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Dr. Tomaino's Blog

Clinical Update: Common Questions Regarding Shoulder Replacement

September 13th, 2009
I recently received several very good questions regarding shoulder replacement surgery from a patient who has shoulder osteoarthritis. Her radiographs show complete loss of joint space; her rotator cuff is strong and not torn, and she experiences pain, and loss of motion. She was told by one provider that an "Arthroscopic" debridement might help by removing loose bodies and potentially cleaning up the worn cartilage. She then saw another provider who advised against this option and directed her to me. She was not interested in a corticosteroid shot, and had been to thereapy. She notes that her pain is not constant, but accompanies use. She is worried that waiting until her pain becomes worse--constant--might "burn a bridge".

I will share my answers to her questions below. First, a couple of things. In 2009, the evidence base does not appear to support arthroscopic debridement for end stage arthritis. However, if exam suggests that rotator cuff disease and/or biceps tendonapathy is the source of pain, arthroscopy may be indicated. And, waiting into the future to undergo a shoulder replacement probably does not jeopardize one's eligibility for one in the future. Though further bony wear might occur, or a rotator cuff tear could develop in the interim, these issues can be addressed when you "are ready" for operative intervention.

Here are the questions, and answers. Feel free to respond to this blog if you happen to have additional questions.

1. I am alergic to metals, as-in jewelery. Is there any history of people being allergic to the shoulder device parts?

It would be most unusual as there is no nickel in the material, which is either titanium or cobalt-chrome. So, as far as this concern exists---there is no need to worry.


2. You recommended a shoulder replacement. In my case, what are the alternatives? Pros and Cons of each?

The alternatives include an "anatomic total replacement" (the most typical type of replacement)----that requires a functioning rotator cuff, and has a design that is consistent with as near normal "biomechanics/kinematics" as possible. The advantages are a long history of this design working--particularly as "modularity" has improved the attributes of these offerings. Another other option would be a Hemiarthroplasty---either stemmed, or simple resurfacing. These would be performed to avoid glenoid resurfacing. However, your xrays show fairly substantial glenoid wear---so you would expect more complete pain relief with a total as opposed to a partial replacement. One reason to advise a hemi would be fear of early glenoid failure---either heavy activity type of expectations or young age. The final option is a Reverse design, which is "nonanatomic"-------and leverages a medialized center of rotation to empower the Deltoid muscle. This is recommended when the rotator cuff is either irreparably torn, or atrophied and not functional. Our short-term success has been high but long term follow-up is still unavailable. That having been said, when little else is available, and one would like to be able to raise the arm overhead, it is a great potential option---so long as the Deltoid muscle is healthy.

3. What are the consequences if I don't have surgery?

The consequences are, firstly, that you will continue to experience the symtoms you are having---pain, loss of motion etc. However, if your symtoms are tolerable, there is little downside to waiting on the replacement until you feel as though you are ready. In other words, there is little if any risk that you would progress in such a way that a replacement would not be an option in the future. If, during a period of several years your rotator cuff function declined, and an anatomic unconstrained replacement was no longer an option, you would still likely be a candidate for a Reverse design.

4. What are the chances of infection from the surgery? Also, what are the consequences if I get a bone infection?

While an acute infection is possible, the risk is less than 2-3%. If this happens in the postoperative period, you would require surgery to debride and wash out the infection, and several weeks of antibiotics. If the components are well fixed and the bacteria is sensitive, the components can usually be retained. However, if they need to be removed, replacment can often be performed again after a few months, so long as the infection has been erradicated.If the infection lingers--there is a small chance that you would not be able to have a revision, and you would be left with a "flail" shoulder.

5. What precautions do you take to prevent infection?

All patients are screened before surgery to ensure that they are not assymptomatic carriers of a Staph bacteria--MRSA. If they are, then the preoperative antibiotics are adjusted. Everyone receives preoperative and postoperative antibiotics. After surgery, forever, we prescrive pills before any dental or GI procedure, as well. Further, we make sure that you do not have any infections, for example, a urinary tract infection, prior to your surgery.

6. I have attended 5 physical therapy sessions. I have authorization for 3 more. Should I complete all 8 previously authorized sessions?

Only if you think it is helping. Alternatively, you can do the exercises on your own.

7. If I have surgery, how long do you typically schedule patient visits after surgery?

I usually see you at 1-2 weeks after surgery, at 6 weeks, 3 months, and either at 6 months and/or at 12 months--depending on how you are doing. This is flexible, however, depending on whether you live out of town or not.

8. How long do the various prosthetic devices last?

How long these replacements last is variable---we hope for a lifetime, but know that failures---which if not from infection- related problems, are usually due to lossening of the glenoid component, and can develop after 10-15 years. But ofcourse, this often does not happen.

9. You didn't mention a reverse prosthesis, or a partial replacement. Are these procedures considered in my case?

I have addressed these above---if you have any further questions, let me know. In your case, your loss of motion and the xrays suggest that a total shoulder replacement would be the best option.

10. If I decide not to have surgery, would any supplements help?

Very difficult to say. There certainly may be a slight benefit, but it could be from a "placebo" effect. As I mentioned, a corticosteroid injection may help transiently. Viscosupplemenation, "Hyaluronate"---as is performed in the knee, has not been FDA approved for the shoulder, so though potentially helpful, most insurances will not pay for this.

11. What brands of glucosamine & chondroitin are more helpful?

I do not have an opinion regarding this.

12. What are the restrictions for shoulder replacement (and/or other options) that I should consider in my decision? Can I expect to play golf with a shoulder replacement?

I do not like patients to lift more than 50 pounds regularly. Golf is okay---tennis might be risky in light of the stresses. You would certainly be able to swim and do most other activities--within reason. Safest to ask as the questions arise.



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