Reverse Shoulder Replacement of the Shoulder - James T. Mazzara, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest Dr. Jim Mazzara. Dr. Mazzara did his medical school training at New York Medical College. He then went on to complete an orthopaedic residency at St. Luke Roosevelt Hospital, which is a teaching hospital affiliate of Columbia University. Good morning, Dr. Mazzara.

Dr. Mazzara: Good morning.

Dr. Sechrest: Dr. Mazzara, what I would like to discuss today is artificial replacement of the shoulder. If you could, could you define for me the type of patients that would benefit from an artificial shoulder replacement?

Dr. Mazzara: Sure. Well, we see quite a few patients in my practice with shoulder pain and a small number of these people end up having arthritis of the shoulder joint that may make them a candidate for total shoulder replacement. The arthritis of the shoulder is generally a consequence of wear and tear of the cartilage in the joint. That cartilage over a period of years will wear out. It wears out to the point where you then have rough surfaces rubbing against one another and as that occurs people develop pain, swelling, inflammation and lose motion.

Dr. Sechrest: It's interesting. I think that we're all familiar with artificial knee replacements, artificial hip replacements; obviously artificial shoulder replacement is not done nearly as much, and a lot of that is because the knee and the hip are weight-bearing joints and commonly wear out. What makes the shoulder wear out?

Dr. Mazzara: It's generally just either genetics or wear and tear. It can be related to previous trauma. In a small number of patients it can be related to prior surgery and in some patients it's related to rotator cuff tears. The focus of a standard shoulder replacement is in somebody who has an intact functional rotator cuff who just has worn out the joint. So it's generally going to be a result of either trauma or what we call idiopathic osteoarthritis in the joint.

Dr. Sechrest: So these people just present to your practice one day with shoulder pain and you take an x-ray and all of a sudden you see this arthritis in the shoulder and they never knew they had it up until that time.

Dr. Mazzara: That's right, and many of those patients have no history of prior surgery or prior trauma, it just wears out.

Dr. Sechrest: Now there's a couple of other patient populations I think we probably ought to mention and one patient population is the patient who has inflammatory arthritis, like a patient who has had rheumatoid arthritis for many years. I'm assuming they're candidates for an artificial shoulder, if that disease process affects their shoulder.

Dr. Mazzara: Yes, rheumatoid arthritis affects all of the joints and it can especially affect the shoulder. It is not necessarily a wear and tear process in the shoulder when it's a rheumatoid patient it's more of an inflammatory process that ends up destroying the joint. But even patients who have rheumatoid arthritis can develop some wear and tear changes. That's not really the primary cause of their pain, though. It's the inflammatory condition. It's the systemic disease that causes it.

Dr. Sechrest: Now you also mentioned the fact that to do a normal artificial shoulder replacement you really normal musculature. You need that rotator cuff to be working okay. How about people who have instability? If you've had shoulder dislocations over many years and have opted not to have a shoulder stabilization, those folks I see can develop a lot of arthritis. Is that a problem for doing an artificial shoulder replacement or can those people go ahead with an artificial shoulder and consider it successful?

Dr. Mazzara: Now who have had multiple dislocations or even prior fracture prior trauma causing deformity and arthritis as a result of that, they can certainly go ahead and have a total shoulder replacement. We have to have a couple of conditions that are satisfied though. They have to have an intact rotator cuff and nerves to the rotator cuff that are working. Under those circumstances, they can certainly have the shoulder replaced with a standard shoulder replacement.

Dr. Sechrest: Okay. One other group that I think is uncommon, but I would like your feeling on that, and that is a person who has a shoulder that's worn out because maybe they've had an infection in the shoulder 20 years ago and that damaged the cartilage and finally it wore out. Do you still feel that those people are safe to undergo a shoulder replacement and what's their risk of that infection coming back if they have an operation and have the shoulder replaced?

Dr. Mazzara: I would generally try to steer away from shoulder replacement under those circumstances. However, if those people have been proven by multiple studies not to have had any residual infection, they potentially could have the shoulder replaced. The concern is always that there is some chronic low-grade indwelling infection in the bone and there is always that very substantial increased risk of having that replacement become infected. However, under the circumstances, that's something that's worthy of a discussion with that individual.

Dr. Sechrest: So the longer after the infection that has supposedly been cured; and I think we all worry that you can never really cure a bone infection, it always might come back.

Dr. Mazzara: Sure. Absolutely. But any patient who has any kind of surgical procedure, including a joint replacement of the shoulder, is at risk for infection, those patients in particular are at increased risk. But if the history of infection was many years before and there are no obvious conditions or lab tests or bone studies that prove they have any infection, it's at least worth the discussion with those individuals.

Dr. Sechrest: Now, in your practice, when you see a patient with shoulder pain that you're getting the feeling that this person may benefit from an artificial shoulder, what do you do to try to make that decision? What do you go about in terms of the diagnostic process to try to determine whether that procedure is appropriate for that patient?

Dr. Mazzara: Well, we'll discuss with them what kind treatment they've had. We'll talk about conservative treatment like pain medication over-the-counter, or some physical therapy. The problem with physical therapy for an arthritic shoulder is that sometimes the therapy actually just makes it worse. You have a deformed arthritic joint, bone spurs, and irregular surfaces, and sometimes trying to stretch that arthritic shoulder is really a source of pain and dissatisfaction for patients. Then we'll talk about other options and if somebody becomes a surgical candidate, it's based on a series of x-rays that we do in the office with special views and then we follow that up with a CT scan. In many cases, if I think somebody has an intact rotator cuff and there a candidate for a standard shoulder replacement, I might even do an MRI to verify that the rotator cuff is intact and functional and that they don't have a big tear on the rotator cuff.

Dr. Sechrest: If you've made the decision now that you're recommending surgery for this patient, and you've done all the preparation work from the standpoint of the imaging and you and the patient have decided, "Yes, this is the procedure for me"; anything else that a patient should prepare for in terms of general health or anything before the operation?

Dr. Mazzara: Well, they need to get medically cleared by their primary care physician. In addition to any studies that I may order, their primary care physician may require other studies be done - they need to be cleared for their heart, their lungs, and any other systems that may be an issue for them. So medical clearance is an important part of getting into the operating room.

Dr. Sechrest: When you're doing this procedure, can you show us a little bit about what's actually done during a shoulder replacement?

Dr. Mazzara: This is a model of a shoulder that has already been partially replaced, but it gives you an idea of what the surface may look like if this is the arthritic surface of the joint. This joins up or rubs against the component of the shoulder called the glenoid. That glenoid is arthritic and can wear out, and wear and tear of both of those surfaces causes pain and discomfort, inflammation, and even deformity of the bone and joint. As a consequence of all that, people have pain and limited motion. When we go in and do a standard shoulder replacement, what we're really doing is we're going in and removing the arthritic head of the component by cutting it off here and replacing it with a metal surface. On the opposing side, we'll have the socket of the joint, called the glenoid, and we resurface that with a plastic surface as well. The component that goes into the shoulder looks something like that. The diameter of the stem, or the size of the head, will actually look different depending on the anatomy of the individual patient. So we may have an individual patient who might require a shoulder replacement like that, whereas another patient requires something that's a little bit different.
Dr. Sechrest: Now a question for you. I know that for a while there was a great amount of interest in only replacing the humeral head and leaving the person's own socket, or the glenoid, intact - not resurfacing that with plastic; and, in some cases, no matter how much arthritis was there, the thought was that still just replacing the one surface would result in adequate pain relief and less loosening because the glenoid component was the real problem. Where are we today with that? Is that fallen by the wayside? Do we know simply go in and replace both sides regardless?

Dr. Mazzara: I think all of the data today will show that if somebody has arthritis, people do much better with better function, better more reliable pain relief, if you replace both sides.

Dr. Sechrest: So you're unlikely to have the recommendation to have a hemiarthroplasty, only half of the joint, unless it's a fracture?

Dr. Mazzara: Very selected circumstances, perhaps in a very young patient who may have arthritis for some unusual reason, may be a candidate for a partial shoulder replacement. The data, however, doesn't really support that as the best long-term functional outcome, and you look at all the studies, and people clearly suggest that a total shoulder replacement exceeds the function pain relief compared to a partial shoulder replacement. So unless somebody's got a fracture, they're going to be better off having a total shoulder replacement, again with very few exceptions where the younger patient, who may not be a candidate for a total shoulder, may need the other surface re-surfaced, not with plastic and not left as it is, but sometimes with tendon graft. That has been a procedure that has evolved over a period of years. We, years ago, used to use meniscus cartilage to resurface the joint; today we're using either dermal grafts or tendon grafts to resurface the glenoid surface of the joint. Very few patients seem to be appropriate candidates for that, and I don't think the long-term data is out there that suggests that that's the best way to handle those patients.

Dr. Sechrest: Let's move on a little bit to the hospital phase of this. I am assuming that this is done as an inpatient procedure.

Dr. Mazzara: Yes.

Dr. Sechrest: This is not done as an outpatient procedure this day.

Dr. Mazzara: No, it's inpatient. Patients will generally stay for 2 or 3 days depending on their needs, and pain management postoperatively.

Dr. Sechrest: What does a patient expect in terms of the postoperative course? They're out of the hospital in 2-3 days. Are they in a sling? Are they beginning to do exercises? How much pain are they having and what should they plan on after surgery?

Dr. Mazzara: There is a bit of pain after surgery. We try to manage that with oral pain medications as they go home. Initially they might get intravenous or injectable pain medications. Postoperatively, assuming everything has gone very well and we have a good repair and good quality tendon and bone to work with, those patients can actually start using the arm fairly quickly after surgery within 2-3 days they can be out of the sling for daily activities. While I might ask them to wear the sling if they're out of the house or sleeping or through different parts of the day, I encourage them to start to lift and to move the arm. They start therapy right away. After the surgery, they start getting back to most of their very light activities at somewhere between 4-6 weeks. Full recovery, however, takes quite a long time, and we're taking these shoulders that have not moved normally, with worn deconditioned tendons, and resurfacing or replacing the joint. That's one part of getting good result. The other part of the good result is conditioning and rehabilitating the shoulder, and what we really need to do is help patients understand that part of their good outcome is going to come from hard work and physical therapy after-the-fact, which can actually take many weeks or months for patients to get their motion and function back. It takes at least 6 weeks for some of the tendons and bones to heal after surgery. But, we allow patients to do many of their light daily activities much earlier than that.

Dr. Sechrest: Now, how long after surgery should a patient expect to be seeing a physical therapist? Is this a 2 week process? Is this a 6 month process? When are they going to be released from physical therapy?

Dr. Mazzara: They're really going to have to plan on going to physical therapy for probably 2-3 months after the surgery and, in many cases, those people are going to need to do home exercises for sometimes many months after that. It's going to depend on what limitations they may or may not have after the surgery. Some of those people do very, very well at 2 months and can do it at home; other patients have a lot of weakness or preoperative deconditioning - it takes those patients a longer time to get their function and motion back. When you look at the outcomes that you get from surgery, people who have arthritis and excellent motion before surgery will get excellent motion and good pain relief after surgery. Those people who have arthritis and very poor motion before surgery will get good pain relief, but somewhat less motion after surgery; but those patients are often very satisfied that they have more motion than they started with and much less pain than they started with. So, that's a good outcome.

Dr. Sechrest: Do you think there's any benefit to having patients go to physical therapy before they have an artificial shoulder replacement and try to get some strengthening before they have the surgery? Or is the shoulder just too painful to expect that to work?

Dr. Mazzara: In many cases the shoulder is just too painful - you can't get an arthritic joint to move through a normal range-of-motion because, very often, there's a lot of bone deformity and bone spurs. Sometimes patients just don't like to go to therapy because it hurts too much, and you can't subject those patients to painful therapy, and there's not always a great value to doing that preoperatively, especially in the more advanced cases where people just have so much bony deformity and so many bone spurs that they'll never get more motion and strengthening is not an option for those people. So, you don't want to get your patients upset before surgery with more therapy. It's better that you explain to them that, preoperatively, this may take you a while because you're starting off with a very bad shoulder. It may not take you 8 weeks to get better; you might take another month or two to get to the point where you really see the value of having had this done.

Dr. Sechrest: Now let's talk a little bit about the restrictions in terms of time. As this patient is recovering from the artificial shoulder replacement, what restrictions do you place on those patients in terms of their daily activities?

Dr. Mazzara: We don't want them to do any heavy work or overhead activity initially except what a therapist may direct them to do. When we do a standard shoulder replacement we make an incision over the front of the shoulder to get into the joint we have to open the front part of the rotator cuff, the tendon called the subscapularis. The way I do that is I take a little piece off the bone to which the rotator cuff, the subscapularis tendon is attached, and reflect that backward. As we have done that we're able to get access to the joint and we get in the joint, we do our replacement, then I repair the subscapularis and the piece of bone called the lesser tuberosity back to the bone. It's going to take at least 6 weeks for that bone to heal back to its normal position. So for that 6 week period of time, while waiting for that bone and that subscapularis tendon to heal, we want some restricted rotation, so that patient may not be able to normal external rotation for several weeks after surgery until I'm satisfied, on x-ray, that subscapularis tendon and the bone to which its attached is healed back to the proper position and I may not allow them to do any work overhead or activities overhead postoperatively simply because we don't want to overstress the rotator cuff. But otherwise, the prosthesis is either press-fit or cemented into place. We don't need to allow the bone to grow in. We don't need to allow anything but that little piece of bone and rotator cuff to heal, so patients can actually start moving fairly quickly after a standard shoulder replacement.

Dr. Sechrest: In the long-term, if this patient was very active before they opted for an artificial shoulder replacement, for example, if they're golfing, playing tennis, if they were a laborer, or if they downhill ski, cross-country ski, are any of those things restricted after an artificial replacement, or can the patient do pretty much anything they want?

Dr. Mazzara: I think it's going to depend on the level of activity that they want to go back to. Certainly they can go back and golf. Tennis of a certain level is going to be acceptable, but very competitive tennis may not be the best thing for shoulder replacement. Overhead work - it's going to depend on how much stress and strain is applied to that shoulder overhead. Certainly the rotator cuff and the joint is functional and it's resurfaced now with a brand new surface, so you may be able to get away with that. But I would say very heavy, physically demanding overhead work is not a good idea; not because it stresses the humerus, or the long bone, but it can put a lot of extra stress on the glenoid, so patients can do that with some limitations postoperatively; weight-training, heavy weights, certainly not advisable.

Dr. Sechrest: So what you're worried about is that plastic component either wearing out more or loosening and having the shoulder replacement fail because of that.

Dr. Mazzara: Absolutely. The more sheer stress there is on the shoulder replacement, the more likely there is to be failure of the glenoid component. So, you can get away with some things, but you can't get away with unlimited activity after shoulder replacement, and so having that discussion preoperatively helps me guide that patient postoperatively. I want to know what that individual patient wants to go back and do. They want to go back bench press heavy weights, or they want to go back and do some very light overhead work periodically, which they can do. Bench pressing, I would say, is a bad idea. Some light to moderate overhead work is not unreasonable to be able to do that. Cycling is a very good thing to do and is not a problem. It doesn't impose that much stress on the shoulder.

Dr. Sechrest: Now, in terms of your follow-up, as an orthopaedic surgeon, once this procedure is over and the patient is healed, how often do you like to see patients back after a replacement to check on it. Is this a yearly visit with you, or every 5 years? What would prompt you to see a patient back?

Dr. Mazzara: Well, my patients always need to know that if there is every a problem, they need to come back and see me and have me check on it. But, under routine circumstances, what I would like to be able to do is have that patient come back every year for a couple of years, and then every 2 years after that.

Dr. Sechrest: What are you looking for at a routine visit, when a patient comes back and says, "You know, doc, I'm not having any trouble with my shoulder. Why am I here?" What are you doing?

Dr. Mazzara: We want to evaluate x-rays, make sure their function is okay, and, on the x-ray, what we would like to do is look for loosening of the prosthesis. We want to see if there is any wear and tear or loosening of the glenoid component of the prosthesis. The glenoid is the cup, or the socket portion of the prosthesis, and that's cemented into the bone. Under the circumstances of cementing it into the bone, we're monitoring for early loosening. If there is loosening of that component or some sign of any other pathology in there, we need to know that early on because the longer we ignore that and let it go unattended, the more difficult it's going to be to fix that over a period of time.

Dr. Sechrest: And these patients may have that occurring without any symptoms?

Dr. Mazzara: Potentially. It's always a concern so we like to follow-up on our patients every couple of years.

Dr. Sechrest: Okay. Let's talk a little bit about the bad sides of any sort of operation. What do you worry about, as an orthopaedic surgeon, that could go wrong with these operations, both at the time of the surgery, in the time after the surgery, and then long-term?

Dr. Mazzara: Well, intraoperatively you always worry about things like nerve damage, bleeding and infection. Nerve damage can certainly result in weakness or numbness of the upper extremity. Bleeding, you need to be treated with transfusion. Infection can accompany, be associated with, any kind of surgical procedure. The chances of those happening are very, very low, but the risk of surgery is obviously number zero. Postoperatively, we monitor for infection and we also monitor for disruption of the tendon repair and the repair of the bone back. We want to make sure that we are giving that sufficient time to heal, so we don't want somebody to be overly aggressive over the next several weeks until we are certain that the subscapularis tendon and the bone is adequately healed. Long-term we worry about infection and loosening. Infection from other sources - from dental procedures, from other systemic infection, from other types of sepsis in the body where you may have an infection in a remote site that seeds the total shoulder replacement that can cause a secondary infection of the total shoulder replacement - that's always a concern.

Dr. Sechrest: Now patients always want to know, "When I go through the airport, am I going to set off the buzzers and what do you do with these patients in terms of after they've had and artificial replacement, how do you advise them and do you prepare or give them any paperwork that will get them through the airport?

Dr. Mazzara: Many patients are able to get through security in the airport without activating the metal detector. Those who do are given a little card. Everybody gets a little card that indicates they have a shoulder replacement or joint replacement in whatever part we've inserted the total shoulder or total knee, but most of those patients are still pulled aside, wanded, inspected and the card may help in that respect.

Dr. Sechrest: Okay. As we close, do you have any other observations about your experience with artificial shoulders? That you could advise patients who are perhaps trying to make a decision whether artificial shoulder replacement is something that would benefit them? What advice would you have for patients to seek out the information and how to talk with their doctor about the possibility of these procedures?

Dr. Mazzara: I think if you know you have shoulder arthritis and you think that you may be a candidate for a total shoulder replacement, you really need to discuss with your orthopaedic surgeon if that's an appropriate option for you? Patients decide to have shoulder replacement surgery when their quality of life is affected, when they find that they have pain all day, every day, and they can't do the things that they want to do, those are usually things that prompt the patients to come in and say, "I'm tired of this. I want to know what my options are" and a shoulder replacement can be an excellent option for somebody who is active and functional, who may be willing to accept some few limitations with their shoulder after surgery, and they want to get back to life without pain, and they want to get back with good function.

Dr. Sechrest: Okay. Well, thank you very much for discussing this technique with us today, and we'll talk again.

Dr. Mazzara: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.