffering and a return to doing what they love.
If you are interested in finding out if this procedure may be a good option for you, I encourage you to make an appointment with an Orthopaedic Specialist at OSC so we can help determine the best course of treatment for you.
Martin R. Coleman, MD is a board- certified Orthopaedic Specialist with Orthopaedic and Spine Center in Newport News, Virginia. His area of specialty is the treatment of shoulder injuries and arthritis, with a focus on rotator cuff repair and both Traditional and Reverse Shoulder Replacements. To learn more about Dr. Coleman or to make an appointment, please call 757-596-1900.