Should You Consider a Shoulder Replacement?
Your shoulder is the most mobile and flexible joint in your body – but also the least stable. Because of the wide range of motion required, it’s more susceptible to injury or dislocation, which can increase the likelihood of painful shoulder arthritis in the future. Further, there is a known genetic contribution which predisposes certain patients to shoulder arthritis. As a result, more and more patients are turning to partial or full shoulder replacement surgeries to restore pain-free function.
Some 53,000 people opt for shoulder replacement surgery each year in the United States – a number that has skyrocketed in the last 15 years due to technological advancements that ensure a reliable, effective result and faster recovery. A new study presented this spring even found that 96 percent of recreational athletes under 55 returned to their sport within just seven months of shoulder replacement surgery.
We asked Dr. Peter Johnston, a shoulder and elbow surgeon, to weigh in on which patients are good candidates for the surgery and what they can expect from the procedure in the long term. Dr. Johnston practices at our Southern Maryland Orthopaedics & Sports Medicine care center and is on the forefront of shoulder replacement research and implementation.
1. First, are there any non-surgical options you pursue before a shoulder replacement?
If the patient has mild to moderate arthritis, we will use the typical non-surgical orthopaedic measures: Activity modification, rest, anti-inflammatory medication and physical therapy as appropriate. Cortisone injections are an example of an anti-inflammatory medication, delivered directly into the shoulder, that can be effective for pain relief and sometimes for improvement in function as well. We’ll also pursue these options for patients who may not be eligible for surgeries due to other health conditions, such as an 85-year-old with advanced heart or lung disease.
These non-surgical approaches – particularly the anti-inflammatory injections – can also be a great opportunity for patients to understand how a pain-free shoulder might feel after a surgery. Many of my patients have been living in pain for so long, and it’s eye-opening to experience relief from anti-inflammatory medication or other non-operative modalities. They realize that they can likely experience this relief every day without medication or activity modification if they have replacement surgery.
2. What type of patient is a candidate for a partial or total shoulder replacement?
In my practice, the most common indication for shoulder replacement surgery is in a patient with severe shoulder arthritis. In that instance, the cartilage is worn down and your body forms extra bone – typically as a response to an injury or the disease. The lost cartilage and extra bone leads to pain, functional limitations and range of motion deficits that can be quite disabling.
3. What type of shoulder surgeries should patients consider?
If we can’t address the pain and improve function with non-operative modalities, then we’ll discuss the patient’s options for shoulder surgery. Arthroscopic, minimally-invasive capsular release surgery is a good fit for patients who are young and active, with only mild to moderate arthritis, or who may have pieces of that extra bone or cartilage floating around in their shoulder. With this surgery, you create a small incision and use a scope to remove any pieces of bone and scar tissue to improve the range of motion.
However, most patients I’ve seen have already had surgery performed on their shoulder, or their arthritis is so far advanced that it doesn’t even make sense to try the minimally invasive approach. Those patients are usually candidates for a partial or full shoulder replacement.
4. What does shoulder replacement surgery entail?
It depends if it’s an anatomic technique or reverse shoulder replacement. Even orthopaedic physicians in other specialties can have a hard time distinguishing the indication for these two very different surgical approaches! The basics are the same: In a full shoulder replacement, we’ll replace the ball (humerus) and socket (glenoid) joint with a metal ball and a plastic socket, ultimately resurfacing both the humerus and glenoid to prevent bone-on-bone rubbing.
In the traditional anatomic shoulder replacement, we’re reconstructing the anatomy of the shoulder joint before arthritis set in. A reverse shoulder replacement, which has been done in the United States since 2004, is typically appropriate for people who have suffered massive rotator cuff tears and are unable to even elevate their arms. With a reverse shoulder replacement, we’re basically changing the mechanics of the shoulder because the rotator cuff is no longer functioning. Because of this, we give the deltoid muscle a structural advantage so that it can function more efficiently in spite of the torn rotator cuff. This way, the patient can raise their arm with the deltoid muscle instead of the rotator cuff.
Thanks to improved technologies and more advanced techniques, our patients have a better than 80 percent chance that the joint will last for 10 years. In my practice, I typically shoot for 15- to 20-year solutions.
5. How long is the recovery process?
Well, it takes three months to return to full activities, but this can vary significantly between patients depending on the severity of the arthritis and their activity-related expectations. But the arthritic pain should be reduced very quickly. In fact, some patients notice this as soon as the day after surgery! They’ll still experience the post-operative pain, but won’t have the achy pain from arthritis. Although patients should be able to do most activities after three months, the patient’s opinion of the function of their new shoulder will actually continue to improve for two full years following the surgery.
6. What can patients expect from physical therapy?
This varies depending on whether the patient has had a traditional, anatomic shoulder replacement or a reverse replacement surgery. Although the recovery time is typically three months regardless of the technique, it does change the physical therapy.
Anatomic patients can expect to see a physical therapist on the day of the surgery and learn two exercises for their range of motion, which they will work at for six weeks. After six weeks, we begin strengthening exercises.
Reverse shoulder replacement patients will delay those initial physical therapy exercises by two weeks. However, they can still begin strengthening exercises at six weeks and anticipate a full recovery by three months.
7. How has shoulder surgery changed in the last 15 years?
Shoulder surgery has actually advanced rapidly over the last 15 years. Our understanding of the mechanics of the shoulder has progressed significantly, as has our improvement in technique and delivery of innovative components to ensure better fixation of the prosthesis. I’ve heard people describe shoulder surgery as “the final frontier” of orthopaedics, simply because we have historically understood less about the shoulder than other major joints such as hips and knees. But because of these advancements, shoulder replacements are actually increasing at a rate much faster than knee and hip replacements.
8. What are the innovations currently underway in shoulder replacement surgery?
I feel fortunate to be on the front end of the newest innovation in technology. Because I specialize in orthopaedic conditions of the shoulder and elbow and perform a very high volume of shoulder replacement surgeries, I’m involved in the research, teaching and utilization of the latest techniques. At the moment, we are able to perform stemless shoulder replacements for the first time and we’re also researching different styles of glenoid prostheses and potential new bearing surfaces as opposed to metal.
9. What drew you to focus on shoulder injuries and surgery?
I’ve suffered personal injuries to my shoulder, which required surgery, and that heightened my interest in the shoulder early on. I also enjoy the challenge: The shoulder is the most complex joint to treat effectively, and there are many different nuances that make it especially difficult.
Dr. Peter Johnston specializes in shoulder and elbow surgery at the Southern Maryland Orthopaedic & Sports Medicine care center. His expertise includes arthroscopic methods of management for arthritis, instability, joint contracture, and soft tissue repair of the shoulder and elbow, as well as total and partial joint replacement and care of the young and aging athlete. Dr. Johnston’s research has been published in numerous peer-reviewed journals and book chapters, and he continues to pursue academic interests and expertise despite being in private practice.